B THE JOURNAL OF THE NATIONAL BLACK NurSES ASSOCIATION *® DECEMBER, 2009



Volume 20 Number 2



Expanding the Scope of Nursing Research in Low Resource and

Middle Resource Countries, Regions, and States Focused on Cervical

Cancer Prevention, Early Detection, and Control



Sandra Millon Underwood, RN, PhD, FAAN

Edith Ramsay-Johnson, RN, EdD



Asante Dean, SN



Jori Russ, SN



Ruth Ivalis, SN



Acknowledgements: This report was supported by grants from the National Institutes of Health, National Center on

Minority Health and Health Disparities (# R24-MD0011231), and the University of Wisconsin Milwaukee Undererad-



uate Research Program.



Abstract



Cervical cancer is the second most commonly diagnosed cancer

and the third leading cause of cancer death in women worldwide.

There are significant disparities in cervical cancer incidence

and mortality globally as well as in the United States. The most

significant global disparities in cervical cancer incidence and mor-

tality are reported in low resource and middle resource countries,

regions, and states. This report provides an overview of cervi-

cal cancer epidemiology and etiology, and identifies “gaps” in

the nursing literature specific to cervical cancer prevention and

control worthy of consideration by nurses within the practice

setting.



Key Words: Cervical cancer, HPV, HPV vaccine, women



Introduction



Cervical cancer is one of the most common forms of can-

cer diagnosed and one of the most common causes of

cancer death among women worldwide (International

Agency for Research on Cancer, 2008; American Cancer

Society, 2007). Once the most common cause of cancer

among women of childbearing age, cervical cancer ranks

as the second most commonly diagnosed cancer and the

third leading cause of cancer death in women worldwide.

According to reports disseminated by the World Health

Organization and the American Cancer Society, an esti-

mated 555,100 new cases of cervical cancer and an

estimated 309,800 deaths due to cervical cancer would

occur worldwide during 2007.



There are significant disparities in cervical cancer inci-

dence and mortality globally and in the United States. The

most significant global disparities in cervical cancer inci-

dence and mortality are reported in low resource and

middle resource countries, regions, and territories (Can-

cer Statistics Working Group, 2009; International Agency

for Research on Cancer, 2008; American Cancer Society,

2007; Sloan & Gelband, 2007). The highest incidence rates

of cervical cancer worldwide occur in Central America,

South America, the Caribbean, Sub-Saharan Africa, and

Southern Asia. The highest mortality rates of cervical can-

cer worldwide occur in Africa, Latin America, Asia, and

India. The global disparities in cervical cancer incidence

and mortality seen between wealthy and poor countries

are reported as being related to gross disparities in access

to screening and treatment.



Within the United States, the highest incidence rates of

invasive cervical cancer are reported in Alaska, Arkansas,

Delaware, the District of Columbia, Florida, Kentucky,

Louisiana, Nevada, New Mexico, New York, Tennessee,

Texas. and West Virginia (Cancer Statistics Working Group,

2009; American Cancer Society, 2007). The highest mor-

tality rates of invasive cervical cancer in the United States

are reported in Alabama, Arkansas, Kentucky, Louisiana,

Mississippi, New Mexico, North Carolina, Tennessee,

Texas, and West Virginia. Among the factors most often

cited and associated with the disparate variations in cer-

vical cancer incidence and mortality within the United

States are race, poverty, and access to resources for cervi-

cal cancer screening and treatment of pre-invasive cervical

cancer lesions.



Sandra Millon Underwood, RN, PhD, FAAN, is a Professor, University of Wisconsin Milwaukee, College of Nursing, Milwaukee, WL.

Edith Ramsay-Johnson, RN, EdD, is a Professor Emerita and Director, Research Education/ Training Core, Caribbean Exploratory Research Cen-



ter, University of the Virgin Islands, St. Thomas, VI.



Asante Dean, is an Undergraduate Nursing Student, Undergraduate Research Fellow, University of Wisconsin Milwaukee, Milwaukee, WI.

Jori Russ, is an Undergraduate Nursing Student, Undergraduate Research Fellow, University of Wisconsin Milwaukee, Milwaukee, WI.

Ruth Ivalis, is an Undergraduate Nursing Student, Undergraduate Research Fellow, University of Wisconsin Milwaukee, Milwaukee, WI.



