Review for 10.1186/s12876-025-04213-2 (2025)

Title: Insights from age-stratified endoscopic detection metrics support initiating colorectal
cancer screening at age 45
Version: 3 Date: 26 Feb 2025
Reviewer's report:
Dear Editor and Authors,
I read with interest the manuscript addressing the adenoma detection rate across different
age intervals and its implications for colorectal cancer screening initiation at 45 years. The
study utilizes a large-scale dataset of over 200,000 colonoscopy reports from multiple centers,
offering a comprehensive analysis of endoscopic findings, including histopathological outcomes
and detection rates of adenomas and polyps. The authors present a compelling evaluation of
age-related differences in ADR and polyp detection rate, contributing valuable insights to the
ongoing discussion on the optimal age for CRC screening initiation. However, to enhance the
study’s clarity, methodological transparency, and overall impact, the authors should address the
following points:"
Major:
- While the manuscript provides clear inclusion and exclusion criteria, could you clarify whether
all included patients were referred specifically for routine screening? Although symptomatic
patients (e.g., those with rectal bleeding or IBD) were excluded, it is unclear whether patients
referred for other non-screening indications (such as incidental imaging findings, anemia, or
surveillance after a prior negative colonoscopy) were also omitted. If a proportion of patients
were referred for non-screening indications, this could introduce selection bias, potentially
affecting the generalizability of the ADR findings. If referral indications were not explicitly
available in the dataset, addressing this as a potential limitation in the discussion would enhance
the study’s methodological transparency.
- Does the dataset include information on gender and ethnicity? If so, conducting sub analyses
based on these demographics could enhance the study by providing a more comprehensive
understanding of screening behaviors and potential disparities. Given that screening rates and
perceived barriers have been shown to vary significantly across different gender and ethnic
groups, incorporating these variables could strengthen the findings and contribute to a more
detailed interpretation of the results?
Minor:
- The manuscript would benefit from grammatical, structural, and stylistic proofreading to
enhance clarity, particularly in the abstract, where precise language and conciseness are essential
for effectively conveying the study's objectives, methods, and key findings.
- Throughout the text, full terms such as 'colorectal cancer (CRC)', 'polyp detection rate (PDR)'
and 'adenoma detection rate (ADR)' were repeatedly used after being initially defined. Please
use the abbreviations consistently after their first mention.
- In the results section, interpretations such as the role of age in polyp development and
recommendations for regular colonoscopy screening introduce discussion elements that are
typically reserved for the Discussion section. To maintain clarity and academic rigor, consider
moving these interpretative statements to the Discussion while keeping the Results focused
solely on reporting the data and statistical findings
- Discussion: Since the study includes only patients referred for screening, the statement about
increased colonoscopy utilization should be more specific. Instead of suggesting a general rise
in colonoscopy use, it would be more precise to state that the utilization of colonoscopy for
screening has increased among individuals aged 55 and above compared to those in the 45–49
and 50–55 age groups.
- Discussion: 'CRC screening' and 'colonoscopy' appear to be used interchangeably. Since CRC
screening includes various modalities such as FOBT/FIT, and colonoscopy, it would be clearer
to specify 'colonoscopy-based screening' when referring specifically to colonoscopy, while
reserving 'CRC screening' for broader discussions that encompass all recommended screening
methods.
- Additionally, given the low rate of malignancy observed in the study but the reported ADR/
PDR findings, it would be valuable for the authors to briefly discuss what the optimal screening
strategy might be in this context. Should the emphasis be on risk stratification, alternative
screening methods, or a combination of approaches?
- The manuscript would benefit from a dedicated paragraph at the end of the Discussion
section addressing the study's limitations. The authors should acknowledge potential limitations,
such as selection bias, the retrospective nature of the data, or any constraints related to
generalizability and potential impact of any missing variables (e.g., lifestyle factors, ethnic and
genetic predisposition) or methodological considerations.