Colposcopy Services Research Articles

Quality Control Assurance in National Screening Programmes for Cervical Cancer

The United Kingdom established a centrally controlled formal screening programme for cervical cancer in 1988. The programme has been an unprecedented success, with the incidence of cervical cancer falling by an accelerated rate of 7% a year. Underlying the success of the programme is a rigorous system of quality assurance at all levels of activity. Quality assurance assessment is performed for coverage of the target population, cytology reporting laboratories and colposcopy services. Each component in the system is examined annually by mandatory returns, and by regular on-site review of the clinical services by independent authorities. Processes also exist to establish and maintain the competency of all clinical and non-clinical staff involved in the programme. Using nationally published figures from the financial year 2001/2002, the different quality assurance strategies are described. The future development of quality assurance in the programme is then discussed.

Outcome of three consecutive inadequate cervical smears

A retrospective audit of women with three consecutive inadequate cervical smears during 1998-99 was conducted at Birmingham Heartlands Hospital. The commonest reasons were obscured by polymorphs (34.5%) and sparse cellularity (28.9%). Seventy-three per cent (73%) were followed up at colposcopy and 22.1% had histological assessment; 15.9% of women had an abnormality detected, 10.6% with abnormal histology and 5.3% with a cytological abnormality only. Cytological abnormalities were seen in 11.1% of the screening population. This study did not identify a cytological criterion to differentiate those that would or would not have an abnormality on follow-up. It is suggested that all women with three consecutive inadequate smears should have adequate follow-up, although this may place increased demands on colposcopy services.

The efficacy of telecolposcopy compared with traditional colposcopy

OBJECTIVE: Rural women have increased rates of cervical neoplasia, but colposcopic services are limited in rural clinics. The purpose of this study was to estimate the efficacy of telecolposcopy for women in rural health care sites.METHODS: Women with an indication for colposcopy were examined by local colposcopists at one of two rural clinics. Images of the colposcopic examination were transmitted to a tertiary care center for interpretation by an expert colposcopist. Another colposcopist (site expert) in attendance at the rural site also examined the same subjects, but did not share findings with the other colposcopists. Colposcopists independently determined the adequacy of the examination, colposcopic impression, biopsy intent and site, and management. Agreement between colposcopic impressions and cervical histology were assessed by using percent agreement, Cohen’s κ statistic, and McNemar’s test with Bonferroni’s adjustment.RESULTS: Teleconsultation was required for 36.2% of colposcopic examinations. A significantly lower percentage of satisfactory colposcopic examinations was noted by the distant colposcopists (60.0%) compared with the other colposcopists (P < .001). Colposcopic impression agreement with histology varied minimally, 59.7% (κ = 0.31) for local colposcopists, 52.7% (κ = 0.22) for site experts, 55.7% (κ = 0.27) for distant experts who concurrently viewed the examination, and 49.7% (κ = 0.16) for distant experts who viewed the examination on videotape at a later time.CONCLUSION: Teleconsultation was used for a substantial number of examinations. Diagnostic accuracy was maintained, but determination of colposcopic examination adequacy may be impaired by telecolposcopy. Telecolposcopy may help reduce barriers to medical access for women in rural areas.

Can pre-colposcopy sessions reduce anxiety at the time of colposcopy? A prospective randomised study

The main objective of this prospective randomised study was to evaluate whether offering pre-colposcopy group sessions reduces anxiety at the time of colposcopy. We also examined whether this strategy improved knowledge about abnormal smears and colposcopy and improved satisfaction with the colposcopy service provided. One hundred and forty-seven women undergoing colposcopy for the first time were randomised into two groups. The control group (n = 75) received conventional management. The study group (n = 72), in addition to conventional management, were invited to attend a pre-colposcopy group session led by a trained colposcopy nurse. Questionnaires were used to determine state anxiety inventory scores and knowledge scores at the time of randomisation, immediately before colposcopy and 6 weeks after the clinic visit. Satisfaction questionnaires were completed 6 weeks after the clinic visit. We found that women attending colposcopy clinics are anxious. Those women who attended the pre-colposcopy session had improved knowledge scores (P = 0·039) at the time of colposcopy and satisfaction (P = 0·037). However, the intervention failed to significantly reduce anxiety at the time of colposcopy (P > 0·05).

Retrospective audit of standards and quality in colposcopy services in a district hospital

Abstract A retrospective audit to compare the performance of a colposcopy clinic with the standards set by National Health Service Cervical Screening Programme (NHSCSP) was carried out at Caerphilly District Miners Hospital, South Wales, United Kingdom. The study sample size consisted of 150 women who underwent colposcopy and diathermy large loop excision of the transformation zone (LLETZ) for abnormal cytology during January l995 to January 1998. The results showed deficiencies in the areas of communication for clinic appointments for women with high‐grade cytology and in information given to general practitioners about test results. The services fell short of the standards in recording of colposcopy findings and grading of lesions. The rest of the parameters audited reached the NHSCSP standards. Recommendations to improve communication and to increase the objectivity of recording colpscopy findings were made. A more practical approach to set standards in areas of communication was suggested.

Retrospective audit of standards and quality in colposcopy services in a district hospital.

A retrospective audit to compare the performance of a colposcopy clinic with the standards set by National Health Service Cervical Screening Programme (NHSCSP) was carried out at Caerphilly District Miners Hospital, South Wales, United Kingdom. The study sample size consisted of 150 women who underwent colposcopy and diathermy large loop excision of the transformation zone (LLETZ) for abnormal cytology during January l995 to January 1998. The results showed deficiencies in the areas of communication for clinic appointments for women with high-grade cytology and in information given to general practitioners about test results. The services fell short of the standards in recording of colposcopy findings and grading of lesions. The rest of the parameters audited reached the NHSCSP standards. Recommendations to improve communication and to increase the objectivity of recording colposcopy findings were made. A more practical approach to set standards in areas of communication was suggested.

The frequency of significant pathology in women attending a general gynaecological service for postcoital bleeding.

To document the frequency of pathology in women who complain of postcoital bleeding. To determine whether negative cervical cytology excludes serious pathology in women with postcoital bleeding. To determine whether postcoital bleeding increases the risk of serious pathology in women with an abnormal smear. A retrospective study. A university teaching hospital. 314 women with postcoital bleeding seen in the gynaecology service from first January 1988 to 31 December 1994. Women were identified from the computerised records of the colposcopy service and copies of correspondence, which was routinely retained on computer. The latter was searched for the text strings coital and intercourse. Histopathological diagnosis. Twelve women (4%) had invasive cancer: 10 were cervical or vaginal cancers and two endometrial cancers. Eight of the 10 cervical or vaginal cancers were clinically apparent. Four women of these 10 had had a normal smear before being referred for further investigation of postcoital bleeding. Two of these cancers were visible only with the aid of the colposcope. Thus, 0.6% of women attending a gynaecology service with postcoital bleeding, a normal looking cervix and a normal smear had invasive cancer of the cervix. Cervical intraepithelial neoplasia were found in 54 women (17.%) and 15 women (5%) had cervical polyps. Nineteen of the 63 women (30%) with significant pathology had a normal or inflammatory cervical smear. No explanation for the postcoital bleeding was found in 155 women (49 %). Although invasive cancer is rare in women with postcoital bleeding, it is much commoner than in the general population. It seems likely that cervical intraepithelial neoplasia is also associated with postcoital bleeding, perhaps because the fragile cervical epithelium becomes detached during intercourse. Postcoital bleeding should continue to be regarded as an indication of high risk for invasive cervical cancer and for cervical intraepithelial neoplasia. Prompt referral to a colposcopy clinic is indicated, but most women with postcoital bleeding will have no serious abnormality.

