Title: Impact of prior underinsurance on cervical cancer screening among Davidson County,
Tennessee, women diagnosed with invasive cervical cancer, 2008-2018
Version: 2 Date: 28 Dec 2021
Reviewer:  J. Elizabeth Jackson
Reviewer's report:
**Overall comments:
Thank you for the opportunity to review this manuscript; I also enjoyed learning about the
broader, ongoing HPV-IMPACT project in Tennessee. This is a very small study of a single
county but provides additional, population-based support for the importance of underinsurance
in the failure to screen or follow-up abnormal screening among women who progress to cervical
cancer. The authors effectively convey the context for this issue and its importance. The data
and methods sections could use some tightening up, and potentially (at the author’s discretion)
some relatively minor adjustments to the analysis.
**Specific comments:
**Lines 111-113: Not true – authors should consult a recent article in Cancer Medicine: Benard,
Vicki B., et al. "A population study of screening history and diagnostic outcomes of women
with invasive cervical cancer." Cancer Medicine (2021).
**Lines 117-120: The second half of this hypothesis would be determined by the first half since
the way this study is set up these outcomes are simply competing risks in this sample of women.
Recommend the authors rephrase.
**Data Collection: Authors should clarify which data elements came from registry reporting
(presumably data of diagnosis and staging, perhaps some of the sociodemographics) and which
were obtained from medical records.
**Data Collection: What efforts were undertaken to ensure that all of a woman’s relevant
medical records were collected to establish screening and follow-up history? As the authors
realize, any gaps in records over the extended time frame of 5.5 years can significantly affect
study findings. Since this is a population-based sample, presumably the authors had to track
down all relevant providers for the women in their sample. If these details are reported elsewhere
in the literature, please cite. If not, please provide more information regarding how relevant
providers were identified, the medical records collected, and their completeness evaluated. If
records review was restricted to the reporting provider, please explain.
**Line 156, “any presenting symptoms”:  Symptoms at what point? At the time of diagnosis?
Determining timing of symptom onset with respect to key clinical events like screening and
diagnosis can be very challenging due to reporting bias and gaps in medical records. Moreover,
if a symptom was initially reported prior to a Pap/HPV test that falls into the “screening” time
frame, that test is probably no longer a screening test, but is instead a diagnostic test and logically
would have to influence the determination of their screening status. Additional discussion of
the meaning and value of this measure is warranted. At a minimum, potential confusion of time
order of symptoms and testing is at issue.
**Lines 162-164, specifically “concerns about poor insurance coverage”: Documented how?
From visit notes or other? If visit notes, how were these coded? Since underinsurance is the
key independent variable, the authors should present a more detailed discussion regarding how
exactly underinsurance was calculated.
**Lines 164-168: Appreciate the effort to account for barriers to care, but medical records
are notoriously unreliable for capturing SDOH factors. How confident are the authors that,
e.g., language proficiency, incarceration history, and homelessness history would have been
systematically documented? For example, it’s generally not possible to distinguish “no” from
“unknown/not reported” for something like incarceration, since providers probably won’t
mention this if it’s NOT an issue. Are there sources the authors can cite indicating that these
data elements are valid and reliable when collected from medical records? Or are the authors
obtaining these measures using other means?
**Lines 172-174: Can the authors cite references to support the 6-month period prior to cancer
diagnosis as the screening window?
**Lines 182-184: Authors make reference to ACOG guidelines for management of
abnormal test results. However, the link provided does not lead to an ACOG guideline
statement, but rather to a FAQ-style ACOG page that appears to be a guide for the
general public rather than providers. The ACOG page where management guidelines are
provided (https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/10/
updated-guidelines-for-management-of-cervical-cancer-screening-abnormalities) actually
references the ASCCP guidelines (Perkins et al, 2019). Please: 1) provide an appropriate citation
for the guidelines; 2) correct the misattributions to ACOG in text and tables, including in the
supplement.
**Lines 182-183: The authors should provide a rationale for using 6 months as the cutoff
point for adequate follow-up for all women with abnormal results when ASCCP management
recommendations can vary significantly based on Pap/HPV results.
**Lines 188-189: Appears to repeat the same statement from the sentence before.
**Lines 203-207: It makes sense that the authors would combine these two categories for the
logistic regression, both conceptually and in practical terms. If the sample size allowed a more
fine-grained analysis (i.e., there are only 22 women in the no follow-up group), would the
authors pursue this, and why? Seems like this might be a limitation and a possibility worthy of
discussion, at the author’s discretion.
**Line 219: Similar to a comment above, how was in/completeness of medical records
evaluated?
**Line 220: Unclear on why the final analysis number is 212 if 61 were excluded because
their relevant screening/clinical history (which is the primary focus of this article) could not be
determined per Figure 1. Specifically, it’s confusing that the 61 women with “indeterminate”
screening are counted among the 212 in the complete sample, which, per this sentence, excludes
women with incomplete/unavailable medical records. In short, what is the difference between
“indeterminate” and incomplete/unavailable medical records? Please clarify.
**Table 1: Perhaps the major points could be summarized in the text in a sentence or two as
background, in lieu of the table.
**Lines 314-316: One significant difference is that women with indeterminate histories were
diagnosed a median 2 years earlier, perhaps pointing in part to poorer data capture due to older
medical records.
**Table 2: 1) Why aren’t underinsurance and other barriers reported in this table? 2)
Recommend moving the no follow-up column next to the no screening column, especially since
these two categories are collapsed in Table 3.
**Table 3: Why isn’t histology type included in this analysis? It’s significant in Table 2.
**Lines 416-418: Would be clearer to say: “Close to two-thirds of  Davidson County women
with incident cervical cancer had not had the recommended screening test in the 5.5 years prior
to their diagnosis ”.
**Discussion: Other limitations/challenges authors should consider mentioning: 1) age of the
records being accessed – in some cases women were diagnosed more than 10 years ago; 2)
management guidelines have also changed over the study period; 3) adequate follow-up is
defined based on a single cut point for all women regardless of their specific test findings;
4) medical records limitations for assessing SDOH/barriers; 5) small sample size limited
exploration of…