EDITORIAL - Published in Acta Cytologica 36 (6): 861-865, 1992
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In recent years, members of the European Economic Community (EEC) have reviewed national practices in many fields with the intention of achieving a degree of uniformity. This has included a project financed by the European Commission and Europe Against Cancer to formula the training programs for medical and paramedical personnel involved in cervical cancer screening programs. The need for a forum in which ideas could be exchanged and that could also form a basis for education was recognized many years ago and resulted in the formation of the European Federation of Cytology Societies (EFCS).
This is an appropriate time to record the early work of the federation.
The concept of a federation, or of a European society of cytology, was introduced by Dr. Paul Lopes Cardozo and others at a symposium on clinical cytology organized and hosted by Dr. Lopes Cardozo and Professor Schmidt and held in Rotterdam in 1967. In the following two years there were many informal discussions about the form this organization should take, and the International Academy of Cytology (IAC) suggested the possibility of a regional section of the IAC, but there was a regional preference for a separate European body, and discussions progressed along those lines. However, to respond to the need for a common educational program at that time, Dr. George L. Wied established the famous Vienna tutorials, which still take place every year. By 1969 the time was ripe for more formal discussions by representatives from countries in western Europe and the Eastern Block. This took place in Sils Maria at a combined meeting of the Austrian, West German and Swiss societies. The meeting was hosted by Dr. Jacques Jenny, then president of the Swiss Society; who invited all national societies in Europe to send representatives to the meeting. In this way a working party, which consisted of 27 appointed delegates from 17 countries, was able to discuss the preliminary suggestions for statutes prepared by Drs. Jenny and Husain.
The statutes were unique in that they envisaged a loose federation of national societies with no loss of authority by individual national societies. The EFCS could organize meetings in the form of congresses, workshops or tutorials, it could gather information (through the courtesy of the national societies), and it could make recommendations, but they would never be mandatory. It was thought that such an organization would be of most value in the development of cytology in Europe, both in screening and as a diagnostic tool.
The statutes were approved in Prague at the first meeting of the new federation, and Dr. Jenny became the first secretary general. The secretary general, together with the treasurers for East and West, were elected for three years with the possibility of a second three-year term. Because frequent meetings were desirable, particularly for the benefit of Eastern Block countries, annual meetings were held, and the president, proposed by the country in which the meeting was held, held the office for one year. At that time it was essential to have meetings in Eastern Block countries on alternate years. Since there were 5 of them as compared with 15 western countries, there was an emphasis on visits to eastern countries; that helped delegates who had restrictions on their freedom to travel. When the lAC held its congress in Europe, the council meetings were held at that venue, and it was usual to have a workshop or tutorial in eastern Europe during that year.
From the EFCS's inception in 1970, the officers have been concerned with identifying variations between and similarities in the practice of diagnostic cytology in individual countries to recognize different types of training required for technical and medical staff so that a basic core curriculum, acceptable by all, could be recommended and also to compare practices in cervical cytology screening.
To deal with the question of training, the Committee for Qualifications and Continuing Education was authorized by the EFCS Council in 1973, and information was sought from member countries by means of a questionnaire. These were returned by 18 national societies (Slovenia returned a separate questionnaire), but not all the questions were answered by all the countries, and the data returned, there and in later questionnaires, could not be verified in all instances. Where obvious discrepancies exist, comments to that effect are made below.
The first need was to establish the status of cytology as a specialty. In 9 of the 18 countries there was a special training program for medical cytologists, and in 11 countries it was mandatory to have full or partial training in pathology. This proviso also applied in 4 of the 10 countries in which the main link was clinical (usually gynecology). The range can be seen in Table I. The same questionnaire dealt with the availability of cytology courses, for both medical and technical personnel, in the different countries. These questions were answered by only 12 of the 18 countries; of those 12, only 4 had established cytology courses for physicians, but 9 of 11 (no cytotechnologists in Greece) had recognized schools for technicians. However, it was apparent that much of this education was in the form of in-service training. These findings were published in the November 1977 EFCS newsletter.
As a result of these findings, work began on creating a "model curriculum" for cytotechnologists. The officers of the EFCS selected competent ad visors to prepare a first draft for circulation to national societies for comment. The advisors included senior cytotechnologists, and a cytotechnologists advisory committee was established in 1979. Reactions to the first draft demonstrated considerable discrepancies between countries with regard to what was required for a cytology technician and therefore to the amount and content of training needed. This ranged from countries in which basic screening of gynecologic specimens, reporting of negative cases and processing of material were all that was considered appropriate to countries in which the cytotechnologist played a much more important role in reporting on cytologic material of all grades and from various sources.
Informal discussions culminated in a symposium on the training of cytotechnologists at the EFCS congress in Madrid in 1985; from this it became apparent that the individual requirements of different countries were such that the EFCS could do no more than make recommendations for a core curriculum, training, examination and practice for cytotechnologists in Europe. They were unanimously accepted at the council meeting held in Brussels in 1986 at the time of the International Congress of Cytology. This document was subsequently submitted to the EEC Standing Representative Committee for Medical Laboratory Technology European Economic Community.
By the mid-1980s it seemed appropriate to compare national practices in screening for cervical cancer. The secretary general at the time (F.R.) and the previous secretary generals (J.J. and O.A.N.H.) pursued this enterprise and, together with the other authors, prepared a structured questionnaire that was circulated to each of the member countries. Returns were received during 1987-1988, and the final analysis was presented at the 1989 EFCS meeting in Switzerland. Eighteen member countries of the federation returned questionnaires, but, again, not all the questions were always answered. Information was submitted by Iceland, and it was included in the analysis.
The questionnaire was in three sections, dealing with national data, national policy and local policy, which, considered methodology. The last was not necessarily uniform throughout each country and a matter for local decision rather than a national mandate.
National data included information on total population, female population over 20 years, whether there were national and /or regional cancer registries gathering incidence rates of cervical cancer, a factual estimate of how many members of the female population underwent cervical cytology and the date of the beginning of a substantial screening program.
National policy contained sections on organization, methods of recruitment to the screening program, policy for age and frequency of collecting smears, previous or anticipated changes in screening activity and the need for and availability of additional financial support.
The section on local policy presented more difficulties. In 10 countries there was enough uniformity to submit a single return, but in 8 countries there was considerable variability between centers in the same country.
National Policy and Data (Table II). The incidence of cervical cancer per 100,000 women varied between a low of 4.7 in Finland to a high of 30 in Austria and Hungary, but only 13 of the 18 countries stated that they had some sort of national cancer registry.
The population that underwent screening varied from 20% (Poland) to 100% (Finland). This wide range may relate to the length of time in which a screening program had been in operation, but it is possible that some respondents misunderstood the question and, instead of giving the cumulative figure as was requested, gave the percentage of the population screened annually.
The year of commencing a national or other substantial screening program also varied, and when the questionnaires were completed (1987-1988), there were no stated national (countrywide) screening programs in Greece, Italy or Spain.
Six countries placed no age limits on women eligible for cervical smears, and in others the lower limit varied between 20 and 35 years and the upper limit between 50 and 70.
Frequency of screening varied between one year and five years, and in four countries the interval was one, two or three years, suggesting that it was left to the discretion of individual women and their physicians. The cost of cervical smears was borne by tax-based government funds alone in only eight countries. Insurance-based government funds were used in 10 countries, either in addition to tax-based funds or as the main source of payment, while in 8 countries smears were also paid for privately; in no country was this the only method of payment.
In all countries some smears were read in state laboratories, and in most countries such laboratories dealt with the majority of the smears. However, in West Germany, Greece and Switzerland, >=0, 50% of the smears were read in private laboratories. In contrast, Hungary, Poland, East Germany, Belgium, Bulgaria and Italy reported state laboratories only.
Local Policy. This section dealt with such items as the role of technical and medical staff and the place of quality assurance. There was so much variation that only a few points of interest can be identified.
Who is in charge (Table Ill). The majority of laboratories were managed by a medical cytologist or cytopathologist with the exception of Finland, where the laboratories were managed by a gynecologist. In Switzerland as well as West Germany some gynecologists ran their own, private laboratories. In Italy, Norway, Spain and Switzerland the laboratory could be headed by a physician who was neither a medical cytologist, cytopathologist nor gynecologist, and in Switzerland a cytotechnologist could be in charge.
Who does what (Table Ill). Primary screening was usually done by a cytology screener or cytotechnologists with the exception of Greece, where there were no cytotechnologists, so all screening was done by medical staff. In Austria, Belgium, Czechoslovakia and Spain some screening was done by medical staff, while in Czechoslovakia, the former East Germany, Hungary and Italy, nonmedical graduates also I worked as primary screeners. Checking was usually done by medical staff (all groups), but in Denmark, the former East Germany, Hungary, Italy, Sweden, Switzerland and the United Kingdom it could also be done by a senior cytotechnologist or nonmedical graduate. In Iceland all checking was done by cytotechnologists.
For the most part negative smears were reported by cytotechnologists or nonmedical graduates with the exception of Greece (see above) and Belgium, where negative smears were reported by a medical cytologist or cytopathologist. In Austria, Italy, Norway, Spain and the United Kingdom, in some laboratories negative smears were signed out by medical staff.
Positive smears were reported by medical staff (all groups) and also by cytotechnologists or nonmedical graduates.
Some form of quality assurance took place in all the countries. Table IV shows the quality assurance methods listed in the questionnaire and the number of countries that practiced each of them at that time. Rereading positive smears and case follow-up were the most popular, with case conferences and retrospective review of all material following a "positive" (histology or cytology) as a close second. Ten countries checked a percentage of "negative" smears, while only four made a statistical analysis of screeners' performance.
The data presented in this editorial date back to the situation five years ago and more, but a more recent questionnaire sent to EEC countries seems to have elicited a similar response and consequently led to the European Commission Training Project on Cervical Cancer Screening. Recommendations are similar to those made previously but may have greater success in view of the creation of the Common Market, centralized bureaucratic initiative and probability of greater movement of medical and paramedical workers among EEC countries. For them was proposed an aptitude test that would be mandatory for medical and technical personnel who wished to work in an EEC country other than their own. Support has been sought from various international bodies, and, it is hoped, from countries previously in the Eastern Block and members of our European Federation of Cytology Societies now seeking EEC membership. In all, these factors lead us to anticipate greater uniformity in both basic training for those practicing cytology and screening for cervical cancer.
E. Blanche Butler, M.D., F.RCO.G., M.RCPath., F.I.A.C.
University of Manchester,
Mary Efstratiadou, M.D., F.I.A.C
Department of Clinical Cytology,
O. A. N. Husain, M.D., F.RCPath., F.RCO.G., F.l.A.C
Charing Cross Hospital,
Jacques Jenny, M.D., F.I.A.C
Franco Rilke, M.D., F.!.A.C
Division of Pathology and Cytology,
Istituto Nazionale Tumori,
1. Douglas G: Report of the manager of the European Commission Training Project on Cervical Cancer Screening. Cytopathology 3:23--25, 1992
2. EFCS Ne wsletter, November 1977
3. EFCS Newsletter, January 1987