HPV IN THE ELDERLY
While the U.S. Preventive Services Task Force, among others, deems it reasonable to use only a Pap smear to screen women older than 65 for cervical cancer because of their low risk (Item 103-18), it seems a bit premature to assume that HPV transmission won’t follow a pattern similar to HIV infection, which has seen its fastest rise in senior citizens. We should also be concerned that current guidelines clash with the increasing rate of cervical cancer in aging patients and that the guidelines may be savings-driven rather than patient-care-driven.
Determining accurately whether the patient is “at high risk for cervical cancer” is sometimes easy and sometimes quite uncertain. Do you want to be the physician who did not do a Pap smear on the woman who develops cervical cancer the following year? Doesn’t cancer of the cervix occur without HPV infection, just as lung cancer occurs in patients who have never smoked?
—John R. Dykers Jr, MD, Siler City, N.C.
Many studies have been published since 1995 investigating cervical cancer screening among older women. The incidence of cervical intraepithelial neoplasia peaks in the mid-reproductive years and begins to decline in the fourth decade of life. The rates of high-grade
intraepithelial lesions are low among older women who have had cervical cytologic screening. If older women are screened, they are disproportionately likely to be evaluated for false-positive findings. In one study involving 2,561 postmenopausal women with normal baseline cytology, annual screening for four years produced 110 abnormal results requiring additional interventions, yet only one case of mild-to-moderate dysplasia was diagnosed. The American Cancer Society, American Academy of Family Physicians, American College of Preventive Medicine, and Canadian Task Force on Preventive Health Care all recommend discontinuing cervical cancer screening or offering this option to patients after age 65-70, provided there is documented evidence of adequate past screening.
—Daniel R. Mishell Jr, MD (104-15)