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Crothers BA, Ghofrani M, Zhao C, Dodd LG, Goodrich K, Husain M, Kurtycz DF, Russell DK, Shen RZ, Souers RJ, Staats PN, Tabatabai ZL, Witt BL, Davey DD. Low-Grade Squamous Intraepithelial Lesion or High-Grade Squamous Intraepithelial Lesion? Concordance Between the Interpretation of Low-Grade Squamous Intraepithelial Lesion and High-Grade Squamous Intraepithelial Lesion in Papanicolaou Tests: Results From the College of American Pathologists PAP Education Program. Arch Pathol Lab Med 2018; 143:81-85. [DOI: 10.5858/arpa.2018-0003-cp] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Obtaining diagnostic concordance for squamous intraepithelial lesions in cytology can be challenging.
Objective.—
To determine diagnostic concordance for biopsy-proven low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) Papanicolaou test slides in the College of American Pathologists PAP Education program.
Design.—
We analyzed 121 059 responses from 4251 LSIL and HSIL slides for the interval 2004 to 2013 using a nonlinear mixed-model fit for reference diagnosis, preparation type, and participant type. We evaluated interactions between the reference diagnosis and the other 2 factors in addition to a repeated-measures component to adjust for slide-specific performance.
Results.—
There was a statistically significant difference between misclassification of LSIL (2.4%; 1384 of 57 664) and HSIL (4.4%; 2762 of 63 395). There was no performance difference between pathologists and cytotechnologists for LSIL, but cytotechnologists had a significantly higher HSIL misclassification rate than pathologists (5.5%; 1437 of 27 534 versus 4.0%; 1032 of 25 630; P = .01), and both were more likely to misrepresent HSIL as LSIL (P < .001) than the reverse. ThinPrep LSIL slides were more likely to be misclassified as HSIL (2.4%; 920 of 38 582) than SurePath LSIL slides (1.5%; 198 of 13 196), but conventional slides were the most likely to be misclassified in both categories (4.5%; 266 of 5886 for LSIL, and 6.5%; 573 of 8825 for HSIL).
Conclusions.—
More participants undercalled HSIL as LSIL (false-negative) than overcalled LSIL as HSIL (false-positive) in the PAP Education program, with conventional slides more likely to be misclassified than ThinPrep or SurePath slides. Pathologists and cytotechnologists classify LSIL equally well, but cytotechnologists are significantly more likely to undercall HSIL as LSIL than are pathologists.
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Affiliation(s)
- Barbara A. Crothers
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Mohiedean Ghofrani
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Chengquan Zhao
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Leslie G. Dodd
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Kelly Goodrich
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Mujtaba Husain
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Daniel F.I. Kurtycz
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Donna K. Russell
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Rulong Z. Shen
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Rhona J. Souers
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Paul N. Staats
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Z. Laura Tabatabai
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Benjamin L. Witt
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
| | - Diane Davis Davey
- From the Joint Pathology Center, Silver Spring, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, University of North Carolina Hospital, Chapel Hill (Dr Dodd); the Surveys Department (Ms Goodrich) a
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Zhao C, Crothers BA, Ghofrani M, Li Z, Souers RJ, Hussain M, Fan F, Ocal IT, Davey DD. Misinterpretation Rates of High-Grade Squamous Intraepithelial Lesion in the College of American Pathologists Gynecologic PAP Education and PAP Proficiency Test Program. Arch Pathol Lab Med 2016; 140:1221-1224. [DOI: 10.5858/arpa.2015-0446-cp] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Misinterpretation of high-grade squamous intraepithelial lesion (HSIL) is an important problem in daily practice and in the College of American Pathologists (CAP) PAP Proficiency Test (PAP-PT).
Objective.—
To investigate factors related to misinterpretation of HSIL through responses in a proficiency test versus an educational environment.
Design.—
We retrospectively evaluated 28 000 responses in the PAP Education Program (PAP-Edu) and 59 140 responses in PAP-PT from 1147 field-validated HSIL slides from 2007 to 2014. The related factors, such as program types, preparation types, participant types, and program years, were evaluated.
Results.—
Overall, 4.0% (2379 of 59 140) of responses for HSIL slides from PAP-PT were misinterpreted as either low-grade squamous intraepithelial lesion (LSIL) or negative, significantly more than those from PAP-Edu (3.2%; 898 of 28 000). However, the false-negative rate (misinterpreted as negative) was 0.9% (519 of 59 140) for PAP-PT, lower than that for PAP-Edu (1.0%; 266 of 28 000). The misinterpretation rates in PAP-PT trended down with time. Misinterpretation rates did not vary significantly by preparation methods. The misinterpretation rate for HSIL in the pathologists' responses was lower than that in cytotechnologists' responses in PAP-PT. More HSIL was misinterpreted as LSIL than as benign in both programs. Cytotechnologists interpreted HSIL as LSIL twice as much as pathologists. The most common false-negative misinterpretations were negative for intraepithelial lesion or malignancy and reparative change.
Conclusions.—
The higher LSIL misinterpretation rate by cytotechnologists may be related to the differences in reporting responsibilities and proficiency test grading criteria. The trend of gradually decreasing misinterpretation rates of a reference diagnosis of HSIL in the PAP-PT program may be related to higher test-taking confidence and better preparation through educational programs. The fact that pathologists performed better than cytotechnologists in PAP-PT, but not in PAP-Edu, may reflect a heightened approach and attentiveness in the test-taking environment for pathologists.
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Affiliation(s)
- Chengquan Zhao
- From the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); the Department of Pathology, Walter Reed National Military Medical Center, Bethesda, Maryland (Dr Crothers); the Department of Pathology, PeaceHealth Laboratories, Vancouver, Washington (Dr Ghofrani); the Department of Pathology, Ohio State University Medical Center, Columbus (Dr Li); th
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Crothers BA, Booth CN, Darragh TM, Zhao C, Souers RJ, Thomas N, Moriarty AT. False-positive Papanicolaou (PAP) test rates in the College of American Pathologists PAP education and PAP proficiency test programs: evaluation of false-positive responses of high-grade squamous intraepithelial lesion or cancer to a negative reference diagnosis. Arch Pathol Lab Med 2014; 138:613-9. [PMID: 24786119 DOI: 10.5858/arpa.2013-0083-cp] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT In cytology proficiency testing (PT), participants fail for incorrectly interpreting a high-grade squamous intraepithelial lesion or cancer (HSIL+) Papanicolaou test result as negative. This penalty may lead to a false-positive interpretation of negative slides as HSIL+ to avoid failure. OBJECTIVE To investigate factors related to false-positive responses in a PT versus an educational environment. DESIGN We analyzed 420,079 responses from 9414 validated negative reference slides in the College of American Pathologists Interlaboratory Comparison Program in Gynecologic Cytopathology (PAP Education) and compared them with responses from the Gynecologic Cytology Proficiency Testing Program for the percentage of false-positive (HSIL+) interpretations in each of 7 negative subcategories. We evaluated the influence of preparation type (ThinPrep, SurePath, and conventional Papanicolaou test), participant type (pathologist or cytotechnologist), and program time interval (preproficiency test or PT) on a false-positive response. RESULTS Reference diagnosis and participant type, but not preparation type, were statistically correlated to false-positive responses. The interaction between program time interval and participant type was also significant. Pathologists had higher rates of false-positive results on preproficiency test (1.2% [800 of 68,690]) than they did on PT (0.8% [993 of 129,857]). Cytotechnologists had no differences between program time intervals (preproficiency, 0.9% [515 of 63,281] versus PT, 1.0 [1231 of 121,621]; P = .91). Negative subcategories frequently mistaken for HSIL+ were reparative changes (4.7% [427 of 9069]), atrophic vaginitis (1.8% [18 of 987]), and negative for intraepithelial lesion or malignancy (1.2% [2143 of 178,651]), but during PT, false-positive rates were significantly increased only for the negative for intraepithelial lesion or malignancy and herpes simplex virus (P < .001). CONCLUSIONS Pathologists had lower false-positive rates in the Gynecologic Cytology Proficiency Testing Program than they did in PAP Education, but participants were more likely to report a false-positive response (HSIL+) for negative for intraepithelial lesion or malignancy and herpes simplex virus in the Gynecologic Cytology Proficiency Test Program.
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Affiliation(s)
- Barbara A Crothers
- From the Department of Pathology and Laboratory Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland (Dr Crothers); the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Booth); the Pathology Cytopathology Laboratory, Mount Zion Medical Center Clinic, University of California, San Francisco (Dr Darragh); Department of Pathology, Magee-Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Zhao); and the Departments of Statistics/Biostatistics (Ms Souers), CAP PAP Program (Ms Thomas), and Pathology (Dr Moriarty), College of American Pathologists, Northfield, Illinois
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Davey DD, Austin RM, Birdsong G, Zaleski S. The impact of the Clinical Laboratory Improvement Amendments of 1988 on cytopathology practice: a 25th anniversary review. J Am Soc Cytopathol 2014; 3:188-198. [PMID: 31051685 DOI: 10.1016/j.jasc.2014.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/15/2014] [Indexed: 11/26/2022]
Abstract
The Clinical Laboratory Improvement Amendments of 1988 were passed into law on October 31, 1988; regulations implementing this law have had a dramatic impact on the practice of cytology as well as the operations of the entire laboratory. Articles in the popular press followed by congressional hearings exposed faulty laboratory practices, with false-negative Pap tests being a major focus. The impact of this law on the cytology profession is reviewed in this paper. We discuss the response by professional organizations and laboratories to proposed regulations, including formation of consortium groups, development of interlaboratory comparison programs, and more stringent laboratory accreditation and inspection procedures. Public perceptions related to false-negative Pap tests and the litigation crisis are reviewed, as well as the development of new technologies that would improve test accuracy. Finally, the role of the Clinical Laboratory Improvement Advisory Committee in advising the government on laboratory regulations and cytology proficiency testing is discussed. Many of the regulations have promoted quality practices and cytology accuracy, but others have proven relatively inflexible and may have blocked innovation.
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Affiliation(s)
- Diane Davis Davey
- Department of Clinical Sciences, University of Central Florida College of Medicine and Orlando VAMC, Orlando, Florida.
| | - R Marshall Austin
- Department of Pathology, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - George Birdsong
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine and Grady Health System, Atlanta, Georgia
| | - Sue Zaleski
- Office of Operations Excellence, University of Iowa Health Care, Iowa City, Iowa
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Howell LP, Nayar R, Savaloja L, Tabbara S, Thomas N, Winkler B, Tworek J. The role of proficiency testing in ensuring quality: findings from the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference working group 3. Arch Pathol Lab Med 2013; 137:183-9. [PMID: 23368860 DOI: 10.5858/arpa.2012-0094-oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Implementation of proficiency testing for gynecologic cytology was delayed 20 years because of challenges addressing the subjective nature of cytologic interpretation and replicating normal working conditions. Concern remains regarding test scoring, slide validation, test environment, and other issues. How these test results are, or should be, used in quality management has never been explored. OBJECTIVE To provide information on good laboratory practices for gynecologic cytology proficiency testing based on findings from the College of American Pathologists' survey-based project funded by the Centers for Disease Control and Prevention. DATA SOURCES An expert working group evaluated results from a Web-based, national laboratory survey plus responses from follow-up questions and findings from the literature. The group created statements on good laboratory practices pertinent to proficiency testing and its role in quality management, which were discussed and voted on at a consensus conference. CONCLUSIONS Two-thirds of laboratories report having an individual with an unsuccessful proficiency testing score. More than 90% did not initiate any remedial action for 1 or 2 unsuccessful tests; 84% of laboratories reported they actively monitored results from proficiency testing, but most laboratories did not initiate any remedial action for cytotechnologists (81.4%; 376 of 462) or pathologists (87.7%; 405 of 462) who passed a proficiency test but who did not score 100%. Proficiency testing pass-fail rates should be monitored globally for the laboratory and for each individual. Proficiency testing slides should be prescreened by cytotechnologists for pathologists who are not primary screeners. Remedial action should not be required for a passed, but imperfect, test. No remedial action is required for an unsuccessful, first proficiency test result before retesting.
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Affiliation(s)
- Lydia Pleotis Howell
- Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento, California 95817, USA.
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