PONE-D-21-01483

Advancing Health Equity in Cancer Care: The Lived Experiences of Poverty and Access to Lung Cancer Screening.

PLOS ONE

Dear Dr. Sayani,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Specifically, the paper is way too long (~5000 words) and needs to be shorted by half.  The topic is of interest, but one of the reviewers was unclear about the heavy focus on affordable housing as a proxy for SES.  This needs to be explained more clearly.  The limitations of the qualitative approach needs to be mentioned in the discussion and what specific next steps would the author recommend to address obvious disparities in lung cancer screening. However, because the paper addresses a topic of important that has not received much attention in the published literature we invite you to submit a substantial revised and shortened version  of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Michael Cummings, PhD

Academic Editor

PLOS ONE

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'AS is supported by a Postdoctoral Fellowship Award from the Canadian Institutes for Health Research. AL is supported by a New Investigator Award from the Canadian Institutes for Health Research, as Clinician Scientist by the Department of Family Medicine at the University of Toronto and as Chair of Implementation Science at the Peter Gilgan Centre for Women’s Cancers at Women’s College Hospital in partnership with the Canadian Cancer Society. AL is the Provincial Primary Care Lead for Cancer Screening at Ontario Health (Cancer Care Ontario). GL is supported by the Lusi Wong Early Detection of Lung Cancer Program and the Alan B. Brown Chair. GL has received funding from an unrestricted Boehringer Ingerheim grant to develop and implement electronic methods of identifying patients suitable for lung cancer screening in family physician offices. PS is a Clinician Scientist funded by Centre of Addiction and Mental Health, Department of Family and Community Medicine and the Ministry of Health and Long Term Care to direct the STOP program- An Ontario wide smoking cessation program focused on reducing inequities of access for discriminated and underrepresented populations. He also receives support from the Medical Psychiatry Alliance. He has independent grants from the GRAND program, created as an arms-length peer reviewed program for smoking cessation. He is an advisor to both Cancer Care Ontario and Canadian Partnership Against Cancer (CPAC) on tobacco cessation in patients with Cancer. EN is an employee of the CPAC, a pan-Canadian health organization, funded by Health Canada.'

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: N/A

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3. 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

Reviewer #2: No

Reviewer #3: Yes

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4. 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

Reviewer #2: Yes

Reviewer #3: Yes

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5. 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: Sayani and colleagues present the results of a qualitative research study aimed at describing barriers and facilitators to lung cancer screening in low income individuals in Toronto. The methodology and theoretical framework are sound, and the findings are important as countries consider how to target those at the highest risk for lung cancer and are also the most disadvantaged due to socioeconomic status. I have the following comments:

1) Overall, the manuscript is quite lengthy of a read at over 5000 words. I understand that PlosOne does not have a limit on words but would encourage the authors to summarize methodology and limitations and strengths sections further.

2) Similarly, the authors chose to embed representative quotes into the body of the text which extends the length of the manuscript. I would suggest considering instead constructing a table that pulls from the themes, subthemes and key findings presented in Figure 2 and putting in representative quotes into the table. If the authors chose to leave the quotes embedded, I would suggest reducing the length of the quotes. For example, participant Philip’s quotes could be shortened considerably. In addition, including quotes from the other 18 participants rather than utilizing the same participants might better support the themes and conclusions identified.

3) In the discussion section, the paragraph that discusses gender-based differences in smoking is not particularly relevant to the focus of the manuscript especially given the low number of female participants and distracts. I would suggest removing.

Reviewer #2: This interesting manuscript aims to address gaps in understanding factors that influence individual choices in preventative health care particularly lung cancer screening. While providing an interesting insight into experiences for the study cohort, the sample size is relatively small and the findings do not appear specific to lung cancer screening, even though the interview questions focussed on screening. The most important finding of this study appears to be the impact of housing instability. However the data presented do not link this tightly to choice in lung cancer screening. Rather this appears (quite logically) to affect health and attitudes more globally. This study describes of the impact of housing instability and income (as markers of SEC disadvantage) on general attitudes towards health and smoking cessation but is limited in its ability to "unpack" detailed reasons to avoid screening. The profound effect of housing instability appears to override other considerations. As a result more detailed reasons may be hard to elicit.

Other comments:

- the screen selection threshold for PLCOm2012 at 2% is higher than some published data and this is worth acknowledging in the discussion

- not clear whether the "derived rapport" technique was used across all three sites or not - could this introduce bias?

- description of sites would be of value for distribution of demographics in the denominator groups

- there are likely to be factors that influence screening uptake that can't be detected in this small sample (noting the very low levels of uptake detected in the USA - Pham Clin Lung Cancer. 2020 May;21(3):e206-e211. )

- the "judgmental and insensitive" clinical encounters warrant further discussion esp. for future research

While the comments from interviewees were very interesting, the sample is small and the findings - dominated by housing status - are not clearly shown to be linked to rejection of LC screening over and above other preventative health interventions.

Reviewer #3: I found the paper very compelling and thorough - and, distressing. As a strong advocate for both LDCT screening and tobacco cessation, it is housing (and associated economic issues) that is a critical factor - which is yet for another discipline to address.

Two typos: one is the difference between the $30 - 50,000 (line 248) or line 173: $30 - 59,000.

Line 323 should be 'groups' rather than 'group'.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Carolyn Dresler, MD, MPA

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Advancing Health Equity in Cancer Care: The Lived Experiences of Poverty and Access to Lung Cancer Screening.

PONE-D-21-01483R1

Dear Dr. Sayani,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Michael Cummings, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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

Reviewer #2: 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

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

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

Reviewer #2: 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

Reviewer #2: Yes

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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: Thank you, all of my comments have been addressed. The work presented here is important and the authors should be complemented.

Reviewer #2: Thank you to the authors for this comprehensive revision.  The paper has improved in response to reviews and my comments have been satisfactorily addressed.  The inclusion of quotes from study subjects in Table 2 works well.  The limitations of the study and areas for further research are presented well in the discussion.

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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

Reviewer #2: No