© 2004 by Oxford University Press
© 2004 Oxford University Press
CORRESPONDENCE |
RESPONSE: Re: Have We Resolved How To Triage Equivocal Cervical Cytology?
Affiliations of authors: Division of Cancer Prevention (DS) and Division of Cancer Epidemiology and Genetics (MS), National Cancer Institute, National Institutes of Health, Bethesda, MD
Correspondence to: Diane Solomon, MD, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, 6130 Executive Blvd., EPN Rm. 2130, Rockville, MD 20852 (e-mail: ds87v{at}nih.gov)
We thank Arbyn and colleagues for providing an analysis using a stringent outcome of cervical intraepithelial neoplasia grade 3 precancer or cancer to evaluate triage strategies. From their useful analysis and other evidence, we agree with their conclusions regarding the triage of equivocal cytology by testing for oncogenic types of human papillomavirus (HPV).
We have a remaining methodologic difference of opinion with Arbyn and colleagues regarding the use of heterogeneous datasets in meta-analyses. In our editorial, we questioned the inclusion of studies that relied on obsolete HPV tests. We raise this point again for consideration because the optimal analysis of improving measurements is a general problem inherent to meta-analyses of rapidly evolving technologies. In their analysis, Arbyn and colleagues included HPV tests that are no longer manufactured because of documented poorer performance than the current Food and Drug Administration–approved kit and comparable, well-validated polymerase chain reaction–based assays (1,2). In defending their thoroughness, Arbyn et al. responded that "absence of heterogeneity is rare, and one purpose of a meta-analysis is to explore sources of the heterogeneity using formal statistical methods." In our opinion, considering obsolete testing strategies is a diversion from the job of clarifying the performance of current assays. The performance of triage using an inferior HPV test does not inform about the performance of triage using state-of-the-art tests. Misclassification resulting from obsolete HPV tests obscures the risk relationships and clinical usefulness of HPV testing (2–4). Because there is little to be learned by studying obsolete tests that will never be used again, we favor meta-analyses that begin by including only viable testing options, regardless of worthy characteristics of the older published studies.
REFERENCES
1 Schiffman M, Herrero R, Hildesheim A, Sherman ME, Bratti MC, Wacholder S, et al. HPV DNA testing in cervical cancer screening: results from women in a high-risk province of Costa Rica. JAMA 2000;283:87–93.
2 Sherman ME, Cox JT, Schiffman M; Atypical Squamous Cells of Undetermined Significance/Low-grade Squamous Intraepithelial Lesion Triage Study Group. Effects of age and human papilloma viral load on colposcopy triage: data from the randomized Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS). J Natl Cancer Inst 2002;94:102–7.
3 Franco EL. The sexually transmitted disease model for cervical cancer: incoherent epidemiologic findings and the role of misclassification of human papillomavirus infection. Epidemiology 1991;2:98–106.[Medline]
4 Schiffman MH, Schatzkin A. Test reliability is critically important to molecular epidemiology: an example from studies of human papillomavirus infection and cervical neoplasia. Cancer Res 1994;54:1944s–7s.
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J Natl Cancer Inst 2004 96: 1401-1402.
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