From the Guidelines
Cervical cancer screening is not recommended after age 65 for individuals with a cervix who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years and have documented adequate negative prior screening in the prior 10 years. This recommendation is based on the 2020 guideline update from the American Cancer Society, which suggests that the risk of developing cervical cancer is very low in women who have been regularly screened by age 65 1. The natural history of HPV infection and cervical cancer, as well as the slow progression from HPV infection to cancer, support this recommendation.
Key Considerations
- The American Cancer Society recommends discontinuing all cervical cancer screening for individuals aged >65 years who meet specific criteria, including no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years and documented adequate negative prior screening in the prior 10 years 1.
- The potential harms of screening in this age group, including false positives, unnecessary procedures, and anxiety, may outweigh the benefits.
- Women with a history of high-grade precancerous lesions, cervical cancer, or immunocompromising conditions like HIV should continue screening beyond age 65, as they remain at higher risk.
Rationale
The rationale for this recommendation is based on the low risk of developing cervical cancer in women who have been regularly screened by age 65. Most HPV infections occur earlier in life, and the slow progression from HPV infection to cancer means that any new infections in older women are unlikely to progress to cancer during their remaining lifetime. The 2020 guideline update from the American Cancer Society provides a strong recommendation for discontinuing cervical cancer screening in women who meet specific criteria, prioritizing the reduction of potential harms and optimizing quality of life 1.
From the Research
Cervical Cancer Screening Recommendations
- The US Preventive Services Task Force (USPSTF) 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 for cervical cancer 2.
- Women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer do not benefit from screening 2.
- The American Journal of Preventive Medicine study found that the incidence rate for cervical cancer among older women, corrected for hysterectomy status, did not decline until age ≥85 years, but routine screening may be discontinued if "adequate" screening with negative results is documented 3.
Definition of Adequate Prior Screening
- Adequate prior screening is defined as 3 consecutive negative Pap smears or a single negative Pap plus HPV test ("cotest") 4.
- A study published in Gynecologic Oncology found that most cervical cancers diagnosed at age 65 and older occur in women who have not met the criteria for stopping screening 4.
Rationale for Stopping Screening at Age 65
- The USPSTF concludes that screening women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer does not provide significant benefit 2.
- A study published in Menopause found that postmenopausal persons are an important population at risk, and screening cessation recommendations are nuanced, but screening should be stopped at the recommended age if adequate screening has occurred or at any age if life expectancy is limited or the patient has had a hysterectomy in the absence of high-grade preinvasive cervical lesions or cervical cancer 5.
Provider and Patient Factors
- A study published in Preventive Medicine found that health care providers may need additional education on current guidelines regarding indications for Pap smears in women ≥70 years of age to help reduce screening of patients who may not benefit 6.
- The same study found that about 70% of women who visited an obstetrician/gynecologist and reported receiving a recommendation to have a Pap smear did so in the past year, while 32.3% of women who visited an obstetrician/gynecologist but did not receive a recommendation obtained one 6.