- Cervical cancer rates have decreased 60% in Sweden due to organized Pap smear screening programs since the 1960s. Colposcopy training courses began in the 1980s but treatment was based solely on cytology until the 1990s. - New Swedish guidelines require colposcopists to investigate at least 50 women with dysplasia annually and perform 25 treatments. A colposcopy certification program is proposed but not yet mandatory. - Professor Sonia Andersson has organized international certificate colposcopy courses in Sweden since 2012. Approximately 350 doctors have been trained. Next steps may include a Swedish examination and addressing barriers like the small population size.

2. Prof Sonia Andersson
Chair of Swedish Colposcopy Society

3. Sonia Andersson
Professor, senior Consultant
Karolinska Institutet
sonia.andersson@ki.se

4. The case for an EFC Diploma in
Sweden
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6. Presentation outline
 Cervical cancer in Sweden
 The history of colposcopy in Sweden
 Swedish guidelines and new requirement to treat women with
dysplasia
 Education in colposcopia in Sweden
 Swedish Society of Colposcopy
 Examination in colposcopy
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7. Since the early sixties, population based vaginal
cytological screening has been available in
most Swedish counties.
Due to organized Pap smear screening the
incidence of squamous cell carcinomas in
Sweden has decreased with 60 %
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8.  The incidence of cervical cancer in Sweden is
7.5 /100 000 women.
 Cervical cancer in Sweden is a relatively
uncommon event with about 560 new cases and
200 deaths yearly.
 5-year survival 73 %

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11. History of colposcopy in Sweden
 Colposkopy has had an uneven history in Sweden.
 Early in the 1980s, colposcopy training courses had been started
and it was a group interested gynecologists but mostly they were
interesting in screening programs and in HPV.
 At the same time, until the 1990s, women with CIN were treated
solely on the basis of the findings of cell sampling in most parts of
the country.
 This led primarily to overtreatment but probably also a certain
undertreatment.
 Treatments procedures were often performed by the least
experienced doctors, and the assessments and interventions were
considered relatively simple.
 No quality control was available!

12.  With time more education in colposcopy has been introduced.
 Colposcopy courses in Gothenburg and in Stockholm for both
seniors and fellows.
 A Swedescore system in Gothenburg has been introduced and
has helped fellows to understand the colposcopy images.

13. Professor Eva Rylander Swedish pioneer in
colposcopy
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14. According to Swedish National Program
 Although basic knowledge of clinical colpososcopy is of high
value.
 In particular, the process of new knowledge about HPV testing,
cytology trials and more complicated guidelines requires a
knowledge in colposcopy.
 The new guidelines sets some limited minimum requirements for
gynecologists to investigate and treat women with different
grade of dysplasia(colposcopists):

15. •Investigate at least 50 women with different grade of dysplasia
during one year.
• Have completed a 3-4 days course as above.
• To treat dysplasia, perform at least 25 treatments per year
 No formal licensing with examination is proposed in Swedish
guidelines, but these minimum levels should be followed up in
the quality register.
 In the long term, a licensing of colposcopists should be
introduced, but it is not mandatory to have to be able to treat
patients with dysplasia!

16. According to Swedish guidelines
Knowledge objectives for colpososcopic education
 Theoretical understanding of the dysplastic process.
 The doctor should be able to •
 Describe and explain the development of precancerous
changes
 Understand all clinically relevant aspects of HPV in the
transformation zone: transmission, natural process,
spontaneous healing, progress, proliferation, genome
integration, cell regulation
•Describe and explain the nomenclature of atypical cell samples
and histopathology.

17. Analyze data and communicate
 The doctor should be able to
•Acquire and interpret the patient's dysplasia and screening history
•communicate with the patient in a clear and incoming way about
her cell sample abnormalities and propose further treatment
•understand the guidelines and be able to make clinically and
scientifically well-founded assessments of patient treatment
•independently handle combinations of discrepancies, findings and
background factors.

