BAC AGM, 4th November 2017, National Railway Museum, York
A post conference reflection by Jenny Davies, FIBMS
Although I have retired, I like to keep up with what is happening in my “old” profession and was enticed to attend this meeting by such a great looking programme. I did arrive in York early though to get my brain fired up with a full English breakfast!
When I started working in cytology there were no computerised records, reports were typed using a typewriter (and quite a bit of Tippex), no call/recall and immuno-histo/cytochemistry was in its infancy. How things have moved on at an almost exponential rate!
After meeting the all-important commercial partners, the scientific programme began with Professor Andrew Fischer from USA telling us not to throw away out microscopes (as if we would). It was quite evident that molecular testing is not a cheap alternative to visual microscopic screening and evaluation, given the cost of machines and sequencing/visualisation reagents, but some criteria for malignancy could be linked to the function of certain oncogenes. 96.5% of driver genes have been detected for Papillary Thyroid Carcinoma, but some 36 years later, the activity of RAS oncogene is still not fully understood.
Using analogies to nature and Darwin’s Finches, he explained that structure is definitely related to function, but it is difficult to determine at which point an important genetic event/modification occurred. The cell to cell variation seen in cancers reflects genetic instability, but there must be something in the transformations which increase cellular fitness that allows the cancer to continue to grow. Although all of this is at molecular level, the testing needs to have an assessment of input material, ie, an affirmation that “cells of interest” are present in the samples to be tested. This is where he said that there was still a place for morphological assessment using a microscope.
A platform is being developed so that live cell imaging can be viewed in real time, and may reveal new sets of dynamic structural changes with a diagnostic utility surpassing that of classical static imaging. It was a shame that the IT system did not allow for the running of embedded videos showing the nuclei in motion. Such a fascinating way forward for cytology staff.
Dr Sally Hales and Dr Paul Cross gave an overview of the Interpretive Diagnostic Cytology EQA scheme, from its beginnings in the NW region in 1993, through the modifications within the NW to going national. The last sputum case was included in 2004, and the first Trans-bronchial FNA was introduced in 2010. Slides are used from submitting laboratories, and the cases should be unequivocal and preferably have a known clinical outcome (not always the case), as results will only be included in end of round reports for individuals if slides have reached consensus.
A few examples of case performance were shown as examples. Because of the difficulty in obtaining good examples and the logistics of circulating fragile slides, digital forms of EQA have been trailed, but so far with limited success. The major advantages of digital images being no loss of slides, and everyone sees the same thing. A new 2 stage pilot will begin in Spring/Easter 2018 , with the intention of going live in 2019. A steering group is being formed and protocols are already being developed. H&E stained slides will not be allowed, but the scheme should be flexible enough to allow for different preparation types, bearing in mind that LBC does not allow for Giemsa stained preparations. Having done EQA in Gynae for years, after having a moan about doing it on occasion when you are busy, it is actually educational in the long run and keeps you on your toes. The same applies for non-gynae, and participation should be encouraged for personal CPD and patient interest.
After break, Jackie Jamison gave an interesting and amusing overview of the Molecular Pathology service offered in Northern Ireland. She explained that it is possible to have a fully integrated service incorporating Cytopathology, Histopathology and Molecular testing. She made the transition to the molecular age seem not quite so daunting, by outlining the evaluation of material, DNA extraction and the stages of PCR. On top of this, she pointed out the limitations (eg cellularity, presence of malignant cells, pre & post analysis) and inhibitors (eg fixation, necrosis, polymorphs) to successful molecular testing which linked to the title of her talk “what cytologists must know”. To get the best results, there must be a good understanding of the principles, and cytologists/BMS staff are well set up for this.
She showed a few cases, a sample request form and highlighted the importance of selection, verification and validation. In summary, teamwork is all important, and clinicians should be included. To be a successful service, staff must know: Cytology, how to maximise material, adequacy, limitations/inhibitors, timescales, molecular technology and finally how to formulate a fully integrated interpretative report.
Cytopathology has been at the forefront for the further development of the role of the Biomedical Scientist (BMS), not least with the introduction of the Consultant Biomedical Scientist; a well-recognised and respected post. It is further being extended with the introduction of BMS cut-up and histopathology reporting. Although I knew about it, I have had no first-hand experience of this development in my time on committees or as training manager, so it was with interest that I listened to Dr Angus McGregor as he talked us through the background of the need for this role to be introduced.
It has been a long time in development, but results from a pressurised expensive workforce, increased volume and complexity of workload, cancer agenda and financial efficiency; more medical pathologists is not necessarily the answer. Also, career advancement for BMS staff in Cellular pathology has been limited, and this is a huge opportunity. The first proposal was given to Histopathology training committee and SAC in 2010; a conjoint board was formed with IBMS and RCPath with the first exam being held in 2013. This is not intended to qualify for RCPath, even though the curriculum is largely the same, but leads to a role for Consultant BMS staff to work alongside Histopathologist colleagues. Unfortunately, at this moment in time, there are no resources to support the project and training, and there is no formal recognition in workforce planning.
Karen Ezard, Consultant BMS, bravely (and proudly) went through her personal experience of the process, explaining that anyone who wishes to undertake this training should be aware of what it entails and not enter lightly. There was a high drop-out rate in the first two years, and the study path is different to that required by IBMS qualifications. The curriculum has expanded throughout the pilots, and she described it as challenging, intensive and all consuming. She gave advice about access to histopathology and the correct range of specimens, and to consider a rota and secondments to achieve it. Candidates have to be self-motivated; don’t underestimate the time input, learn dissection to an appropriate standard and read around the subject. Protected time is very important, which I understand from many years delivering training.
It can be difficult, so candidates should have support from managers, colleagues and family. There were concerns that, after formal selection, if this is a stand-alone role “what if I fail”. However, it does demand a separate job description that reflects the complexities of the role. I wish anyone who goes down these routes to extended roles every success, and thank Karen for the tips!
After lunch in the trade exhibition and visits to the train museum, the scientific programme resumed with Professors Fischer and Vaux talking about The Cell Biology of Cancer, but “not as we know it”. They showed the dynamic changes in cells as they altered shape, highlighting alterations in appearance of the nuclear lamina. Post translational modifications can alter the function of the nuclear envelope and regulation of gene expression, and may be a target for cancer related proteins. They also showed that nuclei are not static within the cell, but move back and forth in the cytoplasm, or with a rolling motion.
Nuclear movement related to cell division tends to occur before the metaphase plate is laid down. These observations in cells cultured on a plastic plate may occur to a greater extent being outside the natural environment. It was very disappointing for delegates, and frustrating for the speakers, that the IT facilities failed to cope with the video clips, which showed the dynamic images of cells. It is hoped that these new imaging techniques will expand the current criteria for malignancy to include the dynamic features. In some respects, it is hard to believe how cell imaging and research has moved on since I started my career. Those entering our profession now could bear witness to, and play a part in, a fascinating future.
The penultimate session saw the audience be brought up to date on HPV Primary Screening from a Five Nations Perspective.
Alison Malkin reported that the screening programme is still very young in Southern Ireland, having started in 2008. At that time the cervical screening was out-sourced to the USA, but approx. 50% has now returned to Ireland. Currently, data shows 88 deaths per year from cervical cancer and 79.6% coverage.
The HPV vaccination programme began in 2010, HPV Test of Cure 2012, and HPV triage for low grade disease began in May 2015. Following the HIQA HTA report on HPV testing as the primary screening method for prevention of cervical cancer , it is projected that €35 million will be saved in the first 8 years 2018 – 2025 (€3m in vaccinated women, €32m in non-vaccinated women). The report supports implementation of primary HPV testing at 5yr intervals at ages 25 – 60yrs, with Cytology as triage for HR-HPV positive women, and states this should improve efficacy of CervicalCheck.
Two subgroups of women were also considered; where women that were 50 year or older in 2008, screening will be extended to age 65, and non-vaccinated women under age 30 will be offered primary HPV screening at 3 yearly intervals. Alison says she is optimistic that there is now an opportunity for cervical cancer screening services to be returned and provided within Southern Ireland. Their website is www.cervicalcheck.ie
Jackie Jamison gave a brief report from Northern Ireland. Currently there are five Trusts and four cytology laboratories covering a population of 1.6 million. As yet there is no policy decision, but it is most likely that one laboratory will ultimately provide this service. Reasons for delay include Exeter call/recall system, LIMS and risk balance. The lack of policy backing and computer support means that NI cannot move forward. However, an HPV planning group has been established, with a view to beginning in 2019. At the moment they are watching progress in the UK.
Steve Court updated everyone on the situation in Wales. Cervical Screening Wales (CSW) has been running since 1999. 236,000 women are invited with an uptake of 77%. CSW rolled out TOC in 2014, and in 2015 an all Wales decision led the screening service to move from Surepath to ThinPrep, with a requirement for conversion training of staff across the cervical screening/primary care sectors, with 2500 sample takers needing training. 2016 saw the introduction of Triage and TOC, and the introduction of a pilot 20% primary HPV testing in April 2017.
Results from the pilot showed a +ve rate of 12%, referral rate of 4.2%, with 42.5% of HPV +ve tests having abnormal cytology. Logistically, there are 4 laboratories operating a hub and spoke model; 1 processing site based in South Wales, and 3 screening laboratories, with transport occurring daily. Wales is currently working with Thinprep LBC + Aptima. It was anticipated that there would be full roll out of HPV testing by October. Challenges to face include a single processing centre serving the whole of Wales, a reduction in sample numbers due to HPV vaccination and extended recall and resulting laboratory mergers leading to the loss of experienced staff.
Allan Wilson reported on the current status in Scotland. There are 7 laboratories offering a cervical cytology service, but this does not include Triage; 2 of these should be ready for HPV primary screening with Cytology Triage from 2019/early 2020. Working towards this has meant the development of a project plan with 5 work-streams, and monitoring impact on SCCRS. Laboratory selection criteria have been produced; labs will have to satisfy the required entry criteria before they can bid for the service of one of the two afore mentioned labs.
Problems which will have to be faced are limited HPV experience, and the service is already working at full capacity. By Spring 2018, it should be announced which laboratories will deliver the service.
Kay Ellis reported for England. There is currently an emphasis on the management of turn-around times (TAT), and HPV screening is being expanded to non-pilot sites. Hot off the Press and with perfect timing, an announcement was made on 3rd November by NHS England, on laboratory configuration for Primary HPV screening. Notification was sent to heads of Public Health commissioning, with a letter to the Chair of the BAC. An update of key decisions included centralisation of between 10-15 laboratories, with a maximum of 13 being selected by the end of 2019.
Information about this announcement is available on the BAC website. This will be a two stage process up to the selection of the maximum 13 labs, but it is on a very short timescale with week by week progression. Timeframes will be communicated throughout.
Following the afternoon break, the finale of the meeting was the Erica Wachtel Lecture, this year delivered by Professor Julietta Patnick. – a very well-known and admired figure in the field of cytology. Many delegates were interested to hear her experiences during her time with the screening programmes from 1979 to 2015, taking the banner of cervical screening in 1994.
She has seen many staff and structural changes, with difficult internal markets and competition rather than co-operation all having an impact on the service, and she thought that the Cervical Cancer Audit actually became a major trauma for the service. She has also witnessed huge developments:
Progress in cancer management includes improvements in prevention, early detection, pain management and palliative care. Some cancers are being treated more successfully, and there are no more frozen section mastectomies. Bowel screening has seen the introduction of the flexible sigmoidoscope, and prostate and ovarian cancer screening are at the research stage.
Revolutions in cervical screening include optimum coverslip sizes (she didn’t get involved), and guidance on sample adequacy. LBC brought an improvement in productivity and reproducibility and 2003 saw changes to age and frequency of screening; and audit was carried out to standardise the frequency and “conspiracy theories abounded”! Other major milestones include HPV testing and vaccination, and changes to RCPath examinations. She thinks that cervical cytology is becoming more isolated, and the “need for expertise is increasing”.
Management of the programme has undergone massive change, from National Co-ordination and National Office to incorporation into Public Health England and restructuring. She thought it important that the BAC should have a large part to play going forward. As a final note, she thinks the NHS is under severe financial strain, and problems to be faced include the outcome of Brexit and the programme being within the remit of PHE which is a civil service setting.
The meeting closed after after questions, and presentation of the Erica Wachtel medal. All in all this was a very well organised and well attended meeting, for which the organisers are to be congratulated.