Rationale and development of an on-line quality assurance programme for colposcopy in a population-based cervical screening setting in Italy

Colposcopy Accuracy and Diagnostic Performance: A Quality Control and Quality Assurance Survey in Italian Tertiary-Level Teaching and Academic Institutions-The Italian Society of Colposcopy and Cervico-Vaginal Pathology (SICPCV)

Quality Control (QC) and Quality Assurance (QA) principles are essential for effective cervical cancer prevention. Being a crucial diagnostic step, colposcopy's sensitivity and specificity improvements are strongly advocated worldwide since inter- and intra-observer differences are the main limiting factors. The objective of the present study was the evaluation of colposcopy accuracy through the results of a QC/QA assessment from a survey in Italian tertiary-level academic and teaching hospitals. A web-based, user-friendly platform based on 100 colposcopic digital images was forwarded to colposcopists with different levels of experience. Seventy-three participants were asked to identify colposcopic patterns, provide personal impressions, and indicate the correct clinical practice. The data were correlated with a panel of experts' evaluation and with the clinical/pathological data of the cases. Overall sensitivity and specificity with the threshold of CIN2+ accounted for 73.7% and 87.7%, respectively, with minor differences between senior and junior candidates. Identification and interpretation of colposcopic patterns showed full agreement with the experts' panel, ranging from 50% to 82%, in some instances with better results from junior colposcopists. Colposcopic impressions correlated with a 20% underestimation of CIN2+ lesions, with no differences linked to level of experience. Our results demonstrate the good diagnostic performance of colposcopy and the need for improving accuracy through QC assessments and adhesion to standard requirements and recommendations.

Cervical Cancer Screening Programs in Europe: The Transition Towards HPV Vaccination and Population-Based HPV Testing

Cervical cancer is the fourth most frequently occurring cancer in women around the world and can affect them during their reproductive years. Since the development of the Papanicolaou (Pap) test, screening has been essential in identifying cervical cancer at a treatable stage. With the identification of the human papillomavirus (HPV) as the causative agent of essentially all cervical cancer cases, HPV molecular screening tests and HPV vaccines for primary prevention against the virus have been developed. Accordingly, comparative studies were designed to assess the performance of cervical cancer screening methods in order to devise the best screening strategy possible. This review critically assesses the current cervical cancer screening methods as well as the implementation of HPV vaccination in Europe. The most recent European Guidelines and recommendations for organized population-based programs with HPV testing as the primary screening method are also presented. Lastly, the current landscape of cervical cancer screening programs is assessed for both European Union member states and some associated countries, in regard to the transition towards population-based screening programs with primary HPV testing.

Intra and Inter-Observer Variability of Transformation Zone Assessment in Colposcopy: A Qualitative and Quantitative Study

INTRODUCTION

Colposcopy is an important tool in the diagnosis of cervical precancer and early cancer. The assessment of women with abnormal cytology and selection of those who require further therapy or follow up depends on the colposcopic assessment of the Transformation Zone (TZ). Identification of the TZ is thus an important part of this examination. Intra and inter-observer variability is known to be relatively high in the colposcopic interpretation of abnormal features. However, there are hardly any studies on the observer variability in the assessment of the type of TZ.

AIM

The present study was conducted with the aim to compare the intra and inter-observer variability of the TZ type classification and the Squamo-Columnar Junction (SCJ) visibility and to quantitatively measure the intra and inter-observer correlations of tracing of the TZ contours.

MATERIALS AND METHODS

Colposcopy images were obtained for a total of 170 cases. They were reviewed by three colposcopists independently. The colposcopists classified the TZ type and also marked the SCJ contours on the images. Each observer independently reviewed the cases on two different instances (few weeks apart) and the result was compiled for intra-observer variation. The intra and inter observer variability on the TZ type was compared using Cohen's Kappa. This was followed by a quantitative measurement of TZ observation variability using Hausdorff distance.

RESULTS

The inter-observer agreement for the TZ type classification was moderate (Kappa= 0.53 to 0.66). The Intra-observer agreement was moderate to strong (0.60 to 0.86).

CONCLUSION

Colposcopic in vivo examination increases the variability in the identification of the TZ when compared to the analysis of recorded images. The disagreement in the TZ type was mostly in categories Type 2 vs Type 3 followed by Type 1 vs Type 2. A computerized quantification method can be used for quality control and training purpose in colposcopy.

Interpretation of colposcopy in population-based cervical screening services in north-eastern Italy: an online interregional agreement study

OBJECTIVE

An innovative web-based colposcopy quality assurance programme was implemented in population-based cervical screening services in three north-eastern Italian administrative regions with different colposcopists' training background. In this study, the levels of intra- and interregional intercolposcopist diagnostic agreement were evaluated.

STUDY DESIGN

Of the 158 registered colposcopists, 125 accessed the website of the programme, logged-in, viewed a posted set of 50 digital colpophotographs selected by an expert steering committee, and classified them for the colposcopic impression, the visibility of the squamocolumnar junction, and the need for biopsy. Anonymous data were downloaded and analysed using the crude, or observed, proportion of agreement and the kappa coefficient.

