Researchers discovered that a significant number of patients aged 65 years and older may be facing late-stage cervical cancer diagnoses and disease-related mortality—despite U.S. Centers for Disease Control and Prevention (CDC) guidelines recommending that most patients stop screening for cervical cancer at age 65, according to a new study published by Cooley et al in Cancer Epidemiology, Biomarkers & Prevention.
“Our findings highlight the need to better understand how current screening guidelines might be failing [patients] 65 and over,” explained lead study author Julianne Cooley, a senior statistician in the California Cancer Reporting and Epidemiologic Surveillance program at the University of California, Davis Comprehensive Cancer Center. “We need to focus on determining the past screening history of older [patients] as well as lapses in follow-up care. We must utilize noninvasive testing approaches for [patients] nearing age 65 or those who need to catch up on their cervical cancer screenings.”
Key Findings
The findings from the study showed that nearly one in five new cervical cancers diagnosed from 2009 to 2018 were in patients aged 65 years and older. Additionally, a greater number of older patients (71%) presented with late-stage disease than younger patients (48%)—with the number of late-stage diagnoses increasing up to the age of 79. Late-stage 5-year relative survival was also lower for patients aged 65 years and over (23.2% to 36.8%) compared with patients younger than 65 (41.5% to 51.5%). Patients aged 80 years and older had the lowest survival of all age groups.
“Our study found worsening [5]-year relative survival from cervical cancer with each increasing age category for both early- and late-stage diagnoses,” said study coauthor Theresa Keegan, PhD, Professor of Medicine in the Division of Hematology and Oncology at the University of California, Davis Medical Center.
California Cancer Registry Provided Critical Data
The study utilized a large set of population-based data from the California Cancer Registry—which has collected data on patient demographics, diagnostics, treatments, and cancer incidences since 1988. The data was used to identify all patients aged 21 years and older who were diagnosed with a first primary cervical cancer in California from 2009 to 2018—the 10 most recent years from which complete data was available.
Among patients aged 65 years and older, those who had comorbidities or were older were more likely to be diagnosed with late-stage cervical cancer.
“Interestingly, prior studies of younger [patients] have found increased late-stage cervical cancer diagnoses among young Hispanic/Latinx and Black [patients],” Ms. Cooley indicated, noting that, “Our study did not observe these associations, and instead found that older [Hispanic/Latin patients] were less likely than non-Hispanic White [patients] to be diagnosed [at a] late stage.”
Current Screening Guidelines
Following the introduction and widespread adoption of the Papanicolaou (Pap) smear test in the 1940s, cervical cancer incidence and mortality have fallen significantly. However, incidence rates have plateaued since 2012, and rates of invasive cervical cancer have increased in recent decades.
Through adequate screening and follow-up, cervical cancer can be prevented or detected at an early stage—leading to excellent patient outcomes. However, current guidelines recommend discontinuing screenings for patients aged 65 years or older who have had a history of normal Pap and/or human papillomavirus (HPV) tests—potentially leaving this age group vulnerable.
Lack of Adherence to Screening
Previous studies have shown that 23.2% of individuals in the United States over 18 years of age may not be up-to-date on their recommended cervical cancer screenings. Disadvantaged individuals—such as those who are uninsured or impoverished—may be the least likely to report being up-to-date with these screenings.
“Scheduled screenings may also decrease as [patients] approach [age] 65, increasing the likelihood that [these patients] have not been adequately screened prior to the upper age cutoff,” stressed study coauthor Frances Maguire, PhD, MPH, a senior epidemiologist at the University of California, Davis Comprehensive Cancer Center.
Additional factors may contribute to patients aged 65 years and older not receiving adequate cervical cancer screening:
- Patients who undergo a supracervical hysterectomy—which leaves the cervix intact—may not realize they need to continue screening for cervical cancer.
- Patients may tire of Pap tests due to discomfort, embarrassment, and the intrusiveness of a speculum-based exam.
- Pap tests may not be as accurate among patients who are postmenopausal in detecting adenocarcinoma—which has been increasing in incidence (as compared to squamous cell carcinoma).
- Patients in the older age group may not have received HPV testing—now the gold standard of cervical cancer screening—which wasn’t widely available until 2003. The CDC reported that almost all cases of cervical cancer are HPV-related.
Conclusions
The researchers emphasized that further studies are needed to determine past screening history, lapses in follow-up care, noninvasive testing approaches, and other areas in which the screening paradigm may be suboptimal. They concluded that patients aged 65 years and older still face a concerning advanced cervical cancer burden, and that efforts to better understand how current screening methods are failing this group of patients may be critical to reducing late-stage diagnoses.
Disclosure: The research in this study was funded by the University of California, Davis Comprehensive Cancer Center and National Cancer Institute. The collection of cancer incidence data used in this study was supported by the California Department of Public Health, the CDC, and the National Cancer Institute Surveillance, Epidemiology, and End Results program. For full disclosures of the study authors, visit aacrjournals.org.
