The new normal – preparing colposcopy clinics for post Covid-19

Tuesday 21st July 2020

In May this year, Professor John Tidy of Sheffield Teaching Hospitals NHS Foundation Trust, and Ms. Uma Krishnamoorthy of East Lancashire Hospitals NHS Trust conducted a webinar, 'Bringing colposcopy back to a new normal and how to manage the challenges', to discuss the impact and potential adjustments cervical cancer services are facing as a result of the coronavirus pandemic.

The Covid-19 pandemic has affected all aspects of healthcare in the United Kingdom as the NHS cleared capacity in hospitals to deal with the crisis. With cervical screening invitations paused in Northern Ireland, Wales and Scotland and in England clinics only seeing urgent referrals, many colposcopy services find themselves surprisingly empty at this time, with some operating at only 20% capacity.

Physical distancing, the pressures on capacity due to the extension of appointment times, and reduced capacity caused by the demand of new hygiene protocols and application of PPE has driven the desire to manage patients appropriately at their first visit and remove the need for subsequent follow up visits.

This suspension of usual service has accrued a backlog we roughly estimate to be a minimum of 20,000 patients waiting for colposcopy examination. This is in addition to an already inflated number of referrals due to the implementation of HPV primary screening across the UK this year.

Additional to this, a number of centralised labs we rely on to process HPV and cytology screening tests and biopsies are also Covid-19 test centres and are increasingly impacted by the wider Government roll-out of testing. Maintaining staffing levels in clinics can also be a challenge as many administrative and clinical staff are still required to shield or self-isolate.

As the Covid-19 crisis rolls on, there is an increasing demand for the return to ‘business as usual’ in cancer services despite the ongoing reduction in capacity caused by increased appointment times required to apply PPE, lengthy cleaning schedules between patients, and the pressures of maintaining social distancing in waiting areas. Alongside this we need to be sensitive to the patients who are still nervous about attending hospital appointments.

It has been recently reported that 600,000 women have had cervical screening delayed due to the COVID-19 efforts and with screening now opening back up across the UK, further referrals in the next few weeks will add significant pressures to colposcopy.

So, what can we do differently to clear the backlog and deliver efficient, effective diagnosis and treatment of patients, while maintaining compassionate service and dignity for the patient in this radically changed environment?

Some services such as those of East Lancashire Hospitals NHS Trust have already implemented an increase in telephone consultations to help reassure women whose appointments or test results have been delayed and conduct individual risks assessments prior to a physical appointment. This helps to allay the fears a patient may have around entering a hospital environment at this time and talk them through the procedure without the depersonalising PPE that makes communication so hard.

Extended clinic hours and waiting in the car in the hospital car park or outside the hospital right up until the appointment time could also become the norm as we seek to avoid concentrating numbers in waiting areas.

As it is widely reported that around 20 percent1 of infections are acquired in the hospital environment, there may even be scope to move colposcopy services out of the hospital environment entirely.

Within the backlog most of the referrals will be low grade cell changes or high-risk HPV positive with negative cytology, which are the most challenging patients for us to access colposcopically. As we seek to manage increased caseloads of both high and low-grade abnormalities with reduced capacity, there will be increasing need to optimise patient management in the minimum number of visits to colposcopy.

Sheffield Teaching Hospitals NHS Foundation Trust are using adjunct technology (ZedScan™, Electrical Impedance Spectroscopy, Zilico Ltd) to release patients back to surveillance or 3-5-year screening in primary care with greater confidence and have seen a 40% reduction of follow up appointments making more appointments available to new patients.2 Subsequent data, submitted for publication has shown that patients with a negative colposcopy and negative ZedScan result, are highly unlikely to develop CIN2 in the following 3 years (1 per 100 women years vs. 3.3 per 100 women years in colposcopy alone). 3

ZedScan has also allowed Sheffield Teaching Hospitals NHS Trust to take a more patient centred approach and reduce the number of diagnostic biopsies and associated co-morbidity while avoiding unnecessary costs. In a recent study they were able to detect more disease (as a result of greater PPV) at a lower biopsy rate with ZedScan-directed biopsy than with colposcopic-directed biopsy when the lesion was less than CIN2.4 This is an effect commonly seen across clinics using ZedScan and can have a profound effect both organisationally and economically, as previously demonstrated in a 2017 study at Birmingham Women’s Hospital, a service managing around 2,000 colposcopy referrals each year over 9 clinics.4 Based upon a 109-patient study they projected a financial benefit to the hospital by year 3 of implementing ZedScan, of £119k and the release of approx. 1184 clinic appointments.5

It was findings such as these that led East Lancashire Hospitals NHS Trust to recently accelerate adoption of ZedScan to manage the expected increase of patients they are anticipating post Covid-19 as effectively as possible.

Read the press release here

The next 12 months are certainly set to be a challenging time across the NHS, but it could also be an opportunity for us to implement positive changes in gynaecology and colposcopy services that could have long lasting positive impacts for both patients and service providers.

To access the webinar in full click here

References

  1. https://www.theguardian.com/world/2020/may/17/hospital-patients-england-coronavirus-covid-19
  2. MacDonald, M.C., Lyon, R., Palmer, J.E., Tidy, J.A. (2015), "The routine use of ZedScan within one colposcopy service in England", unpublished presentation at BSCCP 2015, Nottingham, UK
  3. Brown, B; Tidy, JA, Unpublished longitudinal study into probability of CIN2+ development in women following a negative colposcopy with negative ZedScan result, June 2020
  4. Tidy JA, Lyon R, Ellis K, Macdonald M, Palmer JE. The impact of age and high-risk human papillomavirus (hrHPV) status on the prevalence of high-grade cervical intraepithelial neoplasia (CIN2+) in women with persistent hrHPV-positive, cytology-negative screening samples: a prospective cohort study [published online ahead of print, 2020 Apr 12]. BJOG. 2020;10.1111/1471-0528.16250. doi:10.1111/1471-0528.16250
  5. Byrom, J; Poster presentation BSCCP 2018, Manchester, UK
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