Cervical cancer screening after age 65 in the era of HPV testing: estimating benefits and harms of screening cessation and continuation

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Project Summary Cervical cancer screening represents a remarkable success story that has led to profound reductions in cancer incidence and mortality in the United States (US), yet fundamental questions about screening cessation remain. For the last 25 years, the US Preventive Services Task Force (USPSTF) has recommended screening cessation at age 65 in those deemed to have been adequately screened. The increase in life expectancy over the last 25 years, however, raises questions about whether healthy, well-screened women over age 65 should continue screening. In fact, an estimated 21% of cervical cancer cases and 35% of deaths in the US occur after age 65. Screening older people for cancer, however, involves a judicious consideration of the balance between benefits and harms. For example, cervical cancer prevention through screening is only achieved by performing surgical procedures on the cervix, including hysterectomies, which may pose a higher risk of major medical complications for older women. Because up to 60% of women have not met the criteria to end screening at age 65, an estimated 1,700,000 women turning age 65 each year in the US can be expected to continue screening. In its most recent guideline, the USPSTF stated that research is needed to elucidate the balance of benefits and harms in various groups of women over age 65. The aims of this proposal will fill significant evidence gaps concerning the benefits and harms of cervical cancer screening after age 65. Aim 1 will involve a cohort study of about 280,000 women over 65 who were long-term members of two large health systems during 2005-2022 to investigate cervical cancer incidence, stage at cancer diagnosis, and cancer mortality by screening history documented ages 55 to 65. We will also use causal inference methods to emulate a randomized trial using observational data to estimate the effectiveness of screening after age 65 on cancer outcomes. Aim 2 involves a cohort study of women screened after age 65 to investigate harms, including the incidence and predictors of medical complications resulting from diagnostic procedures and surgical interventions. We will also conduct qualitative interviews in a sample of women to evaluate the personal experiences of women who continue with the screening process after age 65. Aim 3 will involve the enumeration of actual screening outcomes of 33,000 women screened after age 65 to inform a decision analytic model that will estimate benefits and harms of screening continuation after age 65 compared with screening cessation. We have assembled an ideal study team with expertise in obstetrics/gynecology, infectious disease, cancer epidemiology, cancer screening decision modeling, biostatistics, and geriatrics. Completion of this proposal’s aims will fill important gaps and move the field forward by providing evidence to make cervical cancer screening guidelines that better balance benefits and harms in older women.