Cytology: the Backbone of Modern Pathology?

Are cytopathologists a dying breed – soon to be extinct? Is cytology a disregarded specialty, pushed to the bottom of the training checklist? These experts think not.

In this round table, hosted by The Pathologist, three renowned cytopathologists challenge the view that cytology is an endangered specialty. Our expert panel discussed perceptions of cytology, training models in the US, UK, and Europe, how to maintain and improve competency in these regions, and why it will be vital to patient outcomes to do so.

Meet the panelists

How would you describe the status of cytology within the modern pathology lab?
 

Fernando Schmitt: I think that cytology is the backbone of the modern pathology department in three different areas: screening, diagnosis, and, especially, for establishing prognosis and predictive markers. The specialty has received a great boost in the last few years thanks to advances in lung cancer diagnosis that now use, for 50 percent of cases, the cytology materials for molecular tests. And this is now expanding from blood to other liquids, such as effusions, urine, and cerebrospinal fluid.

In the past, cytology has perhaps been considered as a second division, providing a preliminary diagnostic service. But now, if you consider that surgical pathology has progressed recently due to the use of biomarker testing to select the best treatment for patients – well, cytology is the same. This has served to elevate the role of cytology to equal that of surgical pathology in the modern pathology department.

Ashish Chandra: I absolutely agree with that perception. I also think it’s important for cytopathologists to establish its position as an important subspecialty within the department and the institution. There should be a clear organizational structure within the subspecialty with a lead and a named team of consultants. We should ensure the visibility of the cytology services in the institution. This goal can be achieved in a number of ways. As Fernando was saying, we should advertise the clear benefits to our users and clinicians, both in the institution and beyond. For instance, fine needle aspiration cytology may be a more suitable alternative to core biopsy and should be easily available. Ancillary tests are available on cytology samples as easy alternatives to those being performed on core biopsy or other types of histology specimens.

Saying that, we could also contribute to the popularity and the visibility of cytology via grand rounds and educational activities. There are many ways in which a modern pathology department can stand out with all its subspecialties – but we need to make space for each of them, including cytology. 

Eva Wojcik: I'm in complete agreement with both Fernando and Ashish. However, I would expand on this – I would even say that cytology, in many instances, is superior to surgical pathology. 

Currently, with all the developments in imaging techniques, smaller and smaller lesions are being detected. From those lesions, we can practically obtain the best sample by using cytological techniques like fine needle aspiration. In my department, cytology is the main service for dealing with all the newly developed lesions in lung cancer. That’s because – as Fernando mentioned – during this procedure, we not only make the diagnosis of the presence of malignancy, we make the diagnosis of the specific type of malignancy. 

What’s more, we also stage the patients. We use those fine needle aspirations for sampling of the lymph nodes. So we already understand the extent of the disease, and, most importantly, we collect the material for molecular studies, which are critical in lung cancer. So, with one relatively simple procedure, cytopathologists are answering all the diagnostic questions. 

In many instances, those patients – based on cytology results – are treated with appropriate chemoimmunotherapy, and potentially resections; in other words, we are the first line of diagnosis as well as prognosis. With the expansion of our knowledge and experience, and development of new molecular testing, this service will expand to practically every organ and every type of specimen.

So, the role of cytology has never been so crucial. We are truly becoming one of the most important specialties in pathology.

What are the current training models for cytopathologists in your regions?
 

EW: For us to provide this vital service, we have to be well trained. One of the reasons that cytology is underestimated is that many pathologists don’t feel comfortable dealing with this type of specimen. The problem isn’t cytology – it’s that people without sufficient training and competence are trying to perform cytology. And, therefore, the answer is proper training and gaining sufficient expertise.

In the US, we are fortunate – cytology training is very well established. Cytology is recognized as a subspecialty in the residency programs here, which usually takes the form of two or three months of dedicated training. However, I would say that the majority of pathologists who are practicing cytology in the US are fellowship trained, which involves one year of dedicated cytology training that covers screening slides, making diagnoses, performing procedures, using ultrasound, rapid on-site examination, and so on, followed by examination and board certification. 

