Transcript Non Gynaecological Cytology A dinosaur facing extinction

Cytologists - an
endangered species?
Behdad Shambayati
Surrey Pathology Service
An endangered species is a population of
organisms which is facing a high risk of
becoming extinct because it is either few in
numbers, or threatened by changing
environmental or predation parameters.
“It is not the strongest of the
species that survives, nor the
most intelligent that survives. It is
the one that is the most
adaptable to change.”
Charles Darwin
Cytology
“A Dinosaur Facing
Extinction?”
Behdad Shambayati
Ashford and St.Peters HospitalChertsey, Surrey
What Happened to Dinosaurs?
Background extinction
 Slow decline in numbers leading to
eventual extinction
Sudden extinction
 Mass extinction theories
 Most
likely- a slow decline followed by
catastrophic event
THE ALVAREZ ASTEROID
IMPACT THEORY
 widely
accepted theory (proposed in 1980
by physicist/geologist Luis Alvarez), is that
an asteroid 4-9 miles (6-15 km) in
diameter hit the Earth about 65 million
years ago.
The Alvarez asteroid impact theory
“KT extinction”
Cause of Cytologist
Mass Extinction?
Is cytology
facing
background extinction?
1960s- 1990s
Golden age of cytology
Exfoliative Cytology

Respiratory cytology



Urinary




Bronchial samples
Sputum
Voided urine
Washings
Renal Pelvis brushings
GI tract samples



Oesophagus
Stomach
Duodenal, biliary ducts etc
Skin scrapings
Effusion Cytology
CSF
Synovial fluid
Oral scrapings
1960s- 1990s
Golden age of cytology
FNA Cytology

Breast
 Prostate
 Liver
 Lymph nodes
 Kidney & renal pelvis
 Lung
 Thyroid
The carotid body
Bone
The Gonads
Pancreas
Salivary glands
The eye
Soft tissue tumours
Current practice (2004)
Exfoliative Cytology

Respiratory cytology



Urinary




Bronchial samples
Sputum
Voided urine
Washings
Renal Pelvis brushings
GI tract samples



Oesophagus
Stomach
Duodenal, biliary ducts etc
Skin scrapings
Effusion Cytology
CSF
Synovial fluid
Oral scrapings
Current practice (2004)
FNA Cytology

Breast
 Prostate
 Liver
 Lymph nodes
 Kidney & renal pelvis
 Lung
 Thyroid
The carotid body
Bone
The Gonads
Pancreas
Salivary glands
The eye
Soft tissue tumours
? Drivers for the decline in nongynae cytology

Consultant staffing shortage


Some consultant histopathologist apathy towards cytology /non-gynae




Gynae backlogs
Loss of technical expertise in the labs


“Do a biopsy” recommendation
Core biopsy and same day processing can give good TAT
Fear of litigation
Technical staffing shortage


No support for FNA service
Overuse of untrained MLAs
Poor sample preparations
? Drivers for the decline in nongynae cytology

No tissue architecture


Eg Breast (insitu vs invasive carcinoma)
Specific tumour subtyping not always possible

Eg Poorly squamous carcinoma vs adnocarinoma in respiratory cytology

Inadequate samples

Requires practice


Dabbling will not work eg bile duct brushings
Small sample size

? Can not do ancillary test easily• Enough tissue EFGR, KRAS etc
? Drivers for the decline in gynae
cytology

Cytology numbers on the decrease due to fall in
coverage and change in screening age range

Automation (FocalPoint) and HPV testing (especially
primary screening with HPV testing) will reduce
(dramatically) the cytologists’ workload
•

Mergers & centralisation will result in some cytologists
resigning / retiring / redundant!

Who will prepare non-gynae samples?
•
•
Hot lab cytology
Histology department
? Drivers for the decline in gynae
cytology- HPV primary screening

May result in extended screening interval

Will negate the requirement for ‘primary
screening cytologists’ – we will only need
‘checkers’ & ‘reporters’

Molecular markers may replace cytology as the
method of triage in HPV primary screening –
what role will be left for cytologists?
General factors
 Fewer,
larger laboratories are inevitable.
This limits the vocational geographic
location of cytologists
General factors
“Cytology- not an attractive
career”
 Absence

of HSST in MSC
Scientists unable to progress to highest level
in MSC) will limit the desire for scientists to
choose cytology as an option
 Lost
opportunity as experienced BMS
have wealth of transferable microscopy
skills
10,000 hours or 10 year rule

10,000 hours of purposeful of practice in any
subject to achieve mastery
“The role of deliberate practice in the acquisition of
expert performance”
Ericsson etal
Psychological review 100, no 3 (1993): 363-406
Average hour practised (violin
players)
Hours/day
Week (5
days)
Year
10 year
total
0.5
2-3
100-150
1000-1500
Most amateurs
1
5
250
2500
Keen
amateurs
2
10
500
5000
Teachers
3
15
750
7500
Professional
players
4+
20
1000
10,000
Top
professionals
Other examples
• Andy Murray
– 2003 started out on the Challenger and Futures
circuit, 2012 wins first Grand Slam finals
• Bill Gates drops out of Harvard and start a
company…
– By then he had exceeded 10,000 hours of computer
programming in previous 7 years
• Beatles
– 10 years from founding until success of White album
Conclusion
Collaborative Working to harness
existing experience and skills in
BMS cytologists to maintain the
current standards in cervical
screening and help to develop
diagnostic cytology and stop its
path to extinction in near future
Must practice EVIDENCE based
medicine
not
EMINENCE based medicine
Coelacanth ….living fossil

The coelacanth has been nicknamed a “living
fossil”, because it originally was known only
through fossils. The coelacanth is thought to
have evolved into roughly its current form
approximately 400 million years ago
Cytology needs to evolve