Title: The overtreatment rate, medical cost and psychological affection of see-and-treat versus
three-step approaches in the treatment of cervical intraepithelial neoplasia: a systematic review
and meta- analysis
Version: 0 Date: 04 Mar 2025
Reviewer's report:
General Evaluation
The manuscript presents a systematic review and meta-analysis comparing the see-and-treat
(S&T) and three-step approaches in the management of cervical intraepithelial neoplasia (CIN).
The study is well-structured and addresses a relevant clinical question, but certain aspects
require improvement to enhance its rigor and clarity. While the large dataset and PRISMA
adherence add strength, issues related to study selection, heterogeneity, and interpretation of
cost-effectiveness and psychological outcomes need further refinement.
Major Concerns
The methodology lacks sufficient detail on study selection and bias assessment. The
predominance of observational studies over RCTs should be acknowledged more explicitly,
as it affects the reliability of the findings. Greater transparency is needed in explaining how
heterogeneity was handled, and subgroup analyses could strengthen the conclusions.
The statistical methods, though appropriate, could benefit from further explanation, particularly
regarding the pooling of data with significant heterogeneity. Clarifying how different healthcare
systems were accounted for in the cost-effectiveness analysis would make the economic
discussion more robust. The psychological impact findings require a deeper examination,
considering the variability in measurement tools and study designs.
The discussion should be more balanced, avoiding strong claims about the superiority of S&T
without acknowledging the limitations of the available evidence. A more nuanced interpretation
of overtreatment risks, economic factors, and psychological outcomes would improve the
study’s applicability. Expanding the limitations section to include potential biases and the need
for more RCTs would add further credibility.
Specific Comments
The abstract effectively summarizes the study but would benefit from explicitly mentioning the
number of studies included and highlighting the predominance of observational research.
The introduction provides a clear rationale but could better emphasize the existing gaps in
literature and why this review is necessary. A brief discussion of ongoing debates regarding the
effectiveness of S&T versus the three-step approach would help set the stage.
The methods section, while comprehensive, should provide more details on inclusion/exclusion
criteria, how study quality was assessed, and how heterogeneity was addressed in the analysis.
The discussion should also clarify whether direct and indirect medical costs were included in
cost evaluations.
The results section presents the findings well but could be improved by clearly differentiating
between RCTs and observational studies in tables. Further subgroup analyses considering study
design, patient populations, and regional differences would provide a clearer picture of treatment
effects.
The discussion of overtreatment rates should include a more explicit acknowledgment of
inter-study variability. The cost-effectiveness analysis should be expanded to recognize the
impact of healthcare system differences. The section on psychological effects should address
inconsistencies in assessment tools and how patient perceptions might influence outcomes.
The limitations section should be expanded to discuss the potential for bias, the limited number
of RCTs, and possible publication bias. The conclusions should be more measured, reflecting
the limitations of the current evidence and emphasizing the need for further high-quality studies.