Management of Papanicolaou test results that lack endocervical cells

Abstract

Mrs. McTavish is a 25-year old patient whose Papanicolaou (Pap) test results have come back from the laboratory. The smear is described as satisfactory for evaluation; however, it is noted that an inadequate number of endocervical cells were present in the sample. The results of the patient's past Pap tests have been satisfactory for evaluation and negative for abnormality. She is otherwise well. Her physical examination, including pelvic examination, showed nothing unusual. R ates of cervical cancer have been declining in Canada since the implementation of the Papanicolaou (Pap) smear, with reduction in both incidence (from 11.1 per 100 000 in 1970-1972 to 5.2 per 100 000 in [1994][1995][1996] and mortality (7.9 per 100 000 in 1953-1955 to 1.9 per 100 000 in [1995][1996][1997].1 Further improvements will depend on the continuance of screening for cervical cancer and the effectiveness of screening tools. The Bethesda System -the conventional system for reporting cervical cytologic diagnoses -provides feedback about specimen adequacy using the categories "satisfactory" or "unsatisfactory."2 Primary health care providers may receive Pap test results that are identified as satisfactory but accompanied by a note that indicates a sample from the transformation zone is lacking. Some provincial and national guidelines are unclear about how clinicians should respond to this type of report. Because of this uncertainty, we sought to review the current evidence on the topic. How should a care provider proceed with screening when faced with an otherwise satisfactory Pap smear that lacks sampling from the transformation zone? If physicians continue with regular screening intervals without special attention to the lack of endocervical cells, are cervical abnormalities being missed? Literature reviewWe searched MEDLINE from 1975 to the end of July 2010 using the following combination of keywords and subject headings: "unsatisfactory Pap smear," "endocervical component," "endocervical status," "endocervical cells and Pap smear," "Pap smear and quality" and "abnormal Pap smear." Bibliographies from the identified articles were manually searched. Summary sites such as Towards Optimal Practice (Alberta) and Cancer Care Manitoba were also reviewed in July 2010. We identified 462 citations, and reviewed 53 full-text articles. Papers were excluded if they were written in a language other than English, if they did not discuss the topic of Pap smear quality and presence or absence of endocervical cells, and if there were insufficient data to draw conclusions. Twenty-four articles were included in our review and are summarized in Appendix 1 (available at www .cmaj .ca/cgi /content /full /cmaj .101156 /DC1).The level of evidence was determined by the hierarchy developed by the Canadian Task Force on the Periodic Health Examination, 3 according to which the highest level of evidence (Level I) derives from at least one randomized controlled trial, and the lowest level derives from the opinion of experts (Level III). The evidence identified...

2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors

“…53 A recent meta-analysis found that negative cytology had good specificity and negative predictive value despite absent or insufficient EC/TZ component. 54 HPV testing appears to be independent of transformation zone sampling 55 and offers an added margin of safety for women aged 30-64 years now that co-testing is the preferred screening strategy for that age group. An absent EC/TZ component is not associated with an increased incidence of cervical disease after treatment of CIN 2+.…”

Colposcopic Assessment Among Women with Lower Genital Tract Pathology

“…There are few clinical trials reporting a significant improvement in the detection of ASC-US, AGC-US, or adenocarcinoma [5,11,25].…”

“…According to the Cervical Cancer Screening Guidelines, the unsatisfactory cytology should be repeated, suggesting that colposcopic examination is necessary for those women with two consecutive unsatisfactory cytologies [1,5,11,25].…”

“…Also, the sensitivity of colposcopy is limited: the ability of colposcopy to discriminate among dysplasia and microinvasive carcinoma can be difficult. Cervical cancer prevention is a process using a combination between biopsy, cytology, and HPV-DNA testing [1,9,17,25].…”

Updates of the current screening guidelines for the early detection of cervical cancer

“…Prior guidelines recommended early repeat cytology [9]. A recent meta-analysis found that negative cytology had favorable specificity and negative predictive value despite absent endocervical cell component [10]. Given that most cytology is performed using liquid-based media, unsatisfactory cytology results arise mainly from insufficient squamous cells [11].…”