Why Many Older Women Get Pap Tests They Don’t Need

About a decade ago, Andrea Clay went online to read about newly revised cervical cancer screening guidelines.

None of her health care providers had mentioned that women over 65, who were at an average risk of cervical cancer, could omit Pap tests if they had been adequately screened by then.

But that’s exactly what the United States Preventive Services Task Force recommended, Ms. Clay learned along with the American College of Obstetricians and Gynecologists and the American Cancer Society.

A nurse and paramedic in Edison, Washington, Ms. Clay cheered softly. Through decades of screening, she has never had an abnormal Pap result and was not in a high-risk group.

“I didn’t want to be in those stirrups anymore,” she said. “I saw no need for it.” She printed out the guidelines and was ready for the fight if a nurse or doctor insisted she continue with the screening. But nobody did.

She is now 74 and has not 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 plans an annual Pap.

Last year she switched 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’d rather calm down and lean forward.”

Woman. Lockhart is adamant that the task force and medical groups only recommend cervical cancer screening every three to five years (depending on the tests patients undergo) or that women stop after a certain number of normal results can 65

The Task Force for Cervical Cancer Screening in Older Women’s “D” rating, meaning “moderate or high confidence that there is no net benefit from the service or that the harm outweighs the benefit,” didn’t discourage her either.

Many other older women continue to be screened for cervical cancer, a recent study in JAMA Internal Medicine reports.

Using Medicare data to study 15 million women over the age of 20, the researchers found that the proportion who received at least one Pap or HPV (human papillomavirus) test increased from nearly 19 percent in 1999 to 8.5 percent percent has fallen in 2019 – a potential victory for those concerned about overtesting and overtreatment in older adults.

“We expected this trend,” said study lead author Jin Qin, an epidemiologist in the Division of Cancer Prevention and Control at the Centers for Disease Control and Prevention. “But at this scale, at this level, it’s a little surprising.”

The guidelines state that women of average risk may discontinue cervical cancer screening after age 65 if they have had three consecutive negative Pap tests or two consecutive negative HPV tests (taken concurrently with a Pap test) within the past 10 years can) had). The last negative tests must have been carried out within five years.

Women who have had a hysterectomy and have no previous precancerous lesions can also opt out of screening.

I’ve been told they can quit, “many of my patients are overjoyed,” said Dr. Hunter Holt, a primary care physician at the University of Illinois Chicago and co-author of the study. Not many were excited about stripping down and having a speculum inserted so a medical professional could scrape off cervical cells for testing.

Yet, in 2019, more than 1.3 million women over the age of 65 still received screening and related services. 10 percent were over 80, a particularly low-risk group. “With millions of patients, that quickly adds up to costs for everyone,” says Dr. said Qin. The study put Medicare costs in 2019 at $83.5 million.

So are those who continue screening overtested? Not necessarily.

“Retiring at 65 isn’t right for every woman,” said Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital in Boston and co-author of an editorial that Dr. Qin’s study.

Some women are considered at risk because of a history of cervical cancer or precancerous lesions, or because of a compromised immune system. These women should continue screening, sometimes for up to 25 years after a positive test result, Dr. said Feldman. Women who were exposed to the drug diethylstilbestrol (DES) in utero are also considered at high risk.

Other women should continue screening because they haven’t had enough prior tests or aren’t sure how many they’ve had and when. Some may have been under-screened because they were uninsured before they were eligible for Medicare and couldn’t afford testing.

Because the Medicare records did not include medical histories before the age of 65, the researchers could not determine how many tests were unnecessary. However, a number of studies have found that many women do not receive the recommended screening tests until the age of 65 and therefore should not stop testing after that.

About 20 percent of cervical cancer in the United States occurs in women over age 65, said Dr. Feldman stressed. “It’s a preventable disease if you screen and treat the right people,” she said.

However, all screenings come with both disadvantages and advantages. In the case of cervical cancer testing, Dr. Holt said the downsides can include discomfort, particularly as vaginal tissue thins with age, and emotional distress for victims of sexual abuse.

Also, “we have to react when we see something in the test,” he said. “Any positive screening test can lead to anxiety, stress and stigma.”

A positive result also leads to other procedures, typically a biopsy with a colposcope, a viewing instrument that enlarges the cervix. Biopsies can occasionally cause bleeding and infection, and the results often show that the patient does not have cancer or precancerous lesions (although these may develop in the future).

False positive results can also occur. Although there is little data on screening outcomes for women over 65, says Dr. Holt and several co-authors published a 2020 study estimating false-positive rates for younger women. On average, according to their model, women screened for 15 years from the age of 30 would be expected to undergo one colposcopy, maybe two, depending on what tests were done and how often.

60 to 75 percent of these procedures would find no precancerous lesions or cancer, suggesting the initial test results were false positives.

It makes sense for women to talk to their doctor about when to stop testing. Seniors are a heterogeneous demographic: women over 65 may have multiple sexual partners, increasing their risk of cancer, for example, or they may have serious illnesses that are very likely to end their lives long before cervical cancer occurs.

Researchers have found that older adults may be reluctant to give up cancer screening, whatever the guidelines say.

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 age 75 due to insufficient evidence of benefit be cited.

Dr. Schonberg developed a brochure to explain the advantages and disadvantages. She took a sample of 546 women over the age of 75 and found that half who received the booklet were more knowledgeable and more likely to talk to their doctors about mammography. Then more than half of the readers had a mammogram anyway. A similar “decision-making aid” could not deter seniors from colorectal cancer screening.

The Society for General Internal Medicine advises against cancer screening for 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 have performed cervical cancer screening in low-risk women over 65 despite knowledge of guidelines to the contrary revealed what makes it difficult. Fifty-six percent of providers believed they would miss a cancer diagnosis if they stopped the test, but about the same number also acknowledged that it took less time to complete the test than it did to explain to patients why it was unnecessary be. And 46 percent reported “pressure” from patients to keep going.

Woman. Lockhart made an appointment for her next Pap test in February. The office planner explained that she didn’t need another screening, but Ms. Lockhart said she would go ahead anyway.

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