Why continue cervical cancer screening beyond age 65 in certain individuals?

Why Continue Cervical Cancer Screening Beyond Age 65?

Screening should continue beyond age 65 in individuals who lack adequate prior negative screening documentation, have a history of high-grade precancerous lesions or cervical cancer, or have specific high-risk conditions—because approximately 1 in 5 cervical cancers are diagnosed after age 65, and these cases account for 1 in 4 cervical cancer deaths annually, predominantly occurring in unscreened or underscreened individuals. 1

Primary Indications for Continued Screening

Inadequate Prior Screening History

• Continue screening if the individual cannot document adequate negative prior screening, defined as either 3 consecutive negative cytology results OR 2 consecutive negative HPV tests OR 2 consecutive negative cotests within the past 10 years, with the most recent test within the recommended interval. 1
• The highest proportion of unscreened women within recommended screening ages occurs among those aged 60-65 years, with 18.4% not recently screened as they approach the cessation age. 1, 2
• Women with limited healthcare access, minority women, and immigrants from countries without screening programs are particularly likely to lack adequate documentation and require continued screening. 1

History of High-Grade Lesions or Cervical Cancer

• Routine screening must continue for at least 20-25 years after spontaneous regression or appropriate management of CIN2+ (high-grade precancerous lesions), even if this extends screening well past age 65. 1, 3
• Women with a history of cervical cancer remain at increased risk for vaginal cancer and require lifelong surveillance. 3
• Following hysterectomy for cervical intraepithelial lesions, cytology should be performed every 4-6 months initially, with three consecutive negative tests within 18-24 months before modifying the schedule. 3

High-Risk Medical Conditions

• Immunocompromised individuals require continued screening regardless of age, including:
  • HIV-positive individuals (follow CDC/NIH/IDSA guidelines) 1
  • Solid organ or stem cell transplant recipients 1
  • Those on chronic immunosuppressant therapy 1
• Women with in utero diethylstilbestrol exposure require continued surveillance due to elevated risk of clear cell adenocarcinoma and cervical dysplasia. 1

Disease Burden Justifying Extended Screening

Epidemiologic Evidence

• Approximately 20% of new cervical cancer cases are diagnosed in women ≥65 years. 1
• Cervical cancer deaths from diagnoses after age 65 account for approximately 25% of all cervical cancer deaths annually. 1
• Among adequately screened women, the 20-year absolute risk of cervical cancer is only 8 per 10,000, compared to 49 per 10,000 in unscreened women—demonstrating an 84% risk reduction with adequate prior screening. 1

The Underscreening Problem

• Most cervical cancers in women >65 years occur in those who were never screened or inadequately screened before reaching cessation age. 1
• In a national database analysis, only 29% of potentially eligible women had documentation meeting cessation criteria; even among those continuously enrolled for ≥10 years, only 53% met criteria. 1
• Screening rates decline with age, from 90% in women aged 30-39 years to 80% in women aged 50-65 years. 1

Clinical Performance Considerations

Screening Efficacy in Older Women

• Screening between ages 55-64 years demonstrates clear protective effect against cervical cancer death up to age 79 years (OR 0.18), though screening after age 65 shows nonsignificant protection (OR 0.47). 1
• Anatomic challenges increase with age: vaginal atrophy, musculoskeletal disorders, and cervical transformation zone migration make examinations more difficult and potentially less sensitive. 1
• In women aged 60-89 years, the transformation zone is not visible in approximately two-thirds during colposcopy, limiting diagnostic accuracy. 1

Screening Outcomes in Extended Surveillance

• In a retrospective study of 296 patients who continued screening despite meeting cessation criteria, the abnormality rate was 332 per 10,000 person-years (mostly HR-HPV positive with negative cytology), with cytologic abnormalities at 119 per 10,000 person-years. 4
• Critically, no cervical cancers were detected in this extended surveillance cohort, though one HSIL was identified. 4
• Most findings in older women are HR-HPV positive with negative cytology, which confers low progression risk in this age group. 4

Common Pitfalls to Avoid

Documentation Failures

• Never discontinue screening without verifying adequate prior negative screening history through medical records review—verbal patient report is insufficient. 1
• The fragmented U.S. healthcare system makes obtaining complete screening histories challenging; implement electronic health record interoperability to access prior results. 1

Premature Cessation in High-Risk Groups

• Do not stop screening at age 65 in women with prior CIN2+ until 20-25 years have elapsed since treatment, regardless of current age. 1, 3
• Screening should never resume after cessation, even with a new sexual partner, in women who met adequate screening criteria. 1

Inappropriate Screening

• Women who underwent hysterectomy with cervix removal for benign reasons (not high-grade lesions or cancer) should not be screened—this provides no benefit. 1
• Confirm cervical removal through surgical records or direct examination before discontinuing screening. 1

Practical Algorithm for Decision-Making

For any individual >65 years, systematically assess:

1. Can you document adequate prior screening? (3 negative cytology OR 2 negative HPV/cotests in past 10 years, most recent within interval)

   • NO → Continue screening until criteria met
   • YES → Proceed to step 2

2. History of CIN2+ or cervical cancer?

   • YES → Continue screening for 20-25 years post-treatment
   • NO → Proceed to step 3

3. Immunocompromised, HIV+, or DES exposure?

   • YES → Continue screening indefinitely per specialized guidelines
   • NO → Safe to discontinue screening

4. Cervix present?

   • NO (hysterectomy) → Discontinue screening (unless history of CIN2+/cancer)
   • YES → Apply above algorithm

This algorithmic approach prioritizes mortality reduction by identifying the substantial minority of older women who remain at risk while avoiding overscreening in those adequately protected by prior negative results. 1