Cervical cancer is easily preventable with routine screening and follow-up and is highly treatable when caught early.
In screening for cervical cancer, after an abnormal Pap test, the next critical step is a colposcopy. In this procedure, a clinician inspects the tissues of the vagina and cervix with a lighted magnifying device, or colposcope, and then takes samples (biopsies) from the most suspect areas for microscopic examination for abnormal cells.
"Traditionally, colposcopy has been taught through apprenticeship. The student and the experienced colposcopist look through the colposcope, the colposcopist describes the region-of-interest, or lesion, and the student forms a diagnostic impression of what is seen," says Dr. Alan G. Waxman. "You think 'Is the student seeing it the same way I am or not? And will it be perfectly the same the next time?'"
Waxman is professor of obstetrics and gynecology at the University of New Mexico, and serves as president of the American Society for Colposcopy and Cervical Pathology (ASCCP). He has taught colposcopy for more than 20 years.
For him, the challenge always has been to obtain high-quality, unambiguous, validated photos, with diagnoses of cervical lesions, to use for training. "To better diagnose and treat women whose Pap tests show abnormalities, the colposcopist must be able to differentiate among very subtle changes in the cervical tissue; to recognize patterns that correlate with cervical disease, and thereby determine where to biopsy the tissue to make the correct diagnosis," he says.
It is one of a suite of four tools underway in NCI's continuing effort to develop tools for cancer research, screening, and medical expert knowledge assessment and training. The others include the Boundary Marking Tool, which allows the manual identification of important regions in uterine cervix and other kinds of images; the Virtual Microscope, which enables the viewing and evaluation of cervix or other histology slides over the Internet; and the Multimedia Database Tool, which will allow query and retrieval of NCI images, along with their associated clinical text data.
"This has been a truly collegial approach to solving cancer; our engineers working side-by-side with our colleagues from NCI and the ASCCP experts," says George Thoma, CEB chief. "The Teaching Tool trains people to be as accurate as possible in interpreting what they see and to manage patients according to the ASCCP 2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Cancer Screening Tests guidelines. And what they see are real images of women with cancer or varying stages of pre-cancer, accompanied by diagnoses arrived at by expert consensus."
The Teaching Tool has a database of 500 questions organized into 16 different "pools." The questions have been developed by expert medical consensus. The exams are created dynamically, with questions pulled randomly from the question pools. Cervix image data and related clinical data for many of them come from two NCI studies: the four-year ALTS Triage Study cervical cancer clinical trial of 5,000 women, and the seven-year Guanacaste Project cohort study.
ALTS, with its 40,000 cervical images, was done to find the best way to help women and their doctors decide what to do about the mildly abnormal and very common Pap test results known as ASCUS and LSIL. The Guanacaste Project generated some 60,000 cervical images, along with thousands of associated histology and Pap smear images, on about 10,000 women in Guanacaste, Costa Rica, a region with high incidence of cervical cancer.
"The tool has opened a new universe of images for this field," notes Rodney Long, the NLM electronics engineer leading the collaborative development team. "The visual information can be very subtle but that's what experts need to know, and what the training is all about."
The Teaching Tool was put into operation as the ASCCP Online Exams System in May 2010. By March 2012, these self assessment examinations based on the Teaching Tool have been given more than 900 times. Users of the Colposcopy Mentorship Exam include physicians, nurse practitioners, physician assistants and nurse midwives. Residents in obstetrics and gynecology, and family medicine from 95 residency programs have taken the Residents' Online Exam. Participating residency programs include those from the Mayo Clinic; the National Capital Center Uniformed Services; Tripler Army Medical Center; University of Colorado; the University of Texas Southwestern Medical Center; Stamford Hospital at Columbia University; George Washington University; the University of Virginia; the University of New Mexico; Baylor College of Medicine; the University of Puerto Rico; and the University of Toronto.
The exams are organized into three sections: multiple choice, slide ID, and cases. Examples of questions include: "What is my diagnosis? Where would you take a biopsy? and How would you manage this patient based on the biopsy?" Waxman considers the case questions to be the exams’ centerpiece.
The system administers and automatically scores both the Residents’ Online Exam (ROE) and the Colposcopy Mentorship Program (CMP) Exam. The ROE is taken annually by participants in four-year Ob/Gyn or three-year Family Practice programs, and the Teaching Tool tracks exam performance of the resident across program years. The CMP Exam is part of the third and final tier of the ASCCP’s program in basic colposcopy education. A third examination using the Teaching Tool, the Colposcopy Recognition Award is currently in development. This exam will recognize advanced colposcopy proficiency.
"The Teaching Tool simulates the real world; when to take a biopsy and how to manage the patient based on that biopsy," says NCI senior investigator Dr. Mark Schiffman. CEB chief Thoma credits Schiffman with initiating the collaboration with NLM and ASCCP to develop the new software tools.
Reflecting the downward trend in US cervical cancer cases, Schiffman points to a shift over the last 20 years toward training Advance Practice Clinicians -- nurse practitioners, certified nurse midwives, physician assistants - in colposcopy. The ASCCP administers a three-tiered curriculum, including four days of colposcopy lectures and workshops; a one-year "hands on" mentorship requiring at least 35 directly supervised colposcopies, and, if the student is deemed ready, the final CMP Exam.
"This is where the Teaching Tool comes in, and also as a self-assessment exam for practicing clinicians. It's a boon to medical education," Schiffman declares. "Translated into Spanish and French, for example, it could be really helpful in cervical cancer screening in underserved areas of the world, such as Africa. Just imagine the public health impact."