Education Module for Anatomic Pathology Registrars

Year 2: Module No 1

Reporting Cervical Cytology: The Bethesda System


During the evolution of cervical cytology a large number of different reporting systems and classifications were used internationally causing considerable confusion, particularly when women moved locality or country. In 1988 a National Cancer Institute (NCI) workshop was held in Bethesda, Maryland USA to develop a standardised reporting system. While the organisers did not anticipate it, The Bethesda System (TBS) that was developed has gained widespread recognition internationally. 

Three revisions have occurred: the most recent version available internationally is The Bethesda System 2014. In New Zealand we are still using The Bethesda System 2001 but are likely to move to the 2014 version in 2018.

In New Zealand, the National Cervical Screening Programme was set up in 1991, just after The Bethesda System had been first published. Although it was new, New Zealand made the decision to adopt it as our national reporting system, the first country in the world to do so at a national level. We have made only minor modifications to the published versions, and have updated our reporting systems as revisions of The Bethesda System have become available.

Understanding The Bethesda System is fundamental to reporting cervical cytology. 

 Study recommendations 
1.The Bethesda Book for Reporting Cervical Cytology 3rd Edition (Ed: Ritu Nayar and David Wilbur).Reading this book is an imperative for registrars and obtaining a personal copy is recommended. The book contains chapters on cytomorphology as well as outlining the reporting system and most chapters will be referenced in other education modules as part of the NCPTS study programme. For this module, the following is recommended.
Read the Forward: The Bethesda System: A Historical Perspective (Diane Solomon) Pages v-vii. This is a succinct summary of the context in which TBS was developed and discusses the principles on which it is based.An outline of The Bethesda System is given onPages xiii – xv

2. Read the attached NCPTS notes 
covering the use of The Bethesda System 2001 in New Zealand.

The following references are the published versions of the TBS. Obtain and read at least the 2001 version as this is the current reporting system in use. i. The 1988 Bethesda System for Reporting Cervical/Vaginal Cytological Diagnoses. NCI Workshop. JAMA August 18, 1989. Vol 262 No 7 931-4ii. The 1991 Bethesda System for reporting cervical/vaginal cytology diagnoses: report of the 1991 Bethesda Workshop. JAMA 1992;267:1892iii. The 2001 Bethesda System: Terminology for Reporting Results of Cervical Cytology. Solomon D et al. JAMA April 24, 2002. Vol 287 No 16
iv. The Pap Test and Bethesda 2014.Nayar N and Wilbur DC.Cancer Cytopathology May 2015.271-281
 4. For senior registrarsfurther NCPTS notes are provided detailing the differences in reporting systems in use in Australia and New Zealand.

5. Other references:The following additional references provide further explanation about different aspects of the development of TBS. The discussions provide useful insights into the role and limitations of cervical cytology in clinical practice.

1. Clinical Commentary. From Papanicolaou to Bethesda: The Rationale for a new Cervical Cytologic Classification. Kurman RJ, Malkasian GD, Sedis AS, Solomon D. Obstetrics and Gynecology Vol 77 No 5 May 1991 779-782

2. The National Cancer Institute Workshop. The Bethesda System for Reporting Cervical/Vaginal Cytology Diagnoses. Acta Cytol. 1993: 37: 115-24

3. Binary (Bethesda) System for Cervical Precursor Lesions: A Histologic Perspective. Christopher Crum Diagnostic Cytopathology Vol 13 No 5 370-385