2017, Volume 33, Number 2, Page(s) 134-143
What does the Data of 354,725 Patients from Turkey Tell Us About Cervical Smear Epithelial Cell Abnormalities? - The Epithelial Cell Abnormality Rate is Increasing - Quality Control Studies and Corrective Activity are Musts
İlknur Çetinaslan TÜRKMEN1, Alp USUBÜTÜN2, Aslı ÇAKIR1, Özlem AYDIN3, Filiz Aka BOLAT4, Metin AKBULUT5, Serdar ALTINAY6, Sema ARICI7, Figen ASLAN8, Müzeyyen ASTARCI9, Emine Kılıç BAĞIR10, Yılmaz BAŞ11, Nuray BAŞSÜLLÜ12, Betül ÇELİK13, Handan ÇETİNER14, Bengü ÇOBANOĞLU15, Abdullah AYDIN15, Hale DEMİR16, Hayriye Tatlı DOĞAN17, Kamile Gülçin EKEN18, Selma Şengiz ERHAN19, Gülgün ERDOĞAN20, Kıvılcım Eren ERDOĞAN21, Funda EREN22, Şafak ERSÖZ23, Pınar FIRAT24, İclal GÜRSES25, Nihan HABERAL26, Dudu Solakoğlu KAHRAMAN27, Gülçin Harman KAMALI19, Yasemin Yuyucu KARABULUT28, Mehmet KEFELİ29, Meral KOYUNCUOĞLU30, R. Doğan KÖSEOĞLU31, Bahar MÜEZZİNOĞLU32, Binnur ONAL33, Sevgen ÖNDER2, Zuhal ÖZCAN34, Elife KIMILOĞLU34, Hatice ÖZER35, F. Cavide SÖNMEZ7, Sevinç ŞAHİN36, Nurhan ŞAHİN37, Tülin YALTA38
1Department of Pathology, Istanbul Medipol University Faculty of Medicine, İstanbul
2Hacettepe University Faculty of Medicine, Ankara
3Acibadem University Faculty of Medicine, İstanbul
4Başkent University ERH, ADANA
5Pamukkale University Faculty of Medicine, DENİZLİ
6Bagcilar ERH, Istanbul
7Bezmialem Vakif University Faculty of Medicine, Istanbul
8Dumlupinar University Evliya Celebi ERH, KÜTAHYA
9Abant Izzet Baysal University Faculty of Medicine, BOLU
10Cukurova University Faculty of Medicine, ADANA
11Hitit University Çorum ERH, ÇORUM
12Bilim University Faculty of Medicine, Istanbul
13Antalya ERH, ANTALYA
14Zeynep Kamil ERH, İSTANBUL
15Medeniyet University Goztepe ERH, İSTANBUL
16Istanbul University Cerrahpaşa Medical Faculty, İSTANBUL
17Yildirim Beyazit University Ankara Ataturk ERH, ANKARA
18Sisli Hamidiye Etfal ERH, İSTANBUL
19Okmeydani ERH, İSTANBUL
20Akdeniz University Faculty of Medicine, ANTALYA
21Mersin State Hospital, MERSİN
22Marmara University Faculty of Medicine, İSTANBUL
23Karadeniz Technical University Faculty of Medicine, TRABZON
24Istanbul University Faculty of Medicine, İSTANBUL
25Mersin University Faculty of Medicine, MERSİN
26Baskent University Faculty of Medicine, ANKARA
27Tepecik ERH, İZMİR
28Cankiri State Hospital, ÇANKIRI
29Ondokuz Mayis University Faculty of Medicine, SAMSUN
30Dokuz Eylul University Faculty of Medicine, İZMİR
31Gaziosmanpasa University Faculty of Medicine, TOKAT
32Kocaeli University Faculty of Medicine, KOCAELİ
33Diskapi ERH, ANKARA
34Taksim ERH, İSTANBUL
35Cumhuriyet University Faculty of Medicine, SİVAS
36Bozok University Faculty of Medicine, YOZGAT
37Inonu University Faculty of Medicine, MALATYA
38Trakya University Faculty of Medicine, EDİRNE, TURKEY
Keywords: Cervical Smear, Epithelial cell abnormality, Turkey
There is no other screening program close to the success rate of PAP test. Cervical cytology constitutes a large workload so that quality
control in cervical cytology is important for the quality assurance of pathology laboratories.
