Title: Assessment of risk factors for high-grade cervical or endometrial lesions to triage women
with AGC-FN : A retrospective study
Version: 1 Date: 14 May 2023
Reviewer's report:
Overall impression:
This is an original research paper which is looking retrospectively at the risk factors associated
with the development of high-grade lesions in women who screen positive for Atypical
Glandular Cells – Favour Neoplastic (AGC-FN).
The research idea is interesting and clinically relevant, and the experimental design is sound.
However, the wording and grammar of the paper makes it very difficult to follow, and hugely
dampens down the aims and findings from the study. Significant changes are necessary to make
the rationale for the study understandable – a lot of this will involve rewriting the background to
expand on research that has already been done in the field, and having much clearer study aims.
Furthermore, the methods need to be written in a more succinct but detailed manner, and the plan
for statistical analysis explained in the methods. Given this is a study that focuses on identifying
risk factors in AGC-FN patients, a statistical test of association such as regression analysis or
a chi squared test should be included.
Finally, the entire paper requires a careful grammar review as there are numerous grammatical
errors and poorly worded sentences. Authors need to be consistent with the write-up, ensuring
for example that abbreviations are always written out in full the first time with the abbreviation
in parentheses. Subheadings need to be reconsidered, and better arranged and/or titled.
Specific feedback:
Title:
This can be shortened to make it clearer, might want to include ‘retrospective’ in the title.
Abstract:
Needs grammar review. Some sentences too long, wrong use of tenses, etc.
Difficult to get a sense of the study aims, methods and conclusions without reading over several
times.
Data analysis plan should be included in the methods section and the study conclusions are
unclear.
Introduction:
Needs grammar review. Some sentences too long, wrong use of tenses, etc.
Needs a clear definition of what the problem is, which this study is addressing.
Needs a more thorough summary of the existing research in the field, and an explanation of
where the research gaps are, and how this study plans to meet them.
Note that the Bethesda classification has been updated since 2001.
Need to spend more time explaining what is meant by ‘triage’ in this context – i.e., would the
expectation be that women will have different investigations depending on which triage group
they fall into? What changes in clinical practice are being suggested?
The study aims are appropriately located at the end of the introduction, but they need to be better
explained.
Methods:
Needs grammar review and rewording.
Ensure consistency with terms used, e.g., do not interchange between participant, patient and
woman.
Choice of subheading could be improved upon for example, the HPV test, cytology, and
histology sections could all fall under a ‘clinical assessment’ section.
The study design section (titled patients) needs expansion of how the information was gathered
i.e., all retrospective vs. were stored samples retested?
Statistical analysis:
This section needs to be more succinct, with a cleat statistical analysis plan for the study
variables.
Need to clarify what variables are being subjected to diagnostic test accuracy parameters (i.e.,
sensitivity, specificity, PPV and NPV).
As previously mentioned, statistical tests of association should be included such as a regression
analysis and a chi squared test.
It is important to mention in this section that the odds ratios would be calculated, including the
confidence interval.
Results:
Needs grammar review and rewording throughout.
“Age-specific proportions...” – I think what is meant here is the age distribution and this data
could be better presented.
“Positivity rate of HR-HPV genotypes among the women with high-grade lesion in endometrium
or cervix” – title too convoluted
Independent risk factors data: can be better explained and presented in a tabular form,
Pictures and tables:
All the pictures and tables need legends/ explanations.
Figure 2A does not need to have ‘years old’ under each bar (e.g., can have an axis label which
simply states: Age (years)).
Discussion:
Needs grammar review and rewording.
If the study is suggesting that fewer investigations could be done based on triage of AFC-FN
patients, this needs to be clearly stated in the introduction and the justification for this included.
Discussion needs more to be written about the false negative scenarios, if using HPV status and
Ca125 as a triage test.
Need to talk about whether in clinical practice, it can be advised that only either a cervical biopsy
or an endometrial biopsy is done. I think we know the answer is no, but this needs to be expanded
on, and a more detailed description of what would be required before this can be introduced
into clinical practice.