Round 1

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

please refer to the file attached for comments.

Comments for author File: Comments.pdf

Author Response

Dear Editorial Team, please find attached the response to the reviewer.

Kind regards.

Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

This manuscript applies the GRADE Evidence-to-Decision (EtD) framework to develop clinical practice recommendations for the surveillance of non-malignant asbestos-related diseases (NMARDs) in asbestos-exposed populations within Colombia. The topic is of clear public health importance, and the use of a structured EtD approach is methodologically appropriate. However, the current version suffers from critical weaknesses in evidence base, methodological reporting, and the alignment between recommendation strength and evidence certainty. These limitations undermine the reliability and implementability of the proposed guidelines. My comments are as follows:

1.The search strategy for Questions 2 and 3 is poorly designed, yielding an unacceptably thin evidence base.  The use of MeSH/free-text terms such as "Watchful Waiting," "Critical Pathways," and "Eligibility Determination" is poorly aligned with the clinical context of asbestos post-screening follow-up. This resulted in zero retrievals from Embase and the Cochrane Library, leaving only two and three included studies for Questions 2 and 3, respectively. Such a sparse evidence base cannot support definitive recommendations regarding follow-up intervals (e.g., "every three years") or the management of positive findings.  

It's suggest to redesign the search strategies for Q2 and Q3 using relevant terms (e.g., follow-up, surveillance, monitoring, screening interval, radiographic progression, HRCT). If the evidence base remains insufficient after re-searching, the specific follow-up interval must be explicitly labeled as a good practice statement based on expert consensus, not as an evidence-driven recommendation. The rationale for the three-year interval (e.g., latency periods, resource considerations) should be transparently stated.

 

2.The strength of recommendations is inconsistent with the judged certainty of evidence.  The working group formally judges the certainty of evidence as Low and resource use as "Don't know" (Section 3.7). Nevertheless, the Conclusions state that "The working group recommends CXR with ILO classification as the primary screening tool" and advises routine three-year follow-up. Under GRADE principles, low-certainty evidence should yield conditional recommendations rather than strong ones.  

It's suggest to revise all recommendation statements so that their strength accurately reflects the underlying evidence certainty. Use "We conditionally suggest..." or "The working group suggests..." for recommendations supported by low-certainty evidence. Add a dedicated paragraph in the Discussion explaining why the balance of effects favors the intervention despite low certainty.

 

3.The terms "screening" and "surveillance" are used interchangeably throughout the manuscript, creating conceptual confusion.  The authors acknowledge in Section 4.3 that current evidence is insufficient to support formal population screening according to Wilson & Jungner principles. Yet the title, abstract, PICO questions, and main text repeatedly use "screening" (e.g., "optimal screening test," "Mass Screening" as a MeSH term). This contradiction weakens the manuscript’s conceptual clarity.  

Recommendation: Standardize terminology throughout. Use "initial surveillance evaluation" or "baseline assessment" for the first encounter and "periodic surveillance" or "follow-up monitoring" for subsequent evaluations. If the term "screening" is retained, its specific meaning within Colombia’s legally mandated care pathway (RIAS) must be explicitly defined in the Introduction to distinguish it from classical population screening.

 

4.The EtD framework is incompletely reported, and a required dimension is missing.  The Results section lists only brief judgment statements (e.g., "Judgment: Small," "Judgment: Low") without presenting the full GRADE EtD tables. Readers cannot trace how the working group weighed benefits, harms, certainty, patient values, cost-effectiveness, equity, acceptability, and feasibility to reach each recommendation. More critically, the "patient values and preferences" dimension—an obligatory element of the GRADE-EtD framework—is entirely absent. Given the controversies around asbestos surveillance (potential psychological harm, radiation risk, limited treatment options), patient perspectives are essential.  

It's suggest to provide complete GRADE EtD tables (as supplementary material or in-text tables) documenting the evidence summary and judgment rationale for each dimension. Add the missing "values and preferences" domain, drawing on any available patient-preference literature or, if absent, a transparent expert consensus judgment with explicit reasoning.

 

5.Diagnostic accuracy data are not quantitatively synthesized.  Only five of the 23 included studies for Question 1 reported sensitivity and specificity. The authors report only wide ranges (sensitivity 0.60–0.94; specificity 0.47–0.88) without pooled estimates, confidence intervals, or formal assessment of heterogeneity sources. For diagnostic test accuracy studies, meta-analysis using bivariate or HSROC models is standard practice and is necessary to judge precision and consistency.  

Recommendation: Perform a quantitative synthesis of the five diagnostic accuracy studies (e.g., using the mada package in R or the midas module in Stata), reporting pooled sensitivity/specificity with 95% CIs and an SROC curve. If pooling is deemed inappropriate due to excessive heterogeneity (e.g., differing reference standards, populations, or index test protocols), state this explicitly and present subgroup or sensitivity analyses to explore sources of variability.

 

6.The indirectness (applicability) of the included evidence to the Colombian context is insufficiently discussed.  All included studies originate from high-income countries (e.g., Sweden, Canada, Australia, USA, Finland, Japan). Not a single study comes from Colombia or a comparable middle-income setting. Differences in asbestos fiber types, cumulative exposure levels, occupational versus environmental exposure patterns, prevalence of comorbidities (e.g., obesity, smoking), radiological infrastructure, and reader expertise may substantially affect the diagnostic performance of chest X-ray and the feasibility of the proposed surveillance model.  

 

Author Response

Dear Editorial Team, Please find attached the response to the reviewer.

Kind regards.

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overall there is a lack of discussion if this type of screeningprogramme is a good idea for the participants or for society.

As to my notice of ethical concern: There is a total lack of ethical discussion on giving repeatet radiation doses (especially with CT scans) versus the clinical benefit for the participants in finding changes in the lungs at an early stage. No discussion on possible treatment for the non-malignant findings (which are poor). 

The following points from Wilson and Jungner classic screening criteria have not been addressed:

2. There should be an accepted treatment for patients with recognized disease.

4. There should be a recognizable latent or early symptomatic stage. (no discussion on WHEN the screening should take place as to the start time of asbestos exposure - latence periode of more than 20 years ...)

7. The natural history of the condition, including development from latent to declared disease, should be adequately understood

8. There should be an agreed policy on whom to treat as patients. (only mentioned for the malignant cases)

9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.

(ref.: Bulletin of the World Health Organization | April 2008, 86 (4))

As to detailed comments:

• Line 122: What is "an appropriate (asbestos) history"? Which of the asbestos exposed should not be included in the programme? If all participant have been exposed to some extent, then figure 1, 3. column, top box does not make sense: "There is no history of exposure ...."
• Line 142-149: Inclusion and especially exclusion criteria of articles are unclear. I appendix 3, all three flow charts lack explanation on e.g. how for Q1 the 1253 articles get to 84, what were the criteria to exclude 1169 articles (I assumen that they were not all about malignant diseases?) And what were the criteria for the last exclusion from 72 to 23 articles?
• For both flow charts for Q 2 and Q3 it ends up with 1 article, which is not in line with the article text (line 154 and 155) mentioning 2 articles each.
• Line 187-284: It is not transparent how the final judgement for each section is reached. and as mentioned earlier, there is a huge lack of discussion of benifits and harm for the participants. I can hardly believe that none of the articles in the initial search are discussion this aspect.
• Line 238: on app. 2 table 8: 72 articles were found - how were they reduced to 2 articles?? Risk of bias in the selection.
• Line 265-268: It does not make sense to talk about the low risk during the taking of X-ray (and CT), and not talk about the risk of the accumulated radiation doses.
• The discussion section is really not discussing the results of the article.
• The conclusion section is really not a conclusion, but just lining up the recommendations.

Therefor I suggest rejection of the article.

 

 

Author Response

Please find the attachment. Thank you.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. The main text mentions Appendix 1 (search terms), Appendix 4 (study characteristics table), Appendix 6 (GRADE evidence assessment) but does not provide a brief overview of the key appendix contents. It’s suggested to add a note such as Key study characteristics  are summarized in Appendix 4，e.g., study region, sample size, exposure industries, and diagnostic criteria，which could reduce readers' reliance on the appendices.  

2. Clearly specify the reasons for low-quality evidence rather than vaguely referring to methodological limitations. For instance, state if there is a risk of bias due to lack of blinding in CXR (chest X-ray) assessment or if an overrepresentation of small-sample studies may affect result stability.  

3. Compare the guideline with those from other high-asbestos-exposure countries (e.g., Brazil, South Africa) to explain why this guideline prioritizes CXR, highlighting its regional applicability.  

4. The inter-reader consistency of ILO classification is crucial for diagnostic tool validity. While the results mention CXR combined with ILO classification has a sensitivity of 0.60–0.94 and specificity of 0.47–0.88, they do not report inter-reader agreement metrics (e.g., Kappa values). It is recommended to extract or supplement this data from included studies to avoid concerns about result reproducibility. Additionally, the wide variation in CXR sensitivity and specificity should be analyzed to explain the differences.  

5. Current guidelines only mention asbestos-exposed populations without defining exposure thresholds,e.g., cumulative exposure ≥10 year·f/mL" or "occupational exposure ≥5 years or exposure scenarios (occupational, environmental, household). It is advisable to reference the International Labour Organization (ILO) asbestos exposure definitions and clarify screening inclusion criteria, including environmental or household exposure, to prevent over-screening or missed cases in clinical practice.  

6. The statement of informed consent is not applicable for lacks justification. It’s suggested to be revised to: "This study is a secondary analysis of published literature and does not involve human subjects or personal privacy data; therefore, informed consent was not required," ensuring ethical statement completeness.  

Comments on the Quality of English Language

 

Author Response

Please find the attachment. Thank you.

Author Response File: Author Response.pdf