Current guidelines recommend stopping cervical cancer screening at age 65. But women older than age 65 make up more than 1 in 5 new cervical cancer diagnoses and are twice as likely to die after a cervical cancer diagnosis compared to younger women.
New research from Boston Medical Center (BMC) found that fewer than 1 in 3 women aged 64 to 66 met the criteria to discontinue cervical cancer screening while looking at patients with both private insurance and from a safety-net hospital setting. Published in Gynecologic Oncology, researchers found that even among women with 10 years of continuous insurance coverage, 41.5% did not qualify to end screening, and most women (63%) did not receive adequate screening in the 10 years leading up to this important screening decision.
The majority of women aged 65 and older may be at risk for cervical cancer due to inadequate screening or preexisting high-risk conditions. Study findings show that up to 20% of women reported a medical condition or a history of screening abnormalities that make this screening necessary beyond the age of 65. This highlights the need to educate patients and healthcare providers on the importance of ensuring adequate cervical cancer screening at ages 55 to 65, and also on high-risk conditions that necessitate screening beyond age 65. When data are adjusted for patient hysterectomies, the incidence of cervical cancer is highest among women ages 65 to 69 and remains elevated through age 85.
“Providers need to be aware that cervical cancer is a growing problem among women aged 65 and older and that it is preventable,” says Rebecca Perkins, MD, MPH, obstetrics and gynecology physician at BMC. “It’s imperative for providers to proactively ensure that their patients receive adequate screening between the ages of 55 and 65 to decrease preventable cancers in women over the age of 65 and to make sure that their patients are adequately screened to be able to safely exit screening, if their health history qualifies.”
Cervical cancer screening exit guidelines
The study data included 590,901 women aged 64 with employer-sponsored insurance enrolled in the national Truven MarketScan database between 2016 and 2018, and 1,544 women aged 64 to 66 receiving primary care at a safety-net health center in 2019, identified through an electronic health record query. Screening exit eligibility was determined using the current guidelines that include:
- no evidence of cervical cancer or HIV-positive status,
- no evidence of cervical pre-cancer in the past 25 years,
- evidence of either a hysterectomy with removal of the cervix,
- or evidence of fulfilling the screening exit criteria.
The exit criteria are defined as two human papillomavirus (HPV) screening tests or HPV plus Pap co-tests or three Pap tests within the past 10 years without evidence of an abnormal result. (Screening with HPV testing or HPV/Pap co-testing provides more long-term reassurance against cancer development than Pap testing alone).
Data from both the safety net hospital and national claims database indicated that fewer than half of women aged 64 to 66 had documentation of sufficient screening to fulfill the exit criteria. Guidelines specify that patients with immunosuppression, histories of abnormal results or cervical precancer, or cancer should continue screening.
Practical issues with cervical cancer screening guidelines
Current screening exit criteria are complex and require a detailed review of at least 10 years of medical record documentation, which can create barriers to applying the guidelines to clinical practice. The study's authors note that improving the ability to implement these guidelines into clinical practice is paramount.
Possible solutions include a Medicare-funded cancer prevention visit where the need for a cervical cancer screening is reviewed. Providers and patients alike could also potentially have access to support tools that could identify when they need further testing and when they can more safely exit cervical cancer screening. Overall, hospitals and clinical practices need the ability to optimize communication among siloed electronic medical records, so women can access their screening and medical history across providers and if they switch clinicians.
“No patient should ever discontinue screening based on age alone without their healthcare provider completing a thorough review of their medical record,” says Perkins. “Improved cervical cancer screening in women 55 years and older may reduce cancer rates and mortality in women aged 65 and over.”