Why Many Older Women Are 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 had mentioned that women over age 65 who were at average risk for cervical cancer could stop getting Pap tests if they had been adequately screened until then.

But that’s what the United States Preventive Services Task Force recommended, Ms. Clay learned, along with the American College of Obstetricians and Gynecologists and the American Cancer Society.

A nurse and emergency medical technician in Edison, Wash., Ms. Clay quietly cheered. Over decades of screening, she’d never had an abnormal Pap result and wasn’t in any high-risk group.

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

Now 74, she hasn’t undergone tests for cervical cancer in years. “I’m done,” she said.

However, JB Lockhart, 70, a retired office worker in Lake Oswego, Ore., still schedules an annual Pap.

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

She told the doctor, “I’d rather set my mind at ease and be preventive.”

Ms. Lockhart isn’t dissuaded by the fact that the task force and medical groups recommend cervical cancer screening only every three to five years (depending on which tests patients undergo), or by the recommendation that women with a specified number of normal results can stop at 65.

The task force’s “D” rating for cervical cancer screening in older women, meaning “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits,” hasn’t discouraged her, either.

Yet more than 1.3 million women over age 65 still received screening and related services in 2019; 10 percent were over 80, an especially low-risk group. “With millions of patients, it adds up quickly to a cost for everyone,” Dr. Qin said. The study put the Medicare cost at $83.5 million in 2019.

Are those who continue screening over-tested, then? Not necessarily.

“Stopping at 65 is not OK for every woman,” said Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital in Boston and the co-author of an editorial accompanying Dr. Qin’s study.

Some women are deemed high-risk because of a history of cervical cancer or precancerous lesions, or because of compromised immune systems. These women should continue screening, sometimes for as long as 25 years after a positive test result, Dr. Feldman said. Women who were exposed in utero to the drug diethylstilbestrol, or D.E.S., are also considered high risk.

Other women should continue screening because they haven’t had enough previous tests or aren’t sure how many they’ve had and when. Some may have been inadequately screened because they were uninsured before becoming eligible for Medicare and couldn’t afford testing.

Because the Medicare records didn’t include medical histories before age 65, the researchers couldn’t determine how many tests were unnecessary. But a number of studies have found that many women don’t receive the recommended screenings before age 65 and thus shouldn’t stop the tests after then.

About 20 percent of cervical cancer in the United States occurs in women older than 65, Dr. Feldman pointed out. “It’s a preventable disease if you screen the right people and treat it,” she said.

All screening involves harms as well as benefits, however. In the case of cervical cancer testing, Dr. Holt said, the downsides can include discomfort, especially since vaginal tissues thin with age, and emotional distress for victims of sexual abuse.

Moreover, “when we see something in the test, we have to respond,” he said. “Any screening test that’s positive can lead to anxiety and stress and stigma.”

A positive result also leads to further procedures, typically a biopsy involving a colposcope, a viewing instrument that magnifies the cervix. Biopsies can occasionally cause bleeding and infection, and the results often show that the patient has no cancer or precancer (though those may develop in the future).

False positives may also occur. Though data on screening outcomes for women over 65 is scarce, Dr. Holt and several co-authors published a 2020 study estimating false positive rates for younger women. On average, according to their model, women screened for 15 years starting at age 30 would be expected to have one colposcopy, perhaps two, depending on which tests were done and how frequently.

Sixty to 75 percent of those procedures would find no precancerous lesions or cancer, indicating that the initial test results were false positives.

It makes sense for women to talk with their health care providers about when they should stop testing. Seniors are a diverse population: Women over 65 may have multiple sexual partners, increasing their cancer risk, for example, or they may have serious illnesses that could very likely end their lives well before cervical cancer could.

Researchers have found that older adults can be reluctant to give up cancer screenings, whatever the guidelines say.

Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston, has worked for years to help older women reduce unnecessary mammograms, which the Preventive Services Task Force doesn’t recommend for those over 75, citing insufficient evidence of benefit.

Dr. Schonberg developed a brochure to explain the pros and cons. She assembled a sample of 546 women over 75 and found that the half who received the brochure were more knowledgeable and more likely to discuss mammography with their doctors. Then, more than half of those who read it had a mammogram anyway. A similar “decision aid” failed to deter seniors from colon cancer screening.

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