Thames Valley Cytology Society

2009 BSCC Spring Tutorial at Guy's Hospital Medical School

Cytology Training Manager, Watford General Hospital

I have never had the opportunity to attend a BSCC Spring Tutorial and knew I wouldn't be disappointed when I followed the signs to The Gordon museum at Guy's Hospital Medical School. The Gordon Museum was the venue for the tutorial and was awe inspiring with it's collection of interesting and bizarre exhibits, in fact the walls of our lecture theatre were adorned with turn of the century sketches of unfortunate people with HUGE palpable lumps!

Anyway, getting back to the theme of the spring tutorial: quality assurance in cytology. The five speakers gave very informative accounts of different aspects of quality assurance within cytology.

The first of these speakers was Dr Paul Cross who talked about the National EQA scheme for gynae cytology. Proficiency testing came into the NHSCSP in 1988, each region had a different protocol until a national protocol was established in 2002 by Slater, which has evolved ever since. Proficiency testing was a response to 'headline problems' by providing reassurance to the public that external scrutiny is occurring within the NHSCSP. The current protocol set out in NHSCSP publication 15 defines substandard performance at the 2.5 percentile point, states that each case retained in the scheme requires an 80% peer consensus as opposed to the expert consensus required in histology proficiency testing, that the testing should 'closely' mimic normal practice and that it should be about education and learning. Paul Cross had looked at the US and told us of the differences. Across the Atlantic, proficiency testing visits can be unannounced. The pass mark is 90%. If a candidate fails they must re-sit within 45 days, if the candidate fails again they must have remedial training and not sign out. All US laboratories must register for the scheme or withdrawl of Medicare payments will occur.

Back to our proficiency testing, changes that occurred in April 2009 was the implementation of a 'Serious Screening Error' and I'm sure the unpopular move to twice yearly testing. Like it or loathe it no EQA is not an option. However, Paul Cross felt it could be improved by a scheme which offers immediate feedback, such as a web based protocol as used in Wales. I think this could be the future and would maybe reduce the amount of work required of the scheme facilitators especially with the increase to twice yearly testing.

Kay Ellis gave an excellent presentation on another aspect of quality assurance in cytology - The invasive cancer audit. Prior to publication 28 in 2007 audits were patchy, non standardised, incomplete and lacked documentation. Leicester publicised an audit of 403 invasive cases diagnosed between 1993 and 2000 in 2001. They published that 14 cervical cancer deaths had occurred due to incorrect lab reporting, 64 women required radical treatment by the time their cancer was diagnosed and there was discrepant cytology reporting in 122 cases.

Kay pointed out that the on going issues with this type of audit is that the review does not mimic normal screening conditions and that the data is not peer reviewed. Changes to the audit process since Leicester include the right for patients to be informed of the audit process and the outcome, however this concerned trusts about litigation and some trusts even stopped audits awaiting clarification. The result was the long awaited NHSCSP publication 28.

So why do the invasive cancer audit? The NHSCSP is successful; the best in the world, but women still develop cervical cancer. The cancer registry, sensitivities and specificities are useful but do not give the full picture. Audits of invasive cancer cases provide information as to whether there have been any errors in the screening process. Screening is a complicated process with many stages. Potential errors can occur in primary care, registration and invitation, sample taking, specimen transporting and processing, laboratory reporting, result notification and follow up, colposcopy, histological processing and interpretation, treatment and fail safe.

Kay left some points to consider: the audit process does have a purpose, but that the current system is very user unfriendly, it relies on much co-operation between all areas of the screening programme. Time and cost required to complete the audits needs to be considered. Is the review biased? Much of the material requires review of conventional cervical samples which doesn't occur in normal practice since conversion to LBC. Finally, there is no clear guidance for histological review.

Mr Allan Wilson gave a presentation on the technical aspects of the Scottish cytology EQA schemes. Scotland and Northern Ireland provide the only technical EQA for non-gynae preparations, this originated from frustration around the quality of preparations. The problems they have encountered with non-gynae preparations are the use of dense counter stains, poor colour balance and fixation and lack of chromatin detail. There are difficulties with a technical non-gynae scheme. Standardisation is a problem as the scheme receives a variety of samples, processing methods and stains used. There are variations in individual assessor performance and marking criteria. The use of participants meetings are crucial, they give a good opportunity for non medical staff to discuss cases, good and poor examples of staining are discussed and contentious EQA slides can be examined. Other difficulties with the scheme are that it is currently unaccredited, standardising marking criteria and samples is an issue and there is a lack of interest. However, with all the problems the scheme is making progress. Poor performing laboratories are being identified with their performance increasing due to the circulation of digital images and best practice protocols.

Dr Sally Hales' presentation allowed for audience participation. Twelve digital images of non-gynae cases were sent out to the delegates with the programme. These images are part of the North West non-gynae EQA scheme and are made up of ten classic diagnosable cases and two educational cases. I had looked at the images beforehand and brought my answers with me. We discussed each case and I think the audience got a lot out this session and several people commented on their renewed confidence in non-gynae diagnoses!

Sally spoke of the issues of the scheme. The demand is now outstripping supply, it is difficult to police, slides get broken and go missing and it is difficult to get access for trainee medics and non medical staff.

Dr Thomas Giles was our final speaker for the day. He looked at quality assurance in the FNA clinic. The purpose of an FNA service is to enable appropriate patient management. The aims of the service need to be clearly defined. A service can easily be discredited with diagnostic errors, high inadequate and suspicious rates leading to insufficient information to plan management and delaying reaching a definitive diagnosis. At present only breast cytology has defined performance indicators. The Royal College is currently working on performance indicators for thyroid cytology. Audit should be the mainstay and slide exchange schemes can only increase quality.

The afternoon had two workshops. The first was a series of invasive cervical cancer cases. The non-gynae workshop contained lots of head and neck cytology. I found this particularly interesting. There was still enough time to look around the Gordon Museum further and would strongly recommend a visit to this amazing collection for everybody.

I had a great BSCC spring tutorial. The speakers provided a series of very informative and enjoyable presentations on what is quite a dry subject. It was a great opportunity to look at so many cases in the workshops. Many thanks to the Thames Valley Cytology Society for the opportunity to attend the tutorial.

Laura Holland
Cytology Training Manager
Watford General Hospital.