2070

Second International Conference on Cervical Cancer

Supplement to Cancer

The Role of Nursing in Cervical Cancer Prevention

and Treatment

Linda White Hilton, R.N., M.S.N.1
Kathleen Jennings-Dozier, Ph.D., M.P.H.2
Patricia K. Bradley, Ph.D., R.N., C.S.3
Suzy Lockwood-Rayermann, R.N., Ph.D.4
Yvette DeJesus, M.S.N., R.N., A.O.C.N.5
Diane L. Stephens, B.S.N., M.S.N.6
Karen Rabel, B.S.N., M.S.N., A.P.N.7
Judith Sandella, R.N.C., N.P., M.S.8
Alma Sbach, R.N., M.S.N., C.S., F.N.P.8
Catarina Widmark, R.N., R.M.9
1
Ofce of the Special Assistant to the President for
Patient Affairs, The University of Texas M. D.
Anderson Cancer Center, Houston, Texas.
2
Department of Nursing Programs, College of Nurs-
ing and Health Professions, Womans Medical Col-
lege of Pennsylvania and Hahnemann Medical Col-
lege, Drexel University, Philadelphia, Pennsylvania.
3
College of Nursing, Villanova University, Philadel-
phia, Pennsylvania.
4
Harris School of Nursing, Texas Christian Univer-
sity, Fort Worth, Texas.
5
Practice Outcomes Program, The University of Texas
M. D. Anderson Cancer Center, Houston, Texas.
6
Nursing Education Ofce, The University of Texas
M. D. Anderson Cancer Center, Houston, Texas.
7
Ofce of Protocol Research, The University of Texas
M. D. Anderson Cancer Center, Houston, Texas.
8
Center for Biomedical Engineering, The Univer-
sity of Texas M. D. Anderson Cancer Center, Hous-
ton, Texas.
9
Department of Nursing, Karolinska Institutet,
Stockholm, Sweden.
Presented at the Second International Conference on
Cervical Cancer, Houston, Texas, April 1114, 2002.
Address for reprints: Linda White Hilton, R.N.,
M.S.N., Ofce of the Special Assistant to the Pres-
ident for Patient Affairs, The University of Texas
M. D. Anderson Cancer Center, 1515 Holcombe
Blvd., Unit 351, Houston, TX 77030; Fax: (713)
745-4729; E-mail: lwhite@mdanderson.org
Received October 31, 2002; accepted January 21,
2003.
Nurses today assume multiple roles, such as patient advocate, care provider, and
research investigator. At the Second International Conference on Cervical Cancer
(April 1114, 2002, Houston, TX), nurses presented original research describing
these roles in the context of cervical cancer screening, prevention, and detection in
the United States and Sweden; outlined the uses of practice guidelines; and
suggested future directions for nursing research. In the 20th century, nurses
expanded their patient care responsibilities and promoted cancer control by ex-
panding their skills. Some sought to broaden the spectrum of care by investigating
cervical cancer screening disparities, behavioral aspects of screening, and differ-
ences between the stated purposes of screening programs and those of the nurse-
midwives operating them. In the 21st century, nurses interested in cervical cancer
control expect to broaden the scope of their care and their research roles further by
continuing to improve training, advocating screening (and increased education
about screening), and helping to establish new sources of funding for research.
Cancer 2003;98(9 Suppl):2070 4. 2003 American Cancer Society.
KEYWORDS: cervical cancer, nursing, screening, training, Papanicolaou smear,
behavioral control, practice guidelines.
T he present is an exciting time for nursing professionals because
nurses now are both care providers and active investigators. While
maintaining an important role in patient advocacy, nurses have be-
come care providers through nurse practitioner programs. Whether
involved in teaching or functioning independently, nurses also have
formed groups of nursing investigators who submit proposals for peer
review to obtain funding to conduct research.19 At the Second Inter-
national Conference on Cervical Cancer (April 1114, 2002, Houston,
TX), nurses presented original research on cervical cancer screening,
prevention, and detection in the United States and abroad; described
the use of practice guidelines; and suggested future directions for
nursing research.
EXPANDING CANCER CONTROL THROUGH TRAINING
Linda Hilton10 reviewed career experience, emphasized the impor-
tance of education for nurse practitioners, and reiterated the need for
excellent clinical training. Colposcopy is a particularly difcult sub-
specialty of gynecology because it requires outstanding visual recog-
nition skills. In addition, a high level of hand-eye coordination is
required to perform colposcopy-related tasks. The 3-day colposcopy
training program for early nurse practitioners at The University of
Texas M. D. Anderson Cancer Center (Houston, TX) provided both
pedagogic and clinical instruction. Participants were mentored in
colposcopy as they examined their next 100 patients. At the time, this

2003 American Cancer Society

DOI 10.1002/cncr.11677

was the only nurse practitioner colposcopy training
program in the United States; currently, there are
nearly 200 nurse colposcopy training programs na-
tionwide. Nurse practitioners play a critical role in the
colposcopy clinic at The University of Texas M. D.
Anderson Cancer Center. They perform colposcopy,
colposcopically directed biopsy, and loop electric ex-
cision procedures of the vulva and cervix. They are
actively involved in all aspects of patient care and
frequently teach obstetrics and gynecology interns,
residents, and gynecologic oncology fellows.
REACHING OUT TO UNDERSERVED WOMEN
Despite the availability of the Papanicolaou (Pap)
smear for more than 60 years and the accessibility of
the cervix, a signicant percentage of women remain
unscreened. The nursing profession can play a pivotal
role in increasing the number of women who partici-
pate in cervical cancer screening. Barriers to screening
include increased age, nonwhite race/ethnicity, low
educational level, low income, decreased access, in-
sufcient funding, and unfavorable attitudes toward
screening. The goal of the Breast and Cervical Cancer
Mortality Prevention Act was to increase the access of
medically underserved women to breast and cervical
cancer screening.11
In a study that included 3797 patients from the
1992 National Health Interview Survey, an analysis of
ethnicity, employment, income, source of care, edu-
cation, insurance, age, and funding and their impact
on the likelihood of a patients having received a Pap
smear within the last year was performed. Being in-
sured had a dramatic effect on the results: only 15% of
those who were insured had never had a Pap smear,
compared with 85% of those who were uninsured.
Income also was a statistically signicant variable. (P
values less than 0.001 were considered signicant.)
Women from families whose annual income was less
than $20,000 had a 74% chance of never having had a
Pap smear, compared with 26% of women from fam-
ilies whose annual income was greater than $20,000.
Education also was a signicant variable: 66% of
women with no college education had never had a Pap
smear, compared with 33% of women who had at-
tended college. Furthermore, the source of care had
an effect on the results: 85% of patients who under-
went a Pap smear within the last year had a usual
care provider. The source of funding for the Pap
smear was not a statistically signicant variable, as
approximately 10% of patients in the database who
did not have funding had not had a Pap smear and
approximately 10% of women with funding had had a
Pap smear. Because nurses have extended their advo-
cacy role to become providers and coordinators of
Nursing in Cervical Cancer/Hilton et al. 2071
care, they are in a unique position to inuence the
health care behaviors of women in all settings.
CONTRIBUTING TO UNDERSTANDING BEHAVIOR
Nursing professionals also have contributed to the
development of behavioral interventions that inu-
ence Pap testing. These interventions require an un-
derstanding of the underlying screening intentions
and of the psychosocial determinants of screening
adherence. The burden of cervical cancer in the
United States disproportionately affects low-income
women and certain racial and ethnic groups, and
there is a need for tailored interventions for these
groups. Psychologic predictors of Pap testing inten-
tions and adherence in a sample of low-income Afri-
can-American and Latina women were studied by one
conference presenter, who used the Fishbein Theory
of Planned Behavior (TPB) as the guiding framework
for the project.
The project was divided into two studies. In the
rst study,4 a correlational design was used to test the
empiric adequacy of the TPB for use in special popu-
lations. A convenience sample of 108 African-Ameri-
can and 96 Latina adult women was recruited from
urban community-based agencies located in a large
mid-Atlantic metropolitan area. A Pap Smear Ques-
tionnaire (PSQ) was designed and used to capture
attitudes, perceived behavioral control, and intention
to obtain an annual Pap test. The Demographic As-
sessment Survey (DAS) captured screening behavior
and demographic information such as age and socio-
economic status for both groups and level of accultur-
ation for Latina women. In the second study, the PSQ
provided items for measuring the predictive value of
behavioral, normative, and control beliefs on Pap test-
ing adherence, and the DAS was used to measure Pap
testing adherence. Direct correlations of attitudes and
perceived behavioral control with intention to obtain
an annual Pap test were found for African-American
and Latina women. The subjective norm was not a
signicant predictor of intention.
In the second study,3 African-American women
who were adherent were found to be more likely to
report behavioral beliefs about the characteristics and
actions of the physician and less likely to be con-
cerned about the Pap test experience. African-Ameri-
can women were more likely to report normative be-
liefs regarding the approval of their friends, doctors,
and families (and parents and mothers, specically).
They also were more likely to report control beliefs
regarding the choice of a doctor and access to screen-
ing (and free screening in particular). Compared with
women who were not adherent, those who were ad-
herent tended to be less concerned about needing
2072 CANCER Supplement November 1, 2003 / Volume 98 / Number 9
information or reminders regarding annual screening.
Latina women who were adherent were more likely to
report behavioral beliefs about the benets of Pap
tests and less likely to be concerned about the Pap test
experience. They also were more likely to report nor-
mative beliefs regarding the approval of their doctors,
parents (and mothers, specically), spouses/signi-
cant others, and friends. Latina women who were
adherent also were more likely than those who were
not adherent to report control beliefs involving the
need for family assistance, access to screening, screen-
ing reminders, and having a female doctor.
These studies have several implications regarding
nursing practice. A modied version of the TPB may
provide a helpful framework for designing behavioral
interventions that target Pap testing adherence in spe-
cial populations. The ndings from these two studies
have been incorporated into a third studya pilot
intervention tailored to reach female public housing
residents. Preliminary data analysis suggests that the
group experiencing the intervention had a modest
increase in Pap testing adherence and cervical cancer
knowledge.
SWEDISH CERVICAL CANCER SCREENING
One of the advantages of holding an international
conference is the opportunity to discover the different
roles that care providers play in various countries.
Catarina Widmark, from the Karolinska Institutet in
Stockholm, reported a revealing qualitative study on
the role of the nurse-midwife in population-based
cervical cancer screening in urban Sweden.12,13 In
Swedish public health care, nurse-midwives tradition-
ally have had a strong, autonomous role. They are the
main providers of both antenatal care and contracep-
tive counseling. They run adolescent clinics and also
perform Pap smears as part of the population-based
cervical cancer screening program directed at all
women, ages 23 60 years.
In the mid-1960s, the Swedish authorities com-
piled guidelines for population-based cervical cancer
screening using Pap smears to decrease cervical can-
cer mortality and morbidity. The initial recommenda-
tions suggested that Pap smears were to be taken by
nurse-midwives working in antenatal health clinics
(ANHCs) run by the county councils and located
within the community. The guidelines also clearly
stated that nurse-midwives should have time and op-
portunity to speak with participants and provide them
with sufcient information and support.14
The screening program is organized differently in
different regions of Sweden. In the Stockholm region,
women receive a personal letter inviting them to ob-
tain a free Pap smear at regular intervals at the local
ANHC. Abnormal ndings are followed up by gynecol-
ogists at outpatient clinics. Pap smears also are taken
(within and outside the screening program) by gyne-
cologists in private practice as well as those in public
health practice.
Within the larger research project investigating
cervical cancer screening from the perspectives of var-
ious lay and professional stakeholders, a study was
conducted to explore how nurse-midwives working in
the screening program viewed issues such as the ben-
ets and risks of cervical cancer screening, the reli-
ability of the test itself, risk factors for cervical cancer,
and sources of information relevant to cancer screen-
ing. Also noteworthy was the way in which nurse-
midwives described their role in the screening pro-
gram.
Qualitative semistructured interviews were con-
ducted with 21 nurse-midwives (all female) involved
in screening programs at 7 ANHCs located in demo-
graphically different areas within the Stockholm re-
gion. The results of the study indicated discrepancies
between the ideals that otherwise guided the nurse-
midwives in their work at the clinics and the practices
of the screening programs. Positive aspects included
an ideology in which psychosocial care of the individ-
ual woman held primary importance, whereas per-
ceived negative aspects included factors that prohib-
ited the administration of good psychosocial carefor
example, lack of time for adequate communication
with participants, organizational features such as the
lack of feedback, and a lack of familiarity with cancer
and cancer prevention. It appears that midwives view
themselves more as providers of care for individuals
rather than for a population.
Elaborating further on the midwives lack of fa-
miliarity with cancer and cancer prevention, Widmark
reported that beyond their midwifery education the
nurse-midwives had received little or no continuing
education regarding cervical cancer, including its pre-
vention and treatment. It also was evident that the
midwives themselves did not prioritize this area of
their work: they neither sought new knowledge nor
followed current research.
The population-based cervical cancer screening
program described here has the goal of preventing ill
health in a population through one specic type of
intervention and is not focused on the well-being of
individuals or high-risk groups. In other aspects of
their work at ANHCs, nurse-midwives learn to recog-
nize and attempt to meet the needs of individual
women as a means of promoting health for them
during their reproductive years. This tension between
the concept of achieving health for all and the ideol-

ogy of individualized care needs to be understood
better.
Nurse-midwives working in ANHCs have a unique
opportunity to reach teenagers (both male and fe-
male) as well as adult women with information on
how to reduce the risk of contracting sexually trans-
mitted diseases such as the human papillomavirus
(HPV). Nurses also can inform these individuals of the
advantages of regular screening.
Cervical cancer screening can be viewed as a sen-
sitive situation, as it involves both the risk of a poten-
tially life-threatening illness and an intimate physical
examination that can test ideas and assumptions re-
garding the body, sexuality, and norms and values
associated with womanhood. It is important for nurse-
midwives or in other settings, nurse practitio-
nersto realize that their role in cervical cancer
screening involves both the provision of care for a
population and the provision of sensitive, personal
information for the individual participant.
PRACTICE GUIDELINES
Another area of nursing research that deserves atten-
tion is the determination of cervical cancer practice
guidelines as part of a disease management program.
Yvette DeJesus helps create such guidelines at The
University of Texas M. D. Anderson Cancer Center.
Over the past decade, many health care institutions
have developed and implemented clinical practice
guidelines and clinical pathways as a means of stan-
dardizing patient care and managing costs while pre-
serving quality patient care. Disease management is
not a new concept. It is a way to address health care
based on a specic disease (cervical cancer, in this
case) as it occurs across the continuum of care. This
approach allows the implementation of best practices
based on evidence, the education of patients, and the
measurement of the outcomes of care.
Disease management uses tools (e.g., practice
guidelines and pathways) and processes. A clinical
practice guideline, often presented as a owchart, is a
framework for treating a specic disease entity and
includes all treatment modalities supported by the
medical literature, current practice standards, and ex-
pert opinion. A clinical pathway is a detailed, step-by-
step description of how to provide a specic treatment
option that is part of a practice guide.
At M. D. Anderson Cancer Center, institutional
clinical practice guidelines have been used to better
understand and evaluate the centers own practices,
and these guidelines are used to teach quality onco-
logic care on the main campus as well as at institu-
tions afliated with the center. Guidelines frequently
are referred to during multidisciplinary planning con-
Nursing in Cervical Cancer/Hilton et al. 2073
ferences. M. D. Anderson Cancer Centers institutional
guidelines not only outline options for initial treat-
ment of the primary lesion but also 1) address the
indications for and the timing of the neoadjuvant or
adjuvant therapies that are selected according to nd-
ings during clinical or pathologic staging, 2) outline
the way in which follow-up and surveillance testing
should be performed after a given therapy is com-
pleted, and 3) describe the situations in which salvage
treatment and supportive care measures should be
considered. Because M. D. Anderson Cancer Center is
a research institution, the centers guidelines also
mention the possibility of patients eligibility for insti-
tutional or cooperative group protocols whenever ap-
propriate.
Many M. D. Anderson Cancer Center faculty
members have participated in the development of the
National Comprehensive Cancer Network guidelines,
and many of these guidelines have been expanded to
meet specic institutional practice and protocol re-
search strategies. M. D. Anderson Cancer Centers
clinical practice guidelines are developed using se-
lected categories: clinical presentation, evaluation,
primary treatment, adjuvant therapy, surveillance, sal-
vage therapy, and supportive care. These guidelines
are available from the centers Web site.15
The use of practice guidelines and pathways facil-
itates health care processes across the continuum of
care. Guidelines and pathways establish baseline
practices that are used to treat a specic disease, and,
over time, specic outcomes can be measured and
evaluated to determine whether changes in practices
are warranted.
FUTURE DIRECTIONS
One goal of the Second International Conference on
Cervical Cancer was to facilitate discussion of future
opportunities in all areas of cervical cancer research.
The nursing professionals who participated in the
conference proposed several ideas for future research
in cervical cancer nursing. First, although the educa-
tion of nurse practitioners has improved greatly over
the last 20 years, more standardization of training in
womens health is necessary. Ofcial certication,
perhaps through the American Society for Colposcopy
and Cervical Pathology, for nurse colposcopists would
benet both patients and providers by setting a train-
ing standard. Women also need better access to
screening and more education about HPV and other
risk factors for cervical cancer. A study, performed in
the hospital by nurses, of the health outcomes of pa-
tients with cervical cancer could help to determine
new policies and have a direct effect on patient care.
Behavioral analyses and cost-effectiveness studies
2074 CANCER Supplement November 1, 2003 / Volume 98 / Number 9
based on national public health data would be a nat-
ural area of research. Nurses could explore issues rel-
evant to nursing outcomes, such as patient interven-
tion design and improvements in access to care. In
addition, exploration of the roles of nursing profes-
sionals in other countries and how these professionals
t into each countrys cervical cancer prevention and
screening plan could help to determine health poli-
cies. To this end, funding for international databases
of cervical cancer information or for cervical cancer
registries is crucial. Just as breast cancer control ad-
vocates helped create the Susan Komen Foundation,
cervical cancer control advocates need to work toward
the establishment of a foundation for cervical cancer.
With sufcient funding, nursing professionals, be-
cause of their patient care expertise, may be in a better
position than many other types of researchers to or-
ganize such an effort.
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