Title: Can biopsies be omitted after normal colposcopy in women referred with low-grade
cervical cytology? A prospective cohort study.
Version: 2 Date: 04 May 2021
Reviewer:  Robert G. Pretorius
Reviewer's report:
Review of: Jepersen MM et. al. Can biopsies be omitted after normal colposcopy in patients
with low-grade cervical cytology? A prospective cohort study.
Background:
Lines 59-60: This sentence, while true, contributes little to the manuscript.
Lines 63-65: The sentence starting with Patient age is problematic on multiple levels.  First,
‘accuracy’ of colposcopic-guided biopsy is not well-defined.  Rather than using ‘accuracy’, one
might use ‘sensitivity of colposcopic-directed biopsy for CIN 2+ (or CIN 3+; or p16 positive
CIN 2, CIN 3 or cancer)’.  Second, the sentence might be improved by stating that the ‘sensitivity
of colposcopic-directed biopsy is higher (or lower) for each characteristic rather than saying
that the sensitivity is influenced by.  Third, there are no references for patient age, menopausal
status, or type of transformation zone affecting the accuracy of colposcopy. I know of a reference
for patient age [Chen Q et.al. JLGTD 2016;20:207-12] in which women age as 51 and over
had lower sensitivity of colposcopic-directed biopsy for p16 positive CIN2, CIN 3, or cancer.
Fourth, the sentence does not include the characteristics of genotype of HPV 16 [Chen Q], lesion
size, [Chen Q, Pretorius RG, reference 7 in the current manuscript], nor low grade cytology
[Pretorius RG et.al. JLGTD 2019;23:241-247].  In addition, the most important characteristic
that increases the sensitivity of colposcopic-directed biopsy and which is missing from this
sentence is lowering the cut point for defining an abnormal colposcopic impression [Pretorius
RG et.al. JLGTD 2019;23:241-247].
Lines 87-91:  The aim (or object) of the study is not clear.  The object of this study might be better
stated as, “to determine the yield of CIN 2+ from one to four random cervical biopsies among
women referred to a colposcopy clinic for evaluation of LSIL/ASC-US cytology in whom the
colposcopic impression is normal.”
Just as a suggestion, you might start the Background with a discussion of the sensitivity of
colposcopic-directed biopsy in diagnosing CIN 2+.  I am not suggesting outright plagiarism,
but the Introduction in Pretorius RG et.al. JLGTD 2019;23:241-47 would help to explain why
one might study random biopsy at the time of colposcopy.  Though not explicitly stated in
this JLGTD manuscript, the data presented also show that in two series, most of the marginal
increase in yield of CIN 2+ by random biopsy was seen in women with normal colposcopy (in
SPOCCS I/II, 85.1% (120/141) of the marginal increase in yield of CIN 2+ by random biopsy
per colposcopy came from women with normal colposcopy while in SHENCCAST II, 57.1%
(20/35) came from women with normal colposcopy).  This might help the reader understand
why one might chose to study random biopsy in women with normal colposcopic impressions
rather than random biopsy in all colposcopy patients.  Another suggestion, to get a historical
perspective on the accuracy of colposcopy, you might look at Pretorius RG et.al. Gynecol
Minerva 2012;64:173-80.
Methods:
Lines 98-102: Does Denmark use high-risk human papillomavirus (hrHPV) status as an
indication for referral for colposcopy?
Lines 106-107: The sentence beginning with, “Taking four biopsies could be part of the
Background or Discussion, but it cannot be in the Methods.
Line 116-117: Were the biopsies performed in each cervical quadrant and were they done at the
squamocolumnar junction?
Line 132-137: In determining the sensitivity of colposcopic-directed biopsy the definition of an
abnormal colposcopic impression is very important.  It is not clear what the author’s definition
of an abnormal colposcopic impression is.  For example, in Wentzensen’s series [Wentzensen
N et.al. J Clin Oncol 2015;33:83-89], even faint acetowhitening often judged to be physiologic
and benign was considered abnormal.    Are they using Wentzensen’s definition or some other
definition?
Line 140-145:  I do not understand how the power calculation was performed.  The prevalence of
CIN 2+ among women with cytology of LSIL/ASC-US may be 14.83%, but what does this have
to do with the yield of CIN 2+ from random cervical biopsy in women with normal colposcopic
impression and cytology of LSIL/ASC-US?  Did you use McNemar’s test to test for significance
of the differences in proportion of CIN 2+ diagnosed by one or more random biopsies?  What
ever test was used should be stated.
Results:
Lines 171-174: How many of the 173 women were ASC-US/hrHPV positive, ASC-US/hrHPV
neg, LSIL/hrHPV pos, and how many LSIL/hrHPV neg.  It does not matter that 56.1% were
diagnosed with dysplasia.  As was shown in ALTS, and noted by the authors in lines 224-225,
diagnosing CIN 1 as opposed to negative is unimportant, so reporting the proportion of women
with CIN 1+ (i.e. Dysplasia) is not useful.
Lines 200-205:  I think this should directly follow lines 171-174.
Discussion:
Line 208-209:  Reiterating the proportion with dysplasia (56.1%) is not useful.
Line 224-229:  The object of citing the ALTS study was to show that one single biopsy for
diagnosis may lead to underestimation of the true CIN -grade.  This is also discussed in lines
237-244.  It should all be in one paragraph.
Line 231-235:  There is inter-observer variability in colposcopic impressions, but how does this
explain the failure to diagnose CIN 2+ in women with cytology of LSIL/ASC-US?
Line 251-261: How is any of this relevant to the manuscript’s object?
Lines 263-268:  What evidence did you present in this series to suggest that inadequate
colposcopy training was the cause of missing CIN 2+ in women with negative colposcopic
impressions?
Lines 270-276: If you had a Table comparing the yield of CIN 2+ from random biopsies in
women with the three different transformation zones, you might be able to conclude that doing
the random biopsies even when the transformation zone is not visible is useful (or not as the
case may be).
Lines 278-283: This is the major, new finding of this manuscript.
Conclusion:
Lines 304-305: Your data suggests that when the referring cytology is LSIL/ASC-US and the
colposcopic impression is completely normal, there is a significant yield of CIN 2+ from the
first random biopsy (7.3%) and a greater yield of CIN 2+ from 4 random biopsies (16.1%).  Why
is the conclusions not, “We advocate four random biopsies in women referred for colposcopy
for evaluation of cytology of LSIL/ASC-US in whom the colposcopic impression is completely
normal”?
Recommendation:
The manuscript presents new and compelling data advocating performing four random cervical
biopsies in women with cytology of LSIL/ASC-US when the colposcopic impression is normal.
It could be improved by limited revision as suggested above.  It could also be improved
by including the mean number of colposcopically-directed biopsies done for all women
attending these colposcopy clinics (rather than just those with cytology of LSIL/ASC-US).  This
information would help the reader understand how high (or low) the cut point for an abnormal
colposcopy in this clinic is (If the mean number of colposcopically-directed biopsies is 1.0 (as it
is in the USA), then the cut point for an abnormal colposcopic impression is rather high, while
if it is 2.67 (as it was in Wentzensen’s series), it is rather low. [see Pretorius RG et.al. JLGTD
2019;23:241-247]  If the cut point for defining an abnormal colposcopy is rather low, the data
presented suggesting a benefit to random biopsies when the colposcopic impression is normal
is even stronger.
One last question, “Was endocervical curettage (ECC) done on any patients in this series?  If
ECC was done, how many cases of CIN 2+ were diagnosed solely by a positive ECC?