Should a 67-year-old patient with a history of normal screenings, including a normal colposcopy (colposcopy) 6 years ago, continue to have routine Pap (Papanicolaou) smears?

Cervical Cancer Screening Discontinuation for a 67-Year-Old Woman with Normal History

A 67-year-old woman with normal Pap smears for the past 6 years following a colposcopy should discontinue cervical cancer screening, as she meets the criteria for cessation of screening. 1, 2

Rationale for Discontinuation of Screening

• Guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology recommend that women over 65 years of age with evidence of adequate negative prior screening and no history of CIN2+ within the last 20 years should not be screened for cervical cancer with any modality 1
• Once screening is discontinued, it should not resume for any reason, even if a woman reports having a new sexual partner 1
• Adequate negative prior screening is defined as 3 consecutive negative cytology results or 2 consecutive negative cotests within the 10 years before ceasing screening, with the most recent test occurring within the past 5 years 1
• The patient's history of 6 years of normal Pap smears following colposcopy meets these criteria for discontinuation 1, 2

Evidence Supporting Discontinuation

• In well-screened women older than 65 years in the United States, CIN2+ prevalence is low and cervical cancer is rare 1
• Cervical cancer is most commonly diagnosed in unscreened and under-screened women, not in those with adequate prior screening 1
• Based on the extended natural history of the disease, it is improbable that incident HPV infections and newly detected CIN3 after age 65 will have sufficient time to progress to invasive cancer in the woman's lifetime 1
• Modeling studies have concluded that for women who have been screened regularly prior to age 65, the ratio of colposcopies to years of life gained associated with further screening is large because of the small gains in life expectancy 1

Potential Harms of Continued Screening

• Potential harms from screening of this population include discomfort during cytology sampling and false-positive screening tests 1
• Over-screening increases costs and potential harms without significantly improving cancer detection 3
• The absolute benefit in terms of life-years gained from extending screening beyond age 65 is very small 1
• Achieving a very small gain in life-years by extending screening comes at a cost of more colposcopies, indicating that screening becomes less efficient beyond age 65 1

Special Considerations and Exceptions

• If the patient had a history of CIN2, CIN3, or adenocarcinoma in situ, routine screening should continue for at least 20 years, even if this extends screening past age 65 1
• Women with risk factors for cervical cancer may need continued screening beyond age 65-70, even with a history of adequate screening, including multiple sex partners, history of HPV infection, HIV infection or immunosuppression, history of cervical dysplasia, smoking, or pessary use 2
• If documentation of recent screening cannot be obtained, screening tests should be performed until the criteria are met for cessation 1

Algorithm for Decision-Making

1. Verify patient age (≥65 years) ✓
2. Confirm adequate prior screening (3 consecutive negative Pap tests or 2 negative cotests within 10 years) ✓
3. Verify no history of CIN2+ within the past 20 years ✓
4. If all criteria are met, discontinue screening ✓
5. If any criteria are not met, continue screening according to age-appropriate guidelines 1, 2

In this case, the 67-year-old patient with 6 years of normal Pap smears following colposcopy meets all criteria for discontinuation of cervical cancer screening, and screening should be discontinued.