Message from the ASC President

What an honor it is to have been elected to the presidency of the American Society of Michael Henry - ASC PresidentCytopathology. This organization has been central in my professional life for almost 30 years. Many of my friends and mentors have been Presidents of the ASC, and I feel extremely privileged to join their ranks. The ASC has grown and changed significantly since I first joined right out of residency. Over the years these changes have strengthened the organization and put it on a path, which should lead to continued success. As an example, it is interesting that my presidency came from changes made many years ago when we moved to a competitive election for officers, which allowed the members to select from at least two nominees rather than a single candidate. While I did not win the first time I was nominated, I became part of a growing group of well-qualified members with experience and expertise who could be tapped by the Nominating Committee for possible election. Overall, these electoral changes have resulted in a stronger electoral process and demonstrated the wisdom of the Officers and Members who made the changes.

Change and innovation are integral to the message I want to convey in this letter to the ASC membership. All of the messages written by the last several Presidents have talked about the changes that medicine is undergoing and how they may affect the field of cytology and the ASC. We live in an exciting and sometimes uncertain time of growth, new knowledge and innovative techniques, many of which will transform the way we practice medicine. Transformational forces come not only from the scientific side but also from the regulatory and business side of medicine. We are moving away from private practice – fee for service medicine – and no one is sure where this will lead. It is certain, however, that for the foreseeable future cytology will be a valuable part of diagnostic and therapeutic medicine.

The field of cytopathology is unique. In an age when most of pathology is subspecializing into smaller and smaller areas of expertise, cytology remains a generalist field. Cytologic specimens are derived from the entire gamut of tissue and disease. The range of specimens that we utilize is vast, derived from fine needle aspiration, fluids, brushes, washes, core biopsies or any other technique, which yields small tissue samples. To be a good cytopathologist requires knowledge that spans across all of the anatomic pathology specialties and even many of the clinical areas. This generalist background is one of the strengths of cytopathology, which will keep us relevant far into the future. But at the same time, we will need to work to keep this relevance and not let some of these collection techniques become the provenance of subspecialists.

Collaborative efforts between the ASC and other pathology and medical organizations will be necessary to move our agenda forward on a national basis. Under the leadership of our most recent Past Presidents we now have working arrangements or memorandums of understanding with many of the national pathology and other medical organizations. We will continue to make overtures with these and other organizations to collaborate in areas where it makes sense. We are the repository of vast experience in cytologic methods, diagnostic techniques and education. The ASC must be involved with any organization that is making decisions or recommendations where cytology is concerned.

In 2012, under the leadership of Dr. Lydia Powell the ASC Executive Board (EB) developed a new Strategic Plan, which was implemented along with an updated vision and mission statement. This Strategic Plan contained specific goals and benchmarks as well as strategies to accomplish them. Most recently, at the last Board Meeting the EB reviewed the plan to see how well we have accomplished these goals and to write new ones as appropriate. My next President’s Blog will detail the results of this review.

Finally, there are a couple issues that are foremost in my mind and that will need to be addressed in the near future. These are the future role of the cytotechnologist in the laboratory and the role of cytopathology in the field of molecular testing.

The Future Cytotechnologist

We know that primary GYN screening using Pap tests will continue to decrease. During the past year the long anticipated clearance for primary HPV testing with cytology as the reflex test was approved by the FDA. While this is concerning to many in the field, there has been no rush to start this testing on the part of primary care clinicians. As with most new techniques, this type of testing will slowly work its way into the field; and it is still unknown how quickly it will be accepted.

We have known this was coming for some time. The ASC and other organizations are already looking at how the field of cytotechnology will and should evolve as Pap screening becomes a smaller portion of the work cytotechnologists perform. At this year’s Annual Scientific Meeting, the CPRC presented the results of meetings to develop a professional scope of practice for a proposed mid-level pathology practitioner for the field of cytopathology. Over the next year we will work with the CPRC, ASCP, CAP, and ASCT on this concept, especially directed to determining the need for this type of practitioner through a detailed practice analysis. In the meantime, we will also look at how to help current cytotechnologists transition to new technologies from their primary screening roles.

While we still do not have a clear idea of the cytology workforce over the next several years there are worries that the cytotechnologists are aging and that given the small overall numbers in the profession a workforce deficiency is certainly a possibility. There is already a definite shortage of laboratory professionals in areas such as histotechnology and molecular biology and with the steadily decreasing number of cytotechnology schools, now down to only 25 active programs, cytotechnology may also be facing a similar shortage. The recent partnership with the ASCP, ASCT and CAP to provide membership to the CPRC as well as the development of the Cytology Education Learning Lab (CELL) will help to develop the new curriculums that will be needed to provide the innovative education for our cytotechnology students.

I would like to finish this section by talking about the role the Mayo Clinic has taken in redefining the practice of cytotechnology. Over the past 15 years, we have pioneered the use of cytotechnologists to perform many somewhat non-traditional tasks. We have leveraged the cytotechnologist morphology training to utilize them in the screening of FISH cases on cytologic preparations, digital analysis of breast prognostic markers on tissue, analysis of circulating tumor cells and most recently initial review of tissue for molecular studies. This is in addition to the more traditional roles of on-site evaluation of FNA specimens and screening of non-GYN cytology. We have moved away from GYN screening as the primary CT role as our numbers of GYN Pap tests have decreased. Currently, Pap screening involves less than 10% of our technologist workload but we have actually increased the number of cytotechnologists needed to support the laboratory’s needs. We have found that all of this has made economic sense for our laboratory as it has freed up the pathologists to do their job more efficiently. Will this work in other settings? I don’t know the answer to that, but I do believe that as the business of pathology changes, this type of innovative use of qualified cytotechnologists will become more common.

