The Pap smear is a screening test for cervical cancer. It involves collecting cells from the cervix and examining them under a microscope to look for abnormalities that could indicate precancerous or cancerous changes. Regular Pap smear screening is recommended for all women starting around age 21 until age 65. After age 65, guidelines vary on when to stop Pap smear screening. Here we examine the evidence and guidelines on stopping Pap smear screening at age 65 versus later ages.
Pap Smears and Cervical Cancer Screening
The goal of cervical cancer screening with Pap smears is to detect precancerous changes or early stage cervical cancers. Treating these abnormalities can prevent progression to cervical cancer. The Pap smear (also called a Pap test) collects cells from the cervix during a pelvic exam. The cells are examined under a microscope to look for cellular abnormalities.
Pap smears allow for the detection of cellular changes before they progress to cervical cancer. The recommended starting age for Pap smear screening is 21 years old. Screening guidelines then recommend routine Pap smears every 3 years for women ages 21-29. For women ages 30-65, the recommendation is a Pap smear every 3 years or a Pap smear plus human papillomavirus (HPV) test every 5 years.
Regular screening with Pap smears has dramatically reduced the rates of cervical cancer incidence and mortality where adopted. The implementation of widespread Pap smear screening programs in developed countries has decreased cervical cancer rates by 50-90%.
Guidelines on Stopping Cervical Cancer Screening
Most major health organizations recommend continuing regular cervical cancer screening with Pap smears until age 65. After age 65, guidelines vary on when screening can be discontinued in women with adequate prior screening history.
Guidelines to Stop Screening at Age 65
The American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), and U.S. Preventive Services Task Force (USPSTF) recommend stopping cervical cancer screening at age 65.
The ACS and ACOG recommend women with adequate negative prior screening history can stop cervical cancer screening at age 65. Adequate screening is defined as three consecutive negative Pap smears or two consecutive negative co-tests (Pap plus HPV test) within 10 years before stopping screening, with the most recent test within 5 years.
The USPSTF recommends stopping screening at age 65 for women with adequate prior screening and no history of precancer (cervical intraepithelial neoplasia grade 2 or higher [CIN2+]) within the past 25 years. Adequate screening is not specifically defined but regular screening in the prior 10 years is implied.
These organizations conclude that continuing screening past age 65 has little benefit in women with adequate prior screening given the low risk of developing cervical cancer after age 65. Potential harms, such as false-positive results, outweigh the benefits in this population.
Guidelines for Screening Past Age 65
Some organizations recommend continuing screening past age 65 depending on individual risk factors and screening history:
– American Society for Colposcopy and Cervical Pathology (ASCCP) – Recommends stopping screening at age 65 only if there is adequate prior screening, defined as three consecutive negative Pap smears or two consecutive negative HPV tests within 10 years before age 65, with the most recent test within 5 years. They recommend continuing screening until age 70 for women with limited prior screening.
– American Academy of Family Physicians (AAFP) – Recommends screening can stop at age 65 with adequate prior screening. For women with limited screening history, they recommend shared decision making on whether to continue screening up to age 70.
– American College of Physicians (ACP) – Recommends screening up to age 70 for women with limited prior screening histories.
These guidelines recognize that while overall risk of cervical cancer decreases after age 65, there are some women who may benefit from continued screening past age 65 due to insufficient prior screening or other individual risk factors.
Factors that Support Screening Past Age 65
Some of the factors that may warrant extending cervical cancer screening past age 65 include:
– Inadequate screening history – Women who have not had regular screening before age 65 are at higher risk of developing cervical cancer after 65.
– Previous precancer or abnormal results – Women with a history of precancerous changes like CIN2/3 or repeated low-grade abnormal Pap results are at higher risk.
– DES exposure – Women exposed to the medication DES in utero may require later screening.
– HIV infection or decreased immunity – Women with HIV or other conditions causing decreased immunity are at higher risk for cervical cancer.