Address Requests for Reprints and Correspondence to: Sandra Millon Underwood, RN, PhD, FAAN, Professor, University of Wisconsin Mil-

wautkee, College of Nursing, 1921 East Hartford, Milwaukee, WI 53211. Email: underwoo@uwm.edu



42

DECEMBER, 2009 @ THE JOURNAL OF THE NATIONAL BLACK NurSES ASSOCIATION 2



Volume 20 Number 2



Cervical Cancer Etiology and Risk



Cervical cancer is an infection-related cancer caused pri-

marily by the human papilloma virus (HPV) (National

Comprehensive Cancer Network [NCCNI, 2008; Ameri-

can Cancer Society [ACS], 2008; Centers for Disease Control

and Prevention [CDC], 2007; CDC, 2007b; National Can-

cer Institute [NCI], 2004; Koutsky, Galloway, & Holmes,

1988; Ho, Bierman, Beardsley, Chang, & Burk, 1998; Sell-

ors, Karwalajtys, Kaczorowski, Mahony, Lytwyn et al.,

2003; Baseman & Koutsky, 2005; Winer, Lee, Hughes,

Adam, Kiviat et al., 2003; Rylander, Ruusuvaara, Alm-

stromer, Evander, & Wadell, 1994; Kjaer, Chackerian, van

de Brule, Svare, Paull et al., 2001; Moscickim, Hills, Shi-

boski, Powell, Jay et al., 2001). There are more than 100

different HPV types. Approximately 60 HPV types cause

warts on non-genital skin, such as on the hands, arms,

knees, shins, feet and face. Approximately 40 HPV types

can affect mucous membranes and cause genital warts or

low-grade changes, high-grade changes, pre-cancer or

cancer in the cervix, vagina, anus, vulva, penis, urethra,

mouth, throat, tongue or tonsils. In addition, other types

do not cause warts, cancer or symptoms.



Most sexually active women (and men) are infected by

a genital type of the HPV at some time in their lives. Gen-

ital types of the HPV do not cause health problems for

most people. For most women (and men), the virus is elim-

inated by the immune system within one to two years

before it causes any changes in the body. However, among

some women, most notably those infected with the high-

risk type of the virus, the virus persists and leads to the

development of cervical cancer.



Etiology of Exposure



Sexual behavior is a primary risk factor for contracting

the genital type of the HPV. The genital type of the HPV

is usually transmitted skin-to-skin during penetrative

vaginal or anal-genital contact. Oral-genital, manual-gen-

ital and genital-genital contact can lead to the transmission

of the virus. While studies have shown that transmission

of the genital type of the HPV without sexual intercourse

is possible, it is not common.



Women with multiple sex partners have a higher risk

of contracting the genital type of the HPV than monoga-

mous women. Young women between the ages of 15 and

25 have a two-fold higher risk of contracting a genital type

of HPV compared to women over 35 years of age (Frais-

er, 1994). Early age at first intercourse, having many sex

partners, having a sexual partner who has had several dif-

ferent sex partners, and having sex with an uncircumcised

male increase a womans risk of contracting a genital type

of the HPV. Other factors that increase a woman’s risk for

contracting a genital type of the HPV or of developing

cervical cancer have been identified. Included among these

risks are chlamydia infection, smoking, immune sup-

pression, oral contraception use, diets low in fruit and

vegetables, overweight, multiple pregnancies, exposure

to DES in utero, low socioeconomic status, family histo-

ry, and irregular cervical cancer screening (NCCN, 2008;



CDC, 2007; CDC, 2007b; Ho et al., 1998; International Col-

laboration of Epidemiological Studies of Cervical Cancer,

2007; Sedjo, Roe, Abrahamsen, Harris, Craft et al., 2002;

Calle & Kaaks, 2004; International Collaboration of Epi-

demiological Studies of Cervical Cancer, 2006; Hatch,

Herbst, Hoover, Noller, Adam et al., 2001; Troisi, Hatch,

Titus-Ernstoff, Hyer, Palmer et al., 2007).



Common Causations



e Chlamydia infection - Women whose blood tests show

past or present chlamydia infection are at a higher risk

for cervical cancer than women with normal test results.



° Smoking - Smoking can accelerate the cervical damage

caused by HPV. Women who smoke are twice as likely

as non-smokers to develop cervical cancer.



e Immune suppression - Suppression of the immune sys-

tem due to HIV infection, post-organ transplantation

therapy, chemotherapy or chronic steroid use increases

a person’s risk of developing an HPV-associated dis-

ease.



Oral contraception use - Women who take oral contra-

ceptives for five consecutive years are more likely to

develop invasive cervical cancer than are women who

never use oral contraceptives.



Diets low in fruit and vegetables - Women who con-

sumed diets high in vegetables and fruit are less likely

to develop persistent HPV infections.



¢ Overweight - While studies of the association between

BMI and cervical cancer are limited and inconclusive,

several studies have shown an increased risk of cervi-

cal cancer among overweight and obese women.



