Approximately one fifth of cervical cancer cases are diagnosed in women aged 65 years or older, and most of the cases are late-stage disease associated with poor survival rates. The new finding calls into question yet again the many national screening guidelines that advise physicians to halt cervical screening at age 65.
The findings emerged from an analysis of the California Cancer Registry for 2009 to 2018. The authors, from the University of California, Davis, who manage the registry on behalf of the state, found that 17% of women diagnosed with a first primary cancer were aged 65 years or older.
Up to 71% of these older women had late-stage disease, vs 34% to 59% of women aged 21–64.
The team also found that older patients, even those with early disease, had much poorer survival after they were diagnosed with cervical cancer than their younger counterparts. For example, patients aged between 65 and 69 with stage I cervical cancer had a 5-year relative survival – that is, survival adjusted for noncancer causes of death – of 82%. By contrast, 94% of women aged 20–39 survived for at least 5 years.
The study was published on January 9 in Cancer Epidemiology, Bioiarkers and Prevention.
These new data echo similar findings from other recent cervical cancer studies out of California, Massachusetts, Ohio, and nationally. Those studies show that in comparison with younger patients, rates of late-stage disease are higher and survival is poorer among women aged 65 and older.
Even so, a co-author of the present study, Frances Maguire, PhD, who is an epidemiologist at the University of California, Davis, said she and her colleagues were surprised by what they found.
“There are a lot of women in this older age category who are being diagnosed, and they’re being diagnosed later stage and their survival is worse,” Maguire said. “That was surprising to all of us,” given that the current recommendations are to stop screening once women reach the age of 65, and yet this age group is “doing quite poorly.”
The American Cancer Society, the US Preventive Services Task Force, and the American College of Obstetricians and Gynecologists all recommend that cervical screening stop at aged 65 for patients with “adequate prior screening.”
Adequate screening is defined as having three consecutive normal Pap tests or two consecutive negative human papillomavirus tests or two consecutive negative cotests within the prior 10 years, with the most recent screening within 5 years and having no precancerous lesions in the past 25 years.
However, as many as 23% of women aged 60–64 report that their last Pap test was administered more than 5 years ago, according to a recent study by Alex Francoeur, MD, and colleagues at the University of California, Los Angeles.
When asked to comment on the new article, Francoeur said, “There is literature that increasing comorbidities and visits to the doctor [with age] decrease the likelihood of getting a Pap test, which is concerning, as these may be the highest-risk women.”
Said study author Maguire, “It could be that [the guidelines] are perfectly fine if women were properly screened before they hit 65, so that’s one of our big questions. Perhaps this group are not properly screened before age 65, and then they hit 65, they don’t screen, and this is the result we’re seeing.”
The situation is compounded by the lack of continuity in care at this crucial juncture, said Alexander Olawaiye, MD, a professor in the Division of Gynecologic Oncology at the University of Pittsburgh School of Medicine, who was also approached for comment.
At age 65, many women retire, move across the country, or access new healthcare providers through Medicare, which kicks in at age 65, so the woman’s new physician doesn’t have access to her screening history, he commented.
This means that a physician needs to rely on the patient’s memory.
This is unrealistic, said Olawaiye: “Let’s forget about the 65-year-old women for now. Let’s talk about young women with sharp minds. Half of these young adults cannot even remember correctly their last monthly period. And these are the people you want to recollect accurately [at age 65] the number of tests they’ve had over 10 years and the results of those tests? Are you kidding me?” said Olawaiye. “Is that the kind of verification that you rely on?”
Olawaiye has consistently advocated for scrapping the 65+ screening moratorium in past and current versions of the cervical screening guidelines. He is puzzled by the national unwillingness to do so and rejects the economic argument, pointing out that a handful of extra tests is a lot cheaper than caring for a patient with advanced cervical cancer.
“Most American women will die around 84–85 years of age,” Olawaiye commented. “So between 65 and 85, you will need five screens, maybe four. What are you saving by not doing that?”
Maguire, Francoeur and Olawaiye have disclosed no relevant financial relationships.
Cancer Epidemiol Biomarkers Prev. Published online January 9, 2023. Abstract
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