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Special Article

AGS Position Statement

Screening for Cervical Carcinoma in Older Women

BACKGROUND

Screening for cervical carcinoma by means of a papanicolaou (pap) smear leads to early detection of this cancer and has had a significant impact on morbidity and mortality from this disease. The American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) recommend that all women who are or have been sexually active, or have reached age 18 years, should have an annual pap test and pelvic examination. After a woman has had three or more consecutive satisfactory normal annual examinations, the pap test may be performed less frequently at the discretion of her physician (1,2). Consistent with these recommendations, Congress recently extended Medicare benefits to include periodic screening for cervical cancer beyond the age of 65 based on analyses that screening would extend life for older women at an acceptable cost to the Medicare program (3).

The U.S. Preventive Services Task Force recommends that pap smears be performed every 1-3 years beginning with the onset of sexual activity until age 65 when screening becomes unnecessary if previous smears have been consistently normal (4). The National Institute of Health Consensus Conference suggested in 1980 that screening be discontinued at age 60 if two negative pap smears have been obtained (5). However, the more recent National Institutes of Health Consensus Development Conference Statement on Cervical Cancer indicated that women age 65 and older continue to be screened, but did not give details on frequency, and in which patient populations (6). The Canadian National Workshop on Screening for Cancer of the Cervix recommended two screens one year apart, and, if normal, screens every 3 years until age 69 (7). The British Society for Clinical Cytology recommends that cytological testing be discontinued at age 70 but adds that a first smear be taken from an unscreened woman regardless of age (8). These recommendations are consistent in proposing that pap smears need not be done annually and may be stopped after a certain age, yet the optimal frequency and duration of pap smears in older women remain unknown. The limited data that exist, however, can be useful in formulating reasonable recommendations.

A large, prospective study in Sweden of an unselected female population found that the incidence of cervical cancer among women over 70 years of age who had at least one normal pap smear in the previous 10 years was only three cases per 100,000 (9). This figure is low enough that it appears acceptable to stop screening at age 70, provided that there have been at least two previous negative pap smears since age 60. On a cautionary note, it is important to mention that the Swedish population is very homogeneous and this makes it difficult to extrapolate to the heterogeneous society of the United States.

The recommendations to discontinue screening sometime between the age of 60 and 70 assume that prior to these ages frequent screening was performed (1,7). On the contrary, studies reveal that between 28% and 64% of women age 65 and older have never had a pap smear or have not had one done within three years (10). This may account, in part, for the high rate of invasive disease found in older women with abnormal screens (10,11). Women who have never had cervical screening have an incidence of disease which is three to four times that of women who have had at least one prior normal pap smear (9,12). Low rates of screening may be especially common in certain ethnic minorities, those with less education, and those with minimal financial resources (13,14).

The recommendations to discontinue screening after a certain age also do not take into account risk factors for the development of cervical carcinoma. Many of the known risk factors for the development of cervical carcinoma (i.e., multiple sex partners, history of Human Papilloma Virus (HPV), Human Immunodeficiency Virus (HIV), cervical dysplasia, smoking, immunosuppression) are likely to be encountered with increasing frequency in future generations. This may result in the need for continued screening beyond age 65 or 70, despite a past history of adequate screening. Pessary use has been associated anecdotally with development of cervicovaginal cancers (15). Thus, while there are no prospective, controlled studies evaluating the risks of genital tract cancers in pessary users, it may be advisable to continue to perform pap smears in patients using pessaries.

Certain populations are also at increased risk of cervical cancer. Incidence rates for cervical cancer in Vietnamese women are more than two and a half times those for any other racial or ethnic group with the next highest rates occurring in Hispanic women (14). Further, mortality rates from cervical cancer are higher in ethnic minority women than Caucasian women (16-18).