Multiple pregnancies - Women who carry seven or more

full-term pregnancies are at increased risk of develop-

ing invasive cervical cancer.



In utero exposure to DES - Women exposed to DES in

utero are at increased risk of developing clear-cell ade-

nocarcinoma, a rare type of cervical cancer.



® Low socioeconomic status - Low socioeconomic status

is associated with increased risk for developing inva-

sive cervical cancer due to limited access to screening

and treatment for pre-cancerous cervical diseases.



Family history - A woman whose immediate family

member, like a mother or sister, has had cervical cancer

is two to three times more likely to develop invasive

cervical cancer. Scientists believe women with a family

history of cervical cancer may carry a genetic condition

making them more susceptible to HPV infections.



¢ Irregular cervical cancer screening - Women who have

never had cervical cancer screening and women who

do not regularly obtain cervical cancer screening, are



less likely to be treated for pre-cancerous cervical dis- _



eases, resulting in an increased risk of developing

invasive cervical cancer.



43

— Tue JOURNAL OF THE NATIONAL BLACK NuRSES ASSOCIATION @ DECEMBER, 2009



Volume 20 Number 2



Table 1. National Guidelines for Cervical Cancer Screening



US. Preventive Services

Task Force*



National Comprehensive

Cancer Network**



American Cancer

Society***



When to begin cervical

cancer screening



Cervical cancer screening

can safely be delayed until

3 years after onset of sexual

activity or until age 21,

whichever comes first.



Cervical cancer screening

should begin approximate-

ly three years after the

onset of vaginal intercourse

or by 21 years of age.



Screening should begin

approximately 3 years after

the onset of vaginal inter-

course, but no later than

age 21,



Cervical cancer screening

intervals for Conventional

Pap test:



If liquid-based cytology



If liquid-based testing

combined with HPV testing



At least every 3 years.*



Evidence insufficient to rec-

ommend for or against the

routine use of liquid-based

cytology to screen for cervi-

cal cancer.



Evidence insufficient to rec-



ommend for or against the

routine use of HPV testing.



Annually* for women > 30

with 3 consecutive, techni-

cally satisfactory negative

cytology tests.*



Annually; every 2-3 years for

women > 30 with 3 consecu-

tive, technically satisfactory

negative cytology tests.*

Every 3 years if HPV DNA

negative, negative cytology

tests for women > 30.*



Annually; every 2-3 years

for women > 30 with 3 neg-

ative cytology tests.*



Every 2 years; every 2-3

years for women > 30 with

3 negative cytology tests.

Every 3 years if HPV DNA

negative, negative cytology

tests for women > 30.*



When to stop cervical

cancer screening



Women > 65 years with

normal Pap smears, who

are not otherwise at high

risk for cervical cancer.



Women 70 years of age or

older with an intact cervix

who have had 3 or more

documented, consecutive,

technically satisfactory neg-

ative cervical cytology tests,

and no abnormal cytology

tests within the 10 year

period prior to age 70 may

choose to stop having cervi-

cal cancer screening.



Women with a history of cer-

vical cancer, DES exposure

before birth, HIV infection or

a weakened immune system

should continue.



Women with co-morbid or

life-threatening illnesses

may forego cervical cancer

screening.



Women 70 years of age or

older who have had 3 or

more normal Pap tests in a

row and no abnormal Pap

test results in the last 10

years may choose to stop

having cervical cancer

screening.



Women with a history of

cervical cancer, DES expo-

sure before birth, HIV

infection or a weakened

immune system should

continue to have screening

as long as they are in good

health.



Post total hysterectomy



Discontinue routine screen-

ing in women who have

had a total hysterectomy

for benign disease.



Vaginal cytology tests after

total hysterectomy for

benign gynecological dis-

eases is not indicated.



Women who have had a

total hysterectomy may also

choose to stop having cervi-

cal cancer screening, unless

the surgery was done asa

treatment for cervical cancer

or pre-cancer. Women who

have had a hysterectomy

without removal of the

cervix should continue to

follow the guidelines above.



* United States Preventive Services Task Force. (2003). Screening for cervical cancer: Recommendations and rationale. American Family



Physician, 67, 1759-1766.



** National Comprehensive Cancer Network. (2008). NCCN clinical practice guidelines in oncology: Cervical Cancer. Fort Washington, PA:

National Comprehensive Cancer Network.



* Smith, R. A., Cokkinides, V., & Brawley, O. W. (2008). Cancer screening in the United States, 2008: A review of current American

Cancer Society guidelines and cancer screening issues. CA Cancer J Clinicians, 58, 161-179.



44

DECEMBER, 2009 @ THE JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION B



Volume 20 Number 2



HPV in Men



Less is known about the risk factors for contracting a

genital type of the HPV in men. However, outcomes of

several recent studies suggest that the risk factors for con-

tracting a genital type of the HPV infection in men resemble

those found in women (Svare, Kjaer, Worm, Osterlind, Mei-

jer et al., 2002; Nyitray, Nielson, Harris, Fores, Abrahamsen

et al. 2008; Hernandez, Wilkens, Zhu, McDuffle, Thomp-

son et al., 2008). Factors which significantly increase a man’s

risk for contracting a genital type of the HPV are engag-

ing in sex at an early age, having many sexual partners,

having sex with a partner who has had many other part-

ners, engaging in unprotected sex, and being uncircumcised.



Cervical Cancer Prevention, Early Detection and

Treatment



Abstaining from all sexual contact is the only absolute

way to prevent infection by a genital type of HPV (ACS,

2009; NCCN, 2008; CDC, 2007; CDC, 2007b; National Asso-

ciation of Nurse Practitioners in Women’s Health and the

Ad Hoc Committee on Cervical Cancer Screening, 2007;

NCI, 2004). For most adults, complete abstinence is unre-

alistic, so other means of HPV risk reduction, early

detection, and treatment are recommended. Being in a

monogamous long-term relationship with an uninfected

partner will greatly reduce a person’s risk of contracting

a genital type of the HPV. Limiting the number of sexual

partners decreases a person’s risk of contracting different

strains of the HPV. Consistent and correct condom use

also provides some protection. Safer sexual methods and

practices that include condom use are therefore encour-

aged. However, given that condoms do not cover the vulva,

scrotum, perineum, or rectal areas, they cannot completely

prevent the transmission of genital types of the HPV.



The Food and Drug Administration licensed the first

HPV vaccine in June of 2006. The vaccine is indicated for

use among girls and women from 9 to 26 years of age for

the prevention of cervical cancer, precancerous or dys-

plastic lesions, and genital warts. While the HPV vaccine

does not protect against all types of HPV, it does provide

protection against two HPV types that cause 70% of the

cases of cervical cancer (i.e., HPV 16 and HPV 18). It also

provides protection against two of the HPV types that

cause 90% of the cases of genital warts (i.e, HPV 6 and

HPV 11) (FUTURE II Study Group, 2007).



Early Identification and Treatment



Identifying and treating pre-cancerous lesions of the

cervix before they become invasive reduces cervical can-

cer incidence and mortality. Several institutions,

organizations, and societies have developed guidelines

for cervical cancer screening. Included among them are

the U.S. Preventive Services Task Force, the National Com-

prehensive Cancer Network, and the American Cancer

Society. While they all support Pap testing for cervical

cancer screening, the recommendations/ guidelines vary

relative to the age when screening should begin, the age

when screening should end, the interval for regular screen-



ing, screening for women who have had hysterectomies,

and the use of conventional Pap smear, liquid-based cytol-

ogy, computerized technologies, and algorithm-based

technologies (see Table 1).



Several treatments are available to women who have

been diagnosed with pre-cancerous cervical lesions and

invasive cervical cancers (ACS, 2008; NCCN, 2008; NCI

2004). Pre-cancerous lesions of the cervix are most often

treated using electrocoagulation, cryotherapy, laser abla-

tion, or surgery. Invasive cervical cancers are most often

treated using surgery, radiation, chemotherapy and/or

biological therapy.



Gaps and Opportunities Worthy of Consideration by

Nurses



Over the past decade, many reports have been pub-

lished in the literature that describe the etiology,

epidemiology, and prevalence of cervical cancer world-

wide and in the United States. The same is true of reports

published in the nursing literature that describe the out-

comes of efforts undertaken by nurses to explore factors

relevant to cervical cancer detection, diagnosis, and treat-

ment. Consequently, much has been gleaned about

concerns and needs of diverse groups of women relative

to cervical cancer detection and control (see Table 2).



Much has been gleaned about the perceptions, beliefs,

and cervical cancer screening practices of women abroad



_and in the United States (Denny-Smith, Bairan, & Page,



2006; Lee, Fogg, & Menon, 2008; Lee, Tripp-Reimer, Miller,

Sadler, & Lee, 2007; Lee-Lin, Pett, Menon, Lee, Nail et al.,

2007; Schulmeister & Lifsey, 1999; Tung, Nguyen, & Tran,

2008; Donnelly & McKellin, 2007; McFarland, 2003; O’Brien,

Mill, & Wilson, 2009; Steven, Fitch, Dhaliwal, Kirk-Gar-

dener, Sevean et al., 2004). Much has been gleaned about

cultural, personal, social, and economic factors which (pos-

itively and negatively) influence cervical cancer screening

and early detection among women worldwide and in the

United States (Strickland, Squeoch, & Chrisman, 1999;

Ackerson, Pohl, & Low, 2008; Carruth, Browning, Reed,

Skarke, & Sealey, 2006; Ho, Yamal, Atkinson, Basen-

Engquist, Tortolero-Luna, & Follen, 2005; Jennings, 1997;

Jennings-Dozier & Lawrence, 2000; Jennings-Dozier, 1999;

Kim, Yu, Chen, Kim, Kaufman, & Purkiss, 1999; Lee, 2000;

Welch, Miller, & James, 2008; Boonpongmanee & Jittanoon,

2007; Holroyd, Twinn, & Adab, 2004; Thomas, Saleem, &

Abraham, 2005; Twinn, Shiu, & Holroyd, 2002). Much has

been gleaned about concerns and experiences of women

after diagnosis who sought treatment for cervical dys-

plasia or cervical cancer and about concerns and

experiences of women presumed to have cervical cancer

who, for varying reasons, chose to forgo treatment

(Rajaram, 1998; Lauver, Baggot, & Kruse, 1999; Hunt, de

Voogd, Akana, & Browner, 1998; Clemmens, Knafl, Lev,

& McCorkle, 2008; Greenwald & McCorkle, 2007;

Kritcharoen, Suwan, & Jirojwong, 2005; Hunter, 2005;

Idestrém, Milsom, Andersson-Ellstrém, & Athlin, 2006;

Twinn & Cheng, 1999; Park, Yoo, & Chang, 2002; Barnoy,

Bar-Tal, & Treister, 2003; Butler, Banfield, Sveinson, &

Allen, 1998; Eisemann & Lalos, 1999; Twinn, 2006 ; Velji



45

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Volume 20 Number 2



Table 2. Cervical Cancer Detection and Control Evidence Review, 1998-2008



Author/Year Title



Study

Design



Purpose



Sample Instrument/s

Demographics Analytic

Methods



Findings



Study of influence of knowledge, perceptions and experiences on cervical cancer risk behaviors and screening



Denny- Asurvey of female Assess knowledge Descriptive N= 240 Descriptive Female nursing

Smith, et al., nursing students’ ‘of perceived Correlational female bac- Inferential students partici-

2006 knowledge, health —_ susceptibility to, calaureate pate in high risk

beliefs, perceptions seriousness of and nursing stu- sexual behaviors

of risk, and risk risk behaviors dents, 19 to and had fairly

behaviors regarding regarding HPV 58 years of low levels of

HPV and cervical and cervical cancer age knowledge, low

cancer. among female perceived risk of

nursing students contracting HVP,

and low perceived

seriousness of

HPV and cervical

cancer.

Kim, etal, | Cervical cancer Examine cervical Descriptive N= 159 Descriptive Knowledge of the

1999 screening knowledge cancer screening Korean- purpose of the

and practices among knowledge and American Pap test and

Korean-American practices of Korean- women, 40 to adherence with

women. American women 69 years of screening recom-

age mendations was

limited among the

study sample. The

most common

reasons for not

having a Pap test

was the absence

of symptoms.

McFarland, Cervicalcancerand Examine knowledge Descriptive N= 30 Semi- Knowledge of cer-

2003 Pap smear screening and beliefs of low, middie structured vical cancer and

in Botswana: women in Botswana and high interview Pap smear utiliza-

knowledge and about cervical can- income Content ion was limited

perceptions. cer and Pap smear women 31-54 J alysis among the low-

years of age y income women.

O'Brien, Cervical screening in Explore the beliefs Exploratory N=8 In-depth | Women expressed

et al.,2009 Canadian First and attitudes of First Nation- interview _ that they had

Nation Cree women. First Nation Cree al women Thematic adequate infor-

women about cervi- having expe- analysis ation about

cal cancer and rience with y cervical cancer



cervical cancer



cervical can-



and were resistant



screening cer screening to screening

and/or because of embar-

cancer. rassment and fear

of cancer.

Schulmeister, Cervical cancer Describe the knowl- Exploratory N= 96 Thematic Limited knowl-

etal.,1999 screening knowl- edge, beliefs,and — Pyecerinti Vietnamese analysis edge about the

. : escriptive ;

edge, behaviors, and cervical cancer migrant Descriptive Purpose and pro-

2 . : ‘ escriptive

beliefs of Vietnamese screening practices women, cedures used to

women. of Vietnamese 18 to 65 perform Pap test.

American women years of age Perceived the



risk of cervical

cancer to be low.



46

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Volume 20 Number 2



Table 2, Cervical Cancer Detection and Control Evidence Review, 1998-2008 (continued)



Author/Year Title Purpose Study Sample Instruments Findings

Design Demographics Analytic

Methods

Tung, Applying the trans- Describe Pap smear Descriptive N = 80, Descriptive While most

Neuyen, theoretical model to behaviors of Viet- Vietnamese pa rarential Women reported

et al.,2008 cervical cancer namese American American ever having had a

: screening in Viet- women women, Pap test, less than

namese-American 20 to 65 half reported reg-

women. years of age ular screening.



Study of influence of culture, social and economic factors on cervical cancer risk behavior and screening



Ackerson, Personal influencing Explore personal Exploratory N=7 Content —- Family and

et al.,2008 — factors associated influencing factors African- analysis providers were

with Pap smear test- associated with Pap American fy de noted to influence

. : : : pth é

ing and cervical smear testing and lowincome ;, erview Pap testing of the

cancer. perceptions of vul- women from women. Previous

nerability to cervical south central experience with

cancer among a Michigan, Pap smear of

subset of African- 21 to 38 most of the

American women years of age women was per-

ceived as negative

(scary, uncomfort-

able and painful).

Carruth, The impact of farm Identify factors con- Descriptive N= 2,324 Descriptive Having a house

etal.,2006 _—_lifestyleand health _ tributing to cervical farmwomen, Inferential ©"? farm, and

characteristics: cervi- cancer screening 18 to 65+ engaging in no

cal cancer screening behavior among years of age off-farm work and

among southern farmwomen in three minimal involve-

farmwomen. Southern states ment in farm tasks

predicted failure

to obtain cervical

cancer screening.

Previous breast

exam and mam-

mogram were

positive predictors

of cervical cancer

screening.

Jennings, Getting a Pap smear: Identify barriers Exploratory N=52 ~ Focus Factors most com-

1997 focus group responses and. facilitating Descriptive African- group monly identified

of African- American factors associated American Content as facilitating /

and Latina women. with Pap smear and Latinas alysis inhibiting Pap

use among African- women from y testing among

American and healthand Descriptive African-American

Latina women _ social service statistics | women were

agencies in access to a doctor,

the Mid- gender of the doc-

Atlantic tor and cost.



Among Latina

women, the most

common factors

identified were

access to a doctor,

doctor’s gender

and the presence

of symptoms.



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Volume 20 Number 2



Table 2. Cervical Cancer Detection and Control Evidence Review, 1998-2008 (continued)



Author/Year Title Purpose Study Sample Instrument/s Findings

Design Demographics Analytic

Methods

Jennings- Sociodemographic Assess impact of Descriptive N= 204 Descriptive Among Black

Dozier, et al., predictors of adher- age, income, insur- Black and Inferential Wome” insurance

2000 ence to annual ance coverage, Hispanic and level of edu-

cervical cancer marital status, level women, 18 cation were

screening in minority of education and to 83 years of significant pre-

women. number of persons age, from dictors of cervical

living at home on non-profit cancer screening.

cervical cancer service agen- Age and place of

screening in Black cies in birth, were signif-

and Hispanic Philadelphia icant predictors

women of cervical cancer

screening among

Hispanic women.

Lee, 2000 Knowledge, barriers, Identify barriers Exploratory N= 102 Focus Misinformation

and motivators relat- and motivators to Korean groups and lack of knowl-

ed to cervical cancer cervical cancer American Content de about

screening among screening among women, 18 analvsis causative factors

Korean American Korean American to 50+ years y and prevention of

women. A focus women. of age cervical cancer

group approach. was common. Eco-

nomics, language

problems, fear,

fatalism and Con-

fucian thinking

were identified as

barriers to cervical

cancer screening.

Thomas, Barriers to effective Describe factors that Exploratory N= 85 Focus Poor knowledge

et al.,2005 uptake of cancer act as barriers to women and group and underlying

screening among breast and cervical 50 men, 20- Content health and cultur-

Black and minority cancer screening 75 yearsof 1 aivsis al beliefs (Le.,

ethnic groups. among Black minor- age y superstitions,

ity groups living in taboos), language,

the UK and attitudes of

health-care pro-

fessionals were



noted to be barri-

ers to screening.



Study of experiences of women seeking treatment for abnormal Pap smear



Hunt, et al,

1998



Abnormal Pap

screening among

Mexican-American

women: impedi-

ments to receiving



Identify impedi-

ments to receiving

and reporting time-

ly follow-up care for

abnormal Pap tests



Descriptive



and reporting follow- among Hispanic



up care.



women



N=1i

Mexican

American

women.



40 to 73

years of age,

“lapsed” in

follow-up for

abnormal

Pap tests



Structured.

interview



Content

analysis



Reluctance to be

examined by a

male practitioner,

lack of flexibility in

scheduling clinic

appointments, and

poor staff commu-

nication regarding

appointments and

the seriousness of

the condition nega-

tively influenced

follow-up behavior.



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Volume 20 Number 2



Table 2. Cervical Cancer Detection and Control Evidence Review, 1998-2008 (continued)



Author/Year Title Purpose Study Sample Instrument/s Findings

Design Demographics Analytic

Methods

Lauver, et al, Women's experiences Describe experi- Descriptive N=75 Descriptive Primary concerns

1999 in coping with ences and needs of women who identified were

abnormal Pap results women coping with had Pap limited under-.

and follow-up col- — abnormal Pap results standing of

poscopy. results that warrant revealing cancer, the Pap

follow-up col- significant results, and infer-

poscopy abnormali- tility. Social

ties that support and dis-

warranted traction were

colposcopy, identified as the

15 to 41 most commonly

years of age used and helpful

coping strategies.

Rajaram, Non-adherence to Case study of a32- Exploratory N=1, Case study Study findings

1998 follow-up treatment year-old 32-year-old demonstrate how

ofanabnormal Pap African-American African- patients’ illness

smear: a case study. woman diagnosed American explanatory mod-

with an abnormal woman els may not agree

Pap smear, who did diagnosed with biomedical

not follow through with an explanations, and

with the recom- abnormal have an adverse

mended diagnostics Pap smear impact on health

and illness behavior

Study of experiences of women undergoing treatment for cervical cancer

Butler, Conceptualizing Describe women’s Exploratory N= 17 Semi- Sexual functioning

et al.,1998 — sexual health in experiences with women with structured was perceived to

cancer care. changes in sexual endometrial interview be multidimen-

function related to and cervical Thematic onaland

physical comfort, cancer, 23 tov alysis dependent on how

sexual satisfaction, 76 years of y the women per-

and feelings of inti- age ceived the changes

macy after treatment in their lives as a

for gynecological result of having

cancer gynecological can-

cer and treatment.

Clemmens, et Cervical cancer: pat- Describe the quality Exploratory N= 19 Semi- Three distinct pat-

al., 2008 terns of long-term _ of life experienced women diag- structured _ terns specific to

survival. by long-term sur- nosed with interview experience

vivors of cervical cervical can- Thematic emerged from the

cancer and factors cer, 34 to 92 . survivors accounts:

analysis Fj

that promote adap- years of age moving on from

tation cancer as a difficult

place in life;

renewed apprecia-

tion for life pattern,

while focusing on

positive outcomes

of their experience;

and ongoing, while

attempting to man-

age negative

outcomes.



49

f@ THE JOURNAL OF THE NATIONAL BLACK Nurses ASSOCIATION * DECEMBER, 2009



Volume 20 Number 2



Table 2. Cervical Cancer Detection and Control Evidence Review, 1998-2008 (continued)



Author/Year Title Purpose Study Sample Instruments Findings

Design Demographics Analytic

Methods

Greenwald, et Remedies and life Assess the impact of Descriptive N= 208 Descriptive Despite the dis-

al., 2007 changes among inva- invasive cervical women, Inferential °@5¢ many

sive cervical cancer cancer and health 6 to 29 years women found

survivors. practices in popula- after diagno- opportunities for

tion of long-term sis with growth and

survivors of cervical invasive cer- adaptation. Vast

cancer vical cancer majority of

women used.

remedies for

their cervical

cancer other than

those prescribed

by their doctors.

Included among

the most com-

monly used

remedies were

vitamin supple-

ments, prayer,

massage and

herbal teas.

Hunter, 2005 Emelda’s story: Examine the life Case study N=1, Ethno- Cultural, person-

applying ethno- and cervical cancer 42 yearold graphic al and systemic

graphic insights to experience of a 42 woman analysis issues impacting

cultural assessment year old woman dying from the cervical can-

and cervicalcancer from Peru cervical cer experience

control. cancer included cancer



knowledge, ill-

ness behavior,

fear of cancer,

fear of pelvic

examination, and

health care system.



& Fitch, 2001). And, much has been gleaned about the con-

cerns, practices, competencies, and educational needs of

women’s health providers regarding cervical cancer screen-

ing (Morris, McLean, Bishop, & Harlow, 1998; Tessaro &

Herman, 2000; Widmark, Tishelman, Lundgren, Forss,

Sachs et al., 1998; Lundgren, Tishelman, Widmark, Forss,

Sachs et al., 2000; Donnelly, 2008).



