Feature. Cytotechnology: A Profession on the Move Then and Now

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1 Cytotechnology: A Profession on the Move Then and Now Kalyani Naik, MS, SCT(ASCP),1 M. Sue Zaleski, MA, SCT(ASCP)2 (1University of Michigan Hospital, Ann Arbor, MI, 2University of Iowa Hospitals and Clinics, Iowa City, IA) DOI: /MU74MJE9BA8HABDM labmedicine.com Downloaded from April 2008 j Volume 39 Number 4 j LABMEDICINE 201

2 The field of cytotechnology has advanced rapidly since its meager beginnings. It began out of a need to support the invention and expansion of the Pap test, the most successful screening test in medical history, but it has grown into a profession that supports the diagnostic science of detecting cancer in specimens from virtually any body site. It has overcome significant professional challenges throughout its history and continues to be a field on the move, continuing to evolve with the changing face of surrounding environments and the development of new technology. It has far surpassed the boundaries previously set by light microscopy. Today, we have the ability to incorporate cytomorphologic findings visible at the light microscopic level with findings detectable only at the molecular level. It is hard to imagine a time when there was not even a solid connection between cell morphology and disease state. The roots of cytopathology can be traced as far back as the 1800s, when sporadic reports of the detection of cancer cells in a variety of specimens are evident. 1,2 Despite these reports of exfoliated cancer cells during the 19th century, there was no effort towards the development of a systematic application of the cytologic method to diagnose cancer during this time. It was not until the 1900s, with the work pioneered by Dr. George Papanicolaou, that the field began to take on a shape closely resembling the profession that exists today (Image 1). Ironically, Dr. Papanicolaou s initial research, performed at Cornell University in New York City in the early 1900s, focused not on cancer, but rather on the sex chromosomes of guinea pigs and cellular changes seen in vaginal smears of guinea pigs during phases of the menstrual cycle. Eventually, his research extended to cellular changes during the phases of the human menstrual cycle. 1 Inevitably, he received smears from patients with cervical cancer, and he recognized them for what they were. One of the critical advances he made was the application of wet fixation and the development of what is now called the Papanicolaou staining method. 1 This staining method allowed visualization of details of the nucleus, where the heart of making a diagnosis of cancer lies. The systematic collection of vaginal smears from women culminated in New Cancer Diagnosis, a paper presented by Dr. Papanicolaou at the Third Race Betterment Conference in Battle Creek, MI, in How insightful he was in his conclusion: We have a better understanding of the situation in a cancer case, and we may have some help in analyzing the cancer problem in the future. I think this work will be carried a little further, and that analogous methods may be applied in the recognition of cancers in other organs. I think that some method can and will be developed in the future. 3 A newspaper article published in the New York World in January 1928 recognized its potential application in the detection of cancer: Although Dr. Papanicolaou is not willing to predict how useful the new diagnostic method will be in the actual treatment of malignancy itself, it seems probable that it will prove valuable in determining cancer in the early stages of its growth when it can be more easily fought and treated. There is even hope that pre-cancerous conditions may be detected and checked. 