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Ameli Tropé - Training and exit assessment – the case for training in colposcopy

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Ameli Tropé - Training and exit assessment – the case for training in colposcopy

  1. 1. Dr Ameli Tropé Head of the Norwegian Cervical Cancer Screening programme
  2. 2. Training and Exit assessment The case for training in colposcopy Ameli Tropé Head of the Norwegian Cervical Cancer Screening Programme Tropé Kolstad meeting 2017
  3. 3. Outline • Cervical cancer screening in Norway • Colposcopy BSCCP training • Future training?
  4. 4. • 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
  5. 5. NORWAY 5.233 people (2016) Ca 1000 gynecologists No obligatory colposcopy training
  6. 6. 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
  7. 7. 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
  8. 8. Audit of the programme Lönnberg et al. 2017 in preparation, *basert på Lönnberg et al. 2015 IJC
  9. 9. 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%
  10. 10. 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
  11. 11. Free resection margins % ( uncertain%) • Norway 66% (5%) • Ullevål University Hospital 63% (5%) • Akershus University Hospital 71% (12%) Cancer Registry 2012
  12. 12. BSCCP Training in North Staffordshire over a 1,5 year period
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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) –
  17. 17. 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
  18. 18. • 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?
  19. 19. Norwegian cervical cancer screening in transition
  20. 20. Unsatisfactory/ missing analysis n= 430 (0.5%) Normal n= 74 582 (93.4%) Follow-up n= 2 946 (3.7%) Colposcopy/ biopsy n= 1 906 (2.4%) Primary cytology n= 85 193 Unsatisfactory cytology n= 4 757 (5.6%) Normal n= 78 500 (92.1%) Follow-up n= 921 (1.1%) Colposcopy/ biopsy n= 1 015 (1.2%) Women allocated to HPV-test n= 82 996 Women allocated to cytology n= 85 205 Without cytology, only HPV-test n= 12 Without HPVtest, only cytology n= 3 132 Primary HPV-test n= 79 864 Total screened women n= 168 201
  21. 21. Cytology diagnoses; HPV positive women Diagnostic shift after HPV+ screeningtest
  22. 22. 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
  23. 23. 139 205 0 50 100 150 200 250 Cytologi HPV #CIN3+ Increase in i # CIN3+ 817 1.139 0 200 400 600 800 1000 1200 Cytologi HPV #biopsier Increase in i # biopsies Why gradual implementation?
  24. 24. 2022: Vaccinated kohort 25 years old, HPV primary screening
  25. 25. Kevin Pollock, Eurogin 2017 Catch-up vaccination cohorts School-based vaccination cohort
  26. 26. TEACHING and diagnosis using E learning on line and mobile colposcopy
  27. 27. 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
  28. 28. Future?
  29. 29. 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
  30. 30. Conclution • Training and certification is important • Colposcopy specialists if possible • Can use more e- learning and mobile communication • Important with quality assurance
  31. 31. 29/01/2018 Thank you! ameli.trope@kreftregisteret.com
  32. 32. 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
  33. 33. 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

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