– Previous cervical cancer/treatment – Women treated for cervical cancer may need continued surveillance.
In these situations, screening until age 70 provides balance of potential benefits and harms. Screening after age 70 is unlikely to provide significant benefit.
Benefits of Stopping Screening at Age 65
Stopping cervical cancer screening at age 65 (in women with adequate prior screening history) has both psychological and health benefits:
Avoids Unnecessary Procedures
Ending screening at 65 avoids additional Pap smears which have discomfort/inconvenience. Further diagnostic procedures like biopsies may be triggered by abnormal Pap results. Ending screening avoids these invasive procedures and their risks.
Reduces Risk of False-Positive Results
False-positive Pap results are more common in older women due to non-precancerous cellular changes associated with aging and menopause. This can lead to unnecessary follow-up procedures. Stopping screening reduces this risk.
Eliminates Anxiety from Abnormal Results
Abnormal Pap results are frightening even if they don’t represent true precancerous changes. Ending screening reduces this anxiety and worry in older women.
Improves Screening Cost-Effectiveness
Screening older women with low risk of cervical cancer is not cost effective. Stopping at age 65 focuses resources on populations most likely to benefit.
Potential Downsides to Stopping Screening at Age 65
While stopping cervical cancer screening at age 65 is recommended by most groups, there are some potential downsides:
Rare Cases of Cervical Cancer After Age 65
While the risk of invasive cervical cancer is low after age 65, it does still occur. From 2004-2008, the rate of cervical cancer was 2.7 per 100,000 women aged 65-74. Very few cases occurred in women over age 65 with adequate screening. However, stopping screening may result in missed cases.
Increased Anxiety in Some Women
Some women feel anxious stopping cancer screening and perceive it as “giving up”. Clear provider communication can help address fears and reassure women about low risk.
Adequate Prior Screening Can Be Difficult to Determine
Guidelines recommend assessing prior screening history when deciding to stop screening. This can be challenging if records are incomplete or span providers. Effort should be made to verify adequate prior screening.
Does Not Apply to Higher-Risk Women
The recommendations to stop screening at age 65 apply to average-risk women. Women with risk factors may warrant continued screening until age 70. This nuance could result in confusion.
Key Points
Some key points about when to stop cervical cancer screening with Pap smears:
– For average-risk women, most guidelines recommend stopping screening at age 65 if there is adequate prior screening history.
– Adequate screening means regular Pap smears with normal results in the 10-20 years before stopping.
– Some women with risk factors like HIV may benefit from continued screening until age 70.
– Stopping screening avoids harms like false positives and invasive procedures which are more likely in older women.
– Cervical cancer risk is very low after age 65 with prior normal screening. But cancer can still occur rarely.
– Women with concerns should discuss screening with their provider based on their health history.
Discussion with Provider
The decision to stop cervical cancer screening at age 65 should involve a discussion with your healthcare provider:
– Review your screening history – Have you had regular Pap smears in the prior 10-20 years? What were the results?
– Discuss your risks – Do you have any factors that increase your risk for cervical cancer after 65 like HIV or previous precancer?
– Express your preferences – Do you feel strongly about continuing or stopping screening?
– Ask if you are a candidate to stop screening based on history and risks.
– Understand what symptoms should prompt further evaluation (bleeding, pelvic pain, unexplained discharge).
Having this conversation will allow for an informed, shared decision about when to stop screening. Be sure you understand the benefits and potential downsides given your health history.
Conclusion
For women at average-risk with adequate prior screening, most major guidelines agree that cervical cancer screening can stop at age 65. This avoids harms like false-positives, anxiety, and invasive procedures in older women who are at low risk of cervical cancer. However, women with certain risk factors like HIV may benefit from continued screening until age 70. Women should discuss their screening history and risks with their healthcare provider when deciding at what age to discontinue Pap smears. While screening is no longer recommended after age 65 for most women, patients should understand symptoms that warrant evaluation. Optimizing screening based on individual risks and benefits can help balance effectiveness and harms.