- Email: [email protected]
Making Sense of HPV
Making Sense of
HPV Leia Raphaelidis
“I just found out that my ex-girlfriend has HPV, and my new girlfriend is freaking out,” says the panicked caller on the other end of the line. “Can we come in right away to be tested?”Where does a clinician begin to address such a question? Human papillomavirus (HPV) is the country’s most common sexually transmitted infection (STI). Nevertheless, less than one-third of the general population has even heard of it.1 When faced with the diagnosis of HPV, it is natural for patients to feel fear, anxiety, and confusion.The initial information that the clinician provides can serve to allay fears, reduce anxiety, and shed light on what can be a complex diagnosis for any patient to comprehend. In almost all practice settings, clinicians are bound to encounter patients infected with anogenital HPV, whether it is in the form of genital warts, associated with low-oncogenic risk HPV, or in the form of abnormal Pap smears, most commonly associated with high-oncogenic risk HPV. Research has shown that subclinical infection, with neither visible warts nor cytological abnormalities, is likely the most common form of HPV infection,2 but such infections will often avoid detection in the clinical setting. www.npjournal.org
ABSTRACT Human papillomavirus (HPV) is the country’s most common sexually transmitted infection. An estimated 75% of the reproductive-age population will be infected with HPV at some point in their lives. Patients diagnosed with HPV should understand that the virus is most often transient, but persistent infection with high-risk HPV can lead to cervical cancer. A laboratory test for HPV detection is available, but clinicians should only use it for routine screening in women over 30 because HPV is so prevalent in the younger population. Condoms provide only modest protection against HPV transmission. The information clinicians provide to patients about HPV can help reduce anxiety and ensure compliance with appropriate follow-up. Keywords: genital warts, HPV, human papillomavirus, sexually transmitted infection
The Journal for Nurse Practitioners - JNP
329
The current state of knowledge about HPV is changing quickly.This article presents some of the key points that can be useful to clinicians as they answer questions about HPV. PREVALENCE AND CLEARANCE OF HPV Patients should understand how common HPV is. Although prevalence figures vary from study to study, it is estimated that about 75% of the reproductive-age population will be infected with HPV at some point in their lives, and that infection is most common in the 15-24 age group.2 In other words, all sexually active individuals are at risk for HPV, unless they are in a long-term monogamous relationship in which neither partner has ever had any genital contact previously. Most individuals with HPV will never know that they are infected. In my experience, one of the first questions that patients tend to ask about HPV is what they can do to cure it so that they do not infect others. It is very distressing for them to hear that HPV itself is not treatable. I always make the point that HPV is very different from the bacterial STIs with which patients tend to be more familiar. For example, in the case of Chlamydia trachomatis, diagnosis and treatment are more straightforward. The test is performed, it is either positive or negative for the pathogen, positives are treated with antibiotics, and the infection is resolved. But in the case of HPV, only its manifestations are treated. Genital warts can be made to disappear, and dysplastic cervical tissue can be excised or destroyed, but only the patient’s own immune system can clear the virus and make him or her no longer be contagious to others. It is important for clinicians to acknowledge how frustrating it is to have an untreatable infection, especially because of the stigma surrounding STIs. At the same time, we must emphasize to our patients that most HPV will clear on its own. In fact, up to 90% of HPV infections become undetectable by sensitive DNA detection methods within one or two years, even if they have caused mild abnormalities on a Pap smear or cervical biopsy.3,4 The median duration of new infections is typically 8 months.5 Genital warts too can regress spontaneously, often over several months.6 Though genital warts are usually treated, no research to date shows that treatment eliminates their infectivity.7 Unfortunately, even after 330
The Journal for Nurse Practitioners - JNP
