Plus ça change ….

CWE Redman

Colposcopy Symposium, ECC 2016

UHNM

What we know

• HPV primary screening coming

• More sensitive: more HSIL detected

• Increase in workload

• Longer consultations

• More anxiety

HPV Primary Screening Protocol Algorithm All women aged 25-64 on routine call/recall and early recall

HR-HPV Test

HR-HPV -ve HR-HPV +ve

Cytology triage Routine recall 3y(25-49) 5y(≥50)

Cytology normal# Cytology abnormal –

borderline or worse

Re-screen in 12m

HR-HPV -ve

HR-HPV +ve#

Routine recall 3y(25-49)

5y(≥50)

Colposcopy referral

Cytology normal# Cytology abnormal – borderline

or worse

Colposcopy referral Re-screen in 12m

HR-HPV -ve

HR-HPV +ve

Routine recall 3y(25-49)

5y(≥50) Colposcopy referral

HPV Primary Screening Pilot Colposcopy Management Recommendations Algorithm

DRAFT Version 2.0 Aug 2014

Colposcopy Examination

Index HR-HPV +ve

- cytology ≥high grade

Index HR-HPV +ve

- cytology ≤low

grade

Inadequate

Repeat colposcopy

in 12m

Consider

LLETZ –

patient choice

LLETZ

Normal and adequate

No biopsy or

biopsy <CIN1

Abnormal

Biopsy CIN1+

Index HR-HPV+ve/

cytology ≤low grade

Index HR-HPV+ve/

cytology ≥high grade

Discussion at MDT

within 2m

Discharge to 3y recall

Manage

according to

‘abnormal

colposcopy

examination’

Performance

Acetowhitening

Metaplasia CIN3

Density

Comment about spectrum

“The most benign condyloma and most

worrisome intraepithelial neoplasia are linked

by a spectrum of continuous morphological

change”

Colposcopy as a test

Average Sensitivity = 85%

Average Specificity = 65%

Papers 1973-1993

“Colposcopy compares favourably with other diagnostic tests”

Mitchell et al Obstet Gynecol 1998;91:626-31. A meta-analysis

More recently

Punch Biopsy Excision Biopsy CIN2+

Cutoff Sensitivity Specificity

CIN2+ 80% 63%

Sensitivity increases with number of biopsies

Underwood et al BJOG 2012;119:1293-1301. A meta-analysis

Colposcopy as a test

Lower performance in more recent studies

Sensitivity 50-60%

PPV 60%

ALTS Group Am J Obstet Gynecol 2003; 188: 1393-400

Pretorius et al Am J Obstet Gynecol 2004; 191: 430-4

Bekkers et al Eur J Obstet Gynecol Reprod Biol 2008; 141; 430-4

Context

Older studies had higher prevalence HG smears

Association with larger lesions

Increase in low-grade referrals

Test performance influenced by

prevalence

Scope for improvement?

• Dynamic Spectral Imaging System (DySIS)

• Electric Impedance Spectroscopy (EIS)

• Optical Coherence Tomography

• Biomarkers

DySIS

Greater sensitivity than conventional colposcopy

Epitheliometer – APX 100

Electrical Impedance Spectroscopy

Conventional colposcopic sensitivity = 88% (80-94)

Significantly improves colposcopic performance

(ROC curve AOC =0.887 cf. 0.82 in Mitchell’s paper)

Performance profile can be adjusted

Tidy et al Br J Obstet Gynaecol 2013:120;400-11

Managing Capacity

Referrals – trend

20 Midlands and East colposcopy update

Operated by Public Health England

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

22,000

24,000

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

9,885

8,485 8,765

10,139 9,821 9,608

11,118

14,158 14,306 14,344 14,111

13,070

13,652

15,031

13,556 13,908

16,386

21,163

20,405

17,863

11,423 11,856

13,230

14,909

13,946

15,345

17,899

19,944 19,289 19,279

Nu

mb

er

of

refe

rrals

Year

East Midlands West Midlands East of England

Implementation of LBC

Reduced number of

inadequate rate and

non urgent referrals

Jade Goody

effect

Implementation

HPV testing

Combined colposcopy workload 2015/16 Clinical Indications Urgent

21

Midlands and East colposcopy update

Operated by Public Health

England

0

200

400

600

800

1000

1200

1400

1600

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Nu

mb

er

of

Re

ferr

als

Year

West Midlands East Midlands East of England

West Midlands increase 25.5% (1,178 in 2015/16

939 in 2014/15)

