Cytology Education Under Challenge
Daniel F.I. Kurtycz, M.D.
Chair, Ad Hoc Committee on the Status of Cytology Schools
Daniel F.I. Kurtycz, M.D.
The practice of cytology and its infrastructure is under threat. New technologies and the enthusiasm they spawn may prematurely undermine a functional system and result in a serious disruption in health care delivery. Gynecologic cytology has been buffeted by many changes including Liquid Based Cytology, HPV testing, automated screening, image capture and the HPV vaccine. Due to sensational publicity about the new technologies, diminished needs for cervical screening and claims of shrinking budgets, a number of schools of cytotechnology have closed and other schools are at risk. The American Society of Cytopathology (ASC) is responding and creating a long-term plan to deal with the crisis.
The article will review the critical threats to cytotechnology education and update the reader to our Society’s response.
Authors in the professional literature and sources in the lay press have erroneously declared the end of Cervical Screening due to the introduction of the Human Papilloma Virus (HPV) Vaccine and the HPV test.1,2 At least some of these efforts appear to be driven by manufacturers and others by individuals seeking to sell a story.3 Administrators have seen the news articles and advertisements, formed opinions and questioned the continued relevance of schools of cytotechnology. Since there are never good times when people are managing budgets, resources for some schools have been removed and they have closed. Such action is very premature. The proof that HPV testing can supersede cytology is questionable, and the effect of the HPV vaccine is speculative. The literature is conflicted and in part driven by manufacturers.3 Current vaccination schemes still call for the patients who receive vaccination to undergo cervical screening when they reach maturity and begin sexual activity.4,5 Additionally we still have a generation of women who are either not candidates for vaccination, or who will receive less protection due to pre-immunization exposure to HPV. These people will need cytology services in much the same manner as currently delivered. Furthermore, organized HPV vaccination programs are just beginning and the costs are high. Vaccinating the poorest among us at over $300.00 per series is not likely in the short term. The currently available vaccines do not cover the entire range of high-risk HPV serotypes. In addition, by report, the HPV injection is painful and may reduce compliance and further reduce the effectiveness of the vaccine.6
The abandonment of the current system of screening without sufficient proof of efficacy and a nationwide consensus driven plan of institution of alternative schemes would lead to a public health disaster. The fact is that our patients will need gynecologic cytology services into the predictable future. There are estimates of a 50% decrease in the number of Pap tests in a decade due to HPV vaccines, HPV testing and changed Pap test schedules.7,8 Even with these pessimistic estimates, at a 50% decrease there will still be over 30 million Pap tests to perform annually. An additional problem with our workforce is that the average age of our cytotechnologists is nearing 50. Large numbers of our cytotechnologists are going into retirement. We could loose half of the available pool of cytotechnologists to retirement in the next decade. If we do not replace them from our schools, we will indeed have a crisis.
In the face of evolving science and technologic change, our Society has been looking very hard at the future of our profession. As we all know, the Papanicolaou test, on which we base the practice of cytology, has been one of the most successful tools in history to confront the scourge of cancer. In the span of fifty years Dr. Papanicolaou’s test has decreased the number of deaths from cervical cancer in this country from over 40,000 to less than 4,000. With its generalized use the Pap test has won favor, but the test’s well known flaws have been exposed. With over 60 million Pap tests a year performed in the US there is great economic and academic incentive to investigate the method. The statistical performance of the test has been debated since its inception, and as Dr. Andrew Renshaw has pointed out, almost always with incomplete information.9
It is reasonable to be suspicious of less than altruistic motives in companies associated with Pap test improvements or potential replacements, such as HPV testing. The Pap test itself generates over a billion dollars in this country; follow-up and therapy have been estimated to cost another four billion dollars. Any individual or company that can lay a claim to any part of that testing or follow-up, stands to do very well.
There is also great academic incentive to be critical of an established method. Attacking an established test makes one visible, enlarges a CV and may help obtain prestige and promotion. Arguing the other side, and supporting a test may also lead to publication, but tends to be done by senior people already invested and established in the method. For the younger individuals, new techniques and enhancements are easier to come by. The quality of many of our publications is open to question, despite peer review, many of these studies are small, based on opinion, and are more suited to be intra-laboratory quality assurance reports than significant publications.
Given that the practice of cytotechnology is essential for cytology services, the President of the ASC, Dr. Dina Mody, created a committee from members of the Executive Board, the Cytotechnology Program Review Committee (CPRC), and Past Presidents of the ASC, to make a rapid analysis of the problem and respond. The five charges to the committee were:
1) To craft a letter to decision makers regarding the survival of cytology schools and the position of the American Society of Cytopathology;
2) To compile a list of existing schools and determine which are under threat;
3) To investigate how each school is funded;
4) To join with other professional societies and seek to influence the sources of only those schools under threat;
5) To begin to identify possible funding sources for schools.
After initial discussion and review, the committee generated a document describing the situation and the dangers to public health caused by premature closure of these training facilities. A number of professional societies were approached, including:
American Society for Clinical Pathology (ASCP)
The College of American Pathologists (CAP)
United States and Canadian Academy of Pathologists (USCAP)
American Society for Cytotechnologists (ASCT)
American College of Obstetricians and Gynecologists (ACOG)
Papanicolaou Society of Cytopathology (PSC)
Texas Society of Pathologists (TSP)
American Society for Reproductive Medicine (ASRM)
Clinical Laboratory Management Association (CLMA)
The Association for Public Health Laboratories (APHL)
These groups concurred with the ASC’s position that cytologic analysis will still be an essential part of patient management for the foreseeable future, and co-signed the document. The letter was sent directly to six schools that we deemed were at greatest risk. A copy was sent to all cytotechnology school program directors to use as they saw fit. In addition a copy of the letter is now posted in the “Members Only” section of the ASC Web site for your consideration.
Program directors from all of the schools of cytotechnology were interviewed, and information about the status of each school was reported to the committee. We compiled a list of funding sources for each school and their administrators.
In debate it was felt that the best method that the ASC had of influencing the existing funding sources was through cooperation with other professional societies and through the literature. We need to demonstrate that cervical cancer and its precursors will not disappear overnight; that cytotechnologists generated by the schools will be necessary for the foreseeable future; and further, that loss of the schools will be a public health calamity. Ten other societies signed our document. In addition to the ASC, the American Society of Clinical Pathologists (ASCP) also posted the document on its web site.
Members of the committee have written editorials to make the medical and laboratory communities aware of the problem and to encourage individuals to engage in a scholarly effort to determine what the effect of technologic change will have on a system that has proven effective. We hope that such efforts will be critically evaluated beyond personal agendas with the goal of achieving the best result for public health in terms of infrastructure and cost.3,10
Groundwork was laid to form a permanent group to seek resources to maintain our educational facilities and to help recruit students into the field. Dr. Austin and I have contacted some public and private granting agencies, but we recognize that existing institutions have not met the needs of our schools. Central to a longer term plan, Dr. Mody has formed a Resources and Recruitment Committee for Cytotechnology Education (RRCCE) whose continuing mission is to present the facts, show the viability of cytotechnology as it adapts to the changing environment, and find mechanisms of private and public support for our schools.
In conversation with other societies, the problem of maintaining cytotechnology education facilities is seen as part of the larger difficulty of maintaining a laboratory workforce capable of delivering service as we go into the second decade of the 21st century.11
We remain worried that precipitous action on the part of administrators may cause there to be “one less” school of cytology. There may be “one less” cytotechnologist to read the sample. Ultimately, there may be more than “one less” patient cared for.
1. Rubin, R. HPV test replacing Pap smear. USA TODAY. Oct 23, 2007.
2. Miller, C.C. The cancer that shouldn’t be. Forbes.com. Jan, 28, 2008: http://www.forbes.com/global/2008/0128/072.html Accessed 2/15/08.
3. Austin, R. Marshall. Dismantling of the U.S. cytotechnology educational infrastructure is premature and carries significant risks. Arch Pathol Lab Med. 2008;132(2).
4. Chan, J.K., Berek, J.S. Impact of the human papilloma virus vaccine on cervical cancer. J. Clin. Oncol. 2007;25:2975-2982.
5. Debbie Saslow, Philip E. Castle, J. Thomas Cox, et al. (for The Gynecologic Cancer Advisory Group) and Francisco Garcia Pott. American Cancer Society guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors. CA Cancer J Clin 2007;57:7-28.
6. Personal Communication, Dr. Patricia Kokotailo, Professor of Pediatrics and Adolescent Medicine at the University of Wisconsin.
7. Eltoum IA, Roberson J. Impact of expected changes in national Papanicolaou test volume on the cytotechnology labor market. AJCP 2007;128:665-670.
8. Eltoum IA, Roberson J. Impact of HPV testing, HPV vaccine development and changing screening frequency of national Pap test volume. Cancer Cytopathol 2007;111:34-40.
9. Renshaw, A.A. Measuring sensitivity in gynecologic cytology: a review.Cancer Cytopathology Aug 25, 2002;96(4):210-217.
10. Goulart, Robert. Friedlander, Maria. Cytotechnologists today: Much more than “Pap”ologists with schools in need of our support. AJCP (in press).
11. Burton W. Wilcke, Jr.Workforce Challenges in Our Public Health Laboratory System. Labmedicine February 2007;38(2):77-80.
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