6th EFC SATELLITE MEETING AND TRAINING THE TRAINERS
BRUSSELS, 1st DECEMBER 2018
6th EFC SATELLITE MEETING
Introduction
Pekka Nieminen – President-elect of the European Federation for Colposcopy,
Department of Obstetrics and Gynaecology, Helsinki University Hospital, Finland
EFC’s aim is to improve the quality of colposcopy throughout Europe. ESGO has asked for the EFC to collaborate with them to develop colposcopy guidelines as required.
The 2nd round of the Delphi is presented. European guidelines were published in 2008.
There are national guidelines but not in each country, yet every country should have them as the clinical problems are slightly different in each country. They should be evidence based and they should be followed. Grilli et al, (2000) noticed that only 5% of guidelines had the type of stakeholder, strategy was in place for evidence collection and the evidence was graded.
Colposcopic practice has changed since 2008 with HPV-based screening and HPV vaccination. Revision of the existing guidelines is needed. The EFC has publications critiquing the use of guidelines and the quality of care in colposcopy. The EFC has a central role in subsequent guideline writing and dissemination. The document should not be a textbook. The guidelines should concentrate on core issues where there is uncertainty, controversy, with variable management in which guidelines are going to be helpful.
The plan is the develop the format, topic, next steps, process and the need for systematic analysis.
The second of Delphi: top 6 after the second round were – what is the ideal assessment of the endocervical canal for patients with AIS (Delphi score 4.35), when is conservative management of HG CIN appropriate (4.09), how best to maximise coverage of the population (4.3). Treatment – what is the most effective way management AIS when local excision required (4.26) and does excision length matter (4.04). Follow-up what is the most effective test of cure (4.3).
Colposcopic guidelines: a critique
Karl Ulrich Petry – Cancer Center Wolfsburg,
Germany
These are costly documents to produce. There is no 1a level evidence for the use of cytology and colposcopy. TOMBOLA provides level 1b evidence for the non-use of loop in the management of low grade disease. There is 1a evidence for HPV vaccination and HPV-based screening. The German screening programme decided that colposcopy should not be used for screening, the threshold for colposcopy for CIN3 should be 10%. Biopsies are reasonable for type 1 and 2 TZ. Colposcopy should be performed in colposcopy clinic. These were consensus statements over some years.
John Tidy – Consultant Gynaecological Oncologist,
Royal Hallamshire Hospital Sheffield, UK
Evidence grading is not used in the UK as the evidence is largely developed by professional consensus. 6th of the national guidelines is review underway. QA assurance is embedded within all 4 programme in the UK. Audits of all cervical cancers has been performed. Revision is required as HPV-based screening is being introduced. A reduction of the number of cytology labs is being managed at present. The screening interval is being reviewed to have 5yrly review from 24.5-64yr. Self testing is being evaluated for non-responders.
What is the ideal threshold for colposcopic referral in UK practice? Currently between 10-23% of women with low-grade cytology in the UK have high-grade CIN depending upon the performance of various labs. These cut-offs have to be re-calculated. In Sheffield, HPV16 prevalence about 10% but less prevalent with other HPV types after HPV persistence with -ve cytology. A new standard is planned with PPV for colposcopic prediction of high-grade disease to 75% and 35% for low-grade disease (cytology negative). There is a need to develop a new computer database for call-recall.
HPV testing has now re-introduced a group of women who are HPV +ve cytology –ve on short term recall that had been removed by the preceding HPV-triage. This group should shrink once the vaccinated cohort enters the screening programme but perhaps only be 30% as HPV 16/18 appears to account for 30% of the HPV population.
Xavier Carcopino – Chair Education Committee of EFC,
Head of department of colposcopy and cervico-vaginal pathologies North University Hospital of Marseille, France
Guidelines provide optimal patient management, to keep colposcopists up to date, provides ideal outcomes in terms of public health, patient information/ reassurance and medicolegal support. Guidelines assess evidence quality supporting case management. With the same evidence why are there discordant statements. There are many evidence defects. Should we have expert opinion is the absence of evidence in relying on subjectivity, possible error and could have a medicolegal impact?
A question from the audience was that the EFC will not provide any level 1 evidence. Some of the Delphi issues may be answered by research in the near future. An evidence level should be quoted in guidelines. Prof Gultekin from ESGO added that guidelines have more authority than individual publications. A Turkish representative advised that HPV 33 has almost the same underlying incidence of CIN3 as HPV 16
What areas warrant evaluation?
Marc Arbyn – Coordinator of the Unit of Cancer Epidemiology,
Belgian Cancer Centre at the Scientific Institute of Public Health, Brussels, Belgium
The Delphi outcomes are re-considered for the following topics:
What is the most effective way of assessing the endocervical canal with AGC? Could pool studies (Delphi 4.35). Update of meta-analysis.
What is the best way to maximise screening? (4.30) – self sampling. Needs continuous update.
When is conservative management of HSIL acceptable? (4.09)
Most effective way to manage cGIN for treatment of local disease? (4.26)
Does length of excision influence outcome? – database pooling.
What is the most effective test of cure after cervical pre-cancer? (4.30).
Best way to manage management of persistent post-treatment HPV with normal colposcopy and cytology? (4.13)
How should treatment for CIN be performed in women who develop stenosis?
There is a problem with the US literature that SIL is used both for cytology and histology.
A delegate suggested that P16 status could be included. P16 +ve disease should be considered for treatment according 1 one of the delegates.
Any suitable subjects for meta-analysis will need to look at subgroups.
Other subjects could be:
- RNA testing or not?
- The qualitative relationship between cone dimension and obstetrical outcomes who become pregnant after treatment.
- Communicate with the EU commissioner for health, president of the EU commission, European Council to claim for new CC prevention guidelines as screening is not a priority at present. New comprehensive guidelines could be considered in a few years to advice how to eradicate cervical cancer. Histologist should also be invited.
- Self sampling with point of care testing.
Discussion
Moderated by Pekka Nieminen – President-elect of the European Federation for Colposcopy,
Helsinki University Hospital, Finland
A delegate suggested a word of caution is needed before a project is taken on that cannot be delivered. Dr Arbyn responded by saying the money raised can be used for calls for relevant research with a view to produce a new guideline around 2025. Consensus was agreed.
Delegates were asked whether local and European guidelines were necessary. Delegates felt that both were ideal. Prof Petry felt that both sets of guidelines are not mutually exclusive. The Delphi projects could be used for subsequent guidelines.
The meeting agreed to look at what is the most effective way of assessing the endocervical canal with AGC. ECC may be effected with the form of curette used. There is a very small proportion of AGC that are HPV –ve of gastric-type histology (less than 1% of all cancers).
What is the most effective way to manage cGIN for treatment of local disease? Is LLETZ or cold knife cone biopsy needed?
QI update and next steps
Karl Ulrich Petry – Cancer Center Wolfsburg, Germany
6 quality indicators (QIs) agreed published by Moss et al, 2013. Member societies were asked to review these QIs to see if they were useful. These were subsequently refined and re-published in 2017 (Petry et al). Does a standard requesting clear margins at excision cause more obstetric morbidity than benefit? HPV testing is a better predictor of success of treatment than margin status. The 100% targets should be reduced to >95% minimum aim and the margin status should be 75% minimum aim. Excision treatments should have histology of >85% but excluding type 3 TZ and over 45 years. These changes are to be considered for Rome 2019.
Should a new QI be introduced that colposcopy should have biopsies in type 1 or 2 TZ with minor or major changes with atypical screening results? Delegates discussed this point and may need slight modification.
Another was % of patients with +ve margins and –ve HPV testing at 6-18 months or were called for colposcopy. A delegate asked care is needed with the target (offered at 90%). There was no parameter for ablative treatment. Simplification was suggested by delegates. A counselling QI was circulated and needs to made more practical.
Nominations for the executive and EFC 2025
Simon Leeson – Secretary of the European Federation for Colposcopy,
Department of Obstetrics and Gynaecology Betsi Cadwaladr University Health Board, UK
Nominations for the EFC executive and for the congress following Helsinki 2022 was discussed. The mechanism of voting was also discussed.
