Screening for cervical disease in mature women: strategies for improvement

Background: Cervical carcinoma remains a significant health risk for the older woman. In the current study the yield of screening of mature women in an established, opportunistic screening program was examined. Strategies for improving screening in this age group were identified through examination of recent Pap test history of women with high grade squamous intra-epithelial lesions (HSIL).

Methods: From the population based registry of the Ontario Cervical Screening Program, the Pap test cytodiagnoses for almost 700,000 women screened during the first six months of 2000 were classified by age quintile. Screening yields for younger women (< 50 years of age) and mature women (>/= 50 years of age) were compared using the detection ratio (abnormalities per 1000 women tested). Any pap test results during the three years preceding a diagnosis of HSIL in mature women were identified (excluding any Pap test in the six months immediately prior to the HSIL cytodiagnosis) and classified into one of three categories: no prior test known, prior negative Pap test known, and prior abnormal Pap test known.

Results: Twenty four percent of all Pap tests in the six month period were from mature women. Approximately 11% of all cytodiagnoses of HSIL and carcinoma (HSIL+), and 13% of all low grade squamous intra-epithelial lesions (LSIL), HSIL, carcinoma, and atypical glandular cells of uncertain significance (AGUS); [LSIL+ and AGUS] cytodiagnoses, were from mature women. The yield of Pap testing in mature women (1.7 HSIL+ per 1000 women tested) was slightly more than 40% of that for younger women (4.2 HSIL+ per 1000 women tested). Mature women with HSIL were more likely to have had a history of no prior screening (61.1%) than younger women (49.5%). The majority (62.9%) of mature women with HSIL and a prior known Pap test had a prior registered abnormal Pap test.

Conclusions: Pap testing of mature women yields a significant number of abnormalities, but is less efficient than Pap testing of younger women. Screening yield could be increased by recruiting mature women who are currently inadequately screened and by revising guidelines for cessation of screening. Proper followup of mature women with Pap test abnormalities would improve clinical outcome but could adversely affect the yield of Pap testing, since current inappropriate repeat testing of women would decrease.