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

When to Stop Pap Test Screening

Women should discontinue cervical cancer screening at age 65 years if they have had adequate negative prior screening (3 consecutive negative Pap tests OR 2 consecutive negative HPV cotests within the past 10 years, with the most recent test within the past 5 years) and no history of high-grade precancerous lesions (CIN2+) in the past 25 years. 1, 2

Criteria for Discontinuing Screening

Standard Cessation at Age 65

• Stop screening at age 65 when adequate negative prior screening is documented 1, 2
• Adequate screening is defined as:
  • 3 consecutive negative cytology (Pap) tests within the past 10 years, OR 1, 2
  • 2 consecutive negative HPV cotests within the past 10 years 1, 2
  • The most recent test must have occurred within the past 5 years 1
• Women with HPV-negative atypical squamous cells of undetermined significance (ASC-US) should be regarded as negative for the purpose of discontinuing screening 1

Alternative Age Recommendations

While the predominant guideline consensus is age 65, some organizations recommend slightly different ages:

• The American Geriatrics Society recommends screening every 3 years until age 70 1, 2
• The American Cancer Society has also suggested age 70 as an acceptable stopping point after 3 negative tests in the last 10 years 2

However, age 65 remains the most widely endorsed and evidence-based recommendation from USPSTF, ACOG, and the most recent ACS guidelines. 1, 2

When Screening MUST Continue Beyond Age 65

History of High-Grade Lesions

• Continue screening for at least 20-25 years after spontaneous regression or appropriate management of CIN2, CIN3, or adenocarcinoma in situ, even if this extends screening past age 65 1, 2
• This extended surveillance applies regardless of the number of subsequent negative tests 1, 2

High-Risk Populations Requiring Continued Screening

Continue screening beyond age 65 in women with: 2, 3

• History of cervical cancer 1, 2
• HIV infection or immunosuppression (organ transplant, chronic corticosteroids, chemotherapy) 1, 2, 3
• In utero diethylstilbestrol (DES) exposure 1
• Multiple sexual partners 2
• History of human papillomavirus (HPV) infection 2
• Current smoking 2
• Pessary use 2

Inadequate Prior Screening Documentation

• If documentation of adequate prior screening cannot be obtained, perform screening tests until cessation criteria are met, regardless of age 1, 2
• Women who have never been screened should have at least 2 negative tests one year apart before discontinuing 1, 2, 3

Special Circumstances

Post-Hysterectomy

• Discontinue screening immediately in women who have undergone total hysterectomy with removal of the cervix for benign reasons and have no history of CIN2+ or cervical cancer 1, 2, 3
• Women who underwent subtotal (supracervical) hysterectomy with cervix retained should continue screening following standard recommendations 1
• If hysterectomy was performed for cervical cancer or precursors, continue screening per high-risk protocols 1

Once Screening is Stopped

• Screening should NOT resume for any reason, including if a woman reports having a new sexual partner 1, 2
• This is a firm recommendation based on the extended natural history of HPV-related cervical disease 2

Evidence Supporting Age 65 Cessation

Low Cancer Risk After Adequate Screening

• The incidence of cervical cancer among women age 70 and older who had at least one normal Pap smear in the previous 10 years is only 3 per 100,000 per year 2
• Modeling data demonstrate that continued testing of previously screened women reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74 1, 2
• In well-screened women older than 65 years, CIN2+ prevalence is low and cervical cancer is rare 2

Biological Rationale

• It is improbable that incident HPV infections and newly detected CIN3 after age 65 will have sufficient time to progress to invasive cancer within a woman's remaining lifetime, given the extended natural history of cervical disease 2
• Cervical cancer in the United States is most commonly diagnosed in unscreened and under-screened women, not in those with adequate prior screening 1, 2

Harm-Benefit Balance

• The absolute benefit in life-years gained from extending screening beyond age 65 is very small (maximum 3 days in best-case scenario, 0.5 days in realistic scenario) 4
• Potential harms include discomfort during sampling, false-positive results leading to unnecessary colposcopies, anxiety, and overtreatment 1, 2, 4
• The ratio of colposcopies to years of life gained becomes increasingly unfavorable with continued screening beyond age 65 2

Common Pitfalls to Avoid

Over-Screening in Elderly Women

• Approximately 40% of women over age 70 continue to receive Pap smears despite meeting criteria for cessation 5
• Provider recommendation is the strongest predictor of continued screening (10.5-fold increased odds), suggesting a need for better provider education on guidelines 5
• Do not continue screening simply because a woman has a new sexual partner or requests testing 1, 2

Under-Screening High-Risk Women

• Do not stop screening at age 65 in women with a history of CIN2+ in the past 20-25 years, even with subsequent negative tests 1, 2
• Immunocompromised women require indefinite screening regardless of age 1, 2, 3

Inadequate Documentation

• Do not assume adequate prior screening without documentation; if records are unavailable, perform screening until criteria are met 1, 2
• Self-reports of Pap test completion are often inaccurate and require clinical record verification 3

Screening After Hysterectomy

• Do not screen women who have had total hysterectomy for benign indications with no history of high-grade lesions 1, 2, 3
• This is one of the most common areas of inappropriate screening 1

Practical Algorithm for Deciding When to Stop

Step 1: Is the patient ≥65 years old?

• If NO → Continue age-appropriate screening
• If YES → Proceed to Step 2

Step 2: Does the patient have adequate negative prior screening?

• 3 consecutive negative Pap tests OR 2 consecutive negative HPV cotests in past 10 years, with most recent within 5 years? 1, 2
• If NO → Continue screening until criteria met
• If YES → Proceed to Step 3

Step 3: Does the patient have any history of CIN2+ in the past 25 years?

• If YES → Continue screening for 20-25 years from treatment/regression 1, 2
• If NO → Proceed to Step 4

Step 4: Does the patient have any high-risk factors?

• HIV, immunosuppression, DES exposure, history of cervical cancer? 1, 2, 3
• If YES → Continue screening indefinitely
• If NO → STOP SCREENING 1, 2

Step 5: Has the patient had a total hysterectomy with cervix removal?

• If YES and no history of CIN2+ or cervical cancer → STOP SCREENING immediately (regardless of age) 1, 2, 3