PONE-D-19-18831

Socioeconomic predictors for low use of cancer screening in Latin America: a systematic review

PLOS ONE

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2. In the Methods, please provide the start and end dates of the search timeframe (month and year). Furthermore, please clarify why the databases were searched from 2009 onwards, instead of from inception?

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Reviewer #2: Partly

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Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Bernardo Nuche-Berenguer and Dikaios Sakellariou present a well written manuscript; however some issues should be adequately addressed in order to improve the manuscript.

Method and extraction of this paper is not clear. Please add statements regarding:

-no. of publications in each language reviewed. In publications written in Spanish and Portuguese, were only abstract considered? or the authors extract the data from the body of the article? Add a flowchart describing the process of selection of publications in this section (Fig1).

Line 71- Among the socio-economic factors to search should be considered the distance of patients to urban areas, since in LA a large number of people live far from urban regions or in rural-areas?. As well as, data on ethnicity of patients I understand that unfortunately these data are not always available.

Line 89- Inclusion and exclusion criteria:

Authors should describe why the choice of these types of tumor (breast, cervical,

colorectal cancer) are most reported types of tumors in the region?

Line 94.- What is the reason to exclude the Caribbean islands?

Line 98- Data extraction:

Among the factors that can be included if the population lives in rural zones or located in cities?

Authors should describe if used a test statistic for OR? The confidence intervals should be placed in parentheses to separate them from the OR, in all cases.

Improve and use the same format for tables.

In the discussion, the authors mention that some LA countries have made progress in reducing cancer disparities, could provide concrete examples of the country and program, since depending on these recommendations can be extrapolated to other countries in the region. CicLAP and others grups?

Reviewer #2: The article is a narrative review of studies reporting on socioeconomic determinants for access to screening programs for three cancer sites between 2009 and 2018. Only 24 studies on the early detection of breast and cervical cancer were eligible for this analysis, but none for colorectal cancer. Therefore, the title could be changed to refer to screening for the early detection of breast and cervical cancer in women.

Abstract: The Result section should report on the effects of socioeconomic factors, separately for cervical and breast cancer.

Methods: The authors mention that information on the characteristics of the screening programs was frequently limited. However, the type of the program is pertinent for the analysis of socioeconomic factors. With regard to cancer (in particular cervical cancer) screening, it should be clarified, if the screening program was a research or pilot project with special aim to implement screening in a defined population such as a rural district (all socio-economic classes) or in special groups (indigenous women of low socio-economic status) or whether it is a general (nation-wide) free health-care program (for all socio-economic groups). Only the last type of screening programs allows an unbiased analysis of the participation by socio-economic status (SES), because all other screening programs are designed for selected subpopulations. If this information is limited, the analysis could be in two steps: for the studies selected and for those with sufficient information to be classified as a general population-based screening program.

Methods:

Table 1 indicates, with regard to cancer control, “Latin America” is a fractionated continent, but I have problems to understand this table aimed to show the search strategy. For example, the information on screening services and SES is lacking for several countries, such as Paraguay or Uruguay. A figure might be better. Most articles are from Brazil, and, for example, Argentina conducted an important pilot project to implement cervical cancer screening in a rural region. There was, for example, no report from Uruguay, classified with a “very high” Human Development Index and running a well-organized cancer registry.

Table 2 shows the search terms, this may be sufficient to delineate the search concept.

Results:

Because of differences in funding (higher for cervical than for breast cancer in Latin America) and in cancer risks by socio-economic status (SES) (higher risks for developing cervical cancer in women with low SES and higher risks for developing breast cancer in women with high SES), the analysis should be performed separately for these two cancer sites and presented in subtables.

Cervical cancer is of special concern in Latin America. Screening for the early detection of breast and colorectal cancer is less well organized. Cervical cancer screening is not just one step, but a stepwise procedure (HPV screening, if positive CIN screening). This should be considered when presenting the studies.

Challenges for cancer control in Latin America have been subject to comprehensive evaluations. Major problem is disparity in health care between metropolitan und rural regions. Therefore, the studies should be categorized by region (nation-wide, urban, rural).

A table showing the results by country and cancer site would be informative as first table of the Result section. The article should describe the characteristics of the region (country, nationwide or state or department), method (e.g. mammography) and target population more precisely in Table 3, separately for breast and cervical cancer. So far, results were presented in Table 3 in an “unstructured manner” with a variety of formatting errors and not informative due to the crude “listing” of studies. This table requires major revision and a harmonization of the different outcome variables, such as years of education or income, if possible, into low, medium, high SES. By the way, underreporting of the income is not just “forgetfulness”. This harmonized classification would allow a meta-analysis of the effect of SES by cancer site.

