For a woman older than 65 with inadequate prior cervical cancer screening, should screening be continued and what is the recommended interval?

Cervical Cancer Screening for Women Over 65 with Inadequate Prior Screening

Women over 65 years with inadequate prior screening history should continue cervical cancer screening until they meet adequate screening criteria, which requires 3 consecutive negative cytology tests or 2 consecutive negative HPV/cotest results within a 10-year period, with the most recent test within 5 years. 1

Defining Inadequate Prior Screening

The critical determination is whether the woman meets criteria for "adequate prior screening" before age 65. Adequate screening is defined as: 1

• 3 consecutive negative cytology tests within the past 10 years, with the most recent within 5 years, OR
• 2 consecutive negative cotest results (HPV + cytology) within the past 10 years, with the most recent within 5 years, OR
• 2 consecutive negative primary HPV tests within the past 10 years, with the most recent within 5 years

Women who have never been screened or lack documentation of adequate screening fall into the inadequate screening category and require continued screening. 1

Screening Strategy for Women Over 65 with Inadequate History

Preferred Approach

For women aged 30-65 years (which applies to those over 65 continuing screening), the preferred strategy is HPV/cytology cotesting every 5 years. 1 An acceptable alternative is cytology alone every 3 years. 1

Updated 2020 ACS Guidance

The most recent American Cancer Society guideline (2020) recommends primary HPV testing every 5 years as the preferred method, with cotesting every 5 years or cytology alone every 3 years as acceptable alternatives. 1

2026 Exit Screening Update

The newest ACS guidance (2026) now recommends HPV testing at ages 60 and 65 years specifically to qualify for screening discontinuation, with the last HPV test at age 65 years or older as a requisite to exit screening. 2 This addresses the high rates of cervical cancer in women over 65 who were inadequately screened.

Duration of Continued Screening

Screening should continue for at least 20 years after any high-grade precancerous lesion (CIN2, CIN3, or adenocarcinoma in situ), even if this extends screening past age 65 years. 1 For women without prior high-grade lesions but with inadequate screening history, continue until adequate negative screening is documented. 1

Clinical Context and Rationale

Why This Matters

• 29-42% of cervical cancer cases in older women occur in those who were never screened, with the highest proportion (42%) in women ≥65 years. 1
• 59.5% of low-income women over 65 years in one safety net hospital study required continued screening due to inadequate screening history. 3
• Among inadequately screened older women who underwent appropriate testing, 21.9% required biopsies, and 68.8% of those biopsies showed high-grade lesions or cancer. 3
• 18.4% of women aged 61-65 years have not been recently screened (no Pap test in >5 years or never screened), approaching the stopping age without adequate history. 4

Common Pitfalls to Avoid

1. Do not automatically stop screening at age 65 without verifying adequate prior screening documentation. 1
2. Do not resume screening once discontinued in women who met adequate criteria, even with a new sexual partner. 1
3. Do not apply these recommendations to high-risk women (HIV-positive, immunocompromised, history of DES exposure, or prior cervical cancer/high-grade lesions). 1

Special Populations Requiring Continued Screening

Women over 65 who should continue screening include those with: 1

• Limited access to care or minority women less likely to have adequate prior screening
• Women from countries where screening is unavailable
• Inability to document adequate prior screening history
• History of high-grade precancerous lesions requiring 20 years of surveillance

Self-Collection Option (2026 Update)

Self-collected vaginal specimens for HPV testing are now acceptable for average-risk women aged 25-65 years when clinician-collected specimens are not feasible, though clinician-collected samples remain preferred. 2 With self-collection, repeat testing should occur every 3 years (not 5 years) after a negative result. 2