Colposcopy is a critical triaging investigation in the assessment, diagnosis, and management of women with positive cervical screening tests.13 However, colposcopy typically is not available in a primary care setting, and in many LMICs, the alternative is to visualize the cervix with the naked eye after application of acetic acid and Lugol’s iodine, which may result in missed diagnoses.14,15 Indeed, the sensitivity of triaging with VIA/VILI in detecting high-grade cervical lesions among HPV-positive women has been reportedly suboptimal.15,16 A key role of colposcopy in cervical screening continuum is assessing the type of transformation zone and guiding treatment. Studies have reported higher residual disease after excisional treatment (positive excision margin) when treatment was performed without colposcopic guidance.17,18 Further, colposcopy evaluation of screen-positive women has proven to reduce the rate of overtreatment, thereby increasing the effectiveness of screening programs.19,20 Limited resource settings should be enhanced to provide quality healthcare, particularly when specialized physicians are lacking. Priority interventions include task-shifting and provision of more simple and cost-effective equipment for diagnosis and management of conditions of public health concern. Our findings that 12.6% of clinicians involved in cervical cancer prevention activities in Africa had been trained at performing colposcopy highlight the lack of skilled colposcopists in the region.
While organizing colposcopy training courses is an effective way to strengthen the diagnostic ability of colposcopists,11 setting-up these courses in practice may be challenging and difficult to scale. Therefore, distant continuing educational programs where expert colposcopists review cervical images of women screened for cervical cancer provide an opportunity for providers in LMICs to increase their experience and competence in accurately performing colposcopy.10,12 While harmonized diagnostic standards and quality control procedures for colposcopy practice are released by relevant professional organizations,13 many colposcopists in LMICs, because they lack adequate training, do not rigorously apply colposcopy guidelines in their practice, which leads to unharmonized reporting of colposcopy examinations.
The clinical performance of colposcopy depends on the training and experience of colposcopists and the clinical setting, from basic to referral facilities.21 When practiced by competent hands, colposcopy is more accurate and may barely miss severe disease, while it can lead to false-positive results when performed by less experienced providers. These weaknesses of colposcopy can be overcome by adequate training, continuing practice, and quality assessment.10,22 Although only one in eight clinicians in our study sample had been trained to perform colposcopy, 50% of respondents reported that their knowledge about colposcopy was adequate for their clinical practice. This finding suggests that colposcopy is not considered by many African providers as a procedure that requires specific training, which is a matter of concern as it may have implications on the effectiveness of cervical cancer prevention programs in LMICs.
The use of digital colposcopes as an alternative to optic colposcopes may help improve access to cervical cancer screening and early detection.23 Previous studies found that certain digital colposcopes perform comparably to stationary colposcopes,24 including when performed by mid-level providers like nurses.25,26 While the feasibility and accuracy of portable colposcopes in LMICs have been reported, their effectiveness in routine clinical practice is yet to be proven, especially to triage HPV positive women.27,28 The relevance of building capacity to perform colposcopy in African countries with high HIV prevalence has significantly increased after the publication by the World Health Organization (WHO) in 2021, of the new guidelines for cervical cancer screening and management.29 This guideline recommended that all women living with HIV and tested positive for HPV require triaging with VIA, cytology, or colposcopy.
In our model, frontline clinicians (including nurses) are trained to perform VIA and basic colposcopy.10,11 Colposcopy in our study sample was used for routine cervical screening, to better visualize the transformation zone, and to determine treatment modality in screen-positive women. The practicability of colposcopy performed by trained PHPs using a portable colposcope implies that more women in LMICs can access colposcopy, especially in remote areas.
Considering the dearth of providers skilled to perform colposcopy in Africa, a strategy with HPV testing followed by optic colposcopy may result in delays in early detection and increase the risk of lost-to-follow up. Therefore, portable colposcopy performed by trained nurses can be offered in the same setting where HPV testing is done and much earlier than a referral to a physician. While colposcopy practice has been limited to medical doctors in most LMICs, our experience shows that PHPs supervised by experienced gynecologists can perform colposcopy with little side effects.10,11 In our program, capturing of cervical images with colposcopes and other digital equipment helps train PHPs through e-learning sessions (case-based presentation complemented by the review of cervigrams). Moreover, colposcopy with portable devices can be performed during outreaches and generate images that can be used for quality assurance.
Quality assurance is critical to the effectiveness of a cervical cancer screening program. We employ a collaborative approach for quality assurance through regular meetings in which in-house and external experts discuss cases with attending providers.10 Adding quality assurance review by specialists using colposcopy has been reported to improve the diagnostic accuracy of VIA.30 PHPs in more remote facilities can also engage with expert colposcopists through anonymized cervigrams on social media platforms, and colposcopic images can be uploaded to the cloud for quality assurance assessment. This facilitates timely consultation with a distant colposcopist while the patient is still in the healthcare facility and reinforces quality control.31,32
Artificial intelligence (AI) as an adjunct to colposcopy has raised concerns about the importance of training PHPs in basic colposcopy. Introducing AI-based evaluation and interpretation of cervigrams may reduce the learning curves for PHPs in performing colposcopy. While AI is expected to assist less skilled PHPs in providing more accurate diagnosis33,34, follow-up, and treatment of precancerous lesions of the cervix, its use will still require hands-on training and skilled providers.
There were limitations to this study. First, most respondents to the survey were clinicians working in urban settings, suggesting that our findings may not representatively reflect colposcopy practices among providers living in rural areas. Second, respondents were selected among clinicians invited to attend a continuing education e-learning program aimed at building the capacity of African providers in the field of cervical cancer prevention and management, and the survey was administered online. As a result, providers in areas with limited internet penetration were underrepresented in our study sample.