Spill.
HPV test > Pap. End of cytopath as we know it?
- Thread starter Nilf
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eventually HPV testing will replace paps for screening.
If I was a cytotech I would retraining for a different job, yes.
I have stopped screening paps and fired my cytotech a few weeks ago. Best business move Ive done yet.
If I was a cytotech I would retraining for a different job, yes.
I have stopped screening paps and fired my cytotech a few weeks ago. Best business move Ive done yet.
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Are you sending the GYN paps out? That is one sample the ameripaths are welcome to...
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yep, realize gyn cytology is a Clinical Lab CPT as defined by the government so to my business it is no different than sending out serum levels of drugs or enzymes I dont do in house.
The only real way to make gyn cyto worth it for me was to do it in tandem with ISH for HPV, which I didnt get up and running in time before I my patience ran out.
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Ever heard of non-GYN cytology?
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body fluids mainly, and the occasional thyroid FNA. Core needles done in radiology have really just outright replaced FNA esp for breast lesion in most places where radiology is strong and the future is more replacement of cyto, not less.
One area that still dogs me is pul bronch stuff. I hate it. Its hard, reactive can look nasty, malignant cells can be rare etc. But there really is no down side anyway now, if the lesion is so difficult to Dx by FNA they have to get a core because of the need to know which type of non-small cell CA someone has (due to Avastin Tx).
Dunno, personally I would not do a cyto fellowship. I would guess in terms of dollar reimbursement, it has gone from being around 30 cents of every path dollar earned to less 5 cents before I booted gyn, now its not even that!
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I don't think GYN cytology isn't going anywhere for the foreseeable future. You have to do tests and comparisons, many studies. They have to prove that the HPV test is truly finding all the lesions and whether pap smear truly is irrelevant. That will take a while. Imagine what kind of a field day a lawyer would have with that, as the situation stands now.
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Yep until the NEJM article last week. Pretty much took pap cytology out behind the shed, shot it in the head, dismembered the body and fed the parts to piglets.
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Agree. The problem is damn near everyone else wants to do these as well, it's not like walking into a Wal-mart. Any suggestions for the next best backup? I would think surg path at the most solid name institution you can get.
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Surg path at a solid institution (whatever that means) is for tools.....
Grossing and scut for your fifth year after medical school. What other medical fields have this as post post graduate training.... what... Moh's, interventional cardiology , cardiothoracic, robotic prostate, Plastics, microsurgery, the crazy ass stuff radiation oncologists are doing.... If you want to spend another year hacking up meat as a glorified PGY-1 (at a "BIG name") so you can "feel more confident" about signing out... well sheesh be my guest.😱
either get Derm, GI, or GU or quit pathology and open up a fruit stand.
better yet get a job as PA and just gross with no other responsibilities and no malpractice insurance woes.
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i would for sure expect the role of the PAP smear to be significantly altered
this is not a surprise --Crum basically predicted this 4 yours ago in a JCO article
you have to remember the PAP smear was developed like 50?60? years ago in an age when we had no test and women more commonly had advanced disease making this a good screening test
since the 80s/90s when it was basically discovered HPV causes most cervical cancers if not 99.999999999 ...and not only that
but jeez louise--there are a lot of cervices in the world with this virus-- and in terms of the famous Bayes theorem--high prevalance alters the sensitvity of a test no matter how accurate/speciffic it is--the PAP smear isnt THAT sensitive (est. about 50% on all lesions--however this number is quite variable) and not that speciffic for reactive/HPV changes considering the broad overlap between disease and normal
and even if you want to completely take away the influence of a more sensitive molecular test-- we are beginning to screen in the age of vaccinated people-so even if we did not have these tests the GYN pap numbers would decrease
however there is a big explosion in molecular cytology -- so the diagnostics on smaller samples may be the wave of the future
this is not a surprise --Crum basically predicted this 4 yours ago in a JCO article
you have to remember the PAP smear was developed like 50?60? years ago in an age when we had no test and women more commonly had advanced disease making this a good screening test
since the 80s/90s when it was basically discovered HPV causes most cervical cancers if not 99.999999999 ...and not only that
but jeez louise--there are a lot of cervices in the world with this virus-- and in terms of the famous Bayes theorem--high prevalance alters the sensitvity of a test no matter how accurate/speciffic it is--the PAP smear isnt THAT sensitive (est. about 50% on all lesions--however this number is quite variable) and not that speciffic for reactive/HPV changes considering the broad overlap between disease and normal
and even if you want to completely take away the influence of a more sensitive molecular test-- we are beginning to screen in the age of vaccinated people-so even if we did not have these tests the GYN pap numbers would decrease
however there is a big explosion in molecular cytology -- so the diagnostics on smaller samples may be the wave of the future
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HPV testing is sensitive but less specific.
