At what age can Pap (Papanicolau) testing be discontinued in women with a history of negative results and no high risk for cervical cancer?

When to Discontinue Pap Testing

Women should discontinue cervical cancer screening after age 65 if they have had adequate negative prior screening and no history of CIN2+ within the past 25 years. 1

Criteria for Discontinuing Pap Testing

Adequate Negative Prior Screening

Adequate negative prior screening is defined as:

• 3 consecutive negative cytology tests OR
• 2 consecutive negative cotests (cytology plus HPV) OR
• 2 consecutive negative HPV tests 1

These tests must have been performed within the past 10 years, with the most recent test occurring within the past 5 years 1.

Special Considerations

Continue Screening Beyond Age 65 For:

• Women with a history of CIN2, CIN3, or adenocarcinoma in situ within the past 25 years 1
• Women who were exposed to diethylstilbestrol (DES) in utero 1
• Immunocompromised women (including those with HIV infection, organ transplantation, chemotherapy, or chronic corticosteroid treatment) 1
• Women without documented adequate negative prior screening 1

Screening After Treatment for CIN2+

• Women treated for CIN2, CIN3, or adenocarcinoma in situ should continue routine screening for at least 20 years after treatment, even if this extends screening beyond age 65 1

Rationale for Discontinuing Screening at Age 65

The recommendation to discontinue screening at age 65 for women with adequate negative prior screening is based on several factors:

1. Low Risk: In well-screened women over age 65, the prevalence of CIN2+ is low and cervical cancer is rare 1

2. Risk-Benefit Analysis: The potential harms of continued screening (discomfort, false positives, overtreatment) outweigh the small benefits in this population 1

3. Natural History: It is unlikely that new HPV infections acquired after age 65 will have sufficient time to progress to invasive cancer in a woman's lifetime 1

4. Evidence from Modeling: Mathematical modeling shows that continuing screening beyond age 65 in well-screened women prevents only 1.6 cancer cases and 0.5 cancer deaths per 1000 women, while resulting in 58 extra false positives, 127 extra colposcopies, and 13 extra CIN2/3 diagnoses requiring treatment 1

Common Pitfalls and Caveats

1. Inadequate Documentation: If sufficient documentation of prior screening is not available, screening should continue until cessation criteria are met 1

2. Confusion About Hysterectomy Status: Women who have had a total hysterectomy (with removal of the cervix) for benign indications and no history of CIN2+ should not be screened 1

3. New Sexual Partners: Once screening is discontinued at age 65, it should not resume for any reason, including if a woman reports having a new sexual partner 1

4. Limited Life Expectancy: Cervical cancer screening may be discontinued in individuals of any age with limited life expectancy 1

5. Misunderstanding About Annual Exams: Even when Pap testing is discontinued, annual gynecologic examinations may still be appropriate 1

Recent research suggests that cervical cancer incidence and mortality burden remain significant in women over age 65, and advanced cervical cancer rates are increasing 2. However, the current guidelines from major organizations still recommend discontinuing screening at age 65 for women with adequate prior negative screening and no history of high-grade lesions.