PONE-D-24-56636Social Determinants of Health, Health Behaviors, and General Health among Colorectal Cancer SurvivorsPLOS ONE

Dear Dr. Lee,

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 Apr 27 2025 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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We look forward to receiving your revised manuscript.

Kind regards,

Usama Waqar, M.B.B.S

Academic Editor

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: Yes

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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: Yes

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: 1) In the introduction, positive effects of consumption of fruits and vegetables have been repetitive, describe it once and avoid repetition

2) what is the rationale for choosing the 9 chronic conditions? patients with a chronic condition related to GIT, including crohn's, ulcerative colitis etc. may have poor health outcomes and should be accounted for.

3) History of any other type of cancer is a very important covariate that is not being evaluated

4) The categorization of comorbidities into 0,1,2+ is not a standard approach. using a standard comorbidity scale for example, Charlson index will be a good way of categorization

5) A lot of repetition of the same concept/finding through out the paper, avoid repetition to improve clarity for readers

6) It can be logically explained that patients with chronic conditions might have poor health outcome. it would be good to have a subgroup analysis of SDOH and positive health behaviors on patients with no comorbidities.

6) Future recommendation is focused on the role of nurses. Add more about how doctors can play a part during follow ups

Reviewer #2: The authors conduct a cross sectional study to identify SDOH associated with general heatlh among colorectal cancer survivors. The authors concluded that comprehensive social support is needed to enahnce general heatlh of colorectal cancer survivors.

I have the following comments:

1. The results of the study were obtained using a survey level data. This can lead to several biases due to inherest design of data collection and study design. This is a major limitation of the study an may limit the inferences drawn from the results.

2. Several SDOH components were found to be not associated with general health status. This should be addressed in the discussion section along with positive findings. What could be the reasons for such results?

Abstract:

No comment

Introduction:

1. The following statements needs a citation:

a. "SDOH, which encompasses factors such as educational and job opportunities, income, housing, transportation, public safety, food security, social inclusion, and nondiscrimination, drives health inequities and impacts general health status."

b. These inequities arise from differences in exposure to risk factors such as unhealthy diets and sedentary lifestyles, limited access to preventive measures like chemoprevention and screening, and inadequate follow-up of abnormal test results.

2. The authors did a good job of explaining the relationship between SDOH and cancer incidence, and subsequently SDOH, healthy behaviors, and outcomes among colorectal cancer survivors. However, a more succint introduction would improve readability for readers.

3. Please reconsider removing sub-headings from introduction section as per submission guidelines.

Methods:

1. The authors identified colorectal cancer survivors through BRFFS database as "patients who self reported a history of colon or rectal cancer". However, is it possible to ascertain whether these patients are survivors or under treatment or have a recurrence of the disease? This is an important aspect as it has significant role in how SDOH impacts helath outcomes.

2. Since the data related to positive health behaviors was self reported by patients using telephonic encounter. This data is variable and subject to bias depending on patient's recent beahviors. This is a subjective assessment and may significantly impact the results of current study.

3. The authors reported poor/fair health outcome (0=no, 1=yes) as a categorical variable derived from a 5-point Likert-scale. Such data recoding might cause issues with data analsis as data collection / organized may not be intended for such recategorization / analysis.

Results:

No comments

Discussion:

No comments

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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

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PONE-D-24-56636R1Social Determinants of Health, Health Behaviors, and General Health among Colorectal Cancer SurvivorsPLOS ONE

Dear Dr. Lee,

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 see reviewer comments below.

Please submit your revised manuscript by Jul 30 2025 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.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Usama Waqar, M.B.B.S

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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 #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 #3: Yes

**********

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

Reviewer #3: 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 #3: 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 #3: 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 #3: The authors have written a well-structured and timely manuscript analyzing the associations between social determinants of health (SDOH), health behaviors, and self-reported general health in colorectal cancer (CRC) survivors using data from the BRFSS survey. The focus on self-rated health and its predictors is of growing importance, particularly as oncology continues to shift toward patient-centered outcomes. The use of a large, representative dataset and appropriate statistical methodology strengthens the credibility of the findings.

The authors have made a commendable effort to address prior reviewer comments, and the revised manuscript shows improvement in clarity, structure, and scope. However, the following issues still require attention:

• The use of 2021 BRFSS data, which coincides with the COVID-19 pandemic, may have significantly influenced self-reported health status, health behaviors, and access to care. The potential impact of the pandemic on the findings should be acknowledged and briefly discussed in the limitations section.

• A prior reviewer noted that the set of chronic conditions included in the analysis omits gastrointestinal (GIT)-related conditions, which may be particularly relevant in a CRC survivor population. While the authors clarified that they relied on the nine chronic conditions available in the BRFSS dataset, this limitation should be explicitly acknowledged in the Methods or Discussion section.

If these minor but important revisions are made, the manuscript has the potential to make a valuable contribution to the literature on cancer survivorship and public health policy.

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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 #3: No

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[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.

Social Determinants of Health, Health Behaviors, and General Health among Colorectal Cancer Survivors: A cross-sectional study

PONE-D-24-56636R2

Dear Dr. Youran Lee,

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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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. 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.

Kind regards,

Ola Sukkarieh, Ph.D., M.P.H, R.N.

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 #3: 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 #3: Yes

**********

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

Reviewer #3: 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 #3: 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 #3: 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 #3: The authors have done an incredible effort to incorporate the comments from all reviewers while maintaining their own interpretation.

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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 #3: No

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