What are the guidelines for pap (Papanicolaou) testing in a woman over 66 years old with no history of cervical cancer or high-grade precancerous lesions and adequate prior screening?

Pap Testing Guidelines After Age 66

Women over 65 years old with adequate prior negative screening and no history of high-grade precancerous lesions should discontinue cervical cancer screening entirely. 1, 2

Criteria for Stopping Screening at Age 65-66

You can safely stop Pap testing if ALL of the following are met:

• Adequate prior negative screening is documented, defined as either:

  • 3 consecutive negative Pap tests within the past 10 years, with the most recent within 5 years, OR
  • 2 consecutive negative HPV tests (or HPV/Pap cotests) within the past 10 years, with the most recent within 5 years 1, 3

• No history of high-grade precancerous lesions (CIN2, CIN3, or adenocarcinoma in situ) or cervical cancer in the past 20-25 years 1, 3

• No high-risk medical conditions such as HIV infection, immunosuppression, or in utero diethylstilbestrol exposure 1, 3

• Cervix is still present (if hysterectomy was performed, it must have been for benign reasons, not cancer or high-grade lesions) 1, 2

Critical Exceptions: Continue Screening Beyond Age 65-66

History of High-Grade Lesions or Cancer

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

Inadequate or Unknown Prior Screening History

• Continue screening until adequate negative screening is documented if you cannot verify the patient's screening history through medical records 1, 3, 4
• Verbal patient report alone is insufficient—you must review actual medical records 3
• This is particularly important for women with limited healthcare access, minority women, and immigrants from countries without screening programs 1, 3
• Studies show that 40-60% of women over 65 lack adequate documentation to qualify for screening cessation 5, 6

High-Risk Medical Conditions

• Immunocompromised patients (HIV-positive, organ transplant recipients, chronic immunosuppressant therapy) require continued screening regardless of age 3, 7
• In utero diethylstilbestrol exposure requires continued surveillance due to elevated risk of clear cell adenocarcinoma 1, 3

Evidence Supporting Cessation at Age 65

The recommendation to stop screening at age 65 with adequate prior screening is based on strong evidence:

• 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—an 84% risk reduction 3
• Modeling studies demonstrate that for regularly screened women, the ratio of colposcopies to life-years gained becomes very large beyond age 65, indicating screening becomes inefficient 4
• The USPSTF provides high certainty evidence that for women over 65 with adequate prior screening, the benefits of continued screening do not outweigh potential harms 1, 2

Disease Burden Context

While screening should stop for adequately screened women, it's important to understand why inadequate screening is problematic:

• Approximately 20% of new cervical cancer cases are diagnosed in women ≥65 years, accounting for 25% of all cervical cancer deaths annually 3
• However, these cases occur predominantly in unscreened or underscreened women, not those with adequate prior negative screening 3, 2
• 42% of women aged ≥65 diagnosed with cervical cancer had never been screened 3

Common Pitfalls to Avoid

• Never discontinue screening without verifying adequate prior negative screening history through medical records review—verbal patient report is insufficient 3
• Do not stop screening at age 65 in women with prior CIN2+ until 20-25 years have elapsed since treatment, regardless of current age 3, 4
• Do not confuse hysterectomy types: Women who underwent hysterectomy with cervix removal for benign reasons should not be screened, but those with subtotal hysterectomy (cervix retained) or hysterectomy for cancer/high-grade lesions require continued screening 1, 7, 2
• Beware of overscreening: Studies show that 40% of women ≥70 years continue to receive Pap tests, often driven by provider recommendation rather than guideline-based indications 8

Once Screening Stops, It Should Not Resume

• Screening should not resume after cessation at age 65, even if the woman reports having a new sexual partner 1, 4
• This recommendation is based on the extended natural history of cervical cancer—incident HPV infections after age 65 are unlikely to progress to invasive cancer within the woman's remaining lifespan 4