Most women ages 64 to 66 did not meet criteria for stopping cervical screening despite meeting clinical guidelines’ age cutoff, a large retrospective study showed.
Analysis of a national insurance claims database found that 22.2% of almost 600,000 women met the criteria to stop cervical cancer screening, increasing only slightly to 34.2% of patients identified from records at a safety-net health center.
Two thirds of women in the claims database had insufficient data to fulfill the exit criteria, as did 56.7% of patients from the safety-net clinic, reported Rebecca B. Perkins, MD, of Boston University School of Medicine, and colleagues.
As shown in the study online in Gynecologic Oncology, among women with 10 years of insurance claims data, almost 60% would not have met the criteria to discontinue screening for cervical cancer.
“Even among women with 10 years of continuous insurance coverage … 37.0% had too few screens to meet exit criteria and 21.5% had a medical or screening history precluding screening exit,” the authors stated. “These data are concerning because approximately one in five cervical cancers is diagnosed among women aged 65 and older, and older women are often diagnosed at later stages and have higher mortality compared to younger women.”
After adjustment for hysterectomy, cervical cancer incidence is highest among women ages 65 to 69 and remains elevated through age 85, the team added.
“No patient should ever discontinue screening based on age alone without their healthcare provider completing a thorough review of their medical record,” Perkins said in a statement. “Improved cervical cancer screening in women 55 years and older may reduce cancer rates and mortality in women aged 65 and older.”
Cervical cancer incidence in the U.S. has decreased dramatically over the past 30 years as a result of participation in screening. The authors noted that the U.S. Preventive Services Task Force, the American Cancer Society, and the American College of Obstetricians and Gynecologists all recommend discontinuation of screening at age 65 for women with an average risk of cervical cancer and adequate prior screening that has been negative.
Exit from cervical cancer screening at age 65 requires three consecutive negative Pap tests or two consecutive negative human papillomavirus (HPV) tests or HPV plus Pap co-tests in the past 10 years, the most recent being within the past 5 years. Lifelong screening is recommended for patients who are HIV positive, had in-utero exposure to diethylstilbestrol, or have a history of cervical cancer.
Recent data have shown that women age 65 and older account for 20% of new cervical cancers and more than a third of cervical cancer deaths. The findings raise concerns that current exit strategies and criteria are not working as planned, Perkins and co-authors stated.
To examine the applicability of screening exit criteria to real-world clinical settings, the team identified 590,901 women ages 64 to 66 in a nationwide commercial insurance claims database and the medical records for 1,544 women who received care through a safety-net health center. The investigators determined whether patients had undergone hysterectomy with removal of the cervix or fulfilled cervical cancer screening exit criteria.
All the authors’ analyses showed that a minority of patients met criteria to stop screening, the researchers reported. Among women identified through the insurance claims database, 20.6% met the exit criteria and 1.6% had undergone hysterectomy. Records from the safety-net health center showed that 9.3% of women had undergone hysterectomy and 24.9% had negative screening results that qualified them to stop screening.
Perkins and colleagues identified 108,641 women with 10 consecutive years of health insurance coverage, and found that 2.9% had undergone hysterectomy with removal of the cervix and 0.2% had hysterectomy with an intact cervix. Of the remaining 105,525 patients, 38.6% met exit criteria.
The authors said the results raised a number of concerns regarding the current age cutoff for cervical cancer screening. First and foremost, the team said, is a lack of adequate screening prior to 65. Even in the women with 10 consecutive years of insurance coverage, 37% had appropriate screening during ages 54 to 64.
A second issue relates to the need for healthcare providers to evaluate patients’ medical and screening histories prior to screening exit.
“Providers need to be aware that cervical cancer is a growing problem among women aged 65 and older and that it is preventable,” said Perkins. “It’s imperative for providers to proactively ensure that their patients receive adequate screening between the ages of 55 and 65 to decrease preventable cancers in women over the age of 65.”
Finally, the study revealed the difficulty of applying screening exit guidelines to clinical practice settings. The authors singled out providers’ lack of access to long-term medical records, which could lead to discontinuation of screening at age 65 without proper application of exclusion criteria.
“Ensuring adequate screening prior to age 65 and identification of high-risk conditions, as well as implementation of patient and provider tools for improving identification of those who are and are not appropriate for screening exit may be important for reducing preventable cancers in women ages 65 and older,” the authors concluded.
The study was supported by Boston Medical Center.
The authors reported having no relevant relationships with industry.