Reviewer’s report
Title: 
Breast Cancer screening patterns in Jamaican women: review of the
largest national mammography clinic
Version: 
0 
Date: 
28 Sep 2020
Reviewer's report:
REVIEW BMWH-D-20-00164 
This study describes the breast radiology examinations and breast cancer
diagnoses at a large center in Jamaica, with special focus on evaluating women's
participation in screening and the effect that the relatively low participation rate
has on cancer diagnoses.
ABSTRACT
METHODS
1. Specify covariates and outcomes
RESULTS
2. Consider reporting overall screening statistics on person-level, i.e. the total
number of women in the study, what proportion had one screening and what
proportion had two screenings.
3. In relation to your aim, it would be very relevant to report the invasive tumor
size and lymph node involvement for the 4 women who were screen-detected
with the 570 who were not.
4. Please use consistent terminology - if "abnormal" is the same as "suspicious
for breast cancer" choose one of the two, if they are not the same - please make
clear what "abnormal" means (i.e. abnormal mammogram including benign
findings).
5. Is "routine mammography" the same as screening, then please write "screening
mammography" since most people will not understand what is meant by "routine
mammography".
BACKGROUND
6. P4L9-20: Can you write out some numbers for example what proportion has
lymph node involvement?
7. P5L14-48: Can you describe more specifically the workflow for screening? Is
there an organized screening program? Hospital-based? Regionally? Nationally?
How and how often are women invited to come to screening? Is it only
mammography? Is ultrasound performed in screening or only for clinical
patients? Do the women in screening also have a "referring doctor" or is the
screening organized and managed entirely by UHWI/UWI? 
METHODS
8. Please define terms used: "abnormal", "positive", "suspicious for breast
cancer" - now it is a bit difficult to understand if there is a difference between
these or if they are all the same.
RESULTS
9. MISSING DATA: Please report for how many women (if any) you were
unable to find clinical records. Please report for how many women with breast
cancer who had missing data on tumor characteristics (tumor size, lymph node
involvement).
TABLE 1 to 3
10. Please write out the nominator and denominator per group (not only the
percentage). 
RESULTS: 
11. Please see if you can relate any of your metrics to an international
benchmark (or from the US or EU). For EU please see:
http://www.euref.org/downloads?download=24%3Aeuropean-guidelines-for-
quality-assurance-in-breast-cancer-screening-and-diagnosis-pdf.
12. P9L39-54: Can you also report tumor characteristics (for screen-detected and
diagnostic/clinical separately)? At least if the cancer was in situ or invasive, and
tumor size and lymph node involvement. It would be important to illustrate your
claim elsewhere that the cancer is more advanced at diagnosis for clinically
detected cases.
13. P10 L40: You write that 5 percent of women with positive mammogram,
which should be around 29 women had mammogram as surveillance. Yet, earlier
you mention that "only 4 of those women were recorded as not having had any
signs/symptoms". How do you accommodate those two numbers?
DISCUSSION
14. Would it be possible to relate result to some international benchmark?
15. It seems from the "Conclusions" that the main issue is that there is no
organized screening program in Jamaica? Could you include this in the
discussion and if there is any publication or speculation what is the root cause?
Economics? Attitudes? 
16. Regarding dense breasts - please clarify whether the 19% that had ultrasound
was due to dense breast tissue in asymptomatic women (i.e. screening) or due to
regular work-up of symptomatic women.
FIGURE
17. I think the figure does not show what is most interesting in the study. I would
suggest instead to show the number of screening mammograms vs
clinical/diagnostic mammograms year by year. 
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing
interests, considering the following questions:
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 shares 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 received 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 no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes