This issue of the Journal of Lower Genital Tract Disease contains the new ASCCP Colposcopy Standards. These comprehensive standards are evidence based and fill an important gap for clinicians managing women with abnormal cervical cancer screening tests. Since 2001, when the ASCCP first developed their consensus guidelines for managing women with abnormal screening results or biopsy-confirmed cervical disease, we have had evidence-based guidelines to help us determine which women require colposcopy and when repeat colposcopy should to be performed. Inherent in the management guidelines was the assumption that colposcopy is a standard procedure that is performed in a uniform way. This is far from what actually occurs in the United States. Each year in the United States, hundreds of thousands of colposcopies are performed by a wide spectrum of clinicians that include advanced practice clinicians, family practice physicians, gynecologists, gynecologic oncologists, and even some internists and pathologists. Some colposcopists perform only a few procedures on a monthly or even yearly basis, whereas others perform colposcopy on an almost daily basis. There also is considerable variation among colposcopists in training and experience. Some have only limited training in colposcopy obtained during their residency, whereas others take basic and advanced colposcopy courses, join the ASCCP, attend conferences, and even participate in the ASCCP's Comprehensive Mentorship Program. Some countries such as the United Kingdom have addressed this issue by limiting the practice of colposcopy to a select group of clinicians with specialized training who participate in a comprehensive quality assurance program. Given the lack of a single payer health care system in the United States, the lack of a national screening or precancer registry, and the need to provide colposcopy services throughout the entire United Sates, it is unlikely that limitations will be placed on who can perform colposcopy. Given the variability in case load experience and training among colposcopists in United States, it is important that practice recommendations be developed to promote competence. The publication of the ASCCP Colposcopy Standards is an important step forward in assuring that quality colposcopy is available to all women.
Today, we have a much better understanding of the limitations of colposcopy than we had in the past. Numerous well-conducted studies have shown us that both accuracy and reproducibility of colposcopy is not nearly as good as previously thought. The expert group working on the ASCCP Colposcopy Standards identified 3 factors that might be impacting the performance of colposcopy in the United States. One is the lack of a standardized terminology for colposcopy. This has become increasingly important given that the terminology adopted by the International Federation of Cervical Pathology and Colposcopy varies in several important ways from the terminology used by most US-based colposcopists. The new colposcopy standards provide a standardized terminology so that US colposcopists can communicate without confusion. A second factor is the lack of recommendations on how to actually perform colposcopy on a given patient. A number of standard textbooks provide a general description of what a colposcopy entails, but there is considerable variation between the textbooks as well as among “experts” in colposcopy in what constitutes best practice. Added to this confusion is the recognition that a colposcopy does not necessarily need to follow the same format in all women. We have used risk-based guidelines for over a decade, which stratify management of abnormal screening tests based on a woman's risk of having cervical intraepithelial neoplasia 3. It seems obvious that our approach to colposcopy should also be based on risk. Given the large number of colposcopies performed on women with a relatively low risk of cervical intraepithelial neoplasia 3, the new practice recommendations are an important step forward. The third factor limiting the performance of colposcopy in the United States is the lack of quality assurance measures. All colposcopists share a common goal, which is to provide high-quality care to their patients. Performance measures are an integral component of determining how well we are achieving our goal. The development of quality assurance measures for colposcopy is the first step in allowing us to measure our performance.
The ASCCP Colposcopy Standards are an important step forward, but they do not address all the issues that colposcopists must deal with to maximize disease ascertainment. They do not include recommendations on how to obtain an adequate endocervical curettage, and the standards only apply to the cervix. We also need standards for examining the vagina and vulva. In addition, only after they are introduced into routine clinical practice will we learn if the recommended quality measures are practical and useful. Once it has been shown that adherence to the new standards and quality measures actually improve clinical care, it may well be desirable for that some form of certification of colposcopists to become available in the United States.