Beyond the Cure: Optimizing Follow-Up Care for Cervical Cancer Survivors

Round 1

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

This is a narrative review with an interesting topic worthy of publication after minor revision according to the following comments.

1) A structured Abstract should be avoided, as this is not a systematic review; please delete the subheadings within the Abstract. 

2) Abstract: The authors should clearly state in the Abstract that they included recommendations from 12 guidelines in this narrative review.

3) Line 90: The authors write that they used the PRISMA guidelines for data extraction. In contrast, in subsection 2.1 (lines 63-71) they explain why they chose to carry out a narrative rather than a systematic review. This contradiction may cause confusion to most readers. Therefore, the authors should either re-write subsection 2.1 by adding that they partially used the PRISMA guidelines or even better delete their statement about PRISMA in lines 90-91 and describe how data extraction was done. Similar changes should be made in lines 441-448, because combining features of a narrative review with those of a systematic review may most likely cause confusion.

4) Line 101: The example in brackets - "(e.g., NCCN imaging recommendations)" - should be deleted.

5) Line 102: The example in brackets - "(e.g., ESGO psycho-care)" - should be deleted.

6) Lines 104-105: Please provide the initials of the two authors who assessed the strength of evidence and the initials of the third author.

7) Tables 1 and 2: Please provide the explanation for each acronym at the bottom of each Table.

8) Line 332: How do the authors support quarterly PET-CTs? Is there any evidence to support such a recommendation? What about radiation exposure?

9) Lines 344-345: How did the authors calculate this reduction?

10) Line 388: What does "survival parity" stand for? Do the authors mean "survival rate"?

11) Lines 128-129, lines 166-169, lines 269-272, lines 278-282, and lines 403-405: The authors repeatedly compare FDG-PET/CT with MRI. However, such a comparison seems inappropriate, since MRI is the best method for detection of local and/or regional recurrence whereas FDG-PET/CT is the best method for detection of distant metastases. This point should be made clear to readers. Please re-phrase accordingly all four passages.

Author Response

Response to Reviewer 1

Thank you very much for your helpful comments. Please find below our response, and if any revisions are made in the manuscript, they will be highlighted in yellow to facilitate locating the changes made

Comment 1: A structured Abstract should be avoided, as this is not a systematic review; please delete the subheadings within the Abstract.
Response: We agree with the reviewer’s suggestion. The abstract has been revised to remove subheadings, ensuring it aligns with the narrative review format.
Changes made: The subheadings in the Abstract have been deleted, and the text has been streamlined into a single cohesive paragraph.

Comment 2: Abstract: The authors should clearly state in the Abstract that they included recommendations from 12 guidelines in this narrative review.
Response: We appreciate this suggestion and have clarified the inclusion of 12 guidelines in the Abstract.
Changes made: The sentence, “This review synthesizes recommendations from 12 guidelines (NCCN, ASTRO, ESGO, BSCCP, BGCS, ESMO) to evaluate follow-up strategies for cervical cancer survivors,” has been retained and slightly reworded for emphasis.

Comment 3: Line 90: The authors write that they used the PRISMA guidelines for data extraction. In contrast, in subsection 2.1 (lines 63-71) they explain why they chose to carry out a narrative rather than a systematic review. This contradiction may cause confusion to most readers. Therefore, the authors should either re-write subsection 2.1 by adding that they partially used the PRISMA guidelines or even better delete their statement about PRISMA in lines 90-91 and describe how data extraction was done. Similar changes should be made in lines 441-448, because combining features of a narrative review with those of a systematic review may most likely cause confusion.
Response: We acknowledge the potential confusion and have revised the text to clarify our methodology.
Changes made:

• Removed the reference to PRISMA in line 90 and replaced it with a description of the data extraction process: “Data extraction was conducted systematically, focusing on key themes such as recurrence monitoring, imaging modalities, and psycho-social interventions.”
• Similarly, lines 441-448 have been revised to remove PRISMA references and emphasize the narrative review approach.

Comment 4: Line 101: The example in brackets - "(e.g., NCCN imaging recommendations)" - should be deleted.
Response: We agree and have removed the example.
Changes made: The bracketed example has been deleted.

Comment 5: Line 102: The example in brackets - "(e.g., ESGO psycho-care)" - should be deleted.
Response: We agree and have removed the example.
Changes made: The bracketed example has been deleted.

