May 2010
PAP/NGC Programs Review

Nicole E. Thomas, MPH, CT(ASCP)
Lisa A. Fatheree, SCT(ASCP)

Participants in the CAP’s glass-slide interlaboratory comparison programs can send comments and questions with the education evaluations they submit at the end of each program year. The CAP Cytopathology Committee members and staff appreciate the feedback. Here we address the most common issues participants raise.

Why is the staining of the CAP slides so variable?

Laboratories across the entire United States submit slides to the CAP, and the CAP does not have any direct influence on the type or variety of stains used. Members of the Cytopathology Committee (who have diverse experience in academic and private practice) review every slide submitted and accept or reject based on diagnosis and quality of slide. Once accepted, the slides are randomly placed into slidesets that undergo a technical review every six months. While one laboratory may think that a slide appears “too green,” for example, another laboratory may think it is not green enough. Some participants have commented on the de-sire to not have any modified Giemsa slides in the nongynecologic slidesets. However, more than 50 percent of CAP nongyn laboratories use both Pap and modified Giemsa, so we meet the needs of the majority.

It’s important to keep in mind that these are educational programs. While your laboratory may not use a particular stain now, it may do so in the future. Or you may receive slides from another laboratory for review—for example, a patient now at your institution might have had previous cytologic slides prepared elsewhere, or participants may move to a new site of practice where different stains are used. We strive to ensure there are enough morphologic criteria in the nuclear and cytoplasmic details to render an interpretation.

No one in our laboratory saw the abnormal cells. Can we get the slide back so we can review it more closely?

Unfortunately, the CAP cannot return slides to you after you have shipped them back to us. Slides in our programs are in constant circulation and might become broken, lost, or retired for other reasons. We recommend that you follow the schedule presented in the kit instructions to ensure you have time to compare your interpretation to the CAP interpretation. If you believe that the CAP interpretation is incorrect, you can alert us by posting a comment in the “Contact Us” section of the CAP Web site or using the other methods listed in the kit instructions. The Cytopathology Committee will review the slide at the next committee meeting and follow up with you about your concern. If a slide is determined to be suboptimal in quality or the diagnosis is reconsidered, the slide will be removed from the program.

Can we receive more detailed educational feedback about the interpretation of the case?

We have been working to improve this, especially for the newer cases in the programs. The institution that submits the slide provides the clinical history, biopsy results, and educational comments. The Cytopathology Committee may add additional educational comments as pertinent, but it relies heavily on the information presented on the submission form. When submitting diagnostically challenging slides to our programs, we recommend that laboratories provide a rich description and as much followup information as available. Unfortunately, we do have older slides in our program for which there is less direct feedback but which are still technically acceptable and needed so that slidesets can be provided to more than 2,000 laboratories. A Web Enhancement, added last year to the nongynecologic education program, provides participants with ancillary studies such as radiographs, immunohistochemical stains, and flow cytometry reports to enrich the participant’s educational experience.

Why is there a limit to the diagnoses available for interpretation? They don’t always reflect how we sign out cases in real life.

The answer to this question is best reflected in an excerpt from the following paper: Auger M, Moriarty AT, Laucirica R, et al. Granulomatous inflammation: An underestimated cause of false positive diagnoses in lung fine needle aspirates. Observations from the College of American Pathologists Non-Gynecologic Cytopathology Interlaboratory Comparison Program. Arch Pathol Lab Med., in press. The excerpt references the nongynecologic program, but the concept of available diagnoses and real life can be applied also to the Pap education program. It reads as follows:

“It is important to remember that the CAP NGC program is not equivalent to clinical practice. Participants in the CAP NGC program might not interpret challenge cases with the same frame of mind as they might in real life. Although purely educational, the CAP NGC may put unusual pressure on the participant to perform, in particular to be more cautious not to miss a malignant diagnosis (test bias)....The slides used in the CAP NGC originate from different laboratories, resulting in varied staining techniques and preparations which may affect individual performance as well. Participants come from a variety of backgrounds and experience, including cytotechnologists and pathologists with different training experience and practices. In the CAP NGC program, [prior to 2009] cytotechnologists and pathologists must arrive at a diagnosis based upon a single slide and history, without the aid of ancillary morphologic studies, additional clinical consultation or radiological studies. It is artificial and represents a strictly morphologic approach to cytology. It is under-stood that the evaluation of these slides does not mimic daily practice and represents an educational challenge.”

While we would like to include all diagnoses for the Pap and NGC programs, it would be extremely difficult in a glass-slide program to: 1) secure all of the slides for the majority of participants to see them; 2) have inter- and intrapathologist agreement on the nonreproducible categories such as ASC-US; and 3) design the internal computer logistics in a simple manner. Hence, the more obtuse and diagnostically challenging cases are available through the online programs.

Is it possible to increase the number of glass-slide cases in each mailing?

Unfortunately, it is not possible at this time because of the current slide inventory and our limited resources. More than 2,000 laboratories and 11,000 individuals participate in the Pap and NGC education programs. Every year hundreds of slidesets are not returned on time or at all, and some slides are damaged in shipping. We rely on laboratories to submit new cases throughout the year to keep the programs strong. The good news is that the number of cases online will increase from four to five annually for both Pap and NGC programs beginning in 2011. In addition, based on participant comments and requests, all of the 2011 Pap online cases will reflect diagnostic difficulties in glandular lesions.

The 20-minute faxback doesn’t seem to be working properly. What should we do?

The 20-minute faxback is dedicated to the Pap and NGC programs. It is important to remember that only the laboratory result form will generate a faxback providing the rapid educational feedback. If the line is slow, wait a few minutes and try again. If this does not work, call the customer contact center at 847-832-4040 (press 1, then 3) (domestic) or 847-832-7000 (press 1, then 3) (international) to report the problem and, if necessary, ask for an extension with the slideset. Beginning this year, the education activity must be completed and the slidesets returned by the due date printed on the result form. CME credits can only be claimed online and participants are encouraged to submit their individual result forms online and claim CME directly. The kit instructions contain detailed information.