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  1. 1. EVIDENCE BASED PRACTICE PREVENTING CERVICAL CANCER Angelina Almanza, Alexandrea Bartow, Ann Burton
  2. 2. Problem Statement <ul><li>There is an identified problem of an increasing number of young women diagnosed with cervical cancer, mostly linked to HPV.  There are limited screening tools used to help identify the risk of cervical cancer in adolescents.  The feasibility of this topic is to monitor cervical cancer screening with the use of the NP in the primary care setting. HPV vaccination beginning at the age of 11 or 12 is ideal. The HPV vaccine is an acceptable secondary preventative measure for girls and women 11-26. </li></ul>
  3. 3. Population, Intervention, Comparison, Outcome  <ul><li>  </li></ul><ul><li>P : Young adolescent women ages 11-18 seen in a primary care setting by a NP.  Identify risks of cervical cancer, provide education to screening, treatment, causes of cervical cancer and  encourage early prophylaxis with the HPV vaccination. </li></ul><ul><li>  </li></ul><ul><li>I :  Screening and treatment of adolescent females in the primary care setting by the NP </li></ul><ul><li>  </li></ul><ul><li>C : Lack of education currently provided to adolescents and parents  </li></ul><ul><li>  </li></ul><ul><li>O : Improved cervical cancer screening in primary care and developed by Nurse Practitioners, decreased risk of cervical cancer caused by HPV, improved education for adolescent females, modify risks and educate on behavior modification </li></ul><ul><li>  </li></ul>
  4. 4. HPV Prevalence <ul><li>Human Papillomavirus is responsible for the most common sexually transmitted disease </li></ul><ul><li>75% of Individuals 15-50 years old are infected with genital HPV during their lifetime </li></ul><ul><li>HPV DNA is detected in 99.7% of cervical cancers </li></ul><ul><li>1, 650,000 cases of cervical cancer per year in US    </li></ul><ul><li>250,000 of these cases die every year   </li></ul><ul><li>There are 100 different HPV strain types affecting humans </li></ul><ul><li>HPV16 is the most diffuse strain of HPV </li></ul><ul><li>HPV16 and HPV18 are associated with 60% and 10% of all cervical cancers </li></ul><ul><li>HPV6 and HPV11 are associated with squamous –cell carcinoma of the larynx, vulva, penis, anus, and 90% of genital warts </li></ul>
  5. 5. Background <ul><li>Evaluation of current standard of practice indicated by the CDC </li></ul><ul><li>Cervical cancer screening is to start 3 years after onset of vaginal intercourse, but no later than 21 years old </li></ul><ul><li>Young females aged 11 or 12 are recommended by the CDC to receive the HPV vaccination. It is pertinent that they also begin receiving screening for HPV that includes counseling and education followed by a physical examination which includes the Papillomavirus test once sexually active. </li></ul><ul><li>HPV vaccine does not eliminate the need for screening as 30% of cervical cancers are related to HPV types not covered by the vaccine </li></ul><ul><li>Women should continue being screened regardless of vaccine status -The use of a NP in the primary care setting can facilitate the screening of young woman against cervical cancer with appropriate screening tools </li></ul>
  6. 6.    Summary <ul><li>Evidence indicates the importance of initiating preventative measures to decrease the chance of contacting HPV 16,18, thus resulting in Cervical Cancer. </li></ul><ul><li>The preventative measures need to begin prior to sexual activity by administering the HPV vaccination and educating about the importance of compliance of all 3 doses.   </li></ul><ul><li>As the adolescent matures proper sexual education will need to be provided as well as information for the need of annual PAPs.   </li></ul><ul><li>Even with the HPV vaccination a women is still not protected from other HPV strands associated with STDs and or other health problems. </li></ul><ul><li>  </li></ul>
  7. 7. Implications and Evidence <ul><li>Implications for Practice </li></ul><ul><li>A nurse’s role in cervical cancer prevention is to facilitate communication with obtaining a detailed sexual history, provide sexual education, stress the importance of compliance and scheduling follow-up appointments. </li></ul><ul><li>The articles that highly contributed to this EBP were two Systematic Reviews and a Meta Analysis </li></ul><ul><li>  </li></ul>
  8. 8. Assessment Bundle <ul><ul><li>Patient risk factors </li></ul></ul><ul><ul><li>Condom usage </li></ul></ul><ul><ul><li>Cigarette smoking </li></ul></ul><ul><ul><li>Multiple sexual partners </li></ul></ul><ul><ul><li>New sexual partners </li></ul></ul><ul><ul><li>Partner's sexual history </li></ul></ul><ul><ul><li>Young age </li></ul></ul><ul><ul><li>Education of sexual health </li></ul></ul><ul><ul><li>Barriers to screening and preventative services </li></ul></ul><ul><ul><li>Current sexual practices evaluation </li></ul></ul><ul><ul><li>Number of partners </li></ul></ul><ul><ul><li>Men/women </li></ul></ul><ul><ul><li>Vaginal, anal, oral </li></ul></ul><ul><ul><li>Cultural beliefs </li></ul></ul><ul><li>  </li></ul><ul><li>Outcome- Education of risk factors leading to cervical cancer or HPV. </li></ul><ul><li>Increased education related to sexual health, HPV, and cervical cancer </li></ul>
