Innovative Practice Article for the ASC Communicator
By: Israh Akhtar, MD
Professor of Pathology, Temple Health, Philadelphia, PA
Since its inception in 1928, when Dr. George Papanicoloau conceived the idea of evaluation of cervical cytology by Pap smears, cytology has expanded into a field encompassing more and frequently being the first diagnostic modality for a mass lesion.  The advent of molecular diagnostics and image analysis has brought some changes affecting gynecologic and non-gynecologic cytology. Furthermore, molecular testing for HPV has resulted in speculation about demise of the Pap test and destabilized the job security for cytotechnologists. The era of personalized medicine for targeted therapy has caused a significant shift from rapid on-site evaluations (ROSE) performed on fine-needle aspirations (FNA) to touch imprint (TI) cytology of needle core biopsies.[2-3] The trend towards a subspecialty histopathology signout has led to diversion of cytological specimens into the corresponding subspecialty histopathology teams. All the above factors have had a direct impact on cytopathology fellowships, resulting in approximately 13 of 55 unfulfilled positions for 2020, as per Pathology Outlines fellowship listings.  This may be perceived as a challenge but has also provided us with an opportunity to re-model the current cytopathology fellowship structure and framework. Through this study we attempted to explore the major reasons that have led to reduced recruitment in cytopathology fellowship programs and to make some recommendations to refurbish cytopathology fellowship curriculum.
In a pilot study, a two-step anonymous survey was sent to all the pathology residents at University of Mississippi (PGY1 to PGY4) in order to assess the likelihood of them choosing cytopathology as their fellowship. In the first survey, assessment of their choice was made, in the current format of fellowship training. The second survey was conducted with recommended changes including, inclusion of in-depth molecular pathology rotation, ultrasound guided fine needle aspiration (FNA) and training in small biopsy sign out (those accompanied by touch imprints) in order to re-assess interest (Table 1). The same two surveys were administered after a six month interval to evaluate the likelihood of choosing cytology after at least a dedicated month of a resident cytology rotation in which the pattern of training was modified to include all small biopsies as a part of the curriculum. (Table 2). A second survey was more generalized using twitter as a mode of communication and was open to all pathology residents and fellows. The question put forth was about their likelihood to choose cytopathology for fellowship.
In the first in house survey of the ten residents (PGY1-PGY4), only three (30%) considered the possibility of choosing cytology in its current format. The most common reasons cited for pursuing a fellowship other than cytopathology included: a deeper interest in surgical pathology, new trend of subspecialty signout, newer exciting subspecialty fellowships (such as informatics), fewer job opportunities in cytopathology, and geographic location. They noticed reduced demand for cytology as the primary skill set in the job market, and preference for other surgical pathology subspecialties, with cytology experience as an “additional asset” but not a requirement.
After the proposed inclusion of a mandatory rotation of molecular pathology, a month of small biopsy signout and ultrasound guided FNA training, seven residents recognized the increased appeal of cytology, albeit still preferring surgical pathology subspecialty fellowships.
Another survey performed after six months had twelve residents participating (PGY1-PGY 4). During this time period, we had four new residents, three residents graduated and one resident relocated. Of these, two showed interest in cytology, while one wanted to do it as a second fellowship. The three first year residents thought it was too early for them to decide. The most sought fellowship amongst the resident responders was Gastrointestinal(GI)/Liver. While most residents thought the addition of ultrasound and one month of small biopsy and/or frozen section hot seat made cytopathology fellowship more attractive, two residents said it didn’t matter to them as cytology was not their choice. In general, the residents felt that cytopathology is an interesting and challenging subspecialty, where making a diagnosis on a limited amount of sample is a challenge. The fact that screening long cases takes too much time, was another major factor keeping residents away from it. Other factors included the disruption of routine work by ROSE that made them less interested. They however liked the fact that marketability as a pathologist is increased both in academics, as well as private practice, if cytopathology skills are known.
In a 2-day period on the twitter poll, there were 48 responses, in which 29.2% had cytology as their first choice, 56.3 % had other fellowship preferences, and 14.8 % opted for no fellowship. In the comment section none of the participants mentioned which alternate fellowship they would choose, although some did state they enjoyed time on ROSE and appreciated the utility of cytology. As evident from our survey, residents showed more interest in cytopathology fellowship when they were provided the opportunity to review and sign out all the small biopsies that accompanied touch imprints. Often it required the resident to sit with the subspecialist, but it helped the resident to grasp the nuances of small biopsies and integrate it with the findings on touch imprints. The residents also realized that it was not unusual that touch imprints may be the only diagnostic material, and in those scenarios, cytology skills can help in making a more definitive diagnosis. Cytology material in fact provides higher quality DNA for molecular studies and has been validated for performing the molecular studies 3, 4. Residents were encouraged to be present for the ROSEs, especially for the image guided FNAs and endoscopic ultrasound guided FNAs. This gave residents the opportunity to interact with the radiology team, review the mass lesions on imaging, and confirm the adequacy. The residents gained confidence in being able to call specimens adequate thereby limiting the number of aspirations/biopsies and triaging the specimen to the right places. During the rotation in cytology, all residents were required to play an active role in all the palpable FNAs performed by the pathologist. The residents enjoyed the experience of interacting with the patients and performing the FNA. What was most rewarding for the residents was the ability to act as a clinical consultant and the ability to make a preliminary diagnosis within a few minutes of having performed the FNA. Although the addition of telecytology can help in reducing the disruption in routine work due to ROSE, the active interaction of the resident with clinician can be more challenging when not physically on-site.
Overall, cytopathology training fine tunes the skills of a pathologist at a cellular level and is especially useful in today’s world of small biopsy specimens. However, as evidenced by these two surveys, cytopathology fellowship is facing a nationwide challenge and there seems to be a fair amount of unexpected openings for fellowship. These surveys raise the idea that modifying the curriculum of cytopathology fellowships to accommodate the needs of the modern day medicine and involving residents early in their training or introducing mid-residency fellowships may help.
- Nikolaj Lagwinski and Jennifer L. Hunt (2009) Fellowship Trends of Pathology Residents. Archives of Pathology & Laboratory Medicine: September 2009, Vol. 133, No. 9, pp. 1431-1436.
- Rekhtman N, Roy-Chowdhuri S. Cytology Specimens: A Goldmine for Molecular Testing. Arch Pathol Lab Med. 2016 Nov;140(11):1189–90.
- Wei S, Lieberman D, Morrissette JJ, Baloch ZW, Roth DB, McGrath C. Using “residual” FNA rinse and body fluid specimens for next-generation sequencing: an institutional experience. Cancer Cytopathol. 2016 May;124(5):324–9.
Pathology outlines: https://www.pathologyoutlines.com/fellowships?sp=7