Colposcopy (Position Paper)
Worldwide, it is estimated that there are 528,000 new cases of cervical cancer each year and that 266,000 women die from the disease.1 In the United States, the National Cancer Institute (NCI) estimates that 1,200 new cases of cervical cancer will be diagnosed in 2015, and that 4,100 women will die from the disease.2 Currently, the five-year survival rate for localized cervical cancer is 91.5%; the overall (i.e., all stages combined) five-year survival rate is approximately 67.8%.3 Cervical cancer was once one of the most common causes of cancer death among U.S. women, but since the 1980s, the cervical cancer death rate in the United States has decreased by more than 50%.4
Studies show that access to health care is an important predictor of cancer screening. In the United States, pap tests are ordered or provided in approximately 29.4 million physician office visits each year, and it is estimated that more than 3 million women get unclear or abnormal results.5,6
Colposcopy is the diagnostic test indicated for evaluating patients with abnormal Pap test results. 7During the procedure, features of the cervical epithelium are examined under magnified illumination after the application of normal saline, 3% to 5% dilute acetic acid, and Lugol iodine solution in successive steps.7 A green filter highlights vascular patterns.
Neither cytologic sampling nor colposcopic examination alone provides definitive answers. If abnormal tissue is present, it is the histologic result that provides the basis for treatment or observation.
Use of colposcopy-directed biopsies to confirm lower genital tract disease has become common practice for many physicians. It is recognized that performance of colposcopy, in both inpatient and outpatient settings, is within the scope of family medicine, and data from a 2014 member census show that 15.6% of American Academy of Family Physicians (AAFP) members perform this procedure in the office setting.8
It is the position of the AAFP that clinical privileges should be commensurate with the individual physician’s documented training and/or experience, demonstrated abilities, and current competence.9 This policy applies to privileges in all areas. The AAFP also maintains the position that all physicians should be paid for performing all clinical services for which they have documented training and/or experience, demonstrated abilities and current competence to perform.10
The AAFP also advocates the development of explicit patient-centered clinical practice guidelines that focus on what should be done for patients rather than who should do it.11 When clinical practice guidelines address the issue of who should provide care, then recommendations for management, consultation, or referral should emphasize appropriate specific competencies, rather than a clinician’s specialty designation.
The American Medical Association’s policy on staff privileges states that “Decisions regarding hospital privileges should be based upon the training, experience, and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital, and especially patients. Privileges should not be based on numbers of patients admitted to the facility or the economic or insurance status of the patient. Personal friendships, antagonisms, jurisdictional disputes, or fear of competition should not play a role in making these decisions. Physicians who are involved in the granting, denying, or termination of hospital privileges have an ethical responsibility to be guided primarily by concern for the welfare and best interests of patients in discharging this responsibility.”12
The Joint Commission requires hospitals or credentialing entities to establish a process that provides fair and equal treatment to all applicants. The “credentialing and privileging process involves a series of activities designed to collect, verify, and evaluate data relevant to a practitioner’s professional performance. These activities serve as the foundation for an objective, evidence-based decisions regarding appointment to membership on the medical staff. And recommendations to grant or deny initial and renewed privileges. In the course of the credentialing and privileging process, an overview of each applicant’s licensure, education, training, current competence, and physical ability to discharge patient care responsibilities is established.”13
The following, however, are generally considered to be the most specific indications for colposcopy14,15:
- Abnormal Pap test result result (the primary indication for colposcopy).
- Abnormal-appearing tissue in the vagina, on the cervix or vulva, perineum, perianal area, or male genitalia.
- Abnormal-appearing cervix, even if cervical cytology is normal.
- InIntrauterine exposure to diethylstilbestrol.
- Child abuse and rape cases.
- Patient history indicates high risk for cervical cancer, such as a male partner who has had previous or current sex partners who developed cervical cancer.
