Cervical Cancer Screening SOP 12-18-2020.pdf

VA NORTH TEXAS HEALTH CARE SYSTEM

AMBULATORY CARE SERVICE

STANDARD OPERATING PROCEDURE FOR CERVICAL CANCER SCREENING

SOP # [11C01]

North Texas Veterans Service Line (s)

Health Care System Ambulatory Care

Dallas, Texas 75216

Signatory Authority: Effective Date:

Ambulatory Care December 18, 2020

Responsible Owner: Recertification Date:

Ambulatory Care Service December 18, 2025

1. Purpose: To establish a Standard Operating Procedure for cervical cancer screening for

Women Veterans at the VA North Texas Health Care System (VANTHCS).

2. Overview: Cervical cancer screening (CCS) will be offered to women Veterans in accordance with the guidelines established by the U.S. Preventative Services Task Force

(USPSTF) and the Department of Veterans Affairs (VA).

3. Procedures:

a. Every new enrolling women Veteran will be offered assignment to a Designated

Women’s Health Primary Care Provider (DWHP).

b. VANTHCS staff will follow the designated guidelines for ordering, scheduling, performing, documenting, and recording all CCS test results (see Appendix A and B).

c. Providers who perform CCS will have a female chaperone present during the exam.

d. Each provider will be responsible for the tracking and timely follow-up of findings from

CCS of the women Veterans assigned to them.

e. Providers will use the respective Clinical Reminders within the Computerized Patient

Record System (CPRS) and a Database (e.g. VSSC, DataMart) for cervical cancer tracking tool to track completion of clinically indicated screenings.

f. Pathology and Laboratory Medicine Service will notify the providers, via a CPRS View

Alert, when the results of CCS are available for review.

g. Providers will communicate CCS results following the procedures outlined in

VANTHCS Memorandum 11-14.

h. Providers may leverage other members of the Patient Aligned Care Team to assist with results reporting, patient communication, and care coordination duties as deemed appropriate.

i. The VANTHCS Women’s Health Cancer Prevention Coordinator will provide care coordination and follow up care for all abnormal CCS patients. Provide quality assurance through tracking of cervical cancer screening, review of CCS results and test result notification. The data for tracking and trending test result timeliness is reported monthly to Women Veteran Health Committee.

References:

• USPSTF Screening for Cervical Cancer 2018. Available at https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementF inal/cervical-cancer-screening2

• VHA Handbook 1330.01 Health Care Services for Women Veterans, February 16th, 2017.

Amended April 24th, 2018.

• VHA National Center for Health Promotion and Disease Prevention. Considerations for

Practice. Available at http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp

• VHA National Center for Health Promotion and Disease Prevention. Screening for Cervical

Cancer. Available at http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp

• ASCCP Algorithms Updated Concensus Guidelines for Managing Abnormal Cervical

Cancer Screening Tests and Cancer Precautions. From: http://wwww.asccp.org/concensus

Guidelines/tabid/7436/Default.aspx

4. Review:

This SOP will be reviewed at a minimum at recertification, or sooner if there are changes to the governing document or to the health care accreditation body mandate, or any regulatory requirement that necessitates more frequent review.

5. Recertification:

This SOP is scheduled for recertification on or before the last working day of December 18, 2025. In the event of contradiction with national policy, the national policy supersedes and controls.

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2 https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2 http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp http://wwww.asccp.org/concensus%20Guidelines/tabid/7436/Default.aspx http://wwww.asccp.org/concensus%20Guidelines/tabid/7436/Default.aspx

6. Signatory Authority

X Rajani Potu

ACOS, VA North Texas HCS

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available through repository:

https://dvagov.sharepoint.com/sites/ntx/services/ambcare/SitePages/Home.aspx https://dvagov.sharepoint.com/sites/ntx/services/ambcare/SitePages/Home.aspx

APPENDIX A

Cervical Cancer Screening Guidelines for Average-Risk Women

When to start Screening: Recommended to start Screening at age 21

Screening Method and Intervals:

Cytology- Conventional or LB: Age 21-29- Every 3 years

Age 30-65- Every 3 years hrHPV Co-Testing:

hrHPV(High risk HPV) co-testing is NOT recommended for women under 30 years of age.

For women age 30-65 hrHPV co-testing every 5 years is recommended.

Women aged over 65 years with adequate recent screening and normal CCS results are not otherwise at high risk for cervical cancer may discontinue Pap testing.

Screening Post Hysterectomy (removal of uterus and cervix)

CCS is NOT recommended in women who have had hysterectomy with removal of the cervix and who do not have a history of high-grade precancerous lesion (CIN2 or CIN 3) or cervical cancer.

Screening Post Hysterectomy (cervical remnant remaining)

Screening for cervical cancer continues per Average-Risk Women.

USPSTF Screening for Cervical Cancer 2018.

Available at https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal

/cervical-cancer-screening2 https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2 https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2

APPENDIX B

*NOTE: if utilizing hrHPV testing alone every 5 years, the clinician must ensure that the testing used has been FDA approved specifically for this purpose.

These recommendations are congruent with the recommendations from U.S. Preventive Services Task Force Recommendation Statement.1–4

Negative screening tests may not be definitive to rule out any type of cancer.

These recommendations do not apply to individuals who have been diagnosed with a high-grade precancerous cervical lesion or cervical cancer. These recommendations also do not apply to individuals with in utero exposure to diethylstilbestrol (DES) or those who have a compromised immune system (e.g., women living with HIV).1 These women are at increased risk and require individualized follow-up.

Available at http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp

ASCCP Management Guidelines_August 2014.pdf http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp#1 http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp#1 http://vaww.prevention.va.gov/CPS/Screening_for_Cervical_Cancer.asp