Can a 65‑year‑old woman with adequate prior cervical cancer screening and no high‑risk factors discontinue Pap smear screening?

Pap Smear Screening at Age 65

A 65-year-old woman with adequate prior negative cervical cancer screening and no high-risk factors should discontinue Pap smear screening entirely. 1, 2, 3, 4, 5

Criteria That Must ALL Be Met to Stop Screening

To safely discontinue screening at age 65, verify the following through medical record review (not patient self-report):

• Age ≥65 years 1, 2, 3, 4

• Adequate prior negative screening documented within the past 10 years, defined as ANY of the following: 1, 2, 3, 4

  • 3 consecutive negative Pap tests (cytology alone), with the most recent within 5 years
  • 2 consecutive negative HPV tests, with the most recent within 5 years
  • 2 consecutive negative cotests (Pap + HPV), with the most recent within 5 years
  • HPV-negative ASC-US counts as a negative result for exit criteria 3

• No history of high-grade precancerous lesions (CIN2, CIN3, or adenocarcinoma in situ) or cervical cancer in the past 20-25 years 1, 2, 3, 4

• No high-risk medical conditions: 2, 3, 4

  • Not HIV-positive or immunocompromised
  • No solid organ or stem cell transplant
  • Not on chronic immunosuppressant therapy
  • No in utero diethylstilbestrol (DES) exposure

• Cervix still present (or if hysterectomy performed, it was for benign reasons only, not for high-grade lesions or cancer) 1, 2, 3, 4

Critical Exceptions: Continue Screening Beyond Age 65

History of High-Grade Lesions or Cancer

• Continue screening for 20-25 years after treatment for CIN2, CIN3, adenocarcinoma in situ, or cervical cancer, even if this extends screening well past age 65 1, 2, 3, 4
• This extended surveillance reflects the viral etiology of cervical cancer and persistent risk despite treatment 3

Inadequate Prior Screening Documentation

• Continue screening until adequate negative screening is achieved if medical records cannot verify the required negative tests 2, 3, 4
• This is particularly common in low-income women, minority women, and immigrants from countries without screening programs 2
• Research shows 59.5% of low-income women aged ≥65 years lack adequate prior screening documentation 6
• Among these inadequately screened women, 21.9% who underwent appropriate testing required biopsies, with high-grade lesions or cancers found in many cases 6

High-Risk Medical Conditions

• HIV-positive status or immunosuppression: Continue screening indefinitely regardless of age 2, 3, 4
• In utero DES exposure: Continue surveillance due to elevated risk of clear cell adenocarcinoma and cervical dysplasia 2, 3

Evidence Supporting Cessation at Age 65

The recommendation to stop screening at age 65 with adequate prior screening is supported by high-certainty 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—representing an 84% risk reduction 2, 4
• The 5-year risk of CIN3 after two consecutive negative cotests is only 0.041% (95% CI: 0.007%-0.076%), well below the 0.12% threshold that would justify continued screening 7
• Modeling studies demonstrate that the ratio of colposcopies to life-years gained becomes very high beyond age 65, indicating diminishing efficiency 2, 4
• Most cervical cancers diagnosed after age 65 occur in unscreened or underscreened women, not those with adequate prior screening 2, 8, 9
• In one large cohort, only 3 of 46,401 women with negative cotests at age ≥65 were subsequently diagnosed with invasive cancer (2.3 per 100,000 per year), and there is no evidence these would have been prevented by continued screening 9
• Approximately 59% of cervical cancers diagnosed at age ≥65 occur in women who never met adequate screening criteria 9

What Happens After Screening Stops

• Once screening is discontinued, it should NOT be resumed for any reason, including acquisition of a new sexual partner 2, 3, 4
• The low probability of newly acquired HPV progressing to cancer in older, adequately screened women justifies this approach 4
• Incident HPV infections after age 65 are unlikely to evolve to invasive cancer within the remaining lifespan given the slow progression of HPV-related disease 4

Common Pitfalls to Avoid

• Never discontinue screening based on age alone—all cessation criteria must be verified through medical record review, not patient verbal report 2, 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 1, 2, 3, 4
• Verify hysterectomy status and indication: Women who underwent hysterectomy with cervix removal for benign reasons should not be screened, but those with subtotal hysterectomy or hysterectomy for high-grade lesions/cancer require continued surveillance 2, 3, 4
• Document screening history thoroughly: When records are incomplete or unavailable, continue screening until adequate negative results are obtained 2, 3, 4
• The proportion of women not recently screened increases with age, from 12.1% at ages 41-45 to 18.4% at ages 61-65, meaning many women approach age 65 without adequate prior screening 8

Disease Burden Context

Understanding the epidemiology helps frame the recommendation:

• Approximately 20% of new cervical cancer cases are diagnosed in women ≥65 years 2
• Cervical cancer deaths from diagnoses after age 65 account for approximately 25% of all cervical cancer deaths annually 2
• However, 42% of women aged ≥65 diagnosed with cervical cancer had never been screened, demonstrating that the unscreened population drives the disease burden in this age group 2
• 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) 2