A 67-year-old woman, gravida 1 para 1, comes to the office for a routine health examination. The patient feels well. Her last menstrual period was at age 53 with no bleeding since. Pap test and human papillomavirus (HPV) cotesting were negative 2 years ago at age 65. All prior Pap tests were normal. The patient is sexually active in a monogamous relationship with her husband of 42 years. She has no medical conditions. The patient had an ovarian cystectomy via laparotomy at age 37 for a benign cystic teratoma. She takes no medications and does not use tobacco, alcohol, or illicit drugs. There is no family history of cancer. BMI is 25 kg/m². Pelvic examination shows a normal cervix without lesions; a smooth, anteverted, mobile uterus; and no adnexal masses. Screening mammography was normal 6 months ago, and screening colonoscopy was normal 2 years ago. Which of the following is the most appropriate recommendation for cervical cancer screening in this patient?

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Quizplus · Accepted Answer

11ec25c8_d988_ca45_bc81_4dfa1e40a376_MD0003_00 The progression from persistent human papillomavirus (HPV) infection to invasive cervical carcinoma takes many years. Screening for cervical cancer with Pap tests is performed to detect lesions (eg, low-grade squamous intraepithelial lesions) in earlier, more treatable stages. Risk factors for cervical cancer include tobacco use, oral contraceptive use, early onset of sexual activity, sexually transmitted infections, and high-risk sexual activity, all of which are associated with persistent HPV infection. Normal Pap tests exclude persistent HPV infection, and patients with adequate screening by age 65 are at low risk of developing cervical cancer. In such patients, Pap tests may be stopped. If a patient has a history of cervical intraepithelial neoplasia 2 or higher on histology, screening continues for another 20 years after detection (past age 65 if indicated). Terminating Pap tests at age 65 may not be appropriate for women with cervical cancer risk factors (eg, immunosuppression, high-risk sexual activity, tobacco use, diethylstilbestrol exposure). (Choices A, C, D, and E) Pap tests without HPV cotesting are repeated every 3 years beginning at age 21. At age 30, either Pap tests with HPV cotesting or primary HPV testing alone may be done and repeated every 5 years if negative. Regardless of screening interval, Pap testing ends at age 65; therefore, this patient requires no screening. Educational objective: Pap testing may be discontinued in patients age 65 who have had adequate Pap testing without prior high-grade cervical lesions or cervical cancer risk factors (eg, tobacco use, immunocompromised status). References: Cancer screening in the older patient. (http://www.ncbi.nlm.nih.gov/pubmed/19119555) Cervical cancer screening in average-risk women: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. (http://www.ncbi.nlm.nih.gov/pubmed/25928075)

A 67-Year-Old Woman, Gravida 1 Para 1, Comes to the Office