As a result, people who complete fellowship training are very well equipped to practice cytology independently. On top of this, there is regular proficiency testing and various quality measures to ensure we are performing at the appropriate level, as well as continuing professional development.

AC: Back in the days when I trained, in the UK, there was a year-long training program in cytology, culminating in an exam, which awarded a diploma. Sadly, a few years after I achieved my diploma, the exam was discontinued, mainly due to a lack of applicants. This was a bit of a blow to cytology as a subspecialty and, ever since, we have been playing catch up. We’ve had to look at how we can draw people into the specialty early enough in their careers and how we can provide opportunities for fellowships or for dedicated training time to develop their interest in cytology. That is still work in progress in the UK. 

At present, cytology forms just one unit of a five-year integrated cellular pathology training program. But the training does define the minimum number of cytology cases that the trainee must see per year. For example, in the first year, the trainee might be required to assess 150 cervical cytology samples and 150 non-cervical samples. These might be new cases or self-assessment-type teaching cases, with appropriate, structured feedback from a trainer. The number of required cases increases each year; however, by the third year, the trainees have the option to drop cervical cytology cases because the demand for these has dropped since HPV primary cervical screening was adopted.

As trainees progress, they may be expected to report 300 non-cervical cytology cases per year. By year four, they might be able to report cases independently. In short, the level of exposure and responsibility increases over the course of the program.

The reality is that trainees will only spend a few weeks of the year on their cytology training, and this training is region dependent in terms of the scope of the cytology service and supervisor resources.

Clearly, there is work to be done to try to meet the high standards we would like to see for cytology training in the UK.

FS: In Europe, cytology training is extremely heterogeneous, both between the countries and inside the countries. For example, in some countries, during five years of pathology residency, some residents spend only one month in cytology. In other countries, it might be a few months, or a specified number of cases, like in the UK, but it is highly dependent on the place.

You can see there is an imbalance there. In my first comment, I talked about the rising importance of cytology, but in Europe we are seeing less and less training to support the need. 

Another problem is that there are not enough senior people who are adequately trained in cytology in Europe who can train or mentor the less experienced pathologists. The pool is shrinking. I find this very curious, because when pathology leaders are planning resources, we see the gaps and we know we must recruit more young people into cytology. But we can’t find enough young people, which is a consequence of this inadequate training.

One ideas that we have discussed in the IAC is to identify some centers of excellence in cytology that could provide that specialist training. These might not be full fellowships, but good quality training for two months or so to stimulate the interest and desire to develop their skills.

EW: In Europe and perhaps the rest of the world, we are approaching a dangerous situation. As we said at the beginning of this discussion, the role of cytology is becoming increasingly important to patient care. Having samples analyzed by appropriately trained cytopathologists is best for patients. Yet, we are approaching a situation where, as a profession, we won’t be able to provide this crucial service. As Fernando said, if we don’t have teachers and role models, no-one will follow. We became cytopathologists because we were fortunate enough to meet some amazing role models who inspired us. 

But I also want to say that I truly believe that no-one can become a great cytopathologist if they are not also a great surgical pathologist. I heard that there are certain countries that train cytopathologists completely separately from surgical pathologists. I don’t agree with that approach. I think it’s even more dangerous than the model described by Ashish and Fernando.

FS: I completely agree. The readers will appreciate that the history of cytology starts with non-pathologists. Many years ago it was regarded as completely separate from the rest of pathology. 

Here’s a story that illustrates the problem. The President of a country had a nodule in the thyroid. The nodule was aspirated and presented to the country’s most revered surgical pathologist who, unfortunately, had never studied cytology. Nevertheless, trusting his skills, he diagnosed cancer. Based on this, the nodule was removed – however, it was discovered to be benign. Subsequently, when the slides were shown to cytopathologists, they diagnosed follicular benign nodules. The President could have been spared from unnecessary surgery had the correct experts been consulted.