Individual circumstances are considered in any screening program. For example, a short life expectancy would make screening for cervical cancer an unnecessary endeavor. Similarly, screening is without purpose in women who would be unable to tolerate treatment, even radiation therapy, if cancer were detected. In such circumstances, physician-patient-family judgement is the best guide.

Who is the appropriate provider for pap smear screening in older women? Gynecologists are the primary caregivers in pre-menopausal women but are underutilized by older women. Other health professionals, including geriatricians, internists, family practitioners, nurse practitioners, and physician assistants provide primary care for older women, and cervical cancer screening is a logical part of their health maintenance activities.

Efforts to increase screening need to address barriers that result from cultural or health beliefs as well as lack of access. Participation may be influenced by personal, environmental, or system factors. Personal factors that influence screening behaviors include: beliefs about cancer and whether one can influence its occurrence or cure; fear regarding the examination or the diagnosis; embarrassment; cultural or religious beliefs about prevention or illness; present versus future orientation; and knowledge regarding preventive strategies and their benefit (19-24). Environmental factors include family or spousal beliefs and support (20,21,25). System factors include health insurance, accessibility, gender of the health care provider, cost, highly technical health care setting, and transportation (13,19,21-23).

To enhance rates of screening, programs have to be established that address these issues and that consider community participation (20,22,23,26). Additionally, consideration should be given to the fact that motivators for screening procedures as well as appropriate approaches for educating about the importance of screening may have to be adapted to address health beliefs. In a study of Yakama Indian women, fear of death was not a motivator for illness prevention behaviors, and the importance of keeping all body parts influenced the response to the description of what occurred during a pap test, which included the taking of cells (24). The use of female physicians may also facilitate acceptance of the screening procedure (23,25). Further, different strategies may be necessary to achieve screening in those who have never been screened as compared to those who are not screened at regular intervals (19).

The method of obtaining pap smears in older women is another important issue. In a premenopausal woman, the squamocolumnar junction, where cervical neoplasia typically arises, is readily accessible and easily sampled. In contrast, a postmenopausal woman may have an atrophic vagina, stenotic cervical os and an inaccessible squamocolumnar junction (27). To obtain a good cytological specimen, use a wooden or plastic spatula to gently scrape the cervix in a circular fashion. Also insert an endocervical brush and gently rotate to obtain the sample and perform fixation promptly (28). When an atrophic vagina is too small for a speculum it is often difficult even to palpate the cervix. Some experts recommend blind swabbing or vaginal aspiration in older women, but this is of unproven value.

Certain musculoskeletal disorders present in many older women can also make the pelvic examination and pap smear difficult. A woman with such a problem is often unable to lie in the usual supine position with legs in stirrups. The left lateral position has been described as a feasible alternative.

New techniques for preparing (Thinprep) and screening (Papnet System, Autopap System) pap smears have been shown to increase the sensitivity of cervical cytology, and reduce the occurrence of false-negative cervical cytology readings (29). Whether the improved accuracy of these techniques lowers the incidence of invasive cervical carcinoma or improves survival rates from cervical carcinoma remains to be seen (29). Because of their higher costs and unproven benefit in reducing invasive disease, these techniques are not part of the standard of care for cervical cancer screening.

Little has been written about the need to continue cytological screening in women who have had hysterectomies. Many older women are often unsure of the type of hysterectomy they had – subtotal or total. The caregiver thus needs to determine whether or not a cervix is present. If the cervix is present, then the guidelines for women who have not undergone hysterectomy apply. If the cervix has been removed, and the hysterectomy was performed for benign reasons recent literature suggests that the prevalence of abnormal findings on cytological examination of the vagina is sufficiently low that continued screening of the vaginal apex with pap smears may not be warranted (30). ACOG states that the cost effectiveness of cytologic screening for vaginal neoplasia after removal of the cervix for benign disease has not been demonstrated. Nonetheless, periodic cytologic evaluation of the vagina may be warranted in certain cases, based on risk factors (i.e., history of cervical dysplasia) for the development of cervical neoplasia (2).

