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A Randomized Controlled Trial

Albertus G. Siebers, MSc; Paul J. J. M. Klinkhamer, MD; Johanna M. M. Grefte, MD, PhD; Leon F. A. G. Massuger, MD, PhD; Judith E. M. Vedder; Angelique Beijers-Broos; Johan Bulten, MD, PhD; Marc Arbyn, MD, MSc, DrTMH

JAMA. 2009;302(16):1757-1764.

Context  Liquid-based cytology has been developed as an alternative for conventional cervical cytology. Despite numerous studies and systematic reviews, controversy remains about its diagnostic accuracy.

Objective  To assess the performance of liquid-based cytology compared with conventional cytology in terms of detection of histologically confirmed cervical intraepithelial neoplasia (CIN).

Design, Setting, and Participants  Cluster randomized controlled trial involving 89 784 women aged 30 to 60 years participating in the Dutch cervical screening program at 246 family practices. One hundred twenty-two practices were assigned to use liquid-based cytology and screened 49 222 patients and 124 practices were assigned to use the conventional Papanicolaou (Pap) test and screened 40 562 patients between April 2004 and July 1, 2006. Patients were followed up for 18 months through January 31, 2008.

Intervention  Screening for CIN using liquid-based cytology or conventional papanicolaou (Pap) test and the blinded review of all follow-up of screen-positive women (blinded to the type of cytology and the initial result).

Main Outcome Measures  Intention-to-treat and per-protocol analysis of the detection rates of and positive predictive values for histologically verified CIN in both cytology systems. Outcomes are presented as crude and adjusted rate ratios (adjustment for age, urbanization, study site, and period).

Results  The adjusted detection rate ratios for CIN grade 1+ was 1.01 (95% confidence interval [CI], 0.85-1.19); for CIN grade 2+, 1.00 (95% CI, 0.84-1.20); for CIN grade 3+, 1.05 (95% CI, 0.86-1.29); and for carcinoma, 1.69 (95% CI, 0.96-2.99). The adjusted positive predictive value (PPV) ratios, considered at several cytological cutoffs and for various outcomes of CIN did not differ significantly from unity.

Conclusion  This study indicates that liquid-based cytology does not perform better than conventional Pap tests in terms of relative sensitivity and PPV for detection of cervical cancer precursors.

Trial Registration  trialregister.nl Identifier: NTR1032

Author Affiliations: Departments of Pathology (Mr Siebers, Drs Grefte and Bulten, and Ms Vedder) and Obstetrics and Gynaecology (Dr Massuger), Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; Laboratory of Pathology, PAMM Laboratories, Eindhoven, the Netherlands (Dr Klinkhamer and Ms Beijers-Broos); and Scientific Institute of Public Health, Brussels, Belgium (Dr Arbyn).

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