Acceptability and appropriateness of a risk-tailored organised melanoma screening program: Qualitative interviews with key informants

Kate L. A. Dunlop; Louise A. Keogh; Andrea L. Smith; Sanchia Aranda; Joanne Aitken; Caroline G. Watts; Amelia K. Smit; Monika Janda; Graham J. Mann; Anne E. Cust; Nicole M. Rankin

doi:10.1371/journal.pone.0287591

Peer Review History

Original SubmissionNovember 7, 2022
30 Jan 2023 Decision Letter - Maryam Farooqui, Editor PONE-D-22-30659Acceptability and appropriateness of a risk-tailored organised melanoma screening program: Qualitative interviews with key informantsPLOS ONE Dear Dr. Dunlop, 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. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Mar 16 2023 11:59PM If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 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: Abstract: 1. Kindly describe methods section in terms of research design, sampling method and data analysis methods employed. Introduction: 1. The claim in the opening statement is not supported by sufficient evidence. The only reference cited is inconclusive, which doesn’t advocate for “International evidence-based guidelines do not recommend routine screening for melanoma”. 2. Line 92; what are those challenges. Challenges will definitely impact acceptability and of course, appropriateness. Therefore, briefly enlist the main challenges. 3. Lines 96-102; Lack reference 4. Authors have argued that implementation of risk-tailored screening is challenging. I am wondering if they can address the feasibility of intervention first as what is the point of willingness for implementation of an unfeasible intervention. I can understand from Proctor et al’ given framework for ‘outcomes for implementation research’ that acceptability comes before feasibility and cost consideration. But still seems good to anticipate feasibility based on available literature. 5. Overall, introduction section seems reporting available literature rather than building an argument to justify the significance of risk-tailored screening, challenges in its implementation and role of acceptability and appropriateness of a risk-tailored organised melanoma screening program towards its implementation. Methods, results and discussion are well written and address the concerns highlighted above. Reviewer #2: 1. Abstract Suggest changing the pronoun word "we" to "researcher" Please explain the inclusion and exclusion criteria in the method. The author should specify what was the 'valuable information' in the conclusion and briefly describe the importance of the 'valuable information" 2. Introduction The introduction section has a clear statement demonstrating that the focus of the study. The problem definition is stated clearly. 3. Risk-tailored screening, also referred to as ‘risk-stratified screening’ or ‘targeted screening’, tailors screening (e.g. eligibility,frequency, intervals, type of test) to individual risk rather than the mostly one-size-fits-all approach of organised population screening programs. Please add the reference Please add citations when necessary. 4. This qualitative study aimed to explore the acceptability and appropriateness of population based, organised risk-tailored melanoma screening from the perspective of key informants. Please harmonize the statement 5. Methodology I would like to suggest to the author provide more information on the methodology of the study such as: -How about the sample size selected? -The total number of respondents from four expert groups? -The inclusion and exclusion criteria? -The semi-structured interview protocol process consisted of what questions? 6. Ethical consideration Please add the reference number or approval code 7. Table 1 Please add the subtitle in the table Example: Frequency(n) 8. Discussion How do the findings add to the body of scientific knowledge on the particular issue? Should highlight the implication of the results to health policy. 9.Summary Please make a subheading for summary 10. Please state the source of the research funding including the grant name and number. 11. References Please add doi in the article’s references. Example: Trager MH, Queen D, Samie FH, Carvajal RD, Bickers DR, Geskin LJ. Advances in Prevention and Surveillance of Cutaneous Malignancies. Am J Med. 2020 Apr;133(4):417-423. doi: 10.1016/j.amjmed.2019.10.008. Epub 2019 Nov 9. PMID: 31712100; PMCID: PMC7709483. ****** 6. 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 ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Comment author PLOS ONE Qualitative interviews with key informants.pdf https://doi.org/10.1371/journal.pone.0287591.r001
Revision 1
8 Mar 2023 Author Response REVIEWER #1 Abstract: 1.Kindly describe methods section in terms of research design, sampling method and data analysis methods employed. AUTHOR RESPONSE: We deleted the existing wording in the Methods section (Abstract) and replaced it to include research design, sampling method and data analysis methods as follows: “This was a qualitative design study using semi-structured interviews. Key informants were purposively selected to ensure expertise in melanoma early detection and screening prioritising senior or executive perspectives. Consumers were expert representatives. Data were analysed deductively using the Tailored Implementation for Chronic Diseases (TICD) checklist.” [p2, Line 50-54 tracked manuscript] Introduction: 1.The claim in the opening statement is not supported by sufficient evidence. The only reference cited is inconclusive, which doesn’t advocate for “International evidence-based guidelines do not recommend routine screening for melanoma”. AUTHOR RESPONSE: For clarity we have included a new opening statement, revised the previous opening statement to align correctly with the reference and added additional references as follows: “Early detection of melanoma is associated with better survival [1]. However, international evidence-based guidelines report there is insufficient evidence to recommend for or against routine screening for melanoma in the asymptomatic population [2]” due to insufficient evidence that screening using current approaches reduces mortality [3, 4], concern about the potential harms associated with the overdiagnosis of slowly-progressive lesions [4-6] and that costs may outweigh benefits. [p4, Line 74-80 tracked manuscript] 2. Line 92; What are those challenges. Challenges will definitely impact acceptability and of course, appropriateness. Therefore, briefly enlist the main challenges. AUTHOR RESPONSE: We have expanded on the challenges with additional wording and references for clarity as follows: “Moving from opportunistic screening to an organised risk-tailored approach to melanoma screening will be challenging, as it will require changes to practice and policy [21, 24]. Nevertheless, several countries are moving forward with implementing risk-stratified screening as part of their long-term cancer plans. [25-27]” [p5,102-105 tracked manuscript] “This would include redistributing health service resources towards higher-risk individuals to screen more frequently whereas those at lower risk to screen less frequently or perhaps not all. [p5, Line 111-114 tracked manuscript] “Integrating risk factors such as lifestyle behaviours, environmental exposures and personal genomic risk information in addition to traditional risk factors to determine screening eligibility will also bring challenges in communication[26, 27]. These potentially significant policy and practice changes… [p5, Line 111-117 tracked manuscript] 3. Line 96-102; Lack of reference. AUTHOR RESPONSE: References have been added to support existing information added, related to challenges as above: Line: 96-97: Reference added [p5, Line 111 tracked manuscript] Line: 100-102: Reference added [p5, Line 120 tracked manuscript] Line: 105-107: References were moved to reflect findings and an additional reference added: Acceptability of risk-tailored screening programs by key stakeholders has been explored primarily in breast cancer reporting a high level of acceptability [28, 29] but with some reluctance to stop organised screening for those at low risk [30, 31] [p5, Line 119 and 120 tracked manuscript]. To our knowledge, no studies have explored stakeholders’ views of the acceptability and appropriateness of risk-tailored melanoma screening [37]. [p5-6, Line 121-125 tracked manuscript] 4. Authors have argued that implementation of risk-tailored screening is challenging. I am wondering if they can address the feasibility of intervention first as what is the point of willingness for implementation of an unfeasible intervention. I can understand from Proctor et al’ given framework for ‘outcomes for implementation research’ that acceptability comes before feasibility and cost consideration. But still seems good to anticipate feasibility based on available literature. 5.Overall, introduction section seems reporting available literature rather than building an argument to justify the significance of risk-tailored screening, challenges in its implementation and role of acceptability and appropriateness of a risk-tailored organised melanoma screening program towards its implementation. Methods, results and discussion are well written and address the concerns highlighted above. AUTHOR RESPONSE: We thank the reviewer for this observation and guidance. We have revised the wording in the introduction to address the feasibility of the intervention (risk-tailored organised melanoma screening) and to help build an argument to justify its significance as follows: We revised the second paragraph of the introduction to read “A risk-tailored approach to screening for melanoma offers a promising way forward [3, 13-15] and melanoma risk prediction tools validated for the Australian population are available [16-18]. New technologies such as surveillance photography, teledermatology and artificial intelligence, have the potential to support clinicians in screening[19].” [p4, Line 90-94 tracked manuscript] We also added the sentence: ‘This approach will be timely while evidence for this new paradigm in melanoma screening is further developed.” [p6, Line 128-129 tracked manuscript] REVIEWER #2 General comments Congratulations on the submitted manuscript. The topic is timely and will be of interest to the readers of the journal. However, few changes are suggested to improve the clarity of this manuscript. I have several recommendations and questions about the manuscript. 1. Abstract: Suggest changing the pronoun word "we" to "researcher" AUTHOR RESPONSE: ‘We’ has been changed to ‘this study’ [p2, Line 41] ‘We identified’ has been replaced by ‘A’ and ‘were identified’ added [p2, Line 62-63 revised manuscript] Changed ‘models of’ to ‘models’ to reduce word count [p3, Line 65] Please explain the inclusion and exclusion criteria in the method. AUTHOR RESPONSE: We revised the Methods section (Abstract) in response to Reviewer 1 comments. For clarity we have deleted “with policy makers, consumers with lived experience of melanoma or community advocates, healthy professionals and researchers” and added ‘Key informants were purposively selected to ensure expertise in melanoma early detection and screening, prioritising senior or executive perspectives. Consumers were expert representatives.’ [p2, Line 50-53] The author should specify what was the 'valuable information' in the conclusion and briefly describe the importance of the 'valuable information" AUTHOR RESPONSE: For clarity, we added: “Key informants were supportive in principle of risk-tailored melanoma screening, highlighting important next steps.” [p3, Line 68-69 tracked manuscript] and simplified the final following sentence to read: “Considerations around risk assessment, policy and modelling the costs of current verses future approaches will help inform possible future implementation of risk-tailored population screening for melanoma”. 2.Introduction: The introduction section has a clear statement demonstrating the focus of the study. The problem definition is stated clearly. AUTHOR RESPONSE: No changes needed. 3. Risk-tailored screening, also referred to as ‘risk-stratified screening’ or ‘targeted screening’, tailors screening (e.g. eligibility, frequency, intervals, type of test) to individual risk rather than the mostly one-size-fits-all approach of organised population screening programs. - Please add the REFERENCE Please add citations when necessary AUTHOR RESPONSE: Two references [20,21] have been added to support this claim. [p4, Line 97 tracked manuscript] 4.This qualitative study aimed to explore the acceptability and appropriateness of population based, organised risk-tailored melanoma screening from the perspective of key informants. Please harmonize the statement AUTHOR RESPONSE: We have revised the statement as follows: “This study aimed to explore the views of key informants in Australia on the acceptability and appropriateness of risk-tailored organised screening for melanoma.” [p6, Line 133-135 tracked manuscript] 5. Methodology: I would like to suggest to the author provide more information on the methodology of the study such as: -How about the sample size selected? -The total number of respondents from four expert groups? -The inclusion and exclusion criteria? -The semi-structured interview protocol process consisted of what questions? AUTHOR RESPONSE: -To explain sample size selected we included: “Recruitment continued until no new information was generated (i.e., reached data saturation).” [p7, Line 156-157 tracked manuscript] -The total number of respondents from four expert groups are included in Table 1 and in the Abstract. -To further clarify inclusion and exclusion criteria we added: “Key informants were included if they were recognised as a leader in their field, a clinical/policy expert or experienced representative of melanoma patient or community groups.” [p6, Line 144-146 tracked manuscript] “Participants were excluded if they did not hold a current position associated with the key organisations.” [p7,149-150 tracked manuscript] -The semi-structured interview guide with questions used in the interview process is included in S1 File. In addition, the following sentence included in Data collection (Methodology) highlights the main focus of interview questions: “Interview questions explored beliefs and perceptions about melanoma early detection and screening in Australia, the concept of risk-tailored screening, evidence for implementation and the key determinants (barriers and facilitators).” [p7, Line 174-176) 6. Ethical Consideration: Please add the reference number or approval code AUTHOR RESPONSE: The following statement is included on page 7, Line 157-158. “This research was approved by The University of Sydney Human Research Ethics Committee (Project 2021/253).” 7. Table 1: Please add the subtitle in the table Example: Frequency(n) AUTHOR RESPONSE: Subtitles have been added to Table 1 [p10, Line 224] 8. Discussion: How do the findings add to the body of scientific knowledge on the particular issue? Should highlight the implication of the results to health policy AUTHOR RESPONSE: As suggested, we have included the following sentences: “Our findings contribute to the scarce implementation science literature on risk-stratified melanoma screening by identifying where the barriers lie and what potential strategies are applicable for melanoma. Health policy makers need to ensure that the development of an organised screening program has addressed acceptability if it is to be successfully implemented.” [p26, Line 604-609 tracked manuscript] 9. Summary. Please make a subheading for summary AUTHOR RESPONSE: The subheading “Summary” has been added. [p27, Line 619 tracked manuscript] 10. Please state the source of the research funding including the grant name and number. AUTHOR RESPONSE: The source of research funding has been submitted as part of the submission information as required by PLOS ONE submission guidelines and has been updated for clarity to read: Funding: This study has received project grant funding from the National Health and Medical Research Council (NHMRC #1165936 and #2009923). KLAD receives an NHMRC (Australia) Postgraduate Research Scholarship and NHMRC Supplementary Scholarship The University of Sydney 2021-2022 and The Erik Mather PhD Scholarship (Melanoma Institute Australia). AEC receives a NHMRC Investigator Grant (2008454). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. 11. References: Please add doi in the article’s references. Example: Trager MH, Queen D, Samie FH, Carvajal RD, Bickers DR, Geskin LJ. Advances in Prevention and Surveillance of Cutaneous Malignancies. Am J Med. 2020 Apr;133(4):417-423. doi: 10.1016/j.amjmed.2019.10.008. Epub 2019 Nov 9. PMID: 31712100; PMCID: PMC7709483. AUTHOR RESPONSE: Thank you for drawing our attention to the need for a doi. We have amended the Reference list to include this information where available. ADDITIONAL AUTHOR CHANGE: Results: On review, we changed the word ‘disorganised’ to ‘fragmented’ to better reflect the associated quote [p12, Line 248 tracked manuscript]. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0287591.r002
8 Jun 2023 Decision Letter - Jianhong Zhou, Editor Acceptability and appropriateness of a risk-tailored organised melanoma screening program: Qualitative interviews with key informants PONE-D-22-30659R1 Dear Dr. Dunlop, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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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 ******** 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: 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 Reviewer #2: Yes ****** 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 ****** 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 for addressing comments. I hope it come out as a valuable contribution to the body of knowledge. Reviewer #2: Congratulations to the authors. All corrections have been made based on the reviewers comments. This finding will contribute to the valuable literature in risk-tailored population screening for melanoma. ****** 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: Yes: Dr. Ahlam Sundus Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0287591.r003
Formally Accepted
1 Dec 2023 Acceptance Letter - Jianhong Zhou, Editor PONE-D-22-30659R1 Acceptability and appropriateness of a risk-tailored organised melanoma screening program: Qualitative interviews with key informants Dear Dr. Dunlop: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Jianhong Zhou Staff Editor PLOS ONE https://doi.org/10.1371/journal.pone.0287591.r004

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