Western Regional Blog – BC, YK, AB, NWT and Nunavut
By PAULA SPAN
Most older women don’t need the routine Pap tests used to check for cervical cancer.
There are exceptions, which I’ll get to in a minute. But since 2012 the United States Preventive Services Task Force, the American Cancer Society, the American College of Obstetricians and Gynecologists and other medical groups have recommended a Pap smear every three years until age 65. After that, low-risk women (those with a history of negative Pap tests and no previous cancer or precancerous lesions) can stop. Further testing “provides little to no benefits,” the task force said.
For years before the 2012 update, medical groups had been urging less frequent testing for those at average or low risk. So it is clearly going to take a major effort to change behavior and prevent rampant overuse. Just how major an effort has become clearer from data recently published in JAMA Internal Medicine.
Deanna Kepka, a population scientist at the Huntsman Cancer Institute in Salt Lake City, and her co-authors reviewed the responses of nearly 9,500 women participating in the National Health Interview Survey in 2010. They found that:
* More than 58 percent of those over age 65 (who hadn’t undergone a hysterectomy and still had cervices) reported getting a Pap test within the past three years. Some of these women were in their 80s.
* Of these 65-plus women, more than 20 percent said they’d gotten Pap tests annually, “because they think that’s what they’re supposed to do,” Dr. Kepka said.
* Even among women who had undergone hysterectomies, after which the guidelines say Pap tests should stop, more than half had gotten them in the past three years.
Why all this Pap-ing?
“It’s very hard for people to keep it all straight,” said Dr. Sarah Feldman, a gynecologic oncologist at Dana-Farber Cancer Institute in Boston. The guidelines can get complicated, and they depend on a patient’s history of symptoms and test results.
“It’s easier for the clinician to say, ‘I don’t know this patient’s whole prior history, I don’t have time to ask her, I’ll just do it,’” Dr. Feldman said.
Also, Dr. Kepka pointed out, “If you’re paid for the services you provide, there’s an incentive to provide more services.”
We’ve talked before about the overtesting experienced by older Americans. Some of these tests become so automatic, year after year and decade after decade, that neither seniors nor their doctors seem to recognize when it’s time to call a halt.
So older people get too many colonoscopies, despite the U.S. Preventive Services Task Force recommendation against routine screening for colorectal cancer in people over age 75.
After age 50, most women need mammograms every other year, not annually, the task force has concluded, and there’s “insufficient evidence” to decide whether the benefits of mammography outweigh the risks after age 75. Men without symptoms are warned against prostate cancer screening at any age.
As for the cervical cancer guidelines, a chart by the Centers for Disease Control and Prevention outlines the basics. Women over age 65 who’ve had adequate screening — which means three negative Pap tests or two negative combined Pap/human papillomavirus tests in the past decade, the most recent within five years — and who have no history of cancer, lesions or other abnormalities can stop getting tested. Women who’ve had a hysterectomy and no previous cervical cancer or dysplasia (abnormal cervical cells) can stop getting tested.
On the other hand, women who’ve never had a Pap test probably should get one, even if they’re over age 65, and women with a history of high-grade dysplasia in the past 20 years should continue regular screening.
In practice, Dr. Feldman pointed out, older women will probably want to personalize these rules. When Dr. Feldman’s mother and mother-in-law, both long married and monogamous women in their 80s, asked her advice, she told them, in effect, enough already. A 67-year-old who’s had adequate screening and normal results her whole adult life can comfortably decide she’s done.
A 67-year-old who divorced in her 50s, began dating and had several new sexual partners, on the other hand, might want to continue with Pap testing every three or every five years. She should probably discuss the matter with her doctor.
Cervical cancer grows so slowly, however, that for most older women, unnecessary Pap tests run up Medicare expenditures while providing no useful information. “Let’s reframe the idea of the annual exam,” Dr. Kepka suggested. “We need to focus on the screenings that people should be getting.”