Practice Links
Clinical Topic:
Screening/Prevention of
Cancer
“Cancer Screening & Prevention – 65 & Beyond”
By: Practice Committee
March 2014
Background
Preventive medicine with behavior modification and health screening has allowed people to live longer
(Bernstein, 2010). Today’s health care provider practicing with the age 65 and older population is
confronted with the challenge: when to stop cancer screening.
Cancer Screening
Colorectal Cancer – Colorectal cancer is both the third most common cancer and the third most common
cause of cancer death in the United States (Bernstein, 2010; Zoorob 2011). Incidence of colorectal cancer
increases with age, which must be balanced against life expectancy as adenomatous polyps are slow to
progress to malignant lesions (Bernstein, 2010; Zoorob, 2011). Screening is not without adverse events and
can include discomfort from the bowel prep, anesthesia reactions, colon perforation, and fatigue (Eckstrom,
2012).
1. The United States Preventive Services Task Force (USPSTF), The American Cancer Society (ACS), and
The American College of Obstetricians and Gynecologist (ACOG) recommend adults 50 years to 75,
excluding those with specific inherited syndromes (Lynch syndrome or familial adenomatous polyposis) and
those with inflammatory bowel disease receive the following (Bernstein, 2010; Smith, 2014; USPSTF, 2008):
a. Annual screening with high-sensitivity fecal occult blood test.
b. Sigmoidoscopy every 5 years with high-sensitivity fecal occult blood test every 3 years.
c. Colonoscopy every 10 years (Bernstein, 2010; Smith, 2014; USPSTF, 2008).
2. The USPSTF (2008) recommends against routine screening for adults age 76-85 years and older, and
against screening patients older than age 85.
Breast Cancer – Breast cancer is the most common cancer and the second most common cause of death
from cancer in women in the United States (Bernstein, 2010; Smith, 2014).
1. The ACS recommends clinical breast examination every 3 years and annually after age 40 (Smith,
2014). The USPSTF has found insufficient evidence that clinical breast examinations are beneficial
in women over the age of 40 (USPSTF, 2009; Zooroob, 2011). The ACOG recommends annual
clinical breast exam for all women (Bernstein, 2010). The AGS recommends periodic clinical breast
examinations (Bernstein, 2010).
2. The ACS recommends that average-risk women should begin annual mammography at age 40
(Smith, 2014). The USPSTF recommends biennial screening mammography in women age 50-74
years (USPSTF, 2009). The USPSTF does not recommend mammography in women 75 years or
older (USPSTF, 2009). The ACOG recommends mammography every 1-2 years in women age 4049 and annually in women age 50 and older (Bernstein, 2010). The AGS recommends
mammography every 1-2 years up to age 85 in women of average health and estimated life
expectancy of 5 years or more (Bernstein, 2010). The AGS recommends screening mammography in
women older than 85 years if life expectance is greater than 5 years (Bernstein, 2010).
Gerontological Advanced Practice Nurses Association (GAPNA)
East Holly Avenue, Box 56, Pitman, NJ 08071-0056 | (866)-355-1392 | gapna@ajj.com | gapna.org
3. Neither the ACS nor the USPSTF recommend self breast examination (Smith, 2014; USPSTF,
2009). The ACOG recommends breast self examination (Bernstein, 2010). The American Geriatrics
Society (AGS) recommends periodic clinical breast exams, but does not specify frequency (Bernstein,
2010).
Cervical Cancer – Cervical cancer incidence and mortality have decreased since the introduction of the
Papanicolaou (Pap) test or smear (Smith, 2014). The largest risk factor for the development of cervical
cancer is infection with certain strains of the human papilloma virus (HPV) (Berstein, 2010).
1. The USPSTF and the ACS recommend screening for cervical cancer should begin at age 21 (Bernstein,
2010). The USPSTF and the ACS also recommend after initiation of intercourse that a woman should
have a Pap smear every 3 years, even if under the age of 21 (Bernstein, 2010). The ACOG does not
recommend a screening Pap smear under the age of 21 (Bernstein, 2010). Women age 21-65 years
should receive a Pap smear every 3 years (Campos-Outcalt, 2012; Smith, 2014). The ACOG
recommends Pap smears from age 21-30 years every 2 years. Age 30 women with average risk with 3
consecutive normal Pap smears should receive a Pap smear every 2-3 years or may elect to screen with
both Pap smears and HPV testing. Those with both normal cytology and a negative HPV should be
screened no more than every 3 years (Bernstein, 2010). The American Geriatric Society (AGS)
recommend Pap screening every 1-3 years until age 70. Any older woman who has never had a Pap
smear may be screened with 2 negative pap smears 1 year apart (Bernstein, 2010).
2. The USPSTF and the ACS state that women age 30-65 years should be screened every 5 years with the
combination of HPV testing and cytology (Campo-Outcalt, 2012; Smith, 2014). The ACS states that it is
also acceptable to be screened every 3 years with only cytology (Smith, 2014). ACOG recommends at
age 30, women of average risk with 3 consecutive normal Pap smears can space Pap smears to every 2-3
years (Bernstein, 2010). Women may elect to screen with both Pap smears and HPV testing. Women
who have undergone a total hysterectomy who have never had CIN 2 or 3 should discontinue Pap
screening. Those with a history CIN 2 or 3 should continue annual vaginal cytology screening until they
have had 3 consecutive negative tests (Bernstein, 2010).
3. The USPSTF recommends against routinely screening women older than age 65 if they have had
adequate recent screening with normal Pap smears and are not at high risk for cervical cancer
(Bernstein, 2010). The ACS recommends at age 70, women with 3 consecutive normal Pap smears in
the last 10 years may stop getting Pap smears. Women with risk factors including a history of cervical
cancer should continue being screened (Bernstein, 2010). AGOG recommends that physicians
determine on an individual basis when an older woman can stop having cervical cancer screening based
on medical history and the physician’s ability to monitor the patient in the future (Bernstein, 2010). ACS
recommends assessing risk factors, such as the patient’s life expectancy, ability to undergo treatment if
cancer is detected, and ability to cooperate with and tolerate the Pap smear procedure (Bernstein, 2010).
Ovarian Cancer
Ovarian cancer is the most deadly cancer of the female reproductive tract and the fifth most common cause
of cancer death in women (Bernstein, 2010).
1. The USPSTF, the ACS, and ACOG recommend against routine screening for ovarian cancer using
either transvaginal ultrasound or CA-125.
2. The USPSTF and the ACS have no recommendation for or against bimanual pelvic exam
(Bernstein, 2010). ACOG recommends that physicians discuss with patients symptoms such as
increase in abdominal size, bloating, fatigue, pain, indigestion, decreased oral intake, urinary
frequency, constipation, or unexplained weight loss. ACOG recommends annual pelvic exams for
palpation for adnexal masses on bimanual exam (Bernstein, 2010).
Endometrial Cancer
Gerontological Advanced Practice Nurses Association (GAPNA)
East Holly Avenue, Box 56, Pitman, NJ 08071-0056 | (866)-355-1392 | gapna@ajj.com | gapna.org
Endometrial carcinoma is the most common gynecologic malignancy and the fourth most common
malignancy in older women (Bernstein, 2010).
1. The USPSTF, ACS, and AGOG recommend against routine screening for ovarian cancer using
transvaginal ultrasound or CA-125 (Bernstein, 2010).
2. The USPSTF and ACS have no recommendation for bimanual pelvic exam. AGOG recommends
that physicians discuss symptoms such as increase in abdominal girth, bloating, fatigue, pain,
indigestion, decreased oral intake, urinary frequency, constipation, or unexplained weight loss
(Bernstein, 2010). Annual pelvic exams are recommended for palpation of adnexal masses on
bimanual exam (Bernstein, 2010).
Prostate Cancer
Prostate cancer accounts for one third of new cancer cases in men, but only 10% of male cancer deaths
(Zoorob, 2011). Prostate cancer screening has not been shown to decrease prostate cancer mortality (Ilic,
2013).
1. The USPSTF has never endorsed use of the prostate specific antigen (PSA) for men of all ages
(Campos-Outcalt, 2013).
2. The ACS states that prostate cancer screening should not occur without an informed decision-making
process. Men at average risk should receive information regarding the screening beginning at age 50
(Smith, 2014). African American men and men with a father or brother diagnosed with prostate cancer
before age 65 should receive screening information beginning at age 65 (Smith, 2014). Men with
multiple family members diagnosed with prostate cancer prior to age 65 should receive screening
information beginning at age 40 (Smith, 2014). Asymptomatic men who have less than a 10-year life
expectancy, based on age and health status, should not be offered prostate cancer screening (Smith,
2014).
3. ACS prostate cancer screening after shared and informed decision-making includes serum PSA with or
without digital rectal examination (DRE) (Smith, 2014). For men whose PSA is less than 2.5 ng/ml,
screening intervals should be every 2 years (Smith, 2014). A PSA level of 4.0 or higher should be
referred for further evaluation or biopsy (Smith, 2014).
4. The American College of Preventive Medicine (ACPM) concludes that there is insufficient evidence to
recommend routine population screening with DRE or PSA (Qaseem, 2013). For African American
men and those with a family history of prostate cancer may benefit from earlier screening beginning at
age 45 (Qaseem, 2013). Men with 2 or more first degree relatives with prostate cancer before age 65
should be screened at age 40 (Qaseem, 2013).
5. The American Urology Association (AUA) recommends that men who wish to be screened for prostate
cancer should have both a PSA test and a DRE (Qaseem, 2013). This screening should be offered to
asymptomatic men at age 40 who have an estimated life expectancy of more than 10 years (Qaseem,
2013).
References
Bernstein, R., Dejoseph, D., & Buchanan, E. (2010). When to stop screening: A review of breast,
gynecologic, and colorectal cancer screening in women over age 65. Care Management Journals, 11(1), 48-57.
doi:10.1891/1521-0987.11.1.48
Campos-Outcalt, D. (2012). The latest recommendations for the ASPSTF. The Journal of Family Practice,
61(5), 278-282.
Campos-Outcalt, D. (2013). The latest recommendations from the USPSTF. The Journal of Family Practice,
62(5), 249-252.
Ilic, D., Neuberger, M., Djulbegovic, M., & Dahm, P. (2013). Screening for prostate cancer (review). The
Cochrane Library, 1, 1-51.
Gerontological Advanced Practice Nurses Association (GAPNA)
East Holly Avenue, Box 56, Pitman, NJ 08071-0056 | (866)-355-1392 | gapna@ajj.com | gapna.org
U.S. Preventive Services Task Force (USPSTF). (2009). Screening for breast cancer: U.S. Preventive Services
Task Force Recommendation Statement. Annals of Internal Medicine 151(10), 716-726.
U.S. Preventive Services Task Force (USPSTF). (2008). Screening for colorectal cancer: U.S. Preventive
Services Task Force Recommendation Statement. Annals of Internal Medicine, 149(9), 627-637.
Zoorob, R., Kihlberg, C., & Taylor, S. (2011). Aging and disease prevention. Clinics in Geriatric Medicine,
27(4), 523-539.
Gerontological Advanced Practice Nurses Association (GAPNA)
East Holly Avenue, Box 56, Pitman, NJ 08071-0056 | (866)-355-1392 | gapna@ajj.com | gapna.org