Abstract
BackgroundPortable devices that can be used to perform colposcopy may improve cervical cancer screening in low- and middle-income countries (LMIC) where access to colposcopy is limited. The objective of this study was to systematically review the diagnostic test accuracy (DTA) of these devices for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+).MethodsIn accordance with our protocol (Prospero CRD42018104286), we searched Embase, Medline and the Cochrane Controlled Register of Trials up to 9/2019. We included DTA studies, which investigated portable devices with moderate-to-high optical magnification (≥ 6×) for colposcopy, as described in the manual for Colposcopy and Treatment by the International Agency for Research on Cancer, with a histopathological reference standard. We used the QUADAS-2 tool to assess study quality. We examined results for sensitivity and specificity in paired forest plots, stratified by stages in the clinical pathway. We pooled estimates of test accuracy for the index test, used as an add-on to other tests, using a bivariate random-effect model.ResultsWe screened 1737 references and assessed 239 full-text articles for eligibility. Five single-gate DTA studies, including 2693 women, met the inclusion criteria. Studies evaluated two devices (Gynocular™ and Pocket) at different stages of the screening pathway. In three studies, which used the index test in an add-on capacity in 1273 women, we found a pooled sensitivity of 0.79 (95% CI 0.55–0.92) and specificity of 0.83 (95% CI 0.59–0.94). The main sources of bias were partial verification, incorporation and classification bias.ConclusionFew studies have evaluated portable devices able to perform colposcopy, so their accuracy for the detection of CIN2+ remains uncertain. Future studies should include patient-relevant and long-term outcomes, including missed cases, overtreatment, residual and recurrent disease. To meet the challenge of eliminating cervical cancer in LMIC, methods for visual assessment of the cervix need urgent redress.
Highlights
Portable devices that can be used to perform colposcopy may improve cervical cancer screening in low- and middle-income countries (LMIC) where access to colposcopy is limited
Cervical cancer screening in many LMIC is based on the cheapest method, visual assessment with acetic acid (VIA), with screening and treatment on the same day
We found a sensitivity of 0.79 and a specificity of 0.83, with an area under the receiver operating curve (AUC) of 0.88 (0.85–0.90) (Fig. 4)
Summary
Portable devices that can be used to perform colposcopy may improve cervical cancer screening in low- and middle-income countries (LMIC) where access to colposcopy is limited. The World Health Organization has called for coordinated global action to eliminate cervical cancer [1]. To achieve this goal, effective cervical screening in low- and middle-income-countries (LMIC), where 90% of women with cervical cancer live [2], is paramount. Systemic challenges of high costs, limited healthcare infrastructure for laboratory dependent screening tests, transportation and electricity constraints, and limited specialists compromise the effectiveness of screening programs in LMIC. Efforts to improve cervical cancer screening strategies in LMIC must consider their feasibility in relation to systemic factors
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