4 Interestingly, another individual, Dr. Aurel Babeş, a Romanian pathologist, independently published an article on the same subject, Diagnostic du cancer du col utérin par les frottis ( The Diagnosis of Cancer of the Uterine Cervix from Smears ) in La Presse Medicale in April His contributions never took root and went largely unrecognized. Dr. Papanicolaou s initial work also received little notice from the medical community for more than a decade until Dr. Joseph C. Hinsey, dean of Cornell Medical College, encouraged him to resume his former research. 2 In 1939, Dr. Papanicolaou, joined by a gynecologist, Dr. Herbert Traut, reevaluated the use of the vaginal smear for the detection of cervical cancer. Their work together resulted in Diagnostic Value of Vaginal Smears in Carcinoma of the Uterus 6 in 1941 in the American Journal of Obstetrics and Gynecology, and the monograph Diagnosis of Uterine Cancer by the Vaginal Smear 7 in These publications provided evidence of a large pool of undetected cervical cancer and, more important to the development of our profession, that detection was not only possible without biopsy (the preferred method at the time) but could be practical by cytologic screening. The American Cancer Society (ACS) began to educate the public about the value of vaginal smears. As women began taking the advice of the ACS, it became obvious physicians alone would not be able to accomplish the task of evaluating these smears, and that additional personnel would need to be trained to examine the specimens. Early programs were informal, apprentice-type, on-the-job training. The first cytotechnologists were called technical assistants to the pathologist. In 1947, Dr. Papanicolaou taught his first special course in cytology. By the 1950s, the professional designation cytotechnologist, was firmly established. With acceptance of the vaginal smear technique, Dr. Papanicolaou expanded his studies to the detection of cancer in other body sites, including lung, esophagus, stomach, rectum, and bladder. In 1954, he published Atlas of Exfoliative Cytology, a work that included cancer of not only the female genital tract, but also of other body sites. 8 As the evolution of the cytologic technique was leading science beyond the vaginal smear, cervical cancer screening began to take shape. In the 1950s, public health screening projects were sponsored by the ACS and National Cancer Institute. The first large-scale, mass-screening project using the Pap smear was undertaken in 1952 in Memphis and Shelby County, TN, where various sponsoring agencies cooperated to provide cervical cancer screening to the socioeconomically diverse population. The project, funded by the United States Public Health Service for an initial period of 3 years and at an estimated cost of more than $200,000 per year, had a lofty goal: to screen 200,000 women between the ages of 20 and Early accounts of the screening project were documented in Memphis newspapers, the Memphis World and Press-Scimitar, in 1952 and Dr. C. C. Erickson, chairman of the coordinating committee, is frequently quoted in the newspaper as he tells this dramatic story of the success of the Pap smear. The articles explained cytology, Dr. Papanicolaou s discovery of the Pap smear, and the process of physical examination and sample collection. Billboards were used to prompt women to see their doctor about having this annual cancer test. Businesses urged women to get the test, and sororities raised funds to furnish clinic treatment rooms In the first 3 months of the screening project alone, 10,000 women were screened; 63 were found to have cancer. 13 Three and a half years later, 108,000 women more than half of Shelby County s female population had been examined and cancer was detected in 773 women. 9 Dr. Erickson detailed the findings of the screening project in a 1955 publication of the American Cancer Society titled CA: A Cancer Journal for Clinicians, citing 3 significant conclusions: Downloaded 202 from LABMEDICINE j Volume Number 4 j April 2008 labmedicine.com

