Reviewer’s report
Title: 
Screening test accuracy of portable devices that can be used to perform
colposcopy for detecting CIN2+ in low- and middle-income countries: a
systematic review and meta-analysis
Version: 
0 
Date: 
07 Sep 2020
Reviewer's report:
This manuscript provides a systematic review of the diagnostic test accuracy of
portable devices developed for colposcopy in LMIC.
The inclusion of devices that were mobile, not reliant on electricity, and could be
used and maintained in LMIC is appropriate and consistent.
It is, however, unclear as to why the EVA system is omitted (magnifies up to
16x, and although using a mobile phone, does not require connectivity for image
capture, only for backup and sync abilities (as do the other modalities included,
namely GynocularTM and the Pocket device.)1,2
The results as written in the abstract includes much of what should be included
in the body of the paper.
The "Quality assessment" is well done. 
There is perhaps too much made of the Swede system, rather than biopsy
findings and concordance. 
Given that the Swede system is predictive of the
biopsy findings, it is really the biopsy findings and not the swede score per se
that is more important. 
Separating the findings from the nurses and the doctors
makes it appear that there is more data than really exists. 
Figure 3 could be easily
explained/described in the text.
Missing in the introduction and discussion is how including how a portable
device could best be incorporated into cervical cancer prevention in LMIC. 
I
would suggest POC HPV testing, and then use of a portable device for
colposcopy. 
Another option is self collection of HPV testing, and then calling in
only the women with + self-collected screens. 
In both scenarios, colpscopy
would be used as an "add-on" test.
Not clear why figure 1 is needed—especially as not all countries have adopted
HPV testing as the mode of primary screening. 
In addition, although impractical,
many LMIC still use cytology (despite of all of its costs and impracticality) with
referral to colposcopy for abnormal screening results. 
(e.g., south Africa, Brazil,
Argentina). 
In this case, patients have to be referred for colposcopy for these
devices to be used. 
Referrals may be based on VIA findings, or other modalities
of screening eg., cytology and HPV.
In figure 4, Newman 2019 is also mixed—stand alone and add-on, as described
below.
Newman (2019, In j CA) describes the gynocular findings as "VIA with portable
colposcopy";, 24 women had biopsies from "VIA" with only 1 findings of
CIN2+. (which was SCC), the remaining patients underwent HPV testing, which
if positive had cytology testing and the 7 women with abnormal cytology
underwent biopsy. 
In all, 31 women had biopsies, and those biopsies included
CINII (1), CIN III (1) and cancer (1). In the first line of Table 1, the prevalence
of CIN2+ should be 3/488 (0.6%) and not 31/488 as listed.
References
1. 
Kundrod KA, Smith CA, Hunt B, Schwarz RA, Schmeler K, Richards-
Kortum R. Advances in technologies for cervical cancer detection in low-
resource settings. Expert Review of Molecular Diagnostics. 2019;19(8):695-714.
doi:10.1080/14737159.2019.1648213
2. 
Thay S, Goldstein A, Goldstein LS, Govind V, Lim K, Seang C. Prospective
cohort study examining cervical cancer screening methods in HIV-positive and
HIV-negative Cambodian Women: A comparison of human papilloma virus
testing, visualization with acetic acid and digital colposcopy. BMJ Open.
2019;9(2):26887. doi:10.1136/bmjopen-2018-026887
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