Cessation of Pap Smear Screening in Women

Recommendations by Major Guidelines

• The U.S. Preventive Services Task Force (USPSTF) recommends discontinuing regular Pap testing after age 65 in women who have had consistently normal results on previous tests 1, 2
• The American Cancer Society (ACS) recommends stopping screening at age 70 years after 3 negative tests in the last 10 years 3, 4
• The American College of Obstetricians and Gynecologists (ACOG) recommends stopping screening at age 65-70 years after 3 negative tests in the last 10 years 3, 4
• The American Geriatrics Society (AGS) recommends Pap tests every three years until age 70 5, 6

Special Considerations

• Women who have had a hysterectomy with removal of the cervix for benign reasons should discontinue Pap screening 3, 7
• Pap testing is not required in women who have undergone a hysterectomy in which the cervix was removed, unless the surgery was performed because of cervical cancer or its precursors 2, 7
• Screening may be clinically indicated in older women for whom the adequacy of prior screening cannot be accurately assessed or documented 7
• Women who have never had cervical screening have an incidence of disease three to four times that of women who have had at least one prior normal pap smear 8

Women at Higher Risk

• Women with risk factors for cervical cancer may need continued screening beyond age 65-70, even with a history of adequate screening, including multiple sex partners 5, history of human papillomavirus (HPV) infection 7, HIV infection or immunosuppression 5, history of cervical dysplasia 8, smoking 1, and pessary use 5
• Certain populations are at increased risk of cervical cancer, including Vietnamese women and Hispanic women 8

Evidence Supporting Cessation of Screening

• A large prospective study found that the incidence of cervical cancer among women age 70 and older who had at least one normal Pap smear in the previous 10 years was only three cases per 100,000 6, 8
• Modeling data suggest that continued testing of previously screened women reduces the risk of cervical cancer mortality by only 0.18% at age 65 and by 0.06% at age 74 2

Practical Algorithm for Deciding When to Stop Screening

• If a woman is ≥65 years old and has had 3 consecutive negative Pap tests within the past 10 years, stop screening 7, 3
• If a woman has had a hysterectomy with removal of the cervix for benign reasons, stop screening 3, 7
• Continue screening beyond age 65 if there is inadequate prior screening 7, history of cervical dysplasia or cancer 7, immunocompromised status 7, or other significant risk factors 8
• For women who have never been screened, perform at least two negative tests one year apart, regardless of age 6, 9

Cervical Cancer Screening Discontinuation Guidelines

Rationale for Discontinuation of Screening

• The American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology recommend that women over 65 years of age with evidence of adequate negative prior screening and no history of CIN2+ within the last 20 years should not be screened for cervical cancer with any modality 10
• Once screening is discontinued, it should not resume for any reason, even if a woman reports having a new sexual partner 10, 11
• Adequate negative prior screening is defined as 3 consecutive negative cytology results or 2 consecutive negative cotests within the 10 years before ceasing screening, with the most recent test occurring within the past 5 years 10

Evidence Supporting Discontinuation

• In well-screened women older than 65 years in the United States, CIN2+ prevalence is low and cervical cancer is rare 10
• Cervical cancer is most commonly diagnosed in unscreened and under-screened women, not in those with adequate prior screening 10
• Based on the extended natural history of the disease, it is improbable that incident HPV infections and newly detected CIN3 after age 65 will have sufficient time to progress to invasive cancer in the woman's lifetime 10
• Modeling studies have concluded that for women who have been screened regularly prior to age 65, the ratio of colposcopies to years of life gained associated with further screening is large because of the small gains in life expectancy 10

Potential Harms of Continued Screening

• Potential harms from screening of this population include discomfort during cytology sampling and false-positive screening tests 10
• The absolute benefit in terms of life-years gained from extending screening beyond age 65 is very small 12
• Achieving a very small gain in life-years by extending screening comes at a cost of more colposcopies, indicating that screening becomes less efficient beyond age 65 12

Special Considerations and Exceptions

• If the patient had a history of CIN2, CIN3, or adenocarcinoma in situ, routine screening should continue for at least 20 years, even if this extends screening past age 65 10, 11
• If documentation of recent screening cannot be obtained, screening tests should be performed until the criteria are met for cessation 12

Cessation of Pap Smear Screening in Older Women

Standard Cessation Criteria

• Between 28% and 64% of women age 65 and older have never had a Pap smear or have not had one within 3 years, highlighting the need for careful consideration of screening history before cessation, as reported by the Journal of the American Geriatrics Society (JAGS) 13

Critical Exception: Women with Prior Abnormal Results

• Women with a history of prior abnormalities, such as CIN2, CIN3, or adenocarcinoma in situ, must continue routine screening for at least 20 years after treatment, even if this extends screening past age 65, due to their increased risk of cervical cancer 13

High-Risk Factors

• Continue screening beyond age 65 even with adequate prior screening if women have high-risk factors such as HIV infection or immunosuppression, multiple sexual partners, history of HPV infection, smoking, pessary use, or high-risk ethnicity (Vietnamese or Hispanic women) 13

Cervical Cancer Screening Guidelines for Elderly Women

Screening Recommendations

• The USPSTF provides high certainty evidence that for women over 65 with adequate prior screening, the benefits of continued screening do not outweigh potential harms, and recommends stopping screening at age 65 if 3 consecutive negative Pap tests are present within the past 10 years, with the most recent test within the past 5 years 14
• The American Geriatrics Society recommends continuing screening until at least age 70, with screening every 3 years with Pap test alone for women aged 65-70 15
• For women who have never been screened, the American Geriatrics Society recommends receiving at least 2 negative Pap smears 1 year apart, regardless of age 15
• Medicare covers Pap testing and pelvic examination at 3-year intervals for average-risk women, with yearly screening allowed for high-risk women or those with an abnormal Pap smear in the preceding 3 years 16

Cessation of Pap Smear Screening

Standard Cessation Criteria

• Women should discontinue Pap smear screening at age 65 if they have had 3 consecutive negative cytology tests or 2 consecutive negative cotest results (Pap + HPV) within the past 10 years, with the most recent test occurring within the last 5 years, as recommended by the American Cancer Society 17
• The decision to stop screening is based on adequate prior negative screening documentation, with key requirements including 3 consecutive negative Pap tests alone within 10 years, or 2 consecutive negative cotests (Pap + HPV) within 10 years, and the most recent test must be within the past 5 years, according to the American Cancer Society 17

Critical Exceptions: Continue Screening Beyond Age 65

• Women with prior CIN2, CIN3, or adenocarcinoma in situ must continue routine screening for at least 20 years after treatment, even if this extends screening well past age 65 years, as recommended by the American Cancer Society 17
• Women with a history of organ transplantation, chronic corticosteroid treatment, or chemotherapy should continue screening regardless of age, according to the American Cancer Society 17
• Women with a history of in utero DES exposure or cervical cancer should continue screening, as recommended by the American Cancer Society 18

Special Populations Requiring Consideration

• Women who have had a total hysterectomy with cervix removal for benign reasons can stop screening immediately, while those with a subtotal (supracervical) hysterectomy with cervix retained should continue screening per standard guidelines, according to the American Cancer Society 17
• Women who have had a hysterectomy for cervical cancer or high-grade dysplasia should continue screening for at least 20 years post-surgery, as recommended by the American Cancer Society 18