Although the basic technique has remained unchanged, the practice of colposcopy has evolved tremendously over the past half century. The sensitivity of colposcopy for the detection of high-grade cervical intraepithelial neoplasia was estimated to be 85% in a meta-analysis of studies from 1960 to 1996.1 In the 1980s, colposcopic grading became popular as a way of applying scientific method and critical analysis to a technique that had relied primarily on pattern recognition and expertise developed through experience.2 In the 1980s, colposcopy began to be taught universally in obstetrics and gynecology residency training programs. In the 1990s, the American Society for Colposcopy and Cervical Pathology, under the leadership of Tom Sedlacek, began teaching colposcopy to nongynecologists, including family practice physicians, nurse practitioners, physician assistants, and others. As more community practitioners began preforming colposcopy, colposcopy became decentralized; and the large colposcopy clinics that served as the training grounds for the previous generation of colposcopists began to disappear. This was highlighted in a 2001 survey of residency program directors that reported the limited experience available in colposcopy at some residency training programs.3
Cervicography is a technique developed by Adolph Stafl that uses a proprietary camera to take high-resolution colpophotographs that could be transmitted to expert colposcopists for interpretation.4 Several authors studied the use of cervicography as an intermediate triage test for ASC-US Papanicolaou tests and as a supplement to cytology screening, but it was soon superseded by human papillomavirus testing, which was a much more sensitive and specific tool. Cervicography became an excellent and easy-to-use tool for colpophotography and was used in the ASCUS/LSIL Triage Study for Cervical Cancer and reused in subsequent studies.
By the mid-2000s, everything had changed. Newer studies reported that the sensitivity of colposcopy for the detection of high-grade lesions was only 54% to 57%5,6; colposcopic grading systems were shown to be poorly reproducible, even among experts,7,8 and colposcopists with experience and expertise did not identify high-grade lesions as well as less experienced colposcopists who just took more biopsies or even random biopsies.6,9,10 Tom Cox, then president of the American Society for Colposcopy and Cervical Pathology, wrote an editorial trying to explain these findings and suggested that the cause of low colposcopic sensitivity was small high-grade lesions being identified by ever more sensixtive screening tests. He said that these small lesions, of unknown premalignant potential, pushed the limits of detection by colposcopy and predicted that “eventually, new procedures or tests that are better equipped to triage at-risk women identified by increasingly sensitive tests may replace the (traditional) colposcope.”11
Well, those days are rapidly approaching. Researchers and developers are using technology, miniaturization, computing power, and “big data” to develop tools that seek to improve the detection of significant high-grade lesions compared with traditional colposcopy. Among the approaches are the use of high-definition imaging and monitors; the use of computer algorithms that measure the development, fading, and intensity of the acetowhitening effect; or through computer analysis of a combination of optical and multispectral signals to identify potential biopsy sites. Other groups have sought to make the colposcope cheaper and more portable and to use cloud technology to bring colposcopy within the reach of low-resource settings. Two papers in this issue of the Journal report on the application of colposcopic technology within low-resource settings.
