HPV testing will be introduced as the primary screening modality in the cervical screening programmes in all four nations of the UK as well as the Republic of Ireland in the near future.
This will lead, in all or most countries, to centralisation of laboratories and a reduction in the number of cervical cytology slides that will be prepared and therefore require screening. Clearly, there will be significant changes for staff of all grades currently working in Cytology.
In parallel with this, however, there are many potential opportunities for staff trained in cytomorphology which could be used in diagnostic cytology or related disciplines. Examples include the provision of Rapid Onsite Evaluation (ROSE) for the purposes of adequacy and specimen management, Andrology service development, assessment of material for molecular analysis and so on.
The BAC was interested to see whether the HPV pilot sites had, firstly, made plans for diversification of staff skills as a result of HPV primary screening; secondly, whether they had views as to the reporting of cases which had been primarily tested for HPV and lastly, what changes they could foresee would be needed in education and training for cytology staff.
Consequently, in May 2017, the BAC sent a letter to the six HPV primary screening pilot sites asking for their views of and preparations for both cervical and diagnostic cytology services following the introduction of HPV primary screening. Within the letter were six questions, preceded with the caveat that:
“We appreciate that the bidding process for the screening sites has not yet started and that the future role for individual laboratories and services is not certain.”
Four responses were received (arbitrarily referred to as sites 1-4 below), one site declined to comment and one did not respond to two requests. The comments received by question are as follows:
What provision are you planning to make or have you already made for any redeployment of your current screening staff into other roles in cervical cytology, diagnostic cytology, HPV testing, cellular pathology or elsewhere, including administrative roles, and do you have an estimate of how many of these individuals are considering leaving the service entirely?
Sites 1 and 2 said that they were making no provision for any redeployment and one of these stated that all staff were aware of the risk to their employment. Site 3 also said that they were not “currently progressing redeployment” and that the age profile of their service meant that they had seen a significant reduction in screening capacity due to retirement. However, this site was separately developing their diagnostic cytology service (see below). The main change was that they had ceased to take on trainees.
Site 4 was the only one of the responders to confirm a significant attempt at redeployment in that “full time screening staff partake in NG prep. Some are trained in HPV testing. Some were previously Histology staff and will be spending some time in Histology as a trial.” This site also stated that part time screening staff are likely to retire.
Are you considering a change or expansion in your diagnostic cytopathology repertoire?
Sites 1, 2 and 3 all either stated or implied that the diagnostic cytology service was essentially a separate entity, to be considered separately. Site 1 said that “the diagnostic cytology service workload has been gradually declining over the past few years and has probably reached a steady state [although] the repertoire has changed.”
In site 2, “diagnostic cytology [is] based in histology although we have helped and advised on improving the service in the past. [There are no plans] to develop the diagnostic cytology service as it is adequate however there may be an opportunity in the future.”
In site 3, “[the] diagnostic cytopathology service is evolving, but this is independent from the changes to cervical screening. [There has been] a dramatic reduction in the utilisation of breast cytology but an expansion in demand for EBUS, head and neck FNA and EUS FNA services. [We are] expanding the contribution that BMS staff make to non-gynae, with increased in-clinic adequacy assessment and reporting of exfoliative cytology in line with the IBMS/RCPath qualification framework.” Thus, there is an explicit reference to expansion of Rapid OnSite Evaluation (ROSE) and the Diploma of Expert Practice (DEP) and Advanced Specialist Diploma (ASD) in non-gynaecological cytology.
Site 4 confirmed that they were expanding their repertoire of diagnostic cytopathology but gave no further details.
If you became an HPV testing/cytology hub in 2019, what relationship do you anticipate there being between the cervical screening service and diagnostic cytology?
All of the four sites anticipated the relationship to be the same as now. Site 3 elaborated that “the cytology service is co-located but not all staff are shared.” Site 4 stated that there was “staff rotation.”
Have you noticed any changes in the screening, checking or reporting processes when knowledge of HPV status is known?
No site reported a significant change, site 1 commenting that “there has been no increase in abnormal reporting, and fairly strong correlation between first cytology screen and final reporting.”
Site 2 said that there were “very rare” examples of screeners upgrading reactive endocervical/metaplastic cells to borderline endocervical cells in the presence of known HPV18 positivity. Site 2 had also noticed “that if there are minimal changes and depending on compliance these may well be ignored as the woman should be back in 12 months.”
Site 3: “No, but this is with an experienced staff group.” Site 3 elaborate below (see last question) as to why they are not “confident that inexperienced staff entering the programme from the current training arrangements would cope with the context bias so well.”
Site 4 state that there are no changes, other than “a minority of primary screening staff reported slower screening rates for HPV pos samples and overcalling.”
What grade/s of staff do you anticipate will be examining cervical cytology slides post introduction of HPV primary screening?
There is some divergence in response as regards the checker role. Sites 1, 2 and 3 anticipate there being none.
Site 1: “All. At [Site1], HPV+ve slides have one full cytology screen and straight to AP/Paths if abnormal. For the 1st phase of HPV roll-out we used BMS 7 (checkers), and 2nd phase we have expanded this team to include BMS 5 & 6 grade.” In other words, bands 5,6 and 7 are now used as the only intermediate step between primary HPV testing and AP/pathologist for the abnormal cases and all provide the same function, whatever it is called.
Site 2 stated that “we anticipate that you will still need screeners as 70% of samples are negative cytologically so we still need their locating skills and the ABMSP/consultant will do the reporting i.e. no checking. We have evidence to support this that screeners were overall slightly better than checkers and that adding the checking step added no value to the end report.”
Site 3 “anticipate a single primary screen by competent staff followed by rapid review for negative/inadequates and direct to pathologist/AP for potential abnormals...[and]…don’t anticipate a checker function.”
Only site 4 anticipate “same system as now – primary screeners and QC at band 4,5,6 level with band 7 checkers.”
Have you any views on the future training or educational needs of staff within the cervical screening service or those in diagnostic cytology?
This produced the most diverse and discursive set of answers as follows:
Site 1: “Cervical screening is becoming increasingly complex. We plan to recruit and train staff able to demonstrate sufficient academic competence to maintain and develop the service to include cytology screener and BMS grades. In view of the reduced number of staff required to view slides and scale of reconfiguration/ population sizes to be covered by individual labs, sufficient BMS level of knowledge and expertise will be required, to a) meet non-screening roles within the department b) future proof BMS staffing structure. Conversely we have experienced lack of willingness of BMS staff to progress their cytology BMS career due to job uncertainty. There are no plans to divert educational resource to diagnostic cytology.”
Site 2: “The message needs to get across that just because a woman is HPV pos doesn’t mean that she will have disease and that if a woman has symptoms such as PMB she may have an underlying pathology that is not HPV driven and should be investigated appropriately regardless of the cervical sample result.”
Site 3 felt that the impact on primary screening staff and on AP/pathologists would be different and considered them separately as follows:
“Primary screening staff
The provision of a HPV primary screening service provides a considerable training challenge for the screening workforce. I do not believe that the current method of gradually acquiring knowledge and skills over a (minimum) 2 year period, followed by a period of supported practice proceeding to a checker role is practicable in a HPV primary screening environment. The context bias of HPV primary cytology is very different from conventional cytology. In the latter the expectation is that the slide will be negative whereas in the latter it is the reverse. In this regard, the primary screeners are required to undertake a role that is far more akin to the traditional checker role. Established screening staff in my experience cope with this well but inexperienced staff progressing through a training programme will need careful instruction. In essence, the training needs to change from teaching people to recognise abnormal cells to teaching them to recognise normal cells and confidently (and correctly) report cases as cytologically negative. (BAC underline)
For the next few years, the workforce requirements at this level will remain similar to current. The method of training currently used will also remain valid as the shift in context bias seen for primary screening does not apply to the AP/pathologist workload (where currently the expectation is for abnormality). Particularly for medical staff, there are implications for availability of training, however. It has already been made public by PHE that the preferred service delivery model is for a dramatic reduction in the number of units offering cervical cytology which serves to separate cervical cytology from the general training rotation that pathologists utilise. Looking further ahead, the implications of the HPV vaccination programme become relevant. If the Scottish data is replicated in England and Wales, it is likely that in 10 years’ time there will be a dramatic reduction in HPV positivity in the screened population due to the 25-35 year cohort having been vaccinated. This would impact the workforce requirements at AP/pathologist level. A further factor driving down the workload is a recommendation for extension of screening intervals that seems to be probable in this timeframe. I can see a scenario in the 10 – 20 year timescale when cervical screening is no longer appropriate due to changes in disease prevalence.”
Site 4 felt that there needs to be “more Consultant BMS training to make up for lack of Pathologists [and] more diagnostic Cytology training for BMS reporting.”
Any plans for staff redeployment as a result of HPV primary screening?
Any plans for change or expansion of diagnostic cytology?
If an HPV hub in 2019, what relationship between cervical and diagnostic cytology?
Same as now – all sites
Any change in screening, checking and reporting with knowledge of HPV status?
No significant change – all sites
What grades of staff will be involved in cervical cytology post-HPV?
Views on future training/educational needs of staff – various points
• Need screeners and BMS grades
• Need some BMSs to develop non-screening roles in cervical screening
• Some BMSs unwilling to progress cytology career due to job uncertainty
• Need to make points that:
• Different context bias due to higher percentage of abnormal cases:
• For APs/pathologists:
• More consultant BMS training to make up for lack of pathologists
• More diagnostic cytology training for BMS reporting