Is Pap smear screening recommended for a 67-year-old woman with a history of regular Pap smears and no history of high-grade precancerous lesions or cervical cancer?

Pap Smear Screening After Age 67

No, Pap smear screening is not recommended for a 67-year-old woman with a history of regular Pap smears and no history of high-grade precancerous lesions or cervical cancer—screening should be discontinued at age 65 if adequate prior screening has been documented. 1, 2

Criteria for Discontinuing Screening at Age 65

The decision to stop screening hinges entirely on documentation of adequate prior negative screening. Adequate prior screening is defined as:

• 3 consecutive negative cytology (Pap) tests alone within the past 10 years, OR 1, 3
• 2 consecutive negative HPV tests within the past 10 years, OR 4, 3
• 2 consecutive negative cotests (Pap + HPV) within the past 10 years 1, 3

The most recent test must have occurred within 5 years for cytology alone or within the recommended interval for the specific test used. 1, 3

Evidence Supporting Cessation at Age 65

The rationale for stopping screening in adequately screened women is compelling:

• Among women with adequate prior screening, the 20-year absolute risk of cervical cancer is only 8 per 10,000, compared to 49 per 10,000 in unscreened women—representing an 84% risk reduction. 1, 3
• Cervical cancer in the United States occurs predominantly in unscreened and underscreened individuals, not in those with documented adequate prior screening. 1
• The viral etiology of cervical cancer means that serial negative HPV and cytology results identify individuals at very low risk for subsequently developing cervical cancer. 1
• Modeling studies demonstrate that the ratio of colposcopies to life-years gained becomes very large beyond age 65 in previously screened women, indicating screening becomes inefficient. 1, 3

Critical Exceptions: When to Continue Screening Beyond Age 65

Screening must continue beyond age 65 in the following circumstances:

History of High-Grade Lesions

• Women with prior CIN2, CIN3, or adenocarcinoma in situ must continue screening for at least 20-25 years after treatment, even if this extends screening well past age 65. 1, 4, 3
• This extended surveillance is necessary because these women remain at elevated risk for decades after treatment. 4

Inadequate Prior Screening Documentation

• If adequate prior screening cannot be documented through medical records, continue screening until cessation criteria are met. 1, 4, 3
• Verbal patient report alone is insufficient—medical records must verify the screening history. 4
• Women with limited healthcare access, minority women, and immigrants from countries without screening programs are particularly likely to lack adequate documentation. 4

Immunocompromised Status

• HIV-positive individuals, solid organ or stem cell transplant recipients, and those on chronic immunosuppressant therapy require continued screening regardless of age. 4, 3

In Utero Diethylstilbestrol Exposure

• Women with in utero DES exposure require continued surveillance due to elevated risk of clear cell adenocarcinoma and cervical dysplasia. 4

Disease Burden Context

While approximately 1 in 5 new cervical cancer cases are diagnosed in women ≥65 years, and these account for 1 in 4 cervical cancer deaths annually, the vast majority of these cases occur in women who were never screened or underscreened—not in those with adequate prior screening. 1, 4

Screening between ages 55-64 demonstrates clear protective effect against cervical cancer death up to age 79 (OR 0.18), though screening after age 65 shows nonsignificant protection (OR 0.47) in adequately screened women. 4

Common Pitfalls to Avoid

• Never discontinue screening without verifying adequate prior negative screening history through medical records review—verbal patient report is insufficient. 4
• Do not stop screening at age 65 in women with prior CIN2+ until 20-25 years have elapsed since treatment, regardless of current age. 4, 3
• 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, 4, 2
• Anatomic challenges increase with age (vaginal atrophy, musculoskeletal disorders, cervical transformation zone migration), making examinations more difficult and potentially less sensitive. 4

Guideline Consensus

The most recent and authoritative guidelines—the 2018 USPSTF recommendation 2, the 2019 American Family Physician guideline 1, and the 2020 American Cancer Society guideline 1—all uniformly recommend against screening women older than 65 years who have had adequate prior screening and are not otherwise at high risk (D recommendation, meaning the harms outweigh the benefits).