Cytopathology in Focus: Why not call everything ASCUS?

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Of course not.

Every test (including HPV tests) has innate limitations. Pathologists know that. It is the combination of tests that often provides the most convincing evidence of disease.
The beauty of the Pap test is that it can do so much with so little: indicate hormonal status, diagnose infections, evaluate the background microbiome, detect and diagnose dysplasia and cancer. These are akin to cellular biopsies. And, like so much in cytology, it is relatively inexpensive—a lot of information at low cost.

It is unfortunate that our society tends to value high-priced, highly technical processes, but such processes don’t always equate to better health. Look at the re-emergence of organic farming as a healthy alternative; these are ancient ways of food production but they generally provide for better nutrition than commercial agricultural methods.

Primary HPV testing has not been uniformly embraced in the U.S. and it may be because colposcopists are aware of the limitations of colposcopy. The U.S. is a litigious country. Now it will become the gynecologist’s responsibility to detect and biopsy disease in women with a positive HPV test. All of the pathologists who lived in the litigation era are well aware of the high cost of a “missed” Pap test. We are about to enter the era of the “missed” colposcopy test. I predict that the burden of malpractice will begin to swing to the colposcopist, who was somewhat protected when the Pap test could be the target of the claim, but what of the positive high-risk HPV test and negative colpo/biopsies? A negative biopsy will be clear proof it wasn’t an interpretive error; the colposcopist will be held accountable for missing the disease. Add to that extended intervals between HPV testing without a national screening program and we have a potential recipe for disaster.

While it is easy to be glib about tossing out a test that has the best and only true track record for preventing cancer, one should consider the potential ramifications, especially for those of us with mothers, wives, sisters, and friends we love.

1. 1. Parks M, Wang DC. Multiple colposcopy biopsies may improve cervical cancer precursor detection. 2 Minute Medicine website. http://​bit.ly/2JxbCFu. Published Nov. 28, 2014.
   2. Nogrady B. Multiple biopsies increase sensitivity of colposcopy. Oncology Practice website. http://bit.ly/2Np30TF. Published Nov. 24, 2014.
   3. Wentzensen N, Walker JL, Gold MA, et al. Multiple biopsies and detection of cervical cancer precursors at colposcopy. J Clin Oncol. 2015;33(1):83–89.
   4. Massad LS, Jeronimo J, Katki HA, Schiffman M; National Institutes of Health/American Society for Colposcopy and Cervical Pathology Research Group. The accuracy of colposcopic grading for the detection of high-grade cervical intraepithelial neoplasia. J Low Genit Tract Dis. 2009;13(3):137–144.
   5. Apgar BS, Kaufman AJ, Bettcher C, Parker-Featherstone E. Gynecologic procedures: colposcopy, treatments for cervical intraepithelial neoplasia and endometrial assessment. Am Fam Physician. 2013;87(12):836–843.
   6. Yang B, Pretorius RG, Belinson JL, Zhang X, Burchette R, Qiao YL. False negative colposcopy is associated with thinner cervical intraepithelial neoplasia 2 and 3. Gynecol Oncol. 2008;110(1):32–36.
   7. Pretorius RG, Zhang WH, Belinson JL, et al. Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol. 2004;191(2):430–434.
   8. Burger EA, Kim JJ. The value of improving failures within a cervical cancer screening program: an example from Norway. Int J Cancer. 2014;135(8):1931–1939.

Dr. Crothers is president of the American Society of Cytopathology. She is the past chair of the CAP Cytopathology Committee and associate professor, Uniformed Services University of the Health Sciences, Bethesda, Md.