NR 503 Discussion Screening and Reliability
NR 503 Discussion Screening and Reliability
The screening test that I chose is Type 2 Diabetes Mellitus (DM). Healthy People 2020 (2018) states diabetes is one of the significant public health problems and the 7th leading cause of death in the United States. At workplace, I even get to see many patients who didn’t control their glucose levels and ended up getting emergency or intensive care units due to high blood sugar levels such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The complications of diabetes cause cardiovascular disease, however modifiable cardiovascular risk factor such as abnormal blood glucose is considered to be preventable if the levels of hemoglobin A1c, fasting plasma glucose level, and OGTT are under control (Nathan, 2015). This screening test detects abnormal glucose level by measuring HbA1c, fasting plasma glucose or with an oral glucose tolerance test (USPSTF, 2015). According to data from U.S. Preventive Services (2015), patients with glucose for Hemoglobin A1c level is higher than 6.5%, fasting plasma glucose level is higher than 7.0 mmol/L, and OGTT results is higher than 11.1 mmol/L are often considered positive for diabetes type 2. Positive predictive value (PPV) is the percentage of patients with a positive test who actually have the disease (Gordis, 2014). It tells us how many of test positive are true positives and this number is as close to 100 as possible (Thomas, Parikh, Mathai, Parikh, Sekhar, & Thomas, 2008). If the number is higher, it indicates that the test gives us the correct results. When calculating PPV, sensitivity, and specificity are used. Sensitivity is the ability of a test to correctly classify an individual as ‘diseased’ and specificity is the ability of a test to correctly identify those who do not have the disease (Thomas, Parikh, Mathai, Parikh, Sekhar, & Thomas, 2008). Formula of PPV is True positive / true positive + false positive.
Checking the validity of any screening test is essential to verify the accuracy of the test. Validity is also measured by specificity and sensitivity (Thomas, Parikh, Mathai, Parikh, Sekhar, & Thomas, 2008). A new diagnostic test with the gold standard summarized the validity of tests (2008). True positive (TP) occurs when the test correctly diagnosed the disease and the test is positive. False positive (FP) test happens when the test wrongly diagnosed the disease when the disease is absent. False negative (FN) occurs when the test has incorrectly diagnosed a diseased person as normal. Lastly, true negative (TN) occurs when those who have no disease has also negative with the test.
Let’s say there is a patient who is recently diagnosed with type 2. Upon the patient’s history, a healthcare provider finds out that the patient has a great uncle on his father’s side who died of secondary kidney failure due to uncontrolled blood sugar and an aunt on his mother’s side who died of septic shock due to unhealed infection from lower extremity amputation caused by diabetes. Does this information change my recommendation for screening? I will say no since the great uncle and aunt are not considered as first-degree relative and they are second and third-degree relative. However, family history is essential for the identification of individuals who is at risk for diabetes at a younger age.
Gordis, L. (2014). Epidemiology, 5th Edition. Retrieved from https://bookshelf.vitalsource.com/#/books/9781455737338/
Healthy People 2020. (2018). Diabetes. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes (Links to an external site.)
Nathan, D. M. (2015). Diabetes: Advances in diagnosis and treatment. Jama, 314(10), 1052- 1062. doi:10.1001/jama.2015.9536
Thomas, R., Parikh, R., Mathai, A., Parikh, S., Sekhar, G. C., & Thomas, R. (2008). Understanding and using sensitivity, specificity and predictive values. Indian Journal of Ophthalmology, 56(1), 45-50. U.S. Preventive Services (USPSTF). (2015). Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes#tab (Links to an external site.)
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A Papanicolaou test or better known as Pap smear testing is a method of cervical cancer screening. It is used to detect cervical epithelial changes that can be pre-cancerous and cancerous (Sachan, Singh, Patel, & Sachan, 2018). There are two forms of cervical screening testing, conventional and liquid-based cytology. There is no clinical or significant difference in the results. As with any testing and results, there can be a potential false-positive or a false-negative. In essence, one is not better than the other. Both methods share the same high accuracy rate. If further testing is needed a colposcopy is performed as the diagnostic test.
Cervical cancer screening consist of cytology (Pap smear) for women with a cervix at ages 21-29 every 3 years and for women 30 to 65 cytology every 3 years or cytology with human papilloma virus (HPV) every 5 years. There has been a large reduction rate of cervical cancers in the United States. Early screening and detection reduces cervical rates 60% to 90% within 3 years of interventions (U.S. Preventive Services Task Force [USPSTF], 2012). Unfortunately, for developing countries cervical cancer is higher due to the lack of knowledge, technology, and experience.
“The overall sensitivity of the Pap test in detecting a high-grade squamous intraepithelial lesion (HSIL) is 70.2%. A Pap screening done in association with a HPV DNA test increases the sensitivity for early detection of precancerous lesions” (Sachan, Singh, Patel, & Sachan, 2018). There can be 6 different pap results, I will list the severity in ascending order: negative, atypical squamous cells (ASC-US), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells-cannot exclude HSIL (ASC-H), and atypical glandular cells (ACG) (The American College of Obstetrician and Gynecologists [ACOG], 2016). Depending on the results and the patient’s age will depend on if a colposcopy, biopsy, or an endocervical sampling is needed.
