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Comparative Accuracy of Anal and Cervical Cytology in Screening for Moderate to Severe Dysplasia by Magnification Guided Punch Biopsy: a Meta-Analysis

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Comparative Accuracy of Anal and Cervical Cytology in Screening for Moderate to Severe Dysplasia by Magnification Guided Punch Biopsy: a Meta-Analysis Comparative Accuracy of Anal and Cervical Cytology in Screening for Moderate to Severe Dysplasia by Magnification Guided Punch Biopsy: A Meta-Analysis Wm. Christopher Mathews*, Wollelaw Agmas, Edward Cachay Department of Medicine, University of California San Diego, San Diego, California, United States of America Abstract Background: The accuracy of screening for anal cancer precursors relative to screening for cervical cancer precursors has not been systematically examined. The aim of the current meta-analysis was to compare the relative accuracy of anal cytology to cervical cytology in discriminating between histopathologic high grade and lesser grades of dysplasia when the reference standard biopsy is obtained using colposcope magnification. Methods and Findings: The outcome metric of discrimination was the receiver operating characteristic (ROC) curve area. Random effects meta-analysis of eligible studies was performed with examination of sources of heterogeneity that included QUADAS criteria and selected covariates, in meta-regression models. Thirty three cervical and eleven anal screening studies were found to be eligible. The primary meta-analytic comparison suggested that anal cytologic screening is somewhat less discriminating than cervical cytologic screening (ROC area [95% confidence interval (C.I.)]: 0.834 [0.809–0.859] vs. 0.700 [0.664–0.735] for cervical and anal screening, respectively). This finding was robust when examined in meta-regression models of covariates differentially distributed by screening setting (anal, cervical). Conclusions: Anal cytologic screening is somewhat less discriminating than cervical cytologic screening. Heterogeneity of estimates within each screening setting suggests that other factors influence estimates of screening accuracy. Among these are sampling and interpretation errors involving both cytology and biopsy as well as operator skill and experience. Citation: Mathews WC, Agmas W, Cachay E (2011) Comparative Accuracy of Anal and Cervical Cytology in Screening for Moderate to Severe Dysplasia by Magnification Guided Punch Biopsy: A Meta-Analysis. PLoS ONE 6(9): e24946. doi:10.1371/journal.pone.0024946 Editor: Julian Little, University of Ottawa, Canada Received April 25, 2011; Accepted August 24, 2011; Published September 19, 2011 Copyright: ß 2011 Mathews et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This work was supported in part by the Clinical Investigation Core of the University of California San Diego Center for AIDS Research [AI036214], the CFAR Network of Integrated Clinical Systems (CNICS) [R24 AI067039-01A1], and the Pacific AIDS Education and Training Center (PAETC). The funders hadnorolein study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: [email protected] Introduction included the following search terms in any field: cervical cytology AND sensitivity AND specificity AND cervical intraepithelial neoplasia AND year The accuracy of screening procedures for anal cancer and its of publication 2000-2010. Searches were limited to English-language precursors relative to comparable procedures used in screening for publications. Unpublished studies were ineligible for inclusion. cervical cancer and its precursors has not been systematically Authors were not contacted to provide data in the eligible format if defined. The issue is of importance because invasive anal cancer the published manuscript had incomplete data for analysis. rates are increasing among HIV-infected persons[1,2] and because Anal. Data sources included: (1) MEDLINE from 1990 through screening programs modeled on procedures used in cervical 2010; (2) review of published systematic reviews [6–9]. Because the cancer screening are being increasingly implemented among search algorithm comparable to that used for cervical publications persons at increased risk for anal cancer[3]. The primary objective yielded only 33 potentially relevant publications, the search strategy of this study was to meta-analytically compare a summary for anal publications was broadened. The MEDLINE search included operating characteristic of the performance of cervical and anal the following search strategy in any field: (anal cancer OR anal dysplasia cytology testing in the detection of cervical and anal cancer and OR anal cytology OR anal intraepithelial neoplasia)ANDscreening AND their precursors, when the reference standard biopsy is obtained at ((sensitivity AND specificity)ORaccuracy). Unpublished and non-English colposcopy or high resolution anoscopy (HRA), respectively. language publications were ineligible for inclusion. When a publication appeared to be eligible for inclusion but the data Methods presented in the manuscript was incomplete, authors were contacted to request data in the required format (see below). Data Sources and Searches Cervical. Data sources included: (1) MEDLINE from 2000 Study Selection through 2010; (2) review of two previously published meta-analyses In establishing study inclusion and exclusion criteria we used the of cervical cytology accuracy.[4,5] The MEDLINE search strategy following definitions of index and reference tests. The index test was PLoS ONE | www.plosone.org 1 September 2011 | Volume 6 | Issue 9 | e24946 Comparison of Cervical & Anal Dysplasia Screening cytologic sampling of cervicovaginal or anal canal tissues using consensus of the two reviewers. Decisions regarding final eligibility cytology swabs or brushes and processing of the samples using for inclusion were made without knowledge of the cytology ROC either traditional slide fixation or liquid cytologic media. The area, which is the primary outcome metric of the meta-analysis. reference standard was defined as colposcope magnified and directed punch biopsy of the uterine cervix or anal canal, respectively. Validity Assessment: Study Quality and Covariate Rating Operator visual impression without a biopsy could not be included as Eligible publications were reviewed using the QUADAS tool part of the definition of the reference standard result. Inclusion [13–15]. Further specification of quality and covariate review criteria included published reports: (1) of primary screening or criteria was operationalized using the following additional follow up evaluation for previous cytologic abnormalities; (2) use of questions: the Bethesda 1991 or 2001 Classification System (or equivalent); (3) reference standard diagnosis by cervical or anal punch biopsy (1) Were patients undergoing the reference standard procedure obtained using colposcope magnification; the addition of endo- (colposcopy or HRA directed punch biopsy) selected on the cervical curettage sampling was allowed for colposcopy studies; (4) basis of prior screening cytology results? (Yes/No/Unclear)[- average time interval between cytology and punch biopsy #3 verification bias] months; (5) availability of extractable data in the format below (2) What was the time interval between the test cytology and the (Table 1), where ‘‘cases’’ are defined as those with histopathologic reference standard procedure? (same day/ not same day but evidence by punch biopsy (cervical or anal) of cervical or anal within 3 months/Unclear)[disease progression bias] intraepithelial neoplasia 2 (CIN 2 or AIN 2) or greater and (3) Was the reference standard result based only on punch biopsy cytology diagnostic categories include negative (‘‘no atypical or interpretation? (punch biopsy only/composite of punch biopsy malignant cells’’), atypical squamous cells of uncertain significance and colposcopy-HRA visual impression/mixture of punch (ASCUS), atypical squamous cells can’t rule out high grade (ASC- biopsy and other histology/Unclear)[reference standard H), low grade squamous intraepithelial lesion (LSIL), and high definition] grade intraepithelial lesion (HSIL): (4) What cytology method was used? (Conventional/Thin Prep/ Exclusion criteria included: (1) reference standard established Other liquid cytology/Unclear) only by visual inspection at colposcopy or anoscopy without biopsy; (2) patients with normal colposcope magnified visual (5) Were histologic and/or cytologic results reviewed for final impression but no biopsy were classified as normal histology; (3) classification by central adjudication or independent readers? cervical cytology study sample explicitly included patients (Yes/No/Unclear) previously treated by conization or LLETZ (because of unavail- (6) Did the study sample explicitly include HIV infected patients? ability of comparable study populations for anal cytology studies). (Yes/No/Unclear) (7) What was the study design? (Clinical Cohort/Case Control/ Data Extraction Convenience sample of matched cytology and histology In abstracting cytology data from the included publications, the results/Clinical Trial/Other/Unclear) following conventions were followed: (1) inflammatory changes (8) What cytology classification system was used? (Bethesda were categorized with the ‘‘negative’’ category; (2) AGUS was 1991/Bethesda 2001/Other comparable/Other not compa- categorized with ASCUS; (3) HPV changes or koilocytes were rable/Unclear) classified under LSIL; (4) the category ‘‘$HSIL’’ included ASC-H, HSIL, CIS, and invasive carcinoma. The study quality
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