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Comparison of Colposcopic Impression Based on Live Colposcopy and Evaluation of Static Digital Images

Liu, Angela H. BS; Gold, Michael A. MD; Schiffman, Mark MD; Smith, Katie M. MD; Zuna, Rosemary E. MD; Dunn, S. Terence PhD; Gage, Julia C. PhD; Walker, Joan L. MD; Wentzensen, Nicolas MD

Journal of Lower Genital Tract Disease: April 2016 - Volume 20 - Issue 2 - p 154–161
doi: 10.1097/LGT.0000000000000194
Original Research Articles: Cervix and HPV

Objective The aim of the study was to evaluate the agreement and compare diagnostic accuracy of colposcopic impressions from live colposcopy versus evaluation of static digital images.

Materials and Methods Live impressions and corresponding static images obtained during colposcopy of 690 women were independently compared. Diagnostic accuracy was calculated for colposcopic impressions from both methods, varying hypothetical thresholds for colposcopically directed cervical biopsies (acetowhitening or worse, low grade or worse, high grade or worse). Stratified analyses investigated the impact of referral cytology, human papillomavirus 16 infection, and age on colposcopic impression.

Results Overall agreement between live and static colposcopic visualization was 43.0% (κ = 0.20; 95% CI = 0.14–0.26) over normal, acetowhitening, low-grade, and high-grade impressions. Classification of acetowhitening or worse impressions showed the highest agreement (92.2%; κ = 0.39; 95% CI = 0.21–0.57); both methods achieved more than 95% sensitivity for CIN 2+. Agreement between live and static colposcopic visualization was 69.3% for rating low-grade or worse impressions (κ = 0.23; 95% CI = 0.14–0.33) and 71% when rating high-grade impressions (κ = 0.33; 95% CI = 0.24–0.42). Live colposcopic impressions were more likely to be rated low grade or worse (p < .01; odds ratio = 3.5; 95% CI = 2.4–5.0), yielding higher sensitivity for CIN 2+ at this threshold than static image assessment (95.4% vs 79.8%, p < .01). Overall, colposcopic impressions were more likely rated high grade on live assessment among women referred with high-grade cytology (odds ratio = 3.3; 95% CI = 1.8–6.4), significantly improving the sensitivity for CIN 2+ (66.3% vs 48.5%, p < .01).

Conclusions Colposcopic impressions of acetowhitening or worse are highly sensitive for identifying cervical precancers and reproducible on static image-based pattern recognition.

Colposcopic recognition of acetowhitening on static image is highly sensitive for diagnosing cervical precancers; static images reproducibly detect high-grade colposcopic changes and the normal cervix. Supplemental digital content is available in the text.

1Division of Cancer Epidemiology and Genetics, National Cancer Institute; 2Tulsa Cancer Institutes and University of Oklahoma School of Community Medicine; and 3University of Oklahoma Health Sciences Center, Oklahoma City, OK

Reprint requests to: Angela Hui-Chia Liu, BS, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Room 7E-216; E-mail:

The authors have declared they have no conflicts of interest.

The institutional review boards of both the University of Oklahoma Health Sciences Center and the National Cancer Institute approved the study.

The study was supported by the Intramural Research Program of the National Cancer Institute. The funding source has no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Copyright © 2016 by the American Society for Colposcopy and Cervical Pathology