East Midlands decrease 2.4% (842 in 2015/16 863

in 2014/15)

East of England increase 8.2% (1,403 in 2015/16

1,297 in 2014/15)

(a) BORDERLINE CHANGE OR

LOW-GRADE DYSKARYOSIS

HIGH-GRADE

DYSKARYOSIS with treated CIN

HPV -ve HPV +ve

COLPOSCOPY

No repeat cytology

BORDERLINE CHANGE

OR LOW-GRADE DYSKARYOSIS with

negative colposcopy (no biopsy or biopsy with no

CIN)

CIN1

CIN2/3

No treatment

Treatment

(b)Cytology at 12

months with or

without colposcopy (local

preference)

(c)Cytology at 6

months

Normal, borderline

change, or low-grade dyskaryosis

High-grade dyskaryosis

Routine 3- or 5-year

recall (depending on age <50 or ≥50)

HPV –ve HPV +ve

(d)3 year

recall

(e)COLPOSCOPY

Treat or follow-up, according to national guidelines

Normal cytology: routine 3- or 5-year recall

NHSCSP pathway (2011)

Presentation title - edit in Header and Footer

Follow up appointments – trend analysis UPDATE

23 Midlands and East colposcopy update Operated by Public Health England

0

10

20

30

40

50

60

70

80

Jun1

1

Sep1

1

De

c1

1

Ma

r12

Jun1

2

Sep1

2

De

c1

2

Ma

r13

Jun1

3

Sep1

3

De

c1

3

Ma

r14

Jun1

4

Sep1

4

De

c1

4

Ma

r15

Jun1

5

Sep1

5

De

c1

5

Ma

r16

Perc

ent

Robert Peel UHNM Royal Stoke County Hospital, Mid Staffordshire Queen's Hospital, Burton

April 2012:

Implementation of HPV

testing at the University

Hospital of North

Staffordshire laboratory

October 12:

Implementation of

HPV testing at the

Royal Derby Hospital

laboratory

Quality Assurance

Presentation title - edit in Header and Footer

Punch biopsy rate at first visit – trend analysis UPDATE

25 Midlands and East colposcopy update Operated by Public Health England

0

10

20

30

40

50

60

70

Jun1

1

Sep1

1

De

c1

1

Ma

r12

Jun1

2

Sep1

2

De

c1

2

Ma

r13

Jun1

3

Sep1

3

De

c1

3

Ma

r14

Jun1

4

Sep1

4

De

c1

4

Ma

r15

Jun1

5

Sep1

5

De

c1

5

Ma

r16

Perc

ent

Pilgrim Hospital Boston UHNM Royal Stoke Royal Derby Hospital Queen's Hospital, Burton

March 12:

Implementation of

HPV testing at the

Pathlinks

laboratory

October 12:

Implementation of

HPV testing at

the Royal Derby

Hospital

laboratory

Presentation title - edit in Header and Footer

87.9%

8.5% 3.6%

48.9%

51.1%

West Midlands procedure at first attendance low grade referrals

26 Midlands and East colposcopy update Operated by Public Health England

Clinic A Clinic B Clinic C

No treatment

Diagnostic biopsy (punch)

Excision

Other

14.3%

85.3%

0.4%

Proportion of excisional treatments performed at subsequent visit with

an histological outcome of CIN2+

I

R

E

N

Q

S

L

JA

H

K

F

M

G

CB

O

P

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

105%

110%

0 25 50 75 100 125 150 175 200 225 250

Number of excisional treatments performed

Proportion of excisional treatments performed at first visit with

subsequent histological outcome of CIN2+

D

I

QF

J

E

RK

G

LP

S

H

N

C

MA

B

O

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

105%

110%

0 25 50 75 100 125 150 175 200 225 250

Number of excisional treatments performed

1,200 treatments at subsequent visit Average CIN2+ = 77.2%

1,132 treatments at first visit Average CIN2+ = 88.3%

% excisional treatments containing CIN2+

Summary

• Management of capacity

• Adjunctive colposcopic technology

• Proactive Quality Assurance

• Systematic pre-emptive education

Thank you!