Material and Method: In this study, we collected the cervical cytology results from all over Turkey and discussed the parameters influencing the
quality of the PAP test. The study was conducted with Turkish gynaecopathology working group and 38 centers (totally 45 hospitals) agreed to
contribute from 24 different cities. The study was designed to cover the cervical cytology results during 2013. The results were evaluated from
the data based on an online questionnaire.
Results: The total number of Epithelial Cell Abnormality was 18,020 and the global Epithelial Cell Abnormality rate was 5.08% in the total 354,725
smears and ranging between 0.3% to 16.64% among centers. The Atypical squamous cells /Squamous intraepithelial lesion ratios changed within
the range of 0.21-13.94 with an average of 2.61. When the centers were asked whether they performed quality assurance studies, only 14 out of
28 centers, which shared the information, had such a control study and some quality parameters were better in these centers.
Conclusion: There is an increase in the global Epithelial Cell Abnormality rate and there are great differences among centers. Quality control
studies including the Atypical squamous cells/Squamous intraepithelial lesion ratio are important. Corrective and preventive action according
to quality control parameters is a must. A cervical cytology subspecialist in every center can be utopic but a dedicated pathologist in the center
is certainly needed.
Cervical cancer has shown a decreasing incidence since the
use of the Papanicolaou (PAP) test starting at the 1950s.
According to the GLOBOCAN 2012 database, cervical
cancer is the 7th most common cancer in the world and
4th among women1
. According to the 2012 data of the
Cancer Department of the Health Ministry of Turkey, it is
most common cancer among women with a 2.4%
Since the use of the PAP test, there has been no other screening
program with a similar success. There is a population-based
screening program carried out by the Ministry of Health
in Turkey, but hospital-based (opportunistic) screening
still constitutes a great volume in cervical cancer screening.
There are several articles representing the hospital-based
results of cervical cytology from different centers3-13 and
one multi-center study representing data from 33 centers
comprising 140,334 patients in Turkey14.
Cytology slides are usually evaluated by pathologists and
only few centers have cytotechnologists in Turkey. Cervical
cytology constitutes a large volume in the workload within
the pathology routine so that quality control in cervical
cytology is important for the quality assurance (QA) of
the pathology laboratories. There are several proposed
quality control parameters for cervical cytology such as
cytology histology correlation (CHC), retrospective review
of negative smears that have a following positive biopsy,
monitoring diagnostic rates, multi-head review of difficult
cases, and high risk Human Papilloma Virus (hrHPV)
positivity of atypical squamous cells of undetermined
significance (ASCUS) cases15. Two reliable and widely
used criteria are the Atypical squamous cells (ASC)/
Squamous intraepithelial lesion (SIL) ratio and CHC.
ASC is expressed as the total of ASCUS and ASC cannot
exclude High grade Squamous Intraepithelial lesion (HSIL)
(ASC-H)16-18. The recommended ASCUS/SIL ratio
is 2 to 3 in different publications16,19,20 and between
0.87 and 4.49 in others16,20,21. The reported hospital
based ratios from Turkey vary between 3.28 and 12.63-13
and 2.83 in the multi-center study of the Turkish Cervical
Cancer and Cervical Cytology Research Group14.
The CHC is another important parameter to be followed
in terms of QA. In 90.8% of the patients with a positive
cervical cytology, SIL was determined on biopsy and the
biopsy was found to be normal in 62.8% of the cases where
no epithelial cell abnormality (ECA) was seen on cytology22. The CHC increases in direct proportion with the
increase of atypia degree on cytology and can be as high
as 100% for HSIL and decreases to 54% for ASCUS and to
20% for atypical glandular cells (AGC)4,6,7,9,23,24.
The workload is also an important determinant affecting the quality parameters in pathology. The workload limit
can vary; it is reported to be assessed by daily or hourly
slide number, time spent nonstop on screening or daily
total time of screening25. The daily workload of cervical
cytology is important, but the more correlated parameter is
reported to be the ECA-adjusted workload of 7 slides/day,
which means 70 slides/day with a 10% ECA26.
Cervical cancer screening is very important and several
methods can be used. In Turkey, cervical cancer screening
is mostly by opportunistic hospital-based screening. There
are studies for public based screening. The first studies
with this aim were based on the cervical PAP smear test.
However, the current method in Turkey is HPV screening,
and the cervical smear is evaluated if the patient is HPV
In this study, we aimed to collect the cervical cytology results
from all over Turkey to represent the whole country data as
close as possible and discuss the parameters influencing the
quality of the PAP smear reporting.
The study proposal was shared with Turkish
gynaecopathology working group and all the laboratories
were asked to contribute to the study. Thirty-eight centers,
one of which having 8 different hospitals (in total 45
centers), from 24 different cities agreed to contribute to the
study. The study was designed to cover the cervical cytology
results within the period of 1 January-31 December 2013.
An online questionnaire was conducted. Laboratories
were asked to state their annual biopsy/cytology/cervical
cytology counts, method of cervical cytology, pathologist
number responsible for PAP smear and number of total
pathologists, annual diagnoses of ECA with subgroups of
ASCUS, ASC-H, low grade squamous intraepithelial lesion
(LSIL), HSIL, AGC and carcinoma (CA). Additionally, the
biopsy or follow-up PAP smear results of the patients for
whom the ECA diagnosis was available were collected.
The ECA and ASC/SIL ratio were calculated from
participant-reported data. The ECA rate was defined by the
ratio of ECA to the total cervical cytology number. ASC/SIL
defined by the ratio of the sum of ASCUS and ASC-H to the
sum of LSIL, HSIL, and CA cases.
The study group was composed of 38 pathology laboratories
and 45 different hospitals from 24 cities. The participant
distribution is shown in Figure 1
. Among the participant
centers, 12 (26%) were state hospitals while 8 (18%) were
private hospitals and 25 (56%) were university hospitals.
The annual total number of smears was 354,725 and cervical
cytology numbers of the laboratories ranged between 674- 49,483 (Table I
) while total annual biopsy numbers were in
the range of 5827 to 155,497. The cervical smear constituted
28% of the total biopsy volume in average. The type of
method used in cervical cytology was conventional smears
in 18 and liquid based cytology (LBS) in 20 laboratories
while 9 centers were using automated screening program.
The number of pathologists working in the centers
ranged between 1 and 30 and the number of pathologist
responsible for cervical cytology were in the range of 1-13.
The annual number of smears per pathologist varied from
294 to 21,297. Working cytotechnologists were present in
2 centers. Cervical cytology constituted 28% of the volume
on average with a range of 8.87%-92.46%.
The annual total number of ECA was 18,020 in the study
group and the global ECA ratio of the study group was
5.08% in the total 354,725 smears. Among the centers, the
lowest reported ECA rate was 0.3% and the highest ECA
was 16.64%. The ECA rates of the laboratories are shown
in Table I. The distribution of ECA rates varied among
the geographic regions (Figure 2). The relation between
the ECA rates and the total smear number is shown in
the graph (Figure 3). When analyzed based on the type
of the centers, ECA rate varied between 0.52 and 7.76%
(mean: 2.81%, median: 2.18%) in state hospitals while it
was 3.71-16.64% (mean: 12.32%, median: 14% ) in private
hospitals and 0.39-14.57% (mean: 3.16%, median: 2.38%)
in university hospitals.
