PONE-D-25-50559-->-->Can the current radiation dose, in chest tomosynthesis, be reduced with retained image quality? A study in the context of lung cancer screening programs-->-->PLOS ONE?>

Dear Dr. Jadidi,

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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ACADEMIC EDITOR:

Please submit your revised manuscript by Dec 25 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,

Aloysius Gonzaga Mubuuke

Academic Editor

PLOS ONE

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2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

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b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

Please update your Data Availability statement in the submission form accordingly.

3. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure.

4. 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.

5. 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:

The paper talks about an interesting subject in radiology and imaging. The discussion however needs to be strengthened by synthesizing how findings from this study can be useful to a more global audience beyond the setting where the study was conducted from. In addition, the entire paper needs proof-reading to improve on the language.

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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: 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

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: Dear author

I have carefully reviewed your manuscript The study addresses an important and clinically relevant question in radiological imaging—whether chest digital tomosynthesis (DTS) dose levels can be reduced while maintaining diagnostic image quality, particularly in the context of lung cancer screening.

Your data convincingly support that a 30% dose reduction in chest DTS preserves subjective image quality across all assessed anatomical and image-quality classes, whereas a 50% reduction introduces mild yet statistically significant degradation in vessel visibility and disturbance.

With improved statistical reporting, clearer explanation of dose-reduction physics, and compliance with data-sharing requirements(Please check below), the manuscript would make a meaningful contribution to the literature on dose optimization in digital tomosynthesis and its potential integration into lung-cancer screening programs.

Thank you for your contribution to this important area of radiological research. I look forward to seeing a revised version of your manuscript that addresses these points.

Sincerely,

1.Acquisition Physics and Dose-Reduction Mechanism:

The reduced-dose protocols were achieved by adding 20 mm aluminium filtration and lowering the tube voltage to 100 kV, while the vendor-recommended protocol is reported as 125 kV. Please clarify this inconsistency (100 kV vs 120 kV/125 kV) and quantify how the added filtration affected beam quality (e.g., half-value layer, mean photon energy). Including measured or simulated x-ray spectra and HVL data would help validate that image-quality changes are not confounded by spectral shifts rather than dose effects.

2. Dose Estimation and Method Transparency

You report that effective dose was calculated from the dose-area product (DAP) of the scout image, scaled by projection ratios and a field-size factor (0.935).

Please detail how these scaling factors were derived, cite supporting references, and provide per-protocol DAP and effective-dose statistics (mean ± SD or median [IQR]) in a summary table. Consider stratifying by patient size or BMI to demonstrate robustness across different body habitus.

3. Statistical Reporting: Precision, Readers, and Multiplicity:

Provide 95% confidence intervals for AUC_{VGC} values and include effect sizes alongside p-values. Also, Quantify inter-observer agreement (e.g., ICC) to assess consistency between readers. You may consider a multi-reader, multi-case (MRMC) analysis or mixed-effects model to appropriately handle correlated data. Finally, discuss whether corrections for multiple testing across the four quality domains were applied.

4.Link to Clinical Performance and Population:

As your cohort consists of patients with known or suspected malignancy rather than a screening population, please temper the generalization to screening settings. If feasible, include an exploratory analysis of lesion visibility stratified by size (e.g., >10 mm vs <10 mm) using CT as the reference. At minimum, discuss how trends in tumour-homogeneity scores may translate to detection or characterization performance.

5.Observer Study Details and Reproducibility:

Clarify the number of rated items per class, treatment of any missing ratings, randomization order, and the contents of the training set.

Indicate whether reading order was balanced across protocols. And, providing your ViewDEX configuration files and full rating criteria as supplementary materials would enhance reproducibility.

Reviewer #2: The authors have presented a well written and comprehensive manuscript based on their study which looks at the possibility of reducing radiation exposure in patients undergoing chest tomosynthesis for the detection of lung cancer. This is a valuable study with potential significance in the clinical setting.

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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: ALIYA MULATI

Reviewer #2: No

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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.

PONE-D-25-50559R1-->-->Can the current radiation dose, in chest tomosynthesis, be reduced with retained image quality? A study in the context of lung cancer screening programs-->-->PLOS One?>

Dear Dr. Jadidi,

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.

==============================

ACADEMIC EDITOR: The reviewer has provided valuable insights to improve the paper. In addition, please address the following:

1. The discussion should show some practical implication of your findings in a broad sense such that even readers beyond your institution can get some benefit from the study.

2. How do the findings from your study contribute to known literature around this area?

Please submit your revised manuscript by Mar 07 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,

Aloysius Gonzaga Mubuuke

Academic Editor

PLOS One

Journal Requirements:

1. 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.

2. 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 :

The reviewer has provided valuable insights to improve the paper. In addition, please address the following:

1. The discussion should show some practical implication of your findings in a broad sense such that even readers beyond your institution can get some benefit from the study.

2. How do the findings from your study contribute to known literature around this area?

3. The paper needs proof-reading to improve the language

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

**********

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

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

Reviewer #1: Dear Authors,

The revision satisfactorily addresses my prior major points. In particular, the dose-reduction physics and potential spectral confounding are now explicitly handled via spectrum simulation and protocol harmonization across acquisitions. Dose estimation is more transparent, with an explicit DAP→effective-dose coefficient, method citation, and a BMI-stratified summary table that supports robustness across body habitus. Observer-study reproducibility is improved with training-set description, confirmation of no missing ratings, automated randomization, and sharing of ViewDEX configuration files.

I recommend acceptance, with only minor editorial cleanup.

Best,

**********

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 #1: Yes: aliya mulati

**********

[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.

Can the current radiation dose, in chest tomosynthesis, be reduced with retained image quality? A study in the context of lung cancer screening programs

PONE-D-25-50559R2

Dear Dr. Jadidi,

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,

Aloysius Gonzaga Mubuuke

Academic Editor

PLOS One

Additional Editor Comments (optional):

None

Reviewers' comments: