NUR 656 Module 1 Discussion Example

Module One Discussion

"My Mom Always Had a Pap Every Year": Screening Intervals by Age

This week a 21-year-old patient at our community health center asked for her annual Pap test. Her mother had one every year for decades, and she assumed that was the rule. She was surprised, and a little suspicious, when I explained that the recommendation for her age is a Pap test every three years. Her question is a good one to answer carefully, because trust in screening depends on patients understanding why the intervals changed.

Under current US Preventive Services Task Force advice, a woman in her twenties is screened with cytology once every three years. From 30 through 65 she can choose among three routes: cytology on the same three-year cycle, a high-risk HPV test by itself every five years or both tests together on a five-year cycle. The Task Force advises against screening before 21, and it advises stopping after 65 once a woman's past results have been normal and adequate and nothing else raises her risk. Women whose cervix was removed during a hysterectomy for a benign reason need no further screening (Curry et al., 2018). My patient's mother was following advice that made sense before the role of HPV was understood and before evidence showed how slowly most cervical cancers develop.

Why not screen every year just to be safe? Most HPV infections in young women clear on their own within one to two years, and the lesions they cause often regress. Screening more often finds more of these transient changes, leading to repeat tests, colposcopies and sometimes treatments that can affect future pregnancies, without preventing additional cancers. The three-year interval balances the benefit of finding lesions that persist with the harm of chasing ones that would disappear. When a result is abnormal, the 2019 ASCCP guidelines direct follow-up based on each patient's estimated risk of precancer, combining the current result with her screening history, rather than a single rule for every abnormal test (Perkins et al., 2020).

Screening is only part of the story. Lei et al. (2020) tracked more than 1.6 million Swedish girls and young women and reported far fewer invasive cervical cancers among those who had received the HPV vaccine, and the protection was strongest in those vaccinated before their seventeenth birthday. My patient had never been vaccinated. Because the vaccine is recommended through age 26, I offered it that day, and she accepted after we talked about safety.

She left with a reminder for three years from now and her first vaccine dose. My question for peers: how do you explain longer screening intervals to patients who worry that less frequent testing means less care?

References

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Kemper, A. R., Kubik, M., Landefeld, C. S., Mangione, C. M., Phipps, M. G., Silverstein, M., Simon, M. A., Tseng, C. W., & Wong, J. B. (2018). Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA, 320(7), 674-686. https://doi.org/10.1001/jama.2018.10897

Lei, J., Ploner, A., Elfström, K. M., Wang, J., Roth, A., Fang, F., Sundström, K., Dillner, J., & Sparén, P. (2020). HPV vaccination and the risk of invasive cervical cancer. New England Journal of Medicine, 383(14), 1340-1348. https://doi.org/10.1056/NEJMoa1917338

Perkins, R. B., Guido, R. S., Castle, P. E., Chelmow, D., Einstein, M. H., Garcia, F., Huh, W. K., Kim, J. J., Moscicki, A. B., Nayar, R., Saraiya, M., Sawaya, G. F., Wentzensen, N., & Schiffman, M. (2020). 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. Journal of Lower Genital Tract Disease, 24(2), 102-131. https://doi.org/10.1097/LGT.0000000000000525