18. Skills in colpososcopy
 The colposcopist should be able to •
 Determine whether colposcopy is complete and evaluate and
classify the transformation zone
 examine vagina and exclude or evaluate dysplastic lesions
 • identify and describe epithelium and benign pregnancy-related
changes
 • identify, recognize and classify low- grade high-grade changes,
suspicion of microinvasion and invasion •
 apply the Swedescore scoring system
 Apply the IFCPC (International Federation of Colposcopy and
Cervical Patology) classification

19. Skills in biopsy
The colposcopist should be able to:
 Determine where biopsy should be taken
• Determine when to take biopsy
 To be able to take biopsies from different patients with different
types of cervix, transformation zones and lesions.

20. Skills in excision treatment
 The colposcopist should be able to
 handle the current anesthesia method (preferably local
anesthesia) and its conditions and limitations for the procedure
•be familiar with the physical conditions and effects of the method
used (LEEP, LLETZ excision, laser excision, etc.)
• handle the safety aspects of treatment
•after appropriate supervision, independently carry out
interventions on different types of cervix with different
transformation zones and lesions
• manage complications that may occur per- and postoperatively
(bleeding, etc.)

21. Special challenges in the new guidelines
 The National Board of Health's is expected that the introduction
of new guidelines will result in increase of a volume of the
number of coposcopical investigation in 20%.
 This means that the need for educated colposcopists increases,
probably correspondingly.
 The guidelines has a greater emphasis on restraint with
treatments. At the same time, it increases the requirements for
not treating only wait and see and follow-up.
 Adequate delegation for sampling to dysplasia midwife /
dysplasia nurse, as well as referral to control file and relaying
patients to screening, will be essential steps.
 The new guidelines recommends that multidisciplinary
conferences on dysplasia cases be held. In particular, in areas
where colposcopy receptions are outside hospitals.

22. The New Course started
 At spring 2012 we started a course together with doc
Dr Simon Leeson Consultant Gynaecologist and
Oncologist, Honorary Senior Lecturer Betsi
Cadwaladr University Health Board, Wales
 Dr Panos Sarhanis Lead Colposcopist for North West
London Hospital UK
 Dr Nick Nicholas Lead Colposcopist for Hillingdon
Hospital in London UK

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24. We discussed the program and the course was
planed as follow: first day theoretical
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25.  second day practical day in form of interactive lectures and the
third day also practical day and discussions and even we did
candidate assessment from the beginning of day two and when
the course was finished.
 The course have been certificated by EFC and this is only one
Swedish course that have been certificated internationally.
 How much doctors have participated?
 In between 60-70 a year fellows an seniors.
 A lot of doctors have been learned according to international
requirements.
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27.  Approximately 350 doctors participated at ous courses since
2012, and the evaluated our courses very high!
 A Swedish Society for colposcopy had been built and we
became members of EFC

28. LOGGBOK
FOR EDUCATION IN COLPOSKOPI
NAME: ……………………………………………
HOSPITAL………………………………………..
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29.  Some of them that participated in our courses became very
interested in colposcopy, some already leaving the logbook that
are prepared according to our recommendations.
 Those that left log-books also want to do the examination in
form of OSCE or maybe in an other form.
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30. With all this facts in background we need
now answer to some questions
Why is a training program for colposcopists needed?
 Moments during training
Examination, OSCE
Logbook - Instructions for logbook
Theory, knowledge goals
Own cases
Summary of knowledge requirements.
Retention of competence for continued
certification

31. What we need to discuss today
ou need to be
 What will be our next step
 The most easily way to go is maybe to take the British
program and apply it in Sweden, but this will not work!
 Sweden is a small country with a population of 8,5
millions and doctors cannot work at small hospitals
and only concentrate on colposcopy y
all-round

32.  Since 2016 the Swedish Society for Obstetrics and Gynecology
have decided that the courses will be only for seniors and not for
fellows and how we will solve this interesting question????
Nobody knows!!!!!

33. 2017-12-15Sonia Andersson

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