Image 1_Dr. Papanicolaou depicted normal epithelial cells and early cancer (dyskaryotic) type cells in his 1954 publication Exfoliative Cytology.

3 Image 1_Dr. Papanicolaou depicted normal epithelial cells and early cancer (dyskaryotic) type cells in his 1954 publication Exfoliative Cytology.8 Downloaded labmedicine.com from April 2008 j Volume 39 Number 4 j LABMEDICINE 203

The greatest hope for increasing the 5-year survival rates lies in detection while the lesion is confined to the cervix.

4 1. Exfoliative cytology technique in mass screening for detection of uterine cancer is an efficient, practical test. 2. Detection by this method must be coordinated with the essential follow-up investigation of pathological studies of tissue biopsies for early diagnosis. 3. The greatest hope for increasing the 5-year survival rates lies in detection while the lesion is confined to the cervix.14 With women flocking to obtain Pap smears, one problem became obvious: Shelby County did not have enough pathologists to support the project. Fifteen girls were trained as laboratory technicians to run the tests. Another 3 girls received special training in Boston at Massachusetts General Hospital. A newspaper caption read, Cancer Hunters The success of the test hinges on highly trained cyto-technologists like these girls who painstakingly study slides under microscopes to track down cells suspicious of cancer 9 (Image 2). The success of the project led to mass cervical cancer screening programs in other large cities, including Charlotte, NC, Washington, DC, Providence, RI, Louisville, KY, Columbus, OH, and Madison, WI. More than a decade later, the April 14, 1966, New Orleans newspaper The TimesPicayune credited the Pap smear as a true life saver and should be included as part of every woman s yearly medical checkup. 15 The need for more trained cyto-technologists only increased with the expansion of screening programs. Several organizations, including the ACS, College of American Pathologists (CAP), and American Society of Clinical Pathology (ASCP), began to investigate development of standards and prerequisites for applicants to schools of cytotechnology in the 1950s. It was the ASCP Board of Schools of Medical Technology, in collaboration with the American Medical Association (AMA), that developed the first listing of tentatively approved schools in Word began to spread about the cytotechnology profession. A 1959 headline of GIST, a newsletter related to the profession of medical technology, read, Enter the Cytotechnologists! 17 Three years later, GIST reported that Cytotechnology is a profession on the move. By 1961, the ACS reported that 1,300 cytotechnologists were employed in 800 laboratories and 5,100,000 women had been served, and that the number of women served could double to approximately 11 million. More technologists would be needed to meet this demand. The success of the Pap smear and the need for more Image 2_In the 1950s, a corps of technicians at the University of Tennessee Health Sciences Center study Pap smears. In the background, framed pictures of cancer cells can be seen. 204 Downloaded from LABMEDICINE jj Volume 39 Number 4 jj April 2008 labmedicine.com

training programs for cytotechnologists prompted educational workshops in Colorado Springs, CO, in December 1961.

5 training programs for cytotechnologists prompted educational workshops in Colorado Springs, CO, in December Directors of schools of cytotechnology began to share experiences with regard to teaching techniques and student recruiting. The recommendations made at this meeting included education requirements of the faculty, the organization and allocation of study on gynecologic and nongynecologic specimens, materials, space and equipment, and time for required training. Inspections of training programs and certification that included a practical examination were also recommended.18 It was not until 1962 that the first set of educational standards, or essentials for accreditation of cytotechnology training programs, were adopted by the ASCP Board of Schools and the AMA. In the early 1970s, the responsibility of performing accreditation reviews and making recommendations to the AMA was assumed by the National Accrediting Agency for Clinical Laboratory Sciences (NAACLS), and in the mid-1970s, the AMA established the Committee on Allied Health Education and Accreditation (CAHEA) to perform the function of accreditation. Around the same time, the American Society of Cytopathology (ASC) petitioned the AMA for, and was granted recognition as, the official body that would conduct the accreditation reviews and make recommendations for action. The ASC formed the Cytotechnology Programs Review Committee (CPRC) in 1976 to fulfill the responsibility. The CPRC worked in collaboration with CAHEA until the mid-1990s, when the AMA announced its intent to discontinue providing accreditation, and the Commission on Accreditation of Allied Health Education Programs (CAAHEP), the current accrediting body, was incorporated in 1994 to assume responsibility for accreditation. While cytotechnology training started taking on a more formal structure, certification for cytotechnologists was introduced. The first cytotechnologist certification examination, offered in 1957 by the Board of Registry of Medical Technologists, was administered to 63 people and consisted of individual boxes of glass slides and questions sent to each examinee.16 These first examinees represented a 5- to 10-year backlog of individuals who had been trained in cytology as well as students completing their training in cytology at that time.19 Since that first exam, it has undergone many changes in format, transitioning first to kodachromes and written questions still being sent to individual examinees in the 1960s, to centralization of examinations in selected sites in the mid-1960s, to introduction of large color photographs that accompanied questions in the mid-1970s, to the development of computer adaptive testing (CAT) in the mid-1980s and implementation of CAT in In the early years, certification was optional, but with the advent of CLIA 88, ASCP certification or at least eligibility for certification became the rule of the land. The ASCP continues to be recognized today as the sole certifying body for cytotechnologists. With 285 individuals taking the certification exam annually, by the end of 2006 the ASCP had certified 14,423 cytotechnologists. The specialty examination Downloaded labmedicine.com from labmedicine.com April April jjvolume Volume Number Number 44 jjlabmedicine LABMEDICINE

6 in cytotechnology (SCT) was first offered in 1959 as a way to distinguish a higher level of knowledge and skill set. The exam was suspended from 1969 to 1986; yet, by the end of 2006, the ASCP had certified 555 SCT cytotechnologists (personal communication, ASCP Board of Registry, August 2, 2007). The certification exam is based on intensive practice analyses of the profession and thus reflects the role of the cytotechnologist despite its continual evolution. This role, like the profession itself, has come a long way since the discovery of the ability to detect cervical cancer by scraping cells from the cervix and examining them under the microscope. Throughout the history and evolution of the cytological technique in cancer detection, the need for cytotechnologists has been evident. Several decades ago, many forecasted the extinction of cytotechnologists with development of newer and more advanced technologies looming on the horizon. Yet, even with the advent of automated screening devices and molecular testing, the cytotechnologist has not only survived but continues to play a major role in the health care team. Far from becoming extinct, cytotechnologists have proven to be a highly adaptable breed of allied health professionals, and cytotechnology still continues to be a profession on the move! LM Acknowledgments: The authors wish to thank Barbara D. Benstein, PhD, SCT(ASCP), professor and program director of the Cytotechnology Program at the University of Tennessee Health Sciences Center, for sharing archival materials related to the Shelby County cancer detection program and the early years of the cytotechnology training program. 3. Papanicolaou GN. New cancer Diagnosis. Proc. of the 3rd Race Betterment Conference. Battle Creek, Michigan, RBF, 1928, PageWise, Inc.: Babeş A:. Diagnostic du cancer du col utérin par les frottis. Presse Med. 1928;36: Papanicolaou GN, Traut HF. The diagnostic value of vaginal smears in carcinoma of uterus. Am J Obstet Gynecol. 1941;42: Papanicolaou GN, Traut HF. Diagnosis of uterine cancer by the vaginal smear. New York; Commonwealth Fund: Papanicolaou GN. Atlas of exfoliative cytology. Massachusetts; Commonwealth Fund: Porteous C. Memphis site for national cancer tests. University of Tennessee Health Sciences Center Cytotechnology Program, College of Allied Health Sciences, archived materials. 10. Cancer survey project results. Memphis World. Memphis, TN. December 12, Sorority girls help fight against cancer menace. Press-Scimitar. Memphis, TN. May 8, Bruce R. National may take up city s cancer survey. The Commercial Appeal. Memphis, TN. May 3, Hamilton R. Physicians examine 10,000 women 63 cancer cases. Press- Scimitar. Memphis, TN. December 11, Erickson C. Exfoliative cytology in mass screening for uterine cancer: Memphis and Shelby County, Tennessee. CA Cancer J Clin. 1955;5; Schoenberger P. Memphis winning battle against cervical cancer. The Times- Picayune. New Orleans, LA. April 14, Patten F. Cytotechnology: The first half-century. The ASC Bulletin. 2002:39: National Committee for Careers in Medical Technology. GIST. 1959;2: National Committee for Careers in Medical Technology. GIST. 1962;17: Rube I. Cytotechnology: Current status of certification and program accreditation. Lab Med. 1983;4: Naylor B. The century for cytopathology. Acta Cytologica. 2000;44: [No author]. George Nicholas Papanicolaou ( ). CA Cancer J Clin. 1973;23: Downloaded 206 from LABMEDICINE j Volume Number 4 j April 2008 labmedicine.com

Reports. The Current State of Medical Laboratory Staffing With Certified Versus Noncertified Personnel

Reports. The Current State of Medical Laboratory Staffing With Certified Versus Noncertified Personnel The Current State of Medical Laboratory Staffing With Certified Versus Noncertified Personnel Nancie Noie Thompson, 1 Patricia Tanabe, MPA, MT(ASCP), 2 E. Blair Holladay, PhD, SCT(ASCP), 2 Andrea Bennett,