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Commentary

Free Access

Criticism of the Pap Smear as a Diagnostic Tool in Cervical Cancer Screening

Schneider V.

Author affiliations

Pathology Laboratory, Freiburg, Germany

Corresponding Author

Correspondence to: Dr. Volker Schneider

Pathology Laboratory

Burgunderstrasse 1

DE-79100 Freiburg (Germany)

E-Mail volk.schneider@t-online.de

Related Articles for ""

Acta Cytologica 2017;61:338-344

Abstract

This editorial by Dr. Leopold G. Koss appeared in the January 1980 issue of Acta Cytologica. It addressed recent critical opinions in the general media on cervical screening and its costs. It marked the beginning of a more critical approach to cytology by the lay press, health care providers, and epidemiologists. It was also the first of a series of highly informative editorials by Dr. Koss that illustrated the critical issues of cytology during the 1980s. The elegance and clarity of his articles reflect the high standard of editorial writing in Acta Cytologica at this time. These articles are reviewed and excerpts are presented.

© 2017 S. Karger AG, Basel


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The article by Dr. Leopold G. Koss [1] appeared in the 1980 January/February issue of Acta Cytologica, just at the start of the new decade. It was the first of what would become a remarkable series of editorials submitted by this unusually gifted and prolific writer over the next 10 years [1,2,3,4,5,6,7,8,9,10]. With outstanding foresight and wit, he addressed an entire spectrum of issues which excited, intrigued, or even worried the cytologic community. While recently reading through these editorials, I was enchanted by the elegance and clarity of the writing, but even more so by his foresight and the analytical power of his observations. Not surprisingly, many of the questions he raised and discussed are still with us today.

The article “The Attack on the Annual “Pap Smear” [1] was initiated by increasingly critical reports in the lay press on the effectiveness and cost-benefit ratio of cervical screening, exemplified by a cover story in Newsweek, entitled “Flap with Pap”. Some of the questions discussed by Dr. Koss are still with us today. Can the cost be reduced by spacing the screening procedure? How well is the smear being handled in the laboratory? What about the fatigue of the cytotechnologist? What is the risk of progression in the individual patient? However, he also clearly stated that “a large percentage of precancerous lesions detected by cytology will not progress to invasive cancer during the lifetime of the bearer.”

Two editorials [2,6 ]on fine-needle aspiration (FNA) appeared in 1980 and 1984, respectively, and illustrated the remarkable take-off of this technique in the USA within these four years. In 1980, Koss outlined the historic development of aspiration cytology and pathology in Europe, particularly in Sweden, and contrasted it with the lack of interest in FNA in the USA, where surgical pathology was still dominant. In 1984, however, the editorial written together with Dr. Wied introduced the first issue of Acta Cytologica to be dedicated exclusively to FNA, thereby highlighting the foresight and progressive nature of this journal. The subsequent phenomenal success of this technique worldwide was considerably enhanced and supported by the editorial policy of the journal.

The editorial on environmental carcinogenesis and cytology [3] exemplifies the elegant and all-encompassing style of Koss' writing. Starting with the well-known history of lung cancer in cobalt and radium mine workers in Saxony and Czechoslovakia (in Schneeberg and Joachimsthal, respectively), he then moves on to bladder cancer in industrial workers and its detection by means of urinary cytology. Although several studies on developing lung cancer in uranium workers in Utah and asbestos workers in Texas led to the recognition of squamous metaplasia and dysplasia as precursor lesions of lung cancer, Koss did not see any evidence that screening industrial workers would contribute significantly to improving their survival.

The introduction to his article on cytochemistry in 1984 was classic of Koss' historic and cosmopolitan approach, and should not be missed [7]:

Many a visitor to Paris is familiar with a street on the Left Bank of the Seine known as Boulevard Raspail. The street is named after Francois-Vincent Raspail (1794-1878), a renowned political reformer. It is less well known that this extraordinarily versatile man, who is recognized today as the initiator of microscopic chemistry, started his career as a chemist and microscopist. In 1830, Raspail published a pamphlet, in which he described the application of principles of contemporary chemistry to microscopy. Raspail's work was the beginning of a chain of scientific events lasting to this day that have for their purpose the identification of the precise chemical makeup of cells and tissues.

