More Pap Madness

Ed Uthman, MD

Diplomate, American Board of Pathology

17 Apr 1996

Recently some of us have been discussing the rate of reporting Paps as "ASCUS" (atypical cells of undetermined significance), and the ratio of the number of ASCUS reports to those reported as LGSIL or above (the ASCUS:SIL ratio). Managed care clients have apparently been putting pressure on commercial labs to get the ASCUS rates as low as possible, and corporate labs have responded by putting pressure on their cytotechs and pathologists to do the same. The figure that is thrown around is that the ASCUS:SIL ratio should be no greater than 3:1,and the overall ASCUS rate should be no greater than 5%.

Applying pressure from the other side is the blossoming of lawsuits concerning false-negative Paps, which often employ highly visible, widely published cytopathologists as plaintiff's "experts" (I put "experts" in quotes, because I think that there is no such thing as an expert on the subject of ASCUS, since this is one of the most irreproducible and poorly defined nosological entities in pathology. It's like having an "expert" on astrology, full of sound and fury, signifying nothing).

One could consider the philosophy, adopted from criminal law, that "'tis better that a hundred women undergo a repeat Pap smear than for one to suffer a missed cervical cancer," and fairly easily fall into it. After all, a similar philosophy led the FDA to demand the expenditure of tens of millions of dollars to test donor blood for HIV p24 antigen to pick up only a handful of infected donors (but that's for another rant).

It appears to me that the practice of gynecological cytopathology is quickly degenerating into a no-win situation, with the legal system inducing one to make overcalls, and managed care pushing one to make undercalls. I think this is a downright shame, as I have long held the opinion that from a public health standpoint, the interpretation of Pap smears is the most important duty a pathologist performs, and it is truly pathology's Great Success Story of the twentieth century. Of course, like all the other good things civilization has to offer, it is taken completely for granted, and its practitioners are held to a standard that does not exist, except in the minds of a public duped ultimately by the very fathers of cytopathology, who now transform from scientists to hires of trial lawyers and, like Cronus, hungrily devour their own young.