Practice Guideline Information Sheet



Practice Guideline Information Sheet

Guideline Title [Required]

|Cervical Cancer Screening |

Date Submitted [Required] Approved By: (Dept & Person) [Required]

|July 2005 | |Eric France, MD, Chief, Preventive Medicine |

| | |Women’s Health Task Force |

| | |Regional Prevention Committee |

Contact [Required] person to contact regarding this guideline’s content

|Sue Jane Fox, Karin Kempe MD |

|Department |Prevention |

|Phone |303-344-7256, 303-344-7662 |Email |Sue.J.Fox@ |

Author(s)

|Sue Jane Fox, Karin Kempe MD |

|Women’s Health Task Force |

|Rick Spurlock, MD |

Clinical Category [Required] Choose one (more if needed) from the list below.

| Allergy | Geriatrics | Pharmacy |

| Anesthesiology | Hematology/Oncology | Physiatry/Rehab |

| Cardiology | Infectious Disease | Podiatry |

| Cardiovascular Surgery | Mental Health | Pulmonology |

| Dermatology | Nephrology | Radiation Oncology |

| ENT/Head and Neck Surgery | Neurology | Radiology |

| Emergency Care | Neurosurgery | Rheumatology |

|Endocrinology |x Obstetrics/Gynecology | Surgery |

| Eye Care | Orthopedics | Urology |

| Gastroenterology | Pathology/Laboratory Services |xAdult Primary Care/Prevention |

Keywords To aid in searching for the guideline

|Cervical Cancer Screening, Pap Smear, Preventive Care, Women’s Health |

Abstract or other summary description of this guideline

|The use of regular cervical cancer screening has dramatically reduced the incidence of invasive cervical cancer. Regular screening|

|with a pap smear (either conventional or ThinPrep) is recommended for all women who are sexually active at least up to age 65. |

|Women who are at increased risk for cervical cancer should be screened more frequently (at least yearly and more often if following|

|up on an abnormal finding). Women at low risk may choose to stop screening at age 65 if they have a long history of normal results|

|as can women who have had a hysterectomy for non-cancer reasons. |

Intended Audience [Required] Click below to change

|xAll Providers |xPhysicians |

|xAll Providers and Staff |xNurses |

|Members |xPhysician Assistants |

| Other: |

Practice Guideline Plan Sheet

What is the intended clinical outcome of implementing this guideline ?

|Women age 18-65 will be regularly screened for cervical cancer and the incidence of invasive disease will remain low. |

What is the implementation plan?

|The guideline has been communicated in CME educational sessions with primary care. It is also available on the Permanente |

|Knowledge Connection (pkc.) intranet site. |

|With the introduction of our pap tracking system, all eligible women will be prompted for this visit proactively with additional |

|prompts if they are delinquent in seeking care. |

What is the plan for evaluating the outcome of implementing this guideline?

|The number of eligible women age 18-64 who have had a pap smear in the past 3 years is a HEDIS measure that is measured and |

|reported annually. The number of invasive cancers detected each year is also monitored by the Tumor Registry. |

Practice Guideline Attachment Sheet

Attachment One: Reference Document [Required]

This is a “complete” statement of the guideline, which might include

1. Standard disclaimer:

These guidelines are informational only and are not intended to substitute for the reasonable exercise of independent clinical judgment of the providers using the guideline. The guidelines are to be used in conjuction with the provider's clinical judgment in developing care and treatment that is designed for the individual needs of the patient.

2. Rationale

3. Target Patient Population

4. Setting for application of the guideline

5. Source of evidence

6. Recommendations

This can be in Word for Windows, Word for Mac, or HTML form

Attachment Two: Web Document [Required]

This is an HTML (World Wide Web) document that contains the briefest clearest possible graphical or text presentation of the guideline’s intended setting, target population and recommendations. The Clinical Tools Group will be happy to work with you in preparing the web document of your guideline.

Additional Attachments:

Patient education materials

Laminated sheet for providers

Clinician education materials

Baselet content

Other _______________________________________________

Date: Reviewed and Approved July 2005

Title: Cervical Cancer Screening

These guidelines are informational only and are not intended or designed to substitute the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances for each patient encounter. The guidelines are flexible and are intended to be used as a resource for integration with a sound exercise of clinical judgment. They can be used to create an approach to care that is unique to the needs of each individual patient. The implementation of this guideline is not intended to conflict with any agreed upon health plan benefits nor is it intended to prevent access to care that the practitioner believes is warranted based on clinical judgement.

Rationale:

The effectiveness of cervical cancer screening with PAP smears in reducing mortality has not been evaluated with randomized controlled trials, but epidemiologic data linking a reduction from cervical cancer associated with the introduction of screening is strong.

Both modeling and empiric data support a screening interval of every three years. Screening more often than every three years imparts very little additional benefit in reducing mortality at a significantly increased cost. However, coordination with other important preventive services for women make a screening interval of every two years an attractive operational decision and the total cost of care is less than with a three year interval. Seeing women every two years insures that women receive adequate counseling and actually obtain these recommended preventive services.

The cost effectiveness of any screening test improves if applied to a higher risk population. Women are at higher risk for cervical cancer if they have multiple sexual partners or have had abnormal PAP smears (including HPV) on past screenings. Early onset of sexual activity, presence of HIV and smoking have also been associated with increased risk.

There is no evidence that screening women who do not have a cervix improves mortality. Women who have had a hysterectomy for cancer reasons are at increased risk for local recurrence and may benefit from continued screening.

Modeling data suggest a woman age 65 will have her risk of dying from cervical cancer reduced by only 0.18% by screening. A woman age 74 will have her risk of dying from cervical cancer reduced by only 0.06% by screening. However, invasive cervical cancer is almost exclusively found in elderly women who have not had periodic screening prior to age 65.

Target Population: Female members age 18-65 years

Source of Evidence: See attached National KP Cervical Ca Guideline 2005 with references and evidence tables

Settings for Application: Internal Medicine, Family Practice, Pediatics, Ob/Gyn

Methods for Measuring Compliance: HEDIS annually measures the compliance of women age 21-64 with at least one pap smear in the last 3 years. The HRA is distributed to all adult members approximately every 5 years and also measures self-reported compliance of pap smear in the past 3 years. Identification of noncompliant women is done periodically and targeted outreach is provided.

Responsible Party: Department of Prevention

Approval: Chief, Prevention

Review Date: Reviewed biennially by the Women’s Health Task Force and the Regional Prevention Committee. Last approved by Regional Prevention Committee July 2005.

Kaiser Permanente--Colorado

Cervical Cancer Screening

May 2005

This guideline is intended to cover the routine screening of asymptomatic women only. For recommendations regarding follow up of abnormal pap smears see separate guideline.

I. Initiation of screening

A. Cervical cancer screening should begin three years after the onset of sexual activity. The majority of initial HPV infections after onset of activity are cleared within 18 to 24 months without treatment.

B. Initiation or refill of contraceptive pills or other contraceptive counseling therefore should not be dependent on the patient coming in for a pelvic exam or pap smear. Chlamydia testing can be done on a urine sample without a pelvic exam for patients who do not need a pap smear.

C. For women who report that they are not sexually active, cervical screening should start at or after age 21 years at the discretion of the provider.

D. At the onset of screening, women should be screened every two years. There is insufficient evidence to recommend annual screening prior to beginning the biennial screening interval.

II. Maintenance Screening

A. After initiation of screening, low risk women should be screened every two years unless their risk status changes. Some low risk women may elect, through shared decision making with their provider, to be screened every 3 years.

B. Risk for cervical cancer is tied to high risk HPV, previous abnormal screening (CIN 2 to 3), or positive HIV status.

C. High risk women should be screened more frequently (every 6 months x 2, then annually x 4). Providers may choose to return women to routine screening after several years (5 years) at their discretion based on clinical judgment in the individual case.

III. Cessation of screening

A. Cervical cancer screening may be discontinued in women who have had a hysterectomy for non-cancer reasons.

B. Low risk women who have a history of normal PAP smears and no history of high risk HPV may have screening discontinued at age 65 years. Screening should be restarted if risk status changes.

IV. Triage for AS-CUS in asymptomatic average risk women

A. There is good evidence for the use of HPV testing as compared to repeat cytology

for the triage of women with results of ASC-US (Atypical Cells of Undetermined Significance). This HPV triage occurs automatically at the lab without any

intervention from the provider when an AS-CUS pap is read. Colposcopy is

recommended for women with ASC-US and high risk HPV.

B. There is insufficient evidence for the use of HPV testing for triage of women at

cytological cutoffs higher than ASC-US.

-----------------------

Kaiser Permanente Colorado Region

Cervical Cancer Screening Guideline

Date: May 2005

Responsible Party: Sue Jane Fox, Karin Kempe MD, Prevention

Approval Date: July 2005

Next Review Date: July 2007

Cervical Cancer Screening

Date: September 13, 1996

Responsible Party(ies): Department of Prevention, Women’s Health Task Force

Approval Date: June 2001

Review Date: July 2001

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