C ytology can be used in 2 different ways: as a diagnostic test or as a screening test. As a screening test, a cytologic diagnosis is associated with specific levels of risk for malignancy or dysplasia. There are many different words for communicating this risk. These include the well-known negative, atypical, suspicious, and positive diagnoses. However, there are also many more subtle words and phrases: suggestive of, suspicious for, cannot rule out, and consistent with, just to name a few. To every cytologist these different phrases have very specific meanings and levels of risk, and in our department we have had many discussions regarding which of these phrases is best for an individual case. Nevertheless, many of our clinicians do not have such a sophisticated approach to these cases. Either the cytologist can make a diagnosis or he cannot; either he knows the answer or he does not. For these clinicians, all cytologic tests are diagnostic tests, and the idea that some interpretations measure risk very accurately is unknown. At the very least, this represents a communication problem. How can we improve this situation?
One approach would be to try and educate our clinicians concerning the various phrases in use. However, this would be labor intensive and most likely not well received by our busy clinicians, and it is my impression that even cytologists disagree about exactly what level of risk each different phrase represents. In addition, in some settings, the phrases used are simply not very good at describing the risk of an individual case because they are not consistent and may even be contradictory. For example, in thyroid aspirations specimens, a case that is worrisome for a Hurthle cell neoplasm is often diagnosed as being suspicious for a Hurthle cell neoplasm (or even positive in some centers). Yet even with the worst outcome, the risk of malignancy is reported to be no higher than 20%. 1 In contrast, a case with just a few clusters of cells with features of papillary carcinoma is often signed out with no worse a label than atypical cells present, a papillary carcinoma cannot be ruled out. Nevertheless, this case is associated with a risk of malignancy of no less than 30%. 1 As a result, it appears unlikely that any amount of education on the part of the clinician is going to clarify terminology that simply is not used consistently by cytologists.
A better approach, in my opinion, would be to stop emphasizing these different phrases and instead report quantitative assessments of risk in cytology. Every cytologist knows there is a big difference in