Why are so many older women getting Pap tests they don’t need?

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

None of her health care providers mentioned that women over age 65 who are at average risk for cervical cancer could stop Pap tests if they had been adequately screened by then.

But it is Recommended by the US Preventive Services Task ForceAlong with the American College of Obstetricians and Gynecologists and the American Cancer Society, Ms.

Mrs. Clay, a nurse and emergency medical technician in Edison, Wash., cheered quietly. In decades of screening, she has never had an abnormal pop result and is not in the high-risk group.

“I don’t want to be in those stirrups anymore,” he said. “I don’t see the need for it.” She printed out the guidelines, ready for battle if a nurse practitioner or doctor insisted on continuing the screening. But nobody did.

Now 74, she hasn’t had cervical cancer screenings in years. “I’m done,” she said.

Still, JP Lockhart, 70, a retired office worker in Lake Oswego, Ore., still plans the annual pop.

Last year, she switched to a new obstetrician-gynecologist. “She told me I didn’t have to do any more tests,” Ms. Lockhart recalled. “I thought, you can still get cervical cancer over a certain age.”

She told the doctor, “I want to put my mind at ease and be a preventative measure.”

Ms. Lockhart was not upset. Stop at 65.

A “D” rating from the Task Force on Cervical Cancer Screening in Older Women, meaning “no net benefit of the service or moderate or high certainty that the harms outweigh the benefits,” didn’t discourage her either.

Many older women are pursuing cervical cancer screening, recently Study in JAMA Internal Medicine reported.

Using clinical data to look at 15 million women over 20 years, researchers found that the proportion of women who received at least one Pap or HPV (human papillomavirus) test dropped from nearly 19 percent in 1999 to 8.5 percent in 2019. Concerns about over-testing and over-treatment in the elderly.

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

The guidelines suggest that women at average risk who have three consecutive negative Pap tests or two consecutive negative HPV tests (which can be done at the same time as the Pap) in the past 10 years can stop cervical cancer screening after age 65. ) The most recent negative tests must have been done within five years.

Women who have had a hysterectomy and no previous precancerous lesions may also forgo screening.

Told they can stop, “my patients are a lot happier,” said Dr. Hunter Holt, a family medicine practitioner at the University of Illinois at Chicago and co-author of the study. Many people don’t look forward to undressing and inserting a speculum so that a hygienist can remove cervical cells for examination.

Yet more than 1.3 million women over age 65 received screening and related services in 2019; 10 percent are over 80 years of age, a particularly low-risk group. “With millions of patients, it costs everyone quickly,” Dr. Kin said. Medicare spending in 2019 was $83.5 million, according to the study.

Are regular screeners more likely to be tested? Unnecessary.

“Stopping at 65 isn’t right for every woman,” says co-author Sarah Feldman, MD, a gynecologic oncologist at Brigham and Women’s Hospital in Boston. An editorial In addition to Dr. Kin’s study.

Some women are considered to be at higher risk due to a history of cervical cancer or precancerous lesions or a compromised immune system. These women should continue screening, sometimes up to 25 years after a positive test result, Dr. Feldman said. Women exposed in utero to the drug diethylstilbestrol, or DES, are also considered at higher risk.

Other women may need to continue screening because they haven’t had enough previous tests or don’t know how often and when they’ve had them. Some people may not be adequately screened because they are uninsured and unable to pay for testing before they qualify for Medicare.

Because medical records do not contain medical histories before age 65, the researchers were unable to determine how many tests were unnecessary. But many studies have found that Many women do not receive recommended screenings Before age 65 and so Don’t stop testing Later on.

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

However, all screening involves harms and benefits. In the case of cervical cancer screening, Dr. Holt says, the drawbacks can include discomfort, especially as vaginal tissue thins with age, and emotional distress for those who have been sexually abused.

And, “if we find something in the testing, we have to respond,” he said. “Any screening test that is positive can lead to anxiety and stress and stigma.”

A positive result leads to further procedures, usually a biopsy involving a colposcope, a viewing instrument that magnifies the cervix. Biopsies occasionally cause bleeding and infection, and the results often show that the patient does not have cancer or premalignant disease (which may develop in the future).

False positives can also occur. Although data on screening outcomes for women older than 65 years are limited, Dr. Holt and several co-authors published a 2020 assessment. False positive rates For younger women. On average, according to their model, women screened every 15 years beginning at age 30 are expected to have one colposcopy, perhaps two, depending on which tests are performed and how often.

Sixty to 75 percent of those procedures do not detect precancer or cancer, indicating that early test results are false positives.

It makes sense for women to talk to their health care providers about when to stop testing. The elderly are a heterogeneous population: women over 65 may have multiple sexual partners, increasing their cancer riskFor example, or they may have serious illnesses that can end their lives before cervical cancer does.

Researchers have found that older adults are reluctant to skip cancer screenings, regardless of what the guidelines say.

Mara Schoenberg, a physician at Beth Israel Deaconess Medical Center in Boston, has spent years helping older women reduce unnecessary mammograms by providing preventive services. The task force does not recommend it for people over 75 years of ageCiting sufficient evidence of benefit.

Dr. Created by Schoenberg A brochure to explain the pros and cons. He collected a sample of 546 women over age 75 and found that half of those who received the brochure were more knowledgeable and discussed mammography with their doctors. Then, more than half of those who read it got a mammogram anyway. A similar Couldn’t block “decision help”. Seniors from Colon cancer screening.

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

A survey of California providers who screened low-risk women over age 65 for cervical cancer showed what was difficult, despite knowing the guidelines to the contrary. Fifty-six percent of providers believed that stopping the test would result in missing a cancer diagnosis, but the same number admitted that it took less time than explaining to patients why it was unnecessary. And 46 percent said they felt “pressure” from patients to continue.

Ms Lockhart has made a February appointment for her next Pap test. The office scheduler explained that she did not need another screening, but Ms. Lockhart said she would proceed anyway.

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