  9. 9. Intervention <ul><li>Screening and treatment of young women in the primary care setting by an NP. </li></ul><ul><li>The need to create discussion that covered the entire context.  </li></ul><ul><li>HPV and cervical cancer prevention counseling would be part of a broader discussion of anticipatory guidance for STD's.  </li></ul><ul><li>Active and aggressive sexual risk counseling for perceived high levels of risky behavior.  </li></ul><ul><li>Develop counseling strategies that emphasize a preventive focus.  Include parents in the discussion at the time of the vaccination. </li></ul><ul><li>Physical exam/ annual exam </li></ul><ul><li>Promoting use of preventive measures. </li></ul><ul><li>Nurse standing orders </li></ul><ul><li>Special prevention clinics </li></ul><ul><li>Educate </li></ul><ul><li>Use of vaccine is preventative and does not actively treat a HPV diagnosis </li></ul><ul><li>HPV vaccine </li></ul><ul><li>Pap smear starting within 3 years of sexual activity </li></ul><ul><li>HPV DNA testing </li></ul><ul><li>  </li></ul><ul><li>Outcome- Reduction of incidence of HPV and incidence of cervical cancer </li></ul><ul><li>87% effective in preventing cervical infections from HPV 6, 11,16, 18 using tetravalent vaccines.  78% in preventing cervical infections from HPV 16/18 using bivalent vaccines.  </li></ul>
  10. 10. Evaluation Bundle <ul><ul><li>Efficacy of prophylactic HPV vaccines have in prevention of HPV 6, 11, 16, 18 by use of the tetravalent vaccine. </li></ul></ul><ul><li>  </li></ul><ul><ul><li>Compliance with the 3-dose HPV vaccine </li></ul></ul><ul><li>  </li></ul><ul><ul><li>Evaluate the young adolescents and young woman about their knowledge of HPV and cervical cancer </li></ul></ul><ul><li>  </li></ul><ul><ul><li>Organizational change, teamwork, and collaboration are powerful intervention features for introducing practice change.  </li></ul></ul>
  11. 11. Patient and Family Bundle <ul><li>Pap test to be used as principle screening tool to reduce the risk incidence and mortality of cervical cancer. </li></ul><ul><li>Routine vaccination of girls 11-12years old. </li></ul><ul><li>Schedule follow up after vaccine and encourage return fro 3-dose HPV vaccine. </li></ul><ul><li>Co-testing of HPV DNA should be conducted with Pap smear. </li></ul><ul><li>Provide information to young adolescent and young women of the risk of HPV and include families. </li></ul><ul><li>Provide data that can help maximize cost-effective and public health benefits. </li></ul><ul><li>Offer early education and support to women through media, school programs, doctor/NP visits. </li></ul><ul><li>Process indicators- Have patient establish goals with Nurse Practitioner to reduce risk factors. Establish open and Comfortable communication with patient and family. </li></ul><ul><li>Outcome indicator- involvement of patient in decision making will increase likelihood of continuation on decided intervention. </li></ul>
  12. 12. References <ul><li>1. Hartman, K., Halls, S., Nanda, K., Boggess, J., Zolnoun, D. (2002). Systematic Evidence Review: Screening for Cervical Cancer. Agency for Healthcare Research and Quality. Retrieved March 19, 2010 from </li></ul><ul><li>2. La Torre, G., Waure, C., Chiaradia, G., Mannocci, A., Ricciardi, W. (2007). HPV vaccine efficacy in preventing persistent cervical HPV infection: a systematic review and meta-analysis. Vaccine, 25(50). DOI: 10.1016/j.vaccine.2007.09.027   </li></ul><ul><li>  </li></ul><ul><li>3. Saint, M., Gildengorin, G., Sawaya, G. (2005).  Current cervical neoplasia screening practices of obstetrician/gynecologists in the US. American Journal of Obstetrics and Gynecology. 192, 414-421. </li></ul><ul><li>  </li></ul><ul><li>4. Smith, J., Backes, D., Hoots, E., Kurman, R., Pimenta, J. (2009). Human Papillomavirus Type-Distribution in Vulvar and Vaginal Cancers and Their Associated Precursors. American Journal of Obstetrics and Gynecology,113(4), 917-924. </li></ul><ul><li>  </li></ul><ul><li>5. Stone, E., Morton, S., Hulscher, M., Maglione, M., Roth, E., Grimshaw, J. (2002). Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Annals of Internal Medicine , 136 (9), 641-651. Retrieved from CINAHL Plus with Full Text database. </li></ul><ul><li>  </li></ul><ul><li>6. Sussman, A., Helitzer, D., Sanders, M., Urquieta, B., Salvador, M., & Ndiaye, K. (2007). HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care. Annals of Family Medicine , 5 (4), 298-304. Retrieved from CINAHL Plus with Full Text database.   </li></ul><ul><li>  </li></ul><ul><li>7. Wheeler, C., Hunt, W., Joste, N., Key, C., Quint, W, Castle, P. (2009). Human Papillomavirus Genotype Distributions: Implications for Vaccination and Cancer Screening in the United States. Journal of the National Cancer Institute, 101(7)475-487. </li></ul>