CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
May 2014—Recently I received the 2014 CAP PAPM-A (gynecologic pathology) slide set and was surprised to see case No. 5: a Pap test from an 82-year-old woman with a clinical history of “routine exam.” The cervical cancer screening recommendations from the U.S. Preventive Services Task Force recommend against screening women over the age of 65 who have had adequate prior screening and are not at high risk for cervical cancer, while the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology guidelines recommend no screening for women over age 65 with evidence of adequate negative prior screening and no history of CIN2+ within the past 20 years. They go on to further recommend that screening not be resumed for any reason in women over 65, even if a woman reports having a new sexual partner.
If we as pathologists are ignoring the recommendations set forth by these nationally recognized entities, what can we expect from our clinical colleagues charged with performing cervical cancer screening?
Harris Yfantis, MD
Chief, Anatomic Pathology Section Department of Pathology and Laboratory Medicine
VA Maryland Health Care System, Baltimore
Barbara A. Crothers, DO, chair of the CAP Cytopathology Committee, replies:
The Cytopathology Committee appreciates your feedback on the CAP Pap Education program and the discrepancy between current cervical cancer screening guidelines and the clinical history given in some of the slide sets. Some of the slides and histories in the program predate current guidelines and reflect the status of the patient at the time the Pap test was submitted to the program. Although slides in the program are replaced continually, slides of high quality that perform well, especially if they represent unusual or uncommon lesions, may remain in the program for several years. The Cytopathology Committee recognizes that not all of the slide histories are in compliance with current screening guidelines. We have recognized similar limitations with the nongynecologic programs and are updating each body system to comply with current practices. This includes adding enhancements such as immunohistochemical studies and flow cytometry results along with revisions of diagnostic terminology. The committee ensures that newly accepted slides in both programs reflect current standards, but it may take time before all of the older slides are replaced. Slides in the program typically have a life span of two to three years.
Since you have brought this case to our attention, we will evaluate the slide for appropriateness in the program and remove it or make changes in the clinical history appropriate to current guidelines. While it would be unusual for women over age 65 to be screened today, the ASCCP guidelines do recommend that women with a prior history of a high-grade squamous intraepithelial lesion (HSIL) or cancer continue to be screened after age 65, since they remain at risk for invasive squamous cell carcinoma. As with any test, there may be valid reasons to perform testing outside of established guidelines.
The CAP recognizes and supports the current guidelines for cervical cancer screening and issued a statement on Nov. 16, 2012 supporting recommendations issued by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology. This statement can be found on the CAP Web site.
The Cytopathology Committee has developed a program, Fields of View (FOV), to educate participants on the appropriateness of cervical cancer screening and Pap test follow-up guidelines. These are digital slides that are accessible online and not susceptible to breakage or fading. They contain more detailed history than is currently allowed in the glass slide program. Lengthy explanations are provided regarding the appropriateness of screening and followup.