Cytopathologists should have dedicated, specialist training, built on to a foundation of surgical pathology knowledge.

What needs to be put into place to standardize and improve cytology training models?
 

FS: The American model appears to work well. Cytology training needs to start in the pathology residency and continue with a dedicated fellowship led by excellent cytopathologists in a recognized center of excellence. Further, it must include all the latest techniques and technologies. 

EW: What Fernando describes is certainly the ideal, but the starting point is currently quite low. I also find it surprising that pathologists in Europe can practice in different countries, where competency standards might be completely different to their own, without additional training. 

To address this problem, I’m aware that the IAC, as well as European societies, are trying to standardize training curricula and requirements across countries, while exposing early-career pathologists to cytology. The IAC also sets exams for its cytology fellowships, which ideally should set the standards for competency everywhere.

FS: The current reality exposes the gap between regulatory bodies and the practices. I agree that, ideally, the regulatory bodies should require standardized exam certification to practice across regions such as Europe. You might gain a European diploma, for example.

At present, we have the United Medical Education Consortium (UMEC) Medical Society (UMS) in Europe, which covers all medical specialities. They have the goal of standardizing medical practice in Europe, but it is a very slow and political process. It seems they have a great many meetings with very little consensus and few decisions. Many years later, we are still waiting for them to issue the Europe-wide examination they promised.

In the US, the regulatory bodies do require certification by examination to practice. We recognize that examinations aren’t everything, of course – but at least it’s something.

AC: In the UK, the Royal College of Pathology created a syllabus for histopathology higher speciality training, which recommends the minimum number of cytology cases that post-graduate trainees should see, in each year of training, to achieve competence. This provides the opportunity for uniformity in competencies across the UK. It also sets out the training expectations for a department to be recognized as a specialist center for cytology.

However, this is a self-surveillance program, and we have no way of monitoring uptake or measuring the results. So, whilst regulatory bodies can lay out the ground rules, they are not in a position to make them mandatory.

In many cases, trainees, having not received the recommended training for the specialty, find themselves doing “crash courses” in cytology before an impending exam. It’s like trying to learn a new language just before a holiday!

The exam itself includes just eight cytology cases. Hence, many candidates might prepare by focusing on the eight most likely case types, and then consider themselves competent if they pass the exam.

However, for those trainees who are committed to dedicated training, recognized departments like mine will offer a period of observership, as long as the visiting trainee’s institution is prepared to fund it.

EW: It’s interesting that we, as cytopathologists, are trying to solve this training problem ourselves. Perhaps we should be asking our clinical colleagues to support us. The recognition of cytology as an essential service for patients and the requirement for  competent people within the institution to provide that service, could be very powerful. Radiologists, pulmonologists, gastroenterologists – they all need us! They need us to interpret the results of the tests they have ordered and specimens obtained during procedures they performed. Without competent cytopathologists, their efforts will be in vain.

AC: Eva is absolutely right. At my institution, we established our endobronchial ultrasound (EBUS) and pancreaticobiliary cytology (EUS) services on the request of the physicians who needed them. They sought the training to be able to take the samples, but are reliant on the pathologists to read them. It was challenging to get off the ground, but it was exciting, and has drawn more pathologists and cytotechnologists into cytology.

These services are greatly valued in the hospital. We need these drivers to set things in motion, so that we can build on our successes – and then the sky’s the limit.

FS: I think Eva and Ashish can both testify to something that perhaps looks very simple from the outside: urine cytology. But when the urologists realize the value of urine cytology in terms of its diagnostic powers, they also start to value cytopathologists, asking for us by name to analyze their patients’ samples. In these situations, the other specialists do realize the importance of having well trained cytopathologists in place to look at their cases. We need to encourage them to keep advocating for maintaining this level of competence in our institutions.

Another thing that I think would help this cause is if we, as cytopathologists, started to publish our research in the clinical journals. If I’m doing a lot of work with pulmonologists, I need to start publishing my work in the lung journals to get it recognized by the clinicians who benefit from it. The more we reach the medical community, the more our work will be valued, and the louder our voice will be when it comes to demanding excellent training.

