Berman - Figure 25 - Faculty Discussion Text
Berman - Figure 25 - Faculty Discussion
Xian Wen Jin, MD:
Nancy, thank you for such an excellent presentation. I am just wondering how you educate clinicians, as well as patients, about the new Guidelines in your practice.
Nancy Berman, MSN:
Well, I find opportunity during the visit and also, as I mentioned, reinforce with educational materials after the visit. I find that women are fairly accepting of the new guidelines. Of course, there is always that woman who has some trouble letting go, “I have always had a Pap every year.” But I think it is important, and I find that when I explain why we are not doing a Pap every year, there is usually acceptance.
Xian Wen Jin, MD:
I see.
Bradley Monk, MD:
But we need to move on here. I have a saying that the only person that likes change is a baby with a dirty diaper. So, change is difficult, but this change is evidence-based. There is now Level I evidence, and there is consensus across all the organizations.
Nancy Berman, MSN:
I agree, and I think many clinicians may have more trouble letting go than their patients. You know we get a certain sense of comfort after we have done a Pap every year for so long. On the other hand, we have had guidelines for many years that allowed for less frequent screening. But I haven’t seen those past guidelines accepted by many some primary care practices. This is a time when we need to embrace what is evidence-based. We also need to encourage clinicians to be confident, and that confidence will be conveyed to the patient. If we understand and really accept the new Guidelines, and the evidence that created them, we can really help our patients.
Bradley Monk, MD:
So as an OB/GYN doctor, and I like how you said this – we have to dissociate, disconnect, cervical cancer screening from the annual visit, and importantly, disconnect it from birth control discussions.
Remember in the olden days when you told a patient that she needs her birth control pill refilled, the first thing the nurse did was check to make sure the Pap was up-to-date. That is no longer the paradigm, and no longer the reason for the annual visit. The major epidemics: diabetes screening, weight loss, cholesterol screening, bone heath, osteoporosis, and contraception. There are a lot of reasons for the woman to come to see her provider regularly.
I wanted you, though, to tell us exactly how to collect this test. I think we know, but maybe we take it for granted. If our listeners have not done an HPV test from the cervix, are there different options? Is there a vial? Is it a swab? Is it a brush? Tell us how we do that.
Nancy Berman, MSN:
Yes, HPV testing is extremely convenient, as the test may be performed off the residual solution of a liquid-based Pap test. In most cases, if it is for reflex testing after ASC-US, it means the patient is under age 30. With an ASC-US cytology result, I am asking the lab to reflex to an HPV test.
For screening (of women age ≥30), I am asking for an HPV test to be done regardless of the way the Pap is read. There is also one test that may be performed off a separate collected sample, which is obtained at the same time as the other cervical or endocervical swabbing. That is a co-collected test, but all tests can be done off the same vial as the Pap.
Bradley Monk, MD:
So, there are two ways to collect: 1) You can just get it from the liquid from which you do the liquid cytology, or you can do a separate vial for the HPV test (co-collecting).
I also want to emphasize that the brush is very important. So brushes, just like in bronchial brushing or colonic brushing, get more cells. And more cells are important if you are doing a cytology, but more cells are important if you are doing a DNA test, such as an HPV test, because those cells have DNA in them. So, we try to encourage all Pap tests, including a separate vial for HPV testing, to be done with a brush, and also the brush allows one to get inside the endocervix and get up high in the canal. So, the brush technology in and of itself is an important breakthrough.
The other thing that you said, and I just want to make sure that we are clear, is you mean I have to order this test separately? It is not going to be done no matter what? It is in the guidelines? What do you mean?
Nancy Berman, MSN:
Absolutely be certain that you request the testing that you want. Most requisitions at this time do have a place to ask for an HPV test on the cytology form - the same form that will be submitted for the Pap test. You may check HPV on that form, and that means you will get the HPV test regardless. If you check HPV reflex, you will only receive HPV status if the Pap cytology result is first read ASC-US.
Bradley Monk, MD:
So, you really have to order three things: 1) cytology; 2) HPV, if it is ASC-US by cytology, which you call reflex, and; 3) HPV if she is age ≥30.
Nancy Berman, MSN:
That is correct. But if I am ordering HPV regardless, I do not check HPV reflex.
Bradley Monk, MD:
That is understood. Because it is already done.
Nancy Berman, MSN:
Yes. It has been done.
