Prediction of cervical histologic results using an abbreviated Reid Colposcopic Index during ALTS

Interobserver agreement in the assessment of components of colposcopic grading

OBJECTIVE

To estimate the reproducibility of the assessment of visual characteristics of cervical lesions used to judge lesion grade from colposcopy.

METHODS

Digitized cervical images from 862 women enrolled in the ASCUS-LSIL Triage Study were obtained after application of 5% acetic acid. Each image was later assessed online by two randomly assigned evaluators from a pool of 20 experienced colposcopists. Interobserver agreement beyond chance was assessed by kappa statistics.

RESULTS

Of 862 evaluable images with paired assessments, 607 were considered to have an acetowhite lesion by both evaluators, 171 by one, and 84 by neither. Kappa values (95% confidence intervals) for agreement were 0.22 (0.17-0.27) for color, 0.24 (0.18-0.30) for margins, 0.22 (0.16-0.29) for mosaicism, 0.17 (0.11-0.23) for punctation, 0.11 (0.00-0.22) for atypical vessels, and 0.26 (0.22-0.31) for modified Reid Index score.

CONCLUSION

Characteristics used to assign colposcopic grade are poorly reproducible when used to assess static cervical images from women with borderline cytology results.

LEVEL OF EVIDENCE

II.

Early impact and performance characteristics of an established anal dysplasia screening program: program evaluation considerations

BACKGROUND

Screening for invasive anal cancer and its precursors is being increasingly advocated as a response to increasing incidence among HIV-infected persons. We implemented a comprehensive screening program in 2001 and report our early experience to inform monitoring and evaluation of such programs. Our research aims were: (1) to estimate incidence of and mortality from invasive anal cancer (IAC) before (1995-2000) and after (2001-2005) screening program implementation and (2) to examine potential screening program quality indicators.

METHODS

The study cohort included all patients under care for HIV infection at UCSD Owen Clinic between 1995-2005. Person-time incidence rates (IR) and case survival of IAC were estimated for the pre-screening (1995-2000) and post-screening (2001-2005) periods. High resolution anoscopy (HRA) operator accuracy was estimated by kappa agreement between cyto-histologic comparisons. Program quality indicators included: (1) screening coverage; (2) percent technically unsatisfactory cytology smears; (3) time between 1st abnormal cytology and 1st HRA; and (4) time between last clinic visit and last cytology.

RESULTS

28 cases of IAC and 13,411 person-years were observed between 1995-2005. IRs (95% CI) pre-screening and post-screening were 199 and 216 per 100,000 person-years, respectively. There was no routine treatment of high grade squamous intraepithelial lesions (HSIL) during the study period. The percent of patients with IAC requiring chemoradiation decreased from 90.9% to 70.6% (p=0.36). There was a significant improvement in cyto-histologic agreement at HRA with increasing operator experience (r=0.92, p=0.025). Screening coverage was 73% of the target population. Among 14 providers, the percent unsatisfactory cytology smears averaged 27% but varied from 0 - 62%. The median time from 1st abnormal cytology to 1st HRA was 258 days. The median interval between the last cytology and the last clinic visit was 207 days.

CONCLUSION

(1) The overall IR of IAC did not decline in the screening era and was higher than previous estimates for HIV cohorts; (2) stage shift to IAC of more favorable prognosis is a reasonable screening goal; (3) HRA accuracy varied by provider experience; (4) because of delay in access to HRA, digital rectal exam should be combined with cytology screening to detect palpable disease.

Frequency and outcome of cervical cancer prevention failures in the United States

We measured the frequency and outcome of cervical cancer prevention failures that occurred in the Papanicolaou (Pap) and colposcopy testing phases involving 1,646,580 Pap tests in 4 American hospital systems between January 1, 1998, and December 31, 2004. We defined a screening failure as a 2-step or greater discordant Pap test result and follow-up biopsy diagnosis. A total of 5,278 failures were detected (0.321% of all Pap tests); 48% and 52% of failures occurred in the Pap test and colposcopy phases, respectively. Missed squamous cancers (1 in 187,786 Pap tests), glandular cancers (1 in 19,426 Pap tests), and high-grade lesions (1 in 6,870 Pap tests) constituted 4.1% of all failures. Unnecessary repeated tests or diagnostic delays occurred in 70.8% and 63.9% of failures involving high- and low-grade lesions, respectively. We conclude that cervical cancer prevention practices are remarkably successful in preventing squamous cancers, although a high frequency of failures results in low-impact negative outcomes.

Human papillomavirus and cervical cancer

Cervical cancer is the second most common cancer in women worldwide, and knowledge regarding its cause and pathogenesis is expanding rapidly. Persistent infection with one of about 15 genotypes of carcinogenic human papillomavirus (HPV) causes almost all cases. There are four major steps in cervical cancer development: infection of metaplastic epithelium at the cervical transformation zone, viral persistence, progression of persistently infected epithelium to cervical precancer, and invasion through the basement membrane of the epithelium. Infection is extremely common in young women in their first decade of sexual activity. Persistent infections and precancer are established, typically within 5-10 years, from less than 10% of new infections. Invasive cancer arises over many years, even decades, in a minority of women with precancer, with a peak or plateau in risk at about 35-55 years of age. Each genotype of HPV acts as an independent infection, with differing carcinogenic risks linked to evolutionary species. Our understanding has led to improved prevention and clinical management strategies, including improved screening tests and vaccines. The new HPV-oriented model of cervical carcinogenesis should gradually replace older morphological models based only on cytology and histology. If applied wisely, HPV-related technology can minimise the incidence of cervical cancer, and the morbidity and mortality it causes, even in low-resource settings.