the warts have cleared, there is no way for individuals to know for what time period they are still potentially infectious. Normal-looking skin could still harbor the virus, until the immune system finally suppresses or eliminates it. THE RISK OF PERSISTENT INFECTION Given the above data on prevalence and clearance of HPV, one of the challenges in conducting patient education is to strike a balance between presenting the transient, innocuous nature of most HPV, while at the same time not leaving the patient with the impression that HPV is a wholly harmless infection. Patients should understand that there are many types of HPV, and they should grasp the basic distinction between low-risk and high-risk types of HPV, because the implications for follow-up are different.The term “high-risk HPV” is itself a bit of a misnomer because the absolute risk of developing cancer if infected with it is actually extremely low. Despite how prevalent HPV is, invasive cancer occurs only in 8 out of 100,000 American women annually,8 and the vast majority of cases occur in women who have not had a Pap smear in the preceding 5 years.9 Patients diagnosed with dysplasia or high-risk HPV need to understand the importance of complying with the recommended observation or treatment plan, in order to avoid the small but real possibility of developing cervical cancer over time. The essential precursor to cervical neoplasia has clearly been demonstrated to be persistent infection with high-risk HPV. It is not yet known with certainty why the vast majority of HPV infections are transient but a few infections persist. Factors that have been implicated in persistence of HPV include smoking, older age, longterm oral contraceptive use, and multiple sexual partners in the past 5 years.4 In addition, it has been postulated, but not proven, that viral load and the specific type of HPV causing the infection may influence persistence too, though these are not factors that can be assessed in the clinical setting.10 Though a strong evidence base for these recommendations is still lacking, it would certainly be reasonable for clinicians to advise patients diagnosed with HPV to cease smoking and to eat a diet rich in fresh fruits and vegetables, known to boost the immune system. Condom use also appears to protect against HPV persistence in women, potentially by decreasing the viral load to which they are exposed over time.10 May 2006
HPV RESOURCES FOR PATIENTS American Social Health Association: HPV Resource Center www.ashastd.org/hpv/hpv_overview.cfm American Social Health Association: HPV Hotline 877-478-5868 Planned Parenthood: HPV, Pap Tests, and Cervical Cancer — Questions & Answers plannedparenthood.org/pp2/portal/files/portal/ medicalinfo/sti/pub-HPV-cervical-cancer.xml American Academy of Dermatology: Genital Warts www.aad.org/public/Publications/pamphlets/ GenitalWarts.htm
warts who are diagnosed with HPV. In general, the state of knowledge about HPV infection in men is limited, because there is a lack of validated methods for sampling male genitalia, and the burden of HPV is far lighter in men.3 Penile and anal cancers have both been associated with high-risk HPV, but there is no standard screening method for early detection of either disease. It may be reassuring to male patients to know that penile cancer is extremely rare, occurring only in 1 out of 100,000 American men each year.11 Anal cancer, which can affect both men and women, is also rare, with an annual incidence of 2 per 100,000.12
THE HPV TEST Another question that comes up frequently in the clinical setting is that of testing for HPV. Some women will have read about the Hybrid Capture 2/High-Risk HPV DNA test (Digene Corp) and want to be screened, regardless of whether they have had a recent abnormal Pap smear.The test is approved for primary screening for cervical cancer in conjunction with a Pap smear in women over 30 or for triage of Pap smears read as atypical squamous cells of unknown significance in women of any age. It can be a challenge to limit the HPV test only to those cases, especially when patients have been encouraged by print ads to “ask your doctor” for the HPV test. Nevertheless, it is important to adhere to established guidelines. In women under 30, subclinical high-risk HPV is commonplace, and the HPV test performed indiscriminately will result in unnecessary interventions and undue anxiety.The main point to emphasize to patients is that they should follow the recommended schedule for routine screening, which may or may not involve HPV testing.When women are tested, they should understand that the Hybrid Capture 2 only detects high-risk HPV and solely evaluates the cervix.
