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

Reviewer's report
Title:Stoical patients are more likely to have colorectal cancer
Version: 1Date:16 April 2012
Reviewer: Magdalena Esteva
Reviewer's report:
Review: 'Stoical patients are more likely to have colorectal cancer'
Magdalena Esteva
This is a study evaluating how stoical patients (those who consider any symptom
as less seriously than others) waiting for colonoscopy are more prone to have
colorectal cancer.
- An article of limited interest
- Unable to decide on acceptance or rejection until the authors have responded
to the major compulsory revisions
Reviewer comments
1.- Introduction
There are some weakness in the introduction that I think have to be afforded.
The authors consider there is little research on the variability on how seriously
people take their symptoms. However, there is considerable research from
different disciplines as sociology and anthropology ..... on symptom interpretation
process, symptom seriousness and diagnosis delay, symptom seriousness and
help seeking behaviour, how disruptive symptoms are perceived as more
serious. A sounder literature review is needed.
2. Methods:
The design of the study is not well defined in the methods sections but well
defined in the abstract.
In the section 'Assessment of predictive validity', has to be added ' question
predictive validity for presence of colorectal cancer.
Statistical analysis of predictive validity: Logistic regression. Authors must explain
why they have not considered other variables with univariate low p values (<0,10
or <0.25) as recommends Lemeshow in order to explore confusion?. If symptom
perceptions is a new variable more variables of the previous study have to be
included in the model. Nagerkele value of the model could be interesting.
Statistical package used is needed.
Results:
Presentation of data is not sound. It will be much clear if all data is presented in
tables together with results each statistical analysis. No figures in the manuscript
as tables in this case are much more informative. Complete logistic regression
model has to be presented in the correspondent table as it contains valuable
information.
Discussion
In the first paragraph authors declare a 2-fold increase in prevalence of colorectal
cancer in those who take any symptom as less or lot less seriously compared
with the same as others but adjusted OR IS 1.47 with a confidence interval that
contains 1. The importance and dimension of these results have to be discussed
more thoroughly and how this fact affects predictive validity. Consequently, last
paragraph in pg 11 is too ambitious because authors have not built and obtained
a robust predictive model. Moreover, if authors consider that comparison of those
who take symptoms seriously vs less seriously is more relevant, reference
category in adjusted and unadjusted analysis for this variable has to be changed.
Discussion section is quite limited. Discuss very little about differences and
similarities of others authors results. In fact there are only 3 references in the
discussion section.
Discuss how bowel symptoms considered by others as disrupting and often
taken as serious like abdominal pain decreases in patients who take any
symptom seriously.
Others points of interest in the discussion are:
Is the question explored a proxy of stoical?. Content or construct validity
limitations.
If the authors consider that those who take their symptoms more seriously than
others access health services for minor symptoms that do not reflect organic
pathology. How this fits with proven evidence that the main reason to visit a
doctor is bad health?.
People waiting for colonoscopy are not general population, Most of them have
experienced bowel symptoms and most of them could be expecting disappointing
results. Would you expect different results from general population?
Quality of written English: Acceptable
Statistical review: -- Yes, but I do not feel adequately qualified to assess the
statistics.
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I have not conflict of interest