Paps are specific, though less sensitive.
Most HPV infections in women under 30 are transient.
Even if the HPV test becomes first-line, Paps are going to be the likely "confirmatory" test such as with syphilis.
The current HPV vaccine is not a therapeutic vaccine.
And not everyone is going to get it.
And it's the lower socioeconomic class, the same people who didn't get their regular Paps, their HPV DNA tests, who won't be able to afford the vaccine.
There have been projections where because these lower SES groups aren't being reached, there will be initial perceptions of success with the vaccine, followed by a rash of reports of women with frank invasive cervical cancer, if we do away with Pap smears anytime soon - simply because their lesions were progressing undetected.
The American Cancer Society and Am College of Ob/Gyns are stilll recommending we keep level heads and continue with current screening practices until there is solid data to show what exactly is changing in population risks and benefits.
Paps are specific, though less sensitive.
Most HPV infections in women under 30 are transient.
Even if the HPV test becomes first-line, Paps are going to be the likely "confirmatory" test such as with syphilis.
The current HPV vaccine is not a therapeutic vaccine.
And not everyone is going to get it.
And it's the lower socioeconomic class, the same people who didn't get their regular Paps, their HPV DNA tests, who won't be able to afford the vaccine.
There have been projections where because these lower SES groups aren't being reached, there will be initial perceptions of success with the vaccine, followed by a rash of reports of women with frank invasive cervical cancer, if we do away with Pap smears anytime soon - simply because their lesions were progressing undetected.
The American Cancer Society and Am College of Ob/Gyns are stilll recommending we keep level heads and continue with current screening practices until there is solid data to show what exactly is changing in population risks and benefits.
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I know it is distasteful for many, and I may get the smackdown for saying this, but blood banking/transfusion medicine is a real eye-catcher as a fellowship goes. Having just done the rounds of looking at private practice jobs looking for general AP/CP, I was surprised to see how many interviews/telephone calls I got with BB/TM under my belt (and no other AP fellowship either). Anyone looking for a fellowship in BB/TM now would have a pretty easy go finding a spot since so many are going unfilled. And in 5-10 years, there is going to be a serious shortage of BB/TM trained pathologists. Going to be very hard to replace BB/TM with a send out test...
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Dunno what you what want to know, eyerolling? LMAO....Im giving fairly specific advice as it relates to current and future pathology practice and reimbursement codes.
10-15 years ago people were specializing in things like EM, Chemical Pathology, doing Nuclear Med stuff, but even then you could see the writing on the wall and know things were bound to change.
I seriously seriously doubt there will be anywhere near the number of cyto fellowships in 10 years as there are now.
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Interesting point, since I doubt Surg Path will ever be a credential fellowship or one even most clinicians and surgeons recognize, essentially it all for your own self confidence during your first job.
My opinion is that around 12 or so months out of training those with and without surg path fellowship normalize in their ability to tackle bread and butter cases. I dont think personallly doing a fellowship at say MSKCC allows you to send less difficult academic type cases out in consultation.
So if I was sitting around and couldnt get a job or a better fellowship, yes I might consider doing surg path year if I literally had to no work in applying and I didnt have to move if I had 3+ months of electives to do derm.
Conversely, if you are at a tier2 or lower program and want your resume to smell better you might cap it with a surg path experience at a tier1 location.