The frequency of significant pathology in women attending a general gynaecological service for postcoital bleeding

Objectives To document the frequency of pathology in women who complain of postcoital bleeding. To determine whether negative cervical cytology excludes serious pathology in women with postcoital bleeding. To determine whether postcoital bleeding increases the risk of serious pathology in women with an abnormal smear. Design A retrospective study. Setting A university teaching hospital. Population 314 women with postcoital bleeding seen in the gynaecology service from first January 1988 to 31 December 1994. Methods Women were identified from the computerised records of the colposcopy service and copies of correspondence, which was routinely retained on computer. The latter was searched for the text strings coital and intercourse. Main outcome measure Histopathological diagnosis. Results Twelve women (4%) had invasive cancer: 10 were cervical or vaginal cancers and two endometrial cancers. Eight of the 10 cervical or vaginal cancers were clinically apparent. Four women of these 10 had had a normal smear before being referred for further investigation of postcoital bleeding. Two of these cancers were visible only with the aid of the colposcope. Thus, 0.6% of women attending a gynaecology service with postcoital bleeding, a normal looking cervix and a normal smear had invasive cancer of the cervix. Cervical intraepithelial neoplasia were found in 54 women (17.%) and 15 women (5%) had cervical polyps. Nineteen of the 63 women (30%) with significant pathology had a normal or inflammatory cervical smear. No explanation for the postcoital bleeding was found in 155 women (49 %). Conclusions Although invasive cancer is rare in women with postcoital bleeding, it is much commoner than in the general population. It seems likely that cervical intraepithelial neoplasia is also associated with postcoital bleeding, perhaps because the fragile cervical epithelium becomes detached during intercourse. Postcoital bleeding should continue to be regarded as an indication of high risk for invasive cervical cancer and for cervical intraepithelial neoplasia. Prompt referral to a colposcopy clinic is indicated, but most women with postcoital bleeding will have no serious abnormality.

'See and treat' at colposcopy - achieving the standard

The National Health Service Cervical Screening Programme has issued quality standards for the colposcopy service nationally. One standard is that for women who undergo treatment at their first colposcopy clinic visit, 90% should have proven cervical intra-epithelial neoplasia (CIN) on histology. We have assessed data from a teaching hospital colposcopy clinic over a 9-year period to assess the criteria that should be satisfied in order to achieve this target. We propose that only those women with severe dyskaryosis on the referral smear and a colposcopic appearance of CIN 2 or 3, or those in whom the colposcopic appearance suggests CIN 3 with any grade of dyskaryosis undergo treatment at their first visit.

An alternative approach to the management dilemma of the mildly dyskaryotic smear based on audit of outcome.

We describe a study which takes an alternative approach to the management dilemma of the mildly dyskaryotic cervical smear. Two hundred and fifty women with a smear showing mild dyskaryosis were studied by auditing the clinical outcome as well as the cost. The cost of providing the colposcopy services during the index year was approximately pounds sterling 70000 for an average size district general Hospital. The proportion of women managed by the current guidelines and avoiding colposcopy after a first mildly dyskaryotic smear was only 30%. The majority of patients will eventually have colposcopy despite a policy of cytological surveillance. The alternative approach, to offer colposcopy immediately after the first mildly dyskaryotic smear, would result in a small increase in cost for our unit, equivalent to one extra colposcopy patient per week.

Perspectives in Cervical Cancer Prevention and Health Services Management

Preventive screening, management, and treatment of patients at risk for cervical cancer reduces the incidence of cervical cancer in the United States but not without significant costs. The costs can be measured both in dollars and in "opportunity costs" (access to care for one patient affecting another patient visit) associated with providing care to an overburdened colposcopy infrastructure. To provide colposcopic services, sometimes access to other needed care may be neglected in clinical practices that are already overburdened by high demand and limited access to care. Colposcopy services in the fee-for-service, managed-care, health maintenance organizations, and academic health service delivery settings are delivered not solely on the basis of quality (expertise and technological advances) of care. Delivery of colposcopy services should be balanced by economic and service-related issues as well. This study aids clinicians in assessing the value of interventions based on the value equation for health care: quality, service, and cost impact.

An audit of standards and quality in a teaching hospital colposcopy clinic.

The National Health Service Cervical Screening Programme has issued minimum standards for a colposcopy service that facilitates audit. We have looked at the performance of a teaching hospital colposcopy service by analysing the case notes of 639 women who underwent large loop excision of the transformation zone over a nine-month period in 1995. We found delays in patient assessment and communication of results. There was overtreatment, particularly at first visit, and an excessive number of treatments were performed under general anaesthesia. A worrying number of women failed to have a follow up smear performed, but in those that did we found a reassuring treatment success rate. Our findings led to changes in the structure and functioning of the colposcopy clinic that should improve the detection of significant disease and improve the timeliness of diagnosis and the speed with which we communicate results.

A comparison audit of a genitourinary medicine colposcopy service against nationally agreed quality standards.

The National Health Service Cervical Screening Programme (NHSCSP) recently published their document Standards and Quality in Colposcopy outlining recommendations for standards in the service provided by colposcopists. In this first audit of colposcopic practice measured against these agreed UK national guidelines, the authors discuss the standards, their attainability, and their relevance to genitourinary medicine (GUM) colposcopy services.

The short-term financial costs of abnormal Pap smears to women and government in Australia.

Using data collected from a private Canberra colposcopy service, we examined the direct costs, to women and government, of the gynaecological care of women with cervical cytological abnormalities and determine the potential savings of implementing the Commonwealth recommendations for the clinical care of women with screen-detected abnormalities. We performed a case note audit of 502 women who first attended a gynaecologist because of an abnormal Pap smear between 1 January 1989 and 30 April 1990. The smear resulting in their referral--their presenting smear--was categorised as No CIN (showing no evidence of cervical intraepithelial neoplasia), CIN 1, CIN 2 and CIN 3. The average costs to government (p for trend < 0.001) and women (p for trend = 0.006) increase as the presenting smear increases in severity; the median costs to government (p for trend < 0.001) and women (p for trend < 0.001) also rose with increasing cytological severity. Treatment of CIN 1 and No CIN accounted for half the costs incurred by government and women. Although costs increase with increasing severity of cytological abnormality, adherence to new Australian guidelines for the gynaecological care of women with screen-detected cervical abnormalities could result in substantial short-term savings to government and women.

Cervical screening: management of patients referred for colposcopy with smear abnormalities less severe than dyskaryosis.

The cervical smear and biopsy results were reviewed for 141 patients who were referred for colposcopy with either a technically unsuitable smear or with cervical smear abnormalities less severe than dyskaryosis. The number of referrals due to minor smear abnormalities more than doubled from 8.6% to 22.3% of the total colposcopy referrals over the 4 year period studied. The minor smear abnormalities were only associated with cervical intraepithelial neoplasia (CIN) in patients aged < 50 years. In 19 (13.5%) of the 141 patients high-grade lesions (CIN II or CIN III) were diagnosed. There were no cases of invasive cancer. Furthermore, the increased number of patients being referred for colposcopy with minor cervical smear abnormalities highlights the increasing pressures on colposcopy services, with prolonged waiting times for all patients.

Cryotherapy in the management of cervical intraepithelial neoplasia in developing countries

A comparison of outcomes among 11 patients who underwent cold knife biopsy (conization) at a university hospital in Ibadan Nigeria in the pre-1994 period and 23 patients who had cryotherapy after the 1994 introduction of a colposcopy service demonstrated the superiority of the latter method for the treatment of cervical intraepithelial neoplasia I-III. Complications in the conization group included postoperative pain (36.4%) bleeding (45.5%) cervical stenosis (9.1%) hematometrium (9.1%) and cervical incompetence (9.1%). The only complications recorded in the cryotherapy group were postoperative pain (4.4%) and vaginal discharge (8.7%). Cryotherapy was superior to conization in terms of length of the procedure (15 vs. 30-60 minutes) and cost (US$10 vs. $50) and does not require hospital admission or anesthesia. On the other hand conization should be considered in cases where colposcopy is not available in patients with discrepant cytologic and colposcopic findings in cases where lesions extend into the cervical canal or if poor patient compliance with follow-up is anticipated.

On-Site Colposcopy Services in a Family Practice Residency Clinic

Background: Using colposcopy as a model, we examined the impact of introducing a new diagnostic. technology into the ambulatory primary care setting. Methods: Records of patients with abnormal findings on Papanicolaou smears were reviewed from three study periods: 1 year before, 1 year after, and 5 years after initiation of on-site colposcopy services. Data analyzed include physician management decisions, site of colposcopic service, and patient compliance. Practice revenue estimates were based upon patterns of physician management and patient compliance found during each study period. Results: Management of low-grade squamous intraepithelial lesions varied during each study period. By period 3, however, most patients were undergoing colposcopy (P = 0.03). High-grade squamous intraepithelial lesions were uniformly managed with colposcopy during all study periods (P Conclusions: Although offering on-site colposcopy services might have had some impact on physician management of low-grade squamous intraepithelial lesions, the lack of benefit regarding patient compliance, the relatively small patient volume for this procedure, and its modest impact on practice revenue cause us to question the value of including colposcopy in everyday practice.

On-site colposcopy services in a family practice residency clinic: impact on physician test-ordering behavior, patient compliance, and practice revenue generation.

Using colposcopy as a model, we examined the impact of introducing a new diagnostic technology into the ambulatory primary care setting. Records of patients with abnormal findings on Papanicolaou smears were reviewed from three study periods: 1 year before, 1 year after, and 5 years after initiation of on-site colposcopy services. Data analyzed include physician management decisions, site of colposcopic service, and patient compliance. Practice revenue estimates were based upon patterns of physician management and patient compliance found during each study period. Management of low-grade squamous intraepithelial lesions varied during each study period. By period 3, however, most patients were undergoing colposcopy (P = 0.03). High-grade squamous intraepithelial lesions were uniformly managed with colposcopy during all study periods (P < 0.001). Introduction of on-site colposcopic services resulted in a rapid shift to the on-site location for evaluation of low-grade squamous intraepithelial lesions and a more gradual shift to the on-site location for evaluation of high-grade squamous intraepithelial lesions. Patient compliance was not affected by the introduction of on-site services. On-site colposcopy resulted in a nearly 100 percent transfer of revenue to the practice, but the economic benefit was quite modest. Although offering on-site colposcopy services might have had some impact on physician management of low-grade squamous intraepithelial lesions, the lack of benefit regarding patient compliance, the relatively small patient volume for this procedure, and its modest impact on practice revenue cause us to question the value of including colposcopy in everyday practice.

The Role of the Gynaecologist in the UK Cervical Screening Programme

Opportunistic cervical cancer screening began in the United Kingdom in a fragmented manner in the 1960s. Recognizing the failure of this approach to reduce the morbidity and mortality from this preventable cancer, a more structured approach, the National Health Service Cervical Screening Programme, has been in place since 1988. Guidelines for practice and programme management have been developed with the collaboration of the Royal Colleges and those involved in programme delivery. The implementation of quality assurance guidelines for the programme and standards for quality colposcopy services has allowed measurement of me effect of the programme; audits have shewn acceptance of the guidelines. Changes in mortality that had not occurred prior to the implementation of this coordinated programme are beginning to show that the Health of the Nation Target of reducing the incidence of invasive cancer of the cervix by 20 percent by the year 2000 compared to the 1986 rate can be achieved.

CLINICAL ROLE OF HPV TESTING

The subjectivity of morphologic methods contributes to a "swamping" of colposcopic services, excessive costs, overdiagnosis, and overtreatment. HPV DNA testing provides the objectivity required to clarify difficult patient management issues, including follow-up, for low-grade cytologic abnormalities (ASCUS and LSIL), noncorrelating (nonconfirmed) Pap smears, evaluation of nondiagnostic lower genital tract lesions, and cytology and histology laboratory quality assurance. Additionally, favorable preliminary data on HPV testing as a primary screen raise the exciting prospect of potentially lowering costs of cervical cancer-screening programs, while further decreasing the incidence of cervical cancer.