Reviewer ’s report  
 
Title: Towards equity in organised cancer screening: the case of cervical cancer screening in 
France  
 
Version: 0 Date: 30 Aug 2018  
 
Reviewer: Reviewer 2  
 
Review er's report:  
 
PEER REVIEWER COMMENTS: To view the full report from the academic peer reviewer , 
please see the attached file.  
 
REVIEWER COMMENTS FROM REPORT: Brief summary of the data presented in the 
manuscript  
The authors of the present article (article type - debate) aimed to discuss the value step -by-step 
strategy of equity aiming to tackle hea lth cancer inequalities and issues of stigmatization and 
respect for individual freedom. The authors suggest that input from ethics and social sciences 
must be involved in order to potentiate the development of the strategy of proportionate 
universalism.  
 
Background  
In the Background section the authors might consider expanding the description of proportionate 
universalism with more references. For example, Carey et al. have published a review, where 
they propose a proportionate universalism heuristic where  they combine evidence from welfare 
state and social studies (Carey et al. Towards health equity: a framework for the application of 
proportionate universalism. Int J Equity Health. 2015).  
 
Discussion  
The Discussion is well -structured and focused on the ma in ethical issues related to the screening 
process.  
However, there are several additional issues that might be addressed to improve the current 
paper. In particular, the risk of overdiagnosis is morally challenging, since it may significantly 
harm a patie nt. This issue has been highlighted in a number of recent papers, such as Rogers, 
2018 (Rogers. Analysing the ethics of breast cancer overdiagnosis: a pathogenic vulnerability. 
Med Health Care Philos. 2018).  
Another important issue is screening in elderly  patients. For instance, emphasize that clinicians 
should consider functionality, comorbidities, and life expectancy of elderly patients to select the 
appropriate methods of diagnosis and treatment (Varghese et al. Breast Cancer in the Elderly. 
Surg Clin N orth Am. 2018). In addition, the authors may consider a study by Waller et al., which 
shows the specific reasons or barriers to cervical screening due to age differences (Waller et al. 
Exploring age differences in reasons for nonattendance for cervical scr eening: a qualitative 
study. BJOG. 2012).  
With regard to stigmatisation in risk interventions (pages 6 -8), the authors might consider 
mentioning aspects of screening among the ethnic minorities. In particular, a study by Johnson et 
al. has provided analysi s of common health beliefs among minorities and immigrants and named 
sociocultural factors affecting health care utilization in these social groups (Johnson et al. 
Cervical cancer screening among immigrants and ethnic minorities: a systematic review using 
the Health Belief Model. J Low Genit Tract Dis. 2008).  
As to the discussion of the issues related to individual freedom and compulsory vaccination and 
the ways to solve these issues, the authors may cite and discuss a very recent paper by Ward et 
al., Why France is making eight new vaccines mandatory. Vaccine 2018).  
With regard to "Respect for individual freedom and privacy" section, the authors may discuss the 
factors affecting the decision to participate in the screening. For example, Moutel et al. descri bed 
potential obstacles to participation in organized screening in France (Moutel et al., Women's 
participation in breast cancer screening in France --an ethical approach. BMC Med Ethics. 2014).  
Also, with regard to paternalism, the authors may consider to discuss nudging in screening, such 
as framed information, default bias, or authority bias. In particular, Hofmann and Stanak have 
recently reviewed different aspects of nudging in: Hofmann and Stanak. Nudging in screening: 
Literature review and ethical gui dance. Patient Educ Couns. 2018).  
 
 Overall conclusion  
The current debate article highlighted the most important challenges and issues related to the 
medical screening program. The article is well -supported by the relevant references. However, 
there are s everal ethical aspects which would be important to emphasize in this article. The 
current paper will be of clear interest for clinicians, epidemiologists and other relevant healthcare 
professionals.  
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
The authors are recomm ended to expand the discussion on several additional ethical issues 
mentioned in the peer review.  
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 control s 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.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the qu ality 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?  
 
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financially from the publication 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 o f 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?  
 
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below.  If your reply is yes to any, please give details below.  
 
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a specified timeframe. Honoraria for revi ews such as this are paid regardless of the reviewer 
recommendation.  
 
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