1. At United Community & Family Services
Pap Smear Tracking in Adult Primary Care
At United Community & Family Services
Christina C. Cheng
Quinnipiac University
Physician Assistant Program
August 2010

2. Cervix Lower, narrow end of the uterus 3 layers: 2 cell types:
serous membrane, muscular layer, mucous membrane
2 cell types:
Squamous cells, columnar cells
Cervix: lower, narrow end of the uterus (womb)
Cancer: disease where cells have changed function or appearance – instead of dividing/growing at a controlled and orderly way, they grow out of control = mass, “tumor”
Benign: only few cell layers
Malignant: spreads to surrounding layers/tissues, organs
Inner lining = mucous, thin, flat – squamous cells ***
Mild cervical dysplasia – 1/3
Moderate cervical dysplasia – 2/3
Severe cervical dysplasia = CA in situ (CIS) – all layers  histo changes CIN: cervical intraepithelial neoplasias – LSIL, HSIL
85-90% SCC: begins in cells that line inner part of cervix connecting to vagina (ectocervix) meets opens into uterus (endocervix) transformation zone
10% Adenocarcinoma

3. Cervical Cancer
Majority occur at squamocolumnar junction – transformation zone
Cervical cancer: 2nd most common cancer in women worldwide3
4th most common in USA and Connecticut11
Regular screening = sustained
reduction in cervical cancer incidence
and mortality1,2
In 2009, there was an estimated 11,270
new cases of invasive cervical cancer,
with an estimated 4,070 cancer-related
deaths in the U.S.4
Highly curable when found and treated early

4. Risk of Cervical Cancer
ALL WOMEN ARE AT RISK
Not having regular Pap Smears
Not following up with PCP on abnormal Pap results
AIDS/HIV, immunocompromised
Smoking
Most Common age > 30 years old12
Main Cause  Human papillomavirus (HPV)
Sexually transmitted infection
Changes in cervical cells  cervical cancer, genital warts
At least half of sexually active people will have HPV at some point in their lives.
6 out of 10 cervical cancers cases occur in women who have never received a Pap test or have not been tested in the past 5 years.13

5. The Papanicolaou (PAP) Smear
Introduced in US in 1941
This test has been designed as a screening test to be administered to asymptomatic patients rather than as a diagnostic test.
Many studies have shown that a failure of follow-up can lead to advanced cancers.5
Studies have also documented that follow-up for abnormal Papanicolaou tests showed fairly consistent findings that young age, minority race, lack of transportation and low socioeconomic status are risk factors for noncompliance with recommendations for diagnostic testing.6,7

6. Pap Screening
Conventional PAP: cells sampled from cervix and vagina using brush/spatula  placed on slide  chemical fixative
ThinPrep: slide uniformity, less chance of re-screen, cost effective

7. Federally Qualified Health Center (FQHC) look-alike
12,000 individuals in the Norwich community with integrated primary care, dental care and behavioral heath services
Beginning August 2010, UCFS will provide obstetrics and gynecology services
Fulfills one of the Health Resources and Services Administration (HRSA) Core Clinical Measures (CCMs)
HRSA defined a set of evidence-based CCMs that targets high-priority health conditions found about populations defined as “safety-net” populations by the Institute of Medicine (IOM) requiring national action to improve the quality of health care.9
Achieving a CCM, will improve UCFS’s ability to become a FQHC and provide more competent and quality health care to its patients.

8. Current Tracking System

9. Goals & Objectives Objectives:
Establish office protocol for tracking patients’ Pap smears and reminding them to keep recommended follow-up appointments.
Communicate effectively with patients to explain Pap smear results, colposcopy procedure and importance of compliance with management plan.
GOALS:
Establish an updated policies and procedures: Pap Smear and Cervical Cancer Screening Guidelines
Implement an electronic tracking system to help facilitate tracking until a full EMR is in place

10. Policies/Procedures (USTFPS and ACOG)
Start age: 21 yrs old or 3 yrs after first sexual activity
Every year until age 30: if had 3 consecutive normal exams  screened once every 3 years
Stop age: 65 yrs old (3 consecutive normal exams or no abnormal exams in the past 10 years)
No need to screen those who have had a total hysterectomy for non-cancerous reasons
Participate in CT DPH Breast and Cervical Cancer Early detection Program.
No insurance  Lawrence and Memorial Hospital case manager
Breast exam, Pap smear and mammogram free of charge if qualify
STD clinic at Backus Hospital if out of pocket expense is a concern.

11. Follow-up Treatment Given Abnormal Pap Smear
Infection: Trichomonas, BV, Candida
ASCUS
LSIL, HSIL, ASC-H, AGC, AGC favor neoplasm
+ HPV
– HPV
Colposcopy
Follow up in 3 to 4 months with repeat pap smear or proceed to colposcopy

12. Recommend HPV Vaccine
Advisory Committee on Immunization Practices (ACIP)
HPV2 (16, 18) and HPV4 (6, 11, 16, 18)
Series of 3 shots (starting at 11 or 12 years old)
Can start as early as 9years old
Recommended: Boys and Girls between age 9 to 26

13. New Tracking System
Microsoft Access in hopes it will better integrate with future EMR system

14. References
Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American cancer society guidelines and cancer screening issues. CA Cancer J Clin (2008) 58(3):161–179
Guide to Clinical Preventive Services, Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication Accessed August 10, 2010.
Parkin, DM, Bray, F, Ferlay, J, Pisani, P. Global cancer statistics, CA Cancer J Clin 2005; 55:74.
Jemal, A, Siegel, R, Ward, E, et al. Cancer statistics, CA Cancer J Clin 2009; 59:225
Leyden WA, Manos MM, Geiger AM, et al. Cervical cancer in women with comprehensive health care access: attributable factors in the screening process. J Natl Cancer Inst (2005) 97(9):675–683.
Abercrombie PD. Improving adherence to abnormal Pap smear follow-up. J Obstet Gynecol Neonatal Nurs (2001) 30(1):80–88.
Eggleston KS, Coker AL, Das IP, Cordray ST, Luchok KJ. Understanding barriers for adherence to follow-up care for abnormal pap tests. J Womens Health (Larchmt) (2007) 16(3):311–330.
Eheman CR, Benard VB, Blackman D, et al. Breast cancer screening among low-income or uninsured women: results from the National Breast and Cervical Cancer Early Detection Program, July 1995 to March 2002 (United States). Cancer Causes Control (2006) 17(1):29–38.
The Institute of Medicine (IOM). Priority Areas for National Action: Transforming Health Care Quality Report, 2003.
U.S. Preventative Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. Am Fam Physician.(2003) 67(8):
Cervical Cancer, Atlanta, GA: Center for Disease Control. CDC Publication. Accessed August 10, 2010.
U.S. Cancer Statistics Working Group. United States Cancer Statistics: Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute. Accessed August 10, 2010
National Institutes of Health. Cervical Cancer. NIH Consensus Statement. 1996;14(1):1–38.