APPLICATION OF PRECISION MEDICINE TO CERVICAL CANCER PREVENTION: WILL MENOPAUSAL WOMEN BECOME THE HIGHEST RISK POPULATION?
Precision medicine in which variability between individuals is taken into account is often seen as the antithesis of screening which is often presented as being an approach applied to whole populations. Cancer screening already distinguishes based on age.
We argue that (i) the upper age of cervical screening is largely expert-opinion based rather than evidence based; (ii) changing demographics (an in particular the widespread uptake of HPV vaccination in many populations) mean that the focus of cervical screening should shift towards older women; and (iii) the age for exiting cervical screening should be tailored to an individual’s risk and therefor is an application of precision medicine.
It is generally accepted that the upper age for screening in unscreened women should be higher than the age of last screen in previously well-screened women. Many cervical screening programmes and guidelines have statements about the upper age for screening or when it is appropriate to exit from screening but empirical data to justify these recommendations is minimal. What evidence that does exist is primarily from cytology based screening and it is difficult to know whether one could safely exit screening earlier after an HPV negative test (or a negative co-test) than after a cytology negative test. One thing that is widely agreed however is that if one uses HPV testing in 64 year old women, those who test positive should not simply be existed from screening. An important clinical question is what future screening/management is appropriate for a women in her mid-60s who is HPV positive and either cytologically or colposcopically normal.
More research is needed to determine how best to exit women from cervical screening in the age of primary HPV testing.