A random effect model was applied in the stratified meta-analyses due to the existence of significant heterogeneities among studies. We further validated the diagnostic accuracy of the parallel and sequential combinations of ZNF582/HPV DNA test. The results for the stratified analyses were listed in Table 2. The paralleled and sequential combinations of ZNF582/HPV tests achieved AUC values of 0.793 and 0.876, under which, the pooled sensitivity were 0.97 (95% CI: 0.94–0.99) and 0.75 (95% CI: 0.69–0.80), the pooled specificity were 0.48 (95% CI: 0.44–0.52) and 0.87 (95% CI: 0.84–0.89) respectively.
We performed influence analysis based on the platform of Stata 14.0 software. No outlier studies were identified in ZNF582 methylation test (Supplement Digital Content 3, http://links.lww.com/MD/C804). Furthermore, meta-regression and subgroup analyses were conducted by assessing the impacts of 4 pre-specified covariates (average age, publication year, sample size, study location) on pooled sensitivity and specificity. Our data revealed that these covariates introduce heterogeneity in specificity with a P value less than .05. However, these covariates showed a low likelihood of sources of inter-study heterogeneity in sensitivity (Table 3, Supplement Digital Content 4, http://links.lww.com/MD/C804).
The funnel plots for publication bias showed no asymmetry for the pooled ZNF582 methylation analysis. The slope of coefficient was associated with a P value of .36, implying that no publication bias existed in the studies (Supplement Digital Content 5A, http://links.lww.com/MD/C804). For single HPV DNA test (Supplement Digital Content 5B, http://links.lww.com/MD/C804) and paneled ZNF582 tests (data not shown) also showed a low likelihood of publication bias.
Because CIN is a dynamic process, the approximate regression rates for CIN I, CIN II, and CIN III are 60%, 40%, and 33%, respectively, and their corresponding rates of progression to invasive cervical cancer are 1%, 5%, and 12%, respectively. Therefore, early diagnosis and treatment of CIN can reduce cancer mortality rate through effective screening programs drastically.
Papanicolaou cytology screening programs detect most CIN with a potential to transform into malignancy and for which treatment may prevent the cancer. Unfortunately, the cytology test is difficult to implement and retain at high quality, especially in underdeveloped countries. The sensitivity of HPV DNA testing is satisfactory, whereas the high prevalence of transient HPV infections had limited the specificity of this approach.[26,27] Of greater importance are accurate molecular prognostic classifiers which could be done on the screening specimen and would reflexively indicate the future risk of progression. The ability to accurately tell whether the HPV infection will become a CIN3 or disappear would radically trans-form screening programs. The results would be reduced testing, lower costs, fewer overtreatments, and less anxiety.
ZNF582, located at chromosome 19q13.43, encodes the Kru[Combining Diaeresis]ppel-type zinc finger protein 582 (HGNC: 26421), which contains 1 KRAB-A-B domain and 9 zinc-finger motifs. However, the biological function of ZNF582 is not yet well characterized. Most KRAB-ZNF proteins contain the KRAB (AB) domain and bind KRAB-associated protein 1 (KAP1) to co-repress gene transcription.[30,31] Members of the KRAB-ZNF family are probably involved in a variety of biological processes related to the DNA damage response, proliferation, cell cycle control, and neoplastic transformation. Recent studies revealed that methylation of its promotor CPG island is an important regulating manner in epigenetics, which is closed related to the development of malignant tumor, such as oral cancer,[32,33] esophageal squamous cell carcinoma, colorectal cancer, and leukemia.
We further conducted the stratified analyses to compare the diagnostic accuracy of ZNF582 methylation and HPV DNA test. Combined sequential testing of HPV DNA and ZNF582 methylation achieved an improved diagnostic accuracy compared to HPV DNA test alone with AUC and DOR of 0.876 and 19.23.
In this study, heterogeneity from non-threshold effects existed in the pooled studies. It is speculated that sample size, age, and study location may contribute to the heterogeneity sources. We further conducted influence and meta-regression analyses and our results revealed that the study location and sample size were likely to be a source of heterogeneity.
Although we did our best to conduct a comprehensive analysis, some limitations still exist. Only 7 studies were included in this meta-analysis, and all the studies included in this meta-analysis were conducted in Chinese Taipei and China. The results of this analysis in Chinese populations should be applicable to other developing countries with high incidence of CIN.
In conclusion, our meta-analysis revealed that ZNF582 achieves a promising diagnostic performance for CIN3+. And combined sequential HPV DNA and ZNF582 methylation test achieves an improved diagnostic accuracy compared to HPV DNA test alone. Therefore, we suggest that ZNF582 methylation assay can be used as an auxiliary biomarker for cervical cancer screening. Further high-quality studies from other geographies are still warranted to confirm our analyses.
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