Study finds increase in women 65 and older dying of cervical cancer

A new study conducted by UC Davis Comprehensive Cancer Center researchers shows an alarming number of California women 65 and older are facing late-stage cervical cancer diagnoses and dying from the disease. This is despite guidelines that recommend most women stop screening for cervical cancer at this age.

“Our findings highlight the need to better understand how current screening guidelines might be failing women 65 and over,” the study’s lead author, UC Davis senior statistician Julianne Cooley, said. “We need to focus on determining the past screening history of older women as well as lapses in follow-up care. We must utilize non-invasive testing approaches for women nearing age 65 or those who need to catch up on their cervical cancer screenings.”

Our findings highlight the need to better understand how current screening guidelines might be failing women 65 and over.”—Julianne Cooley, UC Davis senior statistician

The findings from the study, published in Cancer Epidemiology, Biomarkers & Prevention on January 9, 2023, showed nearly one in five new cervical cancers diagnosed from 2009-2018 were in women 65 and older. More of these women (71%) presented with late-stage disease than younger women (48%), with the number of late-stage diagnoses increasing up to age 79. Late-stage five-year relative survival was lower for women 65 and over (23.2%-36.8%) compared to patients under 65 (41.5%-51.5%). Women 80 years and older had the lowest survival of all age groups.

“Our study found worsening five-year relative survival from cervical cancer with each increasing age category for both early and late-stage diagnoses,” said co-author Theresa Keegan, a professor in the UC Davis Division of Hematology and Oncology.

California Cancer Registry provided critical data

The study utilized a large set of population-based data from the California Cancer Registry. This state-mandated cancer surveillance system has collected cancer incidence and patient demographic, diagnostic, and treatment information since 1988. The data was used to identify all women 21 years and older who were diagnosed with a first primary cervical cancer in California from 2009-2018, the 10 most recent years that complete data was available.

Our study found worsening five-year relative survival with each increasing age category for both early and late-stage diagnoses.”—Professor Theresa Keegan, UC Davis Division of Hematology and Oncology

Among women 65 and older, those who had comorbidities or were older were more likely to be diagnosed with late-stage disease.

“Interestingly, prior studies of younger women have found increased late-stage cervical cancer diagnoses among young Hispanic/Latina and Black women,” Cooley said. “Our study did not observe these associations and instead found that older Hispanic/Latina women were less likely than non-Hispanic white women to be diagnosed late-stage.”

Current screening guidelines

Following the introduction and widespread adoption of the Papanicolaou (Pap) smear test in the 1940s, cervical cancer incidence and mortality have fallen significantly. However, incidence rates have plateaued since 2012, and rates of invasive cervical cancer have actually increased in recent decades.

Through adequate screening and follow-up, cervical cancer can be prevented or detected at an early stage, which leads to excellent survival. However, current guidelines recommend discontinuing screening for women 65 or older who have had a history of normal Pap and/or Human Papillomavirus (HPV) tests, potentially leaving this age group vulnerable.

Scheduled screenings may also decrease as women approach 65, increasing the likelihood that women have not been adequately screened prior to the upper age cutoff.”—Frances Maguire, UC Davis senior epidemiologist

Lack of adherence to screening

Previous studies have shown that 23.2% of women in the U.S. who are over 18 are not up to date on recommended cervical cancer screening. Disadvantaged women such as those who are uninsured or poor are the least likely to report being up to date with cervical cancer screening.

“Scheduled screenings may also decrease as women approach 65, increasing the likelihood that women have not been adequately screened prior to the upper age cutoff,” co-author and senior epidemiologist Frances Maguire said.

Additional factors may contribute to older women not receiving adequate screening:

• Specific type of hysterectomy. A supracervical hysterectomy leaves the cervix intact and some women do not realize they need to continue screening for cervical cancer.
• Women may tire of PAP smears due to embarrassment and the intrusiveness of a speculum-based exam.
• Pap tests less accurate. The screening may not be as accurate in post-menopausal women in detecting adenocarcinoma, which has been increasing in incidence (as compared to squamous cell carcinoma).
• HPV testing. Women in the older age group may not have received HPV testing, now the gold standard of cervical cancer screening, which wasn’t widely available until 2003. The Centers for Disease Control reports that almost all cases of cervical cancer are HPV-related.

Acknowledgements

Other authors of the study include Cyllene R. Morris, Arti Parikh-Patel, Renata Abrahão and Hui A. Chen.

The study was funded by the UC Davis Comprehensive Cancer Center and National Cancer Institute of the National Institutes of Health under award number P30CA093373. The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s National Program of Cancer Registries, under cooperative agreement 5NU58DP006344; the National Cancer Institute Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the UC San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute.