PONE-D-21-29044Participation and adherence to mammography screening in the Capital Region of Denmark: The importance of age over timePLOS ONE

Dear Dr. Pett,

Thank you for submitting your manuscript to PLOS ONE; I sincerely apologise for the unusually delayed review timeframe. Your manuscript has been assessed by two reviewers, whose comments are appended below. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Although the reviewers comment positively on the potential importance of this work, they raise a number of concerns regarding aspects of the methodology and discussion of the results that should be addressed. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please note, however, that the statements that you have provided regarding 1) the need for ethics approval and 2) review by a data protection committee satisfies our policies for research involving human participants (https://journals.plos.org/plosone/s/human-subjects-research). You therefore do not need to address the first point raised by reviewer 2, although please do include a response to this point in your rebuttal letter when you resubmit your manuscript.

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PLOS ONE

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: No

Reviewer #2: No

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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

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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: The article deals with a very important issue. The manuscript seems technically sound to me, and the statistical analysis was performed appropriately and rigorously. The manuscript is well-written, with the exception of a couple of places where the authors used present tense when past tense was called for. The results are presented clearly in an orderly fashion and include a very informative and clearly presented table. The authors make some good points in the discussion and appropriately compare their results to those of many other studies. However, I am not clear regarding one of their attempts to explain why the most significant change occurred within the older age groups who participated to a larger extent than they did before, that being since the women aged by approximately 10 years during the study period, the higher participation is coherent with their slightly higher participation rate as younger women. I would have liked to see this idea fleshed out a little more. I agree with the authors' suggestion that personalized mammography screening utilizing risk-based screening recommendations could provide a better alternative to one-size-fits-all mammography screening programs. The authors did a good job in delineating possible limitations and a possible strength of the study. Finally, I don't see from the results the authors' statement in the conclusion that adherence was lower than the recommended 70%.

Reviewer #2: Thank you for asking me to review this manuscript.

Breast cancer is one of the most common cancer among women and important cause of death. Detection in early stage is curable and this is one of the cancers that can be screen detected. However, screening also leads to increase number of minor biopsy cases in BIRADS IV category. Voluntary participation is an important factor and adherence to screening program helps in reducing cancer mortality, this makes it an important manuscript.

I have a few observations to make

1. Authors state that this is analysis of registry data, according to me even this requires approval of the ethics committee, as authors state that Danish law does not require the approval, in that case it’s the ethical committee which should issue the waiver.

2. This is a longitudinal data over 20 year period, which is divided in 5 year age groups, during the 20 year period the participant would have moved from first group to nearly the last group, how is the movement of individual participant from one age group to other over subsequent years handled in the study?

3. Number of women participated in the program be separated from number of mammograms, as the mammograms will be repeated over period of time while number of eligible women will increase by addition of newer women becoming eligible.

4. Each women should be treated as a single case even if she underwent screening 10 times, this has not happened in this paper as all women in each round are counted this would mean a person may have been counted 10 times in 20 year period, the data should be separated.

5. There is no description of eligible population even number of women eligible at a point and overall (eligible in first year +added in second/third etc.)

6. It is not clear that the participation rates are for all eligible women or all women invited, authors should provide denominator and numerator beside percentage that is provided in text, it is important to mention how many women were eligible at a particular time

7. Has the reason for not participating recorded? Was invitation sent only once or was repeated?

8. Were any breast cancer awareness program or educational programs conducted between the study period? Were there any efforts to disseminate the importance of breast cancer screening and mammography? if so, could the increase be because of increase awareness

9. Did this increased participation resulted in increased detection (change in incidence)? Or stage shift?

10. Did this increased participation also resulted in increased rate of biopsies?

11. Most importantly did the mortality from breast cancer reduced as a result of increased participation in mammography screening?

12. What was the benefit of the program and increased participation rate that this article shows?

13. Though this study make us understand the age as important factor for participation in program, it does not inform what is the importance of this observation and also the remedies that may improve participation of younger women in breast cancer screening program (or no importance)

14. It is suggested that authors look at additional data and come out with newer findings (or benefits as sought above) that can help in improving the program and reducing the mortality from breast cancer, in its present form, the information provided in the manuscript is already known.

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Reviewer #1: No

Reviewer #2: No

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Participation and adherence to mammography screening in the Capital Region of Denmark: The importance of age over time

PONE-D-21-29044R1

Dear Dr. Pett,

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,

Sandar Tin Tin

Academic Editor

PLOS ONE

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 #2: (No Response)

Reviewer #3: 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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: I Don't Know

Reviewer #3: Yes

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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 #2: No

Reviewer #3: (No Response)

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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 #2: Yes

Reviewer #3: (No Response)

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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 #2: I thank authors for their response however, the response to some of the questions is not satisfactory like that of Q2,3, and 4

I do not see any modifications made in the manuscript as per comments

Reviewer #3: All comments from reviewers have been addressed appropriately. It is now acceptable for publication.

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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 #2: No

Reviewer #3: Yes: Rasmi G. Nair

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