Colposcopy (Position Paper)
The National Cancer Institute estimated that, in 2009, 11,270 new cases of invasive cervical cancer would be diagnosed and about 4,070 women would die from the disease. Some researchers estimate that noninvasive cervical cancer (carcinoma in situ) is about four times more common than invasive cervical cancer. Cervical cancer—once one of the most common cancers affecting U.S. women—now ranks 14th in frequency in this population.1
According to the National Cervical Cancer Coalition (NCCC), women in developing countries account for about 85% of the yearly cases of cervical cancer (estimated at 473,000 cases worldwide) and the yearly deaths from cervical cancer (estimated at 253,500 deaths worldwide). In most developing countries, cervical cancer remains the number one cause of cancer-related deaths among women.2
Studies show that access to health care is an important predictor of cancer screening. The availability of physicians to provide screening could significantly decrease the mortality rate by allowing greater patient access.3 Between 1955 and 1992, the cervical cancer death rate declined by 74%. The main reason for this change was the increased use of the Papanicolaou (Pap) test. This screening procedure identifies changes in the cervix before cancer develops or early stages of cancer. The death rate from cervical cancer continues to decline by nearly 4% each year. Currently, the five-year relative survival rate for the earliest stage of invasive cervical cancer is 92%. The overall (all stages combined) five-year survival rate is about 71%.4 About 55 million Pap tests are performed each year in the United States. Of these, approximately 3.5 million (6%) are abnormal and require further medical care.5
Although the Pap smear has become the standard method of screening, it does not definitively rule out disease. The false-negative rate of the Pap smear ranges from 1.5% to as high as 80%.6 The most likely scenario for false-negatives is that the critical areas on the cervix were not sampled or the laboratory did not identify abnormal cells because of sampling error or the presence of inflammation or excessive blood. The patient may also contribute to the false-negative rate by douching or having intercourse before the examination. If abnormalities go unrecognized, the patient may be erroneously triaged to observation or repeat cytologic surveillance rather than to a diagnostic test such as colposcopy.
Colposcopy is the diagnostic test indicated for evaluating patients with abnormal Pap test results. Colposcopy is a procedure that examines lower genital tract tissue under magnified illumination after the application of 3 to 5% acetic acid. A green filter highlights vascular patterns.7
When researchers looked at the value of using the presence of high-grade precancerous changes in a repeat Pap test (without a human papillomavirus test) to indicate whether colposcopy was necessary, they found that 63.9% of the women who truly needed colposcopy would not have had it. When the presence of lower grades of precancerous changes found on a second Pap test were used to decide who did and did not get a colposcopy, 14.7% of women who truly needed the test would not have had it done.8
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. Colposcopic-directed biopsies to confirm lower genital tract disease have become common practice for many physicians, including family physicians. They are also performed by nurse practitioners and physician assistants.7
It is the position of the American Academy of Family Physicians (AAFP) that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities, and current competence. This policy applies to privileges in all areas.9 The AAFP also advocates the development of specific patient-centered practice policies that focus on what should be done for the patient rather than who should do it. When policies 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.10
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.”11
The Joint Commission requires that a process that provides fair and equal treatment to all applicants be established by the hospital or credentialing entity. The process entails that 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.”12
It is well recognized that performance of colposcopy is within the scope of family medicine. Recent statistics show that 33.6% of active AAFP members perform this procedure in the office setting,13 and approximately 9.6% of members currently maintain colposcopy hospital privileges.14
Evaluation of an abnormal Pap smear is the primary indication for colposcopy. There is no authoritative document or consensus panel report that explicitly details the indications for colposcopy. The following, however, are generally considered to be the most specific indications for colposcopy15:
- Abnormal Pap smear result.
- 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.
- In-utero 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.
A joint task force of the AAFP and the American College of Obstetricians and Gynecologists (ACOG) developed “Recommended Curriculum Guidelines for Family Medicine Residents: Maternity and Gynecologic Care.”16 These core guidelines, which include colposcopy as a recommended skill, are intended to help residency directors develop curricula and to help residents identify areas of needed training.
The AAFP sponsors introductory colposcopy continuing medical education (CME) courses at the Scientific Assembly. In addition, the AAFP offers a freestanding colposcopy course, which is immediately preceded by a women’s health course. The AAFP maintains a registry of accredited courses and has published a comprehensive monograph titled the “FP Comprehensive CD-Rom,” including syllabus, video, and atlas, which was written and edited by family physicians.
A curriculum in colposcopy must impart both cognitive and psychomotor skills.16 The cognitive experience may be achieved using programmed texts such as the AAFP Colposcopy Self-Study CD-ROM, the AAFP colposcopy syllabus and video or online CME from the American Society of Colposcopy and Cervical Pathology (ASCCP). Other colposcopy courses are available through various organizations and institutions.
In the ideal situation, the learner would continue a lifelong learning curve that incorporated participation in intermediate and advanced colposcopy courses and maintain membership in societies actively involved in developing practice guidelines and standards for colposcopic excellence based on evidence-based literature and outcomes data.
