From the Guidelines
The patient does not need another Pap test, as the current guidelines recommend discontinuing screening if adequate negative prior screening has been established, which is the case for this 68-year-old woman with a normal first Pap test. According to the American Cancer Society's 2020 guideline update 1, adequate negative prior screening is defined as 2 consecutive, negative primary HPV tests, or 2 negative cotests, or 3 negative cytology tests within the past 10 years, with the most recent test occurring within the past 3-5 years, depending on the test used.
Key Points to Consider
- The patient's age and normal first Pap test result suggest a low risk of developing cervical cancer later in life 1.
- The natural history of HPV infection and cervical cancer progression typically spans many years, and women who have been adequately screened with normal results by age 65-70 have established a pattern of low risk.
- Continued screening beyond the recommended age may lead to potential harms, such as false positives and unnecessary procedures, without providing significant benefits 1.
- However, if the patient has risk factors such as a history of high-grade precancerous lesions, cervical cancer, immunosuppression, or inadequate prior screening, then continued screening may be warranted beyond these guidelines.
Screening Recommendations
- The American Cancer Society recommends discontinuing screening for women over 65 years old with adequate negative prior screening 1.
- The guidelines also emphasize that individuals without a cervix and without a history of CIN2 or a more severe diagnosis in the past 25 years or cervical cancer ever should not be screened 1.
From the Research
Cervical Cancer Screening Guidelines
- The patient had their first Pap smear at age 68 and the result was normal.
- According to the study 2, recommendations are to space cervical cancer screening intervals for women aged 21-65 and stop in women older than 65.
- However, the same study 2 also mentions that there is limited evidence on which to base the recommendation to stop screening, and cervical cancer incidence and mortality burden are significant in women over the age of 65.
Risk Factors and Prevention
- The study 3 lists risk factors for persistent HPV infections, including a history of multiple sex partners, initiation of sexual activity at an early age, not using barrier protection, and other sexually transmitted infections.
- The study 3 also mentions that vaccination is the primary method of prevention, and the nonavalent HPV vaccine is effective in preventing the development of high-grade precancerous cervical lesions in noninfected patients.
- The study 4 notes that vaccination does not replace routine cervical cancer screening with Pap smears, as the vaccines do not protect against all HPV types.
Screening and Vaccination
- The study 5 discusses the impact of HPV vaccination on cervical cancer prevention, and how it can reduce the need for costly medical procedures and provide substantial benefits to women and communities.
- The study 6 provides information on the role of the HPV vaccine in the prevention of cervical cancer, and how primary care physicians can counsel women with abnormal Pap tests who may need colposcopy or other follow-up evaluation.
- The study 2 highlights the importance of continued screening and vaccination efforts, especially in older women, due to the increasing rates of cervical cancer and limited evidence on which to base the recommendation to stop screening.