Use Trends and Recent Expenditures for Cervical Cancer Screening–Associated Services in Medicare Fee-for-Service Beneficiaries Older Than 65 Years

Abstract

ImportanceSince 1996, the US Preventive Services Task Force has recommended against cervical cancer screening in average-risk women 65 years or older with adequate prior screening. Little is known about the use of cervical cancer screening–associated services in this age group.ObjectiveTo examine annual use trends in cervical cancer screening–associated services, specifically cytology and human papillomavirus (HPV) tests, colposcopy, and cervical procedures (loop electrosurgical excision procedure, cone biopsy, and ablation) in Medicare fee-for-service beneficiaries during January 1, 1999, to December 31, 2019, and estimate expenditures for services performed in 2019.Design, Setting, and ParticipantsThis population-based, cross-sectional analysis included health service use data across 21 years for women aged 65 to 114 years with Medicare fee-for-service coverage (15-16 million women per year). Data analysis was conducted between July 2021 and April 2022.Main Outcomes and MeasuresProportion of testing modalities (cytology alone, cytology plus HPV testing [cotesting], HPV testing alone); annual use rate per 100 000 women of cytology and HPV testing, colposcopy, and cervical procedures from 1999 to 2019; Medicare expenditure for these services in 2019.ResultsThere were 15 323 635 women 65 years and older with Medicare fee-for-service coverage in 1999 and 15 298 656 in 2019. In 2019, the mean (SD) age of study population was 76.2 (8.1) years, 5.1% were Hispanic, 0.5% were non-Hispanic American Indian/Alaska Native, 3.0% were non-Hispanic Asian/Pacific Islander, 7.4% were non-Hispanic Black, and 82.0% were non-Hispanic White. From 1999 to 2019, the percentage of women who received at least 1 cytology or HPV test decreased from 18.9% (2.9 million women) in 1999 to 8.5% (1.3 million women) in 2019, a reduction of 55.3%; use rates of colposcopy and cervical procedures decreased 43.2% and 64.4%, respectively. Trend analyses showed a 4.6% average annual reduction in use of cytology or HPV testing during 1999 to 2019 (P < .001). Use rates of colposcopy and cervical procedures decreased before 2015 then plateaued during 2015 to 2019. The total Medicare expenditure for all services rendered in 2019 was about $83.5 million. About 3% of women older than 80 years received at least 1 service at a cost of $7.4 million in 2019.Conclusions and RelevanceThe results of this cross-sectional study suggest that while annual use of cervical cancer screening–associated services in the Medicare fee-for-service population older than 65 years has decreased during the last 2 decades, more than 1.3 million women received these services in 2019 at substantial costs.

Cervical Cancer Prevention and Cost for Women Older Than 65 Years in the US—Are We Spending Too Much or Too Little?

“…Among the patients studied by Qin et al, 1 it is possible that the identified costs are going to extra testing among those who do not need it, while there may be limited or no testing among those who do require testing because of higher baseline risk.…”

“…5 However, management guidelines complicate these recommendations, as they recommend ongoing surveillance testing for all women with a history of HSIL for at least 20 to 25 years after the HSIL result because of an increased risk of cervical cancer and precancers. 5 Because the tests offered for surveillance (cytology, human papillomavirus [HPV], or the 2 tests combined) are the same as those provided for screening, knowing whether the testing is performed for screening or for surveillance is difficult; thus, understanding the appropriateness of the testing in women older than 65 years in Jin et al 1…”

“…In their informative study, Qin and colleagues study the cost of cervical cancer screening tests, colposcopies, and procedures used to prevent cervical cancer in the US using Medicare fee-for-service claims. Their results suggest that between 1999 and 2019, the use of screening tests roughly halved, and cervical procedures decreased by 64.4%, which mirrors changes in national guidelines favoring less screening.…”

“…Among the patients studied by Qin et al, it is possible that the identified costs are going to extra testing among those who do not need it, while there may be limited or no testing among those who do require testing because of higher baseline risk. Because by definition the Medicare claims database starts at age 65 years, it lacks information about prior screening history.…”

Balancing the benefits and harms of cervical cancer screening in older women

“…A recent study examined the annual use trends of cervical cancer services in women covered under traditional Medicare plans over the course of 21 years as well as the estimated cost of these services in the year 2019 1 . Among the key findings were that more than 1.3 million women older than 65 years who were covered by Medicare fee‐for‐service programs received cervical cancer screening in 2019, and this incurred a cost of more than $83 million.…”