- Follow-up examinations after treatment for high grade squamous intraepithelial lesion (HGSIL) or lower genital tract cancer.
- Follow-up examination after and postive human papillomavirus (HPV) test result when the Pap test is normal.
The AAFP’s recommended curriculum guidelines for family medicine residents are intended to help family medicine residency directors develop curricula and to help residents identify areas of needed training. The curriculum guideline on women’s health and gynecologic care lists colposcopy as a skill that family medicine residents should demonstrate the ability to independently perform or appropriately refer.16 A curriculum in colposcopy must impart cognitive and psychomotor skills.
Ideally, the family physician will continue a lifelong learning program that incorporates participation in intermediate and advanced colposcopy courses, which are offered by the American Society of Colposcopy and Cervical Pathology (ASCCP) and other organizations and institutions. Membership in societies that are actively involved in developing evidence-based practice guidelines and standards for colposcopy may also be beneficial.
The AAFP recommends that family physicians document all significant training and experience so that it is recorded and can be reported in an organized fashion. Such documentation should include at a minimum all procedural skills, intensive/critical care experiences, treatment of major illnesses, and other significant training and experiences.17 Further, procedural skills and professional competency can be effectively evaluated. Clinical proctoring is an important peer review tool for physicians seeking privileges in hospitals and health care organizations including colposcopy. Please see the Academy’s position paper on Clinical Proctoring for additional information.18
As is already established, the AAFP holds that all physicians on the medical staff should have the opportunity to practice medicine in their health care organizations, and should be granted clinical privileges commensurate with their documented training and/or experience, demonstrated abilities, and current competence.19 The AAFP believes that any hospital departmentalized by specialty should establish a department of family medicine that has the right to recommend privileges that fall within the scope of family medicine directly to the appropriate committee.20 Please see the AAFP’s policy on Family Medicine Departments and Privileges for additional information.
The process for credentialing and delineation of family medicine privileges varies among organizations. Before applying for colposcopy privileges, the applicant should do the following:
- Ensure that the documentation of his or her documentation of training, experience, and current competence is in order. It is also advisable to maintain ongoing documentation of relevant clinical experience.
- Review the eligibility criteria for each privileges requested, and review his or her training and experience for any gaps or areas that may need to be addressed before applying for privileges.
- Review the hospital's privileging process and bylaws, including procedures in the event of a denial. If the applicant is denied privileges, he or she should ask for the reason in writing.
- Collect letters of recommendation from past instructors, preceptors, those who have monitored your clinical performance, and colleagues who have worked with you throughout the years.
- Assemble case reports including data about the number and types of cases, treatment outcomes, etc.
- Assemble documentation records maintained during your family medicine residency.
The applicant should include complete documentation, case reports, and letters of recommendation with the application for colposcopy privileges. To avoid losing original documents in the course of the review, he or she should submit copies, not originals.
Some problems with privileges arise because other specialists do not understand the scope of family medicine. Family physicians on the medical staff—or within the hospital’s family medicine department, if there is one— should provide general information about family medicine to other specialists. They should also communicate the following points:
- Clinical privileges should be considered on the basis of each individual physician’s documented training or experience, demonstrated abilities, and current competence.
- Overlap occurs among many specialties.
- No clinical privileges are the exclusive province of one department.
- Determining when to consult and when to refer patients is a vital part of a family physician's training.
- Continuity of care is a primary objective of family medicine, and this objective is consistent with quality patient care.
- Family physicians are supported by the AAFP in their efforts to obtain privileges for which they are qualified.
It is important for family physicians to receive high-quality didactic and procedural training in colposcopy.
Primary prevention through risk-factor identification and patient education is as important in reducing the prevalence of cervical cancer as secondary prevention by identification of dysplastic lesions at the time of colposcopy.
