Reviewer’s report
Title: 
Comparison of cervical cancer screening by self-sampling papillomavirus
test versus pap-smear in underprivileged women in France
Version: 
4 
Date: 
23 Feb 2021
Reviewer's report:
Evaluation of cervical cancer screening strategies for underprivileged women in
France by L reques is a study where self sampling for hrHPV is compared to
standard office based cervical cytology after a personal consultation. Not only
this approach distinguishes the study somewhat from many other, it is also the
distinct separate subpopulation of society that is begin addressed. 
The described the final population was 687 women from an initial approach
4080 women (which seems, incidentally, a limited yield, but not unusual I fear,
for so many approaches). Of the 687 women that finally joined the trial, 304
were assigned to the CG (PS) and 383 to the EG (HPV -self sample self-sample)
by monthly randomisation in four city centers. 
It's a nice effort in be inclusive for, what I assume, very underserved women.
Could you provide in the introduction some more information as to the extend of
being underserved? The percentage of uninsured, or not suboptimal language
level or some socio economic indicator. 
Can you explain in a couple of sentence whether there is a screening programme
in the cities where this study was conducted? Are women in France normally
offered cervical screening by an invitation through public health officials or are
they entitled to it by being insured? It is unclear now for reader not familiair with
the decentralised approach in France. 
The study was evidently not powered. Could you specially indicate that? 
What are the MdM programmes' you mention? One has to read all the way to the
discussion to obtain information on this (homeless, sexworkers, immigrants,
drug users….I wonder if immigrants really fully belong to this societal section).
How is MdM executed ? Eg By subsidized community efforts (volunteers?, or
city/ arrondissement council funded? Does it include prenatal care as well?), to
workers from MdM do this themselves? 
CASO and CAOA seem to be
concordant in the preference for self sampling. The other programmes miss.
Although you mention something in the discussion, I think it could explained a
little bit more
Page 8, you mention that " Cytological abnormalities detection was defined as
the proportion of women with cytological lesions >= ASC-US related to an HPV
infection in the CG and the proportion of women with cytological abnormalities
>= ASC-US among the women who tested positive for HR-HPV in the EG.
My question; ascus is usually associated with hrHPV in only 20-40%. Why you
add HPV infection here? When I saw the tables, I understood that you had added
hrHPV, but that merely confuses at this point of the description. Please omit
here. ASCUS is no proxy for hrHPV. Most readers will understand that. Why not
simply 'cytological abnormalities? 
Discussion. Please add that your endpoint (participation) is very clear. You could
paraphrase that as HP self test offers much ore protection. 
Yet cytological abnormalities is a very weak endpoint. I understand that there are
too few participants to state anything meaningfull about the ultimate effect. Loss
of follow-up is not such a drawback for the test arm: also the control arm is
hampered by it. You may consider rephrasing on of the final sentences of your
abstract. 
Details
Title: I think only one strategy is compared to PS. There is no sensitivity analysis
or modelling with different approaches. 
Terminology: underprivileged / precarious / underserved/ vulnerable… .I
recommend sticking to one term.
The abstract. It's a bit inconsistent 
in abbreviations. You start with CS vs ES
(line 38) to quickly shift to CG vs EG (control group vs experimental group) and
to finish with SC-HPV test vs CCS (inderstandeable if you read further on, but
should not be used in abstract. Why not use CG vs EG all the time? Make it
easier. 
Page 5 , line 29. European guidelines set the acceptable level of coverage at 70%
and the desired level at 85% (8). Nevertheless, national three-year coverage rate
of PS screening is estimated to be insufficient (60%). (9) comment: I don't
understand " nevertheless". There is no contradiction here. .From the first
sentence, is is obvious that 60% is insufficient. Not 'nevertheless' . There is
exculpatory motive of great effort done (at least not mentioned here…)
Pag 7, line 
Patients assigned to CG benefited systematically from a HPV test
when cytological anomalies were detected in the pap smear. Probably:
abnormalities. 
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Is the study design appropriate to answer the research question (including the use
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