Updated approach to screening for cervical cancer in older women

Abstract

Elderly women are inadequately screened for carcinoma of the cervix. Patient, physician, and laboratory factors are responsible for this "performance gap." Patients may be unaware of the need for routine screening; physicians other than obstetricians and gynecologists may not view cervical cancer screening as appropriate; and laboratories are under scrutiny for their quality control problems. Data from a Maryland study demonstrates the barriers to screening for the elderly: they receive sporadic screening, and office-based providers rarely offer this service. A simple protocol for management is suggested to reduce the morbidity and mortality attributable to cervical cancer.

PIP: Older women are often not adequately screened for cervical cancer for several reasons: 1) patients often do not know that they need screening. 2) Primary care physicians may assume that the woman's gynecologist did it, although many women never visit a gynecologist after menopause. 3) There is disagreement about how often screening should be done. 4) Cytologic laboratories vary in thoroughness. Risk factors for cervical cancer are: age over 50, early menarche, young age at 1st intercourse, a large number of sexual partners, history of sexually transmitted disease, and smoking. Oral contraceptive use has shown to be protective against cervical cancer, and the human papilloma virus in now considered the leading cause of it. The American Cancer Society recommends Pap tests every 3 years for women between age 20 and age 65. The single most important risk factor for cervical cancer in older women is failure to receive routine periodic screening. Of 1500 elderly patients seen at an urban ambulatory care center 25% had never been screened before, and the prevalence of positive smears was 13.5/1000. Of 153 women diagnosed with cervical Cancer at Johns Hopkins Hospital in 1982-84, only 1 out of 3 had had pap smear in the previous 3 years; yet over 80% of them were receiving routine office care from a primary care physician. Some barriers that prevent physicians from screening elderly patients include inadequate equipment, need for a chaperone, fears of lack of competence, and patient objections. It is essential that primary care physicians determine the screening history of patients, screen them or refer them for screening, and follow up abnormal results.