Reviewer ’s report  
 
Title:  Health Care Professionals' Attitudes towards Population -Based Genetic Testing and Risk -
Stratification for Ovarian Cance r: A Cross -sectional Survey  
 
Version: 1 Date: 25 Sep 2017 
 
Reviewer:  Alison  Hall 
 
Reviewer’s report:  
 
This paper is a useful addition to the debate about the utility of population based genet ic testing 
for ovarian cancer. In surveying the attitudes of health care professionals for the first time, and 
capturing attitudes towards population based genetic testing and risk stratification, the authors 
have been able to illustrate a number of dimens ions to this issue:  
 
- the lack of utility of screening in ovarian cancer to decrease mortality through early detection. 
As is pointed out early in this paper, definitive evidence on this point still needs to be 
demonstrated  
 
- the knowledge and expertise of a range of health care professionals as to what constitutes low, 
medium and high risk groups when applied to ovarian cancer - i.e. whether the various 
professionals involved have the tools to implement stratification in an ovarian cancer population  
 
- the willingness (and beliefs of self -efficacy) of the various professionals involved.  
 
Given the (admitted) limitations of the study such as small sample size, and potential 
unrepresentativeness of the sample since respondents t o the survey are likely to be those who felt 
some degree of confidence about their abilities to respond - the survey results are a useful pointer 
as to the potential gaps that will need to be addressed if population based genetic testing is to be 
implement ed. 
 
I found it interesting that genetics clinicians were the least likely to agree with the statement 'I 
would be willing to offer all my adult female patients genetic testing for ovarian cancer risk' - as 
it might be thought that this group of profession als might have the most expertise to make an 
informed judgement. I wondered whether the genetics professionals might have more 
reservations about testing given the current debate about classification of pathogenic variants, 
and the possibility that screeni ng tests may generate variants of unknown significance, or 
(depending on the markers involved) the possibility of incidental findings being generated. 
Genetics professionals also might have more experience of dealing with the negative impacts 
associated wi th testing (including fatalism or psychological effects). Some further exploration of 
these issues might be appropriate given that only a few specific harms are mentioned (e.g. at 
page 13 - discrimination by insurers and lack of cost -effectiveness, althoug h other issues are 
mentioned later in the discussion).  
 
The authors suggest at various points in the paper that much of the utility of genetic testing in 
ovarian cancer is predicated on the fact that 50% of individuals with pathogenic BRCA variants 
may not  report a strong family history, but these represent only 7% of ovarian cancer cases (as 
mentioned at the start of the paper) and even if a BRCA variant is detected, given the lack of 
family history, the penetrance associated with these variants may need m ore evaluation. So I was 
pleased that in their discussions of the PROMISE study, the authors refer to the inclusion of 
more risk factors including lifestyle risks which might be important if stratification tools are to 
be applied across the whole populatio n of at -risk women.  
 
In the concluding discussion, the authors were right to emphasise that it may well fall to GP's to 
manage those women who are classified at lower risk. The paper is right to emphasise the 
challenges associated with managing this group.  On the topic of insurance, the Concordat and 
Moratorium on Genetic Testing is currently being revised, and it was good that the authors 
flagged up the fact that knowledge of this policy might be variable amongst different 
professional groups.  
 
It would h ave been helpful if the term 'self -efficacy' - mentioned in the abstract and main text, 
could have been defined earlier in the paper.  
 
In summary an informative, well -written paper with no major flaws or gaps.  
 
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, please 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 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:  
 
Acceptable  
 
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 stocks or shares in an organisation that may in any way gain or lose 
financially from the pub lication 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 decla re 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 in terests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my re port to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Crea tive Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comment s 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal