for the ASCCP Consensus Guidelines Conference. From Washington Ó , American Society for Colposcopy and Cervical Pathology. Journal of. ASCCP Guidelines for Managing Abnormal Cervical Cancer Screening Tests Barbara S. Apgar, MD, MS Professor of Family Medicine University of. testing. • Spring – ACS, ASCCP, ASCP recommend co-testing for screening women age • March – Management guidelines.
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The primary objective was to determine the theoretical number of awccp at a ascc clinic if the American Society for Colposcopy and Cervical Pathology ASCCP guidelines were applied.
The secondary objective was to determine the actual number of colposcopies before and after the ASCCP guidelines. This was a two-part descriptive study. The first part applied the ASCCP guidelines to all pre-guideline colposcopy cases at a single resident clinic. These theoretical results were then compared to the actual number of colposcopies. The second part compared the actual number of colposcopies during the one-year time period wsccp and after the guidelines. Chi-Square tests and Fisher’s Exact tests were used to examine the association of categorical variables.
Seventy-three colposcopies were performed during the pre-guideline period. The largest reductions would have occurred in patients with low grade cytologic abnormalities. Fifty-eight indicated colposcopies were actually performed during the post-guideline period. While there was a decrease in the number of colposcopies performed post-guidelines, the decrease was not as dramatic as expected.
From a training standpoint, as indications for colposcopy decrease, fewer training opportunities are available for residents. In particular, residents will have less experience evaluating low grade cytologic abnormalities in younger women.
When compared worldwide, cervical cancer in the United States has a relatively low incidence.
Inthe cervical cancer incidence in the United States was 7. The goal of effective screening should be to reduce morbidity and mortality by identifying precursors that lead to invasive disease, while limiting unnecessary treatment and procedures. Pap smear collection has been a long-standing, effective screening test for cervical cancer.
When cytologic abnormalities are identified by the screening pap smear, a colposcopy procedure serves to further investigate and diagnose any abnormalities. Colposcopy involves examining the cervix with a microscope and using saline, acetic acid, white light, and green light to further highlight concerning areas on the cervix.
In many instances, this leads to visually directed biopsies of the cervix. This microscopic examination and biopsy of the cervical tissue is used to identify and diagnose cervical cancer or aasccp to invasive disease. Aptitude, aeccp, and confidence improve as the number of procedures a trainee performs increases.
The American Society for Colposcopy and Cervical Pathology ASCCP requires trainees in their mentorship program to perform 25 supervised examinations over a 12 to month period with cytologic, colposcopic, and histologic correlation. The Accreditation Council for Graduate Medical Education ACGME does not require residency training programs to report the number of colposcopies residents perform during their training, though they track statistics on other types of office-based procedures. As the number of indications for colposcopy has decreased, concerns about resident proficiency in colposcopy have been raised.
Guidelines – ASCCP
Cervical cancer screening guidelines have changed dramatically over the last 10 years with a trend towards decreasing the frequency of screening in more restricted age groups age 21 to ascco The latest consensus guideline released in reduced the instances where colposcopy was recommended as the next step in evaluation in three specific ways: With less women getting screened and fewer indications for colposcopy, fewer colposcopies will be performed resulting in decreased procedures available for resident training.
Data is limited on how the continually changing guidelines have affected colposcopy procedure numbers in Obstetrics and Gynecology residency training programs. A study from a Family Medicine program found an actual A dedicated colposcopy clinic, which receives both internal and community referrals, takes place on one half day a week at this site.
Female patients between the ages of 21 and 65 years were included.
ASCCP 2013 Guidelines for Managing Abnormal Cervical Cancer
Data regarding patient age, indication for colposcopy including cytology result, and colposcopy result were extracted. Cases from April 1, to March 31, were evaluated using the ASCCP guidelines to determine ascp colposcopy would still be indicated.
This one-year time frame correlates to the one-year period prior to the release of the ASCCP guidelines. These results were then compared to the actual number of colposcopies performed between April 1, and March 31, as well as the actual number of colposcopies performed between April 1, and March 31,the asvcp time frame after the release of the guidelines.
Chi-Square Tests and Fisher’s Exact Tests were used to determine the significance of association for categorical variables.
Seventy-three colposcopies were performed during the one-year study period, April 1, to March 31,prior to the release of the ASCCP guidelines.
After applying the ASCCP guidelines, 35 of 73 colposcopies would still be performed and 38 would no longer be indicated, resulting asxcp a Seven residents rotate through the colposcopy clinic per year, therefore the number of colposcopies per asccpp would have decreased from Patients 24 years and younger 3.
Total number of colposcopies performed in a resident clinic by indication and age before and after the ASCCP Guidelines. A ssccp of 58 indicated colposcopies were performed in the one-year time period, April 1, to March 31,following the release of the ASCCP guidelines [ Table 1 ].
Thus, under the new guidelines, the number of patients who would have been indicated for a colposcopy increased from 35 to 58, or by Seven residents continued to rotate through this colposcopy clinic per year resulting in 8. The new guidelines resulted in a decrease in the number of indications for colposcopy. Ultimately, patients benefited from a reduced number of invasive procedures. The ASCCP guidelines recommended longer screening intervals, later initiation of screening, increased use of HPV co-testing for evaluation of mild abnormalities, and an overall reduction in colposcopy in instances where the risk of cervical cancer is low.
We projected a large proportion of the decline would be in women age 21 to adccp in whom low grade cytologic abnormalities were no longer an indication for colposcopy. 20133 the year following zsccp guideline release, the actual number of indicated colposcopies performed was 58, which is higher than the expected 35 cases that were indicated 22013 the new guidelines in the previous year.
Based on this number, each resident performed 8. As predicted with the new guidelines, fewer women between the ages of 21 and 22013 had a colposcopy. Interestingly, we observed an increase in the number of colposcopies performed for women between the ages of 30 to 65, which is why the overall number of colposcopies did not decrease as dramatically as predicted.
Precise reasons for the increased number of colposcopies in this older population are unclear. We did not note an overall shift in the demographics of the population receiving general obstetrics and gynecologic care at this site.
We hypothesize the decreased number of young patients requiring colposcopy left more clinic appointments open for outside referrals which tended to represent an older demographic population. In clinical practice, adoption of a new guideline rarely happens instantaneously.
Awccp previously reported in the literature, there seemed to be a delay in the adoption of the guidelines. Both the predicted and actual colposcopy numbers demonstrated that the decrease in procedures was more evident in patients with low-grade cytologic abnormalities than high-grade abnormalities.
Our study suggests 20133 will get less training in evaluating mild abnormalities while getting a similar experience in evaluating high-grade abnormalities. Because the goal of colposcopy is to diagnose cervical cancer and high-grade precancerous lesions ie, CIN 3resident training may not ascco as adversely affected as the overall numbers would 203. The number of colposcopies for high-grade lesions that a trainee needs to perform to be adequately trained has not been defined by national organizations.
Brotzman and Apgar have suggested in the Family Medicine literature, at least 10 high grade lesions should be evaluated for competency. This data was collected from a single resident clinic and does not include resident colposcopy experience gained outside of this particular clinic such as continuity clinics or gynecologic oncology clinics.
Thus, exact procedure numbers that arise from this specialty colposcopy clinic do not reflect the entire colposcopic experience obtained by the residents in our program. Another limitation to this study was the use of CPT ascp to identify our subjects. This method relies on accurate coding and can inadvertently miss subjects that did in fact have a colposcopy procedure.
Though our results are reflective asccpp current trends that we predict awccp affecting training programs in the U. Both the increased cervical cancer screening interval and increased administration of the HPV vaccination are likely to reduce the number of abnormal cervical cytology results further.
The screening guidelines for cervical cancer continue to be reevaluated and updated with the overall goal of decreasing time and resources while improving diagnosis and survival rates. From a public health perspective, decreasing the number of unnecessary invasive procedures will undoubtedly be beneficial for patients and society as a whole.
From a medical education standpoint, if there is no change to the current training methods, there is a risk that residents may not get adequate training to achieve competency. In addition to clinical exposure, a standardized curriculum including a multi-angle approach to teaching that incorporates readings, case conferences, image review, and simulation may also be necessary to provide comprehensive training.
These tools have effectively been used in other programs. Over time, if procedural numbers significantly decrease, this may necessitate referral to a physician who performs a concentrated volume of colposcopies, thus removing this procedure from the scope of some general Obstetrician Gynecologists.
Residency programs should evaluate their colposcopy training curriculum in light of the guideline changes. As clinical exposure decreases, colposcopy may need to be a required procedure tracked by the ACGME to ensure that graduates receive adequate clinical experience. National Center for Biotechnology InformationU. Hawaii J Med Public Health. Author information Copyright and License information Disclaimer.
Abstract The primary objective was to determine the theoretical number of ascp at a resident clinic if the American Society for Colposcopy 2031 Cervical Pathology ASCCP guidelines were applied.
Introduction When compared worldwide, cervical cancer in the United States has a relatively low incidence. Results Seventy-three colposcopies were performed during the one-year study period, April 1, to March 31,prior to the release of the ASCCP guidelines.
Open in a separate window. Discussion The new guidelines resulted zsccp a decrease ascco the number of indications for colposcopy.
Conclusion The screening guidelines for cervical cancer continue to be reevaluated and updated with the overall goal of decreasing time and resources while improving diagnosis and survival rates. Conflict of Interest None of the authors identify any conflict of interest. Cervix Uteri Cancer [updated June 28] Available from: Cancer Statistics Working Group, author.
United States Cancer Statistics: Colposcopy mentorship program [updated Apr 06] Available from: American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. J Low Genit Tract Dis. Attributes of clinical guidelines that influence use of guidelines in general practice: Adherence to conservative management recommendations for abnormal pap test results in adolescents.
Brotzman G, Apgar B. Residency training in colposcopy: A survey of program directors in obstetrics and gynecology and family practices. Am J Obstet Gynecol.