Should a 79-year-old woman with diabetes (Diabetes Mellitus), hypertension (High Blood Pressure), chronic kidney disease (CKD), and heart failure with preserved ejection fraction (HFpEF) undergo cervical cancer screening, given that she has never been screened before?

Should This 79-Year-Old Never-Screened Woman Undergo Cervical Cancer Screening?

Yes, this 79-year-old woman should be offered cervical cancer screening because she has never been screened, and modeling studies demonstrate that screening previously unscreened women can reduce mortality by 74%, with strategies extending to age 70-75 years representing reasonable benefit-harm tradeoffs. 1

Key Evidence Supporting Screening in This Case

The Critical Distinction: Never-Screened vs. Adequately Screened Women

The standard recommendation against screening women over age 65 applies only to those with adequate prior screening history (3 consecutive negative cytology results or 2 consecutive negative HPV tests within 10 years, with the most recent within 5 years). 1, 2 This patient has never been screened, placing her in an entirely different risk category.

Magnitude of Benefit in Unscreened Older Women

• 42% of women aged ≥65 years diagnosed with cervical cancer had never been screened, demonstrating that the unscreened population drives much of the disease burden in this age group. 1
• Approximately 20% of all cervical cancer cases occur in women ≥65 years, and these cases account for 25% of all cervical cancer deaths annually—predominantly in unscreened or underscreened individuals. 3
• The 20-year absolute risk of cervical cancer in unscreened women is 49 per 10,000 compared to only 8 per 10,000 in adequately screened women—an 84% risk reduction with adequate screening. 3
• Half of all invasive cervical cancer cases are diagnosed in women who have never been screened or have not been screened in the last 5 years. 1

Specific Modeling Data for This Population

Modeling studies specifically addressing previously unscreened older women show that screening strategies extending to age 70-75 years with intervals of every 2-5 years represent reasonable benefit-harm tradeoffs. 1 The 74% mortality reduction in never-screened women is substantial and clinically meaningful. 1

Practical Screening Approach

Recommended Strategy

Offer cervical cytology (Pap smear) every 3 years or HPV testing with cytology (cotesting) every 5 years until she achieves adequate negative screening history. 1 Given her age, a reasonable endpoint would be after obtaining 2-3 consecutive negative screens, extending to approximately age 70-75 years if she remains in reasonable health. 1

Important Caveats Regarding Her Comorbidities

While her diabetes, hypertension, CKD, and HFpEF are noted, the decision hinges on:

• Life expectancy: If her comorbidities result in a life expectancy <5 years, screening benefits diminish substantially. 4
• Ability to tolerate examination: Anatomic changes, vaginal atrophy, and musculoskeletal disorders can make examinations more difficult and potentially painful in older women. 1, 3
• Ability to tolerate treatment: If abnormalities are found, she must be able to undergo colposcopy, biopsy, and potential treatment procedures, which carry greater risks in older individuals with multiple comorbidities. 1, 3

Common Pitfalls to Avoid

• Do not assume that age alone disqualifies her from screening—the guideline against screening >65 years applies only to adequately screened women, not never-screened women. 1, 3
• Do not rely on verbal history alone—verify screening history through medical records, as patient recall is often inaccurate. 3, 2
• Do not continue screening indefinitely—once she achieves adequate negative screening (2-3 consecutive negative tests), screening should stop and not resume for any reason, even if she reports a new sexual partner. 1, 2
• Do not screen if she has had a total hysterectomy with cervix removal for benign reasons (not high-grade lesions or cancer), as this provides no benefit. 1, 3

Balancing Benefits and Harms at Age 79

Potential Benefits

• Substantial mortality reduction (74%) compared to remaining unscreened. 1
• Detection of treatable precancerous lesions or early-stage cancer. 1

Potential Harms

• False-positive results leading to unnecessary colposcopies and biopsies. 1
• Examination discomfort due to vaginal atrophy and musculoskeletal changes. 1, 3
• Overdiagnosis and overtreatment of slow-growing lesions that may not progress within her remaining lifespan. 1
• Reduced sensitivity of screening due to anatomic changes (transformation zone not visible in approximately two-thirds of elderly women during colposcopy). 1

The Decision Algorithm

Screen if:

• Life expectancy ≥5 years 4
• She can tolerate pelvic examination 1, 3
• She would accept treatment if abnormalities are found 4
• She has not had a total hysterectomy with cervix removal 1

Do not screen if:

• Life expectancy <5 years due to her comorbidities 4
• She cannot tolerate examination or would decline treatment 4
• She has had total hysterectomy with cervix removal for benign reasons 1

Given that her comorbidities (diabetes, hypertension, CKD, HFpEF) are chronic but manageable conditions rather than immediately life-limiting, and assuming she is in "reasonably good health" despite these conditions, the balance favors offering screening given the substantial mortality reduction demonstrated in never-screened women. 1, 3