Visual appearance of the uterine cervix: correlation with human papillomavirus detection and type

OBJECTIVE

Infection with carcinogenic human papillomaviruses (HPVs) is necessary for cervical precancer and cancer, but the effects of type-specific HPV infection on cervical appearance are poorly understood.

STUDY DESIGN

Twenty expert colposcopists evaluated a total of 939 digitized cervigrams that were obtained during the ASCUS (atypical squamous cells of undetermined significance)-LSIL (low-grade squamous intraepithelial lesion) Triage study after the application of 5% acetic acid. Each reviewer rated the number and severity of lesions in 112 pictures that were matched on histologic diagnoses and HPV typing results so that > or = 2 reviewers rated each image. We used standard tests of association and correlation to relate HPV type and visual appearance.

RESULTS

Pairs of reviewers were significantly (P < .05) more likely to agree that a definite lesion was present when HPV DNA was found, particularly HPV16, regardless of histologic diagnosis. However, the link between infection status and visual appearance was weak for each individual reviewer. Interestingly, many women with multiple HPV infections had no visible lesions and vice versa.

CONCLUSION

HPV16 causes more definite visual abnormalities than other HPV types, regardless of eventual histologic diagnosis. Otherwise, the associations between HPV infection and lesion recognition are weak.

Value of the International Federation for Cervical Pathology and Colposcopy (IFCPC) Terminology in Predicting Cervical Disease

OBJECTIVE

To evaluate the colposcopic accuracy according to the International Federation for Cervical Pathology and Colposcopy (IFCPC) 2002 terminology.

MATERIALS AND METHODS

A series of 3,040 women derived from a general population were screened by means of Pap smear, unaided visual inspection, and high-risk human papillomavirus testing. All colposcopic examination results with abnormal findings and with biopsy confirmation (n = 468) were recorded, reviewed by 2 blinded colposcopists according to the IFCPC nomenclature, and included in this analysis.

RESULTS

The IFCPC terminology was easily reproduced by the 2 observers with excellent interobserver agreement (kappa =.843). Colposcopy had a sensitivity of 86% and a specificity of 30.3% in distinguishing healthy cervix from that with cervical intraepithelial neoplasia (CIN)/carcinoma. In distinguishing healthy cervix/low-grade lesions (CIN 1) from that with high-grade lesions (CIN 2/3)/carcinoma, colposcopy had a sensitivity of 61.1% and a specificity of 94.4%. Colposcopic findings graded as major changes had the highest positive predictive value for detecting high-grade lesion/carcinoma. The colposcopic abnormalities within the transformation zone and large lesions were more closely related to high-grade lesion/carcinoma, whereas a sharp outer border, multiple colposcopic abnormalities, and iodine negativity were not statistically related to severe lesions.

CONCLUSIONS

Colposcopy using the new IFCPC classification is a potentially effective screening method; when used for diagnosis, a histological sampling is necessary. The categorization of major changes and minor changes is appropriate. It is important to describe the lesion localization in relation to the transformation zone and the lesion size because these characteristics are related to high-grade lesions.

Interobserver agreement on interpreting hand drawings of colposcopy in women with borderline cytology to predict high-grade lesions

OBJECTIVE

To assess the interobserver agreement on interpreting hand drawings as a colposcopic image recording technique in women with borderline cytology and to assess the correlation between colposcopic impression and histological outcome.

METHODS

We used colposcopic documentation and histology from a cohort study of women with borderline dyskaryosis. Four gynecologists and four residents scored the same 30 colposcopic documentation forms.

RESULTS

There is a good interobserver agreement on classifying colposcopic hand drawings as high-grade lesions (average kappa 0.58). The interobserver agreement on interpreting colposcopic image was higher for the more highly experienced gynecologists than for the residents. The agreement between colposcopic impression and histological outcome is poor (kappa 0.17) among the observers.

CONCLUSIONS

Hand drawings are a reliable recording technique of interpreting colposcopic impression documented as high-grade lesion. However, the correlation between colposcopic impression and histological outcome is still poor in women with minor cytological abnormalities.

Colposcopy at a crossroads

New cervical cancer prevention strategies are arising from rapidly improving insight into human papillomavirus (HPV) natural history and cervical carcinogenesis, challenging the conventional roles of cytology and colposcopically directed biopsy as the reference standards of screening and diagnosis, respectively. HPV testing has high sensitivity but mediocre specificity and positive predictive value, making the role of colposcopy for the accurate identification of patients requiring treatment even more important. We believe that deficiencies of the colposcopically guided biopsy must be addressed, in particular, the inaccuracy of biopsy placement leading to low sensitivity for detection of CIN3. This opinion outlines our concerns and summarizes new data, suggesting possible steps that may lead to improvement in colposcopic accuracy.