A Clinician’s Guide to Counseling Patients about Cervical Cancer Screening

The use of high-risk HPV testing for primary adjunctive screening of women 30 and over and the triage of inconclusive Paps (ASC-US) creates a need for simple and concise patient education. This tool will help you by offering tips on what to say before you collect the cervical sample(s) needed for the Pap and HPV tests, as well as after the results have returned.

Cervical Cancer Screening for Your Patients

All women should receive HPV information as part of their well-woman exams. For women under 30, this information should include an explanation of the use of high-risk HPV testing when a Pap test is inconclusive.  Women age 30 and older should be advised that a high-risk HPV test can be done as part of their primary screening with the Pap.

Women under age 30

Ø      Pap, and

Ø      Reflex testing with the HPV test for ASC-US triage

Women 30 and older

Ø      Pap, and

Ø      Primary adjunctive screening with the HPV test to test for high-risk HPV DNA types

Pre-Test Counseling

Before testing for HPV, the clinician should provide brief information on HPV, including its prevalence, the nature of transient versus persistent infections, and what it means when a woman is found to have a high-risk type of the virus. Educating patients on key HPV facts facilitates informed decision-making.  It helps women understand the risk factors for cervical cancer and the proposed screening regimen. And pre-test counseling can help reduce post-test anxiety and confusion about results.

Basic Facts

These are the important pre-screening messages to share with patients:  

• Cervical cancer is preventable. It is caused by a virus called the human papillomavirus (HPV).
• It is estimated that as many as 8 out of 10 adults will have HPV at some point in their lives. Most people will never know they had it.
• HPV can be transmitted during sexual activity through skin-to-skin contact, even when condoms are used.
• Even if you have been in a long-term, monogamous relationship, you may have HPV. The virus can stay dormant in your cervical cells for years – even decades.
• While HPV infection is common, cervical cancer is very rare.  HPV usually causes no visible signs or problems before being fought off by your immune system.
• HPV by itself is not a “disease.” It is an infection and there is no treatment for it.
• High-risk HPV types are associated with cervical cancer, whereas low-risk types are associated with genital and other skin-related warts. It’s only when infection with a “high-risk” type of HPV doesn’t go away that it can cause cell changes that can lead to cervical cancer.
• The Pap test is a procedure in which a sample of cervical cells is collected.  The cells are sent to a laboratory where a laboratory professional looks at the cells under a microscope for signs of abnormal changes caused by high-risk HPV. This is a subjective test.
• The HPV Test* is a computerized, molecular test performed on the same sample of cervical cells as the Pap (or sometimes, on a separate sample) which determines whether or not high-risk HPV is present in the cells. This is an objective test.
• Knowing your HPV status can help clinicians better determine how often patients need screening.  It also helps to determine when additional tests or procedures are needed, or to help ensure that treatment is initiated before cancer can develop.

If the woman is younger than 30, also explain that. . .

• Because you are not yet 30 years old, you do not yet need routine HPV testing. Your cervical cancer risk goes up at the age of 30 if you are infected with high-risk HPV.
• Instead, I will ask the lab to test your cervical cells for high-risk HPV only if your Pap results are inconclusive, meaning they don’t look clearly abnormal, but they aren’t clearly normal either.
• Knowing whether you have HPV in this case helps me to determine if I should conduct additional procedures that look for pre-cancerous conditions.

If the woman is 30 or older, also explain that…

• Because you are now in the age group when cervical cancer is more likely to develop, and therefore you are at increased risk for cervical disease or cancer if you are infected with high-risk HPV, I recommend that we test you for high-risk HPV at the same time we do your Pap.
• Screening using both the Pap and the HPV tests allows me to know with greater confidence how often you should be examined in the future and whether other procedures may be needed.

Post-Test Counseling

The goals of post-test counseling are to review the test results and the significance of their HPV status and to discuss recommended follow-up steps.  

Most women will be normal on both tests.  These women may need to be reminded of:

• The importance of the well-woman exam every year, even if a Pap and HPV test is not needed. 
• The need for a repeat Pap and an HPV test in at least 3 years.

Counseling women with HPV

Remind your patient that:

• Most women get HPV at some point.
• Having HPV is not a sign of infidelity since there is no way of knowing how long the virus has been in the cells.  The virus can “hide” for many years without being detected.
• Most women who have HPV do not develop abnormal cells or cancer. However, it also is true that women who have high-risk HPV in their cells a long time (persistent infection) are at greater risk for developing abnormal cells or cancer.

Counseling women who have HPV and ASC-US or Abnormal Pap

Explain to your patient that:

• This does not mean you will develop cancer. However, it does mean that we should do another exam, called a colposcopy, which looks directly at your cervix and helps me determine if there are any pre-cancerous cells that need to be treated.  During a colposcopy, I’ll look at your cervix using a special, magnifying microscope. If necessary, I will also remove some tissue for analysis (a biopsy) so that I can better assess whether treatment is needed.

Counseling women who have HPV and normal Pap
Approximately 5-15% of women will have high-risk HPV but have a normal Pap.  Those women may have further questions regarding the meaning of their results.  They will need to be reminded of:

• The importance of diligent follow-up, according to your recommendations for care.
• The recent recommendation for follow-up of a repeat Pap and HPV test in 6-12 months.

Inform these patients that:

• This does not mean you will develop cancer. In fact, in most women, your HPV infection will go away without causing any problems.

• Just to be safe, however, I may want to repeat both the HPV and Pap tests in 6-12 months. If either result is abnormal at that time, I will look at your cervix more closely using a special microscope called a colposcope.
• We want to ensure that your cervix is healthy and we start treatment as early as possible, if needed.

Counseling women who have a normal Pap and do not have HPV

• Extensive medical experience and research shows that when both your Pap and HPV tests are normal, you have little to no risk of developing cervical cancer for the next several years.
• Thus, medical guidelines say that depending on what is appropriate for you based on your health history, you may not need another Pap and HPV test for up to 3 years.
• You should return in one year for a well-woman exam, when I can check other aspects of your health and we can discuss any concerns or questions you may have.