miR-203 as a novel biomarker for the diagnosis and prognosis of colorectal cancer: a systematic review and meta-analysis

Figures & data

Figure 1 The flowchart depicts the selection of studies for the meta-analysis and quality assessment.

Notes: (A) The flowchart; (B) Quality assessment of the included studies for diagnostic analysis by QUADAS-2. It summarized “risk of bias” and “applicability concerns” through judging each domain for each included study. It shows the major biases concentrated upon the ‘‘index text”.
Abbreviations: CRC, colorectal cancer; QUADAS-2, Quality Assessment of Diagnostic Accuracy Studies 2.

Table 1 Main characteristics of studies included in meta-analysis for diagnosis

Study	Country	Patients/controls	Mean or median age (years)	Assay type	Internal control	Cut-off values	SEa	SPb	AUCc	QUADAS-2	Expression
Hur et al,^Citation8 2017	America	184/24	>60	qRT-PCR, 2^−∆∆ct	U6 snRNA	–	47.50%	85.52%	0.678	5	Upregulated
Sun et al,^Citation32 2016	People’s Republic of China	99/88	55	qRT-PCR, 2^−∆∆ct	U6 snRNA	–	74.70%	71.40%	0.757	4	Upregulated
Wang et al,^Citation33 2014	People’s Republic of China	30/30	>55	qRT-PCR, 2^−∆∆ct	miR-16	9.595	85.29%	96.15%	0.9	4	Downregulated
Fu et al,^Citation31 2016	People’s Republic of China	122/30	–	qRT-PCR, 2^−∆∆ct	RNU6B	0.0384	83.30%	71.30%	0.78	4	Downregulated
Sheinerman et al,^Citation34 2013	America	10/30	57.4	qRT-PCR, 2^−∆∆ct	miR-30e-3p	–	94.00%	90.00%	0.98	5	Upregulated
Hur et al,^Citation8 2017	America	144/24	>60	qRT-PCR, 2^−∆∆ct	U6 snRNA	–	62.50%	77.68%	0.748	5	Upregulated
Wang et al,^Citation33 2014	People’s Republic of China	83/59	>55	qRT-PCR, 2^−∆∆ct	miR-16	9.595	94.55%	91.95%	0.923	4	Downregulated
Sheinerman et al,^Citation34 2013	America	10/30	57.4	qRT-PCR, 2^−∆∆ct	miR-145	–	94.00%	86.00%	0.97	5	Upregulated
Sheinerman et al,^Citation34 2013	America	10/30	57.4	qRT-PCR, 2^−∆∆ct	miR-148a	–	79.00%	67.00%	0.9	5	Upregulated

Notes:

a Sensitivity.

b Specificity.

c The area under the curve. ‘–’ indicates literature did not give relevant data.

Abbreviations: AUC, area under the curve; qRT-PCR, quantitative real-time polymerase chain reaction; QUADAS-2, Quality Assessment of Diagnostic Accuracy Studies 2; SE, sensitivity; SP, specificity.

Table 2 Main characteristics of the studies included in meta-analysis for prognosis

Study	Origin of population	Study design	Number of patients (M/F)	Age (years)	Stage	miR-203 assay	Cut-off	Survival analysis	Follow-up months	HR	MSQA
Deng et al,^Citation25 2016	People’s Republic of China	R	72 (39/33)	>50	I–IV	qRT-PCR	Median	OS	84	SC	8
Hur et al,^Citation8 2017	America	R	Tissue 154 (90/64); Serum186 (107/79)	>60	I–IV	qRT-PCR	Median	OS	72	DE	9
Tao et al,^Citation26 2014	People’s Republic of China	R	90 (47/43)	70	–	qRT-PCR	Median	OS	27 (3–85)	DE	8.7
Bovell et al,^Citation27 2013	America	R	381 (188/193)	>65	I–IV	qRT-PCR	Median	OS	Blacks 228 (84–377), Whites 180 (84–360)	DE	8
Croce et al,^Citation30 2013	America	R	67	>50	I–IV	qRT-PCR	Median	OS	–	DE	7.7
Toiyama et al,^Citation29 2012	Japan	R	120	–	I–IV	qRT-PCR	Median	OS	–	DE	7.7
Schetter et al,^Citation28 2008	America	R	84 (66/18)	64.6	I–IV	qRT-PCR	Median	OS	68	DE	8

Notes: Study design is described as retrospective (R). ‘–’ indicates literature did not give relevant data.

Abbreviations: DE, data extrapolated; HR, hazard ratio; MSQA, mean score of quality assessment; OS, overall survival; qRT-PCR, quantitative real-time polymerase chain reaction; SC, survival curve.

Figure 2 The forest plots show the pooled diagnosis index of miR-203 for the diagnosis of CRC.

Notes: The point efficiencies from each study are shown as circle and the pooled efficiencies are shown as diamond. Inconsistency is used to quantify the heterogeneity caused by nonthreshold effect. For these studies, random effects model was used to pool the data. (A) The pooled sensitivity and specificity for Sheinerman et al;³⁴ (B) The pooled sensitivity for all the included studies; (C) Specificity; (D) PLR; (E) NLR; (F) DOR, and their 95% CI are displayed respectively, which suggests miR-203 might be a potential diagnosis biomarker of CRC.
Abbreviations: CI, confidence interval; CRC, colorectal cancer; DOR, diagnostic odds ratio; NLR, negative likelihood ratio; PLR, positive likelihood ratio.

