Reviewer's report
Title:Factors associated with late stage at presentation among patients with
cervical cancer in Northwestern Tanzania.
Version:2Date:8 September 2015
Reviewer: Lauro Bucchi
Reviewer's report:
Major Compulsory Revisions
Line 106. Clinical stage. Please specify what staging system was used. I
suppose that clinical staging was also used for defining stage IA, IB, and IIA
cancers, that are theoretically susceptible to surgery (with pathologic staging) as
a first therapeutic option. I invite the authors to clarify this essential issue (see my
next comment).
Line 118. Between line 118 and 119, please add a paragraph explaining – in brief
– the treatment protocol according to clinical tumour stage. Information on
treatment is vital. If patients with early-stage cancer are not treated in an
appropriate manner, there is no rationale for educating women on early
symptoms of the disease (line 225).
Line 122. “bivariate” in not correct. Change it to univariate (see my next
comment).
Line 168. “ ... binary logistic regression ...” There is a problem with the statistical
terminology. If I understand correctly, the authors have built several univariate
binary logistic regression models, i.e., one for each determinant studied. The
term binary refers to the dependent variable, i.e., tumour stage, that is a
dichotomous variable. The association between each determinant (for example,
education) and tumour stage is a univariate association. So, please change to:
“When univariate logistic regression was done to identify the factors associated
with a late tumour stage at presentation, lack of formal ....”.
Table 4. Bivariate is not correct. The association shown under this heading is
univariate. Bivariate applies, for example, to the association between two
variables stratified by a third variable.
Minor Essential Revisions
Line 35. Please clarify “.. lack of decision making among women ...”. What does
exactly mean?
Lines 51-52. The sentence “At BMC, ...” should be moved to line 80 (see below).
Line 53. Please change ‘advanced stage of the disease’ to ‘advanced tumour
stage’. Lung and liver metastases are equivalent to an advanced stage of the
disease, and cannot be defined as a frequent complication of ... an advanced
stage of the disease. It must be made clear that the higher the T stage (i.e., the
tumour stage) the higher the probability of detecting distant metastases.
Lines 59-65. I recommend deleting the entire paragraph, which is unnecessary in
the Introduction. Details of detection modalities can be given in the Discussion, in
the paragraph between the lines 211 and 218.
Lines 66-80. Please collapse all these lines into a single paragraph. This will end
with the word ‘illiterate’.
Line 80. Please commence a new paragraph with the statement “At the Bugando
Medical Centre (BMC) of Mwanza, northwestern Tanzania, a previous study has
shown that 47.3% of patients with cervical cancer presented with
advanced-stage disease. Despite this, information about factors [...] challenge.
The current study was designed to bridge this gap. Findings from [...] from
cervical cancer”.
Line 89. Delete “ ... at Bugando Medical Centre (BMC) ...” which is no longer
necessary.
Line 98. “Study population included women with suspicious cervical cancer ...”.
This sentence does not seem correct. The study population included women with
histologically confirmed cervical cancer (line 134) who were identified among
women presenting with suspected cancer. I suggest the authors to modify the
sentence to: “The study population was identified among women with suspected
cervical cancer ...”.
Line 105. Please change ‘... the pre-tested ...” to ‘... a pre-tested ...”.
Line 121. After “percentages.”, please add “Stages IA, IB, and IIA were
considered advanced-stage disease”.
Lines 134-135. Please replace the sentence “Therefore ...”. with the following:
“Therefore, 202 patients with histologically confirmed cervical cancer were
included in the study”.
Lines 147-156. These paragraph needs to be reorganised. Title the paragraph
“Clinical presentation and histological type”. After “... 14.6%.” put the sentence
“Squamous cell carcinoma was the most common tumour type”. No need for
data: numbers are in the Table. Delete all the rest. There is sufficient tumour
stage information in the paragraph titled “Prevalence of late stage cervical
cancer” (delete “among participants”).
Line 161. Delete “Of all patients with cervical cancer”, which is unnecessary.
Line 170. “Lack of self-decision making”. What is “self-decision making”?
Line 172. Traditional healers are equivalent to traditional health practitioners?
Lines 172-173. “.. lack of decision making to attend health care facility ...”. As
stated above, I do not understand what type of decision making is involved.
Line 182-183. Change Napel to Nepal.
Line 205. Change “ ... uninsured women ...” to “... lack of health insurance”.
Discretionary Revisions
Title. The authors have evaluated both patients characteristics (commonly
referred to as ‘factors’) and disease characteristics, including symptoms.
Probably a title like “Patient and disease characteristics associated with late
tumour stage at presentation of cervical cancer in northwestern Tanzania” would
be more appropriate. In any case, please delete the comma between
‘northwestern’ and ‘Tanzania’.
Lines 19-20. I suggest replacing these two sentences with a statement on the
burden of cervical cancer, especially of advanced-stage disease, in Tanzania.
Line 24. Change “... with confirmed cervical cancer by histology ...” to “ ... with
histologically confirmed cervical cancer ...”.
Line 47. Please change ‘detections’ to ‘detection’.
Line 55. Fistulous is an adjective. Probably the authors mean ‘fistulae’. Please
check all medical terms, and change ‘lungs’ to ‘lung’. Also, the abbreviations VVF
and RVF should be given here.
Lines 68-69. If a understand correctly, the authors mean “The influence of social
and demographic factors may differ between different populations”. In addition,
put a full stop at the end of the sentence. As a consequence, the next sentence
will begin with “In a study from New Zealand ...”.
Line 91. “ ... and other paramedics ...”. What does it mean?
Line 97. ... 400 cases. It would be very useful to know whether this number
represents a part or the majority or the large majority of total annual incidence of
cervical cancer that can be hypothesised for the Mwanza area.
Line 107. Please delete. ‘... was recorded ...”.
Line 131. Please change “... clinical diagnosis of cervical cancer ...” to “... clinical
diagnosis of suspected cervical cancer ...”.
Line 138. Change “ ... participants ...” to “ ... patients ...”; and “ ... education, and
those ...” to “... education. Among those with ...”.
Line 142. Please delete “Among all the participants”.
Line 143. Please clarify 110. Is it the sum of 109 married women and one
cohabiting woman? Also, please shorten the sentence “ ... while the rest were not
living with the husband ... “ to “ ... while the rest were not.”. Change “ ... widowed)
and 149 ...” to “... widowed. One hundred forty-nine women ...”.
Line 169. Change “ ... uninsured patients” to “... lack of health insurance”.
Lines 173-174. Delete “...of the patients with cervical cancer.” This is understood.
Line 220. Change “number” to “Proportion”.
Level of interest: An article of importance in its field
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no financial and non-financial competing interests in relation
to this paper.