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The HPV FOCAL Study

This clinical trial randomly assigned women who were due for cervical cancer screening to receive either cytology screening (Pap test) or HPV testing. The goal of the study was to find out which screening method caught precancerous changes earlier. Precancerous cervical changes, known as dysplasias, are graded from mild (grade I) to moderate (grade II) to severe (grade III). After 4 years, this study found that HPV testing resulted in fewer high-grade precancerous changes. The HPV testing intervention group had a grade III rate of 2.3/1000 compared to the cytology screening rate of 5.5/1000 (Ogilvie et al., 2018). This study demonstrated that HPV testing is more effective than traditional Pap tests at detecting precancerous changes earlier.

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The Compass Pilot Study

This trial looked at cervical cancer screening methods in a population with high rates of HPV vaccination. The HPV vaccine has been effective at preventing HPV infection and reducing the rates of cervical cancer (Canfell et al., 2017). The goal of the study was to see if HPV vaccination impacted the effectiveness of HPV testing compared to traditional Pap tests. The study found that HPV testing detects precancerous changes at a higher rate than traditional cytology methods. The findings of this study meant that HPV testing can still be used as a primary cervical cancer screening method in vaccinated groups of women.

Cochrane Database Systematic Review

This systematic review of the literature looked at 40 studies that compared HPV testing and traditional cytology methods. The study concluded that HPV testing has a sensitivity of 89.9% at detecting cervical cancer (Koliopoulos et al., 2017). In comparison, cytology methods detected only 72.9% of the precancerous changes (Koliopoulos et al., 2017). This systematic review demonstrated that HPV testing detects precancerous changes at a higher rate than traditional methods. However, the systematic review found that HPV testing results in more false positives than traditional cytology. Despite the drawback of more false positives, this study concluded that HPV testing could reduce cervical cancer deaths by accurately detecting more early precancerous changes.

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What is the nurse doing?

Nurses have an important role in the secondary prevention of cervical cancer. Nurses utilize secondary prevention when they support HPV testing efforts. Nurses primarily accomplish this through education. Nurses teach young women that HPV testing is an effective detection method for cervical cancer. Many people rely on nurses to tell them when to start testing. Nurses teach young women to start cervical cancer screening at the age of 21.

How is this improving the issue?

Secondary prevention is important because screening means preventing cancer deaths. HPV testing has been shown to increase the early detection of precancerous changes (Canfell et al., 2017). By educating women about HPV testing, the nurse is increasing testing and preventing the development of cervical cancer.

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(Centers for Disease Control and Prevention, 2021).

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Centers for Disease Control and Prevention (CDC)

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Analysis - Importance of the Nurse’s Involvement

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Analysis - Importance of the Nurse’s Involvement

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How can the nurse help?

The nurse can help by being an educator and an advocate. The nurse can educate by teaching patients about HPV testing for cervical cancer prevention. This can be done in the community setting while collecting a patient history. Additionally, acute care nurses can ask their patients about their knowledge of cervical cancer screening. After assessing the patient’s understanding, the nurse can educate them about HPV testing. Nurses can help this issue as advocates by pushing for practice changes. HPV testing is not offered by all providers. In some settings, the traditional Pap test is the only cervical cancer screening offered. Nurses can work with women’s health providers to make sure HPV testing is available to women.

How do nurses help improve the issue?

Every day, nurses speak to advanced practice providers in order to advocate for their patients. Nurse advocacy can increase the rate of HPV testing and reduce the rate of cervical cancer. Nurse education helps patients understand the importance of screening and make patients more willing to get screened.

Why is nurse involvement important?

Nurse involvement is important because nurses have a good rapport with patients. Reproductive health is a very sensitive topic that is surrounded by stigma and cultural beliefs. The nurse can use therapeutic communication to cross barriers and help patients learn about the significance of HPV testing. Additionally, the nurse is an important intermediary between patients and their providers. Through advocacy, nurses can help transition cervical cancer screening from the traditional Pap test to HPV testing.

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What is the problem?
Cervical cancer is a common type of cancer that originates in the cervix of the female reproductive tract. Cervical cancer can be fatal if not detected early. Fortunately, screening efforts have enabled healthcare providers to detect precancerous changes before the cells develop into cancer. New scientific advances have led to a best practice question: What is the best method for screening to prevent cervical cancer?

Who is affected?
Cervical cancer affects thousands of women each year. Over 12,000 women are diagnosed each year in the United States (Ogilvie et al., 2018). Cervical cancer is most frequently diagnosed at the end of the reproductive years (Capriotti & Frizzell, 2016).

How?
Malignant cervical changes are associated with the Human papillomavirus (HPV). HPV is a sexually transmitted infection that is a carcinogen. HPV is present in nearly 100% of cervical cancer cases (Capriotti & Frizzell, 2016). Traditionally, women have been screened for cervical cancer with a Papanicolaou test (Pap test). During a Pap test, a small sample of cervical cells is collected for evaluation. The pap test is a type of cytology screening. Newer science has led to the development of HPV testing as a form of cervical cancer screening. HPV testing is used to detect HPV strains that are known to cause cancer.

Where?
Cervical cancer affects women across the globe. It is the third most prevalent cancer found in women (Capriotti & Frizzell, 2016).

When?
Cervical cancer screening is recommended between the ages of 21 and 65 (Centers for Disease Control and Prevention, 2021).

