Addressing Inequity in Spatial Access to Lung Cancer Screening

Round 1

Reviewer 1 Report

This article examines an important issue, inequities in spatial access to lung cancer screening. The study takes on an important aspect of lung cancer screening, which is inequities in cancer screening. The following observations should be carefully considered for improvements in the credibility of this research study’s findings.

 1.     The authors have completely ignored an important factor concerning special inequities in cancer screening—telehealth and telemedicine. Once this research accounts for the role of telemedicine/telehealth as an equalizer in special accessibility of healthcare services and is included in conceptualization, background, methodology, and discussion, the findings will have entirely different tone and implications.

2.     In the introduction and background, the authors should establish the significance of spatial access to lung cancer screening services and how such accessibility amounts to inequity.

3.     The authors should also include a brief background on why such inequity in access is even more critical in adverse outcomes for lung cancer screening as opposed to some other healthcare screening where timing may not be as crucial.

4.     The authors should establish and acknowledge the role of telemedicine in the background and discussion by highlighting how Telemedicine is being used in cancer care to provide patients with convenience, time and cost savings, flexible scheduling, access to specialists far away, and what many patients and doctors describe as intangible benefits, such as reduced exposure to germs.

5.     Given the timing of the study (COVID pandemic) it is even more relevant to discuss how telemedicine may have offset some of the impact of long distances to screening centers for rural residents by offering patients convenience and time savings.

6.     The authors should include a brief discussion on how (and to what extent) telemedicine was used by cancer experts to guide a paramedic on-site, making the telemedicine approach a viable alternative for onsite lung cancer screening.

7.     There is tons of research before and during covid on this topic. The authors may use PubMed with the  following search criteria: (1)  telemedicine[title/abstract] and cancer  screening; (2) telehealth[title/abstract] and cancer screening

 Methods:

 8.     Except for the first sentence, the entire 1st paragraph of the methods section belongs to the introduction section as it provides background for the study.

 9.     Before delving into population and sampling details, it will be useful for the reader to get the research design for this study. The authors are encouraged to briefly describe their research design right at the outset.

 10.  The authors should include information on telemedicine/telehealth equipment and expertise available (e.g. at the district or rural municipality level) and use that as one of the variables. With geo-coding, the authors should be able to include the telehealth availability variable in their dataset.

 Results:

11.  Tables should be presented in a way that should make sense to the reader without having to consult other parts of the research. So the table titles should be more descriptive and should include which statistics are being presented, as well as time and place.

12.  All abbreviations should be spelled out in the footnotes (e.g., IQR).

Discussion:

13.  The authors should include a discussion on how their findings should be interpreted within the context that they did not consider an important aspect of the accessibility of cancer screening (as discussed in a previous comment).

14.  The discussion is missing an important section, limitations of this study, some of which are described in this review. This section is important in understanding the generalizability and implications of the findings.

15.  The conclusion section should be included in the manuscript, which should also include implications for practice and policy.

Minor edits may be needed, for instance, replacing "social-economically" with "socio-economically."

Author Response

Thank you for reviewing this manuscript and the valuable feedback. Please find our responses in the attached word document.

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the interesting paper. I have a few minor comments:

1. Introduction- Please add the research hypothesis.

2. Discussion - regarding the sentence: "The magnitude of this positional error is unknown however, based on prior literature it is typically small." Please give examples of 2-3 previous studies on which you based on.

3. Conclusions - What are the implications of the findings for health policy? What are the authors' practical recommendations and what are the directions for future research?

Author Response

Thank you for reviewing this manuscript and the valuable feedback. Please find our responses in the attached word document.

Author Response File: Author Response.pdf

Reviewer 3 Report

This study newly examined spatial access to lung screening sites in a regional health care setting considering the impact of age, sex, level of urbanization, and multiple indices of deprivation. It significantly reveals groups that may require support to ensure equitable access to lung cancer screening.

Line number 225-231

 Although this paper identifies lung cancer risk in poor spatial access, the relationship between socioeconomic characteristics and lung cancer risk has been noted in previous studies in the US and Canada. Area of residence is closely related to Socioeconomic groups. In this study, the bivariate relationship between drive time and socioeconomic variables was analyzed, but it is not clear how strongly any of these variables contribute. Multiple regression analysis, for example, could be used to clarify the correlation of each variable and to better understand the interrelationship between each variable. It is advisable to examine confounding factors in this manner or to refer to them in the limitations section of the study.

Table 3

 The name of the statistical analysis should be supplemented with a Note below the table.

Author Response

Thank you for reviewing this manuscript and the valuable feedback. Please find our responses in the attached word document.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The authors did not seem receptive to my feedback and their need to respond to my comments appropriately. Instead, they seemed too focused on finding justifications for rejecting the feedback. For example, it is well established that each reviewer’s comments are independent of others and can differ. So, rather than addressing the issues, the authors have resorted to defending their approach, e.g., “We did not receive comments from the other reviewers...”

The authors' grouped responses approach is not satisfactory. They should provide a point-by-point response to the individual comments. In response to the review points 1, 2, 4, 5, 6, 7,10, 13. Authors lumped their answers together and concluded that “… the concerns you raised about using telehealth does not directly apply in this context.” The telehealth is, however, applicable to the context of health equity in lung cancer screening.” Hundreds of published articles [I pulled 105 in PubMed alone] on lung cancer and telemedicine/telehealth indicate that telemedicine is relevant.  

The authors' limitations section needs clarity. In addition, the authors should mark study limitations as a subsection of the discussion with a subheading "Study limitations" and clearly list each limitation and its implications for the validity/generalizability of the study findings. In addition, it will be helpful for the reader if each limitation is marked clearly (e.g., first, ... Secondly, ....etc.).

The authors' response to the following comment from my review-one is unsatisfactory: "Except for the first sentence, the entire 1st paragraph of the methods section belongs to the introduction section as it provides background for the study." The literature is full of bad examples. I can cite 100 examples (in response to their one cited study) that follow the convention suggested in my comment.

Their response to the following comment is not adequate: “Tables should be presented in a way that should make sense to the reader without having to consult other parts of the research. So, the table titles should be more descriptive and should include which statistics are being presented, as well as time and place.” 

Minor edits are needed after the revision.

Author Response

Thank you for considering this manuscript and the thoughtful review. Please find our responses in the attached word document. We look forward to hearing from you.

Author Response File: Author Response.pdf

Reviewer 3 Report

Thanks for responding to my comment. I have considered it accepted since it meets the requirements for re-review.

Author Response

Thank you for your thoughtful comments, we really appreciate your insight and believe this has contributed to the strength of our manuscript. We believe you have accepted the revision at this point but if there is anything else we can do, pleasel et us know.

Round 3

Reviewer 1 Report

The authors have made the feasible changes and provided acceptable justification for the comments that were not feasible to address or not within the scope of this research.