Whether the performance of colposcopy by family physicians saves money and resources at the societal level is unknown, although it would seem to have several favorable results:
- identification of disease at earlier stages
- improved compliance with follow-up regimens that can be expected with the increased continuity of care
- an increased knowledge of and attention to risk factors
- increased patient satisfaction
Productive areas for educational research on colposcopy privileging include improved definition of the competency-based measures required for performance of colposcopy and analysis of outcomes in family medicine compared with other specialties.
- International Agency for Research on Cancer. Cervical cancer estimated incidence, mortality and prevalence worldwide in 2012. http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp(globocan.iarc.fr). Accessed June 8, 2015.
- National Cancer Institute. SEER stat fact sheets: cervix uteri cancer.
http://seer.cancer.gov/statfacts/html/cervix.html(seer.cancer.gov). Accessed June 8, 2015.
- National Cancer Institute. SEER stat fact sheets: cervix uteri cancer. http://seer.cancer.gov/statfacts/html/cervix.html(seer.cancer.gov). Accessed June 8, 2015.
- American Cancer Society. What are the key statistics about cervical cancer? http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-key-statistics(www.cancer.org). Accessed June 8, 2015.
- Centers for Disease Control and Prevention. Ambulatory and Hospital Care Statistics Branch. National ambulatory medical care survey: 2010 summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf(www.cdc.gov). Accessed June 8, 2015.
- Centers for Disease Control and Prevention. Making sense of your Pap and HPV test results. http://www.cdc.gov/std/hpv/pap/(www.cdc.gov). Accessed June 8, 2015.
- Sellors JW, Sankaranarayanan R. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual. Lyon, France: International Agency for Research on Cancer; 2003.
- American Academy of Family Physicians. Family medicine facts. Table 12: Clinical procedures performed by physicians at their practice (as of June 30, 2014). http://www.aafp.org/about/the-aafp/family-medicine-facts/table-12.html. Accessed June 8, 2015.
- American Academy of Family Physicians. Privileges.
http://www.aafp.org/about/policies/all/privileges.html. Accessed June 8, 2015.
- American Academy of Family Physicians. Payment.
http://www.aafp.org/about/policies/all/payment-physician.html. Accessed June 22, 2015.
- American Academy of Family Physicians. Joint development of clinical practice guidelines with other organizations. http://www.aafp.org/about/policies/all/joint-development.html. Accessed June 8, 2015.
- American Medical Association. AMA code of medical ethics. Opinion 4.07 -- Staff privileges. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion407.page(www.ama-assn.org). Accessed June 8, 2015.
- Joint Commission on Accreditation of Healthcare Organizations. 2009 Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organizations; 2009.
- Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013; 17(Suppl 1):S1-S27.
- Saslow, D., Solomon, D., Lawson, H. W., Killackey, M., Kulasingam, S. L., Cain, J., Garcia, F. A. R., Moriarty, A. T., Waxman, A. G., Wilbur, D. C., Wentzensen, N., Downs, L. S., Spitzer, M., Moscicki, A.-B., Franco, E. L., Stoler, M. H., Schiffman, M., Castle, P. E., Myers, E. R. and ACS-ASCCP-ASCP Cervical Cancer Guideline Committee (2012), American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA: A Cancer Journal for Clinicians, 62: 147–172.
- American Academy of Family Physicians. Women’s health and gynecologic care. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint282_Women.pdf. Accessed June 8, 2015.
- American Academy of Family Physicians. Privileges, Documentation of Training and Experience. http://www.aafp.org/about/policies/all/privileges.html. Accessed June 22, 2015.
- American Academy of Family Physicians. Clinical Proctoring.
http://www.aafp.org/about/policies/all/privileges.html. Accessed June 22, 2015.
- American Academy of Family Physicians. Privileges.
http://www.aafp.org/about/policies/all/privileges.html. Accessed June 22, 2015.
- American Academy of Family Physicians. Family medicine departments and privileges. http://www.aafp.org/about/policies/all/privileges-family.html. Accessed June 8, 2015.
(B1998) (2015 COD)