• Colposcopy (Position Paper)

    Overview and Justification

    It is estimated that there are nearly 570,000 new cases of cervical cancer worldwide each year and that more than 311,000 women die from the disease.1 In the United States, the National Cancer Institute (NCI) estimated that 13,170 new cases of cervical cancer were diagnosed in 2019 and 4,250 women died from the disease.2 Currently, the five-year relative survival rate for localized cervical cancer is 91.8%; the overall (i.e., all stages combined) five-year survival rate is approximately 65.8%.2

    Cervical cancer was once one of the most common causes of cancer death among women in the United States3, but the annual incidence and mortality rate of cervical cancer have decreased significantly since the 1970s.4 One of the primary reasons for this decrease is the routine use of the Papanicolaou (Pap) test. A Pap test is a screening procedure that identifies changes in the cervix before cancer develops; it can also identify early stages of cancer. In addition, evidence has shown a significant decrease in cervical cancer incidence among young women in the United States following the introduction of human papillomavirus (HPV) vaccination in 2006.5

    According to cervical cancer screening recommendations from the U.S. Preventive Services Task Force (USPSTF), women 21 to 29 years of age should be screened for cervical cancer with cervical cytology (i.e., a Pap test) alone every three years.6 Women 30 to 65 years of age should be screened every three years with cervical cytology alone, every five years with high-risk HPV (hrHPV) testing alone, or every five years with hrHPV testing in combination with cytology (known as cotesting). The American Academy of Family Physicians (AAFP) supports the USPSTF’s recommendations.7

    In the United States, Pap tests are ordered or provided in approximately 22.6 million physician office visits each year and HPV testing is ordered in approximately 4.1 million visits.8 Although limited data are available on how many cervical cancer screening tests yield abnormal results, the National Breast and Cervical Cancer Early Detection Program reported that 3.3% of the first-round Pap tests provided through the program had an abnormal result.9 A study of more than 6,700 screening-compliant women 30 to 65 years of age found that 16.4% had an abnormal result, with 10.9% reporting an abnormal Pap test, 2.8% reporting an abnormal hrHPV test, and 2.7% reporting abnormal cotesting results.10

    Colposcopy is a procedure used to evaluate women at increased risk for cervical dysplasia, including those who have abnormal or inconclusive cervical cancer screening tests.11 It involves examining features of the cervical epithelium under magnified illumination after the application of normal saline, 3% to 5% dilute acetic acid, and Lugol iodine solution in successive steps.12 A green filter highlights vascular patterns. If abnormal tissue is present, biopsy sampling allows for a histologic diagnosis to distinguish a patient who requires treatment from one for whom cytological surveillance is appropriate.13 The American Society for Colposcopy and Cervical Pathology (ASCCP) estimates that hundreds of thousands of colposcopies are performed in the United States every year.13

    Section I - Scope of Practice for Family Physicians

    Family medicine is a specialty based on comprehensive care that encompasses a wide range of medical services. Family physicians practice among diverse populations and in geographically varied settings, including rural communities. They choose a personal scope of practice based on factors that include their training experiences, their practice interests, and the needs of their patient populations. Therefore, each family physician must assess the appropriateness of performing colposcopy by considering their training and level of comfort with the procedure, the expertise of staff members, their office setup, local standards of care, and economic implications.

    Broadly speaking, the following indicate that colposcopy is within the current scope of family medicine:

    • According to a 2018 AAFP member census, 12% of members perform this procedure in their practice.14
    • The AAFP’s recommended curriculum guideline on women’s health and gynecologic care specifies that family medicine residents should demonstrate the ability to apply knowledge of cervical dysplasia screening guidelines (including HPV), colposcopic evaluation, biopsy, treatment, and referral.15 Colposcopy is also listed as an advanced skill in obstetrics and gynecology that family medicine residents may wish to include in their practices.
    • The Society of Teachers of Family Medicine (STFM) Group on HospitalMedicine and Procedural Training includes colposcopy on its list of core procedures in family medicine that all residents must have exposure to and be given the opportunity to be trained to perform independently bygraduation.16
      • A task force of Council of Academic Family Medicine (CAFM) member organizations and experienced faculty and program directors published a consensus statement for procedural training in family medicine
      residency. It includes colposcopy as one of the procedures for which all family medicine residencies are expected to offer training, either as routine training for all residents (in more procedure-intensive programs) or as focused training in an elective experience offered to interested residents.17 The task force has also developed a procedure competency assessment tool (PCAT) for colposcopy that residency
      programs can use to assess the required technical and cognitive skills on a scale from novice level to expert level.18

    The AAFP advocates for the development and use of patient-centered, evidence- based clinical  practice guidelines that adhere to principles based on the National Academy of Medicine standards for trustworthy guidelines.19 When clinical practice guidelines address the issue of who should provide care, they should emphasize appropriate specific competencies rather than a clinician’s specialty designation.

    Section II - Clinical Indications for Colposcopy

    The main indication for colposcopy is the evaluation of women at increased risk for cervical dysplasia, including those with the following11:

    • Abnormal or inconclusive cervical cancer screening tests
    • Signs or symptoms of possible cervical cancer, including:
      • Suspicious cervical abnormality found during pelvic examination
      • Abnormal bleeding in the genital tract
      •  Unexplained cervicovaginal discharge
    • Treated or untreated past anogenital tract abnormalities (cytologic and/or pathologic)

    The 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors establish a 4% estimated immediate risk of cervical intraepithelial neoplasia (CIN) 3+ as the threshold for referral to colposcopy.20 The patient's risk of CIN 3+ (which includes CIN 3, adenocarcinoma in situ [AIS], and cancer) is determined by both history and current test results, and may be “due to HPV-positive ASC-US [atypical squamous cells of undetermined significance], HPV-positive low-grade squamous intraepithelial lesion or greater, HPV 16-positive NILM [negative for intraepithelial lesion or malignancy], a posttreatment  positive HPV test, or any other set of results predicting equally high risk.”21 If HPV testing or cotesting indicates HPV infection with low risk of underlying CIN 3+, the ASCCP guidelines recommend repeat HPV testing or cotesting after one year, with referral to colposcopy if the follow-up test results are abnormal.20

    Section III - Training Methodology

    The ASCCP defines a colposcopist as “a clinician who has undergone specialized training to develop proficiency in the performance of colposcopy and additional skills needed to accurately diagnose lower genital tract neoplasia. These skills must be accompanied by a comprehensive knowledge of the cervical cancer screening process, lower genital tract disease, and evidence-based management of abnormal screening and diagnostic tests.”11

    Family physicians most often acquire the skills and knowledge to perform colposcopy during their family medicine residency through didactic instruction followed by clinical preceptorship.11 AAFP policy states, “Family medicine residencies should strive to teach residents all procedures within the scope of family medicine. They should, at a minimum, teach residents those procedures commonly done by practicing family physicians both in the ambulatory and inpatient settings. Whenever possible, family physician faculty should teach these procedures to all interested  learners.”22

    Ideally, a family physician will continue a lifelong learning program that incorporates participation in intermediate and advanced colposcopy courses, which are offered by the 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.

    Section IV - Credentialing and Privileges

    Colposcopy is typically performed in private physician offices, academic centers, and community-based clinics. Currently, there is no national standard for the number of colposcopies required to demonstrate competence, nor is there a formal certificate or accreditation of competence for the procedure in the United States.23 The AAFP believes that privileging should be based on documented training and/or experience, demonstrated abilities and current competence, and, whenever possible, be evidence based.24 Physician privileging should allow for any and all combinations of competencies in adult, pediatric, and obstetric care in both inpatient and outpatient settings. The AAFP recommends that family physicians document all significant training and experience so that this information is recorded and can be reported in an organized fashion, if necessary.25

