Title: Diagnostic and pre-treatment intervals among patients with cervical cancer attending care
at the Uganda Cancer Institute: A cross-sectional study
Version: 1 Date: 27 Oct 2023
Reviewer's report:
I thank you for the opportunity to review this manuscript. Prompt presentation to health facilities
for assessment, diagnosis and treatment for patients with cancer are key for cancer care, and
I congratulate the authors for attempting to bring this information to the pool of knowledge.
There are however some concerns that will need to be addressed by the authors as a means to
improve the manuscript.
Abstract – the issues commented on in the main text will need to be addressed in the abstract
as well.
Methods
1. Cervical cancer has three treatment options i.e., surgery, chemotherapy, and radiation therapy.
Your manuscript seems to zero on pre-treatment intervals - as “…the time from histological
diagnosis to starting cancer chemo-radiotherapy”. Were there no other treatment options for the
study participants?
2. Under Methods, Data management and analysis: from the 3rd sentence, the write up now talks
about breast cancer, e.g., “… and pre-treatment interval (PTI) obtained by subtracting date of
histological diagnosis of breast cancer from the date of start of cancer chemo-radiotherapy at
the UCI”; “…the time period which has survival benefit is based on data from breast cancer
observational studies which showed that diagnosis of symptomatic breast cancer before 3
months…” and “Similarly, it has been shown that the optimum pre-treatment interval for starting
breast cancer specific treatment is 1- 2 months…” in the section. Is the study on breast cancer
or cervical cancer?
Results
In Table 1:
3. What was the basis of age categorization <40, 40 – 49, 50 – 59, >60? Is there any demographic
or epidemiological significance on this age categorization? It is well known that reproductive
age (sexual activity/cancer risks) starts much earlier, thus if the age categories were spread to
include the 20 – 29, 30 – 39,….and 60 - 69 and 70 – 79 and if any occurred above 79 as was
reported by Elima Jedy-Agba et al, 2020.
4. For cervical cancer, how is marital status a risks factor? For a married woman, does the risk
change when one is widowed or divorced? Widowhood or divorce still has the risk of having
been married. In your analysis did you model “divorced” or “widowed” separately? What would
be your results if you considered that “divorced” or “widowed” under subgroup of “married”?
5. What was the basis for dichotomous categorization of parity as <3 and >3? In Uganda by 2021,
the average parity was 4.58. Meaning women can have 0, 1, 2, 3, 4, 5, …X. with the average
4.58. I hope you can reconsider your categorization or provide explanation for your choice.
In Table 2
6. In the Methods section, Data Management and Analysis, you have two outcome variables
where it is stated “The outcome variables were dichotomized; diagnostic interval < 3 months
and # 3months, and pre-treatment intervals # 1 month and > 1 month”. And yet in Table 2 there
are four intervals “Total Interval (TI); Appraisal Interval (AI); Diagnostic Interval (DI); and Pre-
treatment Interval1 (PTI)”. Could you clarify how the different interval have been handled.
Discussions
7. In the discussion you introduced a new terminology of “middle aged” participants. Basing on
the age categorization in your study, what is your definition of “middle aged”? In responding
to this kindly consider comment 3 above as that would have made a definition of “middle age”
easier.
8. The role of marital status in relation to the intervals is not discussed.
9. This study would have benefited from qualitative exploration of the three important intervals
(Appraisal Interval (AI) - the patient; Diagnostic Interval (DI) and Pre-treatment Interval (PTI0
- the Health team) where the intervals are influenced by the specific players.
10. Were there no limitations to this study?
General
11. There are several variables in the questionnaire which were not reported in the study,
e.g., religion, education level of the husband, type of marriage (monogamous or polygamous),
whether they ever had pap smear done, etc. These are questions from which answers would have
provided important inputs to the results and discussions.