TRANSMISSION AND PREVENTION Due to the lack of data on HPV in men, plus the high rates of subclinical infection, our knowledge of the contagiousness of HPV is limited. After exposure to genital warts, as many as three-fourths of individuals may develop warts themselves,7 indicating that the infection is quite contagious.Typically genital warts appear two to three months after exposure, though they can appear even years later.6 Transmission via oral sex appears to be rare, but not impossible.7 It is not known whether subclinical infection is less contagious than HPV with clinical manifestations.13 The evidence regarding the effects of male condom use on HPV transmission has been inconclusive, with some studies showing a protective effect and others not.14 Though viral particles cannot cross a latex barrier, genital skin not covered by latex could shed HPV or become infected with the virus. In the words of the Centers for Disease Control and Prevention, “Condoms may provide some protection in preventing transmission of HPV infections but that protection is partial at best.”5 As mentioned previously, however, condom use after infection occurs does seem to promote clearance of HPV lesions in women.7 The effect of female condom use on HPV transmission has not been studied, though the wider coverage of the labia could theoretically provide greater protection against exposure. Clearly, abstinence or lifelong monogamy is the only sure way to prevent HPV infection.
HPV IN MEN Men often ask to be tested, and they need to know that there is no approved test for HPV in men. Therefore, it is usually only men with visible genital
HPV AND PREGNANCY Female patients may be concerned about the effect of their HPV diagnosis on future pregnancies.They can be reassured that they are unlikely to experience any com-
American Cancer Society: What is Cervical Cancer? www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ What_is_cervical_cancer_8.asp
www.npjournal.org
The Journal for Nurse Practitioners - JNP
331
plications from the virus.Though genital warts may grow during pregnancy, transmission of HPV to infants is rare.7 Furthermore, genital warts can be safely treated during pregnancy. In the case of HPV-related cervical dysplasia, most treatments conserve the integrity of the cervix and do not affect fertility. ABOUT PARTNERS Patients often will ask for help in figuring out who infected them.While this is understandable concern, clinicians need to explain that it is usually impossible to pinpoint who it was, unless they have had only one lifetime sexual partner. Because of the possibility of long latency periods and the existence of subclinical infections, patients should also understand that a diagnosis of HPV cannot be taken as an indicator of infidelity, even after years of presumed monogamy. Patients diagnosed with HPV will also ask for advice about whether they should notify future partners about their status. I have found this to be a complicated issue to address with no clear answers. Some clinicians advise their patients that they do not necessarily need to disclose their HPV infection because HPV is so ubiquitous and most often harmless. Others advocate complete disclosure. When it comes down to it, whether to disclose is an individual decision. On the one hand, the stigma that surrounds STIs in general may mean that disclosing infection with HPV dooms the relationship. On the other hand, not telling may lead to feelings of guilt and dishonesty. If patients with HPV decide to tell their partners or potential partners, they should be prepared to provide accurate up-to-date information about the virus, with the disclosure ideally taking place within the context of a broader discussion about sexual history and sexual health.
