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Ginny Dawe-Woodings, Wellcome Archivist, writes:

The recent acquisition of John Peter Smith’s papers on the foundation of the cervical cytology unit in Manchester has triggered interest into the origins of cervical smear testing in the UK.

Sir John Williams first identified the lesion that would eventually be known as carcinoma in situ of the cervix in 1886; however, cancer has been described since Egyptian times, and both Hippocrates and Galen recorded it in their patients, and Paul of Aegina (c. 600AD) diagnosed and treated the disease cancers of the uterus. However, it would not be until the development of microscopes and histology that diagnosing and effectively treating cancers could be achieved.

The pathologist Walter Schiller was the first to propose the term “pre-invasive carcinoma”, but it would be George N. Papanicolaou’s contributions which would have a profound impact on cervical cancer diagnosis. Papanicolaou discovered, courtesy of a willing (female) hospital volunteer, that individual cells from the cervix have morphological features which may be used to diagnose carcinoma. In 1938 Papanicoloau and gynaecologist Herbert Traut worked on a study which concluded that many asymptomatic cancer cases could be detected by smear at an earlier stage than was detectable by biopsy. The pair were critical of the biopsy method, which they argued was time-consuming and expensive, and thus didn’t have large scale feasibility. This meant that treatment for uterine cancer was limited to well developed or late-stage cancers. This discovery led to preventative screening gaining traction throughout the 1940s and 1950s, and local trials were set up in North America, including one in British Columbia set up by David Boyes and Fidler as a project to determine whether screening with Pap. smears could reduce the incidence and mortality from invasive cervical carcinoma.

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Photograph of John Peter Smith, provided by his family.

It was likely that this project inspired John Peter Smith in 1962. Smith was born on 11 July 1922 and was educated at the University of Manchester. He had a successful career as a pathologist before returning to Manchester in 1954 as a lecturer in pathology. Smith had been made consultant pathologist at the Christie Hospital in 1960 and was now contemplating conducting his own similar cervical screening project in Manchester.

In a research grant application (submitted in 1962) [JPS/1/2/1]  which would help establish a cytodiagnostic unit at the Christie Hospital, Smith makes reference to Vancouver and British Columbian studies (likely Boyes and Fidler’s project), reiterating the success rate of reducing the incidence of invasive cervix cancer.

In 1963 a pilot programme for cervical screening was developed and initiated by Smith. At present Christie Hospital is the largest cancer treatment centre of its kind in Europe, and has a long history of treating cancers, from the industrial cancers of the industrial nineteenth century through to pioneering work in radiotherapy, pharmacological treatments for breast cancer, cultured bone marrow for leukaemia treatment, and photo-dynamic therapy for skin cancers. It was Christie’s that Smith chose to be the site of his pilot study, stating that:

“We feel that an attempt to emulate [the] Vancouver work should be undertaken in this region and that the Christie Hospital is admirably suited to do it…Laboratory accommodation is already available …and our Endowment Fund is able to provide laboratory equipment.” [JPS/1/2/1]

The archival material covers the appointment of Muskett, a graduate cytologist, who was transferred from the Christie’s associated research laboratories to work directly with the pilot scheme. There is also discussion about the best method for performing the cervical test; they weighed up the merits of the “Davis pipette technique”, the Papanicolaou test, and Ayre’s smear. Both the Papanicolaou and Davis tests were praised for their simplicity; being able to be performed without special instrumentation or patient preparation. However, a paper submitted to the Lancet which reflected on the project shows that the project opted for the Ayres method on the grounds that it provided the most complete spectrum of cells for analysis, and the “visualisation of the cervix by a trained person… may assist the interpretation of the smear.” Recognising that the Ayre technique was more complicated and required more training, a demonstration film showing the methods of fixing, preparation and packing was made at the Christie and St Mary’s Hospital in Manchester. The project also developed a new way of transporting the smears from the GP to the cytodiagnostic laboratory, by preparing a fixative with dissolved wax which allowed the samples to be transported by post.

