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

项目摘要 宫颈癌筛查是一个显著的成功故事，导致癌症的大幅减少 美国（US）的发病率和死亡率，但有关筛查停止的基本问题 保持。在过去的25年里，美国预防服务工作组（USPSTF）建议筛查 在65岁时停止在那些被认为已经充分筛选。2000年以来预期寿命的增加 然而，在过去的25年里，人们提出了一个问题，即65岁以上的健康、经过良好筛查的妇女是否应该 继续筛选。事实上，在美国，估计有21%的宫颈癌病例和35%的死亡发生在 六十五岁。然而，对老年人进行癌症筛查需要明智地考虑以下两方面的平衡： 利与弊例如，通过筛查预防宫颈癌， 子宫颈的外科手术，包括子宫颈切除术，这可能会造成更高的重大医疗风险， 老年女性的并发症因为高达60%的女性没有达到年龄结束筛查的标准 65，估计每年有1，700，000名65岁的美国女性可以继续接受筛查。 USPSTF在其最新的指南中指出，需要进行研究以阐明利益的平衡， 对65岁以上妇女群体的危害。这项提案的目的将填补重大的证据空白 关于65岁以后进行宫颈癌筛查的益处和危害。目标1将涉及一项队列研究 在2005-2022年期间，约28万名65岁以上的妇女是两个大型卫生系统的长期成员， 通过筛查史调查宫颈癌发病率、癌症诊断分期和癌症死亡率 年龄在55到65岁之间我们还将使用因果推理方法来模拟随机试验， 观察性数据，以评估65岁后筛查对癌症结局的有效性。目标2涉及 对65岁以后接受筛查的妇女进行队列研究，以调查危害，包括 诊断程序和手术干预导致的医疗并发症。我们还将进行 定性访谈的妇女样本，以评估妇女的个人经验，谁继续与 65岁后的筛查过程。目标3将涉及33，000例实际筛查结果的计数 65岁以后接受筛查的妇女，以告知一个决策分析模型，该模型将估计 65岁后继续筛查与停止筛查相比。我们已经组装了一个理想的研究 拥有妇产科、传染病、癌症流行病学、癌症筛查等专业知识的团队 决策建模、生物统计学和老年医学。完成这项提案的目标将填补重要的空白， 通过提供证据来推动该领域的发展，使宫颈癌筛查指南更好地平衡 对老年妇女的好处和坏处。

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.