February 20, 2001

MEDI -920 -01

TO: ALL MEDICARE PROVIDERS

SUBJECT: PAP TEST FOR WOMEN 65 AND OLDER- DISPELLING THE MYTHS

PRIMARY INTERESTS: BUSINESS OFFICE MANAGERS, MEDICAL DIRECTORS

The Health Care Financing Administration has asked Medicare contractors to publish the following information.

The National Cancer Institute (NCI) estimates that about 12,800 cases of newly diagnosed invasive cervical cancer will occur in the United States each year and that about 4,600 of the women affected will die.

Research has shown that many women aged 65 and older have not had a Pap test or pelvic exam in the past 3 years because they vastly underestimate their risk for cervical cancer, or their providers do not recommend them. The fact is that women aged 65 and older account for 25 percent of all cervical cancer cases, and for 41 percent of all deaths from cervical cancer. Pap tests can detect abnormal cervical cell changes before they become cancerous. It is one of the stated goals of Healthy People 2010 to increase to 90 percent the number of women who receive screening Pap tests and to further reduce cervical cancer deaths.

The attached alerts readers to the significance of Pap tests, discusses some of the medical myths surrounding Pap tests and women over age 65, and provides mortality and morbidity rate information.

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While controlling blood pressure and preventing bone loss are common health concerns for women ages 65 and older, getting Pap tests is not. However, statistics show that regularly scheduled cervical cancer screening also should be a priority for older women: Women ages 65 and older have the highest incidence and mortality rates for cervical cancer. They also have the lowest screening rates.

The National Cancer Institute (NCI) conducted in-depth interviews with general and family practitioners at the 1997 American Academy of Family Physicians (AAFP) Conference. The purpose of these interviews was to identify what prevents family and general practitioners from performing Pap tests on women ages 65 and older, and to create and test effective messages and communication channels to encourage physicians interest in Pap tests for women ages 65 and older.

Comments made during the interviews uncovered some "myths" that physicians believe to be true, or claim that their patients believe to be true. The following quotes are actual comments expressed during the interviews.

According to the 1996 National Institutes of Health Consensus Panel on Cervical Cancer, women ages 65 and older account for nearly 25 percent of all diagnosed cervical cancer cases and 41 percent of cervical cancer deaths in the United States. In addition, more than one-half of all women ages 65 and older have not had a Pap test in the past 3 years.

Frequently, post-menopausal women may still need to get a Pap test. It is also important to note that Pap tests should be done in conjunction with pelvic exams. Pelvic exams aid in the detection of abnormalities such as cancer of the endometrial lining of the uterus and ovarian cancer.

Since very few older women visit gynecologists, their general practitioners or internists may need to perform Pap tests or refer women to an appropriate health care provider.

Some women who are not now sexually active may still need Pap tests. Cervical cancer is caused by the human papillomavirus (HPV)—a sexually transmitted virus—which is why it is so important to screen women who are or have ever been sexually active. Keep in mind that older women who are not currently sexually active may have been infected years before. HPV can live in the body for years, even a lifetime, without any indication.

"By the time women reach age 65, a lot of them have had hysterectomies, and therefore a Pap test would actually not be very important."

Many women ages 65 and older have had hysterectomies. Some women who have had hysterectomies still need to get Pap tests. When determining whether a woman who has had a total hysterectomy should have a Pap test, the reason for the hysterectomy must be considered. If the woman had a hysterectomy because of benign problems such as endometrial bleeding or benign fibroids, then she does not need to have regular Pap tests. However, if the hysterectomy was performed because of cervical abnormalities such as cervical neoplasia, then regularly scheduled Pap tests are recommended. For women who have had supracervical hysterectomies, and therefore still have cervixes, regularly scheduled Pap tests are appropriate.

For many older women, lack of information and cost stop them from having Pap tests. Educating women about the purpose of the Pap test and why it is important to have regularly scheduled Pap tests is crucial.

Medicare helps pay for a screening Pap test once every 3 years. Medicare may pay more often if necessary. For Medicare information, call 1-800-MEDICARE (1-800-633-4227) or visit Medicare’s Web site at www.medicare.gov.

NCI’s Cancer Information Service (CIS) offers free cervical cancer information packages for health care providers. For the latest, most accurate information about cervical cancer and Pap tests, both women and health care providers can call the CIS at 1-800-4-CANCER.