Click Here to Zoom
|Figure 2: The epithelial
cell abnormality rates
according to the
Click Here to Zoom
|Figure 3: ECA rate distribution according to the total smear
number of the center.
ECA: Epithelial cell abnormality.
Among 18020 ECA, the most common lesion was ASCUS
(11557/18020, 64.2%) followed by LSIL (4106/18020,
22.8%), ASCH (1029/18020, 5.8%), HSIL (700/18020,
4%), AGC (548/18020, 3%) and CA (18/18020, 0.2%), in
The ASC/SIL ratios ranged between 0.21 and 13.94 with an
average of 2.61 (±2.95) and median of 2.87. Eight centers
had an ASC/SIL ratio lower than 1.5 and 13 centers had
a value between 1.5 and 3, while 7 centers had an ASC/
SIL ratio of 3-4 and 10 of them had a value higher than or
equal to 4 (Figure 4). When analyzed according to the type
of the centers, the ASC/SIL ratio varied between 0.79 and
10.87 (mean: 4.23, median: 3.05) in state hospitals while it
was in the range of 2.07-5.25 (mean: 2.08, median: 3.74) in
private hospitals and 0.21-13.94 (mean: 3.17, median: 2.75)
in university hospitals.
Click Here to Zoom
|Figure 4: The ASC/SIL ratios distribution of the centers.
ASC: Atypical squamous cell, SIL: Squamous intraepithelial lesion).
The graphical distribution of ECA percentages in relation
to ASC/SIL ratios is shown in Figure 5.
Click Here to Zoom
|Figure 5: The ASC/SIL ratio in relation to ECA rates of the centers.
ASC: Atypical squamous cell, SIL: Squamous intraepithelial lesion,
ECA: Epithelial cell abnormality.
The ASC/SIL ratios in relation to annual cervical cytology
per pathologist in the centers are shown in Figure 6.
Click Here to Zoom
|Figure 6: The ASC/SIL ratio in relation to annual smear number.
ASC: Atypical squamous cell, SIL: Squamous intraepithelial lesion.
When the centers were asked for whether they perform QA
studies, 28 centers shared the information and 14 of them
had such a control study. Eight centers were following the
CHC results, another 5 were following both CHC and ASC/
SIL ratio and in 1 center the annual malignancy rate, ASC/
SIL ratio, and CHC rates were followed and 10% of negative
reported cases were re-evaluated. In the QA-performing
group, the ASC/SIL ratio range was 0.87-8.6 with an average
of 3. In the QA-non performing group ASC/SIL ratio range
was 0.79-13.94 with an average of 4.5.
When we analyzed the centers according to ASC/SIL higher
than 3 and QA study performance, 35.7% (5 of 14) of the
centers in the QA-performing group had an ASC/SIL value
higher than 3 but this was as high as 57.1% (8 of 13) in the
QA-non performing group.
There were lower ASC/SIL ratios in private hospitals and
no difference between university/non-university hospitals.
Private hospitals had a common feature of having quality
control studies in 5 out of 6 centers. Despite such QA
studies, ASC/SIL was higher than 3 (3.37-3.41-5.5-6.21-8.6)
in 5 out of these 14 centers. Among the 8 centers with ASC/
SIL ratios higher than 4, we found that 4 had no QA studies,
3 were performing QA studies and no data was obtained
from 1 of them.
Follow-up data of the patients was reported from 41 centers.
In the study group, 4173 patients in total had at least one
biopsy. Out of the 1951 biopsy-verified ASCUS cases, 722
were SIL and CA (559 LSIL, 152 HSIL, 11 CA) and the
biopsy was negative in 1229 patients. Follow-up biopsy
was performed in 344 patients reported as ASC-H and the
results were 93 LSIL, 98 HSIL, and 15 CA while the number of cases with negative biopsy was 138. The biopsy results of
1461 patients whose smear diagnosis had been LSIL were
documented and SIL was verified in 1005 (726 LSIL, 276
HSIL and 3 CA) (68.8%). The SIL verification rate by biopsy
in patients diagnosed with HSIL was 87% (55 LSIL, 259
HSIL and 48 CA). The positive predictive value (PPV) of
AGC was 47.8% (14 LSIL, 9 HSIL and 35 CA and glandular
pathology in 39 cases) and 97.4% (12 LSIL, 1 HSIL and 24
CA) for carcinoma diagnosis. The biopsy follow-up results
are shown in Table II.
The PPV of the each center according to the smear
diagnosis showed variations. The lowest PPVs for ASCUS,
ASC-H, LSIL, HSIL, CA, and AGC were 9.5; 25; 25;
66.6; 7.4, and 87.5, respectively. When these results were
evaluated according to the ASC/SIL ratio, the PPVs for
ASCUS, ASC-H, LSIL, HSIL, CA, and AGC were 21-75.51-
85, 84-100, 84-100, 87.5 -100, and 28-100 respectively for
the centers having an ASC/SIL ratio lower than 1.5. For the
centers having an ASC/SIL ratio higher than 4, the PPVs for
ASCUS, ASC-H, LSIL, HSIL, CA and AGC were 9.5-44; 25-
51; 29-90; 66.6-100; 7.4-25 and 100, respectively (Table III).
The time-honored PAP test is currently the most effective
cancer screening method. The cervical smear data from
Turkey is documented in hospital-based reports3-13
only one study14
represents a multi-center data reporting
results from 22 cities, 34 hospitals and a total of 140,334
smears. There is an ongoing public-based national cervical
carcinoma-screening program searching hrHPV presence
since 2014, and the Turkish Ministry of Health runs it,
but their data is not published yet. Hence our study is the
largest existing study showing the results based on 354,725
data is required in order to detect the efficiency
of cervical smears. Various data such as the ECA rate and
ASC/SIL ratio can be used for QA. When the ECA rate was
evaluated, it varied between 1.5% and 7.3% in countries
with high-income (28-30). Reported rates from Turkey
range from 1.2% to 12.6%3-13 and were 1.8% in the
multi-center study14. The average ECA rate of 5.08% in
our study is higher than the unreported current data of the
Ministry of Health national screening program31. This
difference can be considered to be partly related to the
patient population as our study used hospital-based rather
than public-based data. To a smaller extent, possible patient
duplications can be a reason, but our data was collected
as patient-based, not test-based, and this cannot be the
explanation for this high rate. Our study method is similar
to the multi-center hospital-based study reported in 2009
in Turkey14 and our current results are also higher than
this study. The difference may be attributed to the difference
in hospital types, as the previous study did not include
private hospitals, and the number of the patients involved
in the studies. Our study includes 2.5 times more patients
than the other study so we believe that our results are more
reliable. As our study also includes private hospitals, we can
also argue that our data represents a more homogeneous
distribution among the Turkish population and hence
it is more generalizable since the previous study did not
represent the private hospitals that play a major role in the
health care system. It is found that there is an increase in
ECA rate in the 6-year period from 2007 (the data of the
previous study shows the 2007 data) to 2013 (the year of
data collection of the present study). The ECA rates of the
private hospitals are seen to be higher than state hospitals,
and this may be attributed to the upper socio-economic
group of high-risk patients. This may reflect the difference
in socio-economical difference among other centers,
similar to the data of countries with high income28-30.
Unfortunately, we do not have data from the eastern part
of the country, and there is a gap in that area. There are
studies representing data from this region32 and the ECA
rate was found to be 1.81% by those studies. Although we
cannot discuss the regional data, there is a lower ECA rate
in this region of Turkey in comparison to the averages of
the whole study group.
