2. Dr Tamar Alibegashvili
MD, PhD and President of the Georgian Colposcopy
Society

3. “The challenges of colposcopy in
Eastern Europe and Central Asia”
Alibegashvili Tamar
Brussels
16.12.2017

4. Eastern Europe and Central Asia
EECA region
Albania Armenia Azerbaijan Belarus Bosnia
Hercegovina
Bulgaria Georgia Kazakhstan Kyrgyzstan Macedonia
Republic
Moldova
Romania Russian
Federation
Serbia Tajikistan
Turkey Turkmenistan Ukraine Uzbekistan

5. ≈38,000 new cases
of Cervical Cancer
≈18,000 deaths
from Cervical Cancer
GLOBOCAN 2012

6. New Cases & Deaths from Cervical Cancer in the
Countries of the EECA Region Compared to Finland
– Globocan 2012

7. Cervical Cancer Screening in EEAC countries
• CC Screening is opportunistic (Exc. Serbia and Turkey)
No centralized data collection, reporting, monitoring and
analyses of results

8. Cervical Cancer Screening in EEAC countries
• CC Screening is opportunistic (Exc. Serbia and Turkey)
No centralized data collection, reporting, monitoring and
analyses of results
• Coverage of population is low (≈15-20%)
Number of detected precancerous lesions is low
Number of new cases of advanced cancer and mortality is
high.

9. Cervical Cancer Screening in EEAC countries
• CC Screening is opportunistic (Exc. Serbia and Turkey)
No centralized data collection, reporting, monitoring and
analyses of results
• Coverage of population is low (≈15-20%)
Number of detected precancerous lesions is low
Number of new cases of advanced cancer and mortality is
high.
• Mainly Cytology (Pap test) Screening
No established Quality control.
Old classification - Papanicolaus classes (Ukraine, Belarus)
HPV test as a triage test is used very occasionally.
VIA screening (Tajikistan).

10. Cervical Cancer Screening in EEAC countries
• CC Screening is opportunistic (Exc. Serbia and Turkey)
No centralized data collection, reporting, monitoring and
analyses of results
• Coverage of population is low (≈15-20%)
Number of detected precancerous lesions is low
Number of new cases of advanced cancer and mortality is
high.
• Mainly Cytology (Pap test) Screening
No established Quality control.
Old classification - Papanicolaus classes (Ukraine, Belarus)
HPV test as a triage test is used very occasionally.
VIA screening (Tajikistan).
• Most countries do not have National Guidelines for Cervical
Cancer Screening.

11. Colposcopy in EEAC countries
Role of Colposcopy:
• Exclude the normal cervix
• Identify the most suitable area for direct biopsy
• Detect Invasive Cancer
• Identify the type of TZ
• Make management decision
• Guide treatment
• Estimate the severity of underlying disease

12. • No enough number of well-trained colposcopists
• No appropriate technical equipment (colposcope, other instruments)
• Absence of colposcopy training program (Albania, Bosnia-
Hercegovina), or poor quality program
Colposcopy in EEAC countries

13. How to improve the quality of colposcopy:
• Standardized equipment of Colposcopy clinic
binocular colposcope
endocervical speculum
punch biopsy forceps etc.

14. How to improve the quality of colposcopy:
• Standardized equipment of Colposcopy clinic
binocular colposcope
endocervical speculum
punch biopsy forceps etc.
• Colposcopy Handbook on native language

15. How to improve the quality of colposcopy:
• Standardized equipment of Colposcopy clinic
binocular colposcope
endocervical speculum
punch biopsy forceps etc.
• Colposcopy Handbook on native language
• National Colposcopy Society

16. How to improve the quality of colposcopy:
• Standardized equipment of Colposcopy clinic
binocular colposcope
endocervical speculum
punch biopsy forceps etc.
• Colposcopy Handbook on native language
• National Colposcopy Society
• Integration of National Society in the International Organizations
(EFC, IFCPC)
International Federation
for Cervical Pathology
and Colposcopy
European Federation for
Colposcopy & Pathology of
the Lower Genital Tract

17. How to improve the quality of colposcopy:
• International conferences and Colposcopy courses

18. How to improve the quality of colposcopy:
• International conferences and Colposcopy courses
• Establishment of own Colposcopy training courses

19. How to improve the quality of colposcopy:
• International conferences and Colposcopy courses
• Establishment of own Colposcopy training courses
• High quality pathology service
CIN2

