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

2. 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

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

4. 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 women).

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

6. 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.

7. 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).

8. 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.

9. 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

10. 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

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

12. 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

13. 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

14. 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

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

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

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

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

19. 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

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

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

22. 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 – 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

23. 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

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

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

26. 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

27. 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.

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

29. 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

30. Summary:
Fight against Cevical Cancer is impossible without Screening Program

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

32. 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.

33. 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.

34. Thank you !