We appreciate the perspective of Drs. Isidean and Franco (1). We agree with them that there are indeed costs (financial, physical, psychological) associated with cervical screening of older women, and that the decision to continue screening beyond a given age needs to weigh these costs against the benefits of screening. The purpose of our commentary (2) was to suggest that the recently formulated guidelines had not adequately considered those benefits.
There are good reasons to believe that even a series of negative screens for cervical neoplasia predicts a low risk of subsequent cervical malignancy only for so long (3–5). Contrary to Isidean and Franco's assertion (1), it is possible that precursor lesions that develop in a woman aged 65 years or older—even a woman who was previously adequately screened—can progress to cervical cancer within her remaining life expectancy. Indeed, this is the main finding from the studies documenting a reduced incidence of invasive cervical cancer associated with receipt of screening among women in this age group (3, 4, 6, 7).
ACKNOWLEDGMENTS
Author affiliations: Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington (Alison S. Rustagi); Group Health Research Institute, Seattle, Washington (Aruna Kamineni); and Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington (Noel S. Weiss).
This work was funded in part by the National Institutes of Health (grant R25CA094880 from the National Cancer Institute and grant TL1 TR 000422 from the National Center for Advancing Translational Sciences).
Conflict of interest: none declared.
REFERENCES
- 1.Isidean SD, Franco EL. Counterpoint: cervical cancer screening guidelines—approaching the golden age. Am J Epidemiol. 2013;178(7):1023–1026. doi: 10.1093/aje/kwt166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rustagi AS, Kamineni A, Weiss NS. Point: cervical cancer screening guidelines should consider observational data on screening efficacy in older women. Am J Epidemiol. 2013;178(7):1020–1022. doi: 10.1093/aje/kwt167. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sasieni P, Adams J, Cuzick J. Benefit of cervical screening at different ages: evidence from the UK audit of screening histories. Br J Cancer. 2003;89(1):88–93. doi: 10.1038/sj.bjc.6600974. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Kamineni A, Weinmann S, Shy K, et al. Cervical cancer screening efficacy in older women [published online ahead of print June 7, 2013] Cancer Epidemiol Biomarkers Prev. doi:10.1007/s10552-013-0239-4. [Google Scholar]
- 5.IARC Working Group on Cervical Cancer Screening. Screening for squamous cervical cancer—the duration of low risk following negative results in cervical cytology test: introduction. IARC Sci Publ. 1986;(76):15–24. [PubMed] [Google Scholar]
- 6.Sasieni P, Castanon A, Cuzick J. Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ. 2009;339:b2968. doi: 10.1136/bmj.b2968. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Andrae B, Kemetli L, Sparén P, et al. Screening-preventable cervical cancer risks: evidence from a nationwide audit in Sweden. J Natl Cancer Inst. 2008;100(9):622–629. doi: 10.1093/jnci/djn099. [DOI] [PubMed] [Google Scholar]