Healthcare Policy: Cervical Cancer Screening Above the Age of 65



Health policies are created to improve health in the public and prevent disease. It includes ways to promote health, lower the risk of illness and decrease the spread of deadly contaminants (CDC, 2017). To healthcare professionals, this means implementing prevention strategies and assisting patients in finding the best healthcare at an affordable cost. One of the most important roles as a public health professional is to be a patient advocate. This means supporting patients in their decisions, advising them in making the best choices when it comes to their health and assisting in preventing unnecessary costs. This can be done by pointing out parts of a healthcare policy that are having a negative impact and suggesting ways to make changes where improvements can be made. Patient’s build trust in their healthcare team, giving them the responsibility to help guide the community to a healthier state of being.



Healthcare Policy Concern

When women become sexually active or turn 21 it is essential for them to begin receiving pap smears. This screens for cervical cancer, which is known as the silent killer because by the time women begin to have symptoms, it may be too late for treatment. According to the American College of Obstetricians and Gynecologist guidelines, women from ages 21 to 29 should have a pap smear every 3 years and women ages 30 to 65 should have a pap smear along with an HPV test every 5 years. Women are advised to stop having pap smears after the age of 65 if they have had all normal pap smears or three negative pap smears in a row, if the last pap was within 5 years. Unfortunately, pap smears are not always accurate. There are many situations that can cause a false negative. Some examples being sexual intercourse and some medications (ACOG, 2019). With the prevalence of cervical cancer cases increasing, pap smears should not be discouraged just because a patient turns 65.


The healthcare policy that may need revision is “A Framework for Patient-Centered Health Assessment Risks”. This is a way to provide preventative care to patients that are on Medicare and states what health risk assessments should be given to patients on Medicare, which includes the population of residents 65 and older. This is to help prevent and manage chronic diseases as the population ages. This policy provides patients on Medicare with a wellness visit they receive within their first year receiving Medicare benefits. This includes a health assessment, looking at the patient’s medical history and health risks so necessary screenings can be added to the patient’s chart as reminders for the patient to have them done per provider recommendations. Doctors are then provided with metrics that they must meet to avoid being fined. For example, if a patient is due for a mammogram, then the patient’s chart will be flagged until a mammogram is provided to satisfy the metric. Though this does include health screenings, immunizations, and mental health risks, it does not include cervical cancer screening for women over the age of 65 with a history of normal pap smear screenings (CDC, 2017).



Cervical cancer is becoming quite common, and this does not exclude women over the age of 65. According to an article called “Cervical Cancer in Women Over 65: An Analysis of Screening” cervical cancer is one of the most common types of cancers in the world. To combat this, more screenings have been initiated with guidelines to make sure healthcare organizations are doing their part to make sure this cancer is caught early so treatment is effective. Guidelines have stemmed from statistical data that shows women from the ages of 35-54 more commonly developing this disease. It may be more prevalent in this age group, but it is common for women over the age of 65 to be diagnosed with cervical cancer. Data has shown that 20% of women that are diagnosed with cervical cancer are over the age of 65. As women age, their risk of cervical cancer increases, yet most of the guidelines do not support women over the age of 65 to continue having pap smears if they have never had an abnormal screening.


A study was conducted to see how many women over the age of 65 developed cervical cancer, after following guidelines which encouraged the screenings to stop after the age of 65 contingent on the patient having a history of normal pap smear examinations. The study was done at a cancer center in Michigan between the years 2004 and 2016. During that time 10% of the women that were diagnosed with cervical cancer were over the age of 65. This does not include the women that were excluded because their previous pap smear history was unable to be obtained or they had not been screened at all. Of the women that were diagnosed, many had never had an abnormal pap smear. The women were diagnosed when symptoms were presented during a routine physical. This age group is still at risk for cervical cancer. That risk does not decrease once the patient turns 65 (Yost and Hoekstra, 2018).



