RECENTLY, there have been newspaper headlines about a cytotechnician who "missed" recognizing abnormal cells on Pap smears from two cases of cancer of the cervix. The patients died from cancer. Despite errors, Pap
smears are necessarySuffering and pain to the patients' family and relatives will be assumed. There will be allegations of carelessness, incompetence, inadequate training and lack of supervision, to name a few.
Litigation will follow. The cytotechnologist and those around her in a supervisory capacity, including the cytopathologist(s) and possibly the institution(s), may also be named in the lawsuit.
Is there any more to be said? Yes, a lot.
These cancer deaths are tragic. However, doctors are very concerned about the general misunderstanding that the screening procedure is perfect. It is NOT.
But the tests do save lives, and women should continue to be tested regularly. Since the Pap test was introduced on a wide scale in the 1950s, the rate of advanced cervical cancer has decreased by 70 percent.
Nationally, the average detection rate is about five cases in 1,000. With double screening, the number of detections rises by two or three cases. If the incidence is 10 cases in 1,000, there are two to five cases missed for every 1,000 examined.
The procedure sounds deceptively simple: The clinician takes the sample and prepares a smear. It is sent to the cytology facility, where technical staffers stain and review the cells, then report their findings as normal or abnormal.
Abnormal findings are reviewed by specially trained cytopathologists, generally together with the technicians. Appropriate recommendations to clinicians are then made to treat the inflammation or to take a biopsy.
The erroneous "misses" are sensationalized in the news, but there are instances where the positive slides are not confirmed initially. We have to obtain the tissue and make serial sections to find the presence of a tiny area of malignant change only several millimeters in size.
The site from which the smear is taken is the cervical-endocervical junction. This is the location where non-cancerous tissues commonly can become inflammed and repair themselves. To distinguish these changes from those that occur with early malignancy is often difficult.
An adequate smear contains anywhere from 300,000-500,000 cells. Often there may only be a few abnormal cells scattered on the smears.
The study is time-consuming and contributes to fatigue and stress in the examiner. Efforts to reduce the effects of distracting influence have been attempted by reducing the volume of cases screened and by adding breaks after each hour.
Competition between labs has definitely played a role in keeping the charges low. At present, the charge is $21.84. Most insurance companies pay less. Medicare recently increased its payment from $7.15 to $7.37. HMSA still pays $10.06.
The cost of screening by cytotechnologists has escalated because of substantial reduction of cases, work hours and days. Instrumentation can improve screening but, being expensive, it does not lower the cost of operation.
How about the cytopathologists? Under consideration somewhere was a figure of $40,000 annually for malpractice insurance premium. Is cytological study affordable? At the present rate of reimbursement, large entities lose millions of dollars annually. If not, is this the beginning of the end of this study?
This must not happen. Cervical cancer screening is too important to too many women.
"Imperfect" cervical cancer detection cytology is in jeopardy mainly because of cost, poor reimbursement and threat of litigation.
Consider, though, what these tests have accomplished: the substantial lowering of the incidence of advanced cervical cancer.
Paul Y. Tamura is a semi-retired
Honolulu pathologist who acts as a consultant for
several testing laboratories.