RESULTS

There were 113 eligible colposcopists. Overall, crude agreement on the colposcopic impression, the visibility of the squamocolumnar junction, and the need for biopsy was 0.72, 0.72, and 0.87, with kappa values of 0.60, 0.36, and 0.69, respectively. The homologous kappa values were 0.61, 0.41, and 0.69 in one region, 0.57, 0.36, and 0.69 in another, and 0.66, 0.38, and 0.74 in the third. Total intra- and interregional agreement were nearly identical, with kappa values of 0.59 and 0.60 for the colposcopic impression, 0.38 and 0.35 for the visibility of the squamocolumnar junction, and 0.69 and 0.69 for the need for biopsy. The width of 95% confidence intervals around the above kappa values was ≤0.01.

CONCLUSIONS

The levels of agreement varied between moderate and substantial both within and between regions. Regional differences in training background had minor effects. The interpretation of colposcopy is potentially well-reproducible.

Accuracy of Colposcopically Directed Biopsy: Results from an Online Quality Assurance Programme for Colposcopy in a Population-Based Cervical Screening Setting in Italy

PURPOSE

To report the accuracy of colposcopically directed biopsy in an internet-based colposcopy quality assurance programme in northern Italy.

METHODS

A web application was made accessible on the website of the regional Administration. Fifty-nine colposcopists out of the registered 65 logged in, viewed a posted set of 50 digital colpophotographs, classified them for colposcopic impression and need for biopsy, and indicated the most appropriate site for biopsy with a left-button mouse click on the image.

RESULTS

Total biopsy failure rate, comprising both nonbiopsy and incorrect selection of biopsy site, was 0.20 in CIN1, 0.11 in CIN2, 0.09 in CIN3, and 0.02 in carcinoma. Errors in the selection of biopsy site were stable between 0.08 and 0.09 in the three grades of CIN while decreasing to 0.01 in carcinoma. In multivariate analysis, the risk of incorrect selection of biopsy site was 1.97 for CIN2, 2.52 for CIN3, and 0.29 for carcinoma versus CIN1.

CONCLUSIONS

Although total biopsy failure rate decreased regularly with increasing severity of histological diagnosis, the rate of incorrect selection of biopsy site was stable up to CIN3. In multivariate analysis, CIN2 and CIN3 had an independently increased risk of incorrect selection of biopsy site.

An online quality assurance program for colposcopy in a population-based cervical screening setting in Italy: results on colposcopic impression

OBJECTIVE

To report the results of an Internet-based colposcopy quality assurance program from a population-based cervical screening service in a large region of northern Italy.

METHODS

In 2010 to 2011, a Web application was made accessible on the Web site of the regional administration. Fifty-nine colposcopists of the registered 65 participated. They logged-in, viewed a posted set of 50 high-quality digital colpophotographs selected by an expert committee, and rated them for colposcopic impression using a 4-tier classification (Negative; abnormal, grade 1 [G1]; abnormal, grade 2 [G2]; suspected invasive cancer [Cancer]) derived from the International Federation for Cervical Pathology and Colposcopy 2002 classification. kappa (κ) coefficients for intercolposcopist agreement and colposcopist-committee agreement were calculated.

RESULTS

Colposcopist-committee agreement was greater than intercolposcopist agreement (overall κ 0.69 vs 0.60, p<.001). The κ values for colposcopist-committee agreement were 0.83 on Negative, 0.53 on G1, 0.66 on G2, and 0.80 on Cancer (all p values for pairwise comparisons<.001, except for Negative vs Cancer [p=.078]). There was no systematic tendency for colposcopists to underestimate or overestimate the colposcopic findings (2-tailed sign test, p=.13). Overall colposcopist-committee agreement was greater among patients 35 years or older (p<.001) and for colposcopists with previous quality assurance experiences (p<.01). Only 0.2% of Negative impressions were formulated for a cervical intraepithelial neoplasia grade 2 or worse. As a parallel finding, the impression of Cancer predicted cervical intraepithelial neoplasia grade 2 or less in 0.5% of cases. The histologic substrates of G1 were dispersed over a large spectrum.

CONCLUSIONS

The reproducibility of colposcopic impression, when classified by trained colposcopists examining high-quality images, is higher than is generally thought.

Issues in optimising and standardising the accuracy and utility of the colposcopic examination in the HPV era

For this tribute to Mario Sideri, we reviewed some of the current issues in colposcopy, many of which we were researching with him. The review concentrates on the impact of HPV testing on cervical screening, specifically on the practice of colposcopy as the major diagnostic procedure in cervical screening programmes. Topics include the changing population of women referred to colposcopy, evolving views of the colposcopic impression, differing approaches to directed and random biopsy, issues in teaching colposcopy using static images, and the development of colposcopy aids, and simplified visual assessment techniques.