Dear Dr. anping,

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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Kind regards,

Li Yang, M.D.

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: No

Reviewer #3: No

Reviewer #4: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: No

Reviewer #3: No

Reviewer #4: 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

Reviewer #3: No

Reviewer #4: 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

Reviewer #3: No

Reviewer #4: Yes

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Reviewer #1: This study represents a valuable contribution to the field of urologic oncology, addressing a clinically relevant question regarding the role of cytoreductive prostatectomy in prostate cancer patients with lung metastasis. The use of a large, population-based dataset from the SEER database and the application of propensity score matching to minimize selection bias are significant strengths. The manuscript is well-structured, the methodology is sound, and the conclusions are clearly supported by the data. The topic is timely and of great interest to clinicians seeking to optimize treatment strategies for metastatic prostate cancer. However, to further strengthen the manuscript, the following revisions are suggested:

1.

The final matched cohort consists of only 79 patients per group. While PSM helps balance covariates, such a small sample may limit the statistical power to detect clinically meaningful differences. Please discuss this limitation and consider performing a power calculation or sensitivity analysis.

2.

The term “reductive prostatectomy” is ambiguous. Please clarify whether this refers to radical prostatectomy, cytoreductive surgery, or palliative debulking. Specify the surgical intent and extent in the Methods section.

3.

Key prognostic factors such as ECOG performance status, comorbidities, PSA doubling time, and specific systemic therapies (e.g., AR-targeted therapies, chemotherapies) are not accounted for. These omissions may introduce residual confounding. Please acknowledge this limitation.

4.

The study does not distinguish between oligometastatic and polymetastatic disease. Patients with solitary lung metastasis may behave differently than those with multiple metastases. Subgroup analysis based on metastatic burden would strengthen the conclusions.

5.

The analysis is based on overall survival. Including cancer-specific survival might provide more direct insight into the effect of surgery on disease progression.

6.

The abstract mentions “1,8006” cases, which appears to be a typo (likely 1,806). Please verify all numerical values throughout the manuscript for consistency.

7.

The study is restricted to patients aged 60–79 years. This limits the applicability of findings to younger or older populations. Please discuss this explicitly.

8.

The type, timing, and dosage of radiotherapy and chemotherapy are not detailed. These treatments likely influence survival and should be considered in the analysis or at least discussed as potential confounders.

9.

The caliper value of 0.02 is quite strict and may have excluded many patients. Justify this choice or consider using a more conventional caliper (e.g., 0.05–0.10) to improve matching efficiency.

10.

The conclusion states that cytoreductive prostatectomy “does not prolong survival,” but the study only shows no statistical difference. Consider rephrasing to reflect that no survival benefit was observed in this cohort, rather than a definitive absence of benefit.

Reviewer #2: 1.Limited to a Specific Age Group: The study only included prostate cancer patients aged 60 to 79, which limits the external validity of the results (i.e., whether the results can be applied to other age groups). Younger or older patients may have different survival prognoses, so the study's conclusions cannot be directly applied to these groups.

2.Lack of Stratified Analysis: The absence of stratified analysis is an important limitation of the study. Stratified analysis could assess the treatment effects based on different patient characteristics (such as age, PSA levels, tumor staging, ISUP grading, etc.), helping to identify subgroups of patients who may benefit from specific treatments. Although the study used propensity score matching (PSM) to reduce selection bias, it did not conduct further stratified analysis, making it impossible to explore whether different patient subgroups have different survival benefits after undergoing prostatectomy.

3.Lack of Multivariable Regression Analysis: The absence of multivariable regression analysis is another limitation. Including multivariable regression analysis could help further quantify the independent effects of surgical treatment and other clinical factors on the survival of prostate cancer patients, providing more detailed statistical evidence. This would not only improve the precision of the study but also offer more meaningful guidance for clinical treatment.

Reviewer #3: This retrospective SEER analysis evaluates whether cytoreductive prostatectomy (cRP) confers a survival benefit in men aged 60–79 with prostate cancer and lung metastasis (2010–2015). After 1:1 PSM (79 vs 79), the Kaplan–Meier comparison shows no OS difference (log-rank P=0.79), and the manuscript concludes cRP does not prolong survival in this subgroup. The clinical question is relevant; however, reporting inconsistencies, methodological limitations (time-related bias, missingness handling, PSM details), and presentation issues currently preclude reliable inference.

Reviewer #4: Nice, well designed and soundly modeled retrospective study on SEER data. Since the study is not controlled trial, I would recommend to authors to downplay their expression in Conclusion section when they talk about how the study confirmed non suitability of surgery in patients with lung metastasis, unfortunately this kind of studies can only suggest relationships, not confirm them.

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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: Yes: Mohammad Ebrahimnezhad

Reviewer #2: No

Reviewer #3: Yes: Yuyi Ou

Reviewer #4: Yes: Benjamin Benzon

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Dear Dr. anping,

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 30 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 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,

Li Yang, M.D.

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.

Additional Editor Comments (if provided):

Please further address reviewer comments.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

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Reviewer #1: (No Response)

Reviewer #3: (No Response)

Reviewer #4: Please rephrase the following text: "This study demonstrates that in patients aged 60 to 79,cytoreductive prostatectomy failed to prolong cancer-specific survival in prostate cancer patients with lung metastases, nor did

the combination of chemotherapy and radiotherapy extend cancer-specific survival." in to something like this: "This study did not show association between cancer specific survival benefit and cytoreductive prostatectomy in 60 to 79 years old patients with lung metastases. The same can be stated for chemotherapy and radiotherapy."

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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 #3: No

Reviewer #4: Yes: Benjamin Benzon

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Survival study of  cytoreductive prostatectomy for prostate cancer with lung metastasis: A propensity score matching study based on the SEER database

PONE-D-25-46062R2

Dear Dr. anping,

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,

Li Yang, M.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Thanks for the authors' efforts to comprehensively improve your manuscript according to editor's and reviewers' comments. I am pleased to inform you that your paper can be accepted for publication now.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: All comments have been addressed

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

Reviewer #4: Yes

**********

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

Reviewer #4: Yes

**********

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

The PLOS Data policy

Reviewer #4: Yes

**********

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

Reviewer #4: Yes

**********

Reviewer #4: All of my comments have been addressed and I recommend the manuscript for publication, congratulations to authors.

**********

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 #4: Yes: Benjamin Benzon

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