So its a pretty rare resident you should be staring down the barrel of a surg path year nowadays.
If you are an IMG and not from Oxford, McGill or something similar, Im not sure any of this really helps you unless you want to stay in academics. It might be better for an IMG cand to get through residency, then immediately begin co-applying to fellowships as well as jobs with Kaiser, Quest, Government hospitals and Ameripath-like groups to maximize hit chances.
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why keep bringing up "low socioeconomic status" ?
you forget that Texas has mandated the vaccine which means that those with "low SES" have to have someone pay for it so they can go to school
"low SES" is the least barrier to HPV vaccination-- try people unwiling to admit their teenage daughters have sexual contact before marriage even though the prevalance of HPV is something like 40% in girls from the age of 14-19 and on the same anti-vaccine front (amusing in the fact that both ultra-con and ultra-lib are on the exact same side of the coin) is the anti-administration, anti-pharma , anti-vaccine people
i also have not seen ANYONE discuss vaccinating gay males or any males for that matter--HPV is also assicated with other mucosal cancers -why would we vaccinate only females when they had to get it from somewhere?
the point of a screening test is to be sensitive not speciffic --although if a screening test had decent specificity --COOL
therefore, why not just swab everyone for the presence of HPV then triage to PAP/colpo etc depending on age--this is the rational for rethinking the testing strategy
i dont know what would be best strategy--i am still wondering why we miss so many on PAP--sampling? preservation? the amount of articles published on the PAP smear could fill a good sized hospital and we are still in the same boat as far as sensitivity goes so i am willing to postulate morphologic clues may not be helpful
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Actually, Gov Perry backed off the HPV vaccine executive order under pressure from the state legislature. All the fundies were clamoring that lowering women's of risk cervical cancer would leads to promiscuous behavior.
"Johnny, stop! I'm saving myself for marriage because I don't want to get cancer!" 🙄
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Interestingly there are some tier 1 programs with surg path fellows who came from that same institution e.g. MGH, UCSF, Mayo to name a few. But it's probably a packaged deal i.e. surg path+something else. Any ideas if a private lab fellowship in GI/GU would be more marketable than a surg path fellowship at a tier 1 major university/teaching institution?
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tier 1 to tier 1 or lateral moves to do a surg path fellowship only are in my experience fairly uncommon unless the 2 places are in geographic proximity, MGH-->BWH or UCSF-->Stanford come to mind. More often than not people do a surg path year and then something else, like heme or derm or what not at that institution.
As for the private lab vs. teach hospital thing, you would need to be specific. Are you referring to like a GU year with Bostwick? If you are referring doing some wierd Ameripath thing where you part time sign out GI biopsies, then I wouldnt really call that a "training" fellowship, its clearly just a job.
Another thing I would watch out for, some surg path fellowships are a scam. Essentially they plop you somewhere and you simply sign out cases, of course at a huge profit for whoever hired you. That is NOT a fellowship, it is a scammy low paying job they are luring you in for.
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Tell that to the boatload of people who applied for the Ameripath GI fellowship in Cleveland with Petras. And it was a solid mix of AMG and IMG applicants from various institutions. I heard residents were following him around like a flock of sheep at a previous CAP meeting. It may not be a real fellowship from a pure teaching standpoint, and just a job; but for those who land that gig, they couldn't be happier. No doubt one's experience would be more complete at a university. But I'm willing to bet, as long as someone gets that GI/GU/etc. fellowship branded on their resume, regardless of it being legit or from a private lab type place, they could care less because it probably makes little difference as far as landing a job afterwards.
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Back on track.
And in a pinch, there are a lot more pressing healthcare priorities for a family living from paycheck to paycheck than cervical cancer (a disease that may develop in 15 to 30 years' time in someone with persistent high-risk HPV) , which is already at relatively low levels in a population with effective Pap screening in place.
Garnett GP et al, Chapter 21: Modelling the impact of HPV vaccines on cervical cancer and screening programmes. Vaccine (2006 Aug 21) 24 Suppl 3:S178-86
Googling "gay hpv vaccine" gets 290,000 hits, so I'm sure people are discussing it. If you're referring to why no trials/studies have been carried out, it's early days yet for vaccine trials. Gay men are walking in the doors of clinics and voluntarily getting the vaccine. The only problem is that Gardasil hasn't been tested on men so it's too soon to say if it's effective in the same fashion. There's nothing sinister about not trying to prevent cervical cancer in men.
And how are do we "swab everyone"? We can only swab those who come in the doors of our clinics and hospitals. If they don't have some method of payment, they're not getting any tests.
Because in a lot of medical literature that's classically how a particular segment of the population with "impaired access to healthcare" is euphemistically referred to.
I brought the "low SES" factor up because while we hear a lot about "geez these parents won't let their kids get the vaccine, are they stupid or something?", we tend to forget that significant barriers to healthcare exist in this country, and tend to correlate with socioeconomic status. If someone is out of a job, chances are they won't have healthcare insurance coverage and can't pay clinic/hospital fees on their own.
And in a pinch, there are a lot more pressing healthcare priorities for a family living from paycheck to paycheck than cervical cancer (a disease that may develop in 15 to 30 years' time in someone with persistent high-risk HPV) , which is already at relatively low levels in a population with effective Pap screening in place.
Well, in immunological models, heterosexual spread of infection can be stopped entirely by complete protection of one sex alone. Vaccinating X number of women achieves more % effective vaccination coverage than vaccinating that same total X number of women and men.
Garnett GP et al, Chapter 21: Modelling the impact of HPV vaccines on cervical cancer and screening programmes. Vaccine (2006 Aug 21) 24 Suppl 3:S178-86
Googling "gay hpv vaccine" gets 290,000 hits, so I'm sure people are discussing it. If you're referring to why no trials/studies have been carried out, it's early days yet for vaccine trials. Gay men are walking in the doors of clinics and voluntarily getting the vaccine. The only problem is that Gardasil hasn't been tested on men so it's too soon to say if it's effective in the same fashion. There's nothing sinister about not trying to prevent cervical cancer in men.
That's what I was referring to when I pointed out the SN/SP of Pap/HPV DNA and said that in the future, Paps will likely be a confirmatory test after HPV DNA testing.
And how are do we "swab everyone"? We can only swab those who come in the doors of our clinics and hospitals. If they don't have some method of payment, they're not getting any tests.
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By the way this will likely mostly hurt cytotechnologists. But we will see.
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What % of paps are done on women under 30? As far as I know, even the biggest HPV screening proponents admit that it's too nonspecific in that age group, and they've been excluded from all the big studies. Of course, you could point out that that age group will all be vaccinated in 15 years. I think the pap is bruised and bleeding, but the pigs are still hungry. 😉
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wow this is a healthy discussion-- i wonder why?
anyway --you can theoretically "swab everyone" via a home kit test
there are several studies out of the UK which try to utilize tampons as a means of collecting the DNA--the results arent that great so far--but an interesting idea
in fact in a rapid test implemented en masse (sic?) vis a vis HIV is probably cheaper as a screening method that speculum exam, pap smear preparation, cytology diagnosis--even considering that the reimbursement of the conventional pap test is considerably lower than it should be in my opinion
you would not be preventing cervical cancer in men -obviously-- you will help prevent anal cancer in men-- especially those with HIV who are at high risk for invasive HPV related anal cancer
didnt mean to jump all over the "SES" factor of your post--but i think it is important to not forget the many barriers to vaccine implementation-if you believe it would help-- i happen to live in a region of the country where the anti-vaccine sentiment is quite strong as well as the "SES" factor -other areas will be overridden by the --people who cant admit sexual contact until marriage in young people despite the overwhelming evidence to the contrary-and beleive discussing such a vaccine would inspire sinful acts
i tried to upload an article addressing this NEJM 365 (19): 1905- May 10, 2007-- file size too big
to me --social, ideological, and political barriers are often more insurmountable than scientiffic and monetary barriers
