About a decade ago, Andrea Clay went online to read the recently revised cervical cancer screening guidelines.
None of her health care providers had mentioned that women over 65 who were at average risk of cervical cancer could stop having Pap tests if they had undergone adequate screening so far.
But that’s what the U.S. Preventive Services Task Force has recommended, Ms Clay learned, along with the American College of Obstetricians and Gynecologists and the American Cancer Society.
A nurse and emergency medical technician in Edison, Washington, Ms. Clay quietly clapped. After decades of being screened, she had never had an abnormal Pap result and was not in any high-risk group.
“I didn’t want to be in those stirrups anymore,” she said. “I didn’t see the need for it.” She printed out the guidelines, ready for a fight if a nurse practitioner or doctor insisted she continue testing. But no one did.
Now 74, she hasn’t been tested for cervical cancer in years. “I’m done,” she said.
However, JB Lockhart, 70, a retired office worker in Lake Oswego, Oregon, still schedules an annual Pap.
Last year, she moved to a new obstetrician-gynecologist. “She told me I didn’t need to get tested anymore,” Ms Lockhart recalled. “I thought you could still get cervical cancer after a certain age.”
She told the doctor, “I prefer to calm down and be preventive.
Ms. Lockhart is not deterred by the fact that the task force and medical groups recommend cervical cancer screening only every three to five years (depending on the tests patients undergo), or by the recommendation that women with a specified number of normal results can stop at 65.
The task force’s ‘D’ rating for cervical cancer screening in older women, meaning “moderate or high certainty that the service has no net benefit or the harms outweigh about the benefits,” didn’t deter her either.
Many more older women are continuing cervical cancer screening, according to a recent study published in JAMA Internal Medicine.
Using Medicare data to examine 15 million women over 20 years, researchers found that the proportion of those who had had at least one Pap or HPV (human papilloma virus) test had risen from nearly 19% in 1999 at 8.5% in 2019 – a potential victory for those concerned about overtesting and overtreatment among older people.
“We expected the trend,” said the study’s lead author, Jin Qin, an epidemiologist with the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control. “But at this magnitude, at this level, it’s a bit surprising.”
The guidelines state that women at average risk can stop cervical cancer screening after age 65 if, in the past 10 years, they have had three consecutive negative Pap tests or two consecutive negative HPV tests (which can be done at the same time as a Pap test). ). The most recent negative tests must have been done within five years.
Women who have had a hysterectomy and who have never had precancerous lesions can also opt out of screening.
When told they could quit, “many of my patients are thrilled,” said Dr. Hunter Holt, a family physician at the University of Illinois at Chicago and co-author of the study. Few people looked forward to stripping naked and having a speculum inserted so that a medical professional could scrape brain cells for testing.
Yet more than 1.3 million women over the age of 65 were still receiving testing and related services in 2019; 10% were over 80, a particularly low-risk group. “With millions of patients, it quickly comes at a cost to everyone,” Dr Qin said. The study estimated the cost of Medicare at $83.5 million in 2019.
Are those who continue screening then over-tested? Not necessarily.
“Stopping 65 isn’t acceptable for all women,” said Sarah Feldman, a gynecological oncologist at Brigham and Women’s Hospital in Boston and co-author of an editorial accompanying Dr. Qin’s study.
Some women are considered high risk due to a history of cervical cancer or precancerous lesions, or due to a weakened immune system. These women should continue screening, sometimes for up to 25 years after a positive test result, Dr. Feldman said. Women who were exposed in utero to diethylstilbestrol, or DES, are also considered at high risk.
Other women should continue screening because they haven’t had enough previous tests or don’t know how many they had and when. Some may have been misscreened because they were uninsured before becoming eligible for Medicare and could not afford to get tested.
Because Medicare records did not include medical history before age 65, researchers could not determine how many tests were unnecessary. But a number of studies have found that many women do not receive recommended screenings until age 65 and therefore should not stop testing after that date.
About 20% of cervical cancers in the United States occur in women over the age of 65, Dr. Feldman pointed out. “It’s a preventable disease if you find the right people and treat it,” she said.
However, all screening has disadvantages as well as advantages. In the case of cervical cancer screening, Dr. Holt said, downsides can include discomfort, especially as vaginal tissue thins with age, and emotional distress for victims. of sexual abuse.
Moreover, “when you see something in the test, you have to react,” he said. “Any positive drug test can lead to anxiety, stress and stigma.”
A positive result also leads to further procedures, usually a biopsy involving a colposcope, a viewing instrument that enlarges the cervix. Biopsies can sometimes cause bleeding and infection, and the results often show that the patient does not have cancer or precancer (although these may develop in the future).
False positives can also occur. Although data on screening results in women over 65 are sparse, Dr. Holt and several co-authors published a 2020 study estimating false positive rates in younger women. On average, according to their model, women screened for 15 years starting at age 30 would have to undergo a colposcopy, perhaps two, depending on the tests performed and how often.
Sixty to 75% of these procedures would find no precancerous lesions or cancer, indicating that the initial test results were false positives.
It makes sense for women to discuss with their healthcare providers when they should stop testing. Older people are a diverse population: women over 65 may have multiple sexual partners, increasing their risk of cancer, for example, or they may have serious illnesses that could very likely end their lives long before cervical cancer.
Researchers have found that older adults may be reluctant to give up cancer screenings, regardless of guidelines.
Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston, has worked for years to help older women reduce unnecessary mammograms, which the Preventive Services Task Force does not recommend for people over 75. years, citing insufficient evidence of benefits.
Dr. Schonberg has put together a brochure to explain the pros and cons. She gathered a sample of 546 women over the age of 75 and found that half who received the brochure were better informed and more likely to discuss mammograms with their doctor. Then, more than half of those who read it still had a mammogram. A similar “decision aid” failed to dissuade older people from undergoing colon cancer screening.
The Society of General Internal Medicine advises against cancer screening in patients with a life expectancy of less than 10 years. But life expectancy can be a difficult concept to discuss with patients.
A survey of California providers who screened low-risk women over 65 for cervical cancer, despite knowing guidelines to the contrary, showed what makes it difficult. Fifty-six percent of providers thought they might miss a cancer diagnosis if they stopped the test, but about the same number also acknowledged that it took less time to do the test than to explain to patients why it was not necessary. And 46% reported “pressure” from patients to continue.
Ms Lockhart made an appointment in February for her next Pap test. The office planner explained that she did not need another screening, but Ms Lockhart said she would continue anyway.
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