The majority of women in this ethnically diverse sample believed that lifelong cervical cancer screening was important; African American and Latina women were more likely to hold this view compared to Asian and White women. Most women had no plans to discontinue screening or had never thought of discontinuing. Regardless of ethnicity, however, most women reported they would end screening if their physician recommended it.
While our finding that women in older age groups and those with no personal or family history of cancer are more likely to end screening based on physician recommendation is logical, the reasons behind having public insurance being a predictor are less clear. We attempted to determine if perception of physicians played a role but were unable to demonstrate trust or beliefs about who should be making decisions as independent risk factors for ending screening. This observation may be due to factors for which we were not able to measure adequately or control.
While several prior studies have explored general attitudes and beliefs about cancer screening in older individuals 11
, our study uniquely focused on elucidating ethnic differences in ending cervical cancer screening. Prior studies have shown that women believe cervical cancer screening is important and 75% of women have come to expect an annual Pap test 12
. Current data indicate that women have mixed attitudes about risk-based screening schedules. Some studies indicate that the majority of women plan to continue cervical cancer screening indefinitely and want annual screening even if their physicians recommend otherwise 8
, perhaps due to mistrust of physicians’ rationales for recommending less frequent testing 13, 14
. However, in a study of younger and middle-aged, educated, White women conducted in New England, women identified patient education and clinician-patient reasons (such as feeling comfortable with the clinician and being taken seriously) as more important in the annual exam than getting a Pap test, leading investigators to conclude that in that population, biennial or triennial screening would be acceptable 15
Although there is a dearth of information about older women’s attitudes about ending cervical cancer screening, some studies have revealed their attitudes about ending other types of cancer screening. Women over age 70 express a disinclination to end breast cancer screening, though they identify increasing age, poor health, and physicians’ recommendations as potential reasons for ending screening 11
. Nevertheless, rates of mammography do decrease with age, as do rates of cervical cancer screening 16
. Physicians’ attitudes and beliefs also play an important role in screening continuation in older women. In a small vignette-based survey of obstetrician/gynecologists 7
, less than 20% of physicians would follow ACS or ACOG guidelines for cervical cancer screening discontinuation in low-risk women over age 70 years. About 40%, however, would discontinue based on patient request, and about half would end screening if life expectancy were less than 5 years.
Our study has both strengths and limitations. We were able to recruit a sizable group of women aged 65 and older most of whom were non-White, allowing us to compare many outcomes by ethnicity. Power to detect differences in some subgroups, however, was limited. While the setting of a structured interview allowed us to gather more complete data than a self-administered survey, the presence of an interviewer may have influenced how some women responded. We also realize that stated beliefs may not reflect actual clinical behaviors. While part of our survey included quantitative information about risk of cervical cancer, we could not assume that women understood these risks, especially since risk were on such a small scale. Some authors have suggested that elderly patients be given quantitative information to facilitate shared informed decision making 17
. Whether or not risks of such a small magnitude, such as those associated with cervical cancer incidence in low-risk older women, lend themselves to the shared informed decision-making model remains unclear. Finally, since one of our main goals was to determine if differences in attitudes and beliefs concerning ending cervical cancer screening varied by race/ethnicity and participants were preferentially targeted for enrollment to achieve that goal, the results must be extrapolated cautiously to other women in this age group.
While our study indicates that many women indicate that they would indeed end screening if their physician recommended it, a substantial proportion would want lifelong testing. Recent decision analyses indicate that lifelong screening of low-risk women is not cost-effective 18
and is associated with harms that eclipse benefits as women age 2
. Such findings support the USPSTF guideline that encourages screening cessation in low-risk women after the age of 65 years in an effort to maximize screening benefits and minimize harms. While clinicians often respect the desires of individuals to continue lifelong screening, it is unclear if such decisions sit squarely within the purview of individual women. It may well be that low-risk women who insist on annual, lifelong screening are requesting care outside the limits of what is reasonable to offer and that other models of care should be considered (e.g., paying out of pocket for cost-ineffective services). Future studies should focus on best ways to explain the rationale behind ending cancer screening in older individuals to facilitate satisfaction with ultimate decisions.