Most normal-risk women are told they no longer need cervical cancer screening after reaching age 65. A new study, however, suggests that this widely adopted recommendation is missing too many cases of cervical cancer, especially among black women.
The study, presented March 27 at the Society of Gynecologic Oncology Annual Meeting on Women’s Cancer in New Orleans, found that one in five cases of cervical cancer may be missed by halting screening after age 65.
Cases of cervical cancer in the United States have declined dramatically over the past 30 years because of screening. About 12,000 women are diagnosed with the disease each year and about 4,000 die, according to the Centers for Disease Control and Prevention.
“We do a really good job of preventing cervical cancer in this country,” says the study’s lead author, Sarah Dilley, MD, a gynecologic oncology fellow at the University of Alabama at Birmingham. “The absolute number of cases in women age 65 and older may be low. But I think we should consider this a population that is at risk.”
Study Findings Contradict Cervical Screening Guidelines
Cancer screening guidelines are often controversial, but most major medical groups have agreed that normal-risk women can stop having cervical cancer screening after age 65. For example, the American Cancer Society states that women older than 65 who have had regular screenings with normal results should not be screened for cervical cancer, but that those who have been diagnosed with cervical pre-cancer should continue to be screened. The American College of Physicians state that women older than 65 can stop screening after three negative Pap tests or two negative Pap-plus-HPV (human papillomavirus) tests. The HPV test is often administered with the Pap test because it can detect HPV, which can cause cervical cancer.
Dr. Dilley and her colleagues opted to look at actual cervical cancer cases because recent studies have hinted that the incidence rates are higher than expected in women older than 65.
“Over the last 10 years, the incidence rates are going down in cervical cancer, but the population of women older than 65 is growing, based on U.S. census data. If you look at the number of cervical cancer cases in that age group, the number hasn’t changed in the past 10 years,” she explains.
They analyzed data from two large, national cancer databases from 2004 through 2014, the National Cancer Data Base (NCDB) and Surveillance, Epidemiology and End Results (SEER).
Both showed that about 20 percent of cervical cancer diagnoses are made in women older than 65.
The strength of the study is that the authors used an actual database to look at diagnoses. Screening guidelines are based on computer modeling, says Sarah Temkin, MD, the division director of gynecologic oncology at Virginia Commonwealth University in Richmond, Virginia, who was not involved in the study.
“A lot of the data for the guidelines come from Northern California Kaiser,” a large health maintenance organization that actively encourages appropriate screening of its members, she says. “Not that the data is bad, but the Kaiser population is different from the rest of the country. If you’ve been well-screened your whole life and you reach age 65, your chances of getting diagnosed with cervical cancer after age 65 are incredibly low.”
In contrast, Dr. Temkin says, the new study reflects all women, including those who have not received regular screening. “This [study] is showing real-world data which includes the whole population of people who may not have ever been screened before.”
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Truth: Not All Women Get Regular Screenings
Studies have indicated that about half of cervical cancer cases in the United States are in women who have never had a Pap test, and about 10 percent of cases are in women who haven’t had a Pap test in the previous five years, Temkin says.
The study also found significant racial differences. Black women older than 65 accounted for about 22 percent of all cervical cancer diagnoses in black women.
The study should prompt discussions on two fronts, both Dilley and Temkin say. One is to improve adherence to screening over women’s adult lifetimes. But revision of the guidelines for screening women older than 65 should also be considered.
“Our data are food for thought,” Dilley says. “It’s something to inform any future guideline changes when modeling is done. But it’s also important for physicians to recognize that just because the guidelines say to stop screening after 65, that doesn’t mean it’s a blanket recommendation for everyone. It’s important to recognize that a patient may not have a good understanding of what her history is. A woman may have thought she had a Pap smear when she didn’t.”
A Preventable Cancer That Isn’t Always Prevented
The tragedy of cervical cancer is that it’s almost entirely preventable, Temkin notes. HPV vaccination— which is recommended for all children, both boys and girls, at ages 11 to 12 — can prevent cervical cancer and other types of cancers, such as anal cancer. Moreover, abnormalities that show up on Pap and HPV tests can be treated to prevent cancer from developing.
“No one in this country should get cervical cancer,” Temkin says. “We have a preventive vaccine. We have screening that works. A large number of cases we see are system failures where either the patient didn’t get the vaccine or wasn’t screening appropriately. Or, if they were screened, they didn’t have access to treatment, didn’t know they had abnormal results, or weren’t referred for the abnormal results.
“I think this study is a little bit reflective of where our failures are in screening, despite guidelines.”