ARTICLE IN PRESS

Seminars in Oncology Nursing, Vol ■■, No ■■ (■■), 2017: pp ■■-■■ 1

CERVICAL CANCER:
PREVENTION AND EARLY
DETECTION
THERESA A. KESSLER

OBJECTIVE: To review effective methods of prevention that can be used to control

the incidence of cervical cancer and detection strategies that can identify the
precancerous lesions before they become true cancer.
DATA SOURCES: Current medical, scientific and nursing literature, and na-
tional and international guidelines of cervical cancer.
CONCLUSION: Nearly all cervical cancers are caused by specific types of human
papillomavirus (HPV). Prophylactic vaccination for HPV provides the most ef-
fective method of primary prevention against HPV-related diseases. The use
of the Pap test and HPV test, according to published guidelines, provides the
most effective means of screening for cervical cancer.
IMPLICATIONS FOR NURSING PRACTICE: Nurses are in a key position to provide
health education with the goal of supporting vaccine uptake and screening
guidelines.
KEY WORDS: cervical cancer, early detection, HPV vaccination, cervical cancer
screening, education.

Theresa A. Kessler, PhD, RN, ACNS-BC, CNE: Profes-
sor and Kreft Endowed Chair for the Advancement of
Nursing Science, College of Nursing & Health Profes-
sions, Valparaiso University, Valparaiso, IN.
Address correspondence to Theresa A. Kessler, PhD,
RN, ACNS-BC, CNE, Advancement of Nursing Science,
College of Nursing & Health Professions, Valparaiso
University, 836 LaPorte Ave, Valparaiso, IN 46383.
e-mail: terry.kessler@valpo.edu
© 2017 Elsevier Inc. All rights reserved.
0749-2081
http://dx.doi.org/10.1016/j.soncn.2017.02.005
C
ervical cancer is a global health concern.
It ranks as the fourth most common
female malignancy worldwide,1,2 with
the incidence of cervical cancer at an
estimated 527,624 women every year, with 265,672
deaths from the disease. 3 Cervical cancer ac-
counts for 4% of all cancers diagnosed worldwide.
When one considers health disparities, cervical
cancer is the third most common cause of death
worldwide for those women who live in low-resource
or less developed countries. 1 In fact, nearly
84% of cervical cancer cases occurred in less
 ARTICLE IN PRESS
2 T.A. KESSLER
developed countries, with the highest incidence in
Africa, Latin America, and the Caribbean, and the
lowest incidence in North America and Oceania.4,5
Women who are poor and live in rural areas of low-
and middle-income countries, as well women who
are poor and live in high-income countries, are at
an increased risk of invasive cervical cancer; this
increased risk is caused by a lack of access to pre-
vention, screening, and treatment services.6
In the United States (US), cervical cancer ranks
14th in frequency among all cancers.7 However, dis-
parities exist in the US as well. Incidence and death
rates in the US are higher in areas with limited
access to cervical cancer screening.8 For 2017, the
American Cancer Society estimates that 12,820 new
cases of invasive cervical cancer will be diag-
nosed in the US, with a projected 4,210 deaths in
the same year.8,9
Nearly all cervical cancers are caused by human
papillomavirus (HPV) infections. HPV is the most
common sexually transmitted infection worldwide,10
and is the cause of nearly all cases of cervical
cancer.10,11 Currently, approximately 79 million
men and women in the US are infected with HPV
and about 14 million will become newly infected
each year.12 In the US, HPV is detected in 99.7%
of cervical cancers,13 and more than 11,000 women
develop cervical cancer as a result of HPV disease.12
Because precancerous lesions can be found by
the Papanicolaou (Pap) test and treated and cured,
cervical cancer is often detected before it becomes
advanced. Early detection has led to lower inci-
dence and death rates. Women treated with
precancerous lesions have nearly a 100% 5-year sur-
vival rate.8,9 Even though secondary screening can
prevent cervical cancer by detecting precancer-
ous lesions, not all women receive the
recommended screening nor receive the screen-
ing in a timely manner. In addition, an effective
primary prevention strategy is available to combat
cervical cancer. Both males and females should
receive HPV vaccinations to prevent the develop-
ment of cervical cancer; however, vaccination rates
remain low.
HISTORY
In the 1940s, cervical cancer was a major cause
of death among women of childbearing age in the
US. In the 1950s, the Pap test was introduced
and effectively reduced the incidence of invasive
cervical cancer. Between 1955 and 1992, US cer-
vical cancer incidence and death rates declined
by more than 60%.7,9 Epidemiologically, it was
believed that cervical cancer might be caused by
a sexually transmitted agent; however, this fact
was not known until the 1980s.9 Between 1975
and 2012, cervical cancer incidence declined by
over 50% because of widespread use of the Pap
test.9 More recently, incidence rates have stabi-
lized in whites younger than 50 years of age and
declined by 3% per year in African Americans.
For women over age 50, incidence has decreased
by about 2% per year in whites and about 4% per
year in African Americans.9 Today, women are
more likely to be diagnosed with cervical precancer
than invasive cervical cancer.9
Worldwide, during the past 30 years, cervical
cancer mortality rates have fallen in most devel-
oping countries because of screening and treatment
programs.6 However, during these same years, rates
in most developing countries have risen or re-
mained unchanged. These increased or steady rates
have been because of limited access to health ser-
vices, lack of awareness about cervical cancer and
its screening recommendations, and the absence
of screening and treatment program.6
ETIOLOGY
As the causative agent for virtually all cases of
cervical cancer, HPV can infect the genital areas
of females and males, including the skin of the vulva,
penis, and anus; the linings of the vagina, cervix,
and rectum; and the linings of the mouth and
throat.12 Unlike other sexually transmitted infec-
tions, most signs and symptoms of HPV are
nonexistent; therefore, most individuals are unaware
of the infection.
There are more than 40 types of HPV that are
sexually transmitted and will infect the epitheli-
um of the skin or mucus membranes. Despite the
fact that the immune system typically clears the
virus from the body within 2 years, some individu-
als will have a persistent HPV infection that can
cause various types of cancers and genital warts.14
“Low-risk” HPV types can cause warts on or around
the genitals and anus of both females and males.
Females may also have warts on the cervix and in
the vagina. Because these genital HPV types rarely
cause cancer, they are called “low-risk” viruses.11
The low-risk types include 6, 11, 42, 43, 44, 54,
61, 70, 72, and 81, while types 6 and 11 account
for 90% to 100% of genital warts.15 It is estimated
 ARTICLE IN PRESS
that approximately 20% to 50% of people with low-
risk infections may also have co-infections with what
is known as “high-risk types.”15
High-risk HPV types cause cancer.11 Fifteen HPV
types can cause cervical cancer16 and include types:
16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68,
73, and 82.15,16 The most frequent precancerous cer-
vical lesions are cervical intra-epithelial neoplasm;
these lesions can become invasive.17 Types 16 and
18 are the most oncogenic strains of the virus and
are responsible for causing over 75% of cervical
cancer cases and the majority of other genital
cancers.11,14 The prevalence of high-risk HPV in-
fections peak shortly after initiation of sexual
intercourse.17 When high-risk HPV lingers and
infects the cells of the vulva, vagina, penis, anus,
or the oropharynx, it can cause cell changes or
precancers.18 These precancers may eventually
develop into cancer if they are not found and
removed. These cancers are much less common
than cervical cancer. Much less is known about how
many people with HPV will develop cancer in these
areas.
CANCER PREVENTION AND EARLY DETECTION
Controlling the incidence of cervical cancer can
be accomplished in two ways. One way is to prevent
the precancers in the first place, and the second
is to detect the precancers before they become true
cancer.
TABLE 1.
Risk Factors for HPV and Cervical Cancer
Risk factors for HPV
First intercourse <18 years
Multiple sex partners or having a partner with multiple partners
Smoking
Immunosuppression from medications or disease
HPV, human papillomavirus; HSV-2, herpes simplex virus 2.
CERVICAL CANCER: PREVENTION AND EARLY DETECTION 3
RISK FACTORS
While epidemiological case series have shown
nearly 100% of cervical cancer cases test positive
for HPV,19 only a small number of those with HPV
will develop cervical cancer. Table 1 shows the
various risk factors for HPV and cervical cancer.
Approximately 90% of HPV infections are tran-
sient and are undetectable within 1 to 2 years.11
Women who have sex at an early age or who have
many sexual partners or a partner with multiple
sex partners are at increased risk for HPV infec-
tion and cervical cancer. However, women may
become infected with HPV even with only one
sexual partner. In fact, HPV infections are common
in healthy women, but those infections rarely cause
cervical cancer. Immunosuppression may also affect
the incidence of HPV. Women who are positive for
HIV are at a higher risk for HPV infection because
precancerous changes may develop into invasive
cancer faster. In addition, women who have AIDS
have an increased risk for cervical cancer.11
In addition to the risks associated with HPV in-
fection, cervical cancer may be influenced by other
risk factors.11 Women who take immunosuppres-
sive drugs are also at higher risk of developing
cervical cancer. Infection with chlamydia has been
linked to a higher risk of cervical cancer in women
whose blood tests show signs of past or current chla-
mydia infection (compared with women with normal
test results). Unfortunately, infection with chla-
mydia produces no symptoms; therefore, women
Risk factors for cervical cancer
HPV
High risk: Types 16 and 18
Low risk: Types 6 and 11
Past or current chlamydia infection
Infection with HSV-2
Diet low in fruits and vegetables
Being overweight
Smoking
Use of combined oral contraceptives
Three or more full-term pregnancies
First full-term pregnancy before age 17
Low income or limited access to health care
Positive family history for cervical cancer
 ARTICLE IN PRESS
4 T.A. KESSLER
may not know that they are infected unless they
are tested for chlamydia during a pelvic exam.11 In-
fection with herpes simplex virus 2 can be
associated with chronic inflammation and micro-
ulcerative changes of the cervical epithelium that
play an important role in initiation and progres-
sion of cancer.15
General lifestyle factors have been considered
weak links to cervical cancer, including eating a diet
low in fruits and vegetables and being overweight.
Women who smoke cigarettes are twice as likely
to get cervical cancer compared with non-smokers.20
Cancer-causing chemicals and tobacco by-products
in cigarettes have been found in the cervical mucosa
of women who smoke.20 These substances damage
the DNA of cervical cells. Long-term use of com-
bined oral contraceptives (COCs) has been
associated with increased risk of cervical cancer;
however, the risk decreases after the COCs are
stopped. In one study, the risk of cervical cancer
was doubled in women who took COCs longer than
5 years, but the risk returned to normal 10 years
after COCs were stopped.21
Women with three or more full-term pregnan-
cies have an increased risk of developing cervical
cancer. The reason for this is unknown.21 Also, when
a women has her first full-term pregnancy before
age 17, she is almost two times more likely to get
cervical cancer later in life than women who waited
to get pregnant until after age 25.21 The use of di-
ethylstilbestrol (DES) in mothers has been linked
to cancer in their daughters, clear cell adenocar-
cinoma of the vagina more so than the cervix.
However, there is an extremely low risk, only about
one in every 1,000 women whose mothers took DES
during pregnancy develop cancer, meaning about
99.9% of DES daughters do not develop these
cancers.21 Having a family history of cervical cancer
can increase risk two to three times higher than
those with no family history.21 Some researchers
suspect some of the familial tendency may be
caused by an inherited condition that makes some
women less able to fight off HPV infection com-
pared with others.21 Lastly, poverty has been linked
to cervical cancer. Women with low incomes or
limited access to health care may not be screened
or treated for cervical cancers and precancers.21
PREVENTION STRATEGIES
Prevention of HPV infection is key to prevent-
ing cervical cancer; however, there is not one
solution to prevent infection with all the different
types of HPV. While the rate of HPV infection is high
and there is no known cure for HPV, effective
primary prevention is available. It is important that
both females and males lower their risk with ef-
fective health behaviors and HPV vaccination. For
females, prevention includes safe sex practices such
as delaying sex until older, limiting the number of
sex partners, and avoiding sex with someone who
has had many other sex partners.22 Men must also
avoid multiple sex partners and be aware that being
uncircumcised increases the risk of being in-
fected with HPV and passing it on to partners.22
However, circumcision does not completely protect
against HPV infection; uncircumcised men can still
be infected with HPV and pass it on to their part-
ners. Men must use latex condoms the correct way
every time they have sex. A condom can lower the
risk of HPV infection; but areas that are not covered
by a condom may still become infected.22 Com-
bining these health behaviors with vaccination is
important. HPV vaccines are safe, effective, and
could prevent the majority of HPV-attributable
cancers, if vaccination coverage is high.23
VACCINATION FOR HPV
Prophylactic HPV vaccination provides the most
effective method of primary prevention against cer-
vical cancer. Vaccination for HPV has been available
in the US since 2006. The Advisory Committee for
Immunization Practices, the Center for Disease
Control and Prevention, and the American Cancer
Society provide recommendations regarding vac-
cination. All three groups recommend three doses
for routine HPV vaccination for females and males
ages 11 or 12 years, and catch-up vaccines for males
through age 21 and for females through age 26.22,24
The vaccine is recommended for gay and bisexu-
al males through age 26 and for females and males
who have compromised immune systems through
age 26, if they were not fully vaccinated when they
were younger.16 Recommendations for vaccina-
tion in the US vary slightly from what is
recommended by the World Health Organization.
In 2014, the World Health Organization updated
their recommendations and cited a vaccine sched-
ule of two doses of the HPV vaccine for girls between
9 and 13 years of age.25
HPV vaccination should occur before the first
sexual contact and prior to exposure to HPV;
however, vaccination after the first sexual contact
 ARTICLE IN PRESS
CERVICAL CANCER: PREVENTION AND EARLY DETECTION 5

is recommended.26 Young adult females are of par- EARLY CANCER DETECTION/SCREENING

ticular concern because HPV prevalence peaks in
20- to 24-year-old females, when almost 45% were
found to be infected.27 Unfortunately, statistics for
HPV prevalence may not provide the true rate of
occurrence. Because HPV infections may clear
quickly, the incidence of HPV may be even higher
than reported. Therefore, routine HPV vaccina-
tion should decrease the burden of HPV-related
diseases.
Three vaccines are available for the prevention
of HPV. In 2006, Gardasil (Merck & Co. Inc.
Whitehouse Station, NJ, USA) was approved by the
US Food and Drug Administration (FDA) as a qua-
drivalent vaccine (4vHPV) that prevents HPV types
6, 11, 16, and 18.28 In 2009, another vaccine,
Cervarix (GSK-GlaxoSmithKline, Rixensart,
Belgium), was released; it is a bivalent vaccine
(2vHPV) that prevents HPV types 16 and 18, which
can cause cervical cancer and precancerous
lesions.29 In December 2014, the FDA approved
Gardasil 9 (9-valent human papillomavirus vaccine
[9vHPV]) for the prevention of diseases caused by
nine types of HPV: 6, 11, 16, 18, 31, 33, 45, 52,
and 58.28 Gardasil 9 added protection against five
additional types of HPV beyond the quadrivalent
vaccine; these additional types are responsible for
approximately 20% of cervical cancers that are not
covered by previously approved HPV vaccines.28
Gardasil 9 is approved for use in females ages 9 to
26 and in males ages 9 to 15. Vaccination of females
is recommended with 2vHPV, 4vHPV, or 9vHPV, and
vaccination of males is recommended with 4vHPV
or 9vHPV.30
GUIDELINES
Because HPV vaccines cannot protect against
established infections, nor do they protect against
all types of HPV, women must still be screened
for cervical cancer and follow cervical cancer
screening guidelines. High-quality secondary screen-
ing with cytology or the Pap test is a simple and
effective procedure. In the US, screening recom-
mendations for the Pap test changed dramatically
in 2012. Data shows abnormal Pap test results
revert to normal even without treatment nine out
of 10 times,15 and approximately 90% of HPV
infections resolve on their own.7,31 Because of
these factors, new screening guidelines were issued
in 2012. The American Cancer Society, the
American Society for Colposcopy and Cervical
Pathology, and the American Society for Clinical
Pathology aligned their screening guidelines with
the US Preventive Services Task Force and the
American College of Obstetricians and
Gynecologists.17,32 Table 2 provides the screening
guidelines.
Preferred screening guidelines now state cervi-
cal cancer screening should begin at 21 years of
age, regardless of sexual history,17 with a routine
Pap test and should continue at 3-year intervals until
the woman is 29 years of age.32 Between 30 and
65 years of age, women should receive the Pap
test and the HPV test every 5 years. This
cotesting is important because it lowers the rate
of false-negatives. 32 An acceptable testing

TABLE 2.
Cervical Cancer Screening Guidelines

Age (yrs) Recommendation

<21 No screening regardless of sexual initiation or other risk factors
21 to 29 Cytology alone every 3 years
No HPV testing as stand-alone or as a cotest with cytology
30 to 65 Cytology plus HPV testing (cotest) every 5 years (preferred)
Or
Cytology alone every 3 years (acceptable)
>65 No screening if 3 consecutive negative cytology results or 2 consecutive negative cotests within the last 10 years,
with the most recent test in the past 5 years

Screening after hysterectomy with removal of the cervix is not recommended.

HPV, human papillomavirus.
 ARTICLE IN PRESS
6 T.A. KESSLER
alternative for women 30 to 65 is to have a Pap test
cytology alone every 3 years. Once a woman is over
65 years of age, she no longer needs screening fol-
lowing an adequate negative prior screening
history.32 Women who cotest HPV-positive and
cytology-negative should repeat cotesting in 12
months or receive immediate HPV genotype-
specific testing for HPV16 alone or for HPV16 and
HPV18.32 If cotesting is positive for either repeat
test, women should be referred to colposcopy.
Women testing negative on both tests should return
to routine screening.32 Women who have a history
of cervical intraepithelial neoplasm 2 (CIN2) or a
more severe diagnosis should continue routine
screening for at least 20 years, even if it extends
screening beyond 65 years of age.32 It is also rec-
ommended that women who are over 65 years and
who also have had exposure to DES in utero, are
immunosuppressed, positive for HIV, or have a
history of an organ transplant should speak to their
health care provider (HCP) for the best screening
approach.15 Yearly screening is no longer recom-
mended because of the higher rates of false-
positive results and the fact that there is little
effect on subsequent cancer with the extended
time between precancerous lesions and
invasion.17
In the past, questions were raised about the ef-
ficacy of conventional versus liquid-based Pap
testing. This concern has resolved in the US because
automated liquid-based cytology has replaced con-
ventional pap smears.15 A positive feature of liquid-
based testing is that the same sample can be used
to test for the presence of high-risk HPV types in
addition to the cytology.33
HPV tests can forecast cervical cancer risk
many years in the future and are currently rec-
ommended for use in conjunction with the Pap
test for women 30 to 65 years of age. HPV testing
alone should not be used in women under 30
years of age, nor should HPV testing be used in
combination with cytology in women under 30
because of the higher rate of HPV infections in
these women.17 Molecular tests for HPV assess
for the high-risk HPV types that can lead to
cervical cancer. There is no role for low-risk
HPV testing in cervical cancer screening.32 The
HPV tests better forecast the development of
CIN3+ over the next 5 to 10 years more so than
cytology alone32 and can identify women at risk
for an uncommon type of cervical cancer (adeno-
carcinoma) that is often missed by the Pap test
cytology.9
BARRIERS TO PRIMARY AND SECONDARY
PREVENTION
HPV Vaccination
Because HPV vaccination is key to preventing cer-
vical cancer, it is important to examine the factors
that influence vaccination behaviors. The percent-
age of females and males who have been vaccinated
in the US has been low and has not reached levels
of other recommended vaccines. In 2012, 17-year-
old females were the most highly vaccinated age
group, with only 44.5% of this age group receiv-
ing all three dosages.34 In 2013, only 36.9% of
females aged 19 to 26 years reported receipt of ≥1
dosages of the HPV vaccine.34 Most female adoles-
cents in commercial and Medicaid health plans do
not currently receive the recommended vaccine
dosages by 13 years of age.35 Even those already
exposed to HPV should still be vaccinated because
vaccination after exposure can still protect against
other high-risk strains.27 In addition to low uptake
of the HPV vaccine, unfortunately, young adults have
reported low intentions of receiving the vaccine.26,36
There are multiple barriers to vaccination. These
barriers include parental, provider, or system-
level factors. In the US, parental consent is needed
to vaccinate adolescents under the age of 18 years.
Parents report lack of knowledge or needing more
information before vaccinating their children,23,37
and report a concern about the vaccine’s effect on
sexual behavior.37 Parents also believe their chil-
dren are at a low risk of HPV infection and, as such,
do not need the vaccine. In addition, parents view
costs or financial concerns as barriers to
vaccination.37 For parents of sons, perceived lack
of direct benefit of the vaccine has led to low vac-
cination rates.37 Unfortunately there are also social
disparities for vaccine series completion. Dispro-
portionately more African American females and
males and females living below or at the poverty
level have lower rates of series completion.34
For young adults aged 19 to 26, perceived bar-
riers to HPV vaccination are reported in the
literature. Lack of knowledge is a barrier to HPV
vaccine uptake.38-41 Other barriers include cost,37,38
concern about the safety of the vaccine,39,42,43 per-
ceived low susceptibility to HPV,38 and low intention
to receive the vaccine.36,43
A lack of provider recommendation has been a
consistent barrier to increasing vaccination rates.44
HCPs may lack knowledge of the HPV vaccine and
recommendations for vaccination.23 In one study,
 ARTICLE IN PRESS
providers reported a lack of knowledge about the
relationship between HPV and urogenital or oral
cancers.37 Additionally, HCPs reported recommend-
ing the vaccine only to select populations rather
than all 11- and 12-year-olds, especially popula-
tions providers perceive as high risk (often low-
income and/or patients of color), while others
reported only vaccinating older teens or females,
but not males.37 Evidence also demonstrates that
HCPs have not adhered to recommended screen-
ing guidelines.45
System-level barriers include limited opportu-
nities during a provider visit to offer HPV vaccine
and a lack of flexible tracking and reminder capa-
bilities for completion of the vaccine series. 23
Another system barrier is cost to patients and to
providers. HCPs consistently mentioned poor in-
surance coverage or reimbursement and the costs
to purchase37 and store the vaccine as barriers.37,44
For school nurses, system barriers included lack
of managerial support, poor staffing, time con-
straints, and strained relationships between the
nurses and educational institutions.46
Pap Test Screening
The literature provides data about barriers to Pap
testing. According to the World Health Organiza-
tion, women lack awareness of cervical cancer.6
Additionally, attitudes toward sexual health, open
discussion of sexual behaviors, and individual beliefs
are barriers to cervical cancer screening. Lack of
knowledge for cervical cancer screening has been
reported in the literature,47-49 while some women
reported not being aware of the benefits of early
detection.50 Socioeconomic barriers exist as well;
these barriers include poverty, lack of transporta-
tion, and immigration status.51
Data from the 2005 Health Information Nation-
al Trends Survey demonstrated that current smokers
are significantly less likely to have regular Pap
tests.52 Obesity, another risk factor for cervical
cancer, was strongly associated with not maintain-
ing regular screening practices.52 Perceived barriers
to the actual Pap test have been reported. Women
reported not looking forward to the perceived in-
vasiveness of the Pap test,47,53 low comfort associated
with the test,53-55 anxiety about the possible results
of the test, and reluctance to screen after a bad
experience54 as reasons for not obtaining screenings.
Individual barriers to lack of testing are impor-
tant, but also understanding why current screening
guidelines are not followed by providers is impor-
tant. Evidence demonstrates that HCPs have begun
CERVICAL CANCER: PREVENTION AND EARLY DETECTION 7
screening women before recommendations and con-
tinued to screen when guidelines recommend that
screening is not needed.56
ROLE OF HEALTH CARE PROFESSIONALS
Methods to Promote Vaccination
Understanding the barriers to HPV vaccination
and providing education to overcome these barri-
ers is essential. As part of regular primary prevention
strategies, vaccination for HPV must be recom-
mended to all parents of 11- and 12-year-olds and
before these children become sexually active.
Parents consistently identify HCPs as a key influ-
encing factor in their decision to vaccinate their
children.37,42 Teaching about the risk of HPV infec-
tion to parents and young adults is important, as
well as equating the vaccine as part of the social
norm of health care.42,57
System barriers must be addressed. Creating com-
munication systems to support initiation of the
vaccine series are important, but there is also a need
to create system strategies for adolescents and young
adults to complete the vaccination series.58 Inno-
vative communication reminders such as text
messaging may lead to increased series completion.37
HCPs must take advantage of missed opportuni-
ties to vaccinate when adolescents are seeking care
within health care systems, such as getting phys-
ical exams for athletics.37 Because there are costs
associated with purchasing and storing the vac-
cines, systems must be developed to help HCPs
manage the additional costs.58 Health care systems
should also initiate community education for schools
and universities.59 Using media to get the message
out about HPV vaccination and the consequences
of not being vaccinated are essential. Mass media
campaigns should be targeted at the end of summer
and when school begins in the fall.58 This timing
coordinates with parents bringing their children in
for well child and school health visits.
Health education on college campuses may lead
to increased awareness and uptake of the vaccine
for those not vaccinated previously.58 Emphasiz-
ing the severity of HPV-related disease is central
to increasing regret if one does not get vaccinated
and has increased intention to seek vaccination.60
Because college males have been shown to be less
knowledgeable about the existence of the HPV
vaccine, educational campaigns on college cam-
puses should increase awareness about the
vaccine41,61 and target males in particular.
 ARTICLE IN PRESS
8 T.A. KESSLER
Methods to Promote Screening
HCPs must receive continued updates on cervical
cancer screening guidelines. While professional or-
ganizations support current recommended screening
guidelines, professional organizations must continue
to focus on getting the word out to HCPs. Health care
systems can play an important role in promoting ad-
herence to guidelines as well.17 Guidelines can be
communicated through system messaging to HCPs
and the public. Using medical record reminders can
be another effective tool in reminding HCPs about in-
appropriate cervical cancer screening practices62 and
what practices are supported by professional orga-
nizations. One key to promoting screening is to
increase patient-provider communication.50 Open com-
munication is necessary for patients to learn about
the benefit of early detection.
Educational sessions can also increase knowl-
edge of cervical cancer screening guidelines along
with the need to complete recommended Pap tests.51
In one study, community health workers who pro-
vided education for Hispanic women resulted in
increased knowledge and report of having a Pap test.51
Education messages about HPV infection and vac-
cination should vary somewhat for females and
males.58 Females need to learn about the risks of
having sex at an early age, having multiple sex part-
ners, having a partner who has had many partners,
and having sex with uncircumcised males.8 Addi-
tionally, data has suggested females have reported
more concerns about the safety or effectiveness of
HPV vaccines; therefore, education should focus on
reducing these barriers.43 Males must learn about
the risks for an HPV infection with multiple sex part-
ners and how to use latex condoms the correct way
every time they have sex.58 The cost of getting an
HPV vaccination is a greater barrier for males.43
Therefore, educational messages should identify con-
venient times to receive the vaccine or direct patients
to a clinic that offers the vaccine at a reduced rate.39
IMPLICATIONS FOR NURSING PRACTICE
Nurses must be aware of effective models to
promote health behaviors. Using models to in-
crease screening and vaccination practices has been
described in the literature. Various health behav-
ior models that predict behavior change may be
categorized broadly as intrapersonal and interper-
sonal approaches. Intrapersonal models include the
Health Belief Model and the Transtheoretical Model
(TTM), while interpersonal models often include
use of the Social Cognitive Theory.63 What these
models share in common is that knowledge is nec-
essary but not sufficient to produce behavior change.
A premise of the Health Belief Model and the TTM
is the need to use education as an initial interven-
tion. The Health Belief Model has been used to
address cervical cancer screening knowledge and
behaviors. Studies have demonstrated that knowl-
edge was related to increased cervical screening
behaviors.47,48,64 The model can also guide health
behavior interventions to address cultural specif-
ic beliefs, attitudes, and behaviors.51 The TTM has
been used to explain health behavior change
through a series of stages.65 However, studies found
inconsistent findings on whether the TTM in-
creases screening behaviors.66,67 Within the Social
Cognitive Theory, self-efficacy is a belief that one
can overcome barriers and execute behaviors or
high-risk situations successfully,68 supporting the
notion that more than knowledge is needed to make
a behavior change. Women with increased self-
efficacy demonstrated increased cervical screening
behaviors.47,69-71 Nurses and other HCPs should use
these models, by supporting increased knowledge
and self-efficacy, to address behavior change and
support an increase in cervical cancer vaccina-
tion and screening.
HPV Education
Nurses and other HCPs should provide clear and
accessible educational information and empha-
size that HPV vaccination is safe, prevents cancer,
and co-administer it with tetanus, diphtheria, acel-
lular pertussis vaccine, and quadrivalent
meningococcal conjugate vaccine.23 All educa-
tional campaigns must provide knowledge but also
address the fact that the vaccine is safe, effective,
and well tolerated in an attempt to promote self-
efficacy. Overall educational campaigns must include
not only the need to receive the initial vaccine but
to return for the remaining dosages. Once vacci-
nation begins, nurses should initiate reminder/
recall strategies for parents to bring their children
back to the HCP for all dosages,72 such as re-
minder phone calls or text messaging.
School nurses can be instrumental in developing
educational campaigns for students. School nurses
should focus on all 11- and 12-year-old students and
provide education on HPV infections and the effec-
tiveness of vaccination. Even use of simple educational
pamphlets about HPV and HPV vaccination can in-
fluence acceptance rates and are cost effective.73 These
pamphlets must be made available in the school
 ARTICLE IN PRESS
nurse’s office and can be sent home to all 11- and 12-
year-old students during the school year. Acquiring
tailored educational materials for specific popula-
tions is important, such as using educational materials
in Spanish language for students to take home in
Spanish-speaking households.73
College health nurses must address the educa-
tional needs of young adults as well. Because there
is a significant gap in the number of young adults
who have received the HPV vaccinations, provid-
ing educational sessions may lead to increased
awareness and uptake of the vaccine for those not
vaccinated previously. Educational messages must
focus on the importance of receiving the vaccine
to prevent cancer and sexually transmitted infec-
tions. While listening to professional lectures or
receiving fact sheets for young adults has shown
mixed results in the literature,74,75 these strate-
gies should be continued as a part of health
education on college campuses.
Screening Education
Educational programs can be an effective method
of helping some women learn about cervical health,
and can create an expectation of success or self-
efficacy with Pap test screening. Evidence indicates
that knowledge of HPV infection and current cer-
vical cancer screening guidelines can increase a
woman’s likelihood of maintaining screening
behaviors.47,52 However, even though women may
know about cervical health and screening behav-
iors, not all women follow screening guidelines.
Knowledge alone does not promote behavior change.
Rather, women need to believe they can execute
screening behaviors successfully. Nurses can be in-
strumental in sharing experiences and verbal
persuasion to increase a woman’s belief that she
can be successful and receive the Pap test.47
FUTURE DIRECTIONS IN CANCER SCREENING AND
IMPLICATIONS FOR NURSING PRACTICE
It is anticipated that future guidelines may include
more sophisticated targeting of women at highest
and lowest risk for cervical cancer.17 Sawaya and
colleagues suggested the age for initiating screen-
ing may increase, as well as the interval for
screening, as the use of HPV vaccinations increase.17
Any new screening must be accessible, afford-
able, and allow for timely treatment when positive
results are found.17
CERVICAL CANCER: PREVENTION AND EARLY DETECTION 9
There is ongoing research into more specific screen-
ing tests for cervical cancer. Testing for E6 and E7
oncoproteins is yielding promising results. The
oncoproteins have been linked to cellular transfor-
mations in cervical cancer and may lead to cotests
for women who are HPV-positive.76 Another new idea
is the development of low-cost, rapid home screen-
ing for HPV. This type of testing may lead to more
women completing screening for HPV.10 A cobas
(Roche Molecular Systems, Inc., Pleasanton, CA, USA)
HPV DNA test was approved by the FDA in 2014.77
The test is a qualitative multiplex assay that can be
used alone to detect a total of 14 high-risk HPV types,
including HPV 16 and 18. The assay is automated on
the cobas 4800 System and provides real-time poly-
merase chain reaction technology for amplification
and detection.77 The FDA approved its use in women
aged 25 and older to determine if there is a need for
additional testing for HPV types.28 A study com-
pleted by Stoler and colleagues found that one in seven
women with normal Pap test cytology was positive
for HPV 16 and had CIN2 or cells indicating moder-
ate dysplagia.78 The researchers also found that HPV
testing alone was better than Pap test cytology in de-
termining severe cervical cell carcinoma.78
CONCLUSION
Nurses must be advocates for increasing knowl-
edge of cervical cancer and its prevention. Education
is an essential initial step in the arsenal for cervi-
cal cancer prevention. Providing clear messages
about best actions for vaccination and screening
behaviors are critical. It is necessary that individu-
als reduce risk and prevent the development of
precancer, and it is necessary to find and treat
precancer before it becomes cancer. Primary pre-
vention strategies about HPV, its risks, and the need
for vaccination are essential in the form of sus-
tained educational campaigns for parents, young
adults, and HCPs. Special attention should be pro-
vided to the social determinants of seeking
vaccinations and the system-level barriers that exist
within the health care system. Encouraging women
to follow cervical screening guidelines is also im-
portant. Helping women to overcome barriers
associated with obtaining a Pap test are needed.
Using models for behavior change are effective ap-
proaches to promote prevention strategies. Nurses
are on the front lines of providing education and
strategies to overcome barriers to vaccination and
screening behaviors in women and men.
 ARTICLE IN PRESS
10 T.A. KESSLER
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