Bradley Monk, MD:
Good. Great! Thank you, I think that is helpful.
Nancy, thank you for such an excellent presentation. I am just wondering how you educate clinicians, as well as patients, about the new Guidelines in your practice.
Nancy Berman, MSN:
Well, I find opportunity during the visit and also, as I mentioned, reinforce with educational materials after the visit. I find that women are fairly accepting of the new guidelines. Of course, there is always that woman who has some trouble letting go, “I have always had a Pap every year.” But I think it is important, and I find that when I explain why we are not doing a Pap every year, there is usually acceptance.
Xian Wen Jin, MD:
I see.
Bradley Monk, MD:
But we need to move on here. I have a saying that the only person that likes change is a baby with a dirty diaper. So, change is difficult, but this change is evidence-based. There is now Level I evidence, and there is consensus across all the organizations.
Nancy Berman, MSN:
I agree, and I think many clinicians may have more trouble letting go than their patients. You know we get a certain sense of comfort after we have done a Pap every year for so long. On the other hand, we have had guidelines for many years that allowed for less frequent screening. But I haven’t seen those past guidelines accepted by many some primary care practices. This is a time when we need to embrace what is evidence-based. We also need to encourage clinicians to be confident, and that confidence will be conveyed to the patient. If we understand and really accept the new Guidelines, and the evidence that created them, we can really help our patients.
Bradley Monk, MD:
So as an OB/GYN doctor, and I like how you said this – we have to dissociate, disconnect, cervical cancer screening from the annual visit, and importantly, disconnect it from birth control discussions.
Remember in the olden days when you told a patient that she needs her birth control pill refilled, the first thing the nurse did was check to make sure the Pap was up-to-date. That is no longer the paradigm, and no longer the reason for the annual visit. The major epidemics: diabetes screening, weight loss, cholesterol screening, bone heath, osteoporosis, and contraception. There are a lot of reasons for the woman to come to see her provider regularly.
I wanted you, though, to tell us exactly how to collect this test. I think we know, but maybe we take it for granted. If our listeners have not done an HPV test from the cervix, are there different options? Is there a vial? Is it a swab? Is it a brush? Tell us how we do that.
Nancy Berman, MSN:
Yes, HPV testing is extremely convenient, as the test may be performed off the residual solution of a liquid-based Pap test. In most cases, if it is for reflex testing after ASC-US, it means the patient is under age 30. With an ASC-US cytology result, I am asking the lab to reflex to an HPV test.
For screening (of women age ≥30), I am asking for an HPV test to be done regardless of the way the Pap is read. There is also one test that may be performed off a separate collected sample, which is obtained at the same time as the other cervical or endocervical swabbing. That is a co-collected test, but all tests can be done off the same vial as the Pap.
Bradley Monk, MD:
So, there are two ways to collect: 1) You can just get it from the liquid from which you do the liquid cytology, or you can do a separate vial for the HPV test (co-collecting).
I also want to emphasize that the brush is very important. So brushes, just like in bronchial brushing or colonic brushing, get more cells. And more cells are important if you are doing a cytology, but more cells are important if you are doing a DNA test, such as an HPV test, because those cells have DNA in them. So, we try to encourage all Pap tests, including a separate vial for HPV testing, to be done with a brush, and also the brush allows one to get inside the endocervix and get up high in the canal. So, the brush technology in and of itself is an important breakthrough.
The other thing that you said, and I just want to make sure that we are clear, is you mean I have to order this test separately? It is not going to be done no matter what? It is in the guidelines? What do you mean?
Nancy Berman, MSN:
Absolutely be certain that you request the testing that you want. Most requisitions at this time do have a place to ask for an HPV test on the cytology form - the same form that will be submitted for the Pap test. You may check HPV on that form, and that means you will get the HPV test regardless. If you check HPV reflex, you will only receive HPV status if the Pap cytology result is first read ASC-US.
Bradley Monk, MD:
So, you really have to order three things: 1) cytology; 2) HPV, if it is ASC-US by cytology, which you call reflex, and; 3) HPV if she is age ≥30.
Nancy Berman, MSN:
That is correct. But if I am ordering HPV regardless, I do not check HPV reflex.
Bradley Monk, MD:
That is understood. Because it is already done.
Nancy Berman, MSN:
Yes. It has been done.
Bradley Monk, MD:
Good. Great! Thank you, I think that is helpful.