20. International Training Program in Colposcopy and Cervical
precancer Management IFCPC/UNFPA EECARO program

21. International Training Program in Colposcopy and Cervical
precancer Management IFCPC/UNFPA EECARO program
Theoretical
knowledge
25 lectures delivered online with
mandatory questions and answers
after each lecture
Image recognition
skills
50 images with specific
colposcopic characteristics
Case
management
skills
100 video cases, each with online
questions and answers, again
delivered on line
Colposcopy
cases seen under
supervision
Direct supervision of 50 cases in a
colposcopy clinic with 10 high
grade cases.
Colposcopy
cases seen
without direct
supervision
Submission of 100 colposcopy
cases details to nominated trainer
for review
Exit Assessment
on completion of
training
OSCE

22. Lyon, IARC, 11.12.2017
International Training Program in Colposcopy and Cervical
precancer Management IFCPC/UNFPA EECARO program
(OSCE)

23. • Population of Georgia ~ 3 800 000
•Cervical Cancer (CC)– the second
most spread malignancy after
Breast Cancer
• CC incidence ~ 17.7/100 000
• Annually ~ 340 new cases CC

24. Cervical Cancer Screening Program in Georgia
• CC screening was initiated in 2008
• Screening is based on the conventional Pap test (Bethesda system
2001)
• Target ages – 25-60 years
• Screening interval – 3 years
• Screening is opportunistic (From 2016 the pilot project of organized
screening in Tbilisi and Gurjaani region)
• All women with abnormal Pap and suspicions for High Grade Lesion
are referred to colposcopy

25. • GSCPC was founded in 2007
• From 2007 GSCPC is a member of EFC
• EFC and IFCPC Colposcopy Basic Courses in 2008, 2010, 2013
• Two doctors form Georgia with support from the EFC and BSCCP
had 2 weeks colposcopy training in UK

26. GSCPC composed guidelines for Screening
and diagnostic of Cervical Cancer based on
Pap test, published in 2010

27. International Classification of Diseases – ICD10
N86 Erosion and ectropion of cervix uteri
Applicable to decubitus (trophic) ulcer of cervix
Eversion of cervix

28. • In 2011 GSCPC one month training course was recognized by the
Council of Continuing Professional Development and approved by
Ministry of Health Georgia.
Colposcopy findings Number
Low grade cervical lesion ( LSIL,
CIN1)
60-80
High Grade cervical lesion (HSIL,
CIN2,3)
20-25
Normal colposcopy findings (ectopy,
Normal transformation zone)
60-80
Miscellaneous findings (polyps,
inflammation, atrophy, CTZ)
60-80
Invasive Cervical Cancer 1-5

29. Course also contains:
1 Training in LEEP,
2. Theoretical lectures,
3. Discussion of coploscopy picture patterns on the base of
Colposcopy Atlas CD.
Final assessment of trainee:
1. Post training questionnaire
2. Independent clinical examination of 20 patients.

30. Histology Sensitivity % Specificity % PPV % NPV %
Normal 56 99 61 94
CIN1 61 88 77 77
CIN2+ 84 70 78 76
ALL 72 86 76 83
Accuracy of Colposcopy for detection of different
histological diagnosis (Analysis of 800 LEEP in 2011-
2016 GNSC)

31. Referral Pap Sensitivity % Specificity % PPV % NPV %
HSIL 84 73 92 58
ASC-H 81 80 79 82
LSIL 50 80 67 66
ASCUS 51 60 66 51
Accuracy of Colposcopy for detection of CIN2+
(Analysis of 800 LEEP in 2011-2016 GNSC)

32. Summary:
• Fight against Cevical Cancer is impossible without Screening
Program

33. Summary:
• Fight against Cevical Cancer is impossible without Screening
Program
• Screening Program is impossible without High quality Colposcopy.

34. Summary:
• Fight against Cevical Cancer is impossible without Screening
Program
• Screening Program is impossible without High quality Colposcopy.
• High quality Colposcopy is impossible without good equipment and
trained colposcopists.

35. Summary:
• Fight against Cevical Cancer is impossible without Screening
Program
• Screening Program is impossible without High quality Colposcopy.
• High quality Colposcopy is impossible without good equipment and
trained colposcopists.
• Any woman attending a doctor or nurse colposcopist should expect
a minimum standard of both knowledge and competence.

36. Thank you !