What is the recommended cervical cancer screening approach for a 66-year-old woman with no prior PAP (Papanicolaou) smear?

Cervical Cancer Screening Recommendations for a 66-Year-Old Woman with No Prior PAP Smear

A 66-year-old woman with no prior PAP smear should undergo cervical cancer screening with either primary HPV testing, cotesting (HPV plus cytology), or cytology alone, despite being past the typical age for screening cessation. 1

Rationale for Screening

While current guidelines generally recommend against routine cervical cancer screening in women older than 65 years who have had adequate prior screening, this recommendation does not apply to women without documented screening history:

• The USPSTF specifically states that "screening may be clinically indicated in older women for whom the adequacy of prior screening cannot be accurately assessed or documented" 1
• Women with limited access to care, minority women, and women from countries where screening is not available may be less likely to meet the criteria for adequate prior screening 1

Screening Algorithm for This Patient

1. Initial Screening Approach:

   • Preferred: Primary HPV testing 1
   • Acceptable alternatives: Cotesting (HPV plus cytology) or cytology alone 1

2. Follow-up Based on Initial Results:

   • If all results are negative, repeat screening in 3-5 years (3 years for cytology alone, 5 years for HPV testing or cotesting) 1
   • If any abnormal results, follow appropriate management guidelines for the specific abnormality detected

3. Screening Cessation Criteria:

   • Continue screening until the patient meets criteria for adequate prior screening:
     • 3 consecutive negative cytology results, or
     • 2 consecutive negative HPV tests or cotests within 10 years, with the most recent test occurring within 5 years 1

Important Considerations

• Risk factors: Assess for risk factors that might warrant more intensive screening, including:

  • HIV infection
  • Compromised immune system
  • In utero exposure to diethylstilbestrol
  • Previous treatment of high-grade precancerous lesion or cervical cancer 1

• Common barriers: Address potential barriers to screening such as:

  • Cost concerns and finding affordable clinics (most commonly reported barriers) 2
  • Transportation issues
  • Fear or anxiety about the procedure

Clinical Perspective

The rationale for screening this patient despite her age is that she has never had documented cervical cancer screening. The goal of screening is to identify high-grade precancerous cervical lesions to prevent development of cervical cancer and early-stage asymptomatic invasive cervical cancer 1. Without prior screening history, we cannot determine if she has already developed precancerous lesions that require treatment.

While there may be concerns about potential harms of screening in older women (false positives, unnecessary procedures), the risk of missing cervical cancer in a woman with no prior screening outweighs these concerns from a morbidity and mortality perspective.

Pitfalls to Avoid

• Don't assume low risk due to age alone: While cervical cancer risk decreases with age, the absence of prior screening means baseline risk is unknown
• Don't delay screening: Prompt screening is important as cervical cancer incidence at age 65 is approximately 13 cases per 100,000 females 3
• Don't stop at one negative test: A single negative screening test is insufficient to exit screening; multiple negative tests over time are required 1