The Rising Risk of Cervical Cancer in Women Over 65: A Call for Continued Screening and an Effective Screening Solution
There is a significant global gap in cervical cancer prevention for older women. Reports from public health platforms in China and other parts of Asia reveal that large numbers of older women, especially those in rural or low-resource settings, have never participated in cervical screening programs. This gap places them at high risk for undiagnosed and advanced-stage cervical cancer, with limited treatment options and worse outcomes.
Cervical cancer incidence and mortality are not negligible in older women; recent data from the World Health Organisation indicates that there were 157,182 new cases in women in this age group and 124,269 deaths from the disease worldwide in 2022.
Emerging global data has prompted a reassessment of long-standing cervical cancer screening guidelines, which often recommend ceasing routine cervical screening at age 65. While this age threshold has traditionally been based on assumptions of a history of negative test results, recent large-scale studies suggest that this approach may leave many older women vulnerable to late-stage cervical cancer diagnoses.
A large-scale study conducted in China involving over 2.1 million women found that high-risk HPV infections remain higher in this age group (13.6% vs 8%), and the age group still exhibits clinically significant rates of high-grade cervical lesions. Notably, 24.5% of these lesions occurred in this older cohort, many of whom had never been screened or had incomplete screening histories. The researchers concluded that continued cervical screening beyond age 65 is crucial, especially in populations with historically low coverage or late commencement screening.
The British Medical Journal (BMJ) also recently reported that women over 65 may be at a higher risk of developing cervical cancer compared to younger women, particularly if they have harboured latent HPV infections. Reactivation of the virus in postmenopausal women, combined with biological changes in the cervix with age, may contribute to increased susceptibility to cancer development. The BMJ's findings support a shift toward risk-based screening rather than a one-size-fits-all age cutoff.
A 2024 systematic review and meta-analysis of women aged 50 and older with normal cytology also found that the global prevalence of high-risk HPV remains substantial even in older populations, contradicting assumptions that infection risk falls sharply after menopause. A California-based population study revealed that this group is more likely to be diagnosed with advanced-stage cervical cancer compared to younger women, and they also experience significantly poorer survival outcomes.
Among women aged 60 years or older, cervical cancer mortality rates have been up to three times higher in South African regions. In either case, mortality is rare among women of any age who have regular screenings.
Existing methods struggle with screening detection in women with Type 3 Transformation Zones
Clinical data, including findings from Clinmed, show that a Type 3 transformation zone (TZ) of the cervix is difficult to assess with current visual screening methods. This limitation means that important precancerous changes can easily be missed in TZ3 cases, allowing them to progress into invasive cervical cancer before they are detected. Since most cervical precancers and cancers develop in the transformation zone, failure to properly examine TZ3 highlights a major weakness of visual screening techniques.
In high-income countries, women with a Type 3 transformation zone (TZ) are often screened using endocervical curettage to collect samples from the part of the TZ that extends into the endocervical canal. In low- and middle-income countries (LMICs), this approach is not practical because pathology services lack the resources and equipment to process such samples. Although HPV DNA testing is shifting the focus of screening toward detecting high-risk HPV infections, women who test positive still need VIA (Visual Inspection with Acetic Acid) and VILI (Visual Inspection with Lugol's Iodine) to check for pre-cancer or invasive disease. This exposes a critical gap: current visual methods cannot reliably assess Type 3 TZ. To address this, new and more effective methodologies are needed to ensure accurate detection in women with TZ3, especially in LMIC settings.
The risk could potentially be reduced by considering shorter follow-up for women with Type 3 TZ, but there are multiple barriers to ensuring reliable follow-up for such women. An acceptable, affordable, and feasible method might be a better solution to this problem, especially a method that would support the “see-and-treat.
TruScreen: World-class technology made simple
In the recent large-scale clinical trial by Xiao and Sui (2024), TruScreen demonstrated strong diagnostic performance in women with TZ3, a group that significantly overlaps with the older population. Among 1,234 women with TZ3, TruScreen achieved a sensitivity of 72.3% and a negative predictive value of 97.1% for detecting high-grade cervical lesions, outperforming both HPV testing and liquid-based cytology in this subgroup. These findings suggest that TruScreen remains effective and reliable for screening women beyond the typical age cutoff, with no evidence of diminished accuracy in older age groups.
TruScreen has a screening accuracy generally comparable to liquid-based cytology, and its strength is even more apparent in patients with type 3 TZ.
This study further evaluated the clinical performance of TruScreen for detecting HSIL, AIS, or more severe lesions in patients with different TZ types. Interestingly, TruScreen performed better in patients with type 3 TZ than those with type 1 and type 2 TZs. The reason for this phenomenon may be attributed to the fact that the TruScreen sensor could be pointed into the external cervical so and get more information from the cervical canal, which consequently improves the detection accuracy.
During a TruScreen examination, tissue is illuminated at four discrete wavelengths in the visible and infrared regions of the spectrum. Furthermore, TruScreen incorporates electrical measurements of decay curves where the rate of electrical decay is inversely proportional to the degree of abnormality on the cervix. However, for liquid-based cytology, if the external cervical os is too small or even closed, it is challenging to acquire cell samples from the cervical canal. Also, during colposcopic examination, the colposcopist cannot properly view the cervical canal and may only appraise its condition by endocervical curettage.
The excellent performance of TruScreen gives women the option of replacing liquid-based cytology screening with TruScreen in areas with limited resources.
Given these findings, experts recommend that healthcare systems adopt more personalised, risk-based screening protocols that consider screening history, HPV status, and life expectancy. Public education campaigns targeting both clinicians and older women are also critical to addressing persistent misconceptions about cancer risk and ageing.
TruScreen offers a valuable alternative for screening women over 65, especially those with cervical atrophy or Type 3 transformation zones, where traditional methods are less effective. Its ability to provide real-time, objective assessment without relying on cytology or visibility of the transformation zone makes it especially well-suited for this population, supporting continued vigilance to reduce preventable cervical cancer deaths among older women.
Citations
Kohli, K. K. (2025, July 16). Women 65+ still at heightened risk of cervical cancer caused by HPV, reveals research [News article summarizing WHO data]. Gynecology and Obstetrics Clinical Medicine. https://medicaldialogues.in/obstetrics-gynaecology/news/women-65-still-at-heightened-risk-of-cervical-cancer-caused-by-hpv-reveals-research-151361
Chen, X., Zhang, C., Zhou, Y., Liu, W., Wang, L., & Zhang, Y. (2024). High-risk HPV distribution and importance of continuing cervical cancer screening of women aged 65 years and older: A study based on 2,152,766 women in China. ResearchGate. https://www.researchgate.net/publication/393265533
Medical Dialogues (reporting BMJ findings). (2025, July 16). Women 65+ still at heightened risk of cervical cancer caused by HPV. Medical Dialogues. https://bmjgroup.com/women-65-still-at-heightened-risk-of-cervical-cancer-caused-by-hpv/
Wang, S. M., Chen, W., & Li, T. (2024). Global prevalence of cervical human papillomavirus in women aged 50 years and older with normal cytology: A systematic review and meta-analysis. ResearchGate. https://www.researchgate.net/publication/386252477
Zhou, X., Ma, Y., Nguyen, T., & Huang, L. (2023). Cervical cancer stage at diagnosis and survival among women 65 years and older in California. ResearchGate. https://www.researchgate.net/publication/366975417
Manga et al. Obstet Gynecol Cases Rev 2021, Type 3 Transformation Zone of the Cervix and Risk of Missed Lesions during Cervical Cancer Screening with Visual Methods: A Case Report from Cameroon, https://clinmedjournals.org/articles/ogcr/obstetrics-and-gynaecology-cases-reviews-ogcr-8-195.php?jid=ogcr
Xiao, F., & Sui, L. (2024). Evaluation of a real‑time optoelectronic method for the detection of cervical intraepithelial neoplasia and cervical cancer in patients with different transformation zone types. Scientific Reports, 14, Article 27220. https://www.nature.com/articles/s41598-024-78773-w
