Why many older women get Pap tests they don’t need

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

None of her health care providers had mentioned that women over age 65 who were at average risk of cervical cancer could stop getting Pap tests if they had been screened properly up until then.

But that’s what the US 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 emergency medical technician in Edison, Washington, Ms. Clay clapped silently. In decades of screening, I had never had an abnormal Pap test and was not in any high-risk group.

“I didn’t want to be in those stirrups anymore,” he said. “I didn’t see the need for that.” She printed out the guidelines, ready for battle if a nurse practitioner or doctor insisted she continue screening. But no one did.

She is now 74 years old and has not been screened for cervical cancer in years. “I’m done,” he said.

However, JB Lockhart, 70, a retired office worker in Lake Oswego, Ore., still schedules an annual Pap.

Last year, he switched to a new obstetrician-gynecologist. “He told me I didn’t need to be tested anymore,” said Ms. Lockhart recalled. “I thought, you can still get cervical cancer after a certain age.”

He told the doctor, “I’d rather take it easy and be preemptive.”

Ms. Lockhart is undeterred 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 the recommendation that women with a certain number of normal results can stop at 65.

The task force’s grade “D” for cervical cancer screening in older women, meaning “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits,” also did not discouraged

Many other older women continue with cervical cancer screening, according to a recent study in JAMA Internal Medicine.

Using Medicare data to look at 15 million women over 20 years, the researchers found that the proportion who received at least one Pap or HPV (human papillomavirus) test dropped from nearly 19% in 1999 to 8.5% in 2019, a possible win for those. Concerned about over-testing and over-treatment in older adults.

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

The guidelines specify 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 at the same time as a Pap test). ). The most recent negative tests must have taken place within five years.

Women who have had hysterectomies and no previous precancerous lesions can also forgo screening.

Told them they can stop, “many of my patients are very happy,” said Dr. Hunter Holt, a family medicine physician at the University of Illinois at Chicago and co-author of the study. Not many expected to strip and have a speculum inserted so a healthcare professional could scrape cervical cells for testing.

However, more than 1.3 million women over 65 still received screening and related services in 2019; 10% were over 80 years old, a particularly low-risk group. “With millions of patients, it quickly adds up to a cost for everyone,” said Dr. Qin said. The study put the cost of Medicare at $83.5 million in 2019.

So are those who continue to be screened overtested? Not necessarily.

“Stopping at 65 is not good for all women,” said Sarah Feldman, a gynecologic 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 because of a history of cervical cancer or precancerous lesions, or because of a compromised immune system. These women should continue screening, sometimes up to 25 years after a positive result, said Dr. Feldman said. Women who were exposed in utero to the drug diethylstilbestrol, or DES, are also considered high risk.

Other women should continue screening because they haven’t had enough previous tests or don’t know how many they’ve had and when. Some may have been inadequately screened because they were uninsured before becoming eligible for Medicare and could not afford the test.

Because Medicare records did not include medical history before age 65, the researchers could not determine how many tests were unnecessary. But a number of studies have found that many women don’t get the recommended tests before age 65, so they shouldn’t stop testing after then.

About 20 percent of cervical cancer in the United States occurs in women over age 65, said Dr. Feldman noted. “It’s a preventable disease if the right people are caught and treated,” he said.

All detection involves both harm and benefit, however. In the case of cervical cancer tests, Dr. Holt said the drawbacks can include discomfort, especially as vaginal tissues thin with age, and emotional distress for victims of sexual abuse.

Also, “when we see something on the test, we have to respond,” he said. “Any screening test that is positive 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 magnifies the cervix. Biopsies can sometimes lead to bleeding and infection, and the results often show that the patient does not have cancer or precancer (although they may develop in the future).

False positives can also occur. Although data on screening outcomes for women over 65 are sparse, Dr. Holt and several co-authors published a 2020 study that estimated false-positive rates for younger women. On average, according to their model, women screened for 15 years starting in their 30s would be expected to have one colposcopy, perhaps two, depending on which tests were done and how often.

Between 60 and 75 percent of these procedures would not find precancerous lesions or cancer, indicating that the initial test results were false positives.

It makes sense for women to talk to their health care providers about when they should stop testing. The elderly 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 breast cancer. cervix

Researchers have found that older adults may be reluctant to forego cancer screenings, no matter what 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 those over 75, citing insufficient evidence of benefits .

Dr. Schonberg produced a brochure to explain the pros and cons. She gathered a sample of 546 women over the age of 75 and found that the half who received the brochure were more knowledgeable and more likely to discuss mammography with their doctors. Then more than half of those who read it got a mammogram anyway. A similar “decision aid” failed to dissuade older people from colon cancer screening.

The Society of General Internal Medicine recommends against cancer screenings for patients with life expectancies of less than 10 years. But life expectancy can be a difficult concept to discuss with patients.

A survey of California providers who performed cervical cancer screening in low-risk women over age 65, despite knowing guidelines against it, showed what makes it difficult. Fifty-six percent of providers believed they could miss a cancer diagnosis if they stopped testing, but about the same number also recognized that it took less time to test than to explain to patients why it was unnecessary. And 46 percent reported “pressure” from patients to continue.

Ms. Lockhart has made a February appointment for her next Pap test. The office planner explained that she didn’t need another test, but Ms. Lockhart said he would continue anyway.

Leave a Reply

Your email address will not be published. Required fields are marked *