Dear Dr. Poelhekken,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

George Kuryan

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?

Reviewer #1: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: The main objective of the paper is to use the SimDCIS248 model for simulations aimed at balancing the benefits and harms of screening and avoiding overdiagnosis. However, the only significant conclusion drawn was that, in order to reduce overdiagnosis of DCIS, at least 20 years of follow-up are required. This does not appear to offer any major improvement to the current screening system, and the usefulness of the evaluation framework is questionable. Furthermore, the authors have already submitted similar findings to another journal, which further reduces the value of publishing this paper on PLOS ONE.

Reviewer #2: I read with interest the article entitled “Influence of follow-up, screening age, interval, and compliance on overdiagnosis of ductal carcinoma in situ (DCIS): a modelling study.” The study addresses an important topic; however, I would like to highlight the following observations and suggestions that require clarification before the manuscript may be considered for publication:

1. Overall, the manuscript is well written and provides an evaluation of factors in breast cancer screening that may contribute to the overdiagnosis of DCIS.

2. The title is concise, accurate, and appropriate for the study.

3. The abstract adequately summarizes the manuscript, covering the background, methodology, results, and conclusions.

4. The introduction is clearly structured and appropriate.

5. In the Materials & Methods section, the screening age and frequency appear to have been chosen arbitrarily and do not correspond with the recommendations of either the American Cancer Society or the European Commission Initiative on Breast Cancer (ECIBC).

6. Biennial screening is not endorsed by these societies, and higher compliance rates are generally not sustainable over long-term follow-up.

7. While patients with a positive family history may require earlier and more frequent screening, the incidence of DCIS in this subgroup is relatively low.

8. The imaging modality used for screening (mammography, ultrasonography, or MRI) has not been specified. As this significantly impacts the likelihood of overdiagnosis, it should be clarified.

9. I am unable to comment on the SimDCIS tool.

10. The discussion is generally appropriate; however, it should also address the interventions and the gold standard histopathological methods required to confirm a diagnosis of DCIS.

11. The conclusion is consistent with the study findings.

12. The references are recent and relevant.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: Yes: GYAN CHAND

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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.]

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Attachments

Attachment

Submitted filename: Review 1.docx

Dear Dr. Poelhekken,

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 15 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.

• 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 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,

Kuryan George

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

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

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

Reviewer #3: There are many definitions of overdiagnosis, the authors need to justify why they chose the one mentioned in the manuscript.

The denominator size has been influenced by excluding direct progression to IBC. The authors need to comment on the magnitude of this bias.

The clarity on generalisability of this study needs to be better.

In table-1 better to avoid arrows to depict the increasing and decreasing trend.

**********

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: Yes: Gurushankari Balakrishnan

**********

[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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Influence of follow-up, screening age, interval, and compliance on overdiagnosis of ductal carcinoma in situ (DCIS): a modelling study

PONE-D-25-39133R2

Dear Dr. Poelhekken

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,

George Kuryan

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: