EFC SYMPOSIUM – RECOMMENDATIONS ON QUALITY STANDARDS IN EDUCATION AND PRACTICE IN COLPOSCOPY
PARIS – WEDNESDAY 11TH JANUARY 2017
Dear Colleagues
The unfortunate cancellation of the planned 7th EFC Congress in Istanbul required the EFC to organize a Symposium and a General Assembly at very short notice. Thanks to the initiative of our President, Christine Bergeron, the SFCPCV was approached and the EFC was invited to hold its symposium and General Assembly in Paris. We are grateful to the SFCPCV and its President, JeanLuc Mergui, for enabling the EFC to use the excellent conference facilities at the Centre de Conférence UPMC prior to its own 40th annual conference. The aim of the symposium was to review the progress made on developing educational courses and performance standards with a view to producing a formal published statement. To that end we received excellent presentations from Professors Nieminen (Finland) and Petry (Germany), as well as Dr Leeson (UK). In addition there was an excellent presentation on adjunctive colposcopic techniques from Professor John Tidy, President of the BSCCP. Over 80 delegates from 28 countries attended this meeting. The EFC is extremely grateful to the BSCCP for providing generous funding that enabled a number of delegates from lower/ middle income countries to attend the meeting and also to sponsorship received from Hologic, BD, Roche and Zilico. The quality of the meeting and the enthusiastic support from the delegates was as impressive as it was reassuring that despite the challenges faced, the EFC continues to thrive.
EFC President
Charles Redman
Welcome and introduction
Christine Bergeron – President of the European Federation for Colposcopy, Laboratoire Cerba, France
Possible options for triage of primary HPV +ve cases will be 16/18 typing and/or cytologyand/or p16/Ki67. Colposcopy will be recommended if one of them is +ve. Colposcopy will remain at the center of this and colposcopists will need to be trained for the programme changes. This Symposium will consider what the EFC can do to prepare colposcopists in Europe for these changes as well as supporting them in their current practice.
EFC concept of quality standards in education, training and practice in colposcopy
Karl Ulrich Petry – Head of Department of Gynaecology and Obstetrics, Klinikum Wolfsburg, Germany
EFC needs to have knowledge of the practice of colposcopy throughout Europe. The Congress in 2010 looked at the differences across Europe. A European colposcopy diploma was requested. Satellite meetings commenced thereafter in Berlin. The 4th Satellite meeting in Brussels in 2015 looked at education including basic and advanced courses; for those in training a minimum case load, exit assessment and ongoing practice EFC minimum case load per year was recommended. EFC plan to continue with annual satellite meetings. In 2017 we will update EFC quality standards, define new areas for further improvement and then publish these.
Education: basic/ advanced colposcopy courses
Pekka Nieminen – Chair Education Committee of EFC Chief Physician, Department of Obstetrics and Gynaecology, Helsinki University Hospital, Finland
General principles: applications come from national societies not individuals. Basic course duration should be between 1-2 days (a minimum of 6 hours excluding breaks). You will receive an answer from EFC within 3 months of submitting an application, cost 100 Euro, needs re-approval after 3 years. The advanced course is a 2 day course and should include QA, recent developments, vulval colposcopy and advice regarding training. It is important to include plenty of discussion rather than interactive sessions. Fee 100 Euro per year. If course uses EFC officers as teachers then 20 Euro per delegate will be payable to EFC. This is a more specific programme with a final course assessment.
Training the trainers
Xavier Carcopino – Obstetrician Gynecologist, Head of Department of Colposcopy and Cervico-vaginal Pathologies North University Hospital of Marseille, France
A trainer needs to be properly trained by an experienced colposcopist. The trainer should be able to allocate sufficient time and have enough cases to offer to the trainee. The trainer will assess satisfactory completion of training, provide workplace assessment and give feedback. The easy bit is getting to a course but more the difficult part is the practical side of clinical practice and enabling the trainee to gain confidence. IFCPC now provides distance learning courses with online lectures and local trainers. There is a final assessment. Training the trainers is included in this model and the EFC is looking to develop a Training the Trainers course.
Colposcopic treatment standards
Simon Leeson – Secretary of European Federation for Colposcopy, Consultant Gynaecologist Lecturer to the University of Wales, UK
Presented data on follow-up with a subsequent cancer diagnosis/ long term treatment failure rate. Suggested that the type of excision be described using nomenclature recommended by the IFCPC. Recommended that a standard for follow-up should be considered as an EFC QI (quality indicator). Preferably this should be the rate of persistent CIN2+ at 12/24 months.
Colposcopic practice performance standards
Karl Ulrich Petry – Head of Department of Gynaecology and Obstetrics, Klinikum Wolfsburg, Germany
European countries offer a variety of different screening concepts from opportunistic to organized call and recall screening with a shift to HPV-based screening in some countries and regions. Colposcopy performs badly without standards so QA is needed. There is a need for an ongoing check of the quality of practice using EFC quality indicators. These are constantly being reviewed to standardise quality parameters. Quality indicators (QI’s) should have criteria altered in due course to be achievable. Modification of the QI’s agreed in Brussels was discussed. Further alterations and 2 additional QI measures were suggested but it was decided to publish the Brussels consensus. Criteria recommended: TZ type >95%; % cases have a colposcopic examination, >95%, Punch biopsies to be taken for type 1 or 2 TZ, >90% (additional QI), CIN2+ in excisional biopsies >80% (exclude type 3/ over 40yr); rate of HPV testing 6 months after treatment >80% (additional QI). QI’s should be published
Adjunctive colposcopic technologies
John Tidy – Consultant Gynaecological Oncologist, Royal Hallamshire Hospital Sheffield, UK
President of the British Society for Colposcopy and Cervical Pathology PPV dropping as prevalence of HG CIN drops after introduction of HPV vaccination. HPV-based screening was introduced in the UK in April 2013. Biomarkers were unhelpful, at least in the UK. Methylation studies are awaited with interest. HPV +ve rate 12.7%. 68.4% of HPV +ve women in Sheffield were not HPV 16/18. 63% of CIN2+ associated with HPV 16/18. In Sheffield over 1000 women seen in colposcopy clinic persistently presented with HPV +ve/ cytology after 24 months. 11% have CIN2+. If HPV 16/18 1 in 9 CIN2+ in this scenario. Colposcopy referral rate will be increased with HPV-based screening. Luviva, DYSIS, ZedScan and TruScreen are new technologies available to colposcopists. TruScreen shows improved sensitivity when combined with cytology. LuViva ideally used as a triage tool for low grade cytological abnormalities. DYSIS is an optical technology. A subanalysis of a Dutch study showed improved detection of CIN2+ of HPV 16 disease as opposed to other, and conventional colposcopy appear better at identifying non-HPV 16 disease. ZedScan uses electrical impedance and is in use in clinics in Sheffield. 8 other centres involved. All show increased sensitivity by about 8% (20% more cases) of CIN2+. With ZedScan improved detection of CIN2+ improved equally both in the HPV 16+ and non HPV16 disease.
Summary
Charles Redman – President-elect of the European Federation for Colposcopy, Consultant Gynaecologist, University Hospital of North Midlands, UK
Consensus statements on colposcopic performance and training have been provided. Pekka Nieminen stated that EFC has agreed to continue with basic courses and start advanced courses including communication with the patient and practice models. Training the trainers will be included. Ulli Petry suggested that Excision margins should be reconsidered, but to publish the revised QI’s as agreed in Brussels. Consider changing the criteria for the SCI, % excisions with CIN2+, % cases having prior colposcopy at a later date