What an honor it is to have been elected to the presidency of the American Society of Cytopathology. 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