“The challenges of colposcopy in Eastern Europe and Central Asia” Alibegashvili Tamar Antalya 19.05.2017

Eastern Europe and Central Asia EECA region Albania Armenia Azerbaijan Belarus Bosnia Hercegovina Bulgaria Georgia Kazakhstan Kyrgyzstan Macedonia Republic Moldova Russian Federation Romania Serbia Tajikistan Turkey Turkmenistan Ukraine Uzbekistan

GLOBOCAN 2012 of Cervical Cancer ≈18,000 deaths from Cervical Cancer ≈38,000 new cases of Cervical Cancer ≈18,000 deaths from Cervical Cancer

New Cases & Deaths from Cervical Cancer in the Countries of the EECA Region Compared to Finland – Globocan 2012 If we take a look at the chart of incidence and death from cervical cancer, we see that lowest figures are that of Turkey and Albania (5:100000) and highest numbers of new cases are in Romania, Kazakhstan, Bulgaria and Kirgizstan (from 25- to 30 cases on 100.000 women).

Cervical Cancer Screening in EEAC countries CC Screening is opportunistic (Exc. Serbia) No centralized data collection, reporting, monitoring and analyses of results

Cervical Cancer Screening in EEAC countries CC Screening is opportunistic (Exc. Serbia) No centralized data collection, reporting, monitoring and analyses of results Coverage of population is low (≈15-20%) Number of detected precancerous lesions is low Number of new cases of advanced cancer and mortality is high.

Cervical Cancer Screening in EEAC countries CC Screening is opportunistic (Exc. Serbia) No centralized data collection, reporting, monitoring and analyses of results Coverage of population is low (≈15-20%) Number of detected precancerous lesions is low Number of new cases of advanced cancer and mortality is high. Mainly Cytology (Pap test) Screening No established Quality control. Old classification - Papanicolaus classes (Ukraine, Belarus) HPV test as a triage test is used very occasionally. VIA screening (Tajikistan).

Cervical Cancer Screening in EEAC countries CC Screening is opportunistic (Exc. Serbia) No centralized data collection, reporting, monitoring and analyses of results Coverage of population is low (≈15-20%) Number of detected precancerous lesions is low Number of new cases of advanced cancer and mortality is high. Mainly Cytology (Pap test) Screening No established Quality control. Old classification - Papanicolaus classes (Ukraine, Belarus) HPV test as a triage test is used very occasionally. VIA screening (Tajikistan). Most countries do not have National Guidelines for Cervical Cancer Screening.

Colposcopy in EEAC countries Role of Colposcopy: Exclude the normal cervix Identify the most suitable area for direct biopsy Detect Invasive Cancer Identify the type of TZ Make management decision Guide treatment Estimate the severity of underlying disease

Colposcopy in EEAC countries No enough number of well-trained colposcopists No appropriate technical equipment (colposcope, other instruments) Absence of colposcopy training program (Albania, Bosnia-Hercegovina), or poor quality program

How to improve the quality of colposcopy: Standardized equipment of Colposcopy clinic binocular colposcope endocervical speculum punch biopsy forceps etc.

How to improve the quality of colposcopy: Standardized equipment of Colposcopy clinic binocular colposcope endocervical speculum punch biopsy forceps etc. Colposcopy Handbook on native language

How to improve the quality of colposcopy: Standardized equipment of Colposcopy clinic binocular colposcope endocervical speculum punch biopsy forceps etc. Colposcopy Handbook on native language National Colposcopy Society

How to improve the quality of colposcopy: Standardized equipment of Colposcopy clinic binocular colposcope endocervical speculum punch biopsy forceps etc. Colposcopy Handbook on native language National Colposcopy Society Integration of National Society in the International Organizations (EFC, IFCPC) European Federation for Colposcopy & Pathology of the Lower Genital Tract International Federation for Cervical Pathology and Colposcopy

How to improve the quality of colposcopy: International conferences and Colposcopy courses

How to improve the quality of colposcopy: International conferences and Colposcopy courses Establishment of own Colposcopy training courses

How to improve the quality of colposcopy: International conferences and Colposcopy courses Establishment of own Colposcopy training courses High quality pathology service CIN2

International Training Program in Colposcopy and Cervical precancer Management IFCPC/UNFPA EECARO program

International Training Program in Colposcopy and Cervical precancer Management IFCPC/UNFPA EECARO program Theoretical knowledge 25 lectures delivered online with mandatory questions and answers after each lecture Image recognition skills 50 images with specific colposcopic characteristics   Case management skills 100 video cases, each with online questions and answers, again delivered on line Colposcopy cases seen under supervision Direct supervision of 50 cases in a colposcopy clinic with 10 high grade cases. Colposcopy cases seen without direct supervision Submission of 100 colposcopy cases details to nominated trainer for review Exit Assessment on completion of training OSCE

(Training of trainers) International Training Program in Colposcopy and Cervical precancer Management IFCPC/UNFPA EECARO program (Training of trainers) Lyon, IARC, 23.07.2016

Population of Georgia ~ 3 800 000 Cervical Cancer (CC)– the second most spread malignancy after Breast Cancer CC incidence ~ 17.7/100 000 Annually ~ 340 new cases CC

Cervical Cancer Screening Program in Georgia CC screening was initiated in 2008 Screening is based on the conventional Pap test (Bethesda system 2001) Target ages – 25-60 years Screening interval – 3 years Screening is opportunistic (From 2016 the pilot project of organized screening in Tbilisi and Gurjaani region) All women with abnormal Pap and suspicions for High Grade Lesion are referred to colposcopy

From 2007 GSCPC is a member of EFC GSCPC was founded in 2007 From 2007 GSCPC is a member of EFC EFC and IFCPC Colposcopy Basic Courses in 2008, 2010, 2013 Two doctors form Georgia with support from the EFC and BSCCP had 2 weeks colposcopy training in UK GSCPC was founded in 2007. The main goals of Society: To distribute a right knowledge regarding Prevention Cervical Cancer. From 2007 GSCPC is a member of EFC EFC and IFCPC Colposcopy Basic Courses were held in Georgia in 2008, 2010, 2012

GSCPC composed guidelines for Screening and diagnostic of Cervical Cancer based on Pap test, published in 2010 24

International Classification of Diseases – ICD10 N86 Erosion and ectropion of cervix uteri  Applicable to decubitus (trophic) ulcer of cervix Eversion of cervix

In 2011 GSCPC one month training course was recognized by the Council of Continuing Professional Development and approved by Ministry of Health Georgia. Colposcopy findings Number Low grade cervical lesion ( LSIL, CIN1) 60-80 High Grade cervical lesion (HSIL, CIN2,3) 20-25 Normal colposcopy findings (ectopy, Normal transformation zone) Miscellaneous findings (polyps, inflammation, atrophy, CTZ) Invasive Cervical Cancer 1-5

Course also contains: 1 Training in LEEP, 2. Theoretical lectures, 3. Discussion of coploscopy picture patterns on the base of Colposcopy Atlas CD. Final assessment of trainee: 1. Post training questionnaire 2. Independent clinical examination of 20 patients.

Accuracy of Colposcopy for detection of different histological diagnosis (Analysis of 800 LEEP in 2011-2016 GNSC) Histology Sensitivity % Specificity % PPV % NPV % Normal 56 99 61 94 CIN1 88 77 CIN2+ 84 70 78 76 ALL 72 86 83

Accuracy of Colposcopy for detection of CIN2+ (Analysis of 800 LEEP in 2011-2016 GNSC) Referral Pap Sensitivity % Specificity % PPV % NPV % HSIL 84 73 92 58 ASC-H 81 80 79 82 LSIL 50 67 66 ASCUS 51 60

Summary: Fight against Cevical Cancer is impossible without Screening Program

Summary: Fight against Cevical Cancer is impossible without Screening Program Screening Program is impossible without High quality Colposcopy.

Summary: Fight against Cevical Cancer is impossible without Screening Program Screening Program is impossible without High quality Colposcopy. High quality Colposcopy is impossible without good equipment and trained colposcopists.

Summary: Fight against Cevical Cancer is impossible without Screening Program Screening Program is impossible without High quality Colposcopy. High quality Colposcopy is impossible without good equipment and trained colposcopists. Any woman attending a doctor or nurse colposcopist should expect a minimum standard of both knowledge and competence.

Thank you !