Low-resource settings lack the health infrastructure and trained personnel to read cytology or perform colposcopy, and they do not have the funding to afford human papillomavirus testing. Without organized screening programs, cervical cancer is not detected in the precancerous state. Furthermore, the population of these countries is often at a distance from their source of care; and with poor access to transportation, women who are screened and tested are frequently lost to follow-up. Recent World Health Organization guidelines recommended a “screen and treat” approach using visual inspection with acetic acid (VIA) in such settings.12 The procedure for VIA involves a naked eye observation of the cervix before and 2 minutes after the application of 3% to 5% acetic acid, and following the application of Lugol’s iodine. Suspicious lesions undergo biopsy; and occasionally, the cervix is treated in a “see and treat” approach. In this issue of the Journal, 2 different papers reported on their experience with colposcopic images obtained using a digital camera to record and evaluate VIA images. Manga et al.13 reported on their experience in Cameroon, used a commercial brand digital camera equipped with a macro–conversion lens to project 30× magnified real-time images onto a TV monitor visible to both patient and examiner. Photographs were archived for follow-up comparison, staff training, consultation, and quality improvement. Ricar-Gauthier et al.,14 who reported on their experience in Madagascar, used a commercially available smartphone to record and evaluate the VIA images. The on-site gynecologist did not use the smartphone photos to establish a diagnosis, but the subsequent off-site review suggested that 95.6% of the images were very good or acceptable for interpretation, and that they increased the sensitivity for the detection of cervical intraepithelial neoplasia grade 2 or higher. Although studies in the United States demonstrated the limitations of interpreting colpophotographs, this may not be true for the VIA photography. The ability to magnify the VIA image, show it to other more experienced practitioners either on-site or online to an off-site expert consultant, to use the images to increase the slope of the learning curve for new staff, and to perform quality control for established staff all represent a major advance. The fact that this can all be obtained for the price of a digital camera or smartphone puts this technology within the reach of even the poorest country. Therefore, in low-resource settings, the technological future is here. Technology has allowed underdeveloped countries to leapfrog past some of their economic and logistical limitations. What is left is the hard part of implementation. Protocols need to be developed, staff needs to be trained, but the payback promises to be great for those low-resource settings that embrace this new technology. The women in these countries will be the big winners.
What about the developed countries? Anyone who remembers their aching back bending over a laparoscope or the poor quality of the image through the cumbersome teaching heads that were used in laparoscopy and hysteroscopy clearly understands the impact that the “video revolution” has had on endoscopic gynecology. The mere fact that both the operator and the assistant are able to comfortably see the same image of the operative field allows surgical cooperation and coordination, which in turn allows the surgeon to undertake more complex procedures through the endoscope. When the attending physician and the resident physician see the same image of the operative field, the attending physician is able to guide the resident physician while making sure that the patient remains safe. An attending physician who can clearly see that the procedure is being done correctly will allow the resident physician to do more, and the resident physician in turn will learn more and gain the confidence to perform those endoscopic procedures when they complete their training. As more endoscopic procedures are done, economic forces encourage industry to develop more sophisticated technology, which has brought us robotics and an endless array of endoscopic instruments.
Monitors are second nature to today’s residents. Laparoscopy, hysteroscopy, and sonography are all viewed on a monitor. Yet, early attempts at video colposcopy never really succeeded. Perhaps it was the low-quality images or the difficulty in focusing under magnification, but most colposcopy today is still done through an optical colposcope. Assuming that digital colposcopy can produce a well-focused, high-resolution image on a high-definition monitor, digital colposcopy has many potential advantages compared with optical colposcopy. Colposcopic images could be permanently recorded in the medical record. This would be a significant advance compared with line drawings currently used in paper or even electronic records. Images would also be available for research. Both the supervising colposcopist and several residents would be able to simultaneously view the same colposcopic image. This would multiply the limited experience that is available in many training programs today. The image could even be transmitted to a second room or observed at a later date in conference so that the number of observers in the examination room could be kept to a minimum. This would help preserve the patient’s dignity. When necessary, images could be broadcast to a remote location either in real time or for later viewing by an expert. Computer learning, using “big data” to analyze histology/image correlation, multispectral signals, or other technological advances may allow the “digital colposcope” to suggest biopsy sites that are not evident by optical colposcopy alone. Furthermore, performing procedures viewed through a video monitor is second nature to today’s resident physicians. Looking through an optical instrument such as a colposcope or a microscope is new to them. Moving colposcopy to the digital age may allow them the comfort level to more rapidly assimilate the skill.
The era of digital colposcopy will be here soon. It will be exciting to see what the future has to offer.
Mark Spitzer, MD
Department of Obstetrics and Gynecology
Hofstra North Shore-LIJ School of Medicine
and Senior Associate Editor
Journal of Lower Genital Tract Disease
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