Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Amanda Wilde (Host): The fourth most common cancer among women is cervical cancer, but it is treatable and even preventable. So today, we're talking about symptoms, risk factors and screening with Dana Fuqua, DNP, WHNP-BC, Women's Health provider at Skagit Regional Health.

This is Be Well with Skagit Regional Health. I'm Amanda Wilde. Dana, thank you for being here.

Dana Fuqua, DNP, WHNP-BC: Thank you so much for having me. It's great to meet you.

Amanda Wilde (Host): What are the most common signs of cervical cancer?

Dana Fuqua, DNP, WHNP-BC: I love that that's the first question because it's one of the trickiest ones. Cervical cancer, often and usually doesn't actually have symptoms. That's part of why we rely so heavily on routine screening. There are some general warning signs, reasons that we want patients to come into the clinic and see us. But these can also be seen with so many of our routine gynecologic conditions. It's things like abnormal vaginal bleeding, pain after sex, bleeding after menopause, concerning vaginal discharge, something that's watery, has an odor and any type of general pain. There are no exact signs or symptoms we can link to cervical cancer. It's generally just these typical symptoms we experience that can then lead to something more serious.

Amanda Wilde (Host): But you may have it and may not even know it, it sounds like.

Dana Fuqua, DNP, WHNP-BC: That's often the case. We heavily rely on routine screening to be able to identify cervical cancer and pre-cancerous changes.

Amanda Wilde (Host): Then cervical cancer, it sounds like, is detected more through screening than it is through symptoms. How do you screen for cervical cancer?

Dana Fuqua, DNP, WHNP-BC: Cervical cancer screenings are also called Pap tests. People are familiar with hearing that a Pap smear. The Pap test is a super highly effective screening tool we have, it's done through a pelvic exam. It takes a small sample of cervical cells and we send that off to a lab, which allows us to identify these really early abnormal markers. Sometimes that can be pre-cancerous cervical changes. Sometimes that can be just general inflammation or cells that don't quite look right. Since the Pap test was introduced, we've really been able to get better with screening, identifying these changes way before anything concerning comes onto the screen. But again, it does require people to come in and having an appointment every three to five years or so.

Amanda Wilde (Host): I was just going to ask, how often are those Pap tests recommended?

Dana Fuqua, DNP, WHNP-BC: Our guidelines continue to change. So, that's one of the things we often end up talking about when you come into an annual or a well-woman exam or a routine GYN exam, is that evidence is constantly evolving. As of right now, our main screening recommendations are based on a couple of different organizations. There's the United States Preventative Service Task Force, USPSTF. They're a great resource for screening and vaccination recommendations. Also, of course, the American Cancer Society. These organizations sort of come up yearly to talk about the evidence and put together a recommendation. And what it's been for the last two or three years or so is everyone beginning Pap testing at age 21 and between the ages of 21 and 29, coming in for Pap tests every three years. Of course, if there's an abnormal, then earlier follow-up than that. And for folks who are over 30 and between 30 and 65, Pap tests every five years, again, unless there are abnormalities. Over 65 is the time that we start talking about considering exiting Pap testing. But again, as is a common theme, only if there's no history of abnormalities and generally within the last 10 to 15 years is what we're looking for.

Amanda Wilde (Host): How do you address abnormal results?

Dana Fuqua, DNP, WHNP-BC: It is entirely patient-specific. What we as clinicians do now is take all the evidence we have and then take your personal history to determine what your individualized follow-up recommendation is after an abnormal Pap. I think the most important thing is coming back, having a conversation. Oftentimes we lose people to follow-up. We lose people after abnormal results. Sometimes it's because it's scary. Dr. Google can be terrifying about its cancer. And generally, that is always not the case, sometimes it is, but we still want to see you for that. And then, have a conversation about what your risk factors are and what your last few results have been. Have you had an abnormal before? Is this your first? What does your particular abnormal result mean? So, we start with just, first of all, that really in-depth conversation so that you feel that even if you walked out of the office without us taking a next step that you know what your results were, you know what your individual risk is and then, going forward, deciding how you want to address that.

Oftentimes our sort of first step is just repeating a Pap test in a year. More often than not, we see that cervical cells changes resolve. The cervix clears itself generally within 12 months. So, we usually recommend no sooner than a year of follow-up. Of course, unless there are more concerning results, then we always have the option for treatment or next steps, things like that. But oftentimes, abnormal results are followed up with a Pap test in a year. It may even be something like three years depending on what your results are. And if there are sort of next steps needed, it's important to know that Pap tests are screening, so they're really helpful at identifying sort of these risks or concerning signs, but they're not diagnostic. So having an abnormal Pap, that starts the conversation, but it's not the end of the conversation.

The next thing is often what's called a colposcopy. A colposcopy is a similar procedure to the Pap test, but it's done by a clinician who has some additional specialization and it uses what's called a colposcopy, which is kind of like a mobile microscope that looks at the outside of your cervix. And we use some special solutions that basically help light up any abnormal cells. We take tiny little samples of those cells, send them off to pathology and that's when we get a more definitive diagnosis of what's going on. The next steps are oftentimes that the cells are sort of these early concerning changes and we monitor. If cells are what we're finding is more concerning, then we have options for going forth with treatment. So, there are a couple of different treatment options for pre-cancerous changes and cervical cancer as well.

Amanda Wilde (Host): Well, let's talk about treatment. What does treatment look like?

Dana Fuqua, DNP, WHNP-BC: The first thing, again, is a conversation. Everyone has a different sort of risk tolerance. And often when we're identifying these abnormal cells, we're at the earlier stages. It's a conversation about how the patient would like to proceed. Maybe they're planning to start a family or they are concerned about what some of the treatment options mean for their ability to get pregnant or stay pregnant, all of that. So, there are a couple of different routes that the conversation can go.

Starting into like what the actual treatment is, again, observation is an option. Having people come back for routine Paps and having follow-up colposcopies done to ensure that no further changes are happening and that the cervix is able to clear itself, which we oftentimes do see. Once we get to a point though of when cells become looking more abnormal, we sort of cross over this line where it's likely that the body will not sort of prevent these cells from going further, and rather after a certain sort of level of cellular change, then it is more likely to require treatment.

One of the older treatment options, it's still out there, but it's not in use as frequently is what's called cryotherapy. It's essentially freezing the cervix and freezing those abnormal cells. Your cervix in the process of healing itself will sort of slough them off. You'll have this sort of watery discharge for a while after as the cervix kind of heals. And as it does so, those abnormal cells are removed.

The more common procedure for treatment is what's called a LEEP. It is a loop electrosurgical excision procedure. That's a hard one to say, it's a mouthful. That's essentially using this small sort of heated loop to remove any abnormal cells on the outside of the cervix. It sounds invasive. In the scheme of things, it's a minimally invasive procedure. Sometimes they are just done in an office visit. Sometimes they are done with some anesthesia depending on patient-provider preference in that conversation. There is numbing, obviously, provided for folks and the outside of those abnormal cervical cells are removed using this device. Basically, what that does, it removes all the abnormal cells and then again, allows the cervix to sort of heal and fight off whatever infection or abnormal cells might be present that are causing those changes.

So, those are the two treatment options when we've caught cervical cancer or abnormal cervical cells early. If we are finding that what our pathology is indicating is more progressed cancer or maybe like overt cancer that is present, then that's usually when, at least for us within Skagit, we're wanting you to see the specialists of specialists, which is gynecological oncology. They are the folks who will then talk to you about surgical management, other treatment options, the traditional cancer treatment options like radiation or chemotherapy. So, removing any affected tissues, whether that be the cervix, the uterus or lymph nodes and then providing cancer treatment as needed with radiation and chemotherapy.

Amanda Wilde (Host): So, there are options for dealing with different stages of cervical cancer. How successful are these treatments when you look at all of them together?

Dana Fuqua, DNP, WHNP-BC: Typically, very successful. Again, one of the unique things about cervical cancer is that not only can it somewhat be prevented with HPV or Gardasil vaccination, we have these really effective screening tools for catching really early markers. But then, we also, with timely intervention, have these sort of minimally invasive treatment options that are really effective at removing abnormal cells and preventing cervical cancer from progressing. Most often, we don't even get to cervical cancer. We generally are catching and treating things when they are abnormal cells. When we get to the phase of it actually being cervical cancer, depending on how progressed it is, depending on how far cancer has spread, all of that is going to impact sort of the efficacy for our treatments. But generally, we are able to really effectively prevent and treat cervical cancer.

Amanda Wilde (Host): That's what we want to hear. It sounds like there have been some progressions in that field over the years, so I would be looking forward to some more. Just one more note on prevention. It sounds like the HPV vaccination is one good way to prevent ever dealing with cervical cancer. Do you have any other suggestions for prevention?

Dana Fuqua, DNP, WHNP-BC: I would say that HPV vaccination is one of our main prevention tools. I think it's good to note that we recommend this for everyone. Starting at age nine, you can begin to get this vaccination. Really routine recommendation is around 11 to 12 years old. For those who are under 15, it's a quick two-dose series. For those who are over 15, it's going be a three-dose series. We used to say if you reach the age of 20, that HPV vaccination was no longer recommended. That's not necessarily the case anymore. There's a limited benefit for those who are over 26, really all the way up until 45. So if you haven't gotten your HPV vaccination, it's not too late. So, that's one of the best ways to protect yourself against those highest risk strains of HPV that can cause cancer later in life. And then also, routine pap testing, coming in for any concerning changes or symptoms you're experiencing, but also coming in for your routine screening. That is the way to catch and prevent any of these abnormal cervical cell changes.

Amanda Wilde (Host): One last question about the Pap test, do you have any tips to make the Pap test more comfortable?

Dana Fuqua, DNP, WHNP-BC: Yeah. I think ideally, of course, is finding or working with a provider that you trust and feel comfortable with. If that isn't the case already, looking for trauma-informed providers, or at least starting the conversation with your provider before a Pap test and asking for what you need. Everyone is really unique in how they experience a pelvic exam. It is, of course, an intense and intimate experience. And so, thinking about what might make you comfortable before you go in, and then feeling empowered to ask for that with your provider.

The first thing is, as hard as it is, trying to take deep breaths and get centered in your body, feeling comfortable, sort of in whatever position you are in. Breathing in to let go of any tension and then asking your provider that before each step, that they communicate what's going to happen next if you're someone who would like to know the whole process, top to bottom so that you know how many steps are involved and at which step where you're at in the Pap process. If you're someone who wants to know absolutely nothing and just have someone talk to you and distract you while the Pap test is being done, that is an option too. If you want to bring a support person to hold your hand or listen to some music, there are so many different options.

Yes, this is a routine thing that we do. It's part of women's healthcare, and yet it also doesn't need to be something that is uncomfortable, and certainly and hopefully not traumatic. So, asking for what you need, asking your provider to ask your consent before each step of the procedure so that you feel prepared, you feel comfortable, and that you feel in control. You, even though sometimes it may not feel like it, are in total control of your exam. So if you need a break, ask for that. If you need everything to stop, ask for that. And if you need the whole thing to be done and everything to be taken out, you absolutely have the right to also say that. So, we are here because we care about your health. We want to provide all of those services to you. And also, we want to make sure that it's an experience you're comfortable with. So please, let us know how we can make this more comfortable for you.

Amanda Wilde (Host): In this case, self-care is healthcare.

Dana Fuqua, DNP, WHNP-BC: Absolutely. Yeah.

Amanda Wilde (Host): Well, Dana, thank you so much for all this information about how we can address cervical cancer before it even develops.

Dana Fuqua, DNP, WHNP-BC: Absolutely. It's been my pleasure and I hope that if there are questions, we have resources or comments, schedule an appointment and let's chat more. We're always happy to talk about this.

Amanda Wilde (Host): Wonderful. We've been talking about women's health and cervical cancer with Dina Fuqua, Women's Health provider at Skagit Regional Health. To learn more, visit SkagitRegionalHealth.org. And if you found this podcast helpful, please share it on your social channels and check the full podcast library for topics of interest to you. Thanks for listening to Be Well, the podcast from Skagit Regional Health. I'm Amanda Wilde, and we'll talk again next time.