Liquid-based cytology can improve efficiency of cervical smear readers: evidence from timing surveys in two NHS cytology laboratories

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.

The advantages of incorporating liquid-based cytology (TACAS™) in mass screening for cervical cancer

We incorporated liquid-based cytology (LBC) in population-based screening for cervical cancer. The usefulness of using LBC in mass screening for cervical cancer was examined. From 2009 to 2014, 157,061 individuals underwent mass screening for cervical cancer in Aomori Prefecture. From 2009 to 2011, cells were collected from 82,218 individuals and the specimens were conventionally prepared (CP). From 2012 to 2014, cells were collected from 74,843 individuals and the specimens were prepared using LBC (TACAS™). Cytology results for the 2 sets of specimens were compared and differences in cytologic features were examined. ASC-US and more severe lesions were detected at a rate of 1.13 % by CP and 1.44 % by LBC, so LBC had a 1.3-fold higher rate of detection. LBC had a 1.6-fold higher rate of LSIL detection and a 1.2-fold higher rate of HSIL detection. CP detected cancer in 20 cases at a rate of 0.024 % while LBC detected cancer in 18 cases at a rate of 0.024 %. Cytodiagnosis of the 18 cases of SCC that LBC identified revealed that 7 were SCC, 8 were HSIL, and 3 were ASC-H. Atypical cells tended to be smaller with TACAS™. LBC reduced the time needed for microscopic examination of a single specimen by 42 % in comparison to CP. LBC using TACAS™ allowed the detection of slight lesions and slight changes in cells. LBC can lessen the burden on medical personnel and may lead to improved accuracy.

Evaluation of a New Automated Processing System (TACAS™ Pro) for Liquid-Based Procedures

OBJECTIVE

To evaluate a fully automated processing system (TACAS™ Pro) for liquid-based procedures (LBPs).

METHODS AND MATERIALS

Materials were 3,483 and additionally 502 specimens that were taken at Kanagawa Health Service Association. Specimens obtained with a Cervex-Brush® were first smeared to glass slides using one side of the brush and then processed to TACAS Pro.

RESULTS

(1) The microscopy watching time per normal case was 3.65 ± 0.85 min in the conventional procedure, whereas in the LBP it was 1.95 ± 0.60 min, and the latter reduced workload to 53%. (2) The handling time of TACAS Pro per day was 2 h and 25.8 min. The workload at a laboratory offset it and revealed the work saving to be 63.8%. (3) Unsatisfactory rates were 0% in the conventional procedure, whereas in the LBP it was 1.88% at first. The latter rate decreased to 0.5% after system improvement. (4) Specimens which may disturb microscopy analysis were found in 1.06%, including 3 cases of possible carry-over of cells to the following slides. An additional study with the revised system confirmed no carry-over. (5) Incidences of abnormal cytology were consistent between the two methods.

CONCLUSIONS

The revised automated processing system TACAS Pro is a feasible and useful LBP and reduces the workload of cytology laboratories.

Health technology assessment of computer-assisted pap test screening in Italy

OBJECTIVE

To assess the introduction of computer-assisted Pap test screening in cervical cancer screening. Various scenarios are considered: conventional and liquid-based cytology (LBC) slides, fully automatic instrumentation (Becton Dickinson FocalPoint™ Slide Profiler and Hologic ThinPrep® Imaging System), and semiautomatic scanner (Hologic Integrated Imager I-Squared).

METHODS

A working group was formed that included researchers from the largest centers already using instrumentation. A questionnaire on laboratory management and on social/ethical issues and annual workload was proposed. Prices for the technology were obtained directly from the producers; costs were calculated from observed and literature data. The scope of the report and final draft were submitted to a consulting committee of stakeholders.

RESULTS

The break-even point was found to be 49,000 cases/year, if conventional slides were used, while it was near the theoretical maximum capacity, 70,000 cases/year, with LBC slides. Efficiency increased with the volume of slides. Screening time decreased by two thirds for conventional slides and by less than half for LBC slides. Acceptance of the instrumentation by the users was good.

CONCLUSIONS

Computer-assisted screening may increase productivity even if in most situations it will mean additional costs. Furthermore, primary screening with human papillomavirus tests will drastically reduce the need for Pap test reading.

Cytological Evaluation and REBA HPV-ID HPV Testing of Newly Developed Liquid-Based Cytology, EASYPREP: Comparison with SurePath

Background

The objective of this study was to evaluate a newly-developed EASYPREP liquid-based cytology method in cervicovaginal specimens and compare it with SurePath.

Methods

Cervicovaginal specimens were prospectively collected from 1,000 patients with EASYPREP and SurePath. The specimens were first collected by brushing for SurePath and second for EASYPREP. The specimens of both methods were diagnosed according to the Bethesda System. Additionally, we performed to REBA HPV-ID genotyping and sequencing analysis for human papillomavirus (HPV) on 249 specimens.

Results

EASYPREP and SurePath showed even distribution of cells and were equal in cellularity and staining quality. The diagnostic agreement between the two methods was 96.5%. Based on the standard of SurePath, the sensitivity, specificity, positive predictive value, and negative predictive value of EASYPREP were 90.7%, 99.2%, 94.8%, and 98.5%, respectively. The positivity of REBA HPV-ID was 49.4% and 95.1% in normal and abnormal cytological samples, respectively. The result of REBA HPV-ID had high concordance with sequencing analysis.

Conclusions

EASYPREP provided comparable results to SurePath in the diagnosis and staining quality of cytology examinations and in HPV testing with REBA HPV-ID. EASYPREP could be another LBC method choice for the cervicovaginal specimens. Additionally, REBA HPV-ID may be a useful method for HPV genotyping.

Liquid-based cervical cytology using ThinPrep technology: weighing the pros and cons in a cost-effectiveness analysis

PURPOSE

Cervical cancer screening with liquid-based cytology (LBC) has been developed as an alternative to the conventional Papanicolaou (CP) smear. Cost-effectiveness is one of the issues when evaluating LBC. Based on the results of a Dutch randomised controlled trial, we conducted cost-effectiveness threshold analyses to investigate under what circumstances manually screened ThinPrep LBC is cost-effective for screening.

METHODS

The MISCAN-Cervix microsimulation model and data from the Dutch NETHCON trial (including 89,784 women) were used to estimate the costs and (quality-adjusted) life years ((QA)LYs) gained for EU screening schedules, varying cost-effectiveness threshold values. Screening strategies were primary cytological screening with LBC or CP, and triage with human papillomavirus (HPV) testing.

RESULTS

Threshold analyses showed that screening with LBC as a primary test can be cost-effective if LBC is less than <euro>3.2 more costly per test than CP, if the sensitivity of LBC is at least 3-5 % points higher than CP, if the quality of life for women in triage follow-up is only 0.39, or if the rate of inadequate CP smears is at least 16.2 %.

CONCLUSIONS

Regarding test characteristics and costs of LBC and CP, only under certain conditions will a change from CP to manually screened ThinPrep LBC be cost-effective. If none of these conditions are met, implementation of manually screened ThinPrep LBC seems warranted only if there are advantages other than cost-effectiveness. Further research is needed to establish whether other LBC systems will be more favorable with regard to cost-effectiveness.

Assessing the wellbeing of cytoscreeners: experience in two NHS cytology laboratories

OBJECTIVE

Cervical screening programmes in England are in transition as the liquid-based cytology (LBC) method replaces conventional Papanicolaou screening and staff in NHS laboratories are trained to analyse LBC smears. Cytoscreeners and biomedical scientists undertake routine microscopy of slides, but the scientists usually have a wider professional role. Attitudinal surveys were carried out in laboratories where LBC was partially introduced.

METHODS

Staff in two cytology laboratories in Greater Manchester were surveyed twice over 6 months. The questionnaire assessed work pressures using scales from the Measures of Work Characteristics instrument, work-related stress using the General Survey version of the Maslach Burnout Inventory, job intentions and job satisfaction.

RESULTS

Cytoscreeners, many aged over 50 years, formed over 60% of respondents in both surveys (27/42 in the first survey), and biomedical scientists and doctors, 30%. Both groups were under moderate pressure from work demands in each survey, but cytoscreeners had significantly less autonomy over their working methods (P < 0.001). Although both groups experienced similar levels of exhaustion, cytoscreeners were much more cynical or indifferent towards work in the second survey (P = 0.008) and had lower expectations of being effective (P < 0.001). For the cytoscreeners, there were strong negative correlations in both surveys between cynicism and the work characteristics of influencing decisions and autonomy/control.

CONCLUSIONS

The strength of the relationship between work performance and wellbeing serves to emphasize the importance of the new LBC technology in ameliorating low morale where it exists. Further attitudinal research involving larger samples of laboratories is warranted to assess the full impact of this innovation.