What are the cervical cancer screening recommendations for a 78-year-old female with regard to Pap (Papanicolaou) smear testing?

From the Guidelines

Cervical cancer screening is not recommended for a 78-year-old female who has had adequate prior screening with normal results, as stated in the American Cancer Society guidelines 1.

Rationale for Recommendation

The rationale for this recommendation is that cervical cancer develops slowly, and the benefits of screening in older women with a history of normal results do not outweigh the potential harms, which include false positives, unnecessary procedures, and anxiety.

Definition of Adequate Prior Screening

Adequate prior screening is defined as three consecutive negative cytology (Pap smear) results or two consecutive negative co-testing (Pap plus HPV testing) results within the past 10 years, with the most recent test occurring within the past 5 years 1.

Exceptions to the Recommendation

However, if the woman has a history of cervical precancer (CIN2 or higher), she should continue screening for at least 25 years after the abnormality was found, regardless of age. Additionally, women with risk factors such as HIV infection, immunosuppression, DES exposure in utero, or a history of cervical cancer should continue screening as long as they are in reasonably good health and would benefit from early detection and treatment.

Guideline Evidence

The American Cancer Society guidelines 1 provide the most recent and highest quality evidence for cervical cancer screening recommendations, and they should be followed in clinical practice to prioritize morbidity, mortality, and quality of life outcomes. Some key points to consider when making a decision about cervical cancer screening in a 78-year-old female include:

• The woman's prior screening history and results
• The presence of any risk factors for cervical cancer
• The woman's overall health and life expectancy
• The potential benefits and harms of screening in older women. It is essential to weigh these factors and consider the latest guidelines when making a decision about cervical cancer screening in a 78-year-old female.

From the Research

Cervical Cancer Screening Recommendations for a 78-Year-Old Female

• The current guidelines recommend that women with a history of adequate screening and not otherwise at high risk may discontinue cervical cancer screening after 65 years of age 2.
• However, screening remains common among US women over 65 years old, with 40.8% of women having a Pap smear within the past 3 years and 19.4% having a Pap smear in the last year 2.
• A study suggests that health care providers may need additional education on current guidelines regarding indications for Pap smears in this age group to help reduce screening of patients who may not benefit 2.
• Another study proposes an algorithm based on current cervical cancer screening guidelines to aid providers in identifying whether exit criteria have been met, and recommends that cervical cancer 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 3.
• There is limited evidence on which to base the recommendation to stop screening, and there is confusion among patients and physicians over who to screen and when 4.
• Recommendations to space or stop screening are often based on the perceived psychological distress of women undergoing testing and the cost of population screening, rather than the risk of cervical cancer 4.
• The American College of Obstetricians and Gynecologists (ACOG) and other organizations recommend that women over 65 years old should not be screened for cervical cancer if they have had adequate prior screening and are not at high risk for cervical cancer 3, 4.

Screening Methods and Intervals

• Guidelines recommend screening for cervical cancer among women 30 years or older 3 years after a normal Papanicolaou test (Pap test) result or a combined normal screening result (normal Pap/negative human papillomavirus [HPV] test results) 5.
• Most primary care physicians (PCPs) do not recommend extending screening intervals to 3 years with an HPV cotest, and instead recommend more frequent screening 5.
• The FDA has approved the use of an HPV test for primary cervical cancer screening for women over the age of 25 years, without the need for a concomitant Pap test 6.
• The use of primary HPV testing with genotyping and reflex cytology for women over the age of 25 years is a topic of debate, with some supporting its use as a more effective screening method and others preferring cotesting 6.