3. Training and Exit assessment
The case for training in colposcopy
Ameli Tropé
Head of the Norwegian Cervical
Cancer Screening Programme
Tropé Kolstad meeting 2017
5. • September 2005 HSIL
• November 2005 Normal biops
• February 2006 ASC-US
• November 2006 Normal cytology + HPV positive, normal biopsy
• November 2007 ASC-H
• January 2008 Inconlusive biopsy
• June 2008 ASC-H
• November 2008 biopsi cervix cancer
50 year old woman
Forenklet casus fra Sørbye Wergeland
6. NORWAY 5.233 people (2016)
Ca 1000 gynecologists
No obligatory colposcopy training
7. Observed and projected incidence of cervical
carcinomas in Norway (rate/100,000 w-y by
calendar year)
Projected SCC
(in absence of screening)
Observed SCC
Observed AC
Putative screening effect
Lönnberg et al, IJC 2015
70%
reduction
8. Registration at the Cancer Registry cervical
cancer screening unit
Opt-out register for reminders and registration
8
1991 CYTOLOGY
1997 CIN TREATMENT
2002 HISTOLOGY
2005 HPV
9. Audit of the programme
Lönnberg et al. 2017 in preparation, *basert på Lönnberg et al. 2015 IJC
10. Women 25-69 1 484 00
Cytology 439 500
Histology 34 400
HPV-test 64 000
Excision
3 200 *
CX cancer
370
Death
79
*2014
Ref: Masseundersøkelsen mot Livmorhalskreft, Årsrapport
2015
Screening activity 2015: 3,5 years coverage 67,7%
11. 18
Long term risk to develop cervical/ vaginal
cancer after treating CIN3
has increased significantly over the last 5
decades in Sweden
Stander et al 2014
12. Free resection margins % ( uncertain%)
• Norway 66% (5%)
• Ullevål University Hospital 63% (5%)
• Akershus University Hospital 71% (12%)
Cancer Registry 2012
17. It aims to record:
• Theoretical understanding Record (Section 1)
• Practical Competence Record (Section 2)
• Personal Case Record (Section 3)
• Trainer details
• attendance at the histology/ cytology sessions and the basic
colposcopy course
• 10 colposcopy MDT sessions.
• Training assessments.
BSCCP Log-Book
18. Direct supervision: 50 cases . At least 20 cases must be
new cases and half of these must have high grade abnormal
cytology.
Indirect supervision: 100 cases. At least 30 must be new
patients of which half of these must have high grade
abnormal cytology.
Personal case records
19. 6 Case based discussions (CbD) – To allow a trainer to
assess the trainee's ability to discuss their management
strategies for individual cases.
12 Clinical evaluation exercises (mini-CEX) - A method
by which the trainee can be assessed on their clinical
skills in history taking, communication and organisation.
Training Assessment Methods
20. There is a series of OSATS for each of the common skills
used in colposcopy.
Diagnostic colposcopy in addition to various treatment
modalities
Minimum of 2 and preferably 3 independent assessors
Objective structured assessments of technical skill
(OSATS) –
21. Written questions
8 questions based on the content of the BSCCP trainees manual and
are topics covered at a basic colposcopy course. These may include
colpophotographs or video clips with examiners at these stations to
discuss images.
There are 5 Written stations with no examiner present which will use
written material based on the theoretical section of the trainees log
book.
Clinical stations
There will be two interactive stations involving interaction with a patient
portraying clinical scenarios.
These stations are designed to test knowledge and communication
skills.
OSCE EXAM
22. • If we can; Yes
• Can we combine it with e- learning course?
• Do we need certification?
• Mobile training communication
• How do we make sure people get recertified?
• Do we have enough colposcopists?
Is all this necessary?
26. Early Concluding Cohort
= women enrolled between 01.02.2015-
31.08.2015, both HPV- and cytology-screening
2015 2016 2017 2018 2
EXPECTED RESULTS 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2 3Q 4Q 1Q
Results from screening tests
Results from immediate biopsy
Results from follow-up triage test
Results from biopsy after follow-up
triage test
Results from 2nd screening test
Total
screened
women
n=32 703
Women allocated
to HPV-test
n= 16 174
Women allocated
to cytology
n= 16 517
31. Project ECHO® (Extension for Community
Healthcare Outcomes) is a teleconsulting and
telementoring partnership between MD Anderson
specialists and providers in rural and underserved
communities.
•Evidence-based, best practice
guidance from specialists
•Case-based "learning-loop"
•Clinical updates and
presentations from specialists
33. Absoluteriskofprecancer
Minimal risk:
Regular screening
interval
Low risk:
Triage or repeat
testing
Medium risk:
Colposcopy
High risk:
Treatment
Population
risk
Primary
screen
Triage Colposcopy
+
-
+
-
+
-
0
1
Patient: Doe, Jane
Age: 42
HPV: Pos
Genotype: 16
Cytology: LSIL
Vaccine: No
Last screen: positive
A
B
Data entry
COLPOSCOPY
REFERRAL
Recommendation
Show details
A 42 year old woman
with LSIL cytology and
HPV16 has a n% risk
of CIN3+, which is
above the colposcopy
referral threshold of
m%.
Castle et al., JLGTD, 2008
34. Conclution
• Training and certification is important
• Colposcopy specialists if possible
• Can use more e- learning and mobile communication
• Important with quality assurance
37. 2015 Cohort
= women enrolled between 01.02.2015-
31.12.2015, both HPV- and cytology-screening
2015 2016 2017 201
EXPECTED RESULTS 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 2 3Q 4Q 1Q
Results from screening tests
Results from immediate biopsy
Results from follow-up triage test
Results from biopsy after follow-up
triage test
Women allocated
to cytology
n= 29 830
Total
screened
women
n=58 971
Women allocated
to HPV-test
n= 29 141
38. Total disease detection, Early Concluding Cohort
(Intention to treat)
HPV-test
Cytology
Colpscopy/biopsy
CIN2+ CIN3+
# % # %
HPV screening 270 211
# of women 16 120 1.7 1.3
Total # of biopsies 1 183 22.8 17.8
Cytology screening 167 142
# of women 16 413 1.0 0.9
Total # of biopsies 854 19.6 16.6
