Factors Affecting Gynecologic and Sexual Assessment in Older Women: A Lesson for Primary Care Providers

Age-associated trends of vulvar cancer in the US

OBJECTIVE

Medical societies have over the years moved away from recommending routine pelvic examinations in older, asymptomatic women above age 65. Consequently, vulvar examination is a largely neglected component of the physical examination, unless sent to a specialist for gynecological evaluation. In recognition of these recommendations, we analyzed US trends in vulvar cancer incidence, age, and stage at diagnosis, survival, and association with human papillomavirus (HPV).

METHODS

Cases of vulvar and cervical cancer from 1992 to 2014 were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results and Centers for Disease Control's data on age at diagnosis, stage of disease, and HPV-association were analyzed and compared. Incidence and mortality rates were extracted and calculated.

RESULTS

From 1992-2014, there was a 14.3% increase in vulvar cancer rates. The absolute average incidence rate was 2.25, with HPV still being seen in vulvar carcinomas in women 65 years and above. Cervical cancer mortality rates declined by 34.2%, while vulvar cancer death rates were unchanged. We show increased intervals for cervical cancer screening is associated with later stage vulvar cancer detection. The proportion of vulvar cancer cases diagnosed in women age <50 steadily decreased, from 42.05% of cases in 1992-1996 to 19.75% of total cases in 2012-2015. Meanwhile, vulvar cancer cases diagnosed in women > 65 yo increased from 36.62% of cases in 1992-1996 to 49.82% of cases in 2012-2015.

CONCLUSION

The incidence of vulvar cancer increases with age, with the median age of diagnosis 67 years, with HPV (+) tumors occurring into 70's and 80's. Though medical societies do not routinely recommend an external genital examination in women 65 years and above, we show this is a missed opportunity to improve cancer outcomes in some older females.

Distribution of cervical lesions in young and older women

INTRODUCTION

Age range for cervical screening varies widely between countries. In addition, sexual behavior has changed, life expectancy is increasing, and new insights have been gained into the pathogenesis of HPV infection. Our aim is to evaluate the distribution of cervical lesions in young and older patients.

METHODS

Review of all cervical smears diagnosed in a public institution (2010-2017) and a private institution (2016-2017) in Madrid, Spain. We have included all women aged younger than 30 and older than 65 years with atypical smears (n = 1573).

RESULTS

Women younger than 30 years were diagnosed with ASCUS, ASC-H, LSIL, and HSIL in 47%, 5.3%, 45.17%, and 2.6% of atypical cases, respectively. Women older than 65 years were diagnosed with ASCUS, ASC-H, LSIL, HSIL, and SCC in 38%, 12.39%, 16.8%, 13.27%, and 19.5% of atypical cases, respectively. Medical records of patients from the public institution were reviewed. Of note, 76.3% of young women showed negative smears at follow-up and 14.1% showed high-grade dysplasia (HGD). Mean ages for low-grade and HGD were 24.7 and 25.7 years, respectively. HGD was found in 37.9% of women with histological examination (33.5%). As for older patients, 25% of them had no Pap smears performed before age 65, and in 60% of the previously screened women, the screening program had not been used adequately. Mean age of first smear was 69.5 years. Carcinoma was subsequently detected in 20.7% of patients.

CONCLUSIONS

Current guidelines seem to be adequately preventing carcinoma in young women. However, screening adherence should be encouraged to detect important lesions in both age groups, especially among older women.