Review for 10.1186/s12876-023-02860-x (2023)

Title: An adjusted Asia-Pacific colorectal screening score system to predict advanced colorectal
neoplasia in asymptomatic Chinese patients
Version: 4 Date: 07 May 2023
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
No - manuscript has some fundamental flaw(s)
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Thank you for allowing me the opportunity to review this interesting
work by Zhang and colleagues. The manuscript is well-written. I have the following comments:
Major:
1. When including variables for multivariate analysis, why was a p <0.2 considered. Can the
authors explain the rationale? Was sensitivity analysis done at other value i.e., p <0.1, p <0.05
etc.
2. The authors noted baseline differences (rates of smoking, drinking, BMI) between the
derivation and the validation cohort. How was this accounted for?
3. The adenoma detection rate was average for derivation cohort and very low for validation
cohort. Can the authors explain this? It seems that Chinese population have an ADR of
approximately 25% in a recent study (Wang et al. Medicine (Baltimore). 2019 Apr; 98(15):
e15103.)
4. For the ease of readers, the authors should make a table of APCS model and A-APCS model
so that the readers can identify the difference based on factors in the two risk model.
5. The authors noted that the c-statistic for risk predictors of A-APCS was slightly higher than
APCS score, however statistical significance was not achieved in validation cohort. I am not
sure why the authors would claim in their conclusion that A-APCS is better than APCS if the
results do achieve statistical significance.
Minor:
1. Page 2, line 35.. “Utilizing the developed score, 20.0%, 41.2%, and 38.6% of patients in the
validation c cohort were classified as average….” The numbers don’t add upto 100%, please
check.
2. Page 4, line 59-60.. “For example, the starting age for CRC screening is over 40 years in
China and Japan, whereas in European and American countries, it is often over 45 years.” Please
add the term average risk screening as starting age is different for high risk individuals.
3. Page 6, line  99-100.. “current or past drinkers as those who consumed alcohol # 2 times/
week…” why was the alcohol not quantified like cigarettes? For e.g. 2 standard drinks, etc.
REQUESTED REVISIONS:
Unfortunately, I identified some flaws in the methodology such as baseline imbalance between
the two study cohorts, low baseline ADR, incorrect interpretation of the results. This will either
be a major revision or rejection based on the comments above.