• cervical cytology;
  • Papanicolaou tests;
  • atypical squamous cells of undetermined significance (ASCUS);
  • reproducibility;
  • the Bethesda System;
  • human papillomavirus (HPV)



Human papillomavirus (HPV) DNA testing may be useful in clarifying equivocal cervical cytologic interpretations. One application might be to standardize the meaning of equivocal interpretations from laboratories in various regions. Because international differences may be particularly marked, international comparisons of emerging data will require clear translations of “equivocal” and similar terms.


To perform a three-country comparison, the authors selected a morphologically diverse set of 188 conventional Papanicolaou tests initially classified as “squamous atypia” from a study of more than 20,000 women in Portland, Oregon (1989–1990). Previously, five U.S. expert cytopathologists independently interpreted the slides with screening cytotechnologists' marks in place. For this comparison, one British and two Scandinavian reviewers involved in HPV research reviewed the slides after original marks had been removed. The authors compared all eight reviewers' classifications of negative, equivocal, or abnormal in a series of pairwise comparisons using the kappa statistic. They then compared cytologic interpretations with HPV DNA testing.


Oncogenic HPV DNA detection was significantly associated with increasingly abnormal interpretations for each reader. The British reader tended to rate tests as more abnormal than the American pathologists did, whereas the Scandinavians tended to rate tests as more normal. Reference to the HPV DNA standard clarified the tendency of readers to render systematically more or less severe interpretations. For example, the Scandinavian cytologists discounted subtle (often HPV-associated) changes in favor of cytologic certainty, making HPV triage of equivocal tests less applicable there.


International research on cytopathology, particularly on the possible uses of HPV DNA testing, will require calibration of local cytologic definitions. Cancer (Cancer Cytopathol) 2002;96:14–20. © 2002 American Cancer Society. DOI 10.1002/cncr.10317