Reviewer ’s report  
 
Title: Regional disparities in the flow of access to breast cancer hospitalizations in Brazil in 
2004  and 2014  
 
Version: 0 Date: 12 Dec 2019  
 
Reviewer: Alessandro Bigoni  
 
Reviewer's report:  
 
Thank you for this interesting piece of work. The rationale is well described, key elements of the 
setting, the variables, the data sources, and the statistical methods reported are comprehensively 
displayed. The discussion is informative and provides the reader with a balanced interpretation of 
the results.  
Please, allow me a few questions and comments.  
1 - [Introduction] Please, consider updating some of the references, especially the 
epidemiological ones.  
2 - [Introduction, 1st Paragraph, Line 1] Althou gh breast cancer is the malignant neoplasm with 
the highest incidence and mortality rates in women, it is not the "most malignant," at least from 
the perspective that "most malignant" refers to lethality. Please, consider revising this sentence.  
3- [Metho ds, Studied Variables, 5th line] You often refer to a "first AIH," however, you also 
state that "each AIH referred to the number of hospitalizations and not the number of patients." If 
you don't have patient identification, you also don't know exactly whic h AIH is the true "first." It 
also means that in a given year, a patient can be hospitalized in their home state and also in 
another state. Is that correct? If yes, please consider changing the term "first AIH."  
4 - [Methods, Spatial Analysis] Your work, a lthough very insightful, is by definition a 
descriptive work and does not contain a spatial analysis. You do a description of the flow and 
also describe the changes that occurred between two time periods. However, you do not apply 
any statistical method to  assess why this flow changed. Please, consider changing this in the 
body of your manuscript.  
5 - [Discussion] Please, provide more information on how you interpreted your results. It is not 
clear to me why you conclude that a "decreased average distance t raveled characterizes a 
reduction of the residents' movement to access treatment." It seems equally possible that an 
improvement in health care provision in neighboring states could have the same effect.  
6 - [Discussion] You state that "[…] with the except ion of the Midwest region, which may be 
justified in part by the decrease in health coverage in this region." However, you provide no 
evidence for this decrease. Please, provide a reference to support this statement.  
7 - [Discussion] Please, provide some discussion on how a change in incidence on the different 
regions could affect your results.  
 
 
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, p lease 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 manusc ript 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:  
 
Needs some language corrections before being published  
 
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 stock s 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.  
 
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