Cytology and Molecular Pathology

We are currently entering a new era of medicine based on molecular techniques used for diagnosis, therapy and the monitoring of treatment response and disease progression. As I mentioned above, the field of cytopathology is unique in the breadth of specimens that we handle and utilize. Many of these specimens can and are being used for molecular testing of many types. This past year the ASC worked closely with the Papanicolaou Society of Cytopathology (PSC) to develop a joint position statement on the use of molecular testing on cytologic specimens. This position statement was approved by the ASC Executive Board at the Annual Scientific Meeting in Dallas. Over the next year the two organizations are also writing a white paper on molecular testing on cytologic specimens that will flesh out the details on many of these techniques and how they can be applied to our practice.

It is obvious that multidisciplinary collaboration will be needed in the effective utilization of these molecular techniques in cytologic specimens. Many molecular tests need to be performed in specialized laboratories and the cytopathologist will be the intermediary between the clinician collecting the sample and the performing laboratory. In those instances cytopathologists and cytotechnologists are well placed to work with clinicians to determine the on-site adequacy of specimens and determine the appropriate triage for the most effective use of small samples. Other molecular tests such as FISH analysis can be performed directly on cytologic preparations such as is currently done for urinary tract cytology and biliary or esophageal brushings. In my opinion, these samples are best interpreted by cytotechnologists trained in FISH techniques. Their morphologic experience in interpreting cytologic preparations makes them the obvious choice to select the appropriate cells for FISH analysis on smears or liquid based preparations.

There are more challenges because of the broad gamut of our tissue samples. We not only have tissue fixed in formalin and paraffin embedded (FFPE) but have samples that are fixed in alcohol and smeared or prepped as thin layer samples. As noted in the position statement: “Given the versatility of cytopreparatory techniques, the development and careful validation of molecular assays for these platforms is important.” The next several years will be a time of growth and greater understanding of which molecular techniques have clinical importance and how we as cytopathologists and cytotechnologists will fit into this burgeoning field. It will be vitally important that the ASC takes a primary role making sure our members are ready to move into the molecular era.

In summary, these are fast changing and exciting times full of challenges to our membership. I will be working with the Officers, Executive Board and the Committees to ensure that the ASC will continue to move in a positive direction to meet these challenges. My challenge to the ASC Members, Officers and Committees is to take the ASC vision to heart and look for innovative ways to grow/move the ASC forward in these turbulent times. Let me know about your ideas. While the Officers, Executive Board and Committee leaders have a wealth of knowledge and expertise, we don’t have all of the answers or specific ideas for projects, educational tools or new ways of doing things. Your contributions can be large or small; it doesn’t matter as long as you are an active participant in the organization. Volunteer – we are always looking for new members to add to the committees or other activities but we can’t use you unless we know who you are. Forms for volunteers are located on the ASC Web site. You are never too young or inexperienced so don’t be shy. We all started somewhere and who knows, someday you may be writing this message yourself.

Michael R. Henry, MD

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ASC: The 2014 Year In Review

Ritu Nayar, MD, Immediate Past PresidentRitu 2013
Chicago, Illinois

It has been my honor to have served as the ASC President in 2013-2014. I would like to take this opportunity to review where the ASC is today, and what we accomplished together in the past year.

In 2012-13, the ASC Executive Board, under the leadership of Drs. Lydia Howell and Andrew Renshaw, defined an updated Strategic Plan that identified our:

  • ASC Vision Statement: Saving Lives One Cell at a Time through Innovation, Teamwork, Education, Advocacy;
  • ASC Mission Statement: ASC promotes education, innovation, advocacy and professional ethics by the cytopathology team to achieve the best healthcare for individuals and communities worldwide;
  • Strategic Goals (chosen to work toward our mission and vision): The ASC identified 7 major strategic goals (membership, education, advocacy, organizational, quality and research) and a number of strategies to meet these goals; and
  • Volunteers: Our member volunteers who serve on ASC committees and as representatives to other organizations are key in identifying ways to accomplish these strategic goals.

Last year when I addressed the Society as incoming President, I talked about the “State of the Nation’s Health Care” as it pertains to our profession and its physician and cytotechnologist members.1 The basic challenges we are facing in the rapidly evolving healthcare arena are not unique to pathology or cytopathology, namely an evolving health care delivery system with rapidly emerging theranostics, along with workforce shortages and economic pressures. I based my priorities for the past year on the evolving health care dynamics that affect our specialty/ practitioners and the support of our ASC member needs as assessed by surveys and personal communications. In 2014, I chose to concentrate more specifically on practice changes relevant to cytopathology and the 3 strategic goals of membership, education and advocacy.

I am a firm believer in teamwork. With professional organizations, there is more that unites than divides us – we are all working towards bettering our profession, raising the standard of practice and improving patient care. Over the past year we have formalized several new collaborations and continue to foster prior ones, in order to ensure that ASC participates as a partner in organized leadership, and can proactively associate with the right efforts to advocate for our profession.

