What to tell clinicians
about the Pap test
Margaret H. Neal, MD
R. Marshall Austin, MD, PhD
A recent addition to the Laboratory Accreditation Program cytopathology checklist 08A is a phase I question that reads as follows: Is there a policy to educate providers of cervicovaginal specimens that the Pap test is a screening test for cervical cancer with an inherent false negative rate? The note that follows the checklist question says the preferred method of communication is an educational note in the report, and it mentions other possible mechanisms such as conference presentations and periodic newsletters.
Cytology is undergoing major changes in automation, technology, and molecular testing, as well as on the legal front. This question addresses the necessary role of pathologists and laboratories in the continuing education of clinicians, and, as a result, we hope, their patients. Health professionals must recognize that the Pap test is a screening test with inherent false positive and false negative rates, and in turn they must educate others. Many clinicians are in fact unaware of the limitations of Pap test screening and may benefit from up-to-date information they can share with their patients.
For example, how many clinicians are aware that the Pap test has never been proved to be effective at decreasing the incidence of cervical adenocarcinoma—or the related mortality—in screened versus unscreened populations?1,2 How many clinicians are aware that diagnostic followup studies are needed whenever suspicious signs or symptoms are evident, regardless of the Pap test screening interpretation/result findings?3 How many clinicians are aware that the sensitivity of conventional Pap test screening is up to 78 percent compared with a gold standard of cervical biopsy for HSIL and malignancies?4,5 How many are aware that a still higher sensitivity of up to 93 to 94 percent has been reported for liquid-based cytology compared with cervical biopsy?5,6 This information will continue to unfold in the published literature.
The new checklist question gives laboratories broad latitude on how to document the processes they have chosen for updating clinicians on the limitations of this screening test. Communication through letters, mailed articles, and staff seminars, for example, is as acceptable as educational notes on Pap reports. The various modes of communication have their distinct advantages, and they may in fact complement each other. Because the question is a phase I question, laboratory accreditation is generally not affected.
The purpose of this question is to help ensure that laboratories promote optimal patient care and provide clinicians with accurate and up-to-date information. In no way does it intend the policy's use as a disclaimer of legal liability. The critical need to educate clinicians is all that lies behind this question.
1. Mitchell H, Medley G, Gordon I, et al. Cervical cytology reported as negative and risk of adenocarcinoma of the cervix: no strong evidence of benefit. Br J Cancer. 1995;71:894-897.
2. Bergstrom R, Sparen P, Adami HO. Trends in cancer of the cervix uteri in Sweden following cytological screening. Br J Cancer. 1999;81:159-166.
3. Members of the Working Party on Cervical Screening. Recommendations for cervical screening 1997. New Zealand Medical Journal. 1998:111:94-98.
4. Baldauf JJ, Dreyfus M, Lehmann M, et al. Cervical screening with cervicography and cytology. Eur J Obstet Gynecol Reprod Biol. 1995;58:33-39.
5. Hutchinson MLK, Zahniser DJ, Sherman ME, et al. Utility of liquid-based cytology for cervical carcinoma screening. Results of a population-based study conducted in a region of Costa Rica with a high incidence of cervical carcinoma. Cancer Cytopathol. 1999;87:48-55.
6. Belinson J, Qiao YL, Pretorius R, et al. Shanxi Province cervical cancer screening study: a cross-sectional comparative trial of multiple techniques to detect cervical neoplasia. Gynecol Oncol. 2001; 83: 439-444.
Dr. Austin is medical director and director of cytopathology and gynecologic pathology services for Coastal Pathology Laboratories, Charleston, SC. Dr. Neal is a pathologist with Ketchum Wood and Burgert Pathology Associates, Tallahassee, Fla. Both are members of the CAP Cytopathology Committee.