Solution

Pap smears for female patients on Medicare should not stop after the age of 65. Cervical cancer screening should continue to be encouraged and guidelines should be updated to support this. Since guidelines have considered pap smears for elderly patient unnecessary, most health insurance plans will not cover it unless there is a previous history of abnormal pap smears. As mentioned previously, a pap smear may have had a false negative due to the sample that was collected. Another thing to mention is that HPV can be latent during the time the sample was collected, also causing a false negative. If a patient is positive for HPV, then this increases their risk for cervical cancer. If pap smears discontinue after the age of 65 then the only way cervical cancer can be diagnosed is if the patient develops symptoms (Yost and Hoekstra, 2018).


To initiate these changes, patients need to be made aware that pap smears are still an important screening to receive after the age of 65 and have reminders set in their chart so they can continue to be screened regularly. Public health departments should not only provide payment services for patients receiving pap smears under the age 65 but need to include all ages. A way to measure this is by using statistical data to see the percentage of patients still diagnosed with cervical cancer after the age of 65 because they continued receiving regular pap smears and HPV screenings.



Challenges

Two challenges of initiating these changes are being presented with two opposing arguments. First, it can be said that receiving pap smears may be too difficult for elderly patients and having the health department include cervical cancer screenings for women over the age of 64 may be an unrealistic expectation. For the first challenge, the response will be that many screenings can be difficult physically and psychologically. A study was conducted to evaluate the traumatic impact cervical cancer screening had on patients. One of the comments given by the participants was their doctor made an enormous difference in what their feelings were towards this exam. If the physician presented information clearly and with compassion, this made a huge improvement on the patient’s perception of their pap smear (Thangarajah et al, 2015).


The second challenge is to make sure health departments and doctor’s offices offer cervical cancer screenings for women over the age of 64. Typically, guidelines that are set state that women over the age of 65 with no history of abnormal cells or HPV don’t need them anymore. The guidelines also state that it is acceptable to receive a pap smear every three years and patients with a weakened immune system are more at risk for cervical cancer. This can be a foundation for improving current guidelines for patients over the age of 65 (ACOG, 2019).

Providers need to realize the impact they have on their patient’s health. According to an article called “Examining Rural Elderly Women's Gynecological Cancer Screening Practices using the Precaution Adoption Process Model” by Leigh Ann Minchew, women over the age of 65 stop pursuing their pap smears for multiple reasons. Most of the women in the research study believed they no longer needed to receive cervical cancer screenings because they had been through menopause and their sex drive had decreased. When their doctor explains to them that they no longer need pap smears because of their age and history, they assume they are no longer at risk for cervical cancer (Minchew, 2015).



Conclusion

There is no better way to improve healthcare then to fight for the betterment of healthcare policies. With some guidelines, certain groups of people may be forgotten or may not be receiving the same benefit as other populations. The healthcare policy concern is bringing awareness to the fact that the population group of women 65 and older are not having regular cervical screenings when evidence shows it is still needed. Guidelines that were given are not set in stone. They are approximations for healthcare providers to go by and can be changed if enough evidence is presented.

References

ACOG (2019) Women’s healthcare physicians. American College of Obstetricians and

Gynecologist. Retrieved from https://www.acog.org/

Centers for Disease Control and Prevention (2017). A framework for patient-centered

health assessment risks. U.S. Department of Health and HumanServices.

Retrieved from https://www.cdc.gov/

Centers for Disease Control and Prevention (2017) What should I know about

screening? U.S.Department of Health and Human Services. Retrieved from

https://www.cdc.gov/cancer/cervical/basic_info/screening.htm

Minchew, L. (2015) Examining rural elderly women's gynecological cancer screening

practices using the precaution adoption process model. Journal of Gynecologic

Oncology Nursing. 24(2), 24-34.

Thangarajah, F., Einzmann, T., Bergauer, F. et al (2015) Cervical screening program

and the psychological impact of an abnormal pap smear: A self-assessment

questionnaire study of 590 patients. Arch Gynecol Obstet, 293, 391-398. DOI:

10.1007/s00404-015-3821-z.

Yost, S. and Hoekstra, A. (2018) Cervical cancer in women over 65: An analysis of

screening. Elsevier. 25, 48-51.


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