The Impact of the Updated Cervical Cancer Screening Guidelines in Women >65 Years of Age: A 10-Year Retrospective Analysis

Abstract

Cervical cytology screening is no longer recommended in women 65 years or older, based on the joint guidelines established by the American Cancer Society (ASC), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) in 2012. This was reaffirmed by the United States Preventive Task Force guidelines in 2018. We examined the effect of implementing these guidelines in this elder population, in order to determine the number of abnormal Pap tests, precancerous lesions, and cancers that would have been missed if screening is discontinued. This retrospective study examined all Pap tests at the Queens Medical Center/Hawaii Pathologists Laboratory between January 2002 and December 2011, in order to determine the prevalence of abnormal Pap tests, their correlation with histologic diagnoses, and positive predictive values (PPV) for cervical intraepithelial neoplasia (CIN) 2 or higher. Chi-square testing was performed in order to detect statistically significant differences between findings in patients 65 years and older, compared to the general population (GP). Cases of malignancy in the >65 year older age group were further analyzed to determine whether the patients exhibited criteria for exclusion from cervical cancer screening, i.e. three consecutive negative Pap tests or two consecutive negative co-tests within the past ten years, with the most recent test having been performed within the past five years; no history of CIN 2 or higher; and no symptoms of abnormal bleeding at the time of Pap testing. From 2002-2011, a total of 1,026,470 Pap tests were examined. 92,247 (10%) were from the >65 year old age group. There were statistically significantly more cancers and glandular lesions found in the Pap tests of >65 year old patients compared to the GP. In contrast, more squamous intraepithelial and atypical squamous lesions were found in the GP compared to the older population. The PPVs for CIN 2 or higher were statistically significantly higher in the >65 year old age group compared to the GP for glandular abnormalities, including for atypical glandular cells of undetermined significance (AGUS) and adenocarcinoma. In contrast, there were no statistically significant differences between the two populations in the PPVs for CIN 2 or higher among any of the squamous lesions. Of the 92,247 patients aged 65 years or older, a total of 135 histologically confirmed cases of precancerous or cancerous lesions were found. If the new 2012 guidelines had been employed, 11 (8%) of these cases would have been missed, including 5 (45%) high grade squamous intraepithelial lesions (HSIL) and 6 (55%) endometrial carcinomas. Although Pap testing is not considered an effective modality for the detection of endometrial cancer, the cessation of cervical cancer screening in patients 65 years or older may lead to the delayed detection of this malignancy.