Review for 10.1186/s12876-023-02697-4 (2023)

Reviewer’s report
Title: 
Determining the survival benefit of postoperative radiotherapy in patients
with pT1-3N1M0 rectal cancer undergoing total mesorectal excision: a
retrospective analysis
Version: 
0 
Date: 
31 Jul 2022
Reviewer's report:
The manuscript by Chen and colleagues describes a SEER based retrospective
analysis of the role of postoperative chemotherapy with or without radiotherapy
in patients with "low-risk" rectal cancer who had not received preoperative
treatment. The rational to conduct this study is the fact that the NCCN guidelines
recommend postoperative chemoradiotherapy in stage III rectal cancer patients
without preoperative therapy in the era of improved TME surgery and standard
preoperative (chemo)radiotherapy in intermediate/high risk patients.
Given the disbalance in the target population, the investigators performed a
propensity score matching allowing to study their primary endpoint of cancer-
specific survival (CSS). 
The main finding from the total matched cohort of 842 patients, was that only in
the subgroups of patients with 3 or more tumor positive lymph nodes and those
with tumors larger than 5 cm, a statistically significant improved CSS can be
expected.
Based on their findings, the authors suggest to take these two adverse prognostic
factors into account in the guidelines to support the decision to treat
postoperatively. 
The question addressed in this study is clinically relevant, however, there are
several major issues that do not justify its acceptance for publication:
1. First of all, the English is very poor, making the article difficult to read. This
starts with the title that is not a proper English sentence. Many more examples
follow. The paper should be checked and rewritten.
2. Current guidelines are based on the highest level of evidence from randomized
trials. Although it can be argued that RWD are important as well, the results
from the current analysis cannot be considered to make treatment choices in
clinical practice. Many relevant factors such as information on CRM, EMI and
MRI (re)staging are lacking. Therefore, the results do not add sufficient new
information to the current knowledge and are therefore of limited value to the
scientific community.
3. The authors indicate pT1-3N1M0 as "low-risk", yet these stages also include
intermediate risk disease that should receive preoperative (chemo)radiotherapy
according to current guidelines. In addition, these stages are not in agreement
with the locally advanced stages mentioned in the NCCN guidelines. It is not
clear why the authors limited their target cohort by making this selection.
4. Figures 3A, 3B, 3C, 3D, 4A, 4B, 6A, 6B, 6C, 6D, 7A, 7B, 7C are redundant
and should be presented in a table or moved to the supplementary part.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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Yes
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No
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from apparent manipulation?
Yes