Review Reports

Round 1

Reviewer 1 Report

Thanks for allowing me to read this paper, it’s interesting in his focus and very clear, consistent and precise in describing the study. There are a couple of minor issues that need to be addressed in order to share the added value of the study itself. Here some suggestions.

Introduction

Please deepen why is important the investigation of wait time: which are the repercussion of waiting time on the oncological population, their caregiver and the healthcare system?

Paragraph 2.2

Authors could briefly explain why these specific criteria (inclusion and exclusion) has been chosen.

Table 2

Please fix the font size in “Material deprivation”, it’s bigger than the rest of the table

Conclusions

The added value doesn’t emerge in terms of operative fallouts of the study. It’s not clear how results could be used by institutions and healthcare services to improve the effectiveness of oncological treatment. Please deepen these aspects, in order to make the study’s results useful to the community and the healthcare system’s policies.

Author Response

Reviewer 1:

 

1) Introduction: Please deepen why is important the investigation of wait time: which is the repercussion of waiting time on the oncological population, their caregiver and the healthcare system?

 

Response 1: Thank you for your comment. The current literature is conflicted regarding the effect of a longer wait time on esophageal cancer survival (it is clearer in other cancer sites). We have alluded to this in the first introduction paragraph. We have highlighted the benefits of a shorter TTS (time to surgery) by adding the following sentence: “Shorter TTS may relieve anxiety for the patient and their caregiver, avoid symptom progression whilst awaiting surgery, and reduce the overall burden on healthcare systems by decreasing the number of cancer related visits between diagnosis and treatment.”

 

 

2) Paragraph 2.2: Authors could briefly explain why these specific criteria (inclusion and exclusion) has been chosen.

 

Response 2: Thank you for your comment. We have added the following sentence to 2.2: “These selection criteria were chosen to create a cohort comprised of patients that would conceivably adhere to the Cancer Care Ontario pathway and be eligible for trimodal therapy. Further exclusions were based on ICES data availability.”

 

 

3) Table 2: Please fix the font size in “Material deprivation”, it’s bigger than the rest of the table

 

Response 3: Thank you for highlighting this. The font size is now the same as the rest of the table.

 

 

4) Conclusions: The added value doesn’t emerge in terms of operative fallouts of the study. It’s not clear how results could be used by institutions and healthcare services to improve the effectiveness of oncological treatment. Please deepen these aspects, in order to make the study’s results useful to the community and the healthcare system’s policies.

 

 

Response 4: Thank you for your comment. We agree that the conclusion section could be improved to highlight the value of our study. We have added the following sentence: “The results of our study can be used by several groups: clinicians and healthcare providers should be aware that older patients may require more support to navigate the system and may wish to flag these patients to the multidisciplinary oncology team as a vulnerable group; individual institutions can compare their data with the provincial median and perform an internal investigation into potential reasons for a prolonged TTS.”

Reviewer 2 Report

This is an excellent study of an under-investigated topic. As a next step, time-to-surgery should be assessed regarding the long-term outcome of patients with esophageal cancer; and specified to individual cancer centers.

 

To check: line 139, 2013 instead of 2003

Are all patients discussed at a multidisciplinary tumor board? please add in the manuscript.

What are the main factors that determine the length of TTC? And how often patients are seen by the surgeons?

Author Response

Reviewer 2:

 

1) This is an excellent study of an under-investigated topic. As a next step, time-to-surgery should be assessed regarding the long-term outcome of patients with esophageal cancer; and specified to individual cancer centers.

 

Response 1: Thank you for your comment. We agree that future research should investigate the effect of wait times on cancer outcomes. We will aim to do this once our data have matured enough to calculate 5-year overall and cancer-specific survival. We also plan to conduct an investigation into the institution-level characteristics that may affect wait times.

 

 

2) To check: line 139, 2013 instead of 2003

 

Response 2: Thank you for highlighting this. The year has been corrected.

 

 

3) Are all patients discussed at a multidisciplinary tumor board? please add in the manuscript.

 

Response 3: Not all patients are discussed at tumour board. We have added the following sentence in the introduction: “Additionally, some patients are discussed at the multidisciplinary tumour board.”

 

 

4) What are the main factors that determine the length of TTC?

 

Response 4: This is a great question. There are no established factors that contribute to the time of consultation. Our unadjusted data shows that diagnosing physician specialty, diagnosing physician academic affiliation, and stage of cancer are statistically associated with the TTC length. However, we did not include these variables in the multivariable regression analysis because of the amount of missing data; therefore, we chose not to comment on these findings in the discussion, but we described them in the 3^rdparagraph of the Results section 3.3 (line 234-240).

 

 

5) And how often patients are seen by the surgeons?

 

Response 5: Patients are usually seen just once by a surgeon, between the time of diagnosis and surgery. We have added the following sentence in the introduction to reflect this: “Most patients are seen only once by a surgeon prior to their operation.”