Finally, it is important to note that the pap smear is but one facet of the pelvic examination. Regardless of the number of pap smears ultimately obtained, periodic pelvic examinations will facilitate detection of remediable and often asymptomatic genito-urinary pathology.

POSITIONS

1. Pap smear screening for older women is the responsibility of the primary care providers with culturally appropriate programs designed to address barriers identified in the population being served.
2. Regular pap smear screening at 1 to 3 year intervals until at least the age of 70 seems reasonable. Beyond age 70, there is little evidence for or against screening women who have been regularly screened in previous years.
3. An older woman of any age who has never had a pap smear may be screened with at least two negative pap smears 1 year apart.
4. Risk factors for the development of cervical carcinoma may be assessed on an ongoing basis and taken into consideration when deciding how often and for how long to screen older women for the development of cervical carcinoma.
5. Individual circumstances such as the patient’s life expectancy, ability to undergo treatment if cancer is detected, and ability to cooperate with and tolerate the pap smear procedure may obviate the need for cervical cancer screening.
6. Women who have had a hysterectomy may have a remaining cervix and, if one is present, may be screened under the same criteria outlined above. If no cervical tissue remains, no further pap smear is needed, provided the hysterectomy was performed for benign disease, and risk factors for the development of cervical neoplasia are not present.
7. Cervical sampling is carried out by means of gentle scraping of the ectocervix with a curved spatula, followed by insertion and rotation of an endocervical brush.
8. More research is needed on pap smear screening in older women. Potential areas of investigation include more clearly defining high risk subsets of the elderly, estimating the utility of screening residents of long-term institutions, and innovative approaches to enhance the participation of appropriate older persons in screening programs.

REFERENCES

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2. ACOG Committee Opinion: Recommendations on Frequency of Pap Test Screening. Number 152, March, 1995.
   
   
3. Mandelblatt JS, Phillips RN. Cervical cancer: How often-and-why-to screen older women. Geriatrics 1996;51:45-48.
   
   
4. U.S. Preventive Services Task Force: Screening for Cervical Cancer. In Guide to Clinical Preventive Services. Baltimore, Williams and Wilkins, 1996, pp 105-117.
   
   
5. Cervical Cancer Screening: The pap smear; Summary of an NIH Consensus Statement. Br Med J 1980;281:1264-1266.
   
   
6. NIH Consensus Development Panel: National Institutes of Health Consensus Development Conference Statement on Cervical Cancer. Gynecologic Oncology 1997;66:351-361.

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14. American Cancer Society, Cancer Facts and Figures, 1997. Racial and Ethnic Patterns, http://www.cancer.org/statistics/97cff/97racial.html
    
    
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18. National Cancer Institute, SEER web page, http://www-seer.ims.nci.nih.gov/News/ index.html. The Annual Report to the Nation on the Status of Cancer, 1973-1996: Rates and Trends for the Top 15 Cancer Sites by Sex and Race/Ethnicity for 1990-1996.
    
    
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21. Chavez LR, Hubbell FA, Mishra SI, et al. The influence of fatalism on self-reported use of Papanicolaou smears. Am J Prev Med 1997;13(6):418-24.
    
    
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28. ACOG Technical Bulletin. Cervical Cytology: Evaluation and Management of Abnormalities. Number 183, August, 1993.
    
    
29. ACOG Committee Opinion. New Pap Test Screening Techniques. Number 206, 1998.
    
    
30. Pearce KF, Haefner HK, Sarwar SF, et al. Cytopathological findings on vaginal papanicolaou smears after hysterectomy for benign gynecologic disease. N Engl J Med 1996;335:1559-62.

Developed by the Clinical Practice Committee and approved by the American Geriatrics Society Board of Directors. Revised November 1991. Reviewed and updated in November 1993. Revised in May 2000 by the AGS Clinical Practice Committee. Address correspondence to: American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.