References 1. Anhang R, Goodman, A, Goldie, SJ. HPV communication: review of existing research and recommendations for patient education. CA Cancer J Clin 2004;54:248-259. 2. Koutsky LA. Epidemiology of genital human papillomavirus infection. Am J Med 1997;102(5A):3-8. 3. Schiffman M, Kjaer, SK. Chapter 2: Natural history of anogenintal human papillomavirus infection and neoplasia. J Natl Cancer Inst Monogr 2003;31:14-19. 4. Scheurer ME, Tortolero-Luna G, Adler-Storthz K. Human papillomavirus infection: biology, epidemiology, and prevention. Int J Gynecol Cancer 2005;15:727-746. 5. Centers for Disease Control and Prevention. Report to Congress: Prevention of genital human papillomavirus infection. January 2004. Available at: www.cdc.gov/std/HPV/2004HPV%20Report.pdf. Accessed February 23, 2006. 6. Handsfield HH. Clinical presentation and natural course of anogenital warts. Am J Med 1997;102(5A):16-20. 7. American College of Obstetricians and Gynecologists. Clinical management guidelines for obstetrician-gynecologists. Number 61, April 2005. Human papillomavirus. Obstet Gynecol 2005;105:905-918. 8. Monk BJ, Wiley DJ. Human papillomavirus infections: truth or consequences. Cancer 2004;100(2):225-227. 9. American Cancer Society. Can cervical cancer be found early? October 2005. Available: www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_cervical_ cancer_be_found_early_8.asp?sitearea=. Accessed March 1, 2006. 10. Richardson H, Abrahamowicz M, Tellier PP, et al. Modifiable risk factors associated with clearance of type-specific cervical human papillomavirus infections in a cohort of university students. Cancer Epidemiol Biomarkers Prev 2005;14:1149-1156. 11. American Cancer Society. What are the key statistics about penile cancer? February 2006. Available at: www.cancer.org/docroot/CRI/content/ CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea=. Accessed February 23, 2006. 12. Johnson LG, Madeleine MM, Newcomer LM, Schwartz SM, Daling JR. Anal cancer incidence and survival: the surveillance, epidemiology, and end results experience, 1973-2000. Cancer 2004;101(2):281-288. 13. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep 2002;51(RR-6):1-78. 14. Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection, external genital warts or cervical neoplasia? A meta-analysis. Sex Trans Dis 2002;29(11):725-735.
Leia Raphaelidis, FNP, BC, is a clinician with Planned Parenthood of the Southern Finger Lakes in Ithaca, New York. She has no financial relationship with business or industry to disclose. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.04.012
CONCLUSION In today’s time-pressured clinical environment, finding the time to answer questions about HPV can be a challenge because the subject does not lend itself to quick explanations. By providing patients with accurate, up-to-date information about the virus, clinicians can help dispel myths and reduce anxiety. In turn, patients who are less distressed are more likely to comply with recommended follow-up, an important consideration for preventing needless deaths from cervical cancer. 332
The Journal for Nurse Practitioners - JNP
May 2006
HPV Leia Raphaelidis
“I just found out that my ex-girlfriend has HPV, and my new girlfriend is freaking out,” says the panicked caller on the other end of the line. “Can we come in right away to be tested?”Where does a clinician begin to address such a question? Human papillomavirus (HPV) is the country’s most common sexually transmitted infection (STI). Nevertheless, less than one-third of the general population has even heard of it.1 When faced with the diagnosis of HPV, it is natural for patients to feel fear, anxiety, and confusion.The initial information that the clinician provides can serve to allay fears, reduce anxiety, and shed light on what can be a complex diagnosis for any patient to comprehend. In almost all practice settings, clinicians are bound to encounter patients infected with anogenital HPV, whether it is in the form of genital warts, associated with low-oncogenic risk HPV, or in the form of abnormal Pap smears, most commonly associated with high-oncogenic risk HPV. Research has shown that subclinical infection, with neither visible warts nor cytological abnormalities, is likely the most common form of HPV infection,2 but such infections will often avoid detection in the clinical setting. www.npjournal.org
ABSTRACT Human papillomavirus (HPV) is the country’s most common sexually transmitted infection. An estimated 75% of the reproductive-age population will be infected with HPV at some point in their lives. Patients diagnosed with HPV should understand that the virus is most often transient, but persistent infection with high-risk HPV can lead to cervical cancer. A laboratory test for HPV detection is available, but clinicians should only use it for routine screening in women over 30 because HPV is so prevalent in the younger population. Condoms provide only modest protection against HPV transmission. The information clinicians provide to patients about HPV can help reduce anxiety and ensure compliance with appropriate follow-up. Keywords: genital warts, HPV, human papillomavirus, sexually transmitted infection
The Journal for Nurse Practitioners - JNP
329
