Title: Rural-Urban Disparities in Preventive Breast and Cervical Cancer Screening among
Women with Early-Onset Dementia
Version: 2 Date: 04 Jan 2023
Reviewer:  Anne Marie Mccarthy
Reviewer's report:
The question of how cancer screening is utilized among early onset Alzheimer's and related
dementias patients is an important, given the high burden of both cancer and ADRDs.  However,
the manuscript displays a lack of full understanding of the issues surrounding cancer screening
among ADRD patients, and I do not agree with the key assumptions and interpretations of the
findings.
I've highlighted several statements and interpretations that I disagree with below.
1. "Breast and cervical cancer screenings are non-invasive tests".  This is a surprising statement.
I think that pelvic exams are indeed invasive. Though not as invasive, mammograms are
uncomfortable and require nudity and touching of breasts by the mammogram tech. Depending
on the stage of their disease, ADRDs may not understand what is happening to them or why,
and may find either procedure traumatic. Furthermore, both procedures require patients to stay
still for periods of time, which can be difficult for dementia patients, who often lose the ability
to follow verbal directions due to loss of short term memory.
2. "Screening may also help avoid extensive and costly treatment, thereby improving the
patient’s quality of life and reducing the financial and care burdens for family caregivers."
I think this statement is dubious. I would argue that screening may actually cause extensive and
costly treatment that would not occur if the patient had not been screened. Cancer treatments,
even for early stage disease, can cause real side effects and may potentially further cognitive
decline. For example, there is evidence that tamoxifen has negative effects on cognitive
performance and language (PMID: 33866625) which would likely hasten the ADRDs disease.
For breast cancer, modeling studies and trials suggest that patients only see a benefit from
screening if they have 10 years of life expectancy, which many dementia patients sadly do not
have. I think there is a good chance that screening for breast and cervical cancer in dementia
patients would cause more harm than good.
3. The authors interpret there to be low utilization of breast and cervical cancer among ADRD
patients. However, I would argue that these rates are high, and interventions to promote cessation
of screening among ADRD patients might be beneficial.
4. "The lower utilization level of preventive care in early-onset ADRD/CI patients is likely
because the cognitive impairments gradually cause a patient to lose the ability to self-manage
health conditions and maintain independence, posing substantial challenges to primary and
secondary care.25–28"
This may be partly true, but I think it is more likely that lower utilization of breast and cervical
cancer screening reflects the perceived futility of these screening tests among patients with an
incurable, terminal illness, ADRD.
The study design and analysis are sound. However, there needs to be  a much more nuanced and
thoughtful discussion of the relevant issues to place the results in proper context.