It is common knowledge that cancer is among the few diseases in the world without a cure. The 21st century saw cancer emerge as one of the leading causes of deaths globally. In 2018, it was ranked second among the leading causes of deaths due to a non-communicable disease globally, with an estimated 9.6 million deaths. That’s about 1 in every 6 deaths worldwide being caused by cancer (Plummer et al., 2016). There exists a number of different types of cancer, with cervical cancer being among the top lethal gynecological types. Recent data suggests that globally, cervical cancer ranks fourteenth among all types of cancers and fourth among cancers that affect women (Fowler & Jack, 2020). For a condition that is easily preventable and manageable if detected early enough, cervical cancer ranks quite high on that list. It is for this reason that the author of this paper takes a look at cervical cancer and all that surrounds it. We define cervical cancer, discuss the significance of cervical cancer, its signs and symptoms, and incidence and prevalence rates in the State of Oklahoma in comparison to the United States as a whole. We also highlight the current surveillance methods for cervical cancer, along with a descriptive epidemiological analysis of the disease. A discussion of screening and guidelines of the disease is provided, as well a plan of action for a nurse practitioner who just graduated to address the condition. We end by giving a summary of the main points from this discussion.
Background and Significance
Cancer is the general term used to describe a large group of diseases that are able to affect any human part of the body, with other terms being malignant tumors or neoplasms (WHO, 2020). The most conspicuous feature of cancer that sets it apart from other conditions that can affect the entire body is the abnormal proliferation of body cells beyond their usual form. These abnormal cells have the ability to invade adjacent cells as well as spread to other organs in the body, in a process that is referred to as metastasis. This process is the major cause of death by cancer. Cervical cancer occurs when there is proliferation of abnormal cancerous cells in the cervix. It is a malignant tumor that is mainly caused by persistent human papillomavirus (HPV) infection (Fowler & Jack, 2020).
Common symptoms of cervical cancer at an early stage include postmenopausal spotting or bleeding, increased vaginal discharge which is foul smelling sometimes, post-coital bleeding and irregular blood spotting or light bleeding in between periods in women of reproductive age. Once the cancer advances, more severe symptoms begin to occur. These include weight loss, loss of appetite, swelling of a leg or both lower extremities, vaginal discomfort and foul-smelling discharge, pelvic pain, persistent back and leg pains (WHO, 2020).
Cervical cancer is estimated to have an annual incidence of more than 500,000 cases; which represents about 7.5% of all female cancer deaths. It is also approximated that globally, 250,000 women die annually due to cervical cancer (Arbyn et al., 2020). In the United States alone, over 12,000 women are affected, with more than 4000 women dying every year from cervical cancer (Denny et al., 2015). Hispanics, African Americans and women living in low-resource areas experience much higher disparities in evidence-based care as well as a much higher mortality rates with regards to cervical cancer. With data available only up to 2017, the State of Oklahoma has over the years had relatively higher incidence and mortality rates compared to the national statistics. The overall incidence and mortality rates in Oklahoma were found to be 8.8 and 4.1 respectively, per 100,000 women (U.S. Cancer Statistics). This was considerably higher than the Healthy People (HP) 2020 targets of 7.3 cases and 2.2 deaths per 100,000 women.
Table 1.1: Comparison of Incidence and Mortality Rates in Oklahoma and the United States
|INCIDENCE RATE||MORTALITY RATE|
Surveillance and Reporting
Surveillance of cervical cancer, as well as all other cancers in the United States, is carried out by the National Cancer Institute (NCI) and the Center for Disease Control and Prevention (CDC). This is done through programs referred to as Surveillance, Epidemiology, and End Results (SEER) funded by the NCI, and the National Program of Cancer Registries (NCPR) funded by the CDC. Established in 1973, the SEER program is a population-based surveillance system authorized by the federal government to collect data from various cancer registries. The NCPR on the other hand was established in 1992 and is also population-based. With regards to cancer incidence and survival rates, the SEER program is the most authoritative and reliable source of information (CDC). The NCI works hand-in-hand with the CDC in enforcing monitoring of cancer statistics through routine cervical cancer screening tests, survival questionnaires and collection of national data from cancer monitoring sites. The organizations produce the official federal statistics on cancer incidence, prevalence and deaths; which are then reported via the U.S. Cancer Statistics. Cancer statistics that are specific to each state or county in the United States are reported via the State Cancer Profiles that is under the National Cancer Institute and the CDC.
Descriptive Epidemiologic Analysis
Descriptive epidemiology provides us with the opportunity to organize and analyze collected data, for the purposes of understanding variations in cervical cancer frequency geographically and over time. It also offers us the chance to study how the disease varies in a population based on a number of personal characteristics, including person, place and time. The use of an epidemiological analysis can increase both the provider’s and patient’s understanding of risk factors, and consequently increasing successful primary and secondary prevention. For this assessment, we will use the 5W’s of descriptive epidemiology which include what, who, where, when and why.
As we have already seen cervical cancer is still a major health concern not only in the United States but also in the entire world. Cervical cancer only affects women, and is ranked fourth among gynecological cancers. Its incidence and mortality rates globally are still significantly high, despite its main causative agent and vaccines to prevent HPV infection being available. Risk factors for cervical cancer include an individual’s immune status, parity, young age at first birth, tobacco smoking, coinfection with other sexually transmitted agents such as those that cause gonorrhea, herpes simplex and chlamydia, and lastly, the HPV type. Women living with HIV are also six times more likely to get cervical cancer as compared to women living without HIV (WHO, 2020).
Healthy People (2020) formulated objectives to increase public health awareness of cervical cancer in an attempt to try and curb spread of the disease. The determinants of health identify social and economic factors that contribute to population health disparities, which increase the chances of individuals acquiring cervical cancer. Policy making can also be an effective tool in decreasing cervical cancer in the United States; for example, creating policies such as increased tobacco taxes and equal healthcare access. Funds from these taxes can be used to create awareness of cervical cancer. Such a policy can go a long way in increasing primary, secondary, and tertiary prevention for women at risk of cervical cancer (ODPHP, 2020). Social determinants of health include the environment in which a person is born, raised, works and lives. Environmental toxicity can increase the risk of cancer, while financial and physical access to healthcare hinder early detection and treatment; thereby increasing incidence and mortality rates (ODHP, 2020).
Screening and Guidelines
Just as in any other type of cancer, early detection is the only way to increase an individual’s chances of surviving the disease. The best way for early detection of most types of cancers is through screening. Screening for cervical cancer entails testing for pre-cancer and cancer lesions. Screening tests are usually conducted on women who have no symptoms whatsoever, and may be feeling perfectly healthy. Once a HPV infection or pre-cancerous lesion is detected, treatment can easily be undertaken and cervical cancer avoided. In treating pre-cancerous lesions, the WHO recommends that cryotherapy is used, or thermal ablation and loop electrosurgical excision procedure (LEEP) when available. Currently, according to the WHO, there are 3 different types of cervical cancer screening tests: the HPV DNA testing for high risk HPV types, Visual inspection with Acetic Acid which is the common one and lastly, conventional (Pap smear) test and liquid-based cytology (LBC).a study by Kim et al. (2018) also found out that screening with cervical cytology alone, or with primary hrHPV testing alone, or contesting, increases the chances of detecting high-grade pre-cancerous lesions and cervical cancer.
As discussed, screening tests are for individuals that have no signs or symptoms of cervical cancer. However, for those with symptoms of cervical cancer of abnormal cervical screening tests, extra diagnostic tests are recommended (ACS). These are initiated by a medical history taking accompanied by a physical exam. The first test is a colposcopy, which is examination of the cervix using a colposcope. A cervical biopsy is then obtained in order to ascertain the presence of cervical cancer. If cancer is present then metastasis is confirmed by cystoscopy, proctoscopy and finally examination under anesthesia.
The American Cancer Society (ACS) recommends that all women follow a strict set of guidelines if the battle against cervical cancer is to be won. These include cervical cancer testing that begins at the age of 25, that those aged 25 to 65 should have a primary HPV test every 5 years, and that individuals that have had a total hysterectomy should cease screening, unless the hysterectomy was undertaken as a treatment for cervical cancer or a serious pre-cancer lesion. However, those that have had a supra-cervical hysterectomy should continue cervical cancer screening as per guidelines for their age.
Plan of Action
One critical approach that a soon to be practitioner can adopt in addressing the problem that is cervical cancer is evidence-based practice (EBP). The use of EBP to address clinical problems such as cervical cancer is one of the core competencies that that nurse practitioners have to demonstrate before successfully completing their training (Hande et al., 2017). In addressing cervical cancer, a nurse practitioner would have to ensure they come up with interventions that support primary, secondary and tertiary prevention. Primary prevention would involve creating awareness at community level such each and every individual is aware of the guidelines that have been set in fighting cervical cancer. This would also help to ensure they understand prevention measures they can take to reduce the risk of acquiring cervical cancer. A secondary prevention measure would involve setting up of screening clinics at strategic points to enable individuals access screening services. Those found to have cervical cancer or pre-cancerous lesions are treated while those without the lesions or abnormal results are given health messages on how to continue leading healthy lives. Tertiary prevention involves management of individuals that have been found to have cervical cancer, through combined chemo- and radiation therapies (CCRT) (Li et al., 2016). However, the adverse effects of CCRT on cervical cancer survival have been poorly investigated and with inconclusive results.
Cervical cancer is currently ranked fourth globally among cancers that affect women (Fowler & Jack, 2020); with an estimated annual incidence of more than 500,000 cases. In the United States, over 12,000 women are affected, with another 4000 women dying every year due to the disease. The State of Oklahoma has over the years had relatively higher incidence and mortality rates as compared to the national statistics: 8.8 and 4.1 respectively, per 100,000 women. Cervical cancer is caused by persistent HPV infection and therefore, as a preventive measure, women worldwide should ensure they are frequently screened for cervical cancer of pre-cancerous lesions. Surveillance of the disease, as well as other cancers in the U.S., is conducted by the NCI and the CDC, with the statistics reported through the U.S. Cancer Statistics. Prevention measures a nurse practitioner can use include creating awareness at community level, setting up of screening clinics to offer screening services as well as providing combined chemo- and radiation therapies to those found with cervical cancer.
Arbyn, M., Weiderpass, E., Bruni, L., Sanjosé, S. D., Saraiya, M., Ir, J. F. & Bray, F. (2020). Estimates of incidence and mortality of Cervical Cancer in 2018: a worldwide analysis. The Lancet Global Health, 2(8); e191-e203. Retrieved from https://doi.org/10.1016/S2214-109X(19)30482-6
Center for Disease Control and Prevention. (2020). The United States cancer statistics. Retrieved from: https://gis.cdc.gov/Cancer/USCS/DataViz.html
Fowler, J. R. & Jack, B. W. (2020). Cervical Cancer. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved form https://www.ncbi.nlm.nih.gov/books/NBK431093/#_NBK431093_pubdet_
Kim, J. J., Burger, E. A., Regan, C. & Sy, S. (2015). Screening for cervical cancer in primary care: a decision analysis for the US Preventive Services Task Force. JAMA. Retrieved from https://doi:10.1001/jama.2017.19872
Office of Disease Prevention and Health Promotion. (2020). Determinants of health. HealthyPeople.gov. Retrieved from: https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health#health%20services
World Health Organization, (2020). Human Papillomavirus (HPV) and Cervical Cancer. Retrieved from https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer
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