-->PONE-D-25-56335-->-->Prevalence and Factors Associated with Treatment Delay Among Colorectal Cancer Patients at Mulago National Referral Hospital and the Uganda Cancer Institute: A Cross-Sectional Study-->-->PLOS One

Dear Dr. Kasagga,

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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?

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Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: I Don't Know

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Reviewer #1: No

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1:  Preamble: Allow me to first thank the authors on this great work on an important topic of public health concern. Below are my review comments;

Introduction: The introduction does not clearly describe what is not known about the delay to initiate treatment for colo-rectal cancer (CRC) and the factors associated with this delay. The knowledge gap (scientific value) which the study intends to address should be clearly described. It is not enough to just mention that there are few studies. Even the few studies are about the causes not the factors associated.

Line 9 and 10: Epidemiologically, low screening results into less incidence as new cases are not detected. Can the authors explain how low screening contributes to the growing incidence of CRC?

Line 15 and 27: Use only abbreviation for CRC to ensure standard writing. This should be done throughout the whole manuscript.

Methods: The methods section is not well written. There is a mix up of what should be included in the various sub-headings under the methods section.

There is need to consult the author guidelines while writing these sub-headings and ensure that all that is required according to the guidelines is addressed.

Specifically, the following should be addressed

i) Study design and setting: The study design is clearly mentioned but is not appropriate for the study question. A cross-sectional study does not appropriately answer the question of time to event (from diagnosis to initiation of treatment). Authors need to explain how they were able to measure this time using a cross-sectional study design.

The authors should justify why use two study sites (Mulago National Referral Hospital and Uganda Cancer Institute). The study setting should clearly describe relevant contextual information for an unfamiliar reader to understand. For example, how many patients (on average) were diagnosed with CRC at each of the two sites, what services are offered, who offers the services etc? Who funds the services? What is their catchment area? This will help to reader to appreciate the feasibility of the study as well as contextual understanding of the findings.

The ethical considerations of the study should not be part of the section. They should be a separate section.

ii) study population and sampling: This section should be chronologically and logically written. The study population is clearly described. Clearly describe how the sample size was determined and the any assumptions made. Explicitly outline the sampling procedure and the exclusion and inclusion criteria. Line 61 and 62, be clear on what prevalence was going to be estimated. Therefore, re-write and re-arrange this section for chronology and logical flow.

How did the sampling cater for contextual differences between MNRH and UCI? Proportionate sampling should have been done.

iii) Data collection: The authors just mention that data was collected using patient interviews and medical record reviews. The authors should explicitly describe which kind of interviews, tools used with their validity and reliability. Which records were reviewed; outpatient forms or in-patient files, what information was extracted from the reviews and what tools were used if any?

iv) Data analysis: The definition of treatment delay as a primary outcome of analysis was derived from an Ethiopian study according to the citation 31. Isn’t there an internationally accepted definition of treatment delay for cancers? This needs to be explained further.

An explanation is needed why Poisson regression , a non-parametric test was used. 95% confidence interval should be revised to 95% level of confidence.

Use of composite scores complicated the interpretation and understanding of the results. All the study set out to do was to measure time from CRC histological diagnosis and initiation of treatment. The appropriate method of analysis should have been survival analysis, a statistical measure of time to occurrence of the event or outcome of interest in this case initiation of treatment.

The composite scores cannot ably measure the factors associated. Multiple regression should have catered for the multi-dimensional nature of the barriers to care.

Therefore, the statistics used in this study are not appropriate.

Results

The results are well presented in both narratives and tables. However, the following issues are noted;

1. The narratives are repetitions of what is already presented in the tables.

2. It is not clear which results are from patient interviews and from review of records.

Tables 3 and 4: The results from analysis of composite scores should be presented in narratives instead of table.

Discussion

The discussion section should start by discussing the key findings from the study, mention their contribution to the current available body of knowledge before comparing them with the available literature. The discussion has significant repeatition of results (results should not be repeated in the discussion section but should be discussed).

The discussion lacks clear strengths and weaknesses/limitations of the study as well as implications of the study results and their possible explanations. For example, why a low sample size yet two study sites were used? Consecutive sampling, a non-probability sampling technique should be acknowledged given the potential bias within such sample.

Reviewer #2: Major Changes

1. Ethical contradictions There is a direct contradiction regarding patient consent that needs to be made clear for ethical reasons:

• The authors say in the Methods section that "Written consent was obtained from all participants."

• But the Declarations section says that the study was "approved with waiver of consent."

• Recommendation: The authors need to make it clear which protocol they followed and make sure the whole manuscript is consistent.

2. Reference Groups and Statistical Stability. The sample size of N=67 causes some regression models to be unstable:

• The bivariate analysis of education levels employs "Postgraduate" as a reference group, comprising merely 2 participants (3.0% of the cohort). The authors themselves say that these results are "likely artefactual."

• Suggestion: The authors should combine educational categories, such as "College/University" and "Postgraduate," to make stronger reference groups for analysis.

3. Check the study's timeline The authors assert that data collection transpired from December 2024 to May 2025.

• Question: Since today is the current date, the authors should check to see if the May 2025 data is final or just a guess. If the study is still going on, the results must be clearly marked as preliminary.

Minor Changes

4. Table 1: Data Completeness

• Table 1 shows that 3 patients (4.5%) are missing data for "Clinical Stage."

• Suggestion: A short note should be added to the Results section or a footnote to Table 1 to explain why this data was not available (for example, because medical records were not complete).

5. Why SES Scoring is Important

• The post-hoc SES composite score incorporates "alternative medicine use" as a variable signifying susceptibility.

• Recommendation: Although this health behaviour is frequently associated with delays, the authors should succinctly elucidate in the Discussion why it was classified as a socioeconomic disadvantage instead of a cultural or clinical factor.

6. Improvement of Figure 1

• Figure 1 (a pie chart) shows "Delay" and "No Delay."

• Suggestion: To make it easier to read, the chart should have the exact percentages (70.1% and 29.9%) right on the visual parts to match the text.

7. Abbreviations • SES (Socioeconomic Status) and DTI (Diagnosis-to-Treatment Interval) should be added to the List of Abbreviations because they are important to the study's results.

Conclusion

This research offers essential evidence concerning the structural and financial impediments to oncological care in Uganda. This manuscript will be a strong candidate for publication if it fixes the ethical problems and improves the way the statistics are presented.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review commetns.docx

Prevalence and Factors Associated with Treatment Delay Among Colorectal Cancer Patients at Mulago National Referral Hospital and the Uganda Cancer Institute: A Cross-Sectional Study

PONE-D-25-56335R1

Dear Dr. Kasagga,

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):

All revisions have been addressed

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Dear Author(s),

Thank you for taking time to revise the manuscript according to the comments raised during the review. I am happy that all the issues/concerns raised during the review were tkaen seriously and addressed.

Reviewer #2: The manuscript discusses a major public health problem: the "triple threat" of rising colorectal cancer (CRC) rates, late diagnosis, and systemic problems in areas with few resources. The study offers significant insights into the Diagnosis-to-Treatment Interval (DTI) in Uganda, revealing a substantial “prevalence delay” of 70.1% and highlighting socioeconomic status (SES) as a key independent predictor. The research is clinically relevant and methodologically robust in its application of composite scores; however, numerous significant inconsistencies and statistical issues require revision prior to publication.

The authors addressed all my comments. I have no further comments now. Thank you

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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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: No

Reviewer #2: No

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