Plus ça change. CWE Redman Colposcopy Symposium, ECC 2016

Transcription

1 Plus ça change. CWE Redman Colposcopy Symposium, ECC 2016

2 UHNM

3

4 What we know HPV primary screening coming More sensitive: more HSIL detected Increase in workload Longer consultations More anxiety

5 HPV Primary Screening Protocol Algorithm All women aged on routine call/recall and early recall HR-HPV Test HR-HPV -ve Routine recall 3y(25-49) 5y( 50) HR-HPV +ve Cytology triage Cytology normal # Cytology abnormal borderline or worse Re-screen in 12m Colposcopy referral HR-HPV -ve HR-HPV +ve Routine recall 3y(25-49) 5y( 50) Cytology normal # Re-screen in 12m Cytology abnormal borderline or worse Colposcopy referral HR-HPV -ve HR-HPV +ve # Routine recall 3y(25-49) 5y( 50) Colposcopy referral

6 HPV Primary Screening Pilot Colposcopy Management Recommendations Algorithm DRAFT Version 2.0 Aug 2014 Colposcopy Examination Inadequate Normal and adequate Index HR-HPV +ve - cytology low grade Index HR-HPV +ve - cytology high grade No biopsy or biopsy <CIN1 Abnormal Biopsy CIN1+ Manage according to abnormal colposcopy examination Repeat colposcopy in 12m LLETZ Index HR-HPV+ve/ cytology low grade Index HR-HPV+ve/ cytology high grade Consider LLETZ patient choice Discharge to 3y recall Discussion at MDT within 2m

7 Performance

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9 Acetowhitening Metaplasia CIN3 Density

10 Comment about spectrum The most benign condyloma and most worrisome intraepithelial neoplasia are linked by a spectrum of continuous morphological change

11 Colposcopy as a test Colposcopy compares favourably with other diagnostic tests Average Sensitivity = 85% Average Specificity = 65% Papers Mitchell et al Obstet Gynecol 1998;91: A meta-analysis

12 More recently Punch Biopsy Excision Biopsy CIN2+ Cutoff Sensitivity Specificity CIN2+ 80% 63% Sensitivity increases with number of biopsies Underwood et al BJOG 2012;119: A meta-analysis

13 Colposcopy as a test Lower performance in more recent studies Sensitivity 50-60% PPV 60% ALTS Group Am J Obstet Gynecol 2003; 188: Pretorius et al Am J Obstet Gynecol 2004; 191: Bekkers et al Eur J Obstet Gynecol Reprod Biol 2008; 141; 430-4

14 Context Older studies had higher prevalence HG smears Association with larger lesions Increase in low-grade referrals Test performance influenced by prevalence

15 Scope for improvement? Dynamic Spectral Imaging System (DySIS) Electric Impedance Spectroscopy (EIS) Optical Coherence Tomography Biomarkers

16 DySIS Greater sensitivity than conventional colposcopy

17 Epitheliometer APX 100

18 Electrical Impedance Spectroscopy Conventional colposcopic sensitivity = 88% (80-94) Significantly improves colposcopic performance (ROC curve AOC =0.887 cf in Mitchell s paper) Performance profile can be adjusted Tidy et al Br J Obstet Gynaecol 2013:120;400-11

19 Managing Capacity

20 Number of referrals Referrals trend 24,000 22,000 20,000 Implementation of LBC Reduced number of inadequate rate and non urgent referrals Jade Goody effect Implementation HPV testing 21,163 20,405 19,944 19,289 19,279 18,000 17,899 17,863 16,000 14,000 14,111 13,070 13,652 13,230 15,031 14,909 13,556 13,946 13,908 15,345 16,386 14,158 14,306 14,344 12,000 11,423 11,856 11,118 10,000 9,885 8,485 8,765 10,139 9,821 9,608 8,000 6,000 4,000 2, / / / / / / / / / /16 Year East Midlands West Midlands East of England 20 Midlands and East colposcopy update Operated by Public Health England

21 Number of Referrals Combined colposcopy workload 2015/16 Clinical Indications Urgent West Midlands increase 25.5% (1,178 in 2015/ in 2014/15) East Midlands decrease 2.4% (842 in 2015/ in 2014/15) East of England increase 8.2% (1,403 in 2015/16 1,297 in 2014/15) / / / / / / /16 Year West Midlands East Midlands East of England Midlands and East colposcopy update Operated by Public Health

22 NHSCSP pathway (2011) (a) BORDERLINE CHANGE OR LOW-GRADE DYSKARYOSIS HIGH-GRADE DYSKARYOSIS with treated CIN HPV -ve HPV +ve COLPOSCOPY No repeat cytology BORDERLINE CHANGE OR LOW-GRADE DYSKARYOSIS with negative colposcopy (no biopsy or biopsy with no CIN) CIN1 CIN2/3 No treatment Treatment (b) Cytology at 12 months with or without colposcopy (local preference) (c) Cytology at 6 months Normal, borderline change, or low-grade dyskaryosis High-grade dyskaryosis HPV ve HPV +ve Routine 3- or 5-year recall (depending on age <50 or 50) (d) 3 year recall Normal cytology: routine 3- or 5-year recall (e) COLPOSCOPY Treat or follow-up, according to national guidelines

23 Jun11 Sep11 Dec11 Mar12 Jun12 Sep12 Dec12 Mar13 Jun13 Sep13 Dec13 Mar14 Jun14 Sep14 Dec14 Mar15 Jun15 Sep15 Dec15 Mar16 Percent Follow up appointments trend analysis UPDATE October 12: Implementation of HPV testing at the Royal Derby Hospital laboratory April 2012: Implementation of HPV testing at the University Hospital of North Staffordshire laboratory 0 Robert Peel UHNM Royal Stoke County Hospital, Mid Staffordshire Queen's Hospital, Burton 23 Presentation Midlands and title East - edit colposcopy in Header update and Footer Operated by Public Health England

24 Quality Assurance

25 Jun11 Sep11 Dec11 Mar12 Jun12 Sep12 Dec12 Mar13 Jun13 Sep13 Dec13 Mar14 Jun14 Sep14 Dec14 Mar15 Jun15 Sep15 Dec15 Mar16 Percent Punch biopsy rate at first visit trend analysis UPDATE October 12: Implementation of HPV testing at the Royal Derby Hospital laboratory March 12: Implementation of HPV testing at the Pathlinks laboratory 10 0 Pilgrim Hospital Boston UHNM Royal Stoke Royal Derby Hospital Queen's Hospital, Burton 25 Presentation Midlands and title East - edit colposcopy in Header update and Footer Operated by Public Health England

26 West Midlands procedure at first attendance low grade referrals No treatment Diagnostic biopsy (punch) Excision Other 8.5% 3.6% 0.4% 51.1% 14.3% 87.9% 48.9% 85.3% Clinic A Clinic B Clinic C 26 Presentation Midlands and title East - edit colposcopy in Header update and Footer Operated by Public Health England

27 % excisional treatments containing CIN2+ 110% 105% Proportion of excisional treatments performed at first visit with subsequent histological outcome of CIN2+ 110% 105% Proportion of excisional treatments performed at subsequent visit with an histological outcome of CIN2+ 100% 95% 90% 85% 80% 75% 70% O 65% 60% 55% 50% 45% 40% 35% M A N S B C P L G H K R E J F 1,132 treatments at first visit Average CIN2+ = 88.3% 30% Number of excisional treatments performed Q I D 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% P O M H B C K G A J F L S Q N E R I 1,200 treatments at subsequent visit Average CIN2+ = 77.2% 30% Number of excisional treatments performed

28 Summary Management of capacity Adjunctive colposcopic technology Proactive Quality Assurance Systematic pre-emptive education

29 Thank you!