From there, Koss moves to the history of the dyes still used today in microscopy such as hematoxylin, eosin, and the Feulgen stain for DNA quantification. He concludes with the development of monoclonal antibodies by Köhler and Milstein [11]; this was hot news in those days whereas today it is daily practice around the world.

Readers who are interested in the development of automation in cytology will thoroughly enjoy the comprehensive editorial entitled “Analytical and Quantitative Cytology: A Historical Perspective” [5]. After detailing the rudimentary beginnings of microscopy, cytochemistry, and cell measurements, Koss gives a personal account of the origins of automation and the people involved, all of whom he knew and worked with personally. The pace of progress, from the beginnings of the “cytoanalyzer” in the 1950s, to the introduction of computers and high-resolution image analysis in the 1970s, and then to flow cytometry, appeared to be painfully slow. However, in 1982, Koss concluded this editoral correctly: “One can imagine that within a forseeable time, any diagnostic analysis of tissues and cells will be computer generated….in this proposed scheme of things to come, analytical and quantitative cytology will play a key role.” And indeed, with computer-aided screening in today's laboratories now a routine procedure, his vision was proved correct.

In 1987, a lead article in TheWall Street Journal about lax laboratory practices in so-called “Pap-mills” caused havoc in the cytology community and among health authorities. Shortly thereafter, Koss analyzed the situation in an extensive review entitled “The Papanicolaou Test for Cervical Cancer Detection: A Triumph and a Tragedy” [9] published in JAMA, the main journal of the American Medical Association. It was an attempt to explain, to lay people and health policy makers alike, the complexity of the cervical cancer detection system. It was a widely quoted article, in which Koss addressed the issues of quality control, the natural history of the lesions, remedies, and sources of errors.

As a consequence, health authorities introduced the “Clinical Laboratory Improvement Act of 1988” with considerably stringent laboratory regulations. In 1989, the cytology community developed The Bethesda System for cytology reporting, which was commented on by Koss in an editorial [10 ]published in the Journal of the National Cancer Institute.

Finally, it is noteworthy and more than appropriate that Koss was the author of a congratulatory editorial on the 25th birthday of Acta Cytologica in 1981 [4]. In it, he fondly recalled the arrival of the first issue in 1957, which was in offset printing on thick paper. Under the guidance of the long-term editor, Dr. George L. Wied, he reviewed the successful development of the journal after its difficult start. He then pondered on the natural course of a scientific journal, and Acta Cytologica in particular. The explicit question: “What about the future of Acta Cytologica?” is related, for him, to the future of cytology. And this, he saw as bright [4]:

As the emphasis shifts, as it must, to preventive care…the cell sample obtained by a variety of means will increasingly replace the tissue sample as the first diagnostic approach to disease identification…Within the framework of these future changes, the survival of Acta Cytologica seems reasonably assured. Dr. Wied and the editorial staff deserve our thanks for the past accomplishments and best wishes for the future.

In summary, the article reprinted here and the series of editorials by Koss in the 1980s give a lively and detailed view on the scientific situation of cytology in the years when Acta Cytologica was the only cytologic journal around. In 1990, in honor of Dr. Koss on his 70th birthday, these editorials were reprinted in a special issue, to be reviewed in their entirety [12]. The special issue illustrates an intense period in the field of cytopathology, with its time-specific expectations, hopes, crises, and solutions. It should give us the necessary support and energy to continue to develop Acta Cytologica to new heights in the future.

Dr. Leopold G. Koss (1920-2012) was a member of the Editorial Board of Acta Cytologica for more than 50 years and contributed significantly to its success. He was the author of numerous articles published in the journal and a reviewer for many years. He also wrote the most recognized textbook on cytopathology, Diagnostic Cytology and Its Histopathologic Bases, which appeared in two volumes and six editions. He was widely traveled and delivered many lectures. George L. Wied, on the occasion of Dr. Koss' 70th birthday [12]:

Above all, he is one of the few renaissance men in our field. He is versed in art, music, history and languages. His lectures are not only scholarly but also a pleasure for the listener. He is a superb cytopathologist and a good friend, and we wish him many happy returns and many more prolific years.

Disclosure Statement

The author has no conflicts of interest to declare.

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References

  1. Koss LG: The attack on the annual “Pap smear”. Acta Cytol 1980;24:181-183.
    External Resources
  2. Koss LG: Thin needle aspiration biopsy. Acta Cytol 1980;24:1-3.
    External Resources
  3. Koss LG: Environmental carcinogenesis and cytology. Acta Cytol 1980;24:281-282.
    External Resources
  4. Koss LG: The 25th birthday of Acta Cytologica. Acta Cytol 1981;25:1-2.
  5. Koss LG: Analytical and quantitative cytology: a historical perspective. Analyt Quant Cytol 1982;4:251-256.
    External Resources
  6. Koss LG: Aspiration biopsy cytology. Acta Cytol 1984;28:195-196.
    External Resources
  7. Koss LG: Cytochemistry. Acta Cytol 1984;28:353-355.
    External Resources
  8. Koss LG: Electron microscopy in cytology. Acta Cytol 1985;29:195-196.
    External Resources
  9. Koss LG: The Papanicolaou test for cervical cancer detection: a triumph and a tragedy. JAMA 1989;261:737-743.
  10. Koss LG: The New Bethesda System for reporting results of smears of the uterine cervix. J Natl Cancer Inst 1990;988-991.
    External Resources
  11. Köhler G, Milstein C: Continuous cultures of fused cells secreting antibody of predefined specificity. Nature 1975;256:495-497.
  12. Wied GL: Leopold G. Koss MD, FIAC, 70th birthday. Acta Cytol 1990;34:593-619.
    External Resources

Author Contacts

Correspondence to: Dr. Volker Schneider

Pathology Laboratory

Burgunderstrasse 1

DE-79100 Freiburg (Germany)

E-Mail volk.schneider@t-online.de


Article / Publication Details

First-Page Preview
Abstract of Commentary

Received: May 22, 2017
Accepted: May 22, 2017
Published online: July 11, 2017
Issue release date: July – October

Number of Print Pages: 7
Number of Figures: 1
Number of Tables: 0

ISSN: 0001-5547 (Print)
eISSN: 1938-2650 (Online)

For additional information: https://www.karger.com/ACY


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References

  1. Koss LG: The attack on the annual “Pap smear”. Acta Cytol 1980;24:181-183.
    External Resources
  2. Koss LG: Thin needle aspiration biopsy. Acta Cytol 1980;24:1-3.
    External Resources
  3. Koss LG: Environmental carcinogenesis and cytology. Acta Cytol 1980;24:281-282.
    External Resources
  4. Koss LG: The 25th birthday of Acta Cytologica. Acta Cytol 1981;25:1-2.
  5. Koss LG: Analytical and quantitative cytology: a historical perspective. Analyt Quant Cytol 1982;4:251-256.
    External Resources
  6. Koss LG: Aspiration biopsy cytology. Acta Cytol 1984;28:195-196.
    External Resources
  7. Koss LG: Cytochemistry. Acta Cytol 1984;28:353-355.
    External Resources
  8. Koss LG: Electron microscopy in cytology. Acta Cytol 1985;29:195-196.
    External Resources
  9. Koss LG: The Papanicolaou test for cervical cancer detection: a triumph and a tragedy. JAMA 1989;261:737-743.
  10. Koss LG: The New Bethesda System for reporting results of smears of the uterine cervix. J Natl Cancer Inst 1990;988-991.
    External Resources
  11. Köhler G, Milstein C: Continuous cultures of fused cells secreting antibody of predefined specificity. Nature 1975;256:495-497.
  12. Wied GL: Leopold G. Koss MD, FIAC, 70th birthday. Acta Cytol 1990;34:593-619.
    External Resources
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