EDITORIAL

Cytotechnologist – a profession with a changing occupationalprofile?

When we talk about cytotechnologists in Europe, the

majority still think of individuals highly gifted and

trained in the recognition of certain images, who use

this knowledge for cervical cancer screening only.

This is despite the fact that the non-gynaecological

component of cytotechnologists’ work has existed as

long as cervical screening, although dwarfed by the

latter in many departments. Training still seems to be

focused on cervical screening in most countries, as

shown in the survey report published by Anic and

Eide in this issue,1 although the report of a ‘discus-

sion forum’ also published in this issue indicates that

pathologists in Europe and elsewhere recognize the

great importance of extending their role and of for-

mal training.2 Non-gynaecological cytopathology will

suffer if an attempt is not made to harness the skills

and knowledge to pass on to the next generation.

The lead article in this issue by Barr Fritcher and col-

leagues at the Mayo Clinic shows how the skills of

cytotechnologists can be utilized for procedures such

as fluorescence in situ hybridization,3 and Shield and

Breeze and their respective co-workers in Australia4

and the UK5 show how successfully and cost-effec-

tively cytotechnologists can contribute to rapid on-

site assessment of fine needle aspirates.

Nevertheless, cervical screening remains a vital

component of the work of cytotechnologists. Since

the days of Papanicolaou, cytological screening is

thought to have been the key factor in the success-

ful story of the control of cervical cancer in Europe.

For decades, cytological screening for precursor

lesions of cervical cancer has been undertaken by

enthusiastic cytotechnologists. In the majority of

western European countries, incidence and mortality

rates from cervical cancer have decreased tremen-

dously, especially when comparing data from the

beginning of screening up to the turn of the millen-

nium, and bearing in mind trends in the risk of the

disease versus the effects of screening in recent birth

cohorts.6,7 Comparing data from 2008 with those of

2002 shows that, despite a continuing fall in mortal-

ity, cytological screening has reached a plateau with

respect to reducing incidence, which has led to a

questioning of its sensitivity and a search for alterna-

tives.8 Liquid-based cytology (LBC) and computer-

assisted screening have become part of a cytotech-

nologist’s professional life and require new skills, but

have been the basis for anxiety at the same time. In

parallel, research has led to a greater understanding

of cervical cancer development.9 Human papilloma-

virus (HPV) tests have been introduced into cervical

screening, followed by HPV vaccination, as a means

of prevention of cervical cancer and its precursors.10

The use of HPV testing as a primary screening tool is

under consideration in many countries or has

already been implemented. A recent publication

concerning disagreement between the results gained

by different HPV assays hints at the limitations of

these tests when used in the primary screening of

women above 30 years of age, but demonstrates

their usefulness for triage in women with abnormal

cytology.11 Furthermore, concern has been raised

about the sensitivity of HPV tests having been over-

estimated.12 Vaccination and primary HPV testing

will significantly change screening policy and reduce

the number of positive tests, as well as the volume

of cytology tests. Effects on the cytotechnology

labour market have already been reported where cy-

totechnologists’ work repertoire is restricted to cyto-

logical screening.13 Nevertheless, well-trained

cytotechnologists will be needed for the triage of

HPV-positive women, the screening of women under

the age of 30 years and even for co-testing. It is the

task of scientific organizations dedicated to training

in cytology to prevent the wastage of expertise

already gained and to provide the basis for extend-

ing professional responsibilities in a changing field.

Considering the published literature and the daily

professional life of a cytotechnologist, what summa-

rizes the occupation of a ’cytotechnologist’ in Eur-

ope? The European Advisory Committee of

Cytotechnology (EACC) was founded in the late

1990s and is led by the authors of the recent

updated survey reported in this issue.1 Its aims and

activities include all aspects of a cytotechnologist’s

profession, including an extended role in molecular

analysis and non-gynaecological cytology, and are

available on the European Federation of Cytology

Societies (EFCS) website: http://www.efcs.eu/index.

php/eacc-section (accessed 7 August 2014); this pro-

DOI:10.1111/cyt.12200

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Cytopathology 2014, 25, 285–287

vides a major forum for obtaining information and

discussing the realities of training and working as a

cytotechnologist in the different countries of Europe.

The first data evaluated by EACC were documented

in 2006. A questionnaire was circulated to named

contacts in 23 European countries. At that time, the

authors stated that the accuracy of these responses

was limited by the competency of the individual

respondents in the English language and the wide

diversity of training and education in cytotechnology

in Europe. In 2007, when preparing the European

guidelines for screening for cervical cancer, the

chapter on a cytotechnologist’s field of responsibili-

ties, as well as their basic and specific training, still

demonstrated huge variation within Europe and was

the subject of long discussions. The statement finally

published in the EU guidelines for quality assurance

in cervical cancer screening was considered an abso-

lute minimum consensus and only concerned gynae-

cological cytology.14 It was thought that some of the

limitations might have been reduced by 2014

according to the generally changing educational

background within Europe, but the latest survey

shows that considerable variation remains, with

notable deficiencies in many countries for training

in non-gynaecological cytology.1

In 1999, the Ministers of Education from 29 Euro-

pean countries signed the Bologna Declaration

which aimed to create a coherent and cohesive

European Higher Education Area and was officially

launched in 2010. The diversity of national systems

and universities should remain, but improved trans-

parency between national higher education systems

and tools to facilitate pan-European recognition of

degrees and academic qualifications should allow

mobility and exchanges between institutions. All

participating countries agreed on a comparable

three-cycle degree system for undergraduates (bach-

elor degrees) and graduates [master and doctorate

(PhD) degrees], which also entered the curricula of

health study programmes. The Bologna declaration

is available online: http://www.eua.be/eua-work-

and-policy-area/building-the-european-higher-educa

tion-area/bologna-basics.aspx (accessed 12 July

2014). Starting points for reaching a common Euro-

pean level in cytotechnology should have been eas-

ier after the establishment of the Bologna criteria for

basic education, but the changes currently taking

place seem to discourage rather than encourage the

process in the field of cytotechnology, probably

because of the widespread belief that cytological

screening will decline, and a lack of understanding

of the wider role of cytotechnologists as emphasized

in the discussion forum in this issue.2 Initial steps

defining general professional requirements and qual-

ity assessment for gynaecological cytology had

already been generated by a working group headed

by G. Peter Vooijs in the 1990s.15 Guidelines for in-

house training and a three-step proficiency test were

suggested. The subsequent Quality Assurance, Train-

ing and Examination Committee (QUATE) examina-

tion has been offered for many years, first using

conventional smears, but now also LBC, but it has

not yet been extended to non-gynaecological cytol-

ogy. The examination includes a multiple choice

questionnaire for the evaluation of the theoretical

background of candidates. Although the examiners

travel on demand, and a number of European coun-

tries offer similar examinations, QUATE has only

been accepted in a minority of states as shown in

the survey report.1 Primary and continuing educa-

tion in cytology may be based on a variety of teach-

ing methods from peer teaching via blended and

team-based learning to e-learning. Digitalization has

added many options to widen education internation-

ally without losing national cultural background. A

pan-European example can be found on the Eurocy-

tology website, which involves all types of cytopa-

thology (http://www.eurocytology.eu/static/eurocyto

logy/ TUR/eacc.html) (accessed 12 July 2014), but

was rarely used by the survey respondents.1 Up-to-

date teaching modalities must provide courses in

gynaecological and non-gynaecological cytology,

such as the annual tutorials conducted by the EFCS

since 2008. The incorporation of new training meth-

ods and their regular evaluation are helpful tools in

retaining the wealth of cytomorphological knowl-

edge gained in the past.16

When looking back to the past, well-known experts

in cytopathology, especially in the countries of north-

ern Europe, stressed the value of cytodiagnosis in

other fields of cancer detection and follow-up many

years ago.17 However, pre-screening by and the

responsibilities of cytotechnologists in non-gynaeco-

logical cytology are even more variable, even within

countries, as demonstrated in both the survey report

and discussion forum in this issue.1,2 No pan-Euro-

pean quality assessment procedures have been estab-

lished to date for pre-screening or provisional

diagnosis in non-gynaecological cytology. Better

imaging methods have led to a resurgence in diagno-

sis based on fine needle aspirates from various organs,

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Cytopathology 2014, 25, 285–287

Editorial286

and bedside diagnosis has resumed in some areas.

Success in transplantation medicine requires follow-

up of organ recipients by urinary cytology. In view of

recent developments, cytomorphology of aspirates

will require immunocytochemistry and molecular

analysis, which are greatly improved by on-site

assessment. Two articles in this issue demonstrate the

importance and cost-effective role of cytotechnolo-

gists in this context.4,5 Furthermore, single cells are

an ideal base for molecular tests, such as fluorescence

in situ hybridization, as explained by Barr Fritcher

et al.,3 who describe an important new role for cyto-

technologists that makes good use of their valuable

cytomorphology skills. Cytomorphology combined

with immunocytochemistry, molecular analysis and

cytogenetics opens up not only new working fields

for cytotechnologists, but provides the chance to

include skills and knowledge gathered in the past. In

certain laboratories now and in the past cytogenetics

is/was included with cytology. Generally accepted

descriptions of the roles and responsibilities of cyto-

technologists are clearly needed.

New diagnostic approaches and economic factors

will probably change the occupational profile of cy-

totechnologists, and the labour market will expect a

uniform European educational level, which should

be based on bachelor and master university degrees,

as recommended by the EACC as well as by the

multi-author discussion forum.2 The experience and

cytotechnology guidelines in Australia and the USA

were included in the discussion forum and provide a

model for what could be achieved in European

countries.2 The demand for a consensual pan-Euro-

pean description of cytotechnologists’ responsibili-

ties, training guidelines and quality assessment

programmes has already become obvious. Stepwise

and realistic evaluation of requirements in the light

of the present situation is necessary in old and new

countries within the growing European Union, and

must take into account the local demands of the

health systems as well as their economic situation.

Modern educational programmes within Europe

should encourage students to be interested in the

field of cytotechnology, which must be fit for future

developments and comparable with that of other

areas such as Australia and the USA.

H. G. Wiener

Department of Clinical Pathology, Medical University

Vienna, Vienna, Austria

E-mail: helene.wiener@meduniwien.ac.at

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Editorial

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