Telecolposcopy in the management of women with abnormal cervical cytology in rural and remote NSW

21 October 2005
Hunter/New England Area Health Service

This project was entered in the Baxter 2005 NSW Health Awards, Access category.

Entries from the Baxter 2005 NSW Health Awards - full list

Author

Jenny Bath, HNEAHS

Abstract

This project enabled women in rural and remote communities in the New England region to access colposcopic expertise without travelling long distances from home.

The pilot project allowed images of abnormalities on cervical smears to be referred from country centres via telecolposcopy to the Gynaecological Cancer Centre at the Royal Hospital for Women (RHW) for expert opinions.

The project clinics began in Tamworth in February 2004 and concluded in October 2004. During this time, 52 women were referred to the clinic where colposcopic images were obtained, stored and transmitted to RHW for expert consultation. Women were then referred for appropriate treatment based on this consultation.

This project improved the assessment, treatment and follow-up of women with abnormal results from pap smears. Acceptability was positive and the project proved to be portable and adaptable on several levels. Staff, too, were satisfied with the clinical process and patient outcomes.

Aim

To:

1. Provide women in rural and remote communities access to colposcopic expertise
2. Test the validity of telecolposcopy in evaluation of abnormal Pap smears; and
3. Improve the assessment, treatment and follow-up of rural women with abnormal Pap smear results

Background

Cervical cancer is the eighth most common cancer affecting women in Australia. (Jelfs, P. (1995), Cervical Cancer in Australia, AIHW: Cancer Series No. 3, AIHW, Canberra.) Incidence of Cervical Cancer per 100,000 women is 6.9 with the mortality rate being 1.7 per 100,00 (age standardised rate.) Source: GLOBOCAN 2002 http://www-depdb.iarc.fr/globocan/GLOBOframe.htm cited in Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities, National Health and Medical research Council, approved 9th June 2005. Population screening for cervical cancer by Pap smear has undoubtedly had a major impact on both morbidity and mortality from cervical cancer, a malignant disease which, on a worldwide basis, is the commonest cause of cancer death in women. Women in rural and remote areas with abnormal cervical cytology frequently have to travel long distances to access colposcopy services in larger centres.

Methodology

Staff at the RHW recognised the trend of rural women accessing colposcopy services following attendance from rural women in their service.

In order to address this issue of access to healthcare, the telecolposcopy pilot project was proposed. The project would seek to pilot telecolposcopy services to see if they would be a viable option for giving women access to such services in other remote and rural communities.

Tamworth was identified as an ideal pilot site. This was because a doctor was currently performing colposcopy at Tamworth and was able to ensure images sent online matched with what was visible and able to be diagnosed on-site. This would ensure the suitability and capability of the technology prior to broader roll-out.

Planning and Implementation

A working party was established consisting of staff at RHW, and the then NEAHS. Meetings took place over several months via teleconference link up between the two centres to fine-tune the NSW Department of Health Telehealth Project Plan. The final plan was submitted in July 2002. Ethics committee approval was gained. Delays were experienced in purchasing the equipment and configuring the software necessary for the project as security of the data and medico legal issues were investigated. Testing of the equipment was carried out at the RHW, Randwick. On delivery of the equipment to the Tamworth site one day of training was provided to the clinicians involved in the project.

The first clinic was held in Tamworth in February 2004 and the final clinic was held in October 2004. All patients were posted information about the project at the time of making an appointment and all patients were required to sign a consent form to participate in the project. Patient privacy was ensured throughout the study.

Women with abnormalities on cervical smears were referred by a local medical officer for assessment that was performed at the telecolposcopy facility established at Tamworth Hospital.

The clinics were run by Colposcopist Dr Keith Hollebone and CNC Women’s Health, Jenny Bath. Colposcopies were attended and five digital images were taken of each cervix then transferred to the RHW Randwick. Colposcopic images were obtained, stored and transmitted to the Preinvasive unit, Gynaecological Cancer Centre, Royal Hospital for women, Randwick for consultation. A recognised expert in colposcopy at Tamworth Hospital performed the consultation. The initial consultation identified the area(s) of abnormality on the cervix and recommendations were made as to the need for and site of direct biopsy.

The images and patient data were transmitted to the SESAHS server and stored in the vault for consultant review. The consultant report was stored in the vault and a recommendation for either follow-up colposcopy, biopsy or loop excision at a subsequent visit was made. Patients with high-grade lesions were referred for appropriate treatment. The initial project was confined to Tamworth with an expectation that if successful it could be further tested in remote communities.

Patients were notified of the result by phone and treatment organised where indicated. Patients were then followed up with a patient satisfaction survey.

Outcomes and evaluation

52 women from rural and remote communities were able to access telecolposcopy services as a result of this pilot project.

Client satisfaction surveys were sent to all patients who attended the clinic. Staff satisfaction surveys were also completed along with a clinical evaluation.

Evaluation of the project was divided into five main categories:

1. Technological: 256 images were transferred and once transferred were of high quality and accurate diagnosis could be made from the images. The technological configuration of the colposcope, TV and camera was reliable and available 100% of the time.
2. Clinical: The clinical process, consultation and management of patients were highly successful for this project. The benefits to patients in respect of receiving accurate quality care without the inconvenience of travelling long distances is a positive outcome of this study.
3. Staff: Staff acceptance of the TeleHealth initiative and method was high with no additional training needed for the project to be useful. The patient outcomes achieved by the project were positive and reflect the clinical viability of the project.
4. Patient: 55 women were recruited to the clinic. Three failed to attend. 52 routine consultations took place. 48 women were fully annotated in the Telecolposcopy software by Dr Campion at RHW. All women requiring treatment visited Dr Hollebone in Tamworth and attended day surgery at Tamworth Hospital or Tamara Private hospital. The patient survey reflected high acceptance of the study and its clinical process. Although women were recruited across a variety of age groups, in different manners and had varied experiences in result communication, all women rated most aspects of the study favourably. Most pleasing was the 100% recommendation of the study to friends and family.
5. Finances: The total expenditure for the project was $186,466

Future scope

A grant of $90,000 has been allocated by the Cancer Institute to expand this project into other rural and remote areas.

Using telecolposcopy for women in rural and remote NSW has proved to be a clinically viable initiative. Planning is already underway to roll-out this project using a product that is appropriately customised for the project and resilient enough to perform under the NSW Health intranet environment.