Situations that can alter the screening for this patient is having a total hysterectomy (medical history). It is not recommended a pap smear be performed on someone without a cervix due to a lack of cervical precancerous lesions. Another alteration could be if their immediate family member has been diagnosed with cancer early in life (family history). If a patient is HIV positive they may require more frequent screening. Also, the patient’s age. Studies have found screening prior to age 21 and after age 65 with previous normal Pap smear results is not beneficial. The risk outweighs the benefits and can potentially cause physical and/or psychological damage.
The American College of Obstetrician and Gynecologists. (2016). Abnormal cervical cancer screening test results. Retrieved from https://www.acog.org
Sachan, P.L., Singh, M., Patel, M.L., & Sachan, R. (2018). A study on cervical cancer screening using pap smear test and clinical correlation. Asia-Pacific Journal of Oncology Nursing, 5(3), 337-341. U.S. Preventive Services Task Force. (2012). Cervical Cancer: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org
I enjoy reading your post, it was quite informative. Cancer is the second leading cause of death globally, and was responsible for 8.8 million deaths in 2015. Globally, nearly 1 in 6 deaths is due to cancer (WHO, 2018). Approximately 15% of cancers diagnosed in 2012 were attributed to carcinogenic infections, including Helicobacter pylori, Human papillomavirus (HPV), Hepatitis B virus, Hepatitis C virus, and Epstein-Barr virus (Plummer, Martel, Vignat, Ferlay, Bray, & Franceschi, 2016). More specifically, cervical cancer was a known cause of death for American women. However, this rate of death was decreased due to the use of the Pap test (WHO, 2018). It has been my experience that many young women visit the ED with vaginal complaints and have never obtained a Pap smear, let alone visit the gynecologist for these complaints. The challenge as a nurse is educating these young women on the importance of this screening. The views or beliefs held by the young ladies are that they are not in need of this test, embarrassed, or just lack of knowledge. To enable a positive moment where the information presented is grasped by the female patient, the nurse should strive to provide education that stresses the importance of the Pap smear and strategies allowing greater understanding of one’s own body (Plummer et.al, 2016). Additionally, continue to build trust and allow for opportunities to plant the seeds of knowledge.
Screening aims to identify individuals with abnormalities suggestive of a specific cancer or pre-cancer who have not developed any symptoms and refer them promptly for diagnosis and treatment. Screening programms can be effective for select cancer types when appropriate tests are used, implemented effectively, linked to other steps in the screening process and when quality is assured. In general, a screening program is a far more complex public health intervention compared to early diagnosis.
Examples of screening methods are:
visual inspection with acetic acid (VIA) for cervical cancer in low-income settings;
HPV testing for cervical cancer;
PAP cytology test for cervical cancer in middle- and high-income settings; and
mammography screening for breast cancer in settings with strong or relatively strong health systems.
Plummer, M., Martel, C., Vignat, J., Ferlay, J., Bray, F., & Franceschi, S. (2016). Global burden of cancers attributable to infections in 2012: a synthetic analysis. Lancet Glob Health. 4(9):e609-16. doi: 10.1016/S2214-109X(16)30143-7.
World Health Organization (2018). Cancer. Retrieved from http://www.who.int/news-room/fact-sheets/detail/cancer on 07/18/2018
Thank you for your follow-up! This information is exactly what I was looking for this week. As you are learning this week, sensitivity and specificity are both characteristics of a test. There is always a trade-off between the two. In other words, a test may be more sensitive, but less specific and vice versa. For example, a test that’s very sensitive will pick up even the slightest abnormal finding. This means it will miss few cases of the disease, but it will also mistake some people as having the disease when they don’t. Unlike PPV and NPV, the sensitivity and specificity of diagnostic tests are not affected by the prevalence of the disease/condition. Instead, they can be influenced by differences in disease characteristics (such as clinical severity or anatomic extent of a disease) and characteristics of patients such as age. As you discuss, the accuracy of a Pap screen greatly depends on the technique and collection method, affecting the quality of the test. Also, the threshold utilized creates varied results regarding sensitivity, and specificity.
Very interesting and informative post! Cancer screenings are an essential preventative measure to inform and continue educating communities. Internationally, an estimated 530,000 new cases of cervical cancer are diagnosed each year, which result in 275,000 deaths; more than 80% of all cases of CC occur in developing countries (March & Holle, 2017).
Dr. Anttila, depending on the sensitivity of a screening exam it can very well result in false positives because of the dire sensitively the test possesses. Disease epidemiology can very well differ and look different in multiple individuals based of the pre-disposition of the individual; including what the individual has been exposed to. Referring to cervical cancer, this can incorporate if the individual has ever been affected by a sexually transmitted infection as well as heredity factors that may be prevalent. Early detection is key; though there may be certain cases of inaccuracy; pap smears have been reported to be 71%-81% when diagnosing abnormalities in patients.
March, P. P., & Holle, M. O. (2017). Cervical Cancer: an Overview. CINAHL Nursing Guide