Meet Dr. Kristen Jacobs

Dr. Kristen Jacobs joined the staff of The Medical Foundation in 1988 after graduating from the University of Iowa and completing a four year residency program with the Foundation. She has lived in the area since and is married to a local family practice physician, John. Dr. Jacobs is certified by the American Board of Pathology in Anatomical and Clinical Pathology and Cytopathology.

Q: How long have you been a Pathologist at The Medical Foundation?

A: I completed my residency of four years here and then Dr. Luis Galup, who was president at the time, offered me a position about 26 years ago.

Q: How did you become interested in Cytopathology?

A: I suppose I became interested when I saw how little tissue material was needed to make a diagnosis. It is simpler than having to process intact biopsy tissue. You just put the bits of tissue and cells on a glass slide, stain it and look at it through the microscope. And then, I was also interested in the focus on women’s health with Pap tests and trying to improve that.

Q: What is a typical day for you at the Foundation?

A: I’d say I look at about 26-30 surgical cases, about 15-20 pap tests and about 5 non-gynecological cytology cases [urine, throat, and thyroid cytology etc]. I also look at abnormal blood smears and answer blood blank and other clinical questions.

  Q: Take me through the process of what happens with a Pap smear after the cells are processed for you to observe.

A: The automated analyzer works by “looking” at every cell on the slide for its nuclear configuration and DNA content. It chooses, according to its data library of millions cells, 22 of the most “abnormal” cells on the slide. We have 10 cytotechnologists who review this information and they are directed to look at those 22 selected cells first. In a normal Pap test, those 22 cells, although according to the analyzer, they were the worst cells on that particular slide, they aren’t really abnormal.

Q: So every Pap slide is reviewed by a cytotechnologist?

A: Yes. A normal Pap, where the analyzer has detected 22 fairly normal cells for the tech to peruse, is fairly straightforward when reviewed by the cytotechnologist. And then if the cells that have been flagged by the analyzer look even remotely abnormal then the techs do a full screen. They review every cell and categorize the abnormality.

Q: And how does that process continue?

A: Anything that is flagged as abnormal will be seen by a staff pathologist. So there are three layers of review: the automated analyzer, the cytotechnologist, and then a pathologist if needed.

Q: How has Reproductive Medicine changed since you became a pathologist?

A: Pap testing has improved, first through thin layer technology. The quality of the Pap test used to depend on how the doctor sampled the cervix and then smeared it onto the slide at the doctor’s office. The quality was often compromised and we had no control over it. The Thin prep system, which came on board in 1996, was a big advancement in technology. The doctor now swishes the Pap sample in a vial and then the vial is well mixed and turned into what is called monolayer preparation. Now, pathologists and technologists look at a nice, clean, single cell layer through the microscope. Abnormalities are more readily visualized. Then later, the automated analyzer was introduced about 10 years ago. It adds another layer of patient protection. It saves our techs time from looking at thousands of normal cells and targets the abnormal cells that we want to focus on. It prevents screening fatigue.

Q: How many Pap tests are looked at each year at the Foundation?

A: In 2013, there were a little over 85,000 Pap tests, which is quite a bit less than in previous years because of the change in recommendations. In contrast, in 2007 we evaluated at least 123,000 Pap tests, so the numbers have dropped significantly. On the other hand, our department has picked up HPV testing. That wasn’t really done very often ten years ago, but HPV test recommendations have become more important to patient care.

Q: What kinds of changes do you see in the future of Cytopathology?

A: Analyzing Pap test cells by Flow Cytometry is a potential technology that has been talked about for years, but it’s never happened. We do Flow Cytometry all the time on blood cells in which abnormal cells are detected by flowing them through a camera-type aperture. The cells are marked with a special stain and then they shoot through an aperture which detects the cell abnormality. Now that the Pap sample is submitted in a liquid vial preparation, we’d somehow have to tag the abnormal cells and then shoot them through the aperture to automatically detect the abnormality without the human eye being involved. But nobody’s figured out how to make that happen yet! The problem with high tech analysis of Pap samples is it can’t be used in low resource settings where most cervical cancer now persists. A manual Pap analysis can be done in the middle of Africa with only a microscope, but none of these other technologies work in low resource places. The Pap test with all its improvements has succeeded in reducing cervical cancer to very low rates in the United States, but cervical cancer is still one of the foremost killers of women in third world countries. Since technology is available to perform a rapid malaria test with a simple finger stick blood sample, it would be nice if technology could find a way to perform a simple field test for cervical cancer. I hope we’ll see that change in the next 10 or 15 years.
 
Q: Is there anything else you would like to add?

A: In terms of educating the public, I would like women to know that it’s not uncommon to have an atypical Pap test result. Atypical results account for about 3% of tests. Patients should not be unduly alarmed but should follow up appropriately. Patients should also know that HPV testing can be quite useful in directing their care.

  For Dr. Jacob’s comments on Human papillomavirus and to learn more about HPV, check our website early next week or learn more on Facebook by becoming a fan of SBMFLAB.