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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?

Reviewer #1: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: This article reported escribing the trends in skin cancer incidence based on demographic and occupational variations may result in differing levels of UV exposure across districts, potentially influencing the incidence of skin cancer.

There are some points that need to be modified. Please find some comments below:

Title

The authors should remove the word “geographic variation” from the title because there is no spatial analysis in this study.

I would suggest the title as follow: “Trends in skin cancer incidence in Songkhla, Southern Thailand, 1989–2020: A population-base study on impact of geographic variation”

Abstract

1) Is the incident presented per 100000? Please clarify.

Introduction

1) Please add the references showing that “Individuals engaged in outdoor occupations, such as farming and fishing, are more likely to experience higher levels of UV exposure. Additionally, clothing style may influence the degree of UV exposure.”

Method

1) How many case were excluded because data on date of diagnosis, age, and sex are missing? How the authors manage when the address of the patient is missing at district level?

2) It would be interesting to see the comparison of the trend incidence in city vs rural district, Muslim vs.non Muslim predominated area, and farming, fishing, gardening and other occupations area. The author cannot conclude the impact of these factors without the control group even though the significant change of incidences are shown because it might also change in the control groups.

3) The change of levels of UV exposure across districts might potentially influence the incidence of skin cancer. It would be interesting if the author could add the information of UV exposure over time in the manuscript.

4) As shown in Figure 1, the author simply classified the 16 districts of Songkhla were grouped into 4 category 1) farming and fishing areas (Ranot, Krasae Sin, Sathing Phra, and Singhanakhon), 2) city areas (Mueang Songkhla and Hat Yai), 3) Muslim predominated areas (Chana, Thepha, and Sabayoi), and 4) gardening areas (Khuan Niang, Rattaphum, Bangklam, Na Mom, Khlong Hoi Khong, Sadao, and Na Thawi) but this classification pool the impact of urbanization, occupation and region together. I would suggest the authors re-classify the group as city (urban) vs rural district, Muslim vs. non-Muslim predominated area, and farming, fishing, gardening and other occupations area.

Results

1) Please clarify this sentence. What are these figures?

“Among the male population, the highest ASR was observed in the city area (3.10–7.14), followed by the fishing and farming area (3.67–6.42), the gardening area (1.18–4.90), and the Muslim predominated area (2.24– 3.93).”

2) Data quality over time of cancer registry is important in particular in the trend analysis. I would suggest authors to add the table of data quality in the results part or as the supplementary file.

Discussion

1) The authors should add the references to support the following statement.

“These variations suggest that the occupational environment and clothing practices may have affected the incidence. Muslim individuals, particularly women, typically wear clothing that covers most of the body, resulting in reduced exposure to UV radiation. The gardening area in Songkhla primarily consists of rubber plantations, which provide shade during working and may reduce exposure to UV radiation. By contrast, individuals residing in fishing and farming areas—particularly those working in rice fields—are generally exposed to greater amounts of sunlight, resulting in a higher incidence of skin cancer. The highest incidence was observed in the city area. This may be attributed to multiple factors. Urban populations are generally more highly educated. Moreover, the presence of three large tertiary hospitals in the city area facilitates better access to healthcare services.”

2) Please add strength and limitation of the study in the discussion part.

Conclusion

The conclusion needs to be modified according to the new analysis I proposed.

Minor:

1) Please make sure that all the abbreviations are described.

2) Has this article been written using AI? If so, please provide the reference appropriately.

3) Please complete the declaration part including Acknowledgement, Funding, Declarations of interest, Author contributions, and Data availability statement.

Reviewer #2: Trends and geographic variation in skin cancer incidence in Songkhla, Southern Thailand, 1989–2020: A Joinpoint regression and age-period-cohort analysis

The authors presented an interesting approach to skin cancer data from Songkhla (Thailand) population-based registry. They aimed to obtain insights on skin cancer incidence based on an ecological approach. The statistical approach is appropriated; they conducted joinpoint regression analyses, including age-period-cohort analysis. Although cancer time trend analysis has been extensively explored in a large number of papers, research from Thailand is scarce.

Authors sought Ethics approval from an Institutional Review Board

Abstract conveys the main results of this research

However, some points deserve particular attention and should be explained in more detail. The following are the comments/suggestions:

Abstract

The conclusion should be focused on practical implications of these results. The authors should avoid to repeat results in the conclusion subheading

Methods

1– The world standardized population used by the authors demands a reference.

2 - The authors used the same acronym – APC – for “annual percent change” and “age period cohort”. They should modify one of these acronyms

3 – Statistical approach should be described in deep. For readers not familiarized with joinpoint regression model, an explanation in brief of such approach would be welcome. Also, it tis not clear for me how did authors performed age-period-cohort analysis. I suppose the authors assumed a multiple regression model with a Poisson distribution. However, there is no explanation about this regression model. Indeed the statistical approach subheading is poor and should be rewritten. Did authors use de joinpoint regression software for age-period-cohort analysis? Based on figures, I supose that yes, but there is no information about this. Also, authors should explain what measures they obtained from these regression models. For example, anual percent change, relative risk for age, period, and cohort. Confidence Intervals for such measures are useful and should be provided.

Results

4 – Figures with results should be improved, it is very difficult to read results from these figures, particularly age-period-cohort results.

5 - Although the authors described in detail time trends results, there is no description about age-period-cohort results. They did not present results on relative risk for age, period, and cohort. A table with these results would make easier to read them.

Discussion

6 - The authors should avoid to repeat results in this section.

7 – In the second paragraph, the statements such as: “In Western countries the increasing incidence has been…” or “In some countries with a high incidence…” demand bibliographic references.

8 – In the fourth paragraph, the authors wrote “Urban populations are generally more highly educated.” This statement demands further explanation on how this characteristic play a role in the occurrence of higher incidence rate. Do more educated people use more frequenly health services or cancer screening? However, more educated people also tend to be aware about risk factors or cancer prevention. The explanation that authors presented is not enough, they should discuss these results in more detail.

9 – The authors should present and discuss the limitations of this study. Please remember, this study was based on an ecological approach.

Conclusion

10 – The conclusion is not supported by the results. The authors stated that the decline in incidence rates was explained by occupational patterns and cultural and tradicional practices. However, the decrease in incidence rates was observed in all groups, this means that occupation, culture or traditional practices could explain variation between areas, but they can’t explain the decrease in incidence rates observed. The explanation of this decrease should be based on factors shared by all groups.

11 - The conclusion should be focused on practical implications of these results.

**********

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Reviewer #1: No

Reviewer #2: Yes:  Cristina Teixeira

**********

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Trends in Skin Cancer Incidence in Songkhla, Southern Thailand, 1989–2020: A Population-Based Study on the Impact of Geographic Variation

PLOS ONE

Dear Dr. Pajareeyaphan,

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 Jan 08 2026 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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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.

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Kind regards,

Phuping Sucharitakul

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Just want to recommend the author to enrich the conclusion, pointing out the impact of geographical and occupational factors in this part and what are the suggestions to prevent or manage the skin cancer based on the results of your study.

Reviewer #2: The authors addressed all my comments and suggestions.

I thhink the manuscript was substantially improved.

I have no more comments.

**********

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Reviewer #1: No

Reviewer #2: Yes:  Cristina Teixeira

**********

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Trends in Skin Cancer Incidence in Songkhla, Southern Thailand, 1989–2020: A Population-Based Study on the Impact of Geographic Variation

PONE-D-25-44756R2

Dear Dr. Pajareeyaphan,

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.

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Kind regards,

Dr. Phuping Sucharitakul

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: