Nevada Breast and Cervical Cancer Toolkit Women’s Health Connection

Get screened! Stay Healthy!

This publication was supported by the Nevada Division of Public and Behavioral Health (DPBH) through the Grant Number # 3U58DP003929-03W1 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the DPBH or CDC.

Table of Contents Introduction 4

About the Program 6 6



a. National Breast and Cervical Cancer Early Detection Program



b. Women’s Health Connection 6



c. Nevada Cancer Registry 8

Breast Cancer

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a. What is Breast Cancer? 10



b. Breast Cancer: The Importance of Early Detection and Screening 10



c. Breast Cancer Facts and Statistics



d. Risk Factors 11



e. Risk Reduction 12



f. Breast Cancer Screening Guidelines 13

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i. Mammography and Early Detection 15



ii. Core Competencies of a Clinical Breast Exam 19

Cervical Cancer

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a. What is Cervical Cancer? 20



b. Cervical Cancer: The Importance of Screening and Prevention 21



c. Cervical Cancer Facts and Statistics 22



d. Risk Factors 22



e. Other Factors 22



d. Risk Reduction 23



e. Cervical Cancer Screening Guidelines 24



i. Pap test and Co-testing (Pap and HPV test) 24



ii. Follow-up Testing for Abnormal Cervical Cancer Screening 27

Resources 30

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a. Public Education 30



b. Statistics and Data Resources 30



c. Resources Program Planning 31



d. Acknowledgments 32 3

Introduction Breast cancer is the most commonly diagnosed cancer in women regardless of race or ethnicity. Men can get breast cancer as well, but it is rare. Notably, breast cancer is the leading cause of death among Hispanic women, and the second leading cause of death among white, black, Asian/Pacific Islander, and American Indian/Alaska Native women. Each year, it is estimated that over 200,000 women in the United States will be diagnosed with breast cancer and more than 40,000 will die from the disease.i It is estimated that 1,690 women in Nevada will be diagnosed with breast cancer in 2015 and that 380 women will die of the disease.ii Although cervical cancer was once the leading cause of death among women in the United States, cervical cancer cases and deaths have decreased significantly during the past 40 years. This decline is essentially due to women getting regular Pap tests, which can detect early stage, treatable cancers. Each year, approximately 12,000 women in the United States are diagnosed with cervical cancer and about 4,000 women die from the disease.iii In Nevada, an annual average of 116 cases of cervical cancer are newly diagnosed every year.iv For both forms of cancer, the evidence is clear – proper screening tests reduces death rates for these two cancers. Screening tests can help find cancer at an early stage, before symptoms appear, when it can be treated more easily. For cervical cancer, screening with a Pap test can identify precancerous abnormalities, which can be treated, thus preventing cervical cancer altogether. Unfortunately, low-income, uninsured, and underserved women are screened at a disproportionally low rate. As a result of the Breast and Cervical Cancer Mortality Prevention Act of 1990, the Centers for Disease Control and Prevention (CDC) created the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in order to address this gap. NBCCEDP provides low-income, uninsured, and underserved women with access to timely breast and cervical cancer screening and diagnostic services. The NBCCEDP funds all 50 states, the District of Columbia, 5 U.S. territories, and 11 American Indian/Alaska Native tribes or tribal organizations to provide screening services for breast and cervical cancer.v

Women Screened through the NBCCEDP, by Year January 2009 to December 2013 National Aggregate

650,000 600,000 550,000 500,000 450,000 400,000 350,000 300,000 250,000 200,000

Since 1991, NBCCEDP-funded programs have served more than 4.7 million women, provided more than 11.8 million breast and cervical cancer screening examinations, and diagnosed more than 66,198 breast cancers, 3,625 invasive cervical cancers, and 169,598 premalignant cervical lesions, of which 40% were high-grade. In calendar year 2013, the NBCCEDPvi: • Screened 331,313 women for breast cancer with mammography and diagnosed 5,977 breast cancers. • Screened 208,682 women for cervical cancer with the Pap test and diagnosed 252 cervical cancers and 9,505 premalignant cervical lesions, of which 36% were high-grade.

150,000 100,000 50,000 0

2009

2010

2011

2012

2013

Women Screened (NBCCEDP-funded Pap Test, Mammogram, or Clinical Breast Exam) Women Receiving NBCCEDP-funded Pap Tests Women Receiving NBCCEDP-funded Mammograms Graphic citation is http://www.cdc.gov/cancer/nbccedp/about.htm

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About The Program

Covered Services Women’s Health Connection has limited funding to provide screening services to Nevada women. For this reason, WHC screens “target populations.” These are populations who are at higher risk to develop breast and cervical cancer.

National Breast and Cervical Cancer Early Detection Programvii

For women 40 to 49 years of age, the Program pays for the clinic office visit at a contracted clinic for the purpose of having the following procedures performed:

Program Eligibility

• Annual pelvic exam

Women’s Health Connection guidelines establish an eligibility baseline to provide direct services to biological women, transgender males (female to male) and transgender women (male to female) with past or current hormone use who are uninsured or underinsured women at or below 250% of federal poverty level; ages 40–64 for cervical cancer screening; ages 40–64 for breast cancer screening. About 11.1% of U.S. women are eligible for NBCCEDP cervical cancer screening, and about 9.8% are eligible for breast cancer screening. The program serves 6.5% of eligible women for cervical cancer screening and 10.6% of those eligible for breast cancer screening.

• Annual Clinical Breast Exam (the hands-on breast exam performed by a clinician)

To reach underserved women, the NBCCEDP Conceptual Framework supports an array of strategies, including program management, screening and diagnostic services, data management, quality assurance and quality improvement, evaluation, partnerships, professional development, and recruitment. Providers in the program work collaboratively to provide breast and cervical cancer screening, diagnostic evaluation, and treatment referrals (where appropriate). The program’s continued success depends in large part on the complementary efforts of a variety of national partner organizations, as well as on state and community partners.

• Annual Clinical Breast Exam (the hands-on breast exam performed by a clinician)

Screening Deaths from breast and cervical cancers could be avoided if cancer screening rates increased among women at risk. Deaths from these diseases occur disproportionately among women who are uninsured or underinsured. Mammography and Pap tests are underused by women who have no regular source of health care, women without health insurance, and women who immigrated to the United States within the past 10 years.

Women’s Health Connectionviii

• Pap test in accordance with established screening schedules and guidelines For women 50 years of age and older, the Program pays for the clinic office visit at a contracted clinic for the purpose of having the following procedures performed: • Annual Pelvic Exam • Pap Test in accordance with established screening schedules and guidelines • Annual Screening Mammogram

How to Get Enrolled In July 2011, the Nevada Division of Public and Behavioral Health contracted through a sub-grant with Access to Healthcare Network to operate Women’s Health Connection. This partnership will increase the access to primary and specialty health care services for breast and cervical cancer screening. To ensure eligibility for the program or for more general information, contact Access to Healthcare Network. Contact information below: Access to Healthcare Network Toll free help line (877) 385-2345 (Se habla Español) Website Accesstohealthcare.org AHN Provider Line 775-284-1904

The Women’s Health Connection Program is part of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) funded by the Centers for Disease Control and Prevention (CDC). This program provides low-income, uninsured, and underserved women access to timely breast and cervical cancer screening and diagnostic services. The Nevada Division of Public and Behavioral Health receives funding from NBCCEDP to conduct the Women’s Health Connection (WHC) Program. Since its inception in 1997, WHC has been 100% federally funded through NBCCEDP and has provided breast and screening services to over 42,276 women in Nevada. The goal of this program is to reduce breast and cervical cancer morbidity and mortality rates of medically underserved women in Nevada. This is accomplished through education, screening, diagnosis, and treatment. As a result of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354), eligible women screened and diagnosed with breast or cervical cancer, or found to have high grade cervical pre-cancer diagnosed through the Women’s Health Connection Program, have access to treatment services through Medicaid. Care coordination/case management services ensure that WHC clients receive timely and appropriate screening and diagnostic testing and if necessary, treatment services. Care coordination also supports clients in overcoming barriers that may prevent them from receiving follow-up and regular screening services. Care coordination/case management services are a collaborative process with all providers to meet the women’s health needs.

Who Qualifies? Women 40 years of age or older who do not have health insurance, Medicaid, Medicare Part B, HMO coverage; or whose health insurance coverage does not pay for preventive services; and who meet the Program’s income guidelines are eligible. 6

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Nevada Cancer Registry Nevada Revised Statute (NRS) 457.230 mandates to establish and maintain a system for the reporting of information on cancer. The primary purpose of the Nevada Central Cancer Registry (NCCR) is to collect and maintain a record of reportable cases of cancer in the state. The data is used to evaluate the appropriateness of measures for the prevention and control of cancer and to conduct comprehensive epidemiological surveys of cancer and cancer-related deaths. Cancer case data is collected from hospitals, medical laboratories and other freestanding facilities and from physicians that provide screening, diagnostic or therapeutic services to patients with respect to cancer. The information on these cases of cancer is reported to NCCR, and collected data is entered into a specialized database where additional case information is added, edited, and consolidated for accuracy and completeness. NCCR annually compiles comprehensive cancer data collected for all years of operation and submits a report to the Centers for Disease Control and Prevention (CDC)/National Program of Cancer Registries (NPCR) and the North American Association of Central Cancer Registries (NAACCR) and for analysis, certifications, and inclusion in national cancer statistics. Timely and complete cancer data are used to evaluate the appropriateness of measures for the prevention and control of cancer and conducting comprehensive epidemiological surveys of cancer and cancer-related deaths statewide and nationally. NCCR is a vital tool for monitoring the incidence of cancer within the state and sharing that information with health care professionals, researchers, and the general public. To report cancer cases to the NCCR, please contact (775)-684-3221.

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Breast Cancer

• Although overall incidence is highest for Caucasian women, African Americans have the highest mortality rate from breast cancer. Caucasian women have the second highest mortality rate, followed by American Indian/Alaska Natives, Hispanic/Latinos, and Asian American/ Pacific Islanders.

What is Breast Cancer?

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According to the Centers for Disease Control and Prevention, cancer is a disease in which cells in the body grow out of control. When cancer starts in the breast, it is called breast cancer. The breast is made up of three main parts: glands, ducts, and connective tissue. Sometimes, breast cells become abnormal and grow faster than normal cells. These extra cells form a mass called a tumor. Most tumors are “benign,” or not cancerous. However, some tumors are “malignant,” meaning they are cancerous and have the ability to spread to other parts of the breast and body and disrupt normal functions in those areas.

What are the symptoms? When breast cancer starts out, it is too small to feel and does not cause signs and symptoms. As it grows, however, breast cancer can cause changes in how the breast looks or feels. Symptoms may include: • A new lump in the breast • A lump that has changed • A change in the size or shape of the breast • Pain in the breast or nipple that does not go away • Flaky, red, or swollen skin anywhere on the breast • A nipple that is very tender or that turns inward • Blood or any other type of fluid coming from the nipple that is not milk when nursing a baby These symptoms may be caused by something other than cancer, but the only way to know is to get checked. Treatment is most effective when breast cancer is found early, and many women go on to live long and healthy lives.

Breast Cancer: The Importance of Early Detection and Screeningx According to the American Cancer Society, the goal of early screening for breast cancer is to find cancers before they start to cause symptoms (like a lump that can be felt). Screening exams are designed to find breast cancer while it is still small and localized – and therefore have better treatment outcomes. Symptomatic breast cancers are usually bigger and are more likely to have spread beyond the breast. The size of a breast cancer and how far it has already spread (its stage) is important in predicting the prognosis of a woman with this disease. Data from the American Cancer Society indicates that in 2012 only 49.6% of Nevada women aged 40+ had a mammogram, and 39.9% had a mammogram and a clinical breast exam. Because early detection and screening can save lives, it’s important for women of all ages to know what screening tests are available and when to get them.

Breast Cancer Facts and Statisticsxii, xiii • In 2015, an estimated 234,190 new cases of invasive breast cancer will be diagnosed in U.S. women. In addition to invasive breast cancer, an estimated 60,290 cases of carcinoma in situ (CIS) will be diagnosed. • In 2015, an estimated 40,290 U.S. women will die from breast cancer. • In 2015, the estimated number of new breast cancer cases in Nevada is 1,690. • In 2015, the estimated number of deaths in Nevada from breast cancer is 380. • The risk of getting breast cancer increases with age. Approximately 77% of women with breast cancer are over the age of 50 at the time of diagnosis. 10

• The breast cancer mortality rate has decreased since 1989, with larger decreases in women younger than 50. The decline is attributed to earlier detection, improved treatments, and possibly, decreased incidence as a result of declining use of postmenopausal hormone therapy. • When detected and treated early, 5-year relative survival for localized breast cancer is 99%. For regional disease, it is 84%. If the cancer has spread to distant organs, 5-year survival drops to 24%. Larger tumor size at diagnosis is also associated with decreased survival. • At this time, there are an estimated 2.8 million breast cancer survivors living in the U.S.

Risk Factors: • Gender: Female gender is the most important risk factor for breast cancer. Men can develop breast cancer, but the risk for females is about 100 times greater. • Age: As women age, the risk of developing breast cancer increases. About 66% of all invasive breast cancers are diagnosed in women age 55 and older, while about 12% are diagnosed in women younger than age 45. •

Race and ethnicity: In the U.S., Caucasian women are slightly more likely to develop breast cancer than are African American women, although African Americans are more likely to die from this disease. Asian, Hispanic, and Native American women have a lower risk than either Caucasian or African American women of developing and dying from breast cancer.

• Family history of breast cancer: Risk is increased for women whose close relatives have breast cancer. In general, the more biological relatives with breast cancer, especially relatives diagnosed before age 50, the higher a woman’s risk. Less than 15% of women with breast cancer have a positive family history in a first degree relative. •

Genetic factors: Certain gene mutations strongly increase a woman’s risk. An estimated 5% to 10% of all breast cancers are directly attributable to inherited gene mutations, most often to mutations in the BRCA1 or BRCA2 genes. In the U.S., BRCA mutations are more common in Jewish women of Ashkenazi origin, but they can occur in any racial or ethnic group. Mutations in the genes ATM, TP53, CHEK2, PTEN, CDH1, STK11 also increase breast cancer risk, but these are much rarer and do not increase risk as much as BRCA genes.



Benign breast conditions: There is a slight to strong increase in risk for women with certain types of abnormalities found with a breast biopsy, depending upon the type of abnormality. Non-proliferative lesions may have a slight effect on breast cancer risk. Proliferative lesions without atypia increase risk 1.5 to 2 times normal. Proliferative lesions with atypia (i.e., ADH, ALH) increase a woman’s risk by 3.5 to 5 times.

• Personal history of breast cancer: A history of breast cancer in one breast increases the risk of developing a new cancer in the other breast or in another part of the same breast by 3 to 4 times. •

Dense breasts: Compared to the same aged women with less dense breast tissue, women whose mammograms show extremely dense breast tissue (usually defined as ≥ 75%) are at 2.1 to 2.3 times higher risk for breast cancer, while women with heterogeneously dense breasts (usually defined as 51-75%) are at a 1.2 to 1.5 times higher risk. Dense breast tissue can also make it harder to detect breast cancer with mammography.

• Reproductive history: Certain reproductive factors slightly increase risk. These include giving birth to a first child after age 30, nulliparity (never having children), starting menstruation before age 12, and/or entering menopause after age 55. The increase in risk is likely due to a longer lifetime exposure to estrogen. •

Hormone therapy after menopause (also called hormone replacement therapy, or HRT): Using combined hormone therapy after menopause (estrogen and progesterone) increases breast cancer risk for current or recent users, especially if used for longer than two to three years. The use of estrogen alone after menopause does not appear to increase the risk of developing breast cancer, however, when used long term (> 10 years) it may increase risk for ovarian cancer per some studies. Both combined hormone therapy and estrogen therapy alone also appear to increase the risk of heart disease, blood clots, and strokes. 11



Radiation therapy to the chest when young: Risk is strongly increased for women treated with radiation to the chest for another cancer as children or young adults (as with Hodgkin’s lymphoma). The risk is highest for those treated during adolescence, when the breasts are still developing. The most vulnerable ages appear to be between ages 10 to 14.

• Weight: Excess weight (as measured by body mass index) and/or weight gain after menopause is associated with a higher risk of breast cancer. In contrast, excess weight in premenopausal women has been associated with a lower risk. The reason for this observed relationship in premenopausal women is unclear. • Alcohol: Compared with nondrinkers, women who drink alcoholic beverages are at increased risk. The risk increases with the amount of alcohol consumed. Risk for those who consume two to five drinks daily is increased by about 1.5 times normal. • Height: Height has been associated with an increased risk of breast cancer in a majority of studies. Risk is about 20% greater for women 69 inches or taller as compared with women less than 63 inches tall. •

Other factors: Exposure to certain environmental substances and two conditions may also increase a woman’s risk of developing breast cancer. Currently there is conflicting evidence regarding the risk of environmental exposure to organochlorines (some exert a weak estrogenic effect) and tobacco smoke, as well as night shift work. Research is ongoing in these and other areas of our current environment with potential for effecting breast cancer risk.

Risk Reduction: For women at average risk, the emphasis is on regular screening and healthy lifestyle choices (e.g., low-fat diet, regular exercise, breastfeeding). Women at increased risk for breast cancer are advised to consider additional risk reduction strategies in consultation with their health care providers. • Physical activity: Regular physical exercise has been shown to provide some protection against breast cancer, especially in postmenopausal women. The reduction in risk for physically active women compared with women who are least active may be as much as 25%. • Diet: A diet that is rich in vegetables, fruit, poultry, fish, and low-fat dairy products has been associated with a lower risk of breast cancer in some studies. There is also some evidence that soy-rich diets may reduce risk. Overall, however, the influence of dietary factors on breast cancer risk remains inconclusive. • Breastfeeding: The risk reducing effect of breastfeeding has been shown in multiple studies, especially if the breastfeeding lasts 1.5 to 2 years. For every year of breastfeeding, the reduction in relative risk has been estimated approximately at 4%.

Breast Cancer Screening Guidelines https://qap.sdsu.edu/screening/breastcancer/facts.html The U.S. Preventative Services Task Force and American Cancer Society differ on their recommendations for screening guidelines. Please refer to the comparison chart below:

USPSTF

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ACS

Biennial screening mammography beginning at age 50.

Annual screening mammography beginning at age 40.

Evidence is insufficient for assessing the additional benefits of screening mammography in women past age 74.

Continue annual screening mammography for as long as a woman is in good health.

Recommends against clinicians teaching women how to perform breast self-examination.

Breast self-examination is optional. Women who choose to do breast self-examination should receive instruction from their health providers.

Evidence is insufficient for assessing the additional benefits of clinical breast examination beyond screening mammography in women 40 years or older.

Recommends clinical breast examination every three years for women in their 20s and 30s, and annually for women aged 40 and older.

Evidence is insufficient for assessing the additional benefits and harms of MRI as a screening method for breast cancer.

In addition to screening mammography, annual MRI screening is recommended for women with greater than 20% lifetime risk of breast cancer. 13

USPSTF recommendations are based on a grading system. USPSTF recommends interventions if there is a high certainty that the net benefit is at least moderate to substantial. USPSTF recommends against interventions if there is a moderate to high certainty there is no net benefit or the harms outweigh the benefits. The USPSTF may conclude that certain interventions have insufficient evidence to make a recommendation. Per CDC guidelines, the Women’s Health Connection program meets all USPFTF guidelines, however Women’s Health Connection screens women more frequently than USPSTF guidelines recommend. Covered services include annual breast and cervical cancer screening starting at age 40 and annual mammograms beginning at age 50. In some cases, the Women’s Health Connection pays for women to be screened at age 65 years and older and for women who are 39 years and younger. Below is an excerpt from the USPSTF guidelines mentioned above:

Summary of U.S. Preventative Services Task Force Screening Recommendations (2015 Draft Guidelines)xiv POPULATION

Mammography and Early Detectionxv The Women’s Health.Gov website provides information on mammograms (detailed below) as part of a complete breast screening protocol. A high-quality mammogram plus a clinical breast exam is the most effective way to detect breast cancer early. Finding breast cancer early greatly improves a woman’s chances for successful treatment. Like any test, mammograms have both benefits and limitations. For example, some cancers can’t be found by a mammogram, but they may be found in a clinical breast exam. If a patient chooses to do breast self exams, she should be reminded that breast changes can occur because of pregnancy, aging, menopause, menstrual cycles, or from taking birth control pills or other hormones, and it is normal for breasts to feel a little lumpy and uneven. Also, it is common for breasts to be swollen and tender right before or during a menstrual period. The patient should contact her doctor if she notices any unusual changes in her breasts.

Types of Mammograms RECOMMENDATION

Women ages 50 to 74 years

The USPSTF recommends biennial screening mammography for women ages 50 to 74 years.

Women ages 40 to 49 years

The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. • For women at average risk for breast cancer, most of the benefit of mammography will result from biennial screening during ages 50 to 74 years. Of all age groups, women ages 60 to 69 years are most likely to avoid a breast cancer death through mammography screening. Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger. • All women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to her health, or even apparent, during her lifetime (known as “overdiagnosis”). This risk is predicted to be increased when beginning regular mammography before age 50 years. • Women with a parent, sibling, or child with breast cancer may benefit more than average-risk women from beginning screening between the ages of 40 and 49 years.

Screening mammograms, which typically involve two x-rays of each breast, are done for asymptomatic women. Screening mammograms can detect lumps or tumors that cannot be felt, and can also find microcalcifications (tiny deposits of calcium in the breast), which sometimes indicate that breast cancer is present. Diagnostic mammograms are used after a lump or other symptom or sign of breast cancer has been found, for further testing after an abnormal screening mammogram, or to view breast tissue that is hard to see on a screening mammogram. A diagnostic mammogram involves two or more x-rays in order to obtain views of the breast from several angles and takes longer than a screening mammogram. The technician can make a more detailed picture by magnifying the problem area to help make a correct diagnosis. A digital mammogram also uses x-rays to produce an image of the breast, but the image is stored directly on a computer instead of on film allowing the recorded image to be magnified and looked at more closely. Current research has not shown that digital images are better at showing cancer than x-ray film images in general. However, the ability to control images on a computer makes digital mammography more accurate for women with dense breasts who are pre- or perimenopausal, or who are younger than age 50. Digital mammography may offer these benefits: • Long-distance consultations with other doctors may be easier because the images can be shared by computer. • Slight differences between normal and abnormal tissues may be more easily noted. • The number of follow-up tests needed may be fewer. • Fewer repeat images may be needed, reducing exposure to radiation. With all mammograms, radiologists analyze the x-ray images for abnormal breast changes and for differences in each breast. Past mammograms are compared with the most recent one to check for changes. Healthcare providers will also look for the following: • Lump or mass. The size, shape, and edges of a lump sometimes can give information about whether or not it may be cancer. On a mammogram, a benign growth often looks smooth and round with a clear, defined edge. Breast cancer often has an irregular shape and a jagged outline. • Calcification. A calcification is a calcium deposit in the breast tissue. On a mammogram, a calcification appears as small white spots. There are two types of breast calcifications: • Macrocalcifications are large calcium deposits often caused by aging and are considered noncancerous. They look like large white dots on a mammogram and are randomly dispersed. • Microcalcifications are small calcium deposits that look like tiny white specks on a mammogram. They may be found in an area of rapidly dividing cells.

For full detail of breast cancer screening algorithms, please refer to the CRICO Breast Care Management Algorithm at https://www.rmf.harvard.edu/~/media/Files/_Global/KC/PDFs/Guidelines/cricormfbca2014_locked.pdf

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If calcifications appear in certain patterns and are clustered together, it may be a sign of precancerous cells or early breast cancer. Other diagnostic tests may be suggested depending on how many calcium specks the patient has, how big they are, and what they look like. Patients should be advised that calcium in the diet does not create calcium deposits, or calcifications, in the breast. 3D mammography, also known as tomosynthesis, takes multiple images of the entire breast and converts the images into a stack of very thin layers that builds a 3-dimensional mammogram allowing radiologists to examine breast tissue in far greater detail than a traditional mammogram. In comparison, conventional digital mammography produces one image of overlapping tissue, making it more difficult to detect cancers. 3D mammography does not replace the conventional mammography. It is used as an additional tool to improve breast cancer detection. 3D mammography has the following benefitsxvi: • Earlier detection of abnormalities that are not detected by traditional mammograms • Provides a clearer, more detailed view compared to digital mammography alone, which is especially beneficial for dense breast tissue

What is breast density? Women’s Health Connection Program is collaborating with the Nevada Cancer Coalition and Each One. Tell One. to change the standard of breast cancer screening for women with dense breast tissue in which a mammogram examination alone is not enough. We are committed to changing current protocols for dense breast tissue screening and engaging patients to speak with their doctor and determine what additional screening option may be right for them.

• 10% of women have Almost entirely fatty breasts

• 40% have Heterogeneously dense breasts

• 10% of women have Extremely dense breasts • 40% have Scattered areas of fibro glandular density in breastsxix

• More accuracy in pinpointing the location, size and shape of abnormalities • Fewer additional tests or unnecessary biopsies • Greater likelihood of detecting multiple breast tumors According to the Journal of American Medical Association (JAMA) , 3D mammography finds significantly more invasive cancers and reduces unnecessary recalls: • 41% increase in invasive cancer detected with 3D mammography • 15% decrease in recall rate from screening mammography • 29% increase in the detection of all breast cancers 3D mammography is recommended for women over 40 who have dense breast tissue or women who are at high risk for breast cancer.

What if a patient’s screening mammogram shows a problem?xvii If a patient has a screening test result that suggests cancer, the health care provider must investigate whether it is due to cancer or to some other cause. The health care provider should inquire about the patient’s personal and family medical history and encourage the patient to have a physical exam. In addition, the following diagnostic tests can be ordered: • Diagnostic mammogram, to focus on a specific area of the breast. • Ultrasound, an imaging test that uses sound waves to create a picture of the breast. The pictures may show whether a lump is solid, which may be cancer, or a cyst filled with fluid, which is not cancer. After the test, the pictures can be stored on video or printed out. This exam may be used along with a mammogram. • Magnetic resonance imaging (MRI), which uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue that can be viewed on a monitor or printed on film. MRI may be used along with a mammogram. • Biopsy, a test in which fluid or tissue is removed from the breast to help determine if there is cancer. The patient can be referred to a surgeon or to another doctor who is an expert in breast disease for a biopsy.

Where can a patient get a high-quality mammogram? Women can get high-quality mammograms in breast clinics, hospital radiology departments, mobile vans, private radiology offices, and doctors’ offices. The Food and Drug Administration (FDA) certifies mammography facilities that meet strict quality standards for their x-ray machines and staff and are inspected every year. A list of FDA-certified facilities can be found on the Internet. If necessary, patients can be advised about local medical clinics or local or state health departments that can refer them to no-cost or low-cost mammograms. The health care provider can also call the National Cancer Institute’s Cancer Information Service toll free at (800) 422-6237. 16

Breasts are made up of fat and breast tissue (the milk ducts and lobules, which may be called glandular tissue). Connective tissue helps to hold everything in place. Breast density is a measure used to describe the proportion of the different tissues that make up a woman’s breasts. • High breast density means there is a greater amount of breast and connective tissue compared to fat. On a mammogram, dense breast tissue appears white, as do cancerous tumors. It is very difficult to detect earlier stage tumors in women with dense breasts. • Low breast density means there is a greater amount of fat compared to breast and connective tissue. Fat is radiolucent, creating a dark background to detect cancerous tumors against.xx

BI-RADS tissue composition categories are divided into 4 classes: • Category A – Predominantly fatty • Category B – Scattered densities • Category C – Heterogeneously dense • Category D – Extremely dense

Fatty

Scattered

Images courtesy of Daniel E. Herron, MD

Heterogeneously Dense

Extremely Dense

Women with dense breast tissue should have a conversation with their doctor to have supplemental screening such as an ultrasound or breast MRI for early breast cancer detection in addition to mammogram. Women with dense breast tissue should be aware of their potential increased risk of breast cancer and the limitations of mammograms in their specific situation. According to Ann Partridge, MD, MPH, Clinical Director of the Breast Oncology Center at Dana-Farber Cancer Institute and Associate Professor of Medicine at Harvard Medical School, “breast density is clearly a risk factor for breast cancer which we are now figuring out how to use to help women better understand their individual risk and hopefully will someday be a risk factor that we can modify to reduce risk.” In Nevada, it is the law for a clinician performing mammography to notify patients who have dense breast tissue about supplementary screening tests by providing a report to the patient (AB147). In the 2015 Nevada Legislature session, SB 458 was passed which revises the language of notices provided to women who receive a mammogram. Please Note: 3D mammography is a beneficial supplemental screening for all women over 40, including those who have dense breast tissue or women who are at high risk for breast cancer. To learn more about dense breast tissue, please visit www.eachonetellone.com.

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Core Competencies of a Clinical Breast Exam

What if a patient has breast implants? Women with breast implants should also have mammograms and an additional supplemental breast screening. A woman who had an implant after mastectomy should be advised as to whether or not a mammogram of the reconstructed breast is needed.

Health history questions regarding age, family history, personal history, reproductive history

Clavicular Palpate deep above & below the clavicle Axillary Palpate in a diamond pattern Deep at the apex Medially along pectoralis muscle Laterally along subscapular muscle High under humeral head

Review patient’s concerns or symptoms

Limitations of Mammography

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Assess actual and perceived risk

Although mammograms are not perfect, they are the best method to find breast changes that cannot be felt. If a mammogram shows a breast change, the patient should be advised that other tests may be needed to investigate further and that it does not necessarily mean it is cancer. Patients should be advised that as with any medical test, mammograms have limits, which include: •

LYMPH NODE EXAM

HISTORY

If the patient has breast implants, they must be sure to inform the mammography facility when the appointment is made. It is important that the patient has a technician and radiologist that are experienced in x-raying patients with breast implants. Implants can hide some breast tissue, making it harder for the radiologist to see a problem when looking at the mammogram. To see as much breast tissue as possible, the x-ray technician will gently lift the breast tissue slightly away from the implant and take extra pictures of the breasts.

PATIENT POSITIONING

VISUAL INSPECTION

Not effective in early detection for women with dense breast tissue. An additional screening tactic such as an ultrasound may be necessary to increase early cancer detection in women with dense breasts. While mammography detected 98% of cancer in women with fatty breasts, it found only 48% of cancer in women with dense breast tissue (American Medical Association: 9/2002 & AMA Scientific Paper of the Year Award).

In sitting position check for: Symmetry Skin changes

• They are only part of a complete breast exam, which includes an annual clinical breast exam. If the mammogram finds something abnormal, other tests will be ordered.

Nipple changes Hip elevated 90° Knees flexed Elbow - 90° angle Support lower back or shoulder Elbow - 90° angle, back of hand on forehead

Dimpling

• Finding cancer does not always mean saving lives. Even though mammography can detect tumors that cannot be felt, finding a small tumor does not always mean that a woman’s life will be saved. Mammography may not help a woman with a fast growing cancer that has already spread to other parts of her body before being found.

VenousPattern

• False negatives can happen. This means everything may look normal, but cancer is actually present. False negatives don’t happen often. Younger women are more likely to have a false negative mammogram than are older women. The dense breasts of younger women make breast cancers harder to find in mammograms.

PERIMETER & PATTERN

• False positives can happen. This is when the mammogram results look like cancer is present, even though it is not. False positives are more common in younger women, women who have had breast biopsies, women with a family history of breast cancer, and women who are taking estrogen, such as menopausal hormone therapy.

(800) 227-2345 (TDD: 866-228-4327)

Breast Health Access for Women With Disabilities

(510) 204-4866 (TDD: 510-204-4574)

Centers for Medicare and Medicaid Services, HHS

(800) 633-4227 (TDD: 877-486-2048)

National Breast and Cervical Cancer Early Detection Program

(800) 232-4636 (TDD: 888-232-6348)

National Cancer Institute, NIH, HHS

(800) 422-6237

Susan G. Komen for the Cure

(877) 465-6636

Each One Tell One

Eachonetellone.com

Nevada Cancer Coalition

(775) 737-9720

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le

American Cancer Society

PRESSURE

Dime size circles

vic

(877) 385-2345 Se habla Español

Pads of three middle fingers

DIME JAMA, Vol. 282, No 13, Oct. 1999

Mid-axillary line

For more information about mammograms, call womenshealth.gov at 800-994-9662 (TDD: 888-220-5446) or contact the following organizations:

Women’s Health Connection

Sternalborder

Cla

InframammaryRidge

More information on mammogramsxxiv

TELEPHONE

PALPATION

(VERTICAL STRIP)

• Mammograms (as well as dental x-rays and other routine x-rays) use very small doses of radiation. The risk of any harm is very slight, but repeated x-rays could cause cancer. The benefits nearly always outweigh the risk. Patients can ask about shielding to protect parts of the body that are not in the picture. Patients should be asked if there is any chance that they are pregnant.

ORGANIZATION

Supine

Cahan

Slide or walk between palpations without lifting fingers

START HERE

PLAN OF ACTION & PATIENT ED Determine next steps for abnormal results

Light

Medium

Deep JAMA, Vol. 282, No 13, Oct. 1999

Stress importance of adherence to f/u Emphasize rescreening Impart cultural sensitivity

DOCUMENTATION Discreet Mass Location Size Shape Margins Mobility Consistency Tenderness

Patient concerns Exam findings Plan of action Referrals made Patient education Results notification (tests/procedures)

Discuss/teach BSE

Information adapted from the 2011 Cancer Detection Section. California Department of Public Health.

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Cervical Cancer

Although cervical cancers start from cells with pre-cancerous changes (pre-cancers), not all women with pre-cancers of the cervix will develop cancer. In addition, cervical cancer does not develop rapidly, and it usually takes several years for cervical pre-cancer to change to cervical cancer, although it can happen in less than a year. For most women, pre-cancerous cells will go away without any treatment, but in some women, pre-cancers turn into true (invasive) cancers.

What is Cervical Cancer?xxv The cervix is the lower, narrow end of the uterus (the womb), which connects the body of the uterus to the vagina (the birth canal). The part of the cervix closest to the body of the uterus is called the endocervix and the part next to the vagina is the exocervix (or ectocervix). The two main types of cells covering the cervix are squamous cells (on the exocervix) and glandular cells (on the endocervix). These two cell types meet at a place called the transformation zone. The exact location of the transformation zone changes as a woman ages and if she gives birth.

What are the symptoms? Cervical cancer may not cause signs and symptoms in its early stages. Advanced cervical cancer may cause bleeding or discharge from the vagina that is new or not normal for the patient, such as bleeding after sex, between periods or after menopause.

Cervical Cancer: The Importance of Screening and Preventionxxvi

Fallopian Tubes

Cervical cancer is one of the most successfully treatable cancers when pre-cancer is detected early, and can be treated if necessary. According to the National Cancer Institute, there are two proven ways to stop cervical cancer from developing – screening and prevention. The Pap and HPV (human papillomavirus) tests are screening tools used to prevent or detect cervical cancer at an early stage when successful treatment is likely.

Ovaries

Endocervix Body of Uterus

Cervical cancer is preventable and highly curable with regular screening tests, follow-up and early treatment. Although cervical cancer occurs most often in women over age 30, all women are at risk.

Cervix Exocervix

Vagina

According to the American Cancer Society, most cervical cancers begin in the cells in the transformation zone where normal cells of the cervix gradually develop pre-cancerous changes that turn into cancer. There are several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia. These cellular changes can be detected by the Pap test and treated to prevent cancer from developing. The main types of cervical cancers are squamous cell carcinoma and adenocarcinoma, categorized by how they look under a microscope. Nine out of ten cervical cancers are squamous cell carcinomas, formed in the exocervix. These squamous cell carcinomas most often begin in the transformation zone where the exocervix joins the endocervix.



The Pap test (or Pap smear), which is recommended for all women starting at age 21, is one of the most reliable and effective cancer screening tests available. The Pap test only screens for cervical cancer; it does not screen for any other gynecological cancer. It looks for precancers, or cell changes, on the cervix that can be treated to prevent cervical cancer from developing.

• The HPV test screens for HPV—the virus that can cause precancerous cell changes and cervical cancer. The HPV test may be used for women aged 30 years and older, or at any age for those who have abnormal Pap test results. If a woman is 30 years or older and her screening tests are normal, her chance of getting cervical cancer in the next few years is very low, and she should be informed that for that reason she will not need another screening test for up to three years. If the patient has cervical cancer, she should be referred to a gynecologic oncologist who is trained to treat these cancers and will work with the patient to create a tailored treatment plan. The cervical cancer death rate in the United States declined by more than 50% over the last 30 years, due to increased screening and diagnosis. This decrease is largely attributed to the effectiveness of Pap test screening. Despite this, and the widely recognized benefits of cervical cancer screening, not all American women take advantage of screening. In fact, the majority of cervical cancers are found in women who have never had a Pap test or who have not had one recently. Women without health insurance and those who have recently immigrated, are even less likely to have timely cervical cancer screening. According the Nevada Cancer Coalition, based on 2012 data, Nevada’s screening rate for cervical cancer is at 72.6%, which is below the national rate of 84.5%. In addition, the percentage of women reported as being up to date with cervical cancer screening dropped nearly 6% from 2010 to 2012.xxvii Efforts must be increased to ensure all women understand the importance of being screened for cervical cancer. For full detail of cervical cancer screening algorithms, please visit the American Society for Colposcopy and Cervical Pathology Algorithms at http://www.asccp.org/Portals/9/docs/ASCCP%20Management%20Guidelines_August%202014.pdf

Most other cervical cancers are adenocarcinomas, which develop from the mucus-producing gland cells of the endocervix. According to the American Cancer Society, cervical adenocarcinomas seem to have become more common in the past 20 to 30 years. Although less common, adenosquamous carcinomas or mixed carcinomas have features of both squamous cell carcinomas and adenocarcinomas. 20

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Cervical Cancer Facts and Statisticsxxviii

• Suppressed immune system: A weakened immune system, such as that caused by HIV or by drugs used for suppressing immune response, places women at higher risk for HPV infection and also for cervical cancer.

• In 2014, an estimated 12,360 new cases of invasive cervical cancer will be diagnosed in U.S. women.

• Smoking: The risk of squamous cell cervical cancer is increased for women who smoke. Smoking not only exposes the body to cancer-causing chemicals but also weakens the immune system. Smoking does not appear to increase risk for adenocarcinoma of the cervix.

• In 2014, an estimated 4,020 U.S. women will die from the disease. • In Nevada, an annual average of 116 cases of cervical cancer are newly diagnosed every year. • In 2006-2008, on average there were 34 deaths by cervical cancer each year in Nevada. • Most women with cervical cancer are diagnosed before the age of 50; from 2006 to 2010, the median age was 49. However, older women remain at risk. More than 20% of new cases are diagnosed in women over 65. Cervical cancer in women younger than age 20 is rare. • In the U.S., African American women have the highest rate of cervical cancer, followed by Hispanics, Caucasians, American Indian/Alaska Natives, and Asian American/Pacific Islanders. Mortality rates are highest for African American women. • Between 1955 and 1992, the rate of cervical cancer deaths in the U.S. declined by nearly 70%. It continued declining more gradually to 2003 before stabilizing. The overall decline is mainly attributed to the increased use of the Pap test. • When detected at its earliest stage, cervical cancer has a 5-year relative survival rate of approximately 91%. For regional disease, it is approximately 57%. If cancer has spread to distant organs, 5-year survival drops to approximately 16%. In general, the prognosis is affected by the extent of disease at the time of diagnosis.

• First full-term pregnancy at a young age: A first full-term pregnancy in women younger than age 17 nearly doubles the risk of developing cervical cancer later in life, as compared with women who had their first full-term pregnancy at age 25 and older. • Multiple full-term pregnancies: Women with three or more full-term pregnancies have an increased risk of developing cervical cancer. Hormonal changes or weaker immune systems during pregnancy are possible reasons. • Family history of cervical cancer: A woman with a mother or sister with cervical cancer has 2 to 3 times the risk of women without this family history. •

Oral contraceptives: The long-term use (five or more years) of oral contraceptives has been shown to increase the risk of developing cervical cancer. A collaborative analysis of data from 24 epidemiological studies found that risk increases with duration and declines after use ceases. After 10 or more years of cessation, risk appears to return to that of normal. Clinicians are encouraged to discuss with their patients whether the benefits of fertility management outweigh the potential risks.

• As of January 2010, there were approximately 250,000 cervical cancer survivors living in the U.S.

• Chlamydia infection: Some studies have shown higher relative risk in women whose blood test results show evidence of either past or current chlamydia infection.

Risk Factors:

• Diet and weight: A diet low in fruits and vegetables, as well as being overweight, may place women at increased risk for developing cervical cancer.

Human papillomavirus (HPV) • Virtually all (99.7%) cervical cancers are caused by persistent infection with a high-risk type of human papillomavirus (HPV). There are approximately 15 high-risk (oncogenic) types of HPV, with just two of these, 16 and 18, responsible for about 70% of all cervical cancers. • Although HPV is most commonly spread from one person to another through sexual activity, it can also be spread without sex, by skin-to-skin contact with an area of the body infected with HPV. • More than half of all sexually active people will be infected with one or more HPV types at some point during their lives. However, the vast majority of HPV infections do not lead to cervical cancer. For cervical cancer to develop, a high-risk infection must also be persistent. • Most HPV infections are transient. Up to 90% resolve within two to five years. On average, a newly diagnosed HPV infection in young women lasts from 8 to 13 months. • Aging is a risk factor for persistent infection. The rate of persistent high-risk infection for women older than age 55 is 50%, compared with a persistence rate of 20% in women younger than age 25. • While long-term infection is necessary for cervical cancer to develop, the vast majority of women with persistent high-risk infection do not develop cervical cancer.

• Diethylstilbestrol (DES): DES may increase the risk of a rare form of cervical cancer in women whose mothers took DES when pregnant. About 1 case of this rare form occurs in every 1,000 DES daughters. (DES was given to some pregnant women in the United States from 1940 to 1971.)

Risk Reduction: •

HPV Vaccines: Three FDA approved vaccines (brand names, Gardasil, Gardisil 9 and Cervarix) are highly effective in preventing infection with the types of HPV they target. Gardasil protects against HPV types 6, 11, 16 and 18, Gardisil 9 protects against 6, 11, 16, 18, 31, 33, 45, 52 and 58, and Cervarix targets against types 16 and 18 (16 and 18 are responsible for about 70% of all cervical cancers). The FDA has approved Gardasil for use in females ages 9 through 26 and males 9 through 21 or males age 22 through 26 who have sex with men, who have a weakened immune systems, or who have HIV. Gardisil 9 is FDA approved for use in females ages 9 through 26, and males 9 through 15 years of age, and Cervarix for use in females ages 9 to 25. Patients should be vaccinated before becoming sexually active; that is, before they may be exposed to HPV. However, even for persons who have been infected with one or more HPV types, the vaccine can still prevent infection from HPV types not yet acquired.

• Screening: Vaccination is not a substitute for screening with Pap tests. Even in women who have been vaccinated, cervical cancer can still occur. Screening is the most effective means for finding changes in the cervix before cancer has a chance to develop.

Other factors: Other factors have been found to increase the risk of developing cervical cancer, either by increasing the risk of HPV infection or by increasing the chances of developing cervical neoplasia following a high-risk infection. These other factors are as follows: • 22

Sexual activity: The main risk factors for HPV infection through sexual activity are early onset of sexual activity, multiple sexual partners, and high-risk sexual partners. However HPV is so prevalent, and most people do not have symptoms so any sexual encounter puts you at risk. Condoms decrease the transmission of HPV, however HPV lives on the skin and condoms do not fully cover the areas where HPV lives. Condoms are important in preventing the spread of HIV and Hepatitis and other sexually transmitted infections. 23

Cervical Cancer Screening Guidelinesxxix How often a patient should have cervical cancer screening depends on her age and health history. New screening guidelines from the American College of Obstetricians and Gynecologists recommend: • Screening starting at age 21. • A Pap test every three years, if the patient is 21-29 years old.

The new approval was based on findings from the long term ATHENA clinical trial that included more than 47,000 women, and produced results showing that the HPV test used in the study performed better than the Pap test at identifying women at risk of developing severe cervical cell abnormalities. HPV testing further demonstrated its benefits in a cohort study of more than a million women who, three years after testing negative on HPV test, had an extremely low risk of developing cervical cancer—about half the already low risk of women who tested negative on the Pap test.

• Stopping screening after age 65, depending on health history. • A Pap test and an HPV test every five years, if the patient is 30-65 years old. A Pap test alone can be done every three years. • Women who have had complete hysterectomies should stop cervical cancer screening unless the hysterectomy was done as a treatment for cervical pre-cancer or cancer. • Women who have had a partial hysterectomy and their cervix was left intact should continue screening. These guidelines are for low-risk women who have had no history of recent abnormal Pap tests, a compromised immune system, HIV infection or diethylstilbestrol (DES) exposure. The guidelines are a change from the annual screening that the patient may have had in the past and are meant to decrease unnecessary testing and potentially harmful treatment from overuse of Pap tests. Health care providers are encouraged to talk to their patients to determine whether and how often screening is necessary based on the individual patient’s needs and health history. Women should still be encouraged to see their health care provider regularly for well-women care, including pelvic and breast exams, and any reproductive health care information.

First-line HPV testing has not yet been incorporated into the current professional cervical cancer screening guidelines. Professional societies are developing interim guidance documents, and some medical practices might incorporate primary HPV screening.

How are the results of cervical cancer screening tests reported?xxxii A health provider may simply describe Pap test results to a patient as “normal” or “abnormal.” Similarly, HPV test results can either be “positive,” meaning that a patient’s cervical cells are infected with high-risk HPV, or “negative,” indicating that high-risk HPV types were not found. Most laboratories in the United States use the Bethesda System, which includes a standard set of terms, to report Pap test results. Under the Bethesda System, samples that have no cell abnormalities are reported as “negative for intraepithelial lesion or malignancy.” A negative Pap test report may also note certain benign (non-neoplastic) findings, such as common infections or inflammation. Pap test results also indicate whether the specimen was satisfactory or unsatisfactory for examination.

Pap test and Co-testing (Pap and HPV test) What are the benefits of Pap and HPV co-testing?xxx The National Cancer Institute (NCI) provides data and screening information about Pap and HPV co-testing on their website, which we have provided below. The NCI states that for women age 30 and older, Pap and HPV co-testing is less likely to miss an abnormality (i.e., has a lower false-negative rate) than Pap testing alone (discussed in detail below). For this reason, a woman with a negative HPV test and normal Pap test has very little risk of a serious abnormality developing over the next several years. In fact, researchers have found that when Pap and HPV co-testing is used, lengthening the screening interval to five years still allows abnormalities to be detected in time to treat them while also reducing the detection of HPV infections that would have gone away on their own. Adding HPV testing to Pap testing may also improve the detection of glandular cell abnormalities, including adenocarcinoma of the cervix (cancer of the glandular cells of the cervix). Glandular cells are mucus-producing cells found in the endocervical canal (the opening in the center of the cervix) or in the lining of the uterus. Glandular cell abnormalities and adenocarcinoma of the cervix are much less common than squamous cell abnormalities and squamous cell carcinoma. There is some evidence that Pap testing is not as good at detecting adenocarcinoma and glandular cell abnormalities as it is at detecting squamous cell abnormalities and cancers.

Can HPV testing be used alone for cervical cancer screening?xxxi On April 24, 2014, the Food and Drug Administration (FDA) approved the use of one HPV DNA test (cobas HPV test, Roche Molecular Systems, Inc.) as a first-line primary screening test for use alone for women age 25 and older. The test detects each of HPV types 16 and 18 and gives pooled results for 12 additional high-risk HPV types.

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The Bethesda System considers abnormalities of squamous cells and glandular cells separately. Squamous cell abnormalities are divided into the following categories, ranging from the mildest to the most severe:

Glandular cell abnormalities describe abnormal changes that occur in the glandular tissues of the cervix. These abnormalities are divided into the following categories:

TYPES OF GLANDULAR CELL ABNORMALITIES

TYPES OF SQUAMOUS CELL ABNORMALITIES Atypical squamous cells (ASC)

Low-grade squamous intraepithelial lesions (LSILs)

High-grade squamous intraepithelial lesions (HSILs)

Squamous cell carcinoma

The most common abnormal finding in Pap tests. The Bethesda System divides this category into two groups, ASC-US and ASC-H. •

ASC-US: atypical squamous cells of undetermined significance. The squamous cells do not appear completely normal, but doctors are uncertain about what the cell changes mean. The changes may be related to an HPV infection, but they can also be caused by other factors.



ASC-H: atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion. The cells do not appear normal, but doctors are uncertain about what the cell changes mean. ASC-H lesions may be at higher risk of being precancerous compared with ASC-US lesions.

Considered mild abnormalities caused by HPV infection. Low-grade means that there are early changes in the size and shape of cells. Intraepithelial refers to the layer of cells that forms the surface of the cervix. When cells from the abnormal area are removed and examined under a microscope (in a procedure called a biopsy), LSILs are usually found to have mild cell changes that may be classified as mild dysplasia or as cervical intraepithelial neoplasia, grade 1 (CIN-1). More severe abnormalities that have a higher likelihood of progressing to cancer if left untreated. High-grade means that there are more evident changes in the size and shape of the abnormal (precancerous) cells and that the cells look very different from normal cells. When examined under a microscope, the cells from HSILs are often found to have more extensive changes that may be classified as moderate or severe dysplasia or as CIN-2, CIN-2/3, or CIN-3 (in order of increasing severity). Microscopic examination of HSILs may also reveal carcinoma in situ (CIS), which is commonly included in the CIN-3 category. This is cervical cancer. The abnormal squamous cells have invaded more deeply into the cervix or into other tissues or organs. In a well-screened population, such as that in the United States, a finding of cancer during cervical screening is extremely rare.

Atypical glandular cells (AGC)

The glandular cells do not appear normal, but doctors are uncertain about what the cell changes mean.

Endocervical adenocarcinoma in situ (AIS)

Severely abnormal cells are found but have not spread beyond the glandular tissue of the cervix.

Adenocarcinoma

Includes not only cancer of the endocervical canal itself but also, in some cases, endometrial, extrauterine, and other cancers.

Follow-up Testing for Abnormal Cervical Cancer Screeningxxxiii For a woman receiving Pap and HPV co-testing: If a woman is found to have a normal Pap test result with a positive HPV test that detects the group of high-risk HPV types, the doctor will usually have her return in a year for repeat screening to see if the HPV infection persists and to determine whether any cell changes have developed that need further follow-up testing. Alternatively, the woman may have another HPV test that looks specifically for HPV-16 and HPV-18, the two HPV types that cause most cervical cancers. If either of these two HPV types is present, a woman will usually have follow-up testing with colposcopy. Colposcopy is the use of an instrument much like a microscope (called a colposcope) to examine the vagina and the cervix. During a colposcopy, the doctor inserts a speculum into the vagina to widen it and may apply a dilute vinegar solution to the cervix, which causes abnormal areas to turn white. The doctor then uses the colposcope (which remains outside the body) to observe the cervix. When a doctor performs colposcopy, he or she will usually remove cells or tissues from the abnormal area for examination under a microscope, a procedure called a biopsy. If a woman is found to have an abnormal Pap test result with a negative (normal) HPV test, the follow-up diagnostic tests will depend on the Pap test result. If the Pap test result is ASC-US, the doctor will usually have the woman return in 3 to 5 years for a repeat screen. If the Pap test result is LSIL, the doctor may recommend colposcopy or might have the woman return in a year for repeat screening. If a woman is found to have an abnormal Pap test result with a positive HPV test that detects any high-risk HPV type, the doctor will usually have the woman receive follow-up testing with colposcopy.

For a woman receiving Pap testing alone: If a woman who is receiving Pap testing alone is found to have an ASC-US Pap test result, her doctor may have the sample tested for high-risk HPV types or may repeat the Pap test to determine whether further follow-up is needed. Many times, ASC-US cell changes in the cervix go away without treatment, especially if there is no evidence of infection with high-risk HPV. Doctors may prescribe estrogen cream for women with ASC-US who are near or past menopause. Because ASC-US cell changes can be caused by low hormone levels, applying an estrogen cream to the cervix for a few weeks can usually help to clarify their cause. Follow-up testing for all other abnormal Pap results will typically involve a colposcopy.

For a woman receiving HPV-alone testing: If a woman who is having HPV-alone testing tests positive for HPV types 16 or 18, she should, according to guidance from the FDA, have a colposcopy. A women who tests negative for types 16 and 18 but is positive for one of the 12 other high-risk HPV types should have a Pap test to determine whether a colposcopy is needed.

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How are cervical abnormalities treated? If biopsy analysis of cells from the affected area of the cervix shows that the cells have CIN-2 or more severe abnormalities, further treatment may be needed depending on a woman’s age, pregnancy status, and future fertility concerns. Without treatment, these cells may turn into cancer. Treatment options include the following: • LEEP (loop electrosurgical excision procedure), in which an electrical current that is passed through a thin wire loop acts as a knife to remove tissue; • Cryotherapy, in which abnormal tissue is destroyed by freezing it; • Laser therapy, the use of a narrow beam of intense light to destroy or remove abnormal cells; • Conization, the removal of a cone-shaped piece of tissue using a knife, a laser, or the LEEP technique. The screening guidelines call for women who have been treated for CIN-2 or more severe abnormalities to continue screening for at least 20 years, even if they are over 65.

Do women who have been vaccinated against HPV still need to be screened for cervical cancer? Yes. Although HPV vaccines protect against HPV strains that cause about 70% of cervical cancers, there are still HPV strains that can cause cervical cell changes. Therefore it is important for vaccinated women to continue to undergo routine cervical cancer screening.

What are the limitations of cervical cancer screening? Although cervical cancer screening tests are highly effective, they are not completely accurate. Sometimes a patient can be told that she has abnormal cells when the cells are actually normal (a false-positive result), or she can be told that her cells are normal when in fact there is an abnormality that was not detected (a false-negative result). Cervical cancer screening has another limitation, caused by the nature of HPV infections. Because most HPV infections are transient and produce only temporary changes in cervical cells, overly frequent cervical screening could detect HPV infections or cervical cell changes that would never cause cancer. Treating abnormalities that would have gone away on their own can cause needless psychological stress. In addition, follow-up tests and treatments can be uncomfortable, and some treatments that remove cervical tissue, such as LEEP and conization, have the potential to weaken the cervix and may affect fertility or slightly increase the rate of premature delivery, depending on how much tissue is removed. The screening intervals in the 2012 guidelines are intended to minimize the harms caused by treating abnormalities that would never progress to cancer while also limiting false-negative results that would delay the diagnosis and treatment of a precancerous condition or cancer. With these intervals, if an HPV infection or abnormal cells are missed at one screening, chances are good that abnormal cells will be detected at the next screening exam, when they can still be treated successfully.

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Resources The list below includes online resources offered by the Centers for Disease Control and Prevention (CDC) and other federal agencies that can support partnership development and programmatic efforts for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) programs. These resources contain information for public education and outreach; local, state, and national statistics and data; and tools for program planning.

Public Educationxxxiv NBCCEDP • Provides an overview of NBCCEDP, including: history, screening data, program highlights, and training materials. www.cdc.gov/cancer/nbccedp/

Current Population Survey (CPS) •

Monthly survey of about 50,000 households conducted by the Bureau of the Census for the Bureau of Labor Statistics. The CPS is the primary source of information on the labor force characteristics of the U.S. population and can be used to estimate the number of women eligible for NBCCEDP’s services in a particular area. Employment, unemployment, earnings, hours of work, and other indicators are evaluated. www.census.gov/cps/

Geographic Information Systems (GIS) •

Mapping software allowing users to map a variable or variables by geographic area. Maps can be overlaid to show bivariate distributions, helping to visualize areas of interest. For example, GIS can depict areas in a state with high cancer mortality rates and then overlay those with locations of screening providers—which can inform how NBCCEDP resources can most efficiently be utilized. http://gis.cancer.gov/

Interactive Cancer Atlas (InCa)

NBCCEDP Resources

• Allows users to create customized United States maps showing how many people were diagnosed with or died from cancer by cancer site, gender, race/ethnicity, and state during a given period. InCA uses data from United States Cancer Statistics (USCS), the official federal statistics on cancer incidence. http://www.cdc.gov/Features/Canceratlas/

• Contains resources for NBCCEDP programs, including: data resources, information on Minimum Data Elements (MDEs), current news, meetings, and past Ask Dr. Miller newsletters. www.nbccedp.org

Morbidity and Mortality Weekly Report (MMWR) - State Health Statistics

Inside Knowledge campaign • Website for Inside Knowledge campaign established to raise awareness of the five main types of gynecologic cancer: cervical, ovarian, uterine, vaginal, and vulvar. Provides resources, consumer materials, and messages. www.cdc.gov/cancer/knowledge/

Breast Cancer • Comprehensive compilation of resources about breast cancer, including basic facts, interactive tools, research, news, and more. Includes some nongovernment resources. www.nlm.nih.gov/medlineplus/breastcancer.html

Cervical Cancer • Comprehensive compilation of resources about cervical cancer, including basic facts, human papilloma-virus (HPV) information, interactive tools, and more. Includes some nongovernment resources. www.nlm.nih.gov/medlineplus/cervicalcancer.html • For information about immunizing against HPV, please visit www.Immunizenevada.org/HPVfreeNV. Immunize Nevada is a diverse coalition of individual, business and organization partners committed to improving and protecting the health of children, teens, adults and seniors in Nevada.

Statistics and Data Resources Behavioral Risk Factor Surveillance System (BRFSS) • State-based system of ongoing telephone health surveys that collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury. Many states use BRFSS data to support health-related legislative efforts. www.cdc.gov/brfss/

CDC Wonder •

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An easy-to-use, menu-driven system that makes the information resources of the CDC available to public health pro fessionals and the public at large. CDC Wonder provides access to a wide array of public health information, including cancer incidence and mortality data. It is also valuable in public health research, decision making, priority setting, program evaluation, and resource allocation. http://wonder.cdc.gov/

• Based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on Friday, and compiled data on a national basis are officially released to the public on the following Friday. www.cdc.gov/mmwr/StateHealth/index.html

National Program of Cancer Registries • Data collected by local cancer registries to help enable public health professionals to understand and address the cancer burden more effectively. Data includes: occurrence of cancer; the type, extent, and location of the cancer; and the type of initial treatment related to cancer cases and deaths in the U.S. www.cdc.gov/cancer/npcr/

Surveillance, Epidemiology and End Results (SEER) Cancer Statistics • Collects information on incidence, prevalence, and survival from specific geographic areas representing 26% of the U.S. population. Compiles reports on all of these plus cancer mortality for the entire country. http://seer.cancer.gov/

State Cancer Profiles •

Comprehensive system of interactive maps and graphs enabling the investigation of cancer trends at the national, state, and county levels. Aims to provide a system to characterize the cancer burden in a standardized manner in order to motivate action, integrate surveillance into cancer control planning, characterize areas and demographic groups, and expose health disparities. It is a collaboration between the National Cancer Institute (NCI) and CDC. http://statecancerprofiles.cancer.gov/

U.S. Cancer Statistics • Contains the official federal statistics on cancer incidence (newly diagnosed cases) from each registry that met data quality criteria. CDC and NCI have combined their cancer incidence data sources to produce these statistics. Mortality data from CDC’s National Vital Statistics System are also included for each state. http://apps.nccd.cdc.gov/uscs/

Resources Program Planning Cancer Control P.l.A.N.E.T. • Portal providing access to data and resources that can help planners, program staff, and researchers to design, implement, and evaluate evidence-based cancer control programs. http://cancercontrolplanet.cancer.gov/ 31

Guide to Community Preventive Services • Free resource to help program planners choose programs and policies to improve health and prevent disease in their communities. More than 200 interventions have been reviewed, and the Task Force on Community Preventive Services has issued recommendations for their use. http://thecommunityguide.org/index.html

National Comprehensive Cancer Control Program (NCCCP) •

Established in 1998 by the CDC, provides seed money and technical support for the development and implementation of plans for comprehensive cancer control, a collaborative process through which a community and its partners pool resources to reduce the burden of cancer. Like NBCCEDP, NCCCP has a national presence, with programs in all 50 states, the District of Columbia, seven tribes and tribal organizations, and seven U.S. territories.

Acknowledgements The Nevada Division of Public and Behavioral Health, Chronic Disease Prevention and Health Promotion Section, Women’s Health Connection would like to acknowledge the support and work of Nevada’s cancer community represented in this tool kit. First off, we would like to thank Each One. Tell One. and the Nevada Cancer Coalition for collaborating with the Women’s Health Connection to improve the standard of breast cancer screening for women with dense breasts. We would also like to thank Jason P. Crawford, MD, MPH, Chief Medical Officer at Community Health Alliance in Reno, Nevada, for your willingness to assist the program at any time and your dedication to the community you serve. A deep thank you to Tristan Stiles, PA-C, Community Health Alliance, for dedicating your time, voice and expertise to this project. Thank you to our partner in screening, the Access to Healthcare Network (AHN), for increasing resources and access to health care for underserved populations in Nevada. Thank you to the Nevada Central Cancer Registry (NCCR) and Nevada Office of Public Health Informatics and Epidemiology (OPHIE) for continuing to provide data collection, analysis and evaluation findings utilization. Thank you to Immunize Nevada’s HPV Task Force for always being available to work with the Women’s Health Connection Program, for your assistance in the completion of this tool kit and for your tireless efforts to educate Nevadans about cervical cancer prevention through immunization. Thank you to Emire Stitt and Cyndy Ortiz Gustafson for making this Breast and Cervical Cancer Toolkit a beautiful reality. Finally, thank you to our readers for serving the women of Nevada by preventing the burden of breast and cervical cancer through early detection. This toolkit was compiled for Nevada health care providers using existing resources, language, facts and statistics from a variety of national sources. We have cited those sources throughout, and thank the authors for the use of their data, definitions, screening guideline information, and models.

Authored by Strategic Progress, LLC. 32

Designed by Canyon Creative.

Producing Partner DP Video Productions. 33

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U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2010 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2013. Available at: http://www.cdc.gov/uscs.

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The American Cancer Society. Cancer Facts & Figures 2015. Atlanta: American Cancer Society; 2015. Available at http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf

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Percha, Bethany, Houssam Nassif, Jafi Lipson, and Et Al. “Automatic Classification of Mammography Reports by BI-RADS Breast Tissue Composition Class.” Standford.edu. J Am Med Inform Assoc. Published Online January 29, 2012. Doi: 10.1136/amiajnl-2011-000607, n.d. Web. Available at http://stanford.edu/~rubin/pubs/amiajnl-2011-000607

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Pinheiro, Paulo S., M.D., Ph.D., Savanna Reid, B.S., M.P.H., Christopher Saccucci, B. S., Deborah H. Harris, M.A., and Mary Guinan, M.D., Ph.D. “CANCER IN NEVADA” (2012): n. pag. UNLV, School of Community Health Sciences. Web. Available at http://health.nv.gov/Cancer/2012/CancerinNevadaReport.pdf iv

“About the Program. National Breast and Cervical Cancer Early Detection Program (NBCCEDP).” Centers for Disease Control and Prevention, 24 Mar. 2015. Web. 20 May 2015. Available at http://www.cdc.gov/cancer/nbccedp/about.htm.

“Breast Density, Breast Cancer Screening.” (n.d.): n. pag. Acr.org. American College of Radiology. Web. Available at http://www.acr.org/News-Publications/~/media/180321AF51AF4EA38FEC091461F5B695.pdf https://www.leg.state.nv.us/Session/77th2013/Bills/AB/AB147.pdf and http://www.leg.state.nv.us/Session/78th2015/Bills/SB/SB458.pdf

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“EPublications.” Mammograms Fact Sheet. Office on Women’s Health, U.S. Department of Health and Human Services, n.d. Web. 20 May 2015. Available at http://womenshealth.gov/publications/our-publications/fact-sheet/mammograms.html xxiii

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“About the Program. National Breast and Cervical Cancer Early Detection Program (NBCCEDP).” Centers for Disease Control and Prevention, 24 Mar. 2015. Web. 17 May 2015. Available at http://www.cdc.gov/cancer/nbccedp/about.htm.

“EPublications.” Mammograms Fact Sheet. Office on Women’s Health, U.S. Department of Health and Human Services, n.d. Web. 20 May 2015. Available at http://womenshealth.gov/publications/our-publications/fact-sheet/mammograms.html xxiv

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“About the Program. National Breast and Cervical Cancer Early Detection Program (NBCCEDP).” Centers for Disease Control and Prevention, 24 Mar. 2015. Web. 20 May 2015. Available at http://www.cdc.gov/cancer/nbccedp/about.htm.

“What Is Cervical Cancer?” The American Cancer Society, N.p., n.d. Web. 17 May 2015. Available at http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-what-is-cervical-cancer xxv

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“Women’s Health Connection (WHC), Breast and Cervical Cancer Early Detection Program.” Nevada Division of Public and Behavioral Health. Department of Health and Human Services, Nevada Division of Public and Behavioral Health, N.p., n.d. Web. 20 May 2015. Available at http://health.nv.gov/CD_WHC_BreastCervical_Cancer.htm. viii

“What Is Breast Cancer?” Centers for Disease Control and Prevention, 07 Oct. 2014. Web. 20 May 2015. Available at http://www.cdc.gov/cancer/breast/basic_info/what-is-breast-cancer.htm.

“The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer.” The American Cancer Society, n.d. Web. 21 May 2015. Available at http://www.cancer.org/cancer/cervicalcancer/moreinformation/cervicalcancerpreventionan dearlydetection/cervical-cancer-prevention-and-early-detection-cervical-cancer-screening-guidelines xxvi

“Cervical Cancer and HPV - The Nevada Cancer Coalition.” The Nevada Cancer Coalition. N.p., n.d. Web. 21 May 2015. Available at http://nevadacancercoalition.org/cancer-facts/cervical-cancer/ xxvii

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American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2015-2016. Atlanta: The American Cancer Society 2015. Available at http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-045101.pdf

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http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf

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“Pap and HPV Testing.” National Cancer Institute. N.p., n.d. Web. 20 May 2015. Available at http://www.cancer.gov/cancertopics/types/cervical/pap-hpv-testing-fact-sheet xxxii

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“Pap and HPV Testing.” National Cancer Institute. N.p., n.d. Web. 20 May 2015. Available at http://www.cancer.gov/cancertopics/types/cervical/pap-hpv-testing-fact-sheet xxxiii

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“National Comprehensive Cancer Control Program (NCCCP).” Centers for Disease Control and Prevention, 20 Apr. 2015. Web. 21 May 2015. Available at www.cdc.gov/cancer/ncccp/ xxxiv

“Massachusetts General Hospital | Imaging.” Breast Tomosynthesis. N.p., n.d. Web. 20 May 2015. Available at http://www.massgeneral.org/imaging/services/3D_mammography_tomosynthesis.aspx xvi

JAMA. 2014;311(24):2499-2507. doi:10.1001/jama.2014.6095.

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“EPublications.” Mammograms Fact Sheet. Office on Women’s Health, U.S. Department of Health and Human Services, n.d. Web. 20 May 2015. Available at http://womenshealth.gov/publications/our-publications/fact-sheet/mammograms.html xviii

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This publication was supported by the Nevada Division of Public and Behavioral Health (DPBH) through the Grant Number # 3U58DP003929-03W1 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the DPBH or CDC.

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Women’s Health Connection

Get screened! Stay Healthy!