Expert Commentary

Focus on Cervical Disease: Bethesda 2001: A more usable system

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Objective

The Bethesda 2001 Workshop updated the 1991 Bethesda System terminology for reporting results of cervical cytology. This effort represents a focus on broad participation utilizing an Internet bulletin board to collect data prior to the workshop.

Method and Results

Eight months before the workshop convened, 9 forum groups of 6 to 10 persons developed recommendations for discussion. These recommendations were posted on the Internet to encourage discussion and commentary. More than 400 cytopathologists, gynecologists, epidemiologists, family physicians, attorneys, and patient advocates from 44 professional societies and 20 countries participated in the workshop.

After more than 1,000 comments were submitted via the bulletin board, the workshop convened in Bethesda, Maryland, from April 30 to May 2, 2001. The most clinically relevant changes to the Bethesda System are listed below.

  • Specimen adequacy.
    • eliminates “satisfactory but limited by” (absence of endocervical cells is not considered unsatisfactory)

  • General categorization.
    • “within normal limits” was changed to “negative for intraepithelial lesion”

  • Interpretation/result.
    • “diagnosis” was replaced by “interpretation” or “result”

  • Epithelial cell abnormalities.
    • ASCUS was replaced by ASC-US or ASC-H (cannot exclude HSIL)
    • 2-tiered LSIL and HSIL classifications remain
    • AGUS classification was significantly revised and changed to AGC, endocervical endometrial, or glandular cells NOS (not otherwise specified)
    • endometrial cells will be noted if present in women over the age of 40 rather than only postmenopausal patients

Who May Be Affected?

Physicians managing patients with cytologic abnormalities.

Expert Commentary

The wide range of participants lends significance to this extraordinary effort to correct and simplify the Bethesda System recommendations. First, a 6-month Internet survey generated many recommendations. This was followed by the actual workshop, which provided another opportunity to finalize the system. The process was deemed so successful that the American Society for Colposcopy and Cervical Pathology and the American College of Obstetricians and Gynecologists used a similar process when the workshop for the management of cytologic abnormalities was held later in 2001.

Overall, this is a kinder and gentler system. Elimination of “satisfactory but limited by” was a major improvement. Narrowing the ASCUS classification to ASC-US and ASC-H makes it possible to use multiple triage methods such as immediate colposcopy, HPV testing, or repeating the smear unless the report is ASC-H, which requires immediate evaluation.

Bottom Line

Physicians who manage patients with cytologic abnormalities will be better served by the Bethesda 2001 System.

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