Reviewer’s report
Title: 
Can the dynamic spectral imaging (DSI) color map improve colposcopy
examination for precancerous cervical lesions? A prospective evaluation of the
DSI color map in a multi-biopsy clinical setting
Version: 
0 
Date: 
11 Oct 2020
Reviewer's report:
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GENERAL COMMENTS:
Only the results of the DSI are reported. Nevertheless the study also included the
colposcopists' choice of biopsy site and diagnosis, of which the results are not
revealed. As a matter of fact the DSI results should be compared to the DSI
directed biopsy results, as well as to the histologic diagnosis of the colposcopist
directed biopsies and the random biopsies separately.
Table 4 is actually a compilation the SENS, SPEC, PPV and NPV from tables 2
and 3, which are also given in the body of the text. So this table seems a bit
superfluous.
Inaccurate listing of references.
MAJOR COMMENTS:
p.2 l.39 The conclusion, namely that the worst color indicated by the DSI does
not necessarily reflect the worst grade of dysplasia, canot directly be concluded
from the data presented in the abstract. It would be better to make the data and
conclusion congruent. 
p.2 l.49 Next to mentioning that not always a biopsy is performed at colposcopy,
it would be good to refer to the EFC Guidelines, which are leading in Europe.
p.5 l.127 To be clear please define somewhere in the text 'conization',
supposedly loop excision and not cold knife conization. Also, what kind of
treatment/follow-up did the 18.9% get who had high-grade disease but were not
treated with conization ?
p.6 l.139 Although not a statistician I doubt whether one can/should use terms as
SENS and SPEC to compare the color and the result of the biopsy taken on basis
of that color. First of all they are not two independent events/observations,
second of all this biopsy does not provide the gold standard result (as in the case
of the second part of the study, where the worst histology is the gold standard).
Better to describe this in terms of correlation.
p.7 l.169 The worst DSI colors are cited for the 7 cancer cases. More importantly
would be to know to what extent the correct diagnosis was made on basis of the
DSI directed biopsies.
p.7 l.184 Louwers e.a. couldn't distinguish between the types of biopsy, but
could the authors (see general remark)?
p.7 l.186 the difference in sensitivity suggested here is quite incomprehensible.
This should be rephrased. I guess the authors mean the difference in sensitivity
of DSI color discrimination between 
analysis of the biopsy associated with it or
of all biopsies? 
p.7 l.191 The percentage of aceto-white observed by the colposcopist has not
been reported in the results section, so this should not be brought up her as new
data in the discussion. Apart from that, the discussion on difference between the
perception of aceto-white between a colposcopist and the DSI should also take
into account that the DSI also measures the fading time, which (most of the
time) a colposcopist would not do.
p.8 l.195 The observed and stated higher PPV for high-grade lesions (by the
DSI) is refuted by earlier studies of Louwers e.a., as well as of Souter e.a.. It
should be explained why the results in this study were different in that respect.
p.8 l.210 It is correct to state that DSI is actually only intended as a 'supplement',
but this has also been stated by others before and is actually not substantiated by
the author's own data as they didn't make the comparison between the DSI
performance and that of the colposcopist (see general remark).
p.9 l.224 As the authors mention conservative management, could they state how
often they didn't treat low- or high-grade lesions (we have been informed that
18.9% of high grade lesions did not receive conization), and whether see-and-
treat has ever been applied ?
MINOR COMMENTS:
p.2 l.50 'Examination' rather than 'exam'. 
p.3 l.75 'Follow-ups' sounds rather colloquial. (see also. P.4 l.108)
p.5. l.120 'for' rather than 'due to'
p.5 l.129 'population' usually refers to the study population, but apparently here it
is used to indicate the subgroup of patients having undergone a conization.
Perhaps better rephrase to avoid confusion.
p.7. l.181 'a NPV' rather than 'an NPV'
p.11 l.503 The link and therefor the reference refer to 'Public Health England.
Guidance 4. Colposcopic diagnosis, treatment and follow up. (updated 5
February 2020)' rather than to 'England PH. Cervical screening: programme etc
..'
p.12 l.308 '....... National Institutes of Health (NIH) - American Society of
Colposcopy for Colposcopy and Cervical Pathology (ASCCP) Research Group'
rather than '...... National Institutes of Health -American Society for C, et al.'
p.12 l.306 'ALTS Group" instead of "Group A'
p.12 l.316 Add other authors than Budithi only.
p.12 l.318 Add other authors than Cholkeri-Singh only 
p.12 l.321 Add Fasero M as co-author
p.12. l.323 Add other authors than de Nardis only
p.12 l.325 Add other authors than Founta only
p.12 l.328 'Louwers JA, Zaal A, Kocken M, Berkhof J, Papagiannakis E,
Snijders PJ, e.a.' rather than 'Louwers JA.' 
p.15 l.382 In table 2 is the diagnosis of the DSI-directed biopsy is called 'Final
diagnosis'. This suggests also a preliminary diagnosis, which is not the case.
Please prevent confusion and skip 'final'.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes