Social inequities and clinical outcomes in young women with cervical cancer: Real-world evidence

Luiza Cupertino Bérgomi; Giselle de Souza Carvalho; Lucas Zanetti de Albuquerque; Daniel Gonçalves Kischinhevsky; Alexssandra Lima Siqueira dos Santos; Luiza de Freitas Maciel; Isabele Ávila Small; Jessé Lopes da Silva; Andreia C. de Melo

doi:10.1371/journal.pone.0343651

Peer Review History

Original SubmissionDecember 23, 2025
19 Jan 2026 Decision Letter - Satyajeet Rath, Editor Dear Dr. de Melo, 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 05 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'. 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We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. “The initial abstract was published as online version in ASCO 2025. The developed manuscript with figure, tables and in-depth discussion of the results is presented in this article.” Please clarify whether this was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript. 3. 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. Additional Editor Comments: Kindly review the manuscript for certain grammatical mistakes. Answer the queries by the reviewers. Additional comments: 1. Why was FIGO 2009 stage used in a study conducted in a sample from 2024-2025. 2. What novelty/value this study adds to the already existing known literature. [Note: HTML markup is below. Please do not edit.] 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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 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 ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The manuscript from L. Cupertino Bérgomi et al. is clearly written. Data are presented in a linear and comprehensive fashion. Conclusions are supported by the data. I, therefore, believe that it is suitable for publication in PLOS One in its present form. Reviewer #2: Review of article PONE-D-25-61883 The article “Social inequities and clinical outcome in young women with cervical cancer: real-world evidence” is well-written, organized and provides good analysis of the study findings. The statistical analyses used are simple yet effective. Some minor comments to consider: 1. The analysis was restricted to women age 18-39 years. Given the prevalence of cancer in older women, why was the analysis restricted to this age group? 2. Line 56 – suggest changing the language to ‘has been’ rather than ‘can also be’… 3. Line 100 – please define the ‘first occurrence of recurrence’ to that limited to what is recorded in the database only 4. Line 113 – please define ‘non-alcoholics” of replace with ‘not consuming any alcohol’. ****** what does this mean? ). 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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0343651.r001
Revision 1
29 Jan 2026 Author Response It is a great pleasure to be considered for publication in PLOS One. We appreciate the constructive suggestions, so we could use them to enhance our study. This letter has the intention to answer the queries by the reviewers. A detailed response to the questions is addressed below: ### Journal Requirements: 1. Please ensure that your manuscript meets PLOS ONE style requirements, including those for file naming. The PLOS ONE style templates can be found at: https://journals.plos.org/plosone/s/fileid=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Answer: Checked. 2. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. “The initial abstract was published as online version in ASCO 2025. The developed manuscript with figure, tables and in-depth discussion of the results is presented in this article.” Please clarify whether this was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript. Answer: This study was selected for presentation as an online-only abstract at the ASCO Annual Meeting 2025. As is standard practice at ASCO, online-only abstracts undergo editorial screening for relevance and scientific merit, but do not constitute full peer-reviewed publications, nor do they include detailed methodological appraisal, complete statistical analyses, figures, or tables. The abstract was published solely in abstract form within the ASCO Meeting Proceedings. At that time, only preliminary and summarized results were presented, without comprehensive and detailed survival analyses or stratified evaluations of sociodemographic determinants. Importantly, no figures, tables, extended methods, or in-depth interpretation were included in the ASCO abstract. The current submission represents a substantially expanded and original full-length manuscript, with major additions that were not previously disseminated. These include a refined and complete statistical analysis, fully developed Kaplan–Meier and Cox regression models, detailed figures and tables, and an extensive discussion contextualizing the findings within the existing literature. Moreover, the manuscript advances the work conceptually by integrating social determinants of health into prognostic modeling and by explicitly discussing implications for patient care pathways and public health policy. In accordance with ICMJE recommendations and the policies of major biomedical journals, prior presentation of preliminary data in abstract form at a scientific meeting does not constitute prior publication, nor does it represent duplicate or redundant publication. The present manuscript, therefore, constitutes the first complete, peer-reviewable, and citable report of this study. 