  • Association of Pathology Chairs (APC): In December 2013, the ASC joined the Pathology Collaborative Roundtable implemented by APC with the aim of facilitating networking and communication and promoting synergistic planning about issues and joint initiatives of high priority to our profession.
  • College of American Pathologists (CAP): A Memorandum of Understanding was signed between ASC and CAP in April 20142
  • American Board of Pathology (ABP): In August 2014, the ASC was approved as a cooperating society of the ABP, a member of the American Board of Medical Specialties.3
  • American Society of Clinical Pathology (ASCP). We continue to increase collaboration under the umbrella of the MOU signed with ASCP in 2012.4
  • Cytotechnology Programs Review Committee (CPRC) is a CAAHEP Committee on Accreditation for Cytotechnology training programs. In 2011, the ASC who sponsors the CPRC, welcomed ASCP, ASCT and CAP as co-sponsors; however ASC still remains the majority (50%) sponsor.
  • Cytopathology Education and Technology Consortium (CETC): The ASC collaborates with ASCP, American Society for Cytotechnology (ASCT), CAP, International Academy of Cytology (IAC), and the Papanicolaou Society of Cytopathology (PSC) on the CETC; ASC also provides the CETC’s administrative leadership support. The history of the CETC is rich and interesting; I refer you to the September 2013 issue of The ASC Bulletin to read about its accomplishments on behalf of cytopathology.
  • Other collaborative efforts have involved various other pathology and non-pathology organizations as detailed below.

PRACTICE CONSIDERATIONS

Cervical Cancer Screening
Since 2002, with increasing use of high risk HPV testing, we have seen shifts in cervical cancer screening and management guidelines, with movement from screening with cytology only to co-testing with cervical cytology + HPV and in April 2014, approval of HPV as a stand-alone option for screening. While all 3 strategies remain as current options for screening in the United States, the impact on cytopathology and cytotechnologists has been significant with respect to the volume of gynecologic cytology.

The ASC and its volunteers actively participated in the development of the 2012 ACS/ASCCP/ASCP screening guidelines. 5 In December 2013, the CETC published an updated HPV Test Utilization Statement in several journals. 6 At the March 2014 FDA hearing for pre-market approval of the Roche Cobas test for HPV Primary Screening, the ASC led the effort on behalf of the CETC to submit a written and verbal statement to the FDA advisory panel.7 The CETC raised concerns that included the use of laboratory-developed HPV tests, quality-control, specimen adequacy, and HPV-negative cancers. Our membership has been regularly kept informed about the laboratory considerations for HPV Primary screening via the President’s Blog 8 (LINK) and publications.9 At the ASC 2014 Annual Scientific Meeting, we organized a “Hot Topic” session entitled “Primary HPV Cervical Cancer Screening – Pros, Cons and Implications for Clinical Practice.”

Interim guidelines for HPV Primary screening in the United States, prepared by a task force appointed by the Society of Gynecologic Oncology (SGO) and the American Society of Colposcopy and Cervical Pathology (ASCCP), will be published in early 2015. 10 Drs. Diane Davey and Robert Goulart served as the joint ASC-ASCP-CAP representatives to this task force, and contributed the laboratory perspective for this guidance document. At this time it is not known when other professional societies, including the ACS and USPSTF, will issue updated guidelines for cervical cancer screening. Currently, cytology only testing, as well as co-testing, are being used variably in different age groups for cervical cancer screening. Any future adoption of primary HPV testing will most certainly require time and ongoing monitoring of clinician acceptance, patient compliance, in addition to cost-benefit and outcomes analysis.

Since mid-2006, the Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of adolescent girls at ages 11 or 12 years with 3 doses of human papillomavirus (HPV) vaccine. The uptake has been low in the United States (only 37.6% adolescent females had received all 3 doses in 2013) compared to countries with organized screening programs. Vaccine cost/availability/ insurance coverage, patient /parental consent and social norms and values have all contributed to this.

In September 2014, the ASC released a new Cervical Cancer Screening Position Statement.11
The ASC and its membership are committed to supporting women’s health and working collaboratively with other pathology and clinical professionals to effectively prevent cervical cancer in the United States. The ASC supports innovations in technology and changes in testing and management based on scientific and clinically‐validated advancements. However, realizing that cervical cancer screening in the United States (a) remains opportunistic, with far from uniform test accessibility and patient compliance, and (b) 50% of cervical cancers diagnosed in the U.S are in women who were never screened, and an additional 10% of cancers occur among women not screened within the past five years, we believe that further improvement in cervical cancer prevention and mortality can only be obtained by screening everyone and HPV vaccination.

Ancillary/Molecular Testing
We have all witnessed the recent explosion of personalized medicine options that are becoming available in medical practice. As cytopathology practitioners, we are uniquely positioned as a crucial member of the multidisciplinary team charged with triaging patient cytologic samples for appropriate, and clinically relevant molecular diagnostic assays. It is essential that we engage relevant stakeholders in our respective institutions to allow for the judicious and effective integration of molecular ancillary testing with cytopathology specimen acquisition, processing, and analysis in order to ensure timely and appropriate patient management. The ultimate goal of these multidisciplinary efforts is to devise “best practice” approaches for cytologic specimen acquisition and processing.

In November 2013, I approached the Papanicolaou Society of Cytopathology (President, Dr. Zubair Baloch) to collaborate on “The Role of Molecular Testing in Cytology Specimens”. The appointed ASC-PSC Task Force (Chairs: Drs Michael Roh and Amy Clayton) formulated an ASC-PSC Joint Position Statement that was released on November 10, 2014.11 The group will continue to work on a “white paper” to provide guidance to practitioners dealing with FNA and small biopsy specimens for molecular testing.

In August 2014, in conjunction with the leadership of the Association for Molecular Pathology (AMP), I formally appointed an ASC-AMP liaison (Dr. Anna Berry) to coordinate efforts with respect to molecular testing on cytology and small biopsy specimens.

Needs Assessment – Data Collection
In 2014, the ASC Clinical Practice Committee (Chair, Dr. Christine Booth) was charged with surveying the membership on cellblock practices and assessing non-gynecologic practice patterns (done in conjunction with the ASCT). The latter will be available in a future issue of The ASC Bulletin for your review. Through our collaborations with ASCP and CAP, we are also planning collection and analysis of additional data relevant to our professions needs assessment.

Reporting Terminology
As anatomic pathologists and laboratorians, we serve as consultants to our clinical colleagues and patients and our pathology reports are the official basis of our communication. Therefore, it logically follows that our reports should clearly communicate the pathology findings in a predictable and reproducible manner so that patient management options can be correctly tailored by the clinician. This past year, the ASC has led the following two major terminology projects, both of which allow(ed) ample time for national and international public comments on proposed outlines.12

  • The Bethesda System for Reporting Cervical Cytology – ASC Bethesda 2014 Task Force
    The cervical cytology Bethesda System (TBS) terminology effort, initiated in 1988, led the way for standardized reporting in cytopathology. In the past decade, considerable experience has been gained with the use and impact of the Bethesda terminology for cervical cytology in clinical practice. Thus 2014 seemed to be the appropriate time for a review and update of the 2001 Bethesda System with incorporation of revisions and additional information into a third edition of the Bethesda Atlas. Since minimal changes were anticipated in terminology, there was no consensus meeting held in association with the 2014 update. Therefore I appointed a task force, chaired by Dr. David Wilbur, comprised of a relatively small group of cytopathologists, cytotechnologists and clinicians/epidemiologists in order to expeditiously accomplish this task. The atlas was completed and submitted to Springer in October 2014; publication is expected in spring of 2015. Another Bethesda Task Force, led by Drs. Daniel Kurtycz and Paul Staats has begun working on a companion web site for the updated (2014) Bethesda System for Reporting Cervical Cytology.
  • Urinary Cytopathology ASC/IAC Urine Cytology Terminology Task Force
    We know that pathologists actively and non-reproducibly use the terminology “suspicious,” “indeterminate” or “atypical,” which causes confusion for clinicians and patients. Despite two well established pathways and prognostic categories for urothelial carcinoma, the cytologic terminology for urinary cytology remains disparate and complex. Drs. Wojcik and Rosenthal took the initiative to streamline this and approached me and Dr. Vielh, President of the IAC, to have ASC/IAC co-sponsor an effort to develop a standardized terminology for reporting urinary cytology specimens, modeled after the cervical and thyroid Bethesda systems – The PARIS System. The group has been working actively within and outside the United States, and has presented the proposed terminology at a number of national and international conferences. A print atlas and corresponding web site are in development with publication expected in May 2016.

Practice Guidelines and Position Statement Updates
The ASC is the premier medical society dedicated to the practice of cytopathology, and as such its leadership recognizes the need for the ASC to take a position on issues of importance to the profession or the association and have policies, guidelines, position statements and recommendations for its members, other professionals and patients.

Over the past year, the ASC Guidelines & Position Statements Review Committee (Patricia Wasserman, MD, Chair) has diligently updated the Society’s Standard Operating Procedure for review of ASC Position Statements and Guidelines, created a “roadmap” to guide reviews, and worked with content experts on updating existing guidelines and formulating new position statements. All policies, guidelines and position statements are opened to the membership for a two week comment period before finalization and are then approved by the Executive Board before posting on the ASC Web site. The ASC has also decided to publish commentaries to accompany its position statements and guidelines.

The following new/updated position statements and guidelines have been approved and posted on line in 2014. 11

  1. Position Statement on Cervical Cancer Screening and Prevention
  2. Position Statement on Rapid On Site Evaluation (ROSE)
  3. Position Statement Regarding State Licensure for Cytotechnologists and Guidelines on State Licensure for Cytotechnologists
  4. ASC/PSC Joint Position Statement on the Use of Molecular Testing on Cytologic Specimens

A Commentary on Cervical Cancer Screening and Prevention was published in The ASC Bulletin, July 2014, and those on commentaries on ROSE and State Licensure for cytotechnologists will follow in our journal, JASC.

Legislative/Regulatory and Reimbursement Issues
We owe a great deal of thanks to the ASC Government Affairs and Economic Committee (GAEC) Chair and AMA Delegate (Dr. Margaret Havens Neal) and our representatives to the AMA RUC (Dr. Swati Mehrotra) and CPT (Dr. Carol Filomena) Committees. It was not until this year that I fully understood the immense time and effort that is spent participating in these committees on behalf of our specialty. I spoke about the process in greater detail in my August 2014 President’s Blog. To support these representatives, in March 2014, I appointed the new ASC AMA-CPT-RUC subcommittee comprised of the ASC officers, chair of our GAEC and the 3 AMA representatives.

In 2014 the ASC participated and represented cytopathology in conjunction with the CAP at the following AMA meetings.

  • AMA Pathology Section Council
    The ASC has a seat in the AMA and our delegate(s) participate in its Pathology Section Council. In 2013-14, a number of issues of importance to pathology were discussed and supported- Network Adequacy, Electronic Health Records-and Meaningful Use, Genetic Testing, Practice Costs across Sites of Service, Opposition to Insurance Company Policies that Interfere with Appropriate Outpatient Laboratory Services, Overregulation of Provider-Performed Microscopy Procedures for Ambulatory Health Care, Facilitating State Licensure for Telemedicine Services and revisions to the AMA Code of Medical Ethics .
  • The AMA Current Procedural Terminology (CPT) and Pathology Coding Caucus (PCC)
    One of the Advisory Committees’ primary objectives is to serve as a resource to the CPT Editorial Panel by giving advice on procedure coding and appropriate nomenclature as relevant to the member’s specialty. The Pathology Coding Caucus (PCC) is a partnership of the AMA and other pathology and laboratory groups, which develops consensus recommendations on proposed new and revised CPT codes prior to consideration by the AMA CPT Editorial Panel. ASC in collaboration with other pathology and laboratory groups contribute regularly to PCC deliberations as part of the work of the AMA CPT Advisory Committee. The majority of the discussions this year focused on Molecular Pathology codes.
    There are no new codes in the 2015 CPT Manual in the Cytopathology section.  The CPT 2015 will include HPV testing (87623, 87624, 87625) and revised immunohistochemistry codes (88342, 88341 and 88344).
  • The AMA/Specialty Society RVS Update Committee (RUC)
    The RUC’s mission is to make recommendations to the Centers for Medicare and Medicaid Services (CMS) regarding the Medicare Resource-Based Relative Value Scale. At the April RUC meeting 2 sets of cytology codes underwent review at the Practice Expense Subcommittee (88104-88106 and 88160-88162 family). The recommendations made by the ASC in conjunction with College of American Pathologists (CAP) were accepted with minor modifications by the RUC.
  • 2015 Physician Pay Schedule (PFS)
    On October 31, 2014, the 2015 Final Medicare Physician Fee Schedule was released.13 Several new policies in the 2015 Medicare rule were a direct result of professional society advocacy. Under CAP’s leadership, the ASC participated actively in the AMA, RUC and CPT process. Evaluation of specifics of the rule and development of appropriate action plans for pathology are ongoing. To address CMS concerns that immunohistochemistry codes were overvalued, review and refinement of the coding and reimbursement for immunohistochemistry codes has been a priority over the last few years and through efforts of multiple pathology organizations, CPT, and the RUC. For 2015 CMS has accepted those revisions, and abandoned use of the G codes that have been in effect for 2014. The revised codes will eliminate confusion between Medicare and non-Medicare payers, and allow for revaluation of the initial single antibody stain procedure as well as for each additional single antibody stain procedure when necessary. A separate code for multiplex procedures was also approved. In the Final Rule CMS “packaged” the technical components of roughly 200 physician services, including 30 pathology services into the hospital’s reimbursement for services provided in the hospital outpatient department (HOPPS) and in ambulatory surgical centers. Relevant to cytopathology are: 88305, 88173 88312, 88342, 88120/21, 88360/61.
  • Scope of Practice for Cytotechnologists
    The ASC has been working with ASCP to enhance the cytotechnologist’s scope of practice in California so that it parallels the scope of practice of cytotechnologists elsewhere in the United States, to revise the regulations for laboratory personnel, including the provisions related to the ability of cytotechnologists to perform molecular testing.

MEMBERSHIP

Workforce Consideration
Some areas of laboratory medicine have had a shortage of qualified non-physician personnel for the last several years as documented by professional societies and based on personal communications.14 Pathology and Laboratory Medicine also have an aging workforce, and recruitment, training and funding challenges. I participated in the Multisociety Pathology Workforce Summit organized by CAP, APC, ASCP, and USCAP in December 2013. The aim was to articulate the broad strokes of a statement of workforce needs in pathology and laboratory medicine suitable for sharing with health policy decision makers and key stakeholders. The focus will be on changes in training (and recruitment) of pathologists and laboratory professionals, how these shortages are likely to impact the workforce’s ability to fulfill its responsibilities to patients, and identifying shared opportunities to advance workforce issues affecting both pathology and laboratory professionals. Follow-up efforts from this group are in progress, and the ASC has participated in the following during 2014: (1) Task force to develop a pathology residency physician–scientist pathway, (2) Task force to address scope of practice issues in ACGME accredited fellowship training requirements and (3) Discussions on pathology extender workforce.

Cytotechnologists

Training Programs
The 2014 Cytotechnology Programs Review Committee (CPRC) Annual Report 15 indicates that currently in the United States we have 25 active (3 inactive) Cytotechnology programs. Of these 12 are Certificate‐only programs (a total of 21 programs offer a Certificate program), 9 are Degree‐only programs (4 offer a Masters level program) and 9 offer both Certificate and Degree programs. Data based on the last graduating class (2012‐2013) from 30 programs reported that of 262 student places available in accredited programs, only 168 (64.10%) were filled. Clearly we need to make the profession more attractive, modernize the curriculum and enable changes in the role(s) these graduates will take on when they enter the workforce.

The history of the ASC’s strategic discussions regarding workforce and preparedness for changes in the profession began in November 2001. Between 2001 and 2006, the ASC conducted surveys, gathered information, and explored ways to define the scope of practice of cytotechnologists in the context of workforce needs, and develop strategies for cytology educators to gear curricula to address those needs. A white paper entitled “Facing the Future of Cytopathology” that focused on discerning the future needs of our profession still remains a valuable source for future directions for the Cytotechnology professional.16

The CPRC, for the past several years, has championed the cause of developing an “advanced pathology laboratory professional” with core skills in cytopathology. A special CPRC retreat, held in February 2013 was successful in developing a revised curriculum to place Cytotechnology Programs on a more modern footing by including areas such as molecular diagnostics and digital pathology. The CPRC appointed a Resource subcommittee to undertake the task of providing Cytotechnology Programs with resources to meet the new Entry-level Competencies (ELC), which went into effect in July 2014. The CELL”- Cytology Education and Learning Lab was launched in February 2014 to support this endeavor17. The CPRC subcommittee and sponsors provided 120 resources for the CELL. As of the end of October 2014, CELL had 828 registrants of varying experience and areas of practice.

To continue implementation of the ELC, Phase II requires a change in the scope of practice of the traditional “cytology practitioner,” Thus in February 2014, the ASC and co-sponsors funded a second retreat for the CPRC to work on this. A “Mid‐level Pathology Practitioner” (MLPP) proposal was submitted by the CPRC to sponsors in March 2014. Responses were returned in September 2014. Committee members shared the MLPP proposal (along with sponsor feedback) with the cytopathology community for the first time in the CPRC Strategies in Cytotechnology Education session on November 14th at the ASC Annual Scientific Meeting in Dallas.

Current Cytotechnologist Roles in the Workforce
It appears that a large number of cytotechnologists in the workforce are still in traditional roles, with morphology comprising the majority of their workday, while others have taken on other “pathologist extender” tasks not previously performed by these laboratory professionals.18 Data from the ASCP Board of Certification (November 2014, personal communication) shows that there are 14,594 certified cytotechnologists of whom 650 hold an SCT certification. Of the 2,895 ASCP Molecular Biology (MB) certificates, 151 (5.2%) are held by cytotechnologists (CT or SCT). Besides the MB certification, the ASCP currently offers added qualification in immunohistochemistry (QIHC). We recognize that change for cytotechnologists is evident and inevitable, and we need to be at the forefront of this change to gather and triage data, create practice opportunities and develop applicable educational modules.

In order to support the growth, retention and placement of cytotechnologists who are already in practice, the ASC approached and began collaborations with the ASCP in June 2014 to form the “ASC/ASCP Workgroup: Focusing on Emerging Roles in Cytopathology.” This is a coordinated effort to (a) support identification of professional trends and offer meaningful resources to the cytopathology community, (b) focus on developing concrete goals towards addressing evolving practice changes while ensuring that education, practice and trending data support the Cytotechnology profession’s longevity and livelihood; and (c) support new roles for pathologists as cytotechnologists are increasingly expected to engage in the rapidly changing health care delivery system. The first year’s endeavors will focus on data collection and analysis, in support of our profession.

The ASC and ASCP also organized a panel presentation for the ASC Annual Scientific Meeting on “Emerging Roles for Cytotechnologists:Reallife Examples” in which five cytotechnologists provided empowering insights via presentations on what they have learned in their careers and what opportunities are available for cytotechnologists in transition. In preparation for this session, a survey was circulated that aimed to glean current insights and data from Cytotechnologists regarding goals and barriers in achieving professional goals; successes or inspirational experiences in expanding professional roles; characterization of future state of cytology professionals; skills that are being sought; and how national societies can contribute to goals. The session moderators (Ms. Amy Wendel Spiczka and Ms. Lynette Savaloja) received 350 responses!

The ASC hopes to enlighten and empower practicing cytotechnologists to pursue new opportunities and educational endeavors. Together with the ASCP, the ASC will be collecting trending data to support practice changes.

Pathologists

Educators
While there has been a projected decrease in the supply of pathologists,9 the demand end is yet to be determined with certainty, since the change in health care delivery systems, advances in technology and therapeutics as well as the political landscape are still in transition. They will all play a role in the need for the number and type of expertise required from medical professionals.

On July 1, 2014, core Anatomic and Clinical Pathology residency programs started to operate under the Next Accreditation System (NAS) from the Accreditation Council of Graduate Medical Education (ACGME). The NAS is designed to provide continuous accreditation data from residency programs to the ACGME each year, instead of three‐ to five‐year intervals between site visits in the old accreditation system. Cytopathology Fellowship Programs will start reporting Milestone data on fellows during in 2015. The ASC Cytopathology Program Directors Committee (CPDC), chaired by Dr. Deborah Chute, in an effort to assist Program Directors prepare for the new reporting requirements, addressed NAS, Milestones, developing a Clinical Competency Committee and assessment tools for Milestones in the 2013 and 2014 Strategies in Cytopathology Education Sessions.

The Committee has reenergized the ASC Program Directors Listserv with information exchange, and surveys. In October 2014, a survey was done to determine how Programs incorporate rapid on‐site evaluation (ROSE) in their Programs, and look for best practices and national trends. Results have been distributed back to the ASC Cytopathology Program Directors Listserv. The CPDC has also increased communications with members through The ASC Bulletin, the CPDC newsletter – Program Directors Communicator, and updates on the ASC Web site.

Pathology Residents and Fellows
The ASC is committed to providing input to the training and certification of pathology residents and fellows in the area of cytopathology. As of October 2014, the Society has 112 cytopathology fellows and 134 pathology resident members.

In August 2014, the ASC was approved as a cooperating society of the American Board of Pathology (ABP), which will allow input into the examination and certification process and input for ABP trustees. In September 2014, the ABP approved the Physician Scientist Research Pathway developed by APC with ASC participation (ASC representative, Marilyn Bui, MD). The ASC and PSC have joint representation on the Ad Hoc Fellowship Directors Committee developed by the Association of Pathology Chairs.

The ASC Progressive Competency Evaluation (PEC) exam has proved to be an extremely popular product for residents and fellows and it has been further strengthened in 2013-14 (PEC chair, Dr Claire Michael). Currently PEC has 234 participants – 118 fellows (75 programs) and 116 residents (13 programs). The PEC final examination performance has recently been reviewed and found to correlate positively with ABP certification.20

In October 2014, the CPDC released a new product on the ASC Web site- Problem‐based Learning Program for Cytopathology Education: seven cases that include Facilitator Notes, Learner Notes, an Assessment Quiz, and Objectives and References. Development of a Lab Management Curriculum and “Sound Bites” are in progress with four examples completed, and more in process.

State and Regional Organizations
Our members (and non-members) have often commented that networking and camaraderie are important factors that motivate them, in addition to the educational offerings to attend the ASC Annual Scientific Meeting. In today’s economy and staffing, not everyone can make it to the Meeting as often as they would like. Thus it was important for the ASC to help sustain local state society meetings. I charged the Executive Board Cytotechnologists to follow through with a needs assessment and develop a plan. They did a wonderful job in surveying and obtaining grant support for 4 societies per year to receive grants from the ASC Foundation to support regional meetings. We began to give these grants at our 2014 Annual Scientific Meeting.

Member Engagement
Our greatest asset is YOU – our members, who come together to support and volunteer to help us sustain the ASC and move us forward. As of October 2014, the ASC has 3038 members – 56.4% pathologists, and 43.6% cytotechnologists (Membership Committee Chair, Dr. Lourdes Ylagan). In 2013, when I appointed committees, 145/294 volunteer positions were new appointees and 85% of new volunteers were assigned to a committee.

The ASC has significantly expanded its communications with members during the past 2 years. While the listserv, The ASC Bulletin and emails are still utilized and popular, there has been good activity on social media (Face book, Twitter, YouTube and Instagram). In August 2014, we launched the ASC App, which provides members easier access to all ASC offerings. The “Member Communiqué,” “Member Spotlight” and CPDC Communicator are electronic communications to various groups in the membership. Since 2012, the ASC Presidents Blogs address various medical and non-medical topics relevant to our specialty and members. The ASC Web site is continually being improved for easy navigation and improved content – “Cytopathology News” and the calendar of events are updated regularly.

EDUCATION

Educational Offerings
The ASC offers a large variety of educational opportunities for the cytopathology community. (Table 1)
In July 2014, the Accreditation Council for Continuing Medical Education (ACCME) conducted a survey of ASC education programs and awarded full accreditation until 2018. The ABP recognizes the ASC as an accredited CME and SAM provider for Maintenance of Certification (MOC).

Table 1blog table

 

The ASC Scientific Program (Chair, Dr. Dina Mody) and Cyto-eConference (Chair, Dr. Güliz Barkan) Committees, overseen by the ASC Continuing Education Oversight Committee (Chair, Dr. Diane D Davey) must be congratulated for providing us a good balance of basics, research and new clinical applications in the ASC educational programming to keep us current. Note that the ASC provides free CME and SAM in the form of monthly e-Journal clubs and associated webinars as well as ASC Case Studies on the ASC Web site.

ASC Publications
In January 2014, the inaugural issue of the Society’s bimonthly journal- Journal of the American Society of Cytopathology (JASC) was published. The editorial team is led by Dr. Syed Ali (Editor in chief). The journal is receiving a steady supply of good articles and we encourage you to submit your research to JASC– Our Journal! In March 2014, a trainee award for the best trainee abstract at USCAP was initiated and will be presented annually. In October 2014, the publisher, Elsevier, released the JASC App for the iPhone and iPad. JASC is included as a member benefit for practicing Medical members and Voting Cytotechnologist members, and available at a discounted rate to other members.

In July 2014, the popular ASC Bulletin (Editor, Dr. Michael Thrall, incoming editor Ms. Brenda Sweeney) was merged with JASC, as one bi-monthly publication; however, the Bulletin remains freely available to all ASC members. This year the Web site Committee (Co-chairs –Drs. Brian Collins and Sara Monaco) presented a new, annual award for the best Case Study of the year at the Annual Scientific Meeting in Dallas.

Companion Meetings
The ASC’s Companion Meeting Committee (Chair, Dr. Eva Wojcik) coordinates educational sessions at a number of other pathology meetings, in coordination with both national and international professional organizations. In 2014, the ASC participated in USCAP, ASCP, and the European Congress of Cytology (ECC). For 2015, in addition to the above, we have planned companion sessions at CAP and also expanded our presence at clinical/non-pathology meetings including the American Association of Nurse Practitioner (AANP), American Urologic Association (AUA) and European Association of Urology (EAU).

ADVOCACY

The collaborations described above pertain to advocacy for our profession; however one of my goals in the past year was to increase advocacy efforts with the allied health care organizations and patient advocacy groups and help connect ASC members who wish to volunteer with educational, training and services required in low resource areas. This charge was assigned to the ASC Public Information and Advocacy Committee (Co-chairs: Drs. Rosemary Tambouret and Barbra Winkler).

In 2014:

  • A webpage has been created on the ASC Web site where volunteer opportunities & experiences are posted. I encourage you to read some of the stories our colleagues have shared and to tell us your own!
  • A list of ASC members who want to volunteer has been compiled.
  • ASC Advocacy Committee member, Britt-Marie Ljung, along with Drs. Ricardo Bardales and Ronald Balassanian led a mission to train of physicians on FNA technique for breast disease in Trujillo, Peru. This was sponsored by PATH, an organization associated with the Gates Foundation.
  • Tambouret, Benedict and Rollins will present a workshop on ultrasound guided FNA at the 2015 American Association of Nurse Practitioners (AANP) Meeting.
  • Tambouret and colleagues are working on the development of a universal curriculum for GYN cytology screening programs in low resource, underserved countries.

Other ASC Advocacy efforts include ASC Foundation Advocacy Grants and future collaborations with the CAP Foundation’s “See, Test and Treat” Program.

ASC Foundation Board
The primary function of the ASC Foundation is to fund the Society’s programs and expand its endowment to assure fiduciary responsibilities to the mission, membership and the public, as it insures the Society’s financial stability. In 2014, the Foundation Board under the leadership of Drs. Mary Schwartz and William Crabtree has collaboratively been designing a bold and innovative plan to ensure a strong future for the ASC Foundation. In April 2014, the Board had a retreat, during which the process of developing the framework for new initiatives and broadening the scope of fundraising activities, programs and services was started. Since then, the Foundation has developed a new logo and web site that gives the Foundation a separate but shared identity with ASC. Please refer to the September 2014 issue of The ASC Bulletin for more information of the Foundations contributions to the ASC mission and vision.

In summary, the Society has been prepared, present (at the right place, at the right time) and proactive in order to help shape the future of our profession.

I have been privileged to have been a member of this Society for the past 24 years, and I am honored to have served as its President. My professional life has been greatly enriched and influenced by the many teachers, mentors and colleagues I have met along the way, so many of whom are now close personal friends. I am grateful to the ASC Executive Board, the ASC staff and all the members and volunteers who worked closely with me to accomplish the past year’s goals. I encourage all of you to be volunteers and advocates and give back to the Society that has been pivotal in shaping our profession.  We are cytopathology professionals and the ASC is OUR Society!

REFERENCES

  1. Nayar, R. State of the Society. Journal of the American Society of Cytopathology, 2014; 3(1), pages I–IV.
  2. ASC-CAP MOU @http://www.cytopathology.org/cap-and-asc-collaborate-on-advancing-patient-care-through-cytopathology/.
  3. ASC and ABP@http://www.cytopathology.org/asc-abpath-collaboration-announcement/.
  4. ASC-ASCP MOU@ http://www.cytopathology.org/ascp-and-asc-sign-a-mou-to-partner/.
  5. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol. 2012;137: 516-542.
  6. Davey DD, Goulart R, Nayar R; Cytopathology Education and Technology Consortium (CETC). 2013 statement on human papillomavirus DNA test utilization. Am J Clin Pathol. 2014 May; 141(5):759.
  7. Cytopathology Education and Technology Consortium (CETC).Letter to the FDA regarding PMA hearing for HPV primary screening, February 27, 2014 [p. 179]. Available at: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/Microbiology DevicesPanel/UCM393482.pdf. Accessed Nov 6, 2014.
  8. ASC Presidents Blog. Available @ https://ascpresidentsmessage.wordpress.com/2014/04/. Accessed November 10, 2014.
  9. Nayar R, Goulart R , Wasserman P, Davey D. Primary Human Papillomavirus Screening for Cervical Cancer in the United States – US Food and Drug Administration approval, clinical trials, and where we are today. Cancer Cytopath; 2014.
  10. Huh W, Ault K, Chelmow D, et al. Use of Primary High Risk Human Papillomavirus Testing for Cervical Cancer Screening: Interim Clinical Guidance. In press.
  11. American Society of Cytopathology Guidelines and Position Statements. Available at: http://www.cytopathology.org/asc-guidelines/ Accessed November 10,2014.
  12. https://paris.soc.wisc.edu/.
  13. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html?redirect=/physicianfeesched.
  14. ASCP 2013 Task Force on the Laboratory Professionals Workforce. Building a laboratory workforce to meet the future. Available at: http://www.ascp.org/PDF/Advocacy/ASCP-Task-Force-on-Lab-Pros.pdf. Accessed November 8, 2014.
  15. CPRC News @ http://www.caahep.org/Committees-On-Accreditation/?ID=CYTO Accessed November 6, 2014.
  16. ASC. Facing the future of cytopathology. Available at: http://www.cytopathology.org/wp-content/dynamic_uploads/3439.pdf. Accessed November 4, 2014.
  17. Cytology Education and Learning (CELL) Website. Available @ http://cytologyedlab.org/. Accessed November 4, 2014.
  18. Kane LE, Root RR, Voss JS, et al. Molecular diagnostics, personalized medicine, and the evolving role of the cytotechnologist: an institutional experience. Acta Cytol. 2012; 56(6):678-85.
  19. Robboy SJ, Weintraub S, Horvath AE, et al., for the Workforce Project Work Group. Pathologist workforce in the United States. Arch Pathol Lab Med 2013 Dec; 137(12):1723-32.
  20. Davey DD, Kaplan DR, Michael CW. Strong performance on the Progressive Evaluation of Competency fellowship final examination predicts American Board of Pathology Certification. Journal of the American Society of Cytopathology; 2014:3, 269-273.