The following case study illustrates some of the common feelings experienced by women confronted with an abnormal Pap test and the healthcare implications involved in the care of the woman and her partner.

Patient M is a female college student, 21 years of age, who presented to the college health clinic for her annual exam to renew her prescription for birth control pills. Patient M had been involved in a serious relationship with a fellow college student for one year. Following the results of her exam and Pap test, Patient M was diagnosed with HPV and epithelial abnormalities of the cervix. The patient was upset, embarrassed, and angry with herself and her boyfriend. Upon confronting her boyfriend, Patient M learned that he had been sexually involved with another girl on campus, during a brief time when they had broken up, and that this was the likely source of transmission of the virus. Patient M confided in her mother, who was also upset at the notion of the sexually transmitted virus. Patient M's mother had recently been treated for breast cancer, and her daughter's diagnosis renewed many fearful and unpleasant feelings regarding cancer.

Care for Patient M involved exploration of preconceived notions of sexuality and cancer. The patient established good communication with her boyfriend, and both attended a clinic session for pretreatment counseling where factual information was given for the recommended cryosurgery treatment. Concerns regarding future problems with sexual intercourse and fertility were dispelled. Discussion of HPV as a risk factor for cervical epithelial changes was reviewed in a factual manner, and the couple had an opportunity to explore their plans regarding their relationship.

The patient described her experiences as follows: "My mother had breast cancer when she was 60, so I was more aware of screening. When I was 52, I went to my gynecologist for a routine checkup and discussed everything. I actually said to my physician, 'By the way, don't you think I should have a mammogram?' So I did, and they discovered it. I cannot sing the praises of a mammogram any higher. The cancer could not be felt, and it was discovered as a result of the mammogram. The cancer had not spread to the lymph nodes, so I had a lumpectomy. After the surgery, the surgeon just said, 'Go home, everything's great, and you'll be fine.' However, I think that fear, once you hear you have any cancer, is awful. Once I found out that it hadn't gone into the lymph nodes, I did feel a whole lot better."

This woman's experiences highlight several key points for health professionals. First, women should act as advocates for themselves if physicians or practitioners do not initiate the topic of breast screenings. Second, this is a good example of breast cancer discovered by a mammogram in its earliest stages, long before the mass was large enough to be palpated. Lastly, the woman's descriptions of her emotions when diagnosed with cancer should be included when developing her treatment plan. Just because a woman is fortunate enough to be diagnosed early and is a good candidate for breast-conserving treatment, such as lumpectomy, does not mean she does not have emotional adjustments to make as a woman living with breast cancer.

Another patient described her experiences with treatment decisions as follows: "You know, I started backwards because the lump was under my arm first. It took the surgeon about 15 minutes to find the spot in my breast. We discussed my options, and I chose to have a lumpectomy. I opted for this because, being 42, I was pretty young, and I could probably get by with just a lumpectomy. Unfortunately, that didn't work, because when the report came back, they said the tissue around the lump was not healthy. So, they left the option to me regarding further surgery, and I had 10 weeks to think about it. During that 10 weeks, I had my chemotherapy. That was a very hard 10 weeks. My husband said it didn't matter to him whether I lost a breast, and he would rather that I was overtreated, but it was a hard decision. I kept thinking: How am I going to look? How am I going to feel? Am I still going to be a woman? It took me a long time, and I finally decided it didn't matter, that I was going to live. It didn't matter what I had to do in order to do it. So, I said okay, and I elected to have the mastectomy done."

This woman's experience also highlights key points for health professionals to understand when working with women with breast cancer. The patient was persistent in seeking care for a lump under her arm. This is a reminder that breast cancer may not always be obvious in the breast. Also, unexpected or borderline test results place the woman and her family in a position where the treatment decisions are not black or white. Health professionals should provide support, information, and a caring attitude as women make decisions that are difficult and emotive.

Patient T is a teacher, 52 years of age, who had Stage 1 breast cancer detected by a screening mammogram seven years ago. At that time, she underwent a lumpectomy and radiation therapy. She chose not to take tamoxifen because it was not recommended as being necessary by her surgeon and she is not a good pill-taker. She adheres to her suggested routine of follow-up care, including BSE, yearly mammogram, and CBE with the surgeon who performed her lumpectomy. She has been in good health since her breast cancer treatment and has had no further incidence of cancer.

Patient T presented to the women's health clinic because she was experiencing hot flashes during the night, which was contributing to sleep deprivation. She was so fatigued that she felt it was interfering with her ability to perform her demanding job. In discussing treatment options, Patient T was well informed of her contraindication for HRT due to her history of breast cancer. Furthermore, she reported that even if she had not had breast cancer, she probably would not adhere to HRT because she did not really believe in taking pills and she was very cautious regarding the risk of cancer. The nurse discussed various complementary therapies, including black cohosh tea, relaxation therapies during the nighttime hot flashes, and the options for her to redirect some work responsibilities. Patient T did find that the tea and relaxation exercises were helpful, and she was able to temporarily reassign some teaching assignments to a student teacher. At her one-month follow-up appointment, Patient T reported that her episodes of hot flashes were becoming less frequent and her sleep patterns had improved. Due to the contraindication for HRT, the issue of osteoporosis was discussed and Patient T had a baseline bone densitometry test. She was given a consultation with a dietician to emphasize dietary and supplemental calcium, vitamin D therapy, and a heart-healthy diet pattern. Patient T also made the choice to maintain a more consistent aerobic exercise program by walking during her lunch hour in the school gym with the purpose of decreasing risk factors for both osteoporosis and heart disease.