Who should be accrediting the training models?
 

FS: This brings us back to the problem I mentioned before. We have regulatory bodies and scientific societies, and they serve very different purposes. IAC is a scientific society. It can put a seal of approval against a training course, but it can’t make it mandatory for accreditation.

Each country in Europe creates its own exams, but there is really no need for this when the IAC can provide good quality, standardized examinations to ensure competency standards worldwide.

The ideal situation is that the regulatory body in each country mandates the IAC exams, for example, as proof of competency to practice cytology in that country. This is actually the situation in Japan for cytotechnologists. For other countries, we have a long way to go. There is some political work to do to convince the local regulatory bodies to accept international standards.

How might the establishment of cytology centers of excellence help improve standards?
 

AC: As Fernando explained, the  IAC cannot directly influence what happens at an institutional or national level. What we try to do is identify leaders in different countries who either have the potential to host, or are already hosting, high standard cytology fellowships. We look for people who have policies in place in their departments to be able to offer training to people in their own countries and, ideally, from other countries whether in the form of observerships, fellowships, or mentorship.

For example, in my institution, we can accept observers free of charge for a stipulated period of time. Participants don’t receive a certificate, but we can write a reference-type letter to confirm their participation and level of interest. 

The IAC’s role in this is to identify the centers and individuals who can offer these opportunities, and to publish a register so that interested individuals can approach them; however, it is unable to govern the process.

EW: I think centers of excellence is a great idea, overall, for recognizing those institutions that are strong in cytology. One benefit is exposure of young pathologists to cytology, so they can see all the things cytopathologists can do, and even help them meet potential mentors.

Regarding observerships, we have always offered those in our department. Some trainees might spend up to a month with us, and even have a chance to do a preliminary review of some cases. However, recently it has become much more difficult to offer these opportunities. Everything was put on hold during the COVID-19 pandemic, and our official policy still states that we cannot accept observers in our labs. This is mostly due to safety and liability reasons. There are also patient confidentiality restrictions – observers cannot have any access to patient medical records. This also affects their ability to contribute to research projects. Then we have to consider cyber security and IT access. And so, though we are all willing to share our experience with the younger generation, we are battling against so many restrictions to do so.

And that is why the development of those robust and regulated training programs is so important.

The good news is that there are opportunities for international fellowships, for those individuals who can secure funding. Virtual fellowships are also available for those who cannot travel. The technology we need to deliver these programs is already in place, and there is a wealth of material available online. But, in my opinion, nothing beats that hands-on experience of being in the EBUS lab and making important clinical decisions about whether a patient needs a procedure or not, for example.

Any closing message for our readers?
 

FS: Thank you for the opportunity to share our ideas. I think this activity is very important for cytology. Many cytopathologists see The Pathologist and maybe our discussion will inspire some thoughts and ideas for them. 

And let’s all take some responsibility for cytology training. We can offer webinars and tutorials, for example. We had a fantastic experience earlier this year when we organized a virtual tutorial which reached two or three hundred people in Africa – free of charge. Technology opens up huge potential for offering training all round the world.

Finally, cytology will not disappear, cytopathologists will not be replaced by machines, so we need to focus on training to ensure an adequate number of well qualified and trusted experts.

EW: I just want to emphasize that cytology is the best possible specialty to get into. I am so grateful for the opportunities I’ve been afforded to specialize in this area. 

We are medical doctors, and that’s what this specialty reminds us every day. That’s because, rather than staying behind a microscope, we are working at the patient’s bedside, performing procedures, examining those patients, and talking to them. This gives us the perfect opportunity to show that we are physicians – and a truly integral part of the medical team. These days, no medical team can exist without us.

Cytology is not yet at its peak, but it is entering a golden era. We hope that there will be many more followers who will choose this amazing specialty.

^{Credit: Images for collage sourced from Adobe Stock and Unsplash}