3. 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. Answer: Please refer to the previous answer. ### Additional Editor Comments: Kindly review the manuscript for certain grammatical mistakes. Answer the queries by the reviewers. Answer: The complete manuscript was reviewed and edited to ensure clarity, consistency, and adherence to academic standards. ### Reviewers´comments: Reviewer #1: The manuscript from L. Cupertino Bérgomi et al. is clearly written. Data are presented in a linear and comprehensive fashion. Conclusions are supported by the data. I, therefore, believe that it is suitable for publication in PLOS One in its present form. Answer: We appreciate that. Reviewer #2: Review of article PONE-D-25-61883 The article “Social inequities and clinical outcome in young women with cervical cancer: real-world evidence” is well-written, organized and provides good analysis of the study findings. The statistical analyses used are simple yet effective. Some minor comments to consider: 1. The analysis was restricted to women age 18-39 years. Given the prevalence of cancer in older women, why was the analysis restricted to this age group? Answer: We thank the reviewer for this important question. The decision to restrict the analysis to women aged 18–39 years was deliberate and hypothesis-driven. First, although cervical cancer remains more prevalent in older women, young women constitute a biologically, socially, and clinically distinct population. This age group is characterized by unique reproductive considerations, different patterns of HPV exposure and persistence, treatment-related fertility implications, and specific long-term survivorship and socioeconomic consequences. Pooling younger and older patients may therefore obscure age-specific associations and dilute the impact of social determinants on outcomes. Second, emerging epidemiologic signals in Brazil motivated this focused analysis. While not yet fully published, ongoing analyses conducted by our research group using national population-based registries suggest a relative increase in cervical cancer diagnoses among younger women, particularly in socioeconomically vulnerable populations. These observations are consistent with international concerns regarding delayed screening uptake, inequitable access to preventive services, and heterogeneous implementation of HPV vaccination in low- and middle-income settings. The present study was designed to address this knowledge gap by providing detailed real-world evidence in a population for which robust data remain scarce. Third, the literature addressing cervical cancer in young women is limited and heterogeneous, with inconsistent age cutoffs and conflicting results regarding prognosis and risk factors. By focusing on a clearly defined age range, this study contributes novel, granular data on clinicopathological features, survival outcomes, and social inequities in a population that is often underrepresented or merged into broader age-based analyses. Finally, from a public health perspective, studying cervical cancer in young women has direct policy relevance. Disease occurring at younger ages carries disproportionate societal impact due to loss of productivity, caregiving responsibilities, and long-term survivorship burden. Identifying modifiable sociodemographic factors in this group may inform targeted prevention strategies, optimized screening policies, and equity-oriented interventions. 2. Line 56 – suggest changing the language to ‘has been’ rather than ‘can also be’… Answer: Checked. Correction made. 3. Line 100 – please define the ‘first occurrence of recurrence’ to that limited to what is recorded in the database only Answer: Checked. Correction made. 4. Line 113 – please define ‘non-alcoholics” or replace with ‘not consuming any alcohol’. Answer: Checked. Correction made. We thank the reviewers and editorial team once again for their insights. With sincere regards, Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0343651.r002
9 Feb 2026 Decision Letter - Satyajeet Rath, Editor Social inequities and clinical outcomes in young women with cervical cancer: real-world evidence PONE-D-25-61883R1 Dear Dr. de Melo, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . 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, Satyajeet Rath Academic Editor PLOS One Additional Editor Comments (optional): I commend the authors on making the required changes. Reviewers' comments: https://doi.org/10.1371/journal.pone.0343651.r003
Formally Accepted
Acceptance Letter - Satyajeet Rath, Editor PONE-D-25-61883R1 PLOS One Dear Dr. de Melo, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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 Dr. Satyajeet Rath Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0343651.r004

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