With the practicalities of staffing, facilities and methodology taken care of, the next area to tackle was garnering interest amongst both the medical and patient communities. Smith had taken smears from family clinics prior to 1963; however this was not a standard practice. A letter was distributed in May 1963 to “family doctors” [General Practitioners] outlining the project and explaining the assistance they needed, both in implementing the project and recommending cases for testing. The project also made contact with the local medical committee, family planning clinics, and local health authorities. They explained their desire for GPs to take smears, “[the GP] can persuade the female patients in [their] own practice to attend for testing; (2) if a positive smear is reported it would naturally fall to the general practitioner to refer [their] patient to the gynaecologist of [their] choice for further investigation and management; and (3) one family practice represents a very manageable group of patients.”

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Photograph presumed to be of the Christie Hospital, labelled ‘Here Beginneth Cytology’ c.1963. Ref. JPS/3/1.

In the 1965 article written by Smith, Muskett and (the then director of radiology at the Christie Hospital) Eric Easson, the trio reflect on the project with a sense of disappointment that the take up wasn’t higher, stating that reaching a 50% engagement rate was proving difficult. Despite this frustration, they revealed that 25,000 smears had been taken since the project had begun (est. 1963 to late 1964),and soon there was interest in their project beyond Manchester. They began accepting requests from GPs outside of the city of Manchester who were interested in contributing to the project by setting up their own cervical smear programs. Smith, Muskett and Easson recommended that each hospital region should “appoint a consultant cytologist to supervise the integration of the two or three sub-regional laboratories and, above all, to maintain the enthusiasm of the staff and quality of reporting.”

Sadly, Smith was killed in a car crash in Italy in August 1964. His untimely death meant he never saw the impact that his pilot had on cervical screening in Manchester or the rest of the UK. It would take until 1988 for the UK government to create a centrally organised cervical screening program. This system placed emphasis on follow-up procedures, something which was highlighted back in 1964 by Smith when he suggested that patients should be recalled every three years or a more optimal period, concluding that “[follow-up] is of particular importance when it is remembered that one smear in a woman’s lifetime is quite useless.”

In the 50+ years since Smith set about establishing his pilot study the [face] of cervical screening has changed. Before 1963 cervical screening was conducted by pathologists and GPs with concerns about individual patients, but by the mid-1990s the NHS screening program had become embedded into routine public health practice, and regular cervical cancer screening combined with a national program of HPV vaccination is now seen as standard for women aged 25-64.

Scholars have described the introduction of cervical screening in 1964 as haphazard; at the time programmes were established on the back of individual cytologists, gynaecologists and pathologists. The early twentieth century saw progress towards identifying the early stages of cervical cancer, which precipitated a move towards not only prediction of the likelihood of cancer but also preventative methods. Smith’s project furthered cervical screening as a practice centred on preventative medicine, instead of a procedure performed purely as a diagnostic tool, and consequently Manchester can regard itself as one of the foundations of cervical smears .

Readers can consult Smith’s archive on the University of Manchester Special Collections catalogue: https://archiveshub.jisc.ac.uk/manchesteruniversity/data/gb133-jps.

Sources:

  • Patricia A Shaw MD FRCPC, ‘The History of Cervical Screening I: The Pap. Test’, Journal of the Society of Obstetricians and Gynaecologists of Canada (2000), 22(2), pp. 110-14.
  • J P Smith, S M Muskett, E C Easson, ‘Evolution of a Community-Screening Project’, The Lancet (July 1965), pp. 74-5.
  • George N Papanicolaou MD PhD, Herbert F Traut MD, ‘Diagnosis of Uterine Cancer by the Vaginal Smear’ (1943), in Dona Schneider and David E Lilienfeld (eds), Public Health: The Development of a Discipline, Twentieth Century Challenges (New Brunswick: Rutgers University Press, 2011).
  • Dona Schneider and David E Lilienfeld (eds), Public Health: The Development of a Discipline, Twentieth Century Challenges (New Brunswick: Rutgers Press, 2011).