Patients older than 65 years may be undergoing unnecessary cervical cancer screenings, and more public health data may be needed on the utilization of cervical cancer screening–associated services among older patients to prevent potential harm and unnecessary costs, according to a new study published by Qin et al in JAMA Internal Medicine.
Study Methods and Findings
In the new study, researchers examined the Medicare claims data of patients older than 65 years who received fee-for-service care from 1999 to 2019. The analysis showed that in 2019, more than 1.3 million patients older than 65 years received cervical cancer screening–associated services—such as a Papanicolaou (Pap) test, colposcopy, and other cervical procedures. While these services cost more than $83 million, the researchers concluded that they were of “unclear clinical appropriateness.”
“Cervical cancer screening[s] and other preventive services are among our most important tools for keeping people healthy throughout life, but screenings should also follow evidence-based guidelines to prevent overspending, potential complications, and patient discomfort,” said study coauthor Hunter K. Holt, MD, MAS, Assistant Professor of Family and Community Medicine at the University of Illinois Chicago.
“Cancer screening involves a judicious consideration of the balance between … [the] benefits and harms. As people get older, the potential benefits decline and the potential harms increase,” said study coauthor George F. Sawaya, MD, Professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco School of Medicine as well as Director of the Colposcopy and Cervical Dysplasia Clinic at the Zuckerberg San Francisco General Hospital.
According to recommendations and guidelines from the U.S. Preventive Services Task Force, the American Cancer Society, and the American College of Obstetrics and Gynecology, patients considered to be of average risk may not require routine cervical cancer screenings once they reach the age of 65 if they have had negative prior screenings.
“The decision to end cervical cancer screening[s] for [patients] after [65 years] requires review of past screening results and related medical history. This process can promote cervical cancer prevention and prevent harms and costs from unnecessary tests and procedures,” said study coauthor Jin Qin, ScD, an epidemiologist in the U.S. Centers for Disease Control and Prevention (CDC) Division of Cancer Prevention and Control.
The researchers noted that the high rates of screenings among older patients were potentially concerning. “It could be that [patients] are getting screened when they do not need to, or that these [patients] are considered to be at higher-than-average risk, for example, because they have not been adequately screened prior to [age] 65. We do not want to see either of these things and unfortunately, there is not enough public health data to shed light on the causes,” stressed Dr. Holt.
“In this study, about 3% of [patients] aged over 80 years received at least one screening-related service. The Society for General Internal Medicine does not recommend cancer [screenings] be performed in individuals with a life expectancy of less than 10 years, which corresponds to [ages] 80 and older in the [United States], so there may well be overscreening,” Dr. Sawaya said.
The study further showed that White patients were more likely to be screened after 65 years, and that Black and Latinx patients were more likely to undergo a diagnostic colposcopy and subsequent cervical procedures.
Conclusions
Overall, the analysis found that the percentage of patients over 65 years who received at least one Pap test decreased from 19% (n = 2.9 million) in 1999 to 9% (n = 1.3 million) in 2019—a reduction of 55%. Rates of colposcopy and cervical procedures decreased by 43% and 64%, respectively.
“While cervical cancer is a more top-of-mind concern for younger [patients] than older [patients], [those] over the age of 65 represent about 20% of diagnoses and 36% of deaths [as a result of] cervical cancer. It is critical that we develop better data to understand how screenings are being used among this population and if screening services are being used appropriately,” concluded Dr. Holt.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
