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The American Society of Clinical Pathologists (ASCP) is a nonprofit medical specialty society organized for educational and scientific purposes. Its 75,000 members include board certified pathologists, other physicians, clinical scientists, and certified technologists and technicians. These professionals recognize the Society as the principal source of continuing education in pathology and as the leading organization for the certification of laboratory personnel. ASCP's certifying board registers more than 150,000 laboratory professionals annually.
While ASCP members are involved in the diagnosis of all types of cancer affecting women, our statement today focuses on cervical cancer detection and prevention.
The Pap Smear Facts The Pap smear is a proven screening method of detecting and preventing cervical cancer. It is the most effective cancer screening test in medical history as it is largely responsible for the 70% to 80% decline in death due to cervical cancer over the last 50 years in the United States.
Approximately 4,900 women die from cervical cancer annually in this country, making it the tenth leading cause of death from cancer in women. Approximately 14,000 new cases of cervical cancer are diagnosed each year.
The Pap smear is a safe, noninvasive, cost-effective medical procedure. Cells collected from a woman's uterine cervix are sent to a cytopathology laboratory where the cells are evaluated. The cytotechnologist prepares the slide and evaluates the specimen, which is composed of thousands of cells - usually between 30,000 to 200,000 cells in a single specimen. If the specimen is within normal limits, a report is sent to the woman's health care provider. If an abnormality is detected, then a pathologist examines the slide and issues a final diagnosis.
Barriers to Pap Smear Testing
While it is difficult to believe, more women (80%) die of cervical cancer because they have never had a Pap smear or they have not had a Pap smear in the last five years than those that die of a false negative Pap smear. We believe this is unconscionable.
There are many reasons why some women do not have Pap smears, or why Pap smears may be less available to women. Some of these reasons are explored below.
Trained Cytotechnologists Are Needed
The American Society of Clinical .Pathologists' Board of Registry, in conjunction with MORPACE International, Detroit, conducts a biennial wage and vacancy survey of 2,500 medical laboratory managers. The survey measures the vacancy rates for 10 medical laboratory positions, and compares and contrasts these data with that from 1988, 1990, 1992, 1994, and 1996 studies. The 1998 data has just been made available, and the information regarding cytotechnologists, the professionals who interpret cellular material such as Pap smears, is of particular interest and concern.
The current vacancy rate for cytotechnologists (staff level) is 10.5%, an increase over the 1996 rate, which was 7.1%. This is the first increase in thecytotechnologist (staff level) vacancy rate in eight years. It is also important to note that for rural areas, the cytotechnologist (staff level) vacancy rate is 17.6%, and totals 9.7% for small-medium size cities and 12.1% in large cities.
Also, while the vacancy rate for cytotechnologist (staff level) in large hospitals is 8.3%, the vacancy rate nearly doubles for hospitals with a 100-299 bed size up to 15.8%. Hospitals with bed size of 300- 499 reported vacancy rates for these professionals at 14.3%. Laboratory managers were questioned about the difficulty they have in filling work shifts. 21% reported problems recruiting cytotechnologist (staff level) for day shifts, three times higher than the 8% reporting such difficulties in 1996.
While the overall vacancy rate for cytotechnologist (supervisor) has decreased over the past two years, 10% down from 12.5%, the vacancy rate in smallmedium size cities for cytotechnologist (supervisor) is 20.0%. Vacancy rates for cytotechnologist (supervisor), while virtually non-existent in the east north central, west south central, and far west regions of the country, are explosive in the northeast (16.7%), south central atlantic (18.2%), and west north central (12.5%) parts of the nation.
These data show some cause for concern. Cytotechnologists are highly skilled and trained individuals, who must have at least a baccalaureate degree followed by a year of specialized training in cytology. Cytotechnologists must then take a rigorous national certifying examination, administered by the ASCP, in order to become certified. Laboratories rely on certified cytotechnologists to evaluate all Pap smears. With high vacancy rates, there is concern that some laboratories will not have the appropriate personnel available to evaluate Pap smears.
Medicare Reimbursement
Cytopathology smears are currently priced at $7.15 on the Medicare laboratory fee schedule. The actual cost of the conventional Pap smear (excluding new technology and the professional component for physicians) is in the range of $13 to $17. The cost of new liquid- based Pap testing is $28-$32. This price includes cytotechnologist salaries, overhead costs, quality control, laboratory supplies, and supplies given to healthcare providers who obtain the smear. The Medicare payment rate for Pap smears should increase significantly.
ASCP and other organizations are working with the Health Care Financing Administration to increase the Medicare payment rate for Pap smears. In addition, Representative Neil Abercrombie and Representative Mary Bono have recently sponsored legislation, HR 976, to increase the Medicare payment rate to $14.60. ASCP supports this effort to bring attention to the need for the Pap test and a more appropriate payment rate.
With annual screening, the chance of a woman developing cervical cancer can be reduced to less than 1%. Pap smears have an irreducible false negative rate (10%-40%) due to sampling errors on the part of health care providers and screening errors occurring in laboratories.
According to a March 1997 report in the Archives of Pathology and Laboratory Medicine, the continued availability of Pap cancer screening test is threatened by lawsuits because the legal system demands a zero error rate which is mathematically unachievable even in the most competent professional hands.