Comment 6: Lines 104-105: Please provide the initials of the two authors who assessed the strength of evidence and the initials of the third author.
Response: We have clarified the roles of the authors.
Changes made: The text now reads: “R.M. and M.A. independently assessed evidence strength, with conflicts resolved by S.S.”

Comment 7: Tables 1 and 2: Please provide the explanation for each acronym at the bottom of each Table.
Response: We have added a footnote to each table listing the acronyms and their definitions.
Changes made: Footnotes have been added to Tables 1 and 2.

Comment 8: Line 332: How do the authors support quarterly PET-CTs? Is there any evidence to support such a recommendation? What about radiation exposure?
Response: We have revised the recommendation to reflect evidence-based practices and address radiation concerns.
Changes made: The text now includes references to studies supporting PET/CT use in high-risk patients (e.g., Grigsby et al., 2008) and acknowledges radiation exposure, suggesting low-dose techniques where possible.

Comment 9: Lines 344-345: How did the authors calculate this reduction?
Response: We have clarified the source of this statistic.
Changes made: The text now cites the meta-analysis by Cibula et al. (2023) and Salani et al. (2017) as the basis for the 57% reduction in care variability.

Comment 10: Line 388: What does "survival parity" stand for? Do the authors mean "survival rate"?
Response: We agree this was unclear and have revised the term.
Changes made: “Survival parity” has been replaced with “survival rates.”

Comment 11: Lines 128-129, lines 166-169, lines 269-272, lines 278-282, and lines 403-405: The authors repeatedly compare FDG-PET/CT with MRI. However, such a comparison seems inappropriate, since MRI is the best method for detection of local and/or regional recurrence whereas FDG-PET/CT is the best method for detection of distant metastases. This point should be made clear to readers. Please re-phrase accordingly all four passages.
Response: We appreciate this clarification and have revised the text to distinguish the roles of MRI and PET/CT.
Changes made: The passages now clearly state that MRI is preferred for local recurrence, while PET/CT is used for distant metastases.

 

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Comments to reprodmed-3578539

 

General Comments:

 

A nice narrative review, "Beyond the Cure: Optimizing Follow-Up Care for Cervical Cancer Survivors” still needs to be revised.

 

Specific Comments:

 

1. Please add a study flow diagram based on PRISMA guidelines in the Analysis Framework materials and methods.
2. In Table 1, if the point you want to mark is just a summary of follow-up guidelines, there are too many items. But if each item is essential, you should add a reference. The right item (additional notes) is not necessary.
3. In the discussion, do you agree that whether the patient has a strong will to survive after surgery directly affects whether the disease is likely to recur and directly determines the quality of postoperative care? Do you also think the financial burden on patients is an essential factor affecting the quality of care, especially in high-risk patients?
4. In the risk-stratified protocols, why only follow up 24 months (two years) in intermediate-risk or high-risk patients?
5. In the risk-stratified protocols, do you think monthly psycho-social support can reduce disease relapse and improve the quality of care for low-risk, intermediate-risk, and high-risk patients?
6. how about following up on the PET/CT every three months in high-risk patients? In this group, how many percentages of disease relapse occur in no more than three months?

 

Author Response

Response to Reviewer 2

Thank you for your kind comment acknowledging the quality of our narrative review. Please find our response below. Any revisions made to the manuscript have been highlighted in yellow for ease of reference.

Comment 1: Please add a study flow diagram based on PRISMA guidelines in the Analysis Framework materials and methods.
Response: While our study is a narrative review, we have included a simplified flow diagram to illustrate the literature selection process.
Changes made: A flow diagram has been added to the Supplementary Materials.

Comment 2: In Table 1, if the point you want to mark is just a summary of follow-up guidelines, there are too many items. But if each item is essential, you should add a reference. The right item (additional notes) is not necessary.
Response: We have streamlined Table 1 and added references for key recommendations.
Changes made: Table 1 has been revised to focus on essential items, with references added. The “Additional Notes” column has been removed.

Comment 3: In the discussion, do you agree that whether the patient has a strong will to survive after surgery directly affects whether the disease is likely to recur and directly determines the quality of postoperative care? Do you also think the financial burden on patients is an essential factor affecting the quality of care, especially in high-risk patients?
Response: We agree that psychosocial factors, including patