Cervical canc

Cervical cancer is the third most common female reproductive cancer diagnosis in women. We give you the lowdown on prevention and treatment.
Mary Alice Tinari, RN, AOCN, MSN Staff Nurse Outpatient Department Fox Chase Cancer Center Philadelphia, Pa.
The author has disclosed that she has no signicant relationships with or nancial interest in any commercial companies that pertain to this educational activity.

LAST WEEK, I spoke with Laurie M., a 49year-old woman with metastatic cervical cancer. While I was explaining her biopsy results, I realized that it had been 9 years since her last internal exam and Pap smear. Could this cancer have been cured if it had been found earlier? Could it even have been prevented? In this article, Ill review the pathophysiology and etiology of cervical cancer, explain diagnostic testing and staging, discuss treatment options and patient teaching, and explore prevention strategies.

Two main types

The cervix forms the bottom (inferior) part of the uterus and projects into the upper portion of the vagina. The two main types of cervical cancer are squamous cell carcinoma and adenocarcinoma (see Picturing cervical cancer). Mixed adenosquamous carcinoma is also possible. Responsible for the majority of cervical cancers, squamous cell carcinoma typically occurs in the transformation zone of the cervix, where the columnar epithelium joins the squamous epithelium. It originates from precursor lesions called cervical intraepithelial neoplasia (CIN). There are two grading systems that can be used to describe these lesions: The CIN grad32 Nursing made Incredibly Easy! November/December 2008

ing system and the National Cancer Institutes (NCI) Bethesda system. The CIN system describes the changes in the precursor lesions. CIN I describes mild dysplasia (atypical changes on the cervical epithelium), CIN II describes moderate dysplasia, and CIN III describes severe dysplasia or a lesion that involves the full thickness of the epithelium. The Bethesda system provides further details about the quality of Pap results. Adenocarcinoma, which accounts for approximately 20% of cervical cancers, is more common in younger women. This type of cancer arises from the mucus-producing gland cells of the endocervix. Its harder to treat than squamous cell carcinoma, and its associated with the presence of human papillomavirus (HPV) and oral contraceptive use.

Risk factors
The most signicant risk factor for cervical cancer is HPV. The most common sexually transmitted disease (STD), HPV is present in 99% of cervical cancers. With a lifetime risk of infection estimated to be as high as 75%, more than one-third of American women are infected with HPV by age 24. Of the more than 6 million new cases of genital HPV diagnosed each year in the United States, 74% of patients were ages 15

2.5
ANCC/AACN CONTACT HOURS

er:

Prevention and treatment

to 24. The risk of acquiring HPV increases with the number of lifetime sexual partners; HPV occurs in less than 2% of women who report no previous sexual intercourse. HPV isnt 100% preventable with condom use because infections can be transmitted on body surfaces that arent covered by a condom. More than 100 types of HPV exist, but most are benign and resolve without treatment. Low-risk HPV types may cause visible, benign lesions or warts known as condylomata accuminata. High-risk HPV types tend to persist and are associated with precancerous lesions and cervical cancer. HPV 16 and 18 cause more than half of cervical cancers. Of the more than 100 types of HPV, about 40 affect the genital tract. The rest infect skin on other areas of the body, such as the hands and feet. The skin of the labia, vagina, and cervix are especially prone to infection. HPV has a special afnity for epithelial cells. The virus enters through a break in the squamous epithelium. Proteins expressed by HPV bind to the p53 tumor suppressor protein, interfering with normal cell growth and blocking cell death from occurring. This allows the damaged cells and the HPV infection to thrive. Most individuals who contract an HPV infection are unaware of it because symptoms may not develop for years, if at all. External genital warts seen as small, at, esh-colored bumps or tiny cauliower-like bumps appear in a small percentage of those infected with HPV. HPV 6 and 11 are mostly responsible for genital warts. The period of time from exposure to the virus to the appearance of warts is 6 weeks to 8 months, but HPV can remain latent for years or decades before warts or cervical disease is
November/December 2008 Nursing made Incredibly Easy! 33

evident. More serious than genital warts are the precancerous changes of the labia, vagina, and cervix that can occur with HPV infection. The changes may take a long time to develop, but may ultimately progress to invasive cancer if left untreated. Skin changes invisible to the eye are 10 to 30 times more common than apparent infections, so determining exactly when, or from whom, the exposure to the virus occurred is virtually impossible. Women with a history of STDs, those who started having sexual intercourse early in life, and those whove had multiple partners or a promiscuous partner are at increased risk for cervical cancer. Low socioeconomic status (may be related to early marriage and early childbearing) or a family history of cer-

vical cancer may also increase a womans risk. Other risk factors for cervical cancer include: cigarette smoking (both active and secondhand). The relationship between smoking and cervical cancer is believed to be a direct carcinogenic effect on the cervix. Some researchers have suggested that smoking suppresses the local immune response to HPV, making the cervix more vulnerable to infection. multiple pregnancies. According to the NCI, women infected with HPV whove had seven or more full-term pregnancies have as much as four times the risk of developing squamous cell carcinoma compared with women who havent been pregnant and as much as three times the risk

Picturing cervical cancer

Carcinoma in situ
Normal cells

Squamous cell carcinoma

Im as normal as they come, but watch out for my enemies the malignant cells!

Premalignant cells

Malignant cells

Ectocervical lesion

34 Nursing made Incredibly Easy! November/December 2008

compared with women with one or two full-term pregnancies. Multiple pregnancies are thought to have a traumatic or immunosuppressive effect on the cervix, which may cause it to be more susceptible to HPV infection. long-term use of contraceptives. Studies show that women using oral contraceptives for 5 years or longer have an increased risk of cervical cancer. Oral contraceptives are thought to interfere with the ability of cervical cells to ght off HPV infections. The benets of oral contraceptives may outweigh this particular risk factor, especially in women who have access to regular Pap screening.

Signs and symptoms

Precancerous changes and early cervical cancers (preinvasive) dont usually cause pain or other symptoms. As the dysplasia gets worse (early invasive disease), women may notice bleeding that occurs between regular menstrual periods or bleeding after sexual intercourse, douching, or pelvic exam. Increased vaginal discharge may be noticed, as well as pelvic pain or pain during intercourse. Locally advanced disease, occurring when the cancer grows into surrounding structures, may cause pain in the legs, back, or pelvis; bleeding from the rectum; or blood in the urine. After the cancer has metastasized, or spread outside the pelvis, a woman may experience all of these symptoms, as well as bone pain, fractures, or lung problems associated with spread to the bones or lungs.

Diagnostic testing
A Pap test is the microscopic examination of cells from the vagina or the cervix. Pap test results may be normal or abnormal and fall into six major categories: normalthe most frequent result, occurring 90% to 95% of the time atypical squamous cells of undetermined signicance (ASC-US)indicating squamous cells that are neither entirely normal

nor entirely abnormal; approximately 60% of women with ASC-US are HPV-negative with no cervical disease and 40% are HPVpositive with detectable changes, mostly low-grade. (If the Pap test shows HPV changes due to a high-risk type [HPV 16, 18, 31, or 33], then further testing is done.) atypical glandular cells of undetermined signicance (AGC-US)indicating glandular cells that are neither entirely normal nor entirely abnormal; about half the women with AGC-US will be found to have normal histology, but high-grade lesions may be found in 20% to 50% of women with this result low-grade squamous intraepithelial lesion (LSIL)typically a result of an HPV infection in women younger than age 35; in older women, its usually due to declining estrogen levels and other effects of the aging process on squamous cells. (An estimated 75% of women with this result will test positive for HPV.) high-grade squamous intraepithelial lesion90% of women with this result will show cell changes due to HPV cancereither squamous cell carcinoma or adenocarcinoma. If a Pap test returns with an ASC-US result, the standard of care is to repeat the test in 4 to 6 months or test for HPV. If HPV testing is positive for a high-risk type, then a colposcopy is indicated. A colposcopy is an examination of the cervix using a binocular microscope and special staining. A biopsy of the abnormal areas is usually done at the same time. If HPV testing is negative, then the Pap test is repeated in 1 year. Postmenopausal women with ASC-US results may require a colposcopy, HPV testing, or estrogen therapy for 3 months before repeating the Pap test. Postmenopausal women may have abnormal squamous cells as a result of atrophy of the vaginal tissue rather than true dysplasia. Three months of estrogen therapy will usually resolve the atrophy and will result in a normal Pap test. Estrogen therapy is stopped 1 week before the repeat testing.

Besides cancer, there are four different types of abnormal Pap test results.

November/December 2008 Nursing made Incredibly Easy! 35

If a Pap test returns with an AGC-US result, a colposcopy is required, as well as an endometrial biopsy for women older than age 35 or those with abnormal bleeding. An AGC-US Pap test result requires endometrial biopsy regardless of age if endometrial cells are present. AGC-US changes are a precursor to adenocarcinoma with a much greater risk of the development of cervical cancer than ASC-US or LSIL Pap test results. If moderate or severe dysplasia is found early, the healthcare provider will usually proceed with a colposcopy to verify the severity of the dysplasia. The only exception is an LSIL result in an adolescent or post-

menopausal woman because the likelihood of true dysplasia is lessened for these patients. If an adolescent patient with an LSIL result has had multiple sexual partners or initiated sexual activity at a young age, a colposcopy is indicated. A postmenopausal woman with an LSIL result is treated with a 3-month course of estrogen therapy, if no contraindications exist. The Pap test is then repeated 1 week after estrogen therapy is stopped. If vaginal atrophy is absent, the woman is treated as if the Pap result was ASC-US. This means either repeat Pap testing in 4 to 6 months or HPV testing. If an early stage cancer is discovered during preg-

Picturing total hysterectomy

Note: The dark lines below show the incision lines for uterus and cervix removal. Suspensory ligament of ovary Fallopian tube Fimbria Isthmus Fundus of uterus

Abdominal opening of fallopian tube

Incision Uterus (womb) Perimetrium (serosa) Endometrium (glandular mucosa) Myometrium Cervical canal (mouth and neck of womb) External os

Ovarian ligament Incision Cavity of uterus Broad ligament Internal os of cervix Cervix Vagina

Ovary Vesicular appendix

36 Nursing made Incredibly Easy! November/December 2008

nancy, treatment options depend on how advanced the pregnancy is. After cervical cancer is diagnosed, its staged using either the International Federation of Gynecology and Obstetrics (FIGO) system or the TNM (tumor, node, metastasis) system (see The FIGO staging system for cervical cancer). Unlike the staging systems used for other cancers, the FIGO system doesnt account for spread of the cancer to local lymph nodes. The TNM system describes the extent of the primary tumor (T), lymph node involvement (N), and spread of the disease (M).

Treatment options
Women with low-grade cervical dysplasia (CIN I) or LSIL may be given the option of no treatment because an estimated 50% to 70% of these lesions spontaneously resolve. A Pap test is necessary every 6 months. If these low-grade lesions dont resolve over a period of up to 2 years, theyre more likely to progress to high-grade dysplasia and may be treated with cryotherapy, loop electrosurgical excision (LEEP), or laser ablation or cold-knife conization (also known as cold conization or cervical conization). Lets take a closer look at these treatment options. Cryotherapy, or freezing, is used to treat CIN I lesions because of its reliability, ease of use, low cost, and low rate of complications. Performed in the ofce, the downside of cryotherapy is that it destroys the lesion and surrounding tissue, making it impossible to do any further diagnostic testing. High-grade lesions may also be treated with cryotherapy, but are more often treated with LEEP or laser ablation. LEEP uses a thin wire loop through which an electric current is passed, turning the loop into an effective cutting tool. The advantages of LEEP are that the healthcare provider can visualize the lesion while its being excised and a tissue sample can be evaluated after removal. Laser ablation is indicated for lesions that extend into the cervical canal. Cold-knife conization uses a scalpel to remove the portion of the cervix that contains the abnormal cells. Requiring general anesthesia, its used when the lesion extends further up into the cervical canal or if glandular disease is present. If invasive cancer is found, the treatment is usually a total hysterectomy performed either through the abdomen or vagina, without removal of the ovaries (see Picturing total hysterectomy). In patients with more advanced cancers, a radical hysterectomy is performed. A radical hysterectomy removes not only the body and neck of the uterus, but also the upper third of the vagina and the

Treatment depends on the type of lesions present.

Vaginal hysterectomy

Ovary Fallopian tube

Vagina Fundus of uterus Uterus Cervix

November/December 2008 Nursing made Incredibly Easy! 37

ligaments on either side of the cervix. This surgery is usually performed together with careful dissection of the lymph nodes in the pelvis. The ovaries are left alone, unless the surgeon suspects that the patient will need additional treatment such as pelvic radiation. In this case, the ovaries are removed as well. The goal of a radical hysterectomy is to clear the tumor from the body with a good margin of normal tissue around it. This surgery is best performed by a gynecologic oncologist, a specialist whos well trained to evaluate tissue for the presence of cancer. If cancer is detected after it has grown to the ligaments next to the cervix, it becomes very difcult to get a good margin of normal tissue. Many healthcare providers will defer surgery and treat the patient with a combi-

nation of chemotherapy and radiation therapy. The decision depends on the age of the patient and her other medical conditions. Typically, patients treated with combined chemotherapy and radiation therapy receive treatments of external pelvic radiation 5 days/week, with one of those days including chemotherapy. A chemotherapy drug combination thats often used is cisplatin and topotecan. This combination was the rst to show an improvement in overall survival for patients with advanced cervical cancer. The regimen usually lasts for 5 to 6 weeks. Further radiation is then given without chemotherapy. Women receiving internal cervical radiation need adequate preparation for the isolation they may feel while receiving this treat-

The FIGO staging system for cervical cancer

Stage 0: The cancer cells are very supercial (only affecting the surface), are found only in the layer of cells lining the cervix,
and havent grown into (invaded) deeper tissues of the cervix. This stage is also called carcinoma in situ or cervical intraepithelial neoplasia grade III. Stage I: In this stage the cancer has invaded the cervix, but it hasnt spread anywhere else. Stage IA: This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope. Stage IA1: The area of invasion is less than 3 mm (about 18 inch) deep and less than 7 mm (about 14 inch) wide. Stage IA2: The area of invasion is between 3 and 5 mm (about 18 to 15 inch) deep and less than 7 mm wide. Stage IB: This stage includes Stage I cancers that can be seen without a microscope. It also includes cancers that can only be seen with a microscope if theyve spread deeper than 5 mm into connective tissue of the cervix or are wider than 7 mm. Stage IB1: The cancer can be seen, but it isnt larger than 4 cm (about 135 inches). Stage IB2: The cancer can be seen and is larger than 4 cm. Stage II: In this stage, the cancer has grown beyond the cervix and uterus, but hasnt spread to the walls of the pelvis or the lower part of the vagina. Stage IIA: The cancer hasnt spread into the tissues next to the cervix (called the parametria). The cancer may have grown into the upper part of the vagina. Stage IIB: The cancer has spread into the tissues next to the cervix. Stage III: The cancer has spread to the lower part of the vagina or the pelvic wall. It may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). Stage IIIA: The cancer has spread to the lower third of the vagina but not to the pelvic wall. Stage IIIB: The cancer has grown into the pelvic wall. If the tumor has blocked the ureters (a condition called hydronephrosis), its also a stage IIIB. Stage IV: This is the most advanced stage of cervical cancer. The cancer has spread to nearby organs or other parts of the body. Stage IVA: The cancer has spread to the bladder or rectum, which are organs close to the cervix. Stage IVB: The cancer has spread to distant organs beyond the pelvic area, such as the lungs.
Source: American Cancer Society, How is cervical cancer staged? http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_cervical_ cancer_staged_8.asp. Accessed August 18, 2008.

38 Nursing made Incredibly Easy! November/December 2008

ment, sensitive support during the treatment, and debrieng afterward. A radiation oncology nurse is best prepared to provide this support to the patient and her caregivers and family. There may be benets to delivering therapy to two women in adjacent beds to enable them to support each other. If cervical cancer comes back or relapses, its usually treated with chemotherapy, but it may be treated with more surgery. Symptom management is the goal at this point. Fertility-sparing surgery may be an option for early stage cervical cancer. Many successful pregnancies have been reported after cold-knife conization, for instance. If the cancer is limited to the cervix, a radical trachelectomy may be done. This procedure includes removing most of the cervix and surrounding tissue but sparing the uterus. During a pregnancy, a cerclage, or stitch, may be placed to help hold the fetus inside the uterus. This procedure is offered in only a few centers at this time. In the case of advanced cervical cancer that requires radiation, ovarian transposition may be an option for women who wish to preserve fertility. During this minimally invasive procedure, the ovaries are moved out of the pelvis and pinned up in the abdomen out of the radiation eld. This doesnt protect the ovaries from chemotherapy, however. Also, theres a 50% rate of ovarian failure from this procedure because of poor blood supply to the ovaries. After successful treatment of cervical cancer, the usual practice is a Pap test every 3 months for the rst year, every 4 months for the second year, and every 6 months for the third year, and then annually thereafter. Additional imaging studies may be ordered depending on the patients symptoms.

Patient teaching
After HPV is diagnosed or a Pap test is abnormal, its vital that you clearly explain what this diagnosis means in simple, understandable terms. Because many women dont know about HPV and are under-

standably frightened Risk factors for about receiving a dicervical cancer agnosis of an STD Exposure to human papillomavirus that may cause can Sexual activity cer, youll need to Multiple sex partners provide emotional Early age at rst intercourse support and educaSex with a promiscuous partner tion with compasHistory of sexually transmitted sion, especially if diseases your patient is expe Family history of cervical cancer riencing feelings of Low socioeconomic status shame or embarrass Smoking and exposure to secondhand ment. Consider the smoke Multiple pregnancies or early childbearing following two pa Long-term contraceptive use tient scenarios. Sara G., 55, has been married for 33 years and was seen for cervical dysplasia and HPV infection. When she was told of Make sure her diagnosis, she questioned the faithfulyour patient ness of her husband and had difculty with understands the thought of sexual relations with an infeca diagnosis tion thats sexually transmitted. You must provide Sara with information about HPV of HPV. and the latent nature of the infection, addressing her concerns about sexuality. Tell Sara and her husband that although Mr. G. likely has an HPV infection, there are relatively few risks for him. Studies indicate that ongoing exposure to the same partner with HPV doesnt reinfect the woman. The couple will need written material so they can review it together at a later time to reinforce the teaching you provide. Follow-up visits may be indicated because questions often arise after reviewing the education material. Beth D., 24, was diagnosed with CIN III dysplasia and recently underwent a successful LEEP procedure. She has many questions about intercourse with past and future partners and the possibility of transmitting the virus to others. You must listen and ask questions to determine Beths view of herself as a sexual being and evaluate her ability to form relationships with others. Stress that regular Pap tests are essential to monitor for recurrence of cervical changes. Beth may need information about abstinence, having

cheat sheet

November/December 2008 Nursing made Incredibly Easy! 39

Emphasize the importance of regular screening.

fewer sexual partners, and getting to know her partners sexual history before becoming intimate. Reinforce the need for regular monitoring after an abnormal Pap test. Women who have HPV cant afford to drop out of the healthcare system between having their children and menopause, as is often the case. If a woman has HPV, she needs to know that regular monitoring is essential for her health. Reminder cards sent by the healthcare provider are a good way to let women know when theyre scheduled to return for evaluation.

Prevention strategies
Cervical cancer prevention strategies include screening and vaccine. Routine Pap testing has signicantly decreased the incidence of cervical cancer in the United States. Screening by Pap test should be started when a woman becomes sexually active or by age 21, regardless of sexual activity. A signicant number of women in the United States are screened rarely or not at all. Patient acceptance of Pap testing depends on a number of factors. Women must understand the purpose of a Pap test and why they need to be tested on a regular basis. They must also have access to affordable testing. Many women fail to get tested because of inability to pay for services, fatalistic attitudes, knowledge decits, and lack of support. The National Breast and Cervical Cancer Early Detection Program, administered by the CDC, provides free or low-cost Pap testing and diagnostic services for low-income and uninsured women. Nurses can be patient advocates and help connect women with the services that they need. Women should be aware of several factors in preparing for and scheduling a Pap test. Pap testing shouldnt be collected during a menstrual period. With the advent of liquid-based Pap technology, a small amount of blood can be tolerated and wont affect the accuracy of the test. However, women should be told not to douche or use
40 Nursing made Incredibly Easy! November/December 2008

vaginal creams for 3 days before the test. Finally, women should know to abstain from sexual intercourse for 24 hours before Pap testing because it can cause inaccurate results. An HPV vaccine has been developed to help prevent the incidence of cervical cancer. Quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine stimulates an immune response against the HPV strains that cause the majority of severe dysplasia and cervical cancers (HPV 16, 18), as well as the HPVs that cause genital warts (HPV 6, 11). The vaccine was approved by the FDA in 2006 for girls and young women ages 9 to 26, given I.M. in three doses over 6 months. It has been show to be 99% effective in preventing precancerous cervical changes. In clinical trials, the vaccine was well tolerated with no serious adverse reactions. The vaccine isnt effective in females who have previously been exposed to HPV, and it doesnt guard against all strains. Therefore, regular cervical cancer screening is essential. So far, the vaccine has only been tested on females ages 9 to 26; however, according to the manufacturers Web site, studies are now being done on males and women over 26, but no data are yet available.

Early detection is key

The relationship between HPV and cervical cancer is clear. Nurses have an obligation to inform their patients about the importance of regular cervical cancer screening. Cervical cancer can be successfully treated when detected early, the key to which is regular monitoring. I

Learn more about it

American Cancer Society. Detailed guide: Cervical cancer. http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ What_is_cervical_cancer_8.asp. Accessed July 27, 2008. Behbakht K, et al. Social and cultural barriers to Papanicolaou test screening in an urban population. Obstetrics and Gynecology. 104(6):1355-1361, December 2004. Dallred C. Cervical cancer screening in older women. Clinical Journal of Oncology Nursing. 10(1):31-33, February 2006. FertileHOPE. Fertility sparing surgery for cervical cancer. http://www.fertilehope.org/learn-more/cancer-and-

fertility-info/gynecologic-cancer.cfm#q1. Accessed September 4, 2008. Jemal A, et al. Cancer statistics, 2007. CA: A Cancer Journal for Clinicians. 57(1):43-66, January/February 2007. Loerzel VW, Bushy A. Interventions that address cancer health disparities in women. Family Community Health. 28(1):79-89, January-March, 2005. National Cancer Institute. Cervical cancer screening. http://www.cancer.gov/cancertopics/pdq/screening/ cervical/healthprofessional. Accessed July 27, 2008. National Cancer Institute. The Pap test: Questions and answers. http://www.cancer.gov/cancertopics/factsheet/ detection/pap-test. Accessed September 4, 2008. Pathophysiology Made Incredibly Visual! Philadelphia, Pa., Lippincott Williams & Wilkins, 2008:228-229. Sherman ME, et al. Effects of age and human papilloma viral load on colposcopy triage: Data from the randomized Atypical Squamous Cells of Undetermined Signicance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS). Journal of the National Cancer Institute. 94(2):102-107, January 2002.

Silverberg SG, Ioffe OB. Pathology of cervical cancer. Cancer Journal. 9(5):335-347, September/October 2003. Smeltzer SC, et al. Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007:1682-1685. Tiffen J, Mahon SM. Cervical cancer: What should we tell women about screening? Clinical Journal of Oncology Nursing. 10(4):527-531, August 2006. Waxman AG. Guidelines for cervical cancer screening: History and scientic rationale. Clinical Obstetrics and Gynecology. 48(1):77-97, March 2005. Wells S. Cervical Cancer: An overview with suggested practice and policy goals. Medsurg Nursing. 17(1):43-50, February 2008. So WK, Chui Y. Womens experience of internal radiation treatment for uterine cervical cancer. Journal of Advanced Nursing. 60(2):154-161, October 2007. Wright T, et al. 2006 Consensus guidelines for the management of women with abnormal cervical cancer screening tests. American Journal of Obstetrics and Gynecology. 197(4):346-355, October 2007.

On the Web
These online resources may be helpful to your patients and their families: American Cancer Society: Learn about cervical cancer: http://www.cancer.org/docroot/LRN/LRN_0.asp?dt=8 National Cancer Institute: Cervical cancer: http://www.cancer.gov/cancertopics/types/cervical National Cervical Cancer Coalition: http://www.nccc-online.org National Womens Health Information Center: Cervical cancer: http://www.womenshealth.gov/faq/ccervix.htm.

Earn CE credit online:

Go to http://www.nursingcenter.com/CE/nmie and receive a certicate within minutes.
INSTRUCTIONS

Cervical cancer: Prevention and treatment

TEST INSTRUCTIONS To take the test online, go to our secure Web site at www.nursingcenter.com/ce/nmie. On the print form, record your answers in the test answer section of the CE enrollment form on page 55. Each question has only one correct answer. You may make copies of these forms. Complete the registration information and course evaluation. Mail the completed form and registration fee of $24.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certicate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certicate within 2 business days of receiving your enrollment form. Deadline is December 31, 2010. You will receive your CE certicate of earned contact hours and an answer key to review your results. There is no minimum passing grade. DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities on nursingcenter.com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of Nursing made Incredibly Easy!, will award 2.5 contact hours for this continuing nursing education activity. LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. LWW is also an approved provider of continuing nursing education by the American Association of Critical-Care Nurses #00012278 (CERP Category A), District of Columbia, Florida #FBN2454, and Iowa #75. LWW home study activities are classied for Texas nursing continuing education requirements as Type 1. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749, for 2.5 contact hours. Your certicate is valid in all states.

November/December 2008 Nursing made Incredibly Easy! 41