The current state of knowledge about HPV is changing quickly.This article presents some of the key points that can be useful to clinicians as they answer questions about HPV. PREVALENCE AND CLEARANCE OF HPV Patients should understand how common HPV is. Although prevalence figures vary from study to study, it is estimated that about 75% of the reproductive-age population will be infected with HPV at some point in their lives, and that infection is most common in the 15-24 age group.2 In other words, all sexually active individuals are at risk for HPV, unless they are in a long-term monogamous relationship in which neither partner has ever had any genital contact previously. Most individuals with HPV will never know that they are infected. In my experience, one of the first questions that patients tend to ask about HPV is what they can do to cure it so that they do not infect others. It is very distressing for them to hear that HPV itself is not treatable. I always make the point that HPV is very different from the bacterial STIs with which patients tend to be more familiar. For example, in the case of Chlamydia trachomatis, diagnosis and treatment are more straightforward. The test is performed, it is either positive or negative for the pathogen, positives are treated with antibiotics, and the infection is resolved. But in the case of HPV, only its manifestations are treated. Genital warts can be made to disappear, and dysplastic cervical tissue can be excised or destroyed, but only the patient’s own immune system can clear the virus and make him or her no longer be contagious to others. It is important for clinicians to acknowledge how frustrating it is to have an untreatable infection, especially because of the stigma surrounding STIs. At the same time, we must emphasize to our patients that most HPV will clear on its own. In fact, up to 90% of HPV infections become undetectable by sensitive DNA detection methods within one or two years, even if they have caused mild abnormalities on a Pap smear or cervical biopsy.3,4 The median duration of new infections is typically 8 months.5 Genital warts too can regress spontaneously, often over several months.6 Though genital warts are usually treated, no research to date shows that treatment eliminates their infectivity.7 Unfortunately, even after 330
The Journal for Nurse Practitioners - JNP
the warts have cleared, there is no way for individuals to know for what time period they are still potentially infectious. Normal-looking skin could still harbor the virus, until the immune system finally suppresses or eliminates it. THE RISK OF PERSISTENT INFECTION Given the above data on prevalence and clearance of HPV, one of the challenges in conducting patient education is to strike a balance between presenting the transient, innocuous nature of most HPV, while at the same time not leaving the patient with the impression that HPV is a wholly harmless infection. Patients should understand that there are many types of HPV, and they should grasp the basic distinction between low-risk and high-risk types of HPV, because the implications for follow-up are different.The term “high-risk HPV” is itself a bit of a misnomer because the absolute risk of developing cancer if infected with it is actually extremely low. Despite how prevalent HPV is, invasive cancer occurs only in 8 out of 100,000 American women annually,8 and the vast majority of cases occur in women who have not had a Pap smear in the preceding 5 years.9 Patients diagnosed with dysplasia or high-risk HPV need to understand the importance of complying with the recommended observation or treatment plan, in order to avoid the small but real possibility of developing cervical cancer over time. The essential precursor to cervical neoplasia has clearly been demonstrated to be persistent infection with high-risk HPV. It is not yet known with certainty why the vast majority of HPV infections are transient but a few infections persist. Factors that have been implicated in persistence of HPV include smoking, older age, longterm oral contraceptive use, and multiple sexual partners in the past 5 years.4 In addition, it has been postulated, but not proven, that viral load and the specific type of HPV causing the infection may influence persistence too, though these are not factors that can be assessed in the clinical setting.10 Though a strong evidence base for these recommendations is still lacking, it would certainly be reasonable for clinicians to advise patients diagnosed with HPV to cease smoking and to eat a diet rich in fresh fruits and vegetables, known to boost the immune system. Condom use also appears to protect against HPV persistence in women, potentially by decreasing the viral load to which they are exposed over time.10 May 2006
HPV RESOURCES FOR PATIENTS American Social Health Association: HPV Resource Center www.ashastd.org/hpv/hpv_overview.cfm American Social Health Association: HPV Hotline 877-478-5868 Planned Parenthood: HPV, Pap Tests, and Cervical Cancer — Questions & Answers plannedparenthood.org/pp2/portal/files/portal/ medicalinfo/sti/pub-HPV-cervical-cancer.xml American Academy of Dermatology: Genital Warts www.aad.org/public/Publications/pamphlets/ GenitalWarts.htm
