Reviewer ’s report  
 
Title: Association between obesity and abnormal Papanicolau(Pap) smear cytology results in a  
resource -poor Nigerian setting  
 
Version: 1 Date: 27 May 2019  
 
Reviewer: Li Cheung  
 
Reviewer's report:  
 
The authors reported a positive association between obesity and abnormal Pap in a cross -
sectional cohort in Nigeria. The paper is well -written and the stat istical analysis conducted is 
appropriate. This paper contributes to the existing literature exploring the link between obesity 
and cervical cancer (or related surrogate outcomes such as precancer, abnormal Pap, or HPV 
positivity).  
 
The literature thus fa r has shown differing directions in the association between obesity and 
cervical cancer related outcomes, depending on the outcome measure used. Of interest to me is 
"Why do we see the associations that we see?" Is it due to biological mechanisms, sexual 
behavior, or screening? For the most part, my comments are directed toward whether more 
details can be added to understand the "why".  
 
1) The authors did an excellent job of controlling age -related differences in the obese and non -
obese population, as table  1 shows these populations to be completely balanced by age deciles. 
In addition, matching is described as considering locale, education level, parity, and total number 
of lifetime sexual partners. What was the size of the larger pool of potential particip ants from 
which matched subjects were obtained from?  
 
2) Currently, table 1 categorizes number of sexual partners as 1 or 2 or more with 75% of 
participants reporting 2 or more. Please expand the categories to better see if there exist 
differences in sexua l behavior between the two groups.  
 
3) Have these women previously been screened or is this primarily an unscreened population? If 
this information (previously screened vs unscreened) is available at the woman level, it would be 
nice to see it included in table 1. If both obese and not obese groups are well -screened, then 
increased cytologic abnormalities in the obese group may be indicative of prior screening 
failures due to the increased difficulty in conducting a Pap smear on obese women. If both 
groups are primarily unscreened, then differential screening is ruled out as a possible explanation 
for the association.  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following question s: 
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or sha res in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you re ceived reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have n o competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
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CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal