CERVICAL CANCER SCREENING for most women can stop at age 65, according to the U.S. Preventive Services Task Force (USPSTF), but recent findings suggest cervical cancer in women past the age of regular screening is more likely to be found at a later stage of the disease.
The study published in the journal Cancer Epidemiology, Biomarkers & Prevention found women 65 and older who were diagnosed with cervical cancer were more likely to be diagnosed at a later stage than younger women with the disease.
In the study, “the higher in age you go, the higher the proportion of diagnosis of later stage cervical cancer was correlated with it, which was surprising to me,” says Nancy Nguyen, a gynecological oncologist at the University of California (UC), Davis, who was not involved in the study. “I’m not sure I would have realized that, but seeing this paper really brought that to life.”
Julianne Cooley, one of the study authors and a senior statistician at the UC Davis Comprehensive Cancer Center, had a similar experience looking at cancer data that led to the new study.
“We were working on a cervical cancer project, and we saw that about 20% of the cervical cancer diagnoses were among women over 65,” Cooley says. “We wanted to quantify how many women over 65 are diagnosed later stage, as most of them are not being screened.”
Cooley and her colleagues turned to the California Cancer Registry, an anonymous database of patient information and clinical outcomes that are reported under legal mandate in that state. They examined the records of 12,422 patients age 21 or older who were first diagnosed with cervical cancer from 2009 through 2018. Of that population, 2,171 patients were 65 or older.
“We found that 71% of women over 65 were diagnosed with late-stage cervical cancer, and among women under 65 who are diagnosed with cervical cancer, about 48% were diagnosed with late stage,” Cooley says. Late stage was defined in this study as stages II through IV.
The older women diagnosed with late-stage cervical cancer also had poorer five-year relative survival than younger women diagnosed with late-stage cancers. Broken down by age group, women 65 and older were 23.2% to 36.8% as likely to be alive five years after a late-stage diagnosis than a woman the same age without a cancer diagnosis. Women younger than 65 with late-stage cervical cancer were 41.5% to 51.5% as likely to be alive five years after diagnosis than a woman the same age without cancer.
Both Cooley and Nguyen emphasized how treatable cervical cancer can be when caught early: The five-year relative survival rate for stage I cervical cancer diagnosis is 92%, according to the National Cancer Institute.
There are several possible reasons for the disproportionate number of older women with late-stage cervical cancer that Cooley and her colleagues explore in the paper, including advances in testing. The Pap test has been used for cervical cancer screening since the 1920s, but more sensitive human papillomavirus (HPV) testing has only been around for about 30 years. Some older women may never have received that type of screening. HPV causes more than 90% of all cervical cancers.
The USPSTF recommends women begin screening for cervical cancer at age 21 with a Pap test every three years. For women ages 30 through 65, the recommendation is every three years with the Pap test or every five years using the HPV test or a combination of the two. But there are a variety of reasons why some women may have not followed cervical cancer screening guidelines before turning 65.
Cooley and her co-authors point out in their paper that women should only stop screening at age 65 if they received three consecutive negative Pap tests, or two consecutive negative HPV tests within the past decade, with at least one of those negative tests coming in the past five years.
Some women may have stopped screening early, Cooley says, or may avoid getting screened for the same reasons many younger women tell researchers they avoid screening tests, such as embarrassment and discomfort. Others may not know they should continue getting screened as they get older, or after they have had a supracervical hysterectomy, a type of hysterectomy that does not remove the cervix.
Studies have shown that women who do follow the screening guidelines are usually not diagnosed with cervical cancer after the age of 65. “In fact, it’s pretty rare,” Cooley says.
What the study cannot shed light on is whether the screening guidelines themselves need to change, according to Nguyen. The California Cancer Registry data is limited in that it cannot tell researchers which patients adhered to the recommended screening guidelines, which did not, and if any abnormal screening tests were followed up.
“The data that backs up why we stop [screening] at 65 is pretty robust,” Nguyen says. “This is thought provoking, but I don’t think it’s enough for us to say let’s change the current guidelines we have now.”
The takeaway for patients and their families from this study, she says, is that while people typically think of cervical cancer as affecting women in their 40s and 50s, it can still be diagnosed in women over 65, and these women should pay attention to and discuss with their doctor any new symptoms such as vaginal bleeding, pelvic pain or back pain with swelling of the legs.
For women younger than 65, Cooley adds, it’s important to make sure they understand the recommended cervical cancer screening guidelines and follow them up to the cutoff, making sure to get a catch-up screening if they miss one.
“It’s just really important to offer a catch-up test,” she says. “I’d like to stress that cervical cancer is preventable, and you can also catch it at stage I when survival is excellent.”
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