These reports provide valuable information and insights

essential to cervical cancer screening, diagnosis, and treat-

ment. However, review of this body of literature in light

of current knowledge reveals several “gaps” worth

thoughtful consideration by nurses in the practice setting.

For example, several reports have been published by the

International Agency for Research on Cancer, the Nation-

al Cancer Institute, the Centers for Disease Control and

Prevention, the American Cancer Society, and other orga-

nizations dedicated to the prevention and control of cervical

cancer that highlight worldwide population-specific trends



relative to cervical cancer morbidity and mortality. How-

ever, few reports have been published in the nursing

literature that describe strategies designed to address glob-

al disparities in cervical cancer incidence and mortality

in low and middle resource countries, regions, territories

and states. And, few reports have been published in the

nursing literature that describe efforts to address the needs

of younger women, mature women, economically chal-

lenged women, medically underserved women and other

women at increased risk for developing and or dying from

cervical cancer.



Several reports have been published that describe efforts

undertaken by nurses to examine the impact of percep-

tions, beliefs, socio-demographics, and other factors on

cervical cancer screening, diagnosis, and treatment. How-

ever, while acknowledging that cervical cancer is an

infection-related cancer associated with exposure to the

HPV, few reports have been published in the nursing lit-



50

DECEMBER, 2009 ®@ THE JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION Fm



Volume 20 Number 2



Textbox 1: Resources for Nursing Practice, Education, and Outreach



Cervical Cancer



HPV-Associated Cervical Cancer Statistics (Centers for

Disease Control and Prevention)

http:/ /origin.cde.gov /cancer/hpv/statistics/cervical.htm



Cervical Cancer (Medline Plus)

http:/ /wwwalm.nih.gov/medlineplus/cervicalcancerhtml



Cervical Cancer (National Cancer Institute)

http:/ /www.cancer.gov /cancertopics/types/cervical /



What You Need To Know About™ Cervical Cancer

(National Cancer Institute)

http:/ /www.cancer.gov/cancertopics/wyntk/cervix



Cervical Cancer (National Women’s Health Information

Center)

http: / /www.womenshealth.gov /faq/cervical-cancer.cfm



Detailed Guide: Cervical Cancer (American Cancer Society)

http:/ /www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=8



Cervical Cancer (American Society of Clinical Oncology)

http://www.cancer.net/patient/Cancer+Types /

Cervical+Cancer



Cervical Cancer (Women’s Cancer Network/Gynecologic

Cancer Foundation)

http://www.wen.org/articles/types_of_cancer/cervical/

overview /



HPV



HPV-Associated Cancers (Centers for Disease Control

and Prevention)

http: / /origin.cdc.gov/cancer/hpv/



HPV Infection (Centers for Disease Control and Prevention)

http://www.cde.gov/std/hpv/



Genital HPV Information Fact Sheet (Centers for Disease

Control and Prevention)

http://www.cde.gov/std/HPV/STDFact-HPV.htm



HPV Vaccine Information for Young Women



(Centers for Disease Control and Prevention)



http:/ /www.cde.gov/std/hpv/STDFact-HPV-vaccine-

young-women.htm



HPV Vaccine Questions and Answers (National Cancer

Institute)

http:/ /www.cancergov/cancertopics /factsheet/Risk/HPV



HPV, Cancer and Vaccines: Frequently Asked Questions

(American Cancer Society)



http:/ /www.cancer.org /docroot /CRI/content/CRI 2 _

6x_FAQ_HPV_Vaccines.asp?sitearea=



HPV and Cancer: Questions and Answers (National

Cancer Institute) http:/ /www.cancer.gov /cancer-



‘ topics /factsheet/Risk/HPV



erature that describe efforts undertaken to examine the

impact of these factors on behaviors associated with the

transmission of the HPV. And, few have been published

that describe efforts undertaken to describe perceptions

of women about abstinence, monogamy, condom use, vac-

cination, and other strategies recommended to prevent

the HPV from being acquired and transmitted.



Conclusions



Concern for the well being of women worldwide should

prompt nurses within the clinical, academic, and research

arena to work to change these trends. Concerted effort

needs to be undertaken by nurses to apply current knowl-

edge specific to HPV and cervical cancer prevention and

control within the practice setting. Working together with

nurses within the clinical, academic, and research arena,

much could be done to reduce cervical cancer morbidity

and mortality. However, in order for this vision to be real-

ized, nurses will need to expand the current scope of

outreach, practice, education, and science, and focus greater

attention on populations with the greatest risk and pop-

ulations with the greatest need. Doing so could contribute

much to efforts geared toward reducing global and region-

al disparities in cervical cancer morbidity and mortality

and to efforts that aim to improve the quality of life of

women diagnosed with cervical cancer worldwide and

within the United States.



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