Performance of Screening Tools for Cervical Neoplasia Among Women in Low- and Middle-income Countries: A Systematic Review and Meta-Analysis Public

Smith, Sabrina (Spring 2021)

Permanent URL: https://etd.library.emory.edu/concern/etds/3b591985w?locale=fr
Published

Abstract

Introduction: Cervical cancer continues to be a public health threat worldwide, disproportionately affecting low- and middle-income countries (LMICs). Screening for cervical cancer allows for early detection and treatment. Given the context of limited resources and challenges of traditional screening via Pap smears, the performance of different screening methods needs further evaluation.

Objective/Aim: This systematic review and meta-analysis evaluates the performance of visual inspection with acetic acid (VIA) testing, visual inspection with Lugol’s iodine (VILI), primary HPV testing, and conventional Pap smear in detecting cervical intraepithelial neoplasia grade 2 or greater (CIN2+) among non-pregnant women aged 30-65 in LMICs between 1990 and 2020.

Methods: CENTRAL, CINAHL, Embase, Global Health, PubMed and Web of Science databases were systematically searched to identify studies. Diagnostic test accuracy meta- analysis evaluated the performance of screening methods in detecting CIN2+. Summary statistics for sensitivity, specificity, diagnostic odds ratios (DORs), and summary receiver operating characteristic (SROC) curves were determined for each method. Subgroup analyses were performed to examine whether there was variation in performance based on different reference standards, specifically: colposcopy-directed biopsy, biopsy alone, colposcopy alone, or liquid-based cytology.

Results: Eighteen studies were identified through systematic review. Six were narratively synthesized and excluded from meta-analysis given limitations in outcome values reported. Of the 12 studies included in meta-analysis, 11 were cross-sectional and 1 was a randomized controlled clinical trial. Summary estimates for sensitivity for VIA, VILI, HPV, and conventional Pap smear were 72.3%, 64.5%, 79.5%, and 60.2%, respectively; summary estimates for specificity were 74.5%, 68.5%, 72.6%, and 97.4%, respectively; the DORs were 7.31, 3.73, 10.42, 69.48, respectively; and the area under the SROC curves were 0.766, 0.647, 0.959, and 0.818, respectively. Performance of screening method varied based on reference standard used; summary estimates using colposcopy- directed biopsy or biopsy generally reported lower estimates; summary estimates using colposcopy or liquid-based cytology generally reported higher estimates.

Conclusion: This meta-analysis found primary HPV testing and VIA to be the highest performing cervical cancer screening methods in accurately identifying or excluding CIN2+. In resource-constrained countries, VIA may be the most feasible screening method. Further evaluation of performance at different CIN thresholds is warranted. 

Table of Contents

INTRODUCTION

Introduction & Rationale

Problem Statement

Purpose Statement

Objectives and Aims

Significance Statement

Definition of Terms

LITERATURE REVIEW

Burden of Cervical Cancer

Risk Factors for Cervical Cancer

Screening Methods

VIA as an Alternative Approach to Cytology Screening in LMICs

Knowledge Gap

Conclusion

STUDENT CONTRIBUTION

JOURNAL ARTICLE

Title Page

Abstract

Introduction

Methods

Results

Discussion

Conclusions and Implications

References

Tables and Figures

PUBLIC HEALTH IMPLICATIONS

REFERENCES

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