Reviewer ’s report  
 
Title:  Characteristics of cervical disease among symptomatic women with histopathological 
sample at Hawassa University referral hospital, Southern Ethiopia  
 
Version: 3 Date: 09 Mar 2017 
 
Reviewer:  Alejandra  Castanon  
 
Reviewer’s report:  
 
The authors have misunderstood my comments on how the availability of a screening 
programme and whether you select a symptomatic population or not influences the results. In the 
presence of screening it is more likely that histological samples will show precancerous disease 
particularly if  the population is asymptomatic. If there is no screening and the population is 
symptomatic then the histological samples are more likely to show cancer. The results in this 
study provide evidence to show that some form of cervical cancer prevention is war ranted in 
Ethiopia. It is also encouraging because most of the cancers were squamous and screening is 
better at identifying squamous lesions when compared to adeno lesions. I am not invalidating the 
results my comments are intended to lend weight to the co mparisons made with the other 
literature in the discussion.  
 
Line 190 -194: The authors have misunderstood my previous comments. What I meant is that 
since there is very little screening in Ethiopia (line 107 -108 "in Ethiopia national cervical cancer 
screeni ng programme is not established and screening coverage was only 0.8%") one would 
expect very few of the lesions observed in this study to be precancerous (these are usually 
asymptomatic lesions). Therefore I think only the last sentence "There is less awar eness of 
cervical cancer screening in the area and women come to hospital only after symptoms" is 
appropriate.  
 
Line 200: The authors in their response have argued against this, but I still feel that the 
comparison with the study in Addis Ababa should inclu de a sentence to say that differences may 
be because they restricted samples to those from women who has postmenopausal bleeding. This 
is a particularly high risk symptom which explains why that study found cancers other than 
cervical among their populatio n whilst this study did not.   
 
Line 201 -207: In the end of the first paragraph in the discussion of the Malaysian study the 
author's state "screening exists for women aged 25 -55 years". This explains the difference in 
results between studies.  
 
My comments a bove do not invalidate your study or the comparison. A better way to frame the 
discussion would be to use the references to say that because there is little awareness and 
screening in Ethiopia most lesions are already cancerous when diagnosed. Whereas in o ther 
places where screening is undertaken this was not the case.  
 
Paragraph starting line 208 could be combined with paragraph starting line 218 as they both 
discus histological differentiation.  
 
Line 231: the authors have misunderstood my comment. The sent ence "Due to availability HPV 
tests, screening tests with Pap smear is recommended ……" does not make sense here. It may be 
better to amend the next sentence to: "In developing countries like Ethiopia where there in no 
well organised screening programme thi s pattern is expected and the only way to reverse that is 
by investing in screening and awareness. Studies show that one -third of cancer deaths can be 
prevented through screening tests, vaccination and lifestyle changes."  
 
Line 256: "cervical cancer was alm ost increasing in study periods" - does this mean it was not 
statistically significant?  
 
Line 258: suggests that the ministry of health has introduced a screening programme - is this 
true? As I pointed out above in the introduction you state there is no scr eening programme.  
 
Line 267: I would remove the sentence about further studies should focus on screening of 
asymptomatic women.  
 
Are the methods appropriate and wel l 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 ad equately 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:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
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