At what age can Pap (Papanicolau) tests be stopped?

When to Stop Pap Smear Screening

Women should stop cervical cancer screening at age 65 if they have had adequate prior screening with negative results and are not otherwise at high risk for cervical cancer. 1, 2

Definition of Adequate Prior Screening

• Women can discontinue screening at age 65 if they have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap co-tests within the last 10 years, with the most recent test occurring within the last 5 years 2
• The U.S. Preventive Services Task Force (USPSTF) specifically recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk 3
• The American Cancer Society (ACS) recommends stopping screening at age 70 years after 3 negative tests in the last 10 years 1

Women Who Should Continue Screening Beyond Age 65

Screening should continue beyond age 65 in women who:

• Have inadequate prior screening history 1, 2
• Have a history of cervical dysplasia or cervical cancer 1, 2
• Are immunocompromised (including HIV positive) 3, 1
• Have other significant risk factors, such as:
  • Multiple sex partners 1
  • History of HPV infection 1
  • Smoking 1
  • Pessary use 1

Special Populations

• Women who have had a hysterectomy with removal of the cervix for benign reasons should discontinue Pap screening immediately 1, 2
• Women who have had a hysterectomy but still have a cervical cuff present may still need screening 2
• Women who have never been screened have an incidence of disease three to four times that of women who have had at least one prior normal Pap smear and should undergo at least two negative tests one year apart, regardless of age 1

Evidence Supporting Cessation of Screening

• The risk of cervical cancer among properly screened women over 65 is very low - only 3 cases per 100,000 in women age 70 and older who had at least one normal Pap smear in the previous 10 years 1
• Modeling data suggests that continued testing of previously screened women reduces the risk of cervical cancer mortality by only 0.18% at age 65 and by 0.06% at age 74 1
• A study found that only 2.3 per 100,000 women per year with one or more negative co-tests at age 65 and older were subsequently diagnosed with invasive cancer 4

Challenges and Pitfalls

• Many older women, especially in low-income populations, approach the "stopping age" without adequate prior screening history 5, 6
• In one study, 59.5% of women aged 65 and older needed to continue testing due to inadequate screening histories 5
• Overscreening remains common among women over 70, with 40.8% having had a Pap smear within the past 3 years despite guidelines recommending cessation 7
• Provider recommendation significantly influences whether older women continue to receive Pap tests, suggesting that healthcare providers may need additional education on current guidelines 7

Practical Algorithm for Deciding When to Stop Screening

1. If a woman is ≥65 years old, assess her screening history:

   • If she has had 3 consecutive negative Pap tests or 2 negative co-tests within the past 10 years (most recent within 5 years) → Stop screening 1, 2
   • If screening history is inadequate → Continue screening 1, 2

2. If a woman has had a hysterectomy:

   • With removal of cervix for benign reasons → Stop screening 1, 2
   • For cervical cancer or precancer → Continue screening 1, 2

3. Assess for high-risk factors regardless of age:

   • History of cervical dysplasia or cancer → Continue screening 1, 2
   • Immunocompromised status → Continue screening 3, 1
   • Other significant risk factors → Continue screening 1