Socioeconomic Barriers
According to Healthy People 2000, the National Health Promotion and Disease Prevention Objectives, there are several key assumptions that may be used to help overcome barriers to cervical cancer screening. The objectives state, "low income, low education and advancing age are all associated with a decreased likelihood of receiving Pap tests." The report continues that "age influences both cervical cancer incidence and survival. While younger women are more frequently diagnosed with cervical cancer, older women are more often diagnosed at later stages of the disease and are more likely to die from it than younger women." We are also aware that certain populations of women - African American, Hispanic, Asian, and low-income rural women often face cultural and economic barriers to Pap screening.
For example, it is not uncommon for low-income women of Hispanic descent to refuse Pap testing. Even if the Pap smear is free or of little cost, these women, whose families may rely on them for income and support, refuse the test because they do not want to know if they have cancer. A cancer diagnosis, in this instance, would mean extensive, and often prohibitive, medical costs to treat the cancer, and would tear the women away from their families for extended periods of time. Many women in this situation prefer not to know their potential cancer status. In addition, a lack of culturally appropriate materials or information communicated in Spanish is a barrier to Hispanic women being screened.
In a study compiled by the Centers for Disease and Prevention, it was determined that transportation and its costs were barriers to Pap testing for Native American women.
In speaking with public health officials, we are also aware of examples in certain Asian-American communities where it is considered shameful for women to have a Pap smear. In this culture, husbands may not want their wives to be examined "in that way" by a male physician.Solutions The Pap smear, named for its creator Dr. George N. Papanicolaou, is one of the most effective cancer screening tools available to women today. There are ways to lessen the barriers that exist to Pap testing, so that cervical cancer becomes a less formidable disease to women. ASCP continues to work with the cytology community to provide continuing education and certification for these laboratory professionals. ASCP has also established a scholarship program for medical technology students, including cytotechnologists. The Society awards 100 student scholarships each year to assist with educational finances.
Title VII of the Public Health Service Act (Health Professions Education Partnerships Act of 1998, P.L. 105-392), includes a program for Allied Health Project Grants. This program has been effective in addressing the training and educational needs of allied health personnel, including cytotechnologists. However, further strides in funding are still needed to increase the number of cytotechnologists to an adequate level.
Increasing the Medicare reimbursement for Pap testing to an amount more in line with current costs would also help to attract and retain professionals in the field.
ASCP, along with many other organizations, are working to educate the general public and the priority populations mentioned above about the importance and effectiveness of the Pap smear. We are particularly proud of the efforts we have undertaken to help educate other health care providers about the Pap smear.
ASCP believes it is important to develop and disseminate educational materials to targetted populations and to the health care providers that serve them, and develop relationships with community organizations, such as schools, retailers, employers, social facilities, and churches, to assist inreaching women that are not participating in cervical cancer screening programs.
We aim to continue these educational efforts, and look forward to working with you and others in the prevention of cervical cancer.

LOAD-DATE: June 11, 1999

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