warts who are diagnosed with HPV. In general, the state of knowledge about HPV infection in men is limited, because there is a lack of validated methods for sampling male genitalia, and the burden of HPV is far lighter in men.3 Penile and anal cancers have both been associated with high-risk HPV, but there is no standard screening method for early detection of either disease. It may be reassuring to male patients to know that penile cancer is extremely rare, occurring only in 1 out of 100,000 American men each year.11 Anal cancer, which can affect both men and women, is also rare, with an annual incidence of 2 per 100,000.12
THE HPV TEST Another question that comes up frequently in the clinical setting is that of testing for HPV. Some women will have read about the Hybrid Capture 2/High-Risk HPV DNA test (Digene Corp) and want to be screened, regardless of whether they have had a recent abnormal Pap smear.The test is approved for primary screening for cervical cancer in conjunction with a Pap smear in women over 30 or for triage of Pap smears read as atypical squamous cells of unknown significance in women of any age. It can be a challenge to limit the HPV test only to those cases, especially when patients have been encouraged by print ads to “ask your doctor” for the HPV test. Nevertheless, it is important to adhere to established guidelines. In women under 30, subclinical high-risk HPV is commonplace, and the HPV test performed indiscriminately will result in unnecessary interventions and undue anxiety.The main point to emphasize to patients is that they should follow the recommended schedule for routine screening, which may or may not involve HPV testing.When women are tested, they should understand that the Hybrid Capture 2 only detects high-risk HPV and solely evaluates the cervix.
TRANSMISSION AND PREVENTION Due to the lack of data on HPV in men, plus the high rates of subclinical infection, our knowledge of the contagiousness of HPV is limited. After exposure to genital warts, as many as three-fourths of individuals may develop warts themselves,7 indicating that the infection is quite contagious.Typically genital warts appear two to three months after exposure, though they can appear even years later.6 Transmission via oral sex appears to be rare, but not impossible.7 It is not known whether subclinical infection is less contagious than HPV with clinical manifestations.13 The evidence regarding the effects of male condom use on HPV transmission has been inconclusive, with some studies showing a protective effect and others not.14 Though viral particles cannot cross a latex barrier, genital skin not covered by latex could shed HPV or become infected with the virus. In the words of the Centers for Disease Control and Prevention, “Condoms may provide some protection in preventing transmission of HPV infections but that protection is partial at best.”5 As mentioned previously, however, condom use after infection occurs does seem to promote clearance of HPV lesions in women.7 The effect of female condom use on HPV transmission has not been studied, though the wider coverage of the labia could theoretically provide greater protection against exposure. Clearly, abstinence or lifelong monogamy is the only sure way to prevent HPV infection.
HPV IN MEN Men often ask to be tested, and they need to know that there is no approved test for HPV in men. Therefore, it is usually only men with visible genital
HPV AND PREGNANCY Female patients may be concerned about the effect of their HPV diagnosis on future pregnancies.They can be reassured that they are unlikely to experience any com-
American Cancer Society: What is Cervical Cancer? www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ What_is_cervical_cancer_8.asp
www.npjournal.org
The Journal for Nurse Practitioners - JNP
331
plications from the virus.Though genital warts may grow during pregnancy, transmission of HPV to infants is rare.7 Furthermore, genital warts can be safely treated during pregnancy. In the case of HPV-related cervical dysplasia, most treatments conserve the integrity of the cervix and do not affect fertility. ABOUT PARTNERS Patients often will ask for help in figuring out who infected them.While this is understandable concern, clinicians need to explain that it is usually impossible to pinpoint who it was, unless they have had only one lifetime sexual partner. Because of the possibility of long latency periods and the existence of subclinical infections, patients should also understand that a diagnosis of HPV cannot be taken as an indicator of infidelity, even after years of presumed monogamy. Patients diagnosed with HPV will also ask for advice about whether they should notify future partners about their status. I have found this to be a complicated issue to address with no clear answers. Some clinicians advise their patients that they do not necessarily need to disclose their HPV infection because HPV is so ubiquitous and most often harmless. Others advocate complete disclosure. When it comes down to it, whether to disclose is an individual decision. On the one hand, the stigma that surrounds STIs in general may mean that disclosing infection with HPV dooms the relationship. On the other hand, not telling may lead to feelings of guilt and dishonesty. If patients with HPV decide to tell their partners or potential partners, they should be prepared to provide accurate up-to-date information about the virus, with the disclosure ideally taking place within the context of a broader discussion about sexual history and sexual health.
References 1. Anhang R, Goodman, A, Goldie, SJ. HPV communication: review of existing research and recommendations for patient education. CA Cancer J Clin 2004;54:248-259. 2. Koutsky LA. Epidemiology of genital human papillomavirus infection. Am J Med 1997;102(5A):3-8. 3. Schiffman M, Kjaer, SK. Chapter 2: Natural history of anogenintal human papillomavirus infection and neoplasia. J Natl Cancer Inst Monogr 2003;31:14-19. 4. Scheurer ME, Tortolero-Luna G, Adler-Storthz K. Human papillomavirus infection: biology, epidemiology, and prevention. Int J Gynecol Cancer 2005;15:727-746. 5. Centers for Disease Control and Prevention. Report to Congress: Prevention of genital human papillomavirus infection. January 2004. Available at: www.cdc.gov/std/HPV/2004HPV%20Report.pdf. Accessed February 23, 2006. 6. Handsfield HH. Clinical presentation and natural course of anogenital warts. Am J Med 1997;102(5A):16-20. 7. American College of Obstetricians and Gynecologists. Clinical management guidelines for obstetrician-gynecologists. Number 61, April 2005. Human papillomavirus. Obstet Gynecol 2005;105:905-918. 8. Monk BJ, Wiley DJ. Human papillomavirus infections: truth or consequences. Cancer 2004;100(2):225-227. 9. American Cancer Society. Can cervical cancer be found early? October 2005. Available: www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_cervical_ cancer_be_found_early_8.asp?sitearea=. Accessed March 1, 2006. 10. Richardson H, Abrahamowicz M, Tellier PP, et al. Modifiable risk factors associated with clearance of type-specific cervical human papillomavirus infections in a cohort of university students. Cancer Epidemiol Biomarkers Prev 2005;14:1149-1156. 11. American Cancer Society. What are the key statistics about penile cancer? February 2006. Available at: www.cancer.org/docroot/CRI/content/ CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea=. Accessed February 23, 2006. 12. Johnson LG, Madeleine MM, Newcomer LM, Schwartz SM, Daling JR. Anal cancer incidence and survival: the surveillance, epidemiology, and end results experience, 1973-2000. Cancer 2004;101(2):281-288. 13. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep 2002;51(RR-6):1-78. 14. Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection, external genital warts or cervical neoplasia? A meta-analysis. Sex Trans Dis 2002;29(11):725-735.
Leia Raphaelidis, FNP, BC, is a clinician with Planned Parenthood of the Southern Finger Lakes in Ithaca, New York. She has no financial relationship with business or industry to disclose. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.04.012
CONCLUSION In today’s time-pressured clinical environment, finding the time to answer questions about HPV can be a challenge because the subject does not lend itself to quick explanations. By providing patients with accurate, up-to-date information about the virus, clinicians can help dispel myths and reduce anxiety. In turn, patients who are less distressed are more likely to comply with recommended follow-up, an important consideration for preventing needless deaths from cervical cancer. 332
The Journal for Nurse Practitioners - JNP
May 2006