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Follow-up of Unsatisfactory Papanicolaou Test Results
To the Editor: Use of the Papanicolaou (Pap) test has resulted in a 6- to 10-fold decline in the rate of invasive cervical cancer in screened populations.1 The Bethesda System (TBS) was developed in 1988 and revised in 1991 to clarify the varied terminology for cytological findings.2-3 An important aspect of TBS is the evaluation of the specimen for adequacy, which is reported as satisfactory, satisfactory but limited (with description), or unsatisfactory. Retrospective studies have indicated that unsatisfactory Pap test results are associated with a high incidence of subsequent cervical malignancy or premalignant epithelial abnormalities.4-6 By judging the adequacy of the Pap test, TBS aims to decrease false-negative reports. Due to concerns that introduction of TBS terminology has confused practitioners and resulted in inadequate follow-up of abnormal test results, we reviewed the management of patients at a major teaching institution who had Pap test results that were diagnosed as "unsatisfactory for evaluation."
Methods
In 1997, 65 (0.4%) of 18,118 Pap test results reviewed at our institution were reported to be "unsatisfactory for evaluation." Forty-three percent of the tests were submitted by obstetrician-gynecologists, 25% by internists, 14% by family practitioners, and 18% by other departments. Patients ranged in age from 18 to 74 years, with a mean of 44 years. Thirteen patients (20%) had a documented history of prior abnormal Pap test results or cervical carcinoma. The majority (37 slides, 58%) were unsatisfactory because of scant cellularity.
Results
Review of the teaching institution's medical database in June 1998, 6 to 18 months after the unsatisfactory reports, revealed that none of the 65 patients had received a repeat Pap test. In the medical records of 13 patients (20%), attempts to contact the patient by telephone or letter were documented. Thirty patients (46%) were seen subsequently in the initial clinic or in another clinic within the university setting, but the Pap test was not repeated.
Comment
Practitioners may not be responding appropriately to reports of unsatisfactory Pap results, even though TBS had been in use for more than 5 years at our institution at the time of the study. Possible explanations for the lack of follow-up include patients' lack of compliance and practitioners' lack of appreciation of the significance of unsatisfactory specimens.
There are no uniform guidelines for the management of an unsatisfactory Pap test. However, a repeat Pap test at a reasonable interval seems prudent in the majority of cases. Our department of pathology has now added a recommendation on the cytology report to repeat the Pap test if specimen adequacy is unsatisfactory. Institutional review may be necessary to ensure appropriate management of inadequate Pap tests.
Amy McGaraghan, MD;
Karen Smith-McCune, MD, PhD
University of California at San Francisco
1. Eddy DM. Screening for cervical cancer. Ann Intern Med. 1990;113:214-226.
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2. Broder S. Rapid communication—The Bethesda System for reporting cervical/vaginal cytologic diagnoses—report of the 1991 Bethesda Workshop. JAMA. 1992;267:1892.
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3. Kurman RJ, Solomon D. The Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses: Definitions, Criteria and Explanatory Notes for Terminology and Specimen Adequacy. New York, NY: Springer-Verlag; 1994:30-38.
4. Kristensen GB, Skyggebjerg KD, Holund B, Holm K, Hansen MK. Analysis of cervical smears obtained within three years of the diagnosis of invasive cervical cancer. Acta Cytol. 1991;35:47-50.
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5. Ransdell JS, Davey DD, Zaleski S. Clinicopathologic correlation of the unsatisfactory Papanicolaou smear. Cancer. 1997;81:139-143.
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6. Sherman ME, Kelly D. High-grade squamous intraepithelial lesions and invasive carcinoma following the report of three negative Papanicolaou smears: screening failures or rapid progression? Mod Pathol. 1992;5:337-342.
Letters Section Editors: Phil B. Fontanarosa, MD, Deputy Editor; Stephen J. Lurie, MD, PhD, Fishbein Fellow.
JAMA. 2000;283:1290-1291.
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