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.17
The process for credentialing and delineation of family medicine privileges varies among organizations. Before applying for colposcopy privileges, the applicant should ensure that his or her documentation of training, experience, and current competence is in order. The following advice might help the applicant navigate the credentialing process18:
Review the eligibility criteria for each privilege requested and review your training and experience for any gaps or areas that may need to be addressed before applying for privileges.
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.
Review documents and hospital bylaws before submission, including procedures in the event of a denial. If you are denied privileges, ask for the reason in writing.
Include complete documentation, case reports, and letters of recommendation with your application for medical staff privileges. Submit copies, not originals, to avoid the possibility that original documents will be lost in the course of review. Maintain ongoing documentation of relevant clinical experience.18
The AAFP recommends the establishment of family medicine departments in all hospitals departmentalized by specialty. The department of family medicine should have rights, duties, and responsibilities comparable to those of other specialty departments of the medical staff. It should have the right to recommend directly to the appropriate committee those privileges that fall within the scope of family medicine without being required to have the assent or approval of any other department.19
The AAFP believes that the department of family medicine should establish and use a core privileging process based on criteria developed by the department. Core privileges within the department of family medicine should reflect the core curriculum and training offered in accredited family medicine residency programs. Criteria for privileges outside of the core should be pre-established by the department of family medicine in consultation with other appropriate clinical departments. Recommendations for privileges outside the family medicine core may then be considered by the department of family medicine according to the criteria jointly established by the relevant clinical departments. In all cases, clinical review of a physician should be done in the department where the privilege originated.19
Some privilege problems arise because other specialists do not understand the scope of family medicine. In addition to providing other specialists with general information about family medicine, family physicians on the medical staff or the family medicine department, if there is one, should consider addressing 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.
- A vital part of a family physician’s training is when to consult and when to refer patients.
- 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.
Quality assurance of didactic and procedural training in colposcopy is important and can be fostered through the AAFP prescribed credit mechanisms using expert physicians within the AAFP.
Expanding family physicians’ use of colposcopy results in improved access to timely care for patients. Primary prevention by 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 in the area of colposcopy privileging include better defining the competency-based measures required for performance of colposcopy and analyzing outcomes to compare clinical practices of all specialties.
- National Cancer Institute. Cervical Cancer. Retrieved December 2009 from http://www.cancer.gov/cancertopics/types/cervical(www.cancer.gov)
- The National Cervical Cancer Coalition. NCCC homepage. Retrieved December 2009 from http://www.nccc-online.org/(www.nccc-online.org)
- Campbell R, Ramirez A, Perez K, Roetzheim R. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med 2003;35:60-4.
- American Cancer Society. Key facts about cervical cancer. Retrieved December 2009 from http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-key-statistics(www.cancer.org)
- National Cancer Institute. Cervical Cancer. Retrieved December 2009 from http://www.cancer.gov/cancertopics/factsheet/Detection/Pap-test(www.cancer.gov)
- Olaniyan O. Validity of colposcopy in the diagnosis of early cervical neoplasia – a review. Afr J Reprod Health 2002;6(3):59-69
- Mayeaux E, Newkirk G. Introduction to colposcopy. Retrieved December 2009 from http://lib-sh.lsuhsc.edu/fammed/atlases/colpoat.html.
- American Cancer Society. New Screening Test Helps Women with Uncertain Pap Tests. Retrieved December 2009 from http://www.cancer.org/docroot/NWS/content/NWS_1_1x_New_Screening_Test_Helps_Women_with_Uncertain_Pap_Tests"/content/aafp/about/policies/all/joint-development.html">http://www.aafp.org/about/policies/all/joint-development.html.
- American Medical Association. Staff privileges E-4.07. In: AMA policy compendium. Protection of medical staff member’s personal proprietary financial information. Chicago, IL: American Medical Association; 2008 Retrieved December 2009 from http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_7a08.pdf(www.ama-assn.org).
- Joint Commission on Accreditation of Healthcare Organizations. 2009 Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organizations; 2009.
- American Academy of Family Physicians. Survey on procedural skills training. Leawood, KS: American Academy of Family Physicians; 2009. Retrieved December 2009 from http://www.aafp.org/online/en/home/aboutus/specialty/facts/64.html.
- American Academy of Family Physicians. Performance of colposcopy in hospital practices. Leawood, KS: American Academy of Family Physicians; 2009. Retrieved December 2009 from http://www.aafp.org/online/en/home/aboutus/specialty/facts/58.html.
- Schiffman M, Solomon D. Findings to date from the ASCUS-LSIL triage study. Arch Pathol Lab Med 2003;127(8):946-9.
- American Academy of Family Physicians-American College of Obstetricians and Gynecologists. Recommended curriculum guidelines for family practice residents: maternity and gynecologic care. Retrieved December 2009 from http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf(18 page PDF).
- American Academy of Family Physicians. Clinical proctoring. Retrieved December 2009 from http://www.aafp.org/about/policies/all/clinical-proctoring.html.
- American Academy of Family Physicians. Protocol for handling hospital privileges problems for family physicians who are medical staff members. Retrieved December 2009 from http://www.aafp.org/practice-management/administration/privileging/resolve-problems.html.
- American Academy of Family Physicians. Position on family medicine departments and privileges. Retrieved December 2009 from http://www.aafp.org/about/policies/all/privileges-family.html.
(B1998) (2010 COD)