Why?
Improving screening efforts is important because women continue to die from cervical cancer each year. Over 4000 women are estimated to die each year in the United States from cervical cancer (Ogilvie et al., 2018). Adopting the best screening practices can save lives.

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Challenges the Nurse Faces

Nurses are often on the outside of cervical cancer screening efforts. Cervical cancer screening is generally performed in the community setting by advanced practice providers. Nurses must be active advocates to change screening practices.

Why is nurse participation limited?

Ethical Concerns: Autonomy

Cervical cancer screening requires the active participation of the patient. It would violate patient autonomy to compel a patient to have an HPV test performed. Generally, the patient must independently make an appointment with a provider to have screening performed. As a result, the nurse must focus on motivational education that encourages women to take charge of their health.

Legal Concerns

Nurse participation in cervical cancer screening is limited by the legal scope of a nurse. HPV testing and Pap smears are performed by advanced practice providers. The nurse must collaborate with the provider about using HPV testing as the primary method of testing. Additionally, the nurse must be proactive in starting a dialogue with women about cervical cancer screening recommendations.

Financial Concerns

The research showed that HPV testing results in more false-positive tests than traditional Pap tests (Koliopoulos et al., 2017). Every positive test requires additional testing to determine if cancer is present. These additional tests increase the total cost of care. Some organizations may prefer to stick with traditional Pap testing because it may be lower cost than HPV testing.

Social Implications

Nurses may face social barriers when they present HPV testing as a screening method. First, many women are used to having Pap smears and may not want to switch to HPV testing. Secondly, HPV is a sexually transmitted infection (STI). Many women are embarrassed about being tested for an STI. Nurses will have to overcome the stigma surrounding STI testing while advocating for HPV testing as the primary method for cervical cancer prevention.

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(Centers for Disease Control and Prevention, 2021).

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1. Meet with the Interdisciplinary Team

HPV testing is a recent development in cervical cancer prevention efforts. The entire interdisciplinary team should be on the same page when it comes to recommended screening. In the outpatient setting, I recommend nurses meet with their women’s health providers about current screening guidelines. Nurses can accomplish this by scheduling a meeting or requesting time at a recurring staff meeting. Some providers are only offering Pap tests. Other providers offer a combination of HPV testing and Pap tests. The research supports HPV testing as the primary form of screening. The nurse can share this research and advocate for patients receiving HPV testing as the primary detection method for cervical cancer. Creating new procedures requires the cooperation of advanced practice providers. Together, the interdisciplinary team can bring HPV testing to all women from 25 to 65.

2. Educate Fellow Nurses

Many practicing nurses received their nursing education before the development of HPV testing as a primary form of cervical cancer screening. The nurse has an important role in peer education. All nurses can bring knowledge of HPV testing to their peers. My recommendation is that nurses share a fact sheet with their peers at staff meetings. The fact sheet will help convey the research and explain what HPV testing is. These fact sheets will help all nurses be prepared to answer questions about cervical cancer prevention.

3. Increase Education in the Community

Nurses are crucial educators in the community. My recommendation is for nurses to work with community organizations to increase the community's knowledge of cervical cancer screening. This would include reaching out to local organizations at colleges, churches, and fitness centers. The nurse can offer to come to speak at a meeting or provide flyers for distribution. The CDC has a cervical cancer fact sheet that can be printed for this purpose. Nurses can also work within their current organization to facilitate community outreach. For example, a hospital staff nurse could ask about bringing a cervical cancer prevention display to the hospital lobby.

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Evidence-Based Practice

During our entire program, we have focused on evidence-based practice (EBP). EBP is a QSEN competency that involves considering the best available evidence, patient preferences, and clinical expertise when planning patient care (Treas et al., 2018). Each semester, I have practiced reviewing current literature to find the best available evidence. I used my knowledge of EBP to learn about cervical cancer prevention strategies. I looked at both research and considered how patient preferences and cultural practices would impact the adoption of HPV testing. The EBP skills I have learned in school will help me continue to bring the most current evidence into the clinical space.

Leadership in EBP

I can use the EBP process to address new issues I encounter in the clinical space. I know that leading my peers to make a change starts with reviewing the literature and identifying potential solutions for the problem. The EBP process learned in school will help me be a leader and advocate for improved patient care.

Interdisciplinary Collaboration

Throughout this BSN program, we have discussed the importance of the interdisciplinary team. The interdisciplinary team includes the nurse, physicians, respiratory therapists, dieticians, and other professionals who provide services to patients (Treas et al., 2018). As nurses, we must be prepared to successfully collaborate with the other team members in the interest of the patient. Collaboration involves joint decision-making (Treas et al., 2018). Interdisciplinary collaboration is crucial when it comes to practice changes like HPV testing for cervical cancer prevention. The nurse needs the cooperation of advanced practice providers to bring HPV testing to practice.

Leadership in Collaboration

As a nurse, I can take the lead in bringing the research to the providers on my team. Together, we can discuss the literature and I can advocate for change on behalf of my patients. Practicing interdisciplinary collaboration in school has given me the leadership skills to effectively advocate for patients. I now know how to organize the evidence and present recommendations to providers. Interdisciplinary collaboration will always be an important tool for providing my patients with the best care.

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Example of a cervical cancer prevention flyer from the CDC
(Centers for Disease Control and Prevention, 2021).