Over the last 3 decades, the incidence of cervical cancer in the United States has dramatically decreased. This decrease is, in part, the result of widespread participation in screening, which, compared with no screening, has estimated to result in substantial reductions in cancer cases and deaths. However, there marked disparities in both disease occurrence and screening remain.[1]

Current guidelines, established by the United States Preventive Services Task Force, the American Cancer Society, and the American College of Obstetricians and Gynecologists recommend discontinuation of screening recommend stopping cervical cancer screening at age 65 for women at average risk with adequate prior negative screening. However, current data shows that women over age 65 make up over one in five new cases of cervical cancer, and are twice as likely to die after a cervical cancer diagnosis compared to younger women.[2][3][4]

Discontinuing screening
New research by researchers from Boston Medical Center, a private, not-for-profit, 514-bed, academic medical center that is the primary teaching affiliate of Boston University School of Medicine, found that fewer than one in three 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. The study was funded by a Supporting Effective Educator Development (SEED) grant from the Department of Obstetrics and Gynecology at Boston Medical Center.

The results of the study, published online on June 3, 2021, in Gynecologic Oncology, showed that even among women with 10 years of continuous insurance coverage, 41.5% did not qualify to end screening and most women did not receive adequate screening in the ten years leading up to this important screening decision.[5]

Women at risk
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 percent 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.

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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.

Rebecca Perkins, MD, MPH, obstetrics & gynecology physician at Boston Medical Center.

A preventable problem
“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 & gynecology physician at Boston Medical Center.

“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,” she added.

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 1544 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, and 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 with the most recent testing being within the prior five years, and no diagnosis of a precancerous lesion in the past 25 years (screening with HPV testing or HPV/Pap co-testing provides longer-term reassurance against cancer development than Pap testing alone).

Not meeting exit criteria
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. Current screening exit criteria are complex and require a detailed review of at least ten years of medical record documentation, which can create barriers to applying the guidelines to clinical practice.

“No patient should ever discontinue screening based on age alone without their healthcare provider completing a thorough review of their medical record,” explained Perkins, who is also an associate professor of obstetrics and gynecology at Boston University School of Medicine.

“Improved cervical cancer screening in women 55 years and older may reduce cancer rates and mortality in women aged 65 and over,” she added.

Solving the problem
Possible solutions to improve these rates include a Medicare-funded cancer prevention visit where the need for a cervical cancer screening is reviewed, and the optimization of electronic medical records to prompt a review of the cervical cancer exit screening criteria prior to a patient’s screening discontinuation.

Study limitations
The authors of the study acknowledge that the results of this study are inherent to the data sources used. They note that the commercial claims database does not include medical test results, hence, assumptions were made about Pap and HPV test results based on diagnosis codes and subsequent tests and procedures performed.  The authors also acknowledge other limiting factors, including the fact that the safety net cohort included in the study could have limited generalizability since it included only a single healthcare facility, which may have better safety net services than other states due to mandated universal insurance coverage since 2006.

Reference
[1] Singh GK, Jemal A. Socioeconomic and Racial/Ethnic Disparities in Cancer Mortality, Incidence, and Survival in the United States, 1950-2014: Over Six Decades of Changing Patterns and Widening Inequalities. J Environ Public Health. 2017;2017:2819372. doi: 10.1155/2017/2819372. Epub 2017 Mar 20. PMID: 28408935; PMCID: PMC5376950.
[2] Kim JJ, Burger EA, Regan C, Sy S. Screening for Cervical Cancer in Primary Care: A Decision Analysis for the US Preventive Services Task Force. JAMA. 2018 Aug 21;320(7):706-714. doi: 10.1001/jama.2017.19872. PMID: 30140882.
[3] US Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW Jr, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Phipps MG, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Aug 21;320(7):674-686. doi: 10.1001/jama.2018.10897. PMID: 30140884.
[4] Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A, Guerra CE, Oeffinger KC, Shih YT, Walter LC, Kim JJ, Andrews KS, DeSantis CE, Fedewa SA, Manassaram-Baptiste D, Saslow D, Wender RC, Smith RA. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020 Sep;70(5):321-346. doi: 10.3322/caac.21628. Epub 2020 Jul 30. PMID: 32729638.
[5] Mills JM, Morgan JR, Dhaliwal A, Perkins RB. Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort. Gynecol Oncol. 2021 Jun 3:S0090-8258(21)00441-8. doi: 10.1016/j.ygyno.2021.05.035. Epub ahead of print. PMID: 34090706.

Featured image: A friendly doctor holding a patient’s hand sitting at her desk for encouragement, empathy, and support following a medical examination. Photo courtesy: © 2018 – 2021

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