The differences in ECA rates among different cities show an
increase in some cities on the coast. This can be attributed
to socio-cultural differences. However, this cannot be the
only explanation as there are low rates from the some cities
such as Mersin, Adana, Istanbul and low rates reported
from Izmir another city on the coast. One striking result
of the ECA rates is that a laboratory having 8 different
hospitals reported the highest rates (shown in purple in
Figure 2) among other hospitals in the same cities. In terms
of QA, this laboratory has a highly acceptable ASC/SIL ratio
smaller than 3, so the ECA rates can be considered reliable.
This center is a private laboratory and most of the hospitals
are A+ hospitals where the patient group consisted mostly
upper socio-economic group of high-risk patients. This
may reflect the difference in socio-economical difference
among other centers. The data from this center is similar to
the data of high income countries28-30.
The ranges of ECA rates showed no great differences when
evaluated according to hospital type as public-private or
The ASC/SIL is reported to be less variable when compared
to ECA and creates mathematical data recommended for
use in QA16,19,21. This ratio is recommended to be 1.73 -
2.05 for cytopathologists and 0.87- 4.5 for cytotechnologists
in several articles16,21 and under 2-3 in others16,19,20.
The ASC/SIL ratio in hospital-based studies from Turkey
varies between 2.25 and 12.63-13. This value was 2.83
in the multi-center study from Turkey14. The ASC/SIL
ratios from this study showed a great range among centers.
The values changed from 0.21 to 13.94 with a mean of 2.83.
When grouped, 8 centers had a ratio lower than 1.5 (21%)
and 13 centers reported a ratio of 1.5-3 (34%). The number
of centers having a ratio higher than 3 was 17 (45%) and
9 of them had a ratio higher than 4. These values are not
totally correlated to ECA percentages, as shown in the
graph in Figure 5. It is seen that there are very low ASC/
SIL values in some high ECA reporting centers as well as
high ASC/SIL values in some low ECA reporting centers,
although the majority are grouped in the left part of the
graph with acceptable values in terms of QA. It is stated that
the ASC/SIL ratio may be lower in high-risk populations and higher in low-risk populations28. However, this
statement cannot explain the difference in our study group,
as there are centers with high ASC/SIL ratios although they
have low ECA rates, as well as some low ASC/SIL ratios
with high ECA rates.
The workload is an important determinant, affecting the
quality parameters in pathology. The workload limit can be
variable, it can be assessed by daily or hourly slide number
or time spent nonstop on screening or daily total time of
screening25. As well as the daily workload, a more highly
correlated parameter is reported to be the ECA-adjusted
workload as 7 slides/day, which means 70 slides/day with
a 10% ECA26. However, similar to ECA rates, the great
range of ASC/SIL among centers in this study cannot be
ascribed solely to workload as there are high values with
low workload and very accurate values with very high
workload. Figure 6 shows that there are very low ASC/SIL
values in 2 high workload centers as well as ASC/SIL values
higher than 4 in 7 centers that of which have a low workload
of cervical cytology per pathologist although most of the
centers are grouped in left part of the graph. The laboratories
having the two highest values are different than the others,
as they have cytotechnologists working with pathologists.
Therefore, they can be evaluated separately. Other than
these two highest volume centers, the annual PAP smear
load is under 3000 cases in the 16 laboratories with ASC/
SIL higher than 3 when ASC/SIL ratio is evaluated in terms
of the workload (defined by PAP smear per pathologist).
So the ASC/SIL ratio cannot be said to depended on the
workload, based on our study.
The QA is important in pathology laboratories as in all
other fields. The Hawthorne effect describes the better
performance of observed subjects than unobserved subjects
and it is stated that pathologists in small laboratories
working as solo screeners have the highest failure rate15.
Quality control studies were performed in 14 centers. There
was no difference in parameters among hospital type, other
than the low ASC/SIL ratios in private hospitals. It is seen
that this group has a common feature to have quality control
studies in 5 out of 6 centers. It is obvious that this cannot be
the only explanation but the effect of quality control studies
cannot be denied. However, it is observed that ASC/SIL was
higher than 3 (3.37-5.5-6.21-8.6) in 4 out of the 11 centers
with quality control studies. In this context, it is noted that
not only does the presence of quality control studies ensure
quality but also the presence of corrective and preventive
action is a must. Most of the centers declared they have
QA studies documenting the CHC data required by the
Ministry of Health.
Centers with an ASC/SIL ratio higher than 4 have another
common property that cervical cytology was evaluated by
all of the pathologists working in the laboratory and there
was no dedicated pathologist in most of these centers. In
89% of the centers that have a ratio higher than 4, cervical
cytology is evaluated by all of the pathologists while only
46% of the centers reporting low ASC/SIL values have
such a working principle. Based on this result, one can
discuss whether cervical cytology should be reported by
all pathologists or whether it should be a subspecialty or
at least reported by some dedicated pathologist at the
centers. In the pathology routine, cervical cytology is easily
shared and with the current health performance system,
every pathologist wants to evaluate it in order to increase
performance. This is also discussed in other countries and
it is stated that when health care professionals are paid for
each service they provide, the health care neither becomes
more efficient and well coordinated nor has high quality33.
Cervical cytology constitutes a large work volume of
pathology routine and it made up an average of 28%
of the patients in our study group. In this context, the
adequacy of cytology training during pathology training
should be discussed. At a survey of pathologists training
in cytopathology in European countries (responded from
26 countries), pathologists without specific training in
cytopathology signed out cytology reports in 54.7%, more
often in centers where training was 3-6 months or less in
duration. However, 92.2% of respondents thought that
cytology should not be reported by pathologists without
experience in cytopathology (cervical cytology workloads
of survey respondents varied from 500 to 200,000 requests
per year; those defined as large processed a range of
13,000-200,000 with an average of 38,000 per year)34.
Another important point to note is that cervical smears are
accepted as the most efficient screening test and but are now
becoming a somewhat diagnostic test due to the changing
screening methods with the use of HPV typing as the first
step. The curriculum of pathology residents should also be
reviewed according to this changing profile.
In terms of QA of cervical cytology, the best parameter
that can be used is ECA confirmed by cervical biopsy.
The specificity and sensitivity rates of cervical cytology
are reported to be highly variable29,30,35. Specificity is
reported as 14 to 97% with a mean of 69% and sensitivity as
11 to 99% with a mean of 58% in the literature23,30,35,36.
The CHC increases in direct proportion with the increase
of degree of atypia on cytology to as high as 100% for
HSIL, and decreases to 54% for ASCUS and 20% for AGC4,6,7,9,23,24. When PPVs are compared with the literature
values, the mean rates of the study group are in accordance
with the literature. Low PPV values are noteworthy in the
centers that had ASC/SIL > 4. Quality control studies and
follow-up of the ASC/SIL ratio are important. However,
the number of patients with biopsy follow-up varied. Some
centers that had very low follow-up numbers may therefore
have appeared to have very high or very low PPVs.
In conclusion, this study shows that there is an increase
in ECA rates in Turkey. There are great differences among
centers. The most important result of this study is that
QA studies including ASC/SIL are vital. However, QA
activity does not mean to record the data to be sent to the
Ministry of Health and taking corrective and preventive
action according to quality control parameters is a must.
A cervical cytology subspecialist in each center can be a
dream at this stage but assigning dedicated pathologists for
cervical cytology should be discussed and attempted. The
pathology community should overview cervical cytology
training during pathology residency and should be ready
to the changing role of the pathologist in the future with
cervical screening by hrHPV testing.
CONFLICT of INTEREST
The authors have no conflicts of interest to disclose.
We want to thank Leyla Durmuş, Nevin Kaya, Zeki
Günlüoğlu, Emel Filiz Özbay and Gökhan Türkmen for
their support in the preparation of the article.
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