Cervical cancer screening strategies in women 65 years and older in the human papillomavirus era: A systematic review and meta-analysis of human papillomavirus-based testing and self-sampling approaches.

backgroundCervical cancer elimination efforts increasingly rely on human papillomavirus (HPV)-based screening. However, the optimal approach to screening beyond age 65 years and the role of self-sampling in older women remain uncertain in the HPV era.

objectivesTo evaluate HPV-based cervical cancer screening strategies, including self-sampling, in women aged 65 years and older and to quantify outcomes relevant to extended-age or "catch-up" approaches. SEARCH STRATEGY: We searched major bibliographic databases for studies assessing HPV-based screening and self-sampling in women 65 years and older in the HPV era. SELECTION CRITERIA: We included studies evaluating HPV-based testing, self-sampling modalities, and age-adapted pathways in women 65 years and older. Studies meeting prespecified eligibility criteria were included in qualitative synthesis; those providing data for at least one prespecified outcome were included in meta-analysis. DATA COLLECTION AND ANALYSIS: Core studies contributing data suitable for quantitative synthesis were analyzed alongside supportive studies addressing participation, acceptability, implementation, and policy-relevant outcomes. MAIN

resultsThe search identified 3461 records; after duplicate removal, 2918 titles/abstracts were screened and 1704 full texts were assessed. Forty-five studies met inclusion criteria for qualitative synthesis, including 13 core studies eligible for meta-analysis of at least one prespecified outcome. Across the core evidence base, clinically meaningful high-risk HPV positivity and histologically confirmed high-grade lesions were observed beyond conventional exit ages, particularly among women with incomplete prior screening. A strong program-level signal was reported in a Danish catch-up initiative, where uptake was ≈62% in the intervention region versus ≈2% in the reference region, with cervical intraepithelial neoplasia grade 2 or worse detection ≈3.9 per 1000 eligible women compared with ≈0.3 per 1000 in the reference setting. Self-sampling, including messenger RNA-based approaches, appeared feasible in older women and may reduce barriers related to postmenopausal anatomy and speculum discomfort. Supportive evidence indicates that invitation design and outreach intensity substantially influence participation and downstream pathway efficiency.

conclusionsThe evidence supports recalibrating cervical cancer screening beyond age 65 years using risk-informed HPV-based strategies. Targeted catch-up testing and well-designed self-sampling pathways may improve coverage and detection of clinically relevant disease in select older populations.