Discussion

There are excellent publications on cervical cancer in Latin America. Nation-wide HPV vaccination programs have been established in a many countries, for example also in Paraguay, with support of international agencies, including PAHO, covering all girls in schools. The next step is the detection of HPV infections and precancerous lesions (CIN) in young women. Here, SES may play a crucial role, but mainly with regard to the clinical treatment capacity of those tested positively with higher CIN stages, which is limited to metropolitan regions. Poorer women from rural regions cannot travel to distant health care centers. This problem is not captured when investigating the role of SES in CIN screening in rural regions.

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Reviewer #1: Yes: Andrea Orue

Reviewer #2: No

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Socioeconomic determinants of cancer screening utilisation in Latin America: a systematic review

PONE-D-19-18831R1

Dear Dr. Sakellariou,

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Thomas Behrens

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: All the observations were considered and the manuscript improved.

1. Method and extraction of this paper is not clear. Please add statements regarding:

-no. of publications in each language reviewed.

RESPONSE: We added a clear statement about this in lines 111-113 and 132-142, and we also show this information in the PRISMA diagram. 127 articles were subjected to full review (74 in English, 36 in Portuguese and 17 in Spanish). Data were extracted from 24 articles (13 in English, 8 in Portuguese and 3 in Spanish.

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2.In publications written in Spanish and Portuguese, were only abstract considered? or the authors extract the data from the body of the article? Add a flowchart describing the process of selection of publications in this section (Fig1).

RESPONSE: Please see answer above.

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3.Line 71- Among the socio-economic factors to search should be considered the distance of patients to urban areas, since in LA a large number of people live far from urban regions or in rural-areas?. As well as, data on ethnicity of patients I understand that unfortunately these data are not always available.

RESPONSE: We revised the 24 selected articles to extract the specific information related to the impact of the place of residence on cancer screening participation. This information has been added to the column of independent variables in tables 4 and 5 and also a new subsection summarizing this information has been added in line 214-219 and also in the discussion (lines 268-271). The information about the impact of race ethnicity is briefly summarized in the subsection “Other factors”.

4. Line 89- Inclusion and exclusion criteria:

Authors should describe why the choice of these types of tumor (breast, cervical,

colorectal cancer) are most reported types of tumors in the region?

RESPONSE: Breast, cervical and colorectal cancer are together with other cancer types such as prostate or lung cancer the most common cancer types in Latin America. Countries in Latin America have national screening programmes for breast, cervical and colorectal. While breast and cervical cancer screening are recommended by WHO, colorectal cancer screening is recommended by other organizations such as USPSTF or the American Cancer society. Analysis in the access to prostate cancer screening was excluded because although prostate cancer screening is available in some countries there are no widespread national screening programmes and the benefits of prostate cancer screening are not clear. This is now explained from lines 51-55 and again in lines 92-94 (inclusion and exclusion criteria).

5. Line 94.- What is the reason to exclude the Caribbean islands?

RESPONSE: The Caribbean is a different sociopolitical region with a very different geographical and cultural characteristics. We feel that a similar analysis could be conducted in the Caribbean but that this should be done apart of the present analysis as the interpretation of the results may be different. This is explained in lines 99-101.

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6. Line 98- Data extraction:

Among the factors that can be included if the population lives in rural zones or located in cities?

RESPONSE: Thank for your comment. As stated above this information is now included in the results and discussion sections.

perfect!

7.Authors should describe if used a test statistic for OR? The confidence intervals should be placed in parentheses to separate them from the OR, in all cases.

RESPONSE: We made sure that all confidence internals (where available) were placed within parentheses. However, not all studies reported confidence intervals. The authors of the included studies used logistic regressions to calculate OR.

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8. Improve and use the same format for tables. We streamlined the presentation of the tables and we also divided the main results table into two separate tables (tables 4 and 5) for clarity, as suggested by reviewer 2.

9. In the discussion, the authors mention that some LA countries have made progress in reducing cancer disparities, could provide concrete examples of the country and program, since depending on these recommendations can be extrapolated to other countries in the region. CicLAP and others grups?

RESPONSE: We have added an example in lines 319-321.

ok

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No