EFC TRAINING THE TRAINERS
Optimizing training: What should be the ideal training nowadays
Maggie Cruickshank – Professor MB ChB MD FRCOG, Division of Medical and Dental Education and Medical Sciences, School of Medicine University of Aberdeen, UK (TBC)
What is ideal training. How should the EFC go about this?
Trainees need to understand equipment, their national programme but also professional behaviour, communication and problem solving skills. Reading and courses needed (both basic and advanced). Discussion is important and also then there can be remote access to a colposcopy expert. Most member societies offer basic, advanced courses and mentorship.
Need a training curriculum with the ability to deliver that knowledge to the trainees.
The above largely transmits theoretical knowledge.
Image recognition is important but there is variability. Some reasoning needed. Practical skills with simulation has limited problem solving but is resource heavy. Observation in clinic is resource heavy but the trainee is passive. An apprenticeship is authentic clinically with the development of all the competencies needed to practice. Needs knowledgeable trainers providing adequate supervision. Knows, knows how, shows how and does are the 4 steps of Millar’s pyramid which illustrates how training can lead to competence.
Moss’s paper (2015) in a survey of colposcopy training in Europe suggests that a training committee should oversee the programme. 1/3 looked to the EFC for guidance for that programme and that there should be some sort of quality assurance of training programmes.
There are differences across Europe with differing screening programmes as well as colposcopy is part of training for all obstetricians and gynaecologists (as recommended by EBCOG) or recommended just for those that wish to do colposcopy. TTT sessions are crucial to lead and review training programmes. Assessments must have quality assistance. Of course, future trainees will progress to become trainers of the future. The EFC has a role in supporting training across Europe.
A question was asked whether all gynaecologists should be colposcopists? Prof Cruickshank said that each country has a different environment to deal with but Prof Petry the numbers of CIN3 will be small per colposcopist. Colposcopists must be adequately trained.
Who can be a trainer and what does the role entail?
Ameli Tropé – MD, PhD, Head of the Norwegian Cervical Cancer Screening Programme, Norway (TBC)
Cannot be assumed that just because you are doctor you will be a good trainer. Specialist training is required. To be a trainer you should be a trained colposcopist, progress to a TTT programme and have sufficient clinical activity for the trainee.
Students value enthusiasm from trainers, a +ve attitude, availability, competent and an expert in your field.
A training course needs preparation, an agenda, an environment conducive to learning and be safe to practice, de-brief (eg a Norwegian model for colonoscopy training – Debriefing Assessment for Simulation in Healthcare (DASH)). Prepare well, as proper preparation prevents poor performance.
In order to teach then adhere to Knowles’ 7 principles of adult learning:
- establish a safe learning climate
- involve learners in planning their learning
- diagnosing their needs
- develop their own learning objectives
- ask trainees decide what resources they need
- carry out their own plans
- and evaluate their own learning.
How do you like to learn? Are there any teaching methods that you find particularly helpful or unhelpful?
Can be an activist – like to do, reflectors like to watch, theorists need the theory and the pragmatists need to know to put into action but like to experiment.
Can be visual, auditory or kinaesthetic (the last being a learner by touching and doing). Tell the learner what you are going to say, say it and summarize what you have said.
Feedback requires dialogue.
Professional colposcopy trainers are needed and their practice and evaluation are needed. Kahoot use of surveys demonstrated which a free service from Norway.
A question was asked whether the shy trainee could be encouraged to participate with Kahoot? Also Dr Trope said that Kahoot also demonstrates the level of disagreement amongst experts.
Providing feedback and making an action plan
Maggie Cruickshank – Professor MB ChB MD FRCOG, Division of Medical and Dental Education and Medical Sciences, School of Medicine University of Aberdeen, UK (TBC)
Feedback informs development. This is useful not only to the trainee, but also to the trainer and healthcare provider. According to Millar’s pyramid the trainee has to ‘show how’ before they ‘do’ (ie are competent). Feedback has to be reliable – is the same result achieved with the same intervention time and again, and has to be valid – does it do what it is supposed to do. What have I learnt, what new do I need to do and what plans are there going forward? Should be non-judgemental, comments are specific and that it is not too verbose.
Bad feedback can bewilder the trainee and it does evoke an emotional response. It needs to be positive and interactive with the trainee. Ask the trainee to reflect on the observations in a chronological manner. Be supportive and summarise the findings. There is no point on commenting on what cannot be changed. Focus of process and not personality.
Don’t generalise and don’t be inappropriately kind.
Pendleton’s rules of feedback are that; check the learner know they are ready, let the learner comment on the action, what they have done well, what could be improved and the trainer to comment. An example was given.
BOOST for feedback – balance, observed, objective, specific and timely.
A question was asked whether feedback should be in isolation? Prof Cruickshank said that should be in isolation. Another question was that feedback may not be given or is inadequate and wondered if it could be online? Prof Cruickshank agreed that sequential feedback can see progress in training. A further question was where is the time burden on the training? Prof Cruickshank is the there should be time in clinic for the trainee to see the patients and for discussion outside clinic time.
Use of new image capturing and sharing systems in colposcopy training
Ameli Tropé – MD, PhD, Head of the Norwegian Cervical Cancer Screening Programme, Norway (TBC)
There are options for learning with colposcopy courses nationally and overseas, e-learning and invited lectures, writing easy read articles for magazines and asking students having attended courses to teach at clinic.
But there are not enough colposcopy trainers and colposcopy accreditation for training is difficult. There will be a low incidence of CIN2+ in the HPV-based screened post HPV-vaccinated population. In Norway where HPV-based screening was implemented stepwise but the biopsy rate was x2 in the HPV-screened group although cancer rate increased by 50% in the same group. Do colposcopists trust return to 3 year screening if colposcopy normal with low grade cytology with an HPV +ve test if TZ normal? Training has to be as thorough as possible.
Are there further options? Smartphone images can work as well as real time colposcopy (iEXAMINER, mobile ODT are options). These data have to be secure and the phones hygienically cased. The software must be easy to update. Data transfer to hospital databases needs careful discussion with local IT departments. The training log can be maintained and accessed on a smart phone.
Another approach is Extension for Community Healthcare Outcomes – Project ECHO looks at telementoring underdeveloped countries. The Moonshot project uses a supercomputer in the US for civil defence but by neural networking can use screening histories of cases that develop cervical cancer following screening. This sort of work can improve pattern recognition and risk reporting.
Can women take pictures of their own cervix (see ‘Love my cervix’ website).
A question was asked whether this is the future for screening. Dr Trope said that if the images are in focus they can be for non-responders. Is the mobile colposcope used in Norway? Dr Trope said she was planning to set this up with Dr Cruickshank.
Building a training model for treatment of CIN
Xavier Carcopino – Chair Education Committee of EFC,
Head of department of colposcopy and cervico-vaginal pathologies North University Hospital of Marseille, France
Dr Carcopino discussed how to build your own LLETZ trainer. A patient should not have a LLETZ done by a colposcopist doing a LLETZ for the first time. Various self-build models can be constructed which have been published or available on You-tube.
A model trainer is useful to see the trainee knows how to use the colposcope. It is important to use the rest of the equipment you would use during treatment with the generator, smoke extractor, tubing, speculum and loops. The model should be on the examination couch.
A delegate asked if a 3D printer could be used as a cheaper option. Prof Carcopino felt this was a good idea. Another delegate asked if industry could bring models to clinic. A third question was that is there a limitation for colposcopists if they only have experience with monocular colposcopy? Prof Carcopino felt that expertise with binocular colposcopy is essential for treatment. The delegates were divided on this point but treatment should be performed under colposcopic vision.
Demonstration and use of training models for the treatment of CIN
Xavier Carcopino – Chair Education Committee of EFC,
Head of department of colposcopy and cervico-vaginal pathologies North University Hospital of Marseille, France
3 models were available for the delegates to use. Many LLETZ procedures using sausages were performed by the group.
Thanks for coming! We wish to see you all in ROME!
For any further information please contact:
EFC Secretariat
Rue de la Presse, 4 B-1000 Bruxelles
Tel: 32 (0) 2 2272730
Mobile: +32 (0) 490 411136
E-mail: efcsecretariat@thetriumph.com
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