Review for 10.1186/1471-230X-12-130 (2012)

Reviewer's report
Title:Stoical patients are more likely to have colorectal cancer
Version: 1Date:8 May 2012
Reviewer: Alice Simon
Reviewer's report:
This is an interesting and well-written article. However there are a few issues
which need to be resolved.
Major compulsory revisions
1. The authors propose that they have identified a single item measure of
‘stoicism’. I am not convinced that this item measures ‘stoicism’. In the existing
literature ‘stoicism’ appears to refer to a stable personality trait describing a
disposition related to the control of emotions. The item used in this study may be
associated with this trait, but not measuring the trait itself. The item seems to be
measuring a tendency to appraise symptoms in a particular way, and not some
form of emotional processing. Therefore, I don’t think that it is entirely appropriate
that the paper be framed around the term ‘stoicism’ - and re-writing with a
different narrative is required.
2. The questions have been asked in the context of having a colonoscopy. Were
the people in this study referred for colonoscopy on the basis of their symptoms
rather than through some kind of screening programme? If so, then the scenario
is retrospective i.e. after help-seeking has taken place. One might think that
response to the symptom appraisal item will be somewhat coloured by how long
each person actually took to seek help for their bowel symptoms. Can the
authors comment on this and what effect it might have?
3. The finding of an association between the symptom appraisal item and the
presence of CRC is intriguing. However, there is a lack of clarity about what the
underlying construct being measured is (see above) and also about what the
underlying mechanism is for this association. The authors suggest that ‘stoics’
are simply more accurate. Might they also like to consider that stoics are
‘delayers’ ie. have taken a much longer time to seek help? Perhaps people who
take symptoms more seriously seek help earlier and therefore do not ever get to
the point of a CRC diagnosis e.g. maybe they have pre-cancerous polyps
identified and removed ? This is purely speculative, but it seems that
consideration of time to help seeking could be important in the observed
relationship. Could the authors consider this - and perhaps also suggest other
specific factors that may be mediators in the ‘discussion’?
4. Overall this paper would be better if it was written in a more tentative manner
with a view to encouraging some more detailed research – ie saying that this
interesting relationship has been found, and encouraging future work that
attempts to understand the underlying constructs and mechanisms. A short
report or ‘letter’ format may be more appropriate. BMC Gast. may not support
this type of submission – in which case an alternative publisher might be better.
Minor essential revisions:
5. The abstract cites ‘3.3’ times – it would be more accurate to report the
adjusted model here instead.
Discretionary revisions:
6. The authors might like to explore de Nooijer and van Osch’s work on paying
attention to symptoms e.g de Nooijer et al 2003 Soc Sci Med, van Osch et al
2007 EJ Cancer Prev.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests