Colposcopy in the U.S.- Standardized Training and Quality ...
Transcript of Colposcopy in the U.S.- Standardized Training and Quality ...
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Alan G. Waxman, MD, MPH
Dept. of Obstetrics & Gynecology
University of New Mexico
The University of New Mexico
Colposcopy in the U.S.- Standardized
Training and Quality Assessment: Is it time?
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Disclosures
• No financial relationships or conflict of interest to disclose
• Photos : • John Wayne, David Niven: IMDb.com
• Other photos are mine.
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Objectives
• Contrast colposcopy education and quality standards between the U.S. and U.K.
• Discuss colposcopy education in the U.S.
• Review factors leading to a need for more quality assurance in colposcopy in the U.S.
•List three elements of the ASCCP Colposcopy Standards that might meet that need.
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The U.S. and U.K. different approaches to colposcopy training and QA.
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The U.S. and U.K. different approaches to colposcopy training and QA.
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Colposcopy in the U.K.
• Standard education includes • Didactic course
• Hands-on mentorship
• Written certification examination and OSCE
• BSCCP certification required to practice in NHS
• Minimum new patients per year, required CME
• Required recertification every 3 years
• Structured standards for colposcopy practice• Rigorous quality standards for practice activities and structure as well as
providers
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Colposcopy in the U.S.
Requirements• State license to practice medicine / nursing
• Colposcope
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32% of ASCCP Colposcopists responding to a practice survey perform 0-5 exams per month. 20% perform over 20 per month.
U.S. Colposcopists have a wide range of practice volume
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Is this disparity in training and volume acceptable?
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The U.S. is a large country with a lot of remote places far from a high-volume colposcopy practice.Are women living here better servedBy a local, low volume colposcopist or a 100+ mile drive for their colposcopy?
agw
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Globocan 2012
The U.S. and U.K. approaches are different. Does it matter?
6.6
7.1
Globocan 2012
Cervical Cancer Incidence per 100,000
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Colposcopy Education in the U.S. –Most U.S. colposcopists are ob/gyns and learn colposcopy in residency
CREOG monitors many procedures learned in ob/gyn residency.• Colposcopy is not one of them
• Adequacy of colposcopy training is assumed• As for all outpatient procedures
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In the U.S. healthcare providers generally learn colposcopy via one of two broad formats.
PHYSICIANS
-Ob/Gyn
-Family Practice
Advance Practice
Clinicians
-NP
-CNM
-PA-C
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PHYSICIANS
-Ob/Gyn
-Family Practice
Residency(3-4 year specialty training that includes
colposcopy)
Colposcopy
“Competence”
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PHYSICIANS
-Ob/Gyn
-Family Practice
Residency
Regulation
Colposcopy
“Competence”
State
Licensure
Specialty
Societies and
Boards
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Advance Practice
Clinicians
-NP
-CNM
-PA-C
Free-Standing Colposcopy Course and / or
Hands-on Mentorship
Colposcopy
“Competence”
ASCCP Exam?
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Advance Practice
Clinicians
-NP
-CNM
-PA-C
Free-Standing Colposcopy Course and / or
Hands-on Mentorship
Colposcopy
“Competence”
ASCCP Exam?
Regulation
State
Licensure
Nurse
Practice
Acts
Employers,
Payers
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ASCCP Mentorship Program
Three tiered learning program• Comprehensive Colposcopy Course
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Curriculum: ASCCP Comp Courses
• Epidemiology of cervical cancer / Natural history of HPV infections
• Cytology and histology of the cervix
• Colposcopy technique, equipment, set-up
• Colposcopy of normal cervix / squamous metaplasia
• Colposcopy of abnormal cervix
• ASCCP Management guidelines
• Where to biopsy
• HPV vaccines
• Colposcopy of vulva and vagina
• Benign vulvar disease
• AIS / Adenocarcinoma
• Treatment with LEEP / Cryo
• Colposcopy in pregnancy
Breakout sessions that include cases, and simulations of colposcopy, LEEP and cryo
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ASCCP Mentorship Program
Three tiered learning program• Comprehensive Colposcopy Course
• Hands-on mentorship with volunteer mentor
• Experienced colposcopist
• At least 25 directly supervised colposcopies including
• 5 HSIL, 12 biopsies, 4 ECCs
• Mentor approves student for independent practice
• Passing score on interactive on-line exam
Leads to document of completion, not certification.
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Residency training in colposcopy is variable
Colposcopy is a part of the curriculum of a four year obstetrics and gynecology residency
There is no standard curriculum residencies are required to follow• Very variable in terms of didactics and number of cases seen
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Residency training in colposcopy is variable
At the University of New Mexico curriculum has three components• Didactic education with cases and
simulations
• Education conferences centered on patient cases, pathology and journal clubs
• Clinical experience supervised by faculty (mentorship)
• Half day colposcopy on gynecology service 1st and 3rd year
• Half day LEEP clinic 1st year
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Colposcopy volume is declining in residency clinics- UNM
0
100
200
300
400
500
600
700
2004-5 2008-9 2015-16
Number of Cases per Year
Colpo High grade LEEP
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Colposcopy volume is declining in residency clinics- UAB
Landers EE et al J low Genit Tract Dis 2016;20:292-295
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Why is volume declining in U.S. academic colposcopy clinics?
•New Guidelines: No longer screen before age 21
•New Guidelines: Extended screening intervals
•New Guidelines: No longer colpo 21-24 y.o. with ASC-US or LSIL
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• Over the past 5 decades, once common large “prevalent” lesions have given way to frequent smaller harder to diagnose “incident” lesions.
• New guidelines mean fewer colposcopy cases seen
• Immunization means fewer high-grade lesions • Lower positive predictive value of screening tests• Fewer high grades mean more false positives• Colposcopists will have less experience
• The future: 11-12 year old cohort immunized in 2006 are now entering the screening pool!
Perhaps it’s time to introduce colposcopy quality
standards in the U.S.
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Quality Assurance of Colposcopy in the U.S.
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Cytology laboratories are already centrally monitored.
• Laboratories including cytology and histopathology labs are monitored by the federal government through the College of American Pathologists
• Colposcopy education and quality are not controlled by any central agency
• ASCCP plays a central role in education
• With today’s ASCCP Colposcopy Standards, ASCCP will also significantly influence the practice, terminology, and quality assurance of colposcopy.
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New 2017 Quality Indicators for Colposcopy
• Document that squamocolumnarjunction visualized
• Document if any acetowhite lesion is present
• Documentation of colposcopicimpression
• Documentation of cervix visibility
• Documentation of Extent of Lesion Visualized
• Documentation of Location of Lesion(s)
• Take multiple biopsies• All acetowhite areas, metaplasia or
higher abnormalities
• At least two and up to four biopsies
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New 2017 Quality Indicators for Colposcopy
• Attempt to contact any patient with suspected invasive disease within 2 weeks of receipt of report or referral
• See patients with suspected invasive disease within 2 weeks of contact.
• Attempt to contact a patient with high grade Pap results within 4 weeks of receipt of report or referral.
• See patients with high grade Pap results within 4 weeks of contact.
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The ASCCP approach includes multiple safety features to assure
diagnoses will not be missed.
• Risk-based colposcopy
• Emphasis on taking 2-4 biopsies
• ASCCP Guidelines recommend close post-colposcopy follow-up
Massad et al J Lower Gen Tract Dis. 2013;17:S1-27
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This new ASCCP system of colposcopy standards has
no teeth. It will be voluntary. It’s unlikely that any U.S. regulatory agency
will require its use.But U.S. colposcopists want the best for their patients and we hope, in that spirit,
they will adopt these standards as the new “best
practice” of colposcopyagw
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Thank you.