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Educating women on options

Midwife raises awareness of HPV testing for cervical cancer

Photo by Jill Schramm/MDN Nurse midwife Shawn Brooking at CHI St. Alexius in Minot encourages women to be knowledgeable about their care.

Cervical cancer screening is a routine aspect of women’s health care. That doesn’t mean women are necessarily aware of their options or are receiving the screening that’s best for them, said Shawn Brooking, women’s primary care provider at CHI-St. Alexius Clinic in Minot.

As a certified nurse midwife, Brooking views her role as that of a patient advocate. She seeks to educate women about different procedures and the importance of those procedures so her patients can make informed decisions.

“Because it’s very important that you’re in control. And for too long in women’s health, we’ve just listened to what people said and had no idea why we were doing it,” she said.

In the case of cervical screenings, the traditional procedure has been cytology-based screening known as the Pap test, used to detect abnormal cells. Women aren’t always aware of a second form of testing that detects the presence of the human paillomavirus (HPV), of which certain strains are known to lead to cancer.

“Over a decade ago, we made some changes to the national guidelines, where we incorporated HPV testing into what we do when we screen for cervical cancer,” Brooking said.

For a woman older than 30, the HPV test, along with the Pap, will give a better risk projection for cervical cancer, she said. While cytology alone is acceptable, the preferred method is co-testing, she said.

“It’s very important that testing be there,” she said of HPV screening. “All the evidence is there. And yet women are getting their Paps every three years without the co-testing.”

Eighty to 90 percent of cervical cancers are caused by two strains of HPV, identifiable in HPV testing, she said.

“If we’re not doing the HPV testing and we don’t know if you have it, let alone which strain you have, you’re kind of at a disadvantage,” she said.

A large study showed women who have negative tests for HPV have a less than 1 percent chance of developing severely abnormal cells on the cervix or higher risk lesions within the next five to 10 years, Brooking said.

If a test suspects HPV, a colposcopy can be performed to examine the cervix and take a biopsy, which could catch a potential problem earlier than abnormal cells might show up on a Pap, Brooking said. HPV testing is generally covered by insurance. In co-testing, only a single sample is necessary to perform both HPV and Pap tests.

For women younger than 30, the HPV test isn’t routine because the risk of cervical cancer at younger ages is too low to warrant the testing, Brooking said. However, she sees medical recommendations adapting as evidence grows.

“I think that in the next 20 or 30 years, we’re going to see huge changes – where we will probably do away with a Pap and go straight to HPV testing, and we probably won’t start testing until a little bit later,” Brooking said.

The HPV vaccine given to youth and now being made available at older ages may well reduce the incidence of cervical cancer even more in years ahead, she said.

Brooking attended a conference last July at which there was discussion about home testing for HPV. Such testing particularly is viewed as a solution in countries with less access to routine health care.

The biggest issue worldwide is half of women who develop cervical cancer have never been screened appropriately, Brooking said.

“Of women diagnosed with invasive cervical carcinoma, half have never had a Pap test and another 10 percent have not had a test in the last five years. In the United States in 2015, 83 percent of women 21 to 65 with a cervix had a Pap within the previous three years or co-testing within five years. So in the United States, we do a really good job of getting that word out,” she said. However, she added, there is concern over the 17 percent of U.S. women who go unscreened.

Brooking said one reason some women aren’t screened is cervical testing tends to be unpopular with patients. It’s important to her to make patients comfortable during the procedure but also to educate them about what the screening entails and why it’s important.

“Many women have no idea why they’re getting a Pap. They think the Pap is testing for sexually transmitted disease, ovarian cancer, uterine cancer. They think they need it every year. We haven’t needed it every year for a long time. The evidence isn’t there for that,” she said.

A medical provider may recommend more frequent testing than indicated in standard guidelines based personal experience with outcomes, but patients have a right to know why a recommendation might differ from the guidelines, Brooking said.

Various governing bodies from the American College of Obstetricians and Gyneologists to the America Cancer Society publish guidelines for cervical cancer screening, and those groups do not agree in all areas. Brooking said they do agree that women younger than 21 should not be tested. They also have established three-year Pap screening for women 21 to 29 and co-testing for women 30 to 65 every five years, assuming no other risk factors. Testing typically ends at age 65, although that should be a conversation a woman has with her provider, Brooking said.

For some of the best information on cervical cancer, she directs patients to the Centers for Disease Control and Prevention website at cdc.gov/cancer/cervical/index.htm.

Cervical cancer doesn’t have to be a scary thought for women, Brooking added. With screening and early detection, cancer can be stopped.

“We really shouldn’t have anybody developing cervical cancer,” Brooking said. “We should be able to get there with early screening.”

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