Reviewer ’s report  
 
Title:  Massive single visit cervical pre -cancer and cancer screening in eastern Democratic 
Republic of Congo  
 
Version: 0 Date: 03 Oct 2018 
 
Reviewer:  John Condon  
 
Reviewer’s report:  
 
This paper describes a pilot of a short, intensive screen -and-treat strategy for cervical screening 
(implemented as two one -week screening campaigns)  in a resource -poor environment in which 
there is no prospect of a permanent cervical screening program. The paper describes the rationale 
for the screen and treat strategy, its implementation (including recruitment process and clinical 
service), and basic  demographic characteristics of the women screened and their screening 
results. The paper is clearly and concisely written. Data collection was limited but appropriate. 
Statistical analysis was appropriate for the available data. The screening program was apparently 
implemented effectively, demonstrating that, in this hospital at least, this strategy is feasible.  
 
Overall, this is a well written paper that provides important information for cervical screening 
and similar health initiatives in Democratic Rep ublic of Congo and other very resource -poor 
areas. It is a useful contribution to the public health literature, particularly for resource -poor 
countries for which reliable evidence is scarce.  
 
There are several aspects of the paper that need to be improved.  
 
1. The research questions for the research component of the project are not articulated. 
There appear to have been three research questions relating to: the feasibility of the 
screen and treat strategy; the prevalence of CIN/SCC in this population; and ri sk factors 
for CIN.SCC in this population. The research questions and the study design to 
investigate each question should be explicit.  
 
2. The feasibility question is addressed in regard to the organisation of and resources 
required for the campaigns, rec ruitment strategy and number of participants, and clinical 
processes. However, there is no mention of cost or impact on routine services (which are 
presumably highly over -worked).  
 
3. It is quite an achievement that 644 women (440 from within Goma) screene d over nine 
days, but there is no mention of the size of the population eligible for screening or of the 
participation rate in the eligible population; is there any (even approximate) information 
available of the size of the adult female population of Goma ?  
 
4. The context in which these campaigns arose is also important, as is what the pilot study 
indicates about the potential sustainability of the screen and treat strategy. Who initiated 
this program and why? Was it a local or external priority? Could it have been conducted 
without the input of the Australian gynaecologist? If not, was there a training component 
for local staff and has the experience of these two campaigns made it locally sustainable? 
Was there a substitution strategy of training nurses or  others to do the screening (such as 
those mentioned in the Discussion), instead of relying only on (rare) gynaecologists? Has 
the experience of these two campaigns resulted any plans to use this strategy in Goma or 
elsewhere in DRC?  
 
5. The finding that 3 9.75% of women reported abnormal cervical bleeding in the previous 
year is overlooked. This is mentioned in the 'Results' (L185) as "A majority of the 
patients did not report a history of abnormal bleeding (60.25%)…", but is 40% 
prevalence of abnormal blee ding in a one -year period unusual? There is no further 
discussion of why this might have been so commonly reported; was the abnormal 
bleeding a motivator for these women to seek screening (the paper did not mention 
asking about the reason for attending), i n which case the prevalence of cervical 
abnormalities in participants would overestimate (because of selection bias) prevalence of 
cervical abnormalities in the Goma population.  
 
6. The association of abnormal cervical bleeding with prevalence of CIN/SCC is  discussed 
as the proportion of women with/without CIN/SCC who reported bleeding (L203). The 
cervical pathology might be causing the bleeding, but it is the abnormal bleeding (not the 
cervical pathology) that a woman might notice and act on. Consideration of the predictive 
value of abnormal bleeding to indicate cervical pathology (neoplastic or inflammatory) is 
needed, particularly with 40% of screened women reporting abnormal bleeding (although 
this might also be affected by selection bias).  
 
 
Minor correc tions  
 
7. The two screening campaigns are sometimes described as a program, sometimes as a 
pilot (e.g. L101 & L106); this should be consistent.  
 
8. L690 "… reduced prevalence…" and L72: "…cervical cancer prevalence…": should this 
be "incidence" rather than " prevalence"? Reference 4 reports incidence and mortality 
rates, not prevalence. I have not checked references 3 and 5.  
 
9. L72-73: cervical cancer incidence in developing countries is reported in ref 4 as 17.8 per 
100,000, not 15.7 (ref 4 table 1).  
 
10. The numbers included in the text of the Results section should be considerably reduced. 
There are too many numbers included in the text, most of which duplicate the numbers 
reported in the Tables. This unnecessarily reduces the clarity and flow of the text.  
 
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.  
 
No 
 
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 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 a n 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 reimb ursements, 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.  
 
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