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Reviewer A:
Authors developed MARK’s quadrant scoring system, the symptom based targeted screening tool for
gastric cancer, in early phases of this study and, then, they evaluated feasibility of this scoring system
for gastric cancer. The idea is very interesting, important and practical but I think the article is better to
be revised in order to make the contents simpler and more understandable. I could understand
overview of this study but it was little bit complex for me so that I could not understand the whole in
detail.
MAJOR POINTS
1) METHODS and RESULTS: In table 1, were the odds ratios calculated on the basis of presence
or absence of each variable? In my understanding, odds ratio is provided regarding one category of
each variable as reference: 1. For example, Age [50yrs] Y.YY (95%CI).
Yes, the Odds ratios were calculated based on presence and absence of cancer for each variable.
2) METHODS and RESUTS: Some description relating to the method is written in the RESULTS
section. Please move the description about the methodology to the METHODS section. Please
explain about the method in detail in the METHOD section and present only concise result according
to each method in the RESULT section.
Changes made according to reviewers suggestions.
3) METHODS: Please explain definition of “routine referral system” and “RAPID ACCESS system”
in the method section. It was unclear how patients were treated with those systems and compared the
outcomes.
Changes made according to reviewers suggestions. Page 7
4)
RESULT:
I would like to know a stage of the detected gastric cancer, especially in the validation phase.
This scoring tool was validated based on presence and absence of gastric cancer. However, during
the validated process there were 2 early cancer at stage Ib, IIa.(page 10) . More than 90% of gastric
cancer patients in our centre presents in late stage. This is true for most of the low incidence region
too.
Some symptom variables are related to presence of advanced gastric cancer (upper GI bleeding,
anemia, persistent vomiting, etc…).
Patients with early (T1) gastric cancer usually have more mild symptoms. Is this model suitable to
detect those patients?
There are differences between detecting early gastric cancers and detecting gastric cancers early.
Our aim was to detect high risk patients and perform endoscope early. We found in our earlier study,
reference 13. There is a delay in diagnosis due to discernibility of symptoms from benign diseases.
This score increases primary care physician awareness to refer.
Nevertheless, our early gastric cancer detection has been increased over time. Currently, we are
collecting the data for 1 year post Open Access endoscope service. We are finding early lesions now.
Please provide a comment about it in the discussion section.
Changes made according to reviewers suggestions.
5)
RESULTS: I could not find Figure 2, Table 2, Figure 3 and Figure 4.
Tables and figures were rearranged with correct numbers.
6) DISCUSSION: I think there is a likelihood estimation equation using logistic regression model
that provides percentage of likelihood. Please explain the difference with this methodology.
IN this method, logistic regression used in the first phase only to get the odds ratio. This was done to
get each symptoms likelihood to detect cancer. These scores were validated using new set of data in
phase two to group all the scores as the tool to predict cancer. So the score of 10 was agreed to be
cut off point for high risk prediction based on PPV.
MINOR POINTS
Please provide tables and figures separately.
Changes made according to reviewers suggestions.
-----------------------------------------------------Reviewer B:
This is a very interesting article. The big advantage is that it deals with a very difficult diagnostic
problem [identification of high risk patients for gastric cancer] using only clinical criteria avoiding
expensive laboratory workup.
My comments are the following
1. the language of the article is far below standard and the whole article should be rewritten in good
English
Some changes made according to reviewers suggestions.
2. It is interesting that 7 out of 10 patients with a score over 10 had precancerous lesions in the
stomach. I would like the authors to comment on that and suggest a possible reason.
This symptom based scoring tool was created to address the delay in sending patients for diagnostic
test which is endoscope procedure. Those patients who were symptomatic were scoped, during
analysis we grouped all precancerous lesion which were already stated in other journal eg. Active
gastritis with Helicobacter pylori infection, Intestinal metaplasia, Atrophic gastritis as precancerous
lesion as positive. Hence, it is true that Helicobacter infection can cause early symptoms in these
patients too.
3. Could family history of gastric cancer be examined as additional risk factor?
This is a symptom based scoring tool. We left out family history in view of difficulty in our pre-test
population where it was difficult to assess those family have mixed marriages. Many of them can’t
recall their family history especially cause of death. This may be largely due to poor education level of
these patients and poor diagnostic / recording database to verify this facts.