Cervical Cancer Screening Among Women by Hysterectomy Status and Among Women Aged ≥65 Years — United States, 2000–2010

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Since 2003, major U.S. organizations consistently have recommended against screening most women for cervical cancer after a total hysterectomy for benign disease. Starting in 2003 and becoming consistent across organizations in 2012, guidelines also state that women with a history of adequate screening no longer should be screened after age 65 years. Reports have shown that many of those women continue to receive Papanicolaou (Pap) testing, contrary to recommendations. To measure recent screening behaviors and trends in accordance with evidence-based recommendations, biennial cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) on women aged ≥30 years were analyzed and stratified by hysterectomy status and by age (30–64 years and ≥65 years). The proportion of women reporting having had a hysterectomy who reported a recent (within 3 years) Pap test declined from 73.3% in 2000 to 58.7% in 2010. Declines among women having had a hysterectomy were significant among those aged 30–64 years, from 81.0% in 2000 to 68.5% in 2010, and among those aged ≥65 years, from 62.0% to 45.0%. Among women aged ≥65 years with no history of hysterectomy, recent Pap testing also declined significantly, from 73.5% to 64.5%. Although recommendations have resulted in reductions in screening posthysterectomy and of those aged ≥65 years, many women still are being screened who will not benefit from it.

Routine screening for cervical cancer by Pap testing is no longer recommended for women who have undergone a total hysterectomy (the removal of the uterus, including the cervix) or for adequately screened women after age 65 years.* Before 2003, the American College of Obstetricians and Gynecologists (ACOG) recommended regular screening be continued posthysterectomy, the American Cancer Society (ACS) did not address screening posthysterectomy, and the U.S. Preventive Services Task Force (USPSTF) stated that most women did not benefit from posthysterectomy screening (Table 1). In late 2002 and 2003, when the three organizations updated their guidelines, they all recommended that most women having had total hysterectomies for benign reasons should no longer be screened regularly, and USPSTF recommended that women aged >65 years with a history of normal screening results should no longer be routinely screened (Table 1). Updates in 2009 and 2012 did not significantly change recommendations not to screen women posthysterectomy, and as of 2012, ACOG and ACS also recommended against routinely screening women aged >65 years with a history of normal screening results. Biennial cross-sectional data from BRFSS were analyzed to measure recent screening behaviors and trends in accordance with evidence-based recommendations on screening.

BRFSS is a state-based, random-digit–dialed telephone survey of the noninstitutionalized, U.S. civilian adult population aged ≥18 years. Trained interviewers ask questions about general health status and healthy behaviors. The BRFSS questionnaire is comprised of core questions and optional modules. The Women's Health section is included in the core questions biennially; during 2000–2010, each adult female respondent was asked whether she had ever had a Pap smear or test,† (described as "a test for cancer of the cervix"). Respondents also were asked, "How long has it been since you had your last Pap test?" and if they had had a hysterectomy. Overall survey response rates ranged between 46.0% and 55.7% over the 10 years.§ Of the sample population, 97.8% responded to the question "have you ever had a Pap smear/test?" and 97.4% responded to the question "have you had a hysterectomy?" No questions were asked about the reason for the hysterectomy or whether the cervix was removed.

Weighted analyses were performed to account for the complex sampling design. Percentages and 95% confidence intervals (CIs) were calculated for women aged ≥30 years reporting a recent Pap test (defined as a Pap test within the past 3 years), and were stratified by hysterectomy status and age. Unadjusted logistic regression models were used to test for differences in Pap testing behaviors over the 10-year period, with the year treated as a categorical variable. Statistically significant differences from 2000 to 2010 had a p-value <0.05. Age was limited to ≥30 years, because only 1.6% of women aged <30 years reported hysterectomies. These proportions were then examined according to race/ethnicity (white, non-Hispanic, black, non-Hispanic, other/multiracial, and Hispanic), U.S. Census region (Northeast, Midwest, South, and West), and health-care coverage (covered by insurance or another payer, and not covered).

Screening of Women Who Reported Having Had
a Hysterectomy

Numbers of women reporting a recent Pap test were stratified by hysterectomy status, age, race/ethnicity, U.S. Census region, and health-care coverage (Table 2). The proportion of women aged 30–64 years who reported both a recent Pap test and having had a hysterectomy declined significantly, from 81.0% (CI = 79.8%–82.1%) in 2000 to 68.5% (CI = 67.7%–69.3%) in 2010 (Figure). Women aged 30–64 years of all races/ethnicities who had a hysterectomy reported fewer recent Pap tests in 2010 than in 2000. The proportion of women aged 30–64 years who had a hysterectomy and who reported recent Pap testing declined significantly in all U.S. Census regions, with the steepest drop (15.6%) in the West. Steep declines in recent screening among women aged ≥65 years who had a hysterectomy also were observed, although 45.0% of these women still reported a recent Pap test in 2010.

Screening of Women Who Did Not Report Having Had a Hysterectomy

Among women of all ages without a hysterectomy, the proportion of women reporting a recent Pap test fell. The greatest decline was among women aged ≥65 years, from 73.5% (CI = 72.0%–74.9%) in 2000 to 64.5% (CI = 63.8%–65.3%) in 2010 (Table 2). Among women aged 30–64 years, with no history of hysterectomy, and who therefore should be screened, slight but statistically significant decreases in recent Pap testing occurred for white women and black women, and across all U.S. Census regions. Women aged 30–64 years who did not have health-care coverage and had not had a hysterectomy were less likely to have a recent Pap test in 2010 (68.7%) than in 2000 (74.4%).

Reported by

Meg Watson, MPH, Jessica King, MPH, Umed Ajani, MBBS, Keisha A. Houston, DrPH, Mona Saraiya, MD, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Meg Watson, [email protected], 770-488-3097.

Editorial Note

Cervical cancer screening has resulted in well-documented declines in cervical cancer incidence and mortality (1). However, the net benefits of screening some women, particularly women who have undergone hysterectomy and adequately screened women aged >65 years, might be outweighed by the net harm (e.g., false-positive tests leading to needless patient anxiety and invasive procedures) (2). Despite consistent guidelines by three national organizations (USPSTF, ACS, and ACOG) recommending against routine screening for cervical cancer posthysterectomy, the proportion of women aged <30 years who have had a hysterectomy and recently have been screened declined only 15 percentage points, and approximately 59% of these women still reported recent (in the past 3 years) Pap testing in 2010.

Analyses conducted before current recommendations were in place showed that many women who had hysterectomies continued to receive cervical cancer screening. A 2001 analysis found that 78% of women who had hysterectomies reported recent screening (3). A more recent study suggested that physicians were continuing to recommend Pap tests posthysterectomy in 2006 and 2007, despite guidelines recommending against such testing (4). Proponents of continued screening after hysterectomy have raised concerns about vaginal cancer and its precursors (5). However, vaginal cancer is rare, and the value of cytology tests to detect vaginal cancer in the absence of a cervix is unknown (6). Approximately 90% of hysterectomies are conducted for benign reasons, and the cervix is removed in approximately 94% of hysterectomies, so only a small proportion of women need continued screening after a hysterectomy (3,7). In addition, the positive predictive value of screening among adequately screened postmenopausal women is low, and lesions detected and treated among this population are unlikely to progress to cancer (2).

Some groups of women are not screened as often as they should be. Of particular concern, one third of women aged 30–64 years with no health-care coverage and no history of hysterectomy reported not having a recent Pap test in 2010. Women not receiving recommended screening and followup are at increased risk for cervical cancer mortality (1). Underscreening among women with less education, no usual source of health care, and no health-care coverage is well-documented and a persistent cause of health disparities (8).

The findings in this report are subject to at least five limitations. First, validation studies of self-reported Pap test data have shown that women might over-report being screened with a Pap test and under-report the time since the last test (9), but self-reported hysterectomy status generally is reliable (10). Second, information on the timing of recent Pap tests relative to the timing of hysterectomy is not available, so a small number of hysterectomies could have been performed after the Pap test (7). Third, BRFSS data do not contain information on reasons for hysterectomy, whether the cervix was removed with the uterus or not, whether women had normal screening histories in the past 10 years, whether women had high-grade precancer, or other reasons for which women might need continued screening. Fourth, the survey response rates were low, ranging from 40.0% to 55.7%. Finally, BRFSS is limited to noninstitutionalized populations and, during the period studied, used only landline telephones.

This study used a large, state-based national survey to document 10-year trends in Pap testing among women aged ≥30 years, by hysterectomy status and age. Declines in Pap testing among women having had a hysterectomy and among women aged ≥65 years showed improved concordance between guidelines and practice. However, estimates of the BRFSS data show that nearly 22 million women with hysterectomies might have received unnecessary screening, contrary to consistent recommendations by USPSTF, ACS, and ACOG that have been in place for nearly a decade. Research is needed to determine how to further reduce unnecessary screening. Monitoring Pap test prevalence among U.S. women is important to ensure that resources are targeted to women with the most need.

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