    The ASCCP has developed evidence-based colposcopy resources that may be useful for family  physicians who perform colposcopies and want to maintain and/or demonstrate their competence. In 2017, the ASCCP released a core set of evidence- based recommendations for U.S.  colposcopists to “provide guidance for colposcopy terminology, practice, and documentation and lay the groundwork for future quality improvement efforts.”13 The recommendations establish minimum and comprehensive colposcopy practice standards for six major components of the procedure: (1) precolposcopy evaluation; (2) the examination; (3) use of colposcopy adjuncts; (4) documentation; (5) biopsy sampling; (6) and postcolposcopy procedures.26 The minimum practice standards describe baseline requirements for performing a colposcopy adequately and safely.  Although this level of competence is acceptable for individuals who perform colposcopy  infrequently, the ASCCP states that most colposcopists in the United States should be able to practice at the comprehensive level.26

    Evidence suggests that new approaches to cervical cancer screening, updated colposcopy guidelines, and increased HPV vaccination have resulted in a downward trend in the number of  colposcopies performed, particularly those involving lesions associated with HPV 16, which are typically easier to visualize.27-29 Since family physicians are likely performing fewer colposcopies overall and a higher percentage of the colposcopies they perform are more challenging, a focus on quality improvement is key in training new colposcopists and helping existing colposcopists maintain proficiency. Therefore, the ASCCP has identified 11 quality indicators related to documentation, biopsy protocols, and follow-up intervals, with minimum and comprehensive target  percentages for each indicator.28

    Section V - Miscellaneous Issues

    • It is important for family physicians to receive high-quality didactic and procedural training in colposcopy. AAFP policy states, “The AAFP should seek to work collaboratively with other specialty societies, when appropriate, concerning issues of procedure skills, including but not limited to: training, privileging and credentialing, and joint political action.”30 Productive areas for research on colposcopy include improved definition of the competency-based measures for performance of
      colposcopy and analysis of outcomes in family medicine compared with other specialties. It would be ideal if the AAFP and other specialty organizations could work together to improve patient care by disseminating information to educate all physicians.
    • Primary prevention through risk factor identification and patient education is as important in reducing the prevalence of cervical cancer as secondary prevention through identification of cervical dysplasia at the time of colposcopy.
    • It is not known whether the performance of colposcopy by family physicians saves money and other resources at the societal level. However, it may offer the following benefits:
      • Identification of disease at earlier stages
      • Improved access to timely care for patients
      • Better continuity of care, which may support improved compliance with follow-up regimens
      • Increased knowledge of and attention to risk factors
      • Increased patient satisfaction
      • Improved access to the see-and treat approach (i.e., performing
        loop electrosurgical excision procedure [LEEP] at the time of the
        colposcopy visit), which can save patients time and decrease their
        anxiety about medical visits, lower costs, and reduce the risk of
        loss to follow-up, especially among transient populations and in
        settings with limited resources11,31,32

    Section VI - References

    1. International Agency for Research on Cancer. Cervix uteri. Accessed March 2, 2020. http://gco.iarc.fr/today/data/factsheets/cancers/23-Cervixuteri-
    fact-sheet.pdf

    2. National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER) Program. Cancer stat facts: cervical cancer. Accessed March 2, 2020. https://seer.cancer.gov/statfacts/html/cervix.html
    3. American Cancer Society. Key statistics for cervical cancer. Accessed March 2, 2020. https://www.cancer.org/cancer/cervical-cancer/about/keystatistics.html
    4. Committee on Practice Bulletins–Gynecology. Practice bulletin no. 168: cervical cancer screening and prevention. Obstet Gynecol. 2016;128(4):e111–e130.
    5. Guo F, Cofie LE, Berenson AB. Cervical cancer incidence in young U.S. females after human papillomavirus vaccine introduction. Am J Prev Med. 2018;55(2):197- 204.
    6. U.S. Preventive Services Task Force. Final recommendation statement. Cervical cancer: screening. August 2018. Accessed April 14, 2020.
    https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical- cancer-screening
    7. American Academy of Family Physicians. Clinical preventive services recommendation: cervical cancer. Accessed April 14, 2020.
    8. Centers for Disease Control and Prevention. National ambulatory medical care survey: 2016 national summary tables. Accessed April 14, 2020. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf
    9. Centers for Disease Control and Prevention, Division of Cancer Prevention and Control. National Breast and Cervical Cancer Early Detection Program: national report for program years 2003-2014. Accessed March 2, 2020. https://www.cdc.gov/cancer/nbccedp/pdf/nbccedp-national-report-2003-2014-508.pdf
    10. Chido-Amajuoyi OG, Shete S. Prevalence of abnormal cervical cancer screening outcomes among screening-compliant women in the United States. Am J Obstet Gynecol. 2019;221(1):75-77.
    11. Khan MJ, Werner CL, Darragh TM, et al. ASCCP colposcopy standards: role of colposcopy, benefits, potential harms, and terminology for colposcopic practice. J Low Genit Tract Dis. 2017;21(4):223-229.
    12. Sellors JW, Sankaranarayanan R. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual. International Agency for Research on Cancer; 2003.
    13. Wentzensen N, Massad LS, Mayeaux EJ Jr, et al. Evidence-based consensus recommendations for colposcopy practice for cervical cancer prevention in the United States. J Low Genit Tract Dis. 2017;21(4):216-222.
    14. American Academy of Family Physicians. Family medicine facts. Table 12: Clinical procedures performed by physicians at their practice (as of December 31, 2018). Accessed March 2, 2020. https://www.aafp.org/about/the-aafp/family- medicine-specialty/facts/table-12(rev).html
    15. American Academy of Family Physicians. Women’s healthand gynecologic care. Accessed March 2, 2020. https://www.aafp.org/dam/AAFP/documents/medical_education_residency/prog
    ram_ directors/Reprint282_Women.pdf

    16. Nothnagle M, Sicilia JM, Forman S, et al. Required procedural training in family medicine: a consensus statement. Fam Med. 2008;40(4):248-252.
    17. Council of Academic Family Medicine (CAFM). Consensus statement for procedural training in family medicine residency. Accessed March 2, 2020. https://afmrd.socious.com/d/do/966
    18. Council of Academic Family Medicine (CAFM). Procedure competency  assessment tool–colposcopy. Accessed March 2, 2020. https://www.afmrd.org/d/do/767
    19. Academy of Family Physicians. Joint development of clinical practice guidelines with other organizations. Accessed March 2, 2020. http://www.aafp.org/about/policies/all/joint-development.html
    20. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24(2):102-131.
    21. Schiffman M, Wentzensen N, Perkins RB, Guido RS. An introduction to the 2019 ASCCP risk-based management consensus guidelines. J Low Genit Tract Dis. 2020;24(2):87-89.
    22. American Academy of Family Physicians. Procedural skills, scope of training in family medicine residencies. Accessed March 2, 2020. https://www.aafp.org/about/policies/all/procedural-skills-scope.html
    23. Huh WK, Papagiannakis E, Gold MA. Observed colposcopy practice in US community-based clinics: the retrospective control arm of the IMPROVECOLPO Study. J Low Genit Tract Dis. 2019;23(2):110-115.
    24. American Academy of Family Physicians. Privileging policy statements. Accessed March 2, 2020. https://www.aafp.org/about/policies/all/privilegingpolicy.
    html

    25. American Academy of Family Physicians. Privileges, documentation of training and experience. Accessed March 2, 2020. https://www.aafp.org/about/policies/all/privileges-documentation.html
    26. Waxman AG, Conageski C, Silver MI, et al. ASCCP colposcopy standards: how do we perform colposcopy? Implications for establishing standards. J Low Genit Tract Dis. 2017;21(4):235-241.
    27. Landers EE, Erickson BK, Bae S, Huh WK. Trends in colposcopy volume: where do we go from here? J Low Genit Tract Dis. 2016;20(4):292-295.