Title: Cervical cancer screening by cytology and the burden of epithelial abnormalities in low
resource settings: A tertiary-center 42-year study
Version: 1 Date: 26 Apr 2024
Reviewer's report:
The authors report their 42-year long study of cervical cytology in Greater Cairo, Egypt. Such
studies and data are vital in understanding the cervical cancer control efforts in resource-
constrained countries that have a higher burden of cervical cancer. There are a few concerns that
need to be addressed, as detailed below:
1. The Bethesda system of classification of cervical smears has evolved over the time period
in this study. The authors need to include in their methodology as to how this evolution in
terminology was incorporated in the results. This is important because categories such as AGUS
were replaced by AGC-NOS and AGC-FN having different clinical implications.
2. Since 42 years is a long period, we assume that at least a proportion, even though small, of
women might have had a repeat cervical smear. The authors should specify how were the repeat
smears in the same woman included in the study?
3. The percentage utilization of cervical cancer screening services should be depicted, if possible.
This would help understand the temporal trend in the uptake of screening services. Mere numbers
of cervical smears do not provide this information.
4. In Table 2, the cervical cytology results are depicted as per TBS 2014. The categories of AGC-
NOS and AGC-FN were introduced in 2001 only. Were all the smears reviewed by the authors
for classification as per TBS 2014? If not, how were the smears reported as AGUS reclassified
as per the TBS 2014?
5. In Figures 2 and 3, the color coding of graphs has not been explained.
6. "Epithelial abnormalities were significantly more common in women who underwent routine
check-ups than in symptomatic women". Does this include 11414 routine asymptomatic and
30352 symptomatic women? The numbers should also be given.
7. "The yearly number of screened women was positively associated with the observed LSIL".
Is this association for the total number of women screened? Is there any difference in the
association for symptomatic and asymptomatic women?
8. "Furthermore, these abnormalities were more prevalent among women who underwent the
screening process at a relatively advanced age than among their counterparts". There is no data
supporting this statement.
9. "The yearly utilization of cervical screening by cytology was positively associated with LSIL
and negatively associated with invasive lesions". The utilization of cervical screening should
not be used in this sentence, since only the numbers screened are being used. The utilization
rate has not been calculated.
10. "This finding suggests that routine cervical cancer screening may be more effective in
detecting precancerous changes than relying solely on the presence of symptoms." This is a bold
statement and should be modified. We do not know if the rate of specific infections in cervical
smears was higher among symptomatic women. The sentence may be modified to "This finding
can provide support to the cervical cancer control efforts by providing evidence on the benefit
of routine screening rather than only when symptoms arise."
11. "we found that women older than 60 had the highest prevalence of epithelial abnormalities".
This data has not been provided in the manuscript.
12. "Over a 42-year period, the prevalence of SIL abnormalities decreased from 6.9–4.3% for
LSILs and from 1.2–0.13% for HSILs. The relative frequency of preinvasive abnormalities
(ASC, LSIL, and HSIL) started at approximately 10% in 1981 and decreased to 5% in 2022.
" The prevalence of cervical intraepithelial lesions would make sense with data of percentage
utilization of screening services. As seen in Figure 1, number of screened has reduced over years.
13. Since the study spans a very long period. I would be interested in knowing the practice of
cervical cytology. Is it a one-tier screening or two-tier screening method? Has anything changed
over the years?