Figure 3 The SROC of miR-203 for the diagnosis of CRC.

Notes: Every circle stands for a study, the SROC curve is symmetric and the AUC is 0.89, which is consistent with moderate diagnostic accuracy for diagnosing CRC.
Abbreviations: AUC, area under the curve; CRC, colorectal cancer; SENS, sensitivity; SPEC, specificity; SROC, summary receiver operating characteristic.

Figure 4 Forest plots of studies evaluating HRs of high miR-203 level.

Notes: (A) The nine survival data sets from CRC tissue and serum samples were pooled to calculate OS. The random effects analysis model showed the pooled HR for OS is 1.62 with 95% CI: 0.93–2.82, and P=0.09. (B) The six survival data sets from CRC tissue studies. The random effect analysis model was used to calculate the pooled HR, and HR =1.63 (95% CI: 1.03–2.57, P=0.04) for OS. (C) The three survival data sets from CRC serum. The random effect analysis model was used to calculate the pooled HR, and HR =1.59 (95% CI: 0.31–8.12, P=0.58) for OS.
Abbreviations: CI, confidence interval; CRC, colorectal cancer; HR, hazard ratio; OS, overall survival.

Table 3 Summary table of HRs and their 95% CI

Study	HR	95% CI (LL–UL)	P-value	Outcome	Origin	Expression
Bovell et al,^Citation27 2013	1.9	1.05–3.43	0.002	OS	Tissue	Upregulated
Croce et al,^Citation30 2013	3.2	1.1–9.4	0.03	OS	Tissue	Upregulated
Deng et al,^Citation25 2016	0.62	0.32–1.2	0.0006	OS	Tissue	Downregulated
Deng et al,^Citation25 2016	0.36	0.20–0.64	0.0001	OS	Serum	Downregulated
Hur et al,^Citation8 2017	1.56	0.80–3.05	0.1962	OS	Tissue	Upregulated
Hur et al,^Citation8 2017	4.47	2.10–9.5	0.0001	OS	Serum	Upregulated
Schetter et al,^Citation28 2008	3.1	1.5–6.4	0.003	OS	Tissue	Upregulated
Tao et al,^Citation26 2014	1.38	0.77–2.47	0.273	OS	Tissue	Upregulated
Toiyama et al,^Citation29 2012	2.6	1.17–5.77	0.019	OS	Serum	Upregulated

Abbreviations: CI, confidence interval; HR, hazard ratio; LL, lower limit; OS, overall survival; UL, upper limit.

Figure 5 Publication bias based on the eligible studies for diagnosis and prognosis.

Notes: Every point represents one study, and the line is the regression line. They show no publication bias exists. (A) Publication bias from Deeks’ test is shown by funnel plots for miR-203 diagnostic value; (B) Publication bias from Egger’s test is shown by funnel plots for tissue and serum miR-203 prognostic value; (C) Publication bias from Egger’s test is shown by funnel plots for serum miR-203 prognostic value.
Abbreviation: ESS, effective sample size.

Figure S1 miR-203 diagnostic analysis based on the eligible studies.

Notes: (A) Fagan’s nomogram describes the possibility of miR-203 assay to confirm or exclude cancer patients. In detail, for any people with a pretest probability of 20% to have cancers, if the miR-203 test in cancer detection was positive, the posttest probability to have cancer would rise to 54%; while a negative result of miR-203 assay meant the posttest probability would drop to 5% for the same people. Hence, miR-203 assay may play an important role as an initial screening method for cancer. (B) The overall distribution of studies is summarized in the likelihood matrix. Each corresponds to a study.^⑦, Sheinerman et al³⁴ was on the bottom left side of the matrix, indicating a sensitive “rule out” test. However, it reported reasonable sensitivity with incorporation bias from knowledge of a desaturation study outcome.

Abbreviations: RUQ, upper right quadrant; LUQ, upper left quadrant; RLQ, lower right quadrant; LLQ, lower left quadrant; LRN, negative likelihood ratio; LRP, positive likelihood ratio; NLR, negative likelihood ratio; PLR, positive likelihood ratio; prob, probability.

Figure S2 The sensitivity analysis based on the studies for prognosis of OS.

Notes: Forest plot for the sensitivity analysis shows the results of the meta-analysis did not change after the removal of any one paper. (A) The nine survival data from CRC tissue and serum; (B) six survival data from CRC serum.

Abbreviations: CRC, colorectal cancer; OS, overall survival.

Figure S3 The publication bias based on the studies for prognosis of OS.

Notes: Publication bias from Begg’s test is shown by funnel plots. Every point represents one study. (A) The nine survival data from CRC tissue and serum; (B) six survival data from CRC serum.

Abbreviations: CRC, colorectal cancer; Inhr, In hazard ratio; OS, overall survival; SE, standard error.

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