Accessibility of Criteria to Exit Cervical Cancer Screening at Age 65 Years in the Electronic Health Record

Abstract

Objective: To describe the proportion of patients with documentation of meeting cervical cancer screening exit criteria in the medical record and to estimate the incidence of cancer and high-grade precancerous lesions after age 65 years detected by the end of the study period, by screening exit eligibility.

Methods: We conducted a retrospective analysis of patients who turned 66 years old between 2010 and 2019 at two large health care systems located in Dallas, Texas, and Boston, Massachusetts, from the METRICS (MultilEvel opTimization of the ceRvIcal Cancer Screening process in diverse Settings & populations) Research Center, part of the PROSPR II (Population-based Research to Optimize the Screening Process) consortium. The primary outcomes were 1) the percentage of patients who were eligible for screening exit at age 66 years after adequate documented negative screening history (at least three consecutive negative cytology test results or two consecutive negative human papillomavirus [HPV] test or co-test results [cytology+HPV testing] within the prior 10 years) and 2) the worst pathology or cytology outcome documented in the cohort after age 65 years.

Results: Among 42,393 people who turned 66 years old while in the METRICS cohort, approximately 75.7% (n=32,094) were not eligible to exit screening at age 66 years, primarily because too few screening tests were documented (n=29,354, 91.5% of those ineligible). Furthermore, only 4,037 patients at both sites had 10 years of prior observation within the health care system, meaning data from current and prior health care delivery sites would be needed to assess exit eligibility for more than 90% of the cohort. Patients remained in the cohort after their 66th birthday on average for 3.8 years (interquartile range 2.0-6.5 years), and most (79.3%) had no subsequent evaluation after their 66^th birthday. Among those ineligible to exit due to insufficient screening history, 83.7% were not subsequently screened. Of the 16.3% who were screened, 90 (1.9%) were diagnosed with cancer or high-grade precancerous lesions, including 34 (0.7%) who were diagnosed with cervical cancer. By contrast, among patients eligible to exit with sufficient screening history, 34.3% had at least one subsequent cytology or pathology result or both, and high-grade precancerous lesions or cervical cancer were diagnosed in only 0.6% (n=16).

Conclusion: Data documented in the medical record are often insufficient to meet guidelines for exiting cervical cancer screening.

Fig. 1.. Identification of screen exit eligibility on 66th birthday. We included all METRICS (MultilEvel opTimization of the ceRvIcal Cancer Screening) cohort members who turned 66 years old from 2010 to 2019 while in the cohort. Among people in the study cohort, we first identified people who were under surveillance on their 66th birthday due to the following: a previous history of cervical cancer, no cervix after a full or total hysterectomy or trachelectomy at any age and abnormality (atypical squamous cells of undetermined significance [ASC-US] cytology or worse, human papillomavirus [HPV]–positive test result or cervical procedure, regardless of pathology outcome) from age 40–65 years, a high-grade result (high-grade squamous intraepithelial lesion cytology or worse or HPV 16/18–positive test result) from age 40–65 years, a low-grade result (ASC-US or low-grade squamous intraepithelial lesion cytology or HPV non–16/18-postive test result) from age 55–65 years, or prior human immunodeficiency virus (HIV) diagnosis. People who met any of these criteria were deemed ineligible to exit screening on their 66th birthday. Next, among people not under surveillance on their 66th birthday, we identified people without a cervix after a full or total hysterectomy or trachelectomy at any age and a further subset based on whether the person had one or more documented normal test results; people who had one or more documented normal test results were deemed eligible to exit screening on their 66th birthday, and people who did not were deemed ineligible to exit screening on their 66th birthday. Lastly, among people not under surveillance and with a cervix (ie, no documented previous cervix removal), we identified people with a sufficient screening history based on either a normal co-test result from age 61 to 65 years with one or more preceding normal co-test results from age 56 to 65 years, or a normal Pap test result from age 63 to 65 years with two or more preceding normal Pap test results from age 56 to 65 years. People who met these criteria were deemed eligible to exit screening on their 66th birthday, and people who did not meet these criteria were deemed ineligible to exit screening on their 66th birthday.

Fig. 2.. Next event after 66th birthday by exit eligibility. Next event (cytology, human papillomavirus test, pathology, or cancer registry diagnosis) after 66th birthday among the total cohort (top panel), with at-risk counts reported (bottom panel), based on screen exit eligibility as follows: ineligible due to being under surveillance (pink line), ineligible due to insufficient screening history (orange line), eligible after hysterectomy and no documented abnormality (blue line), and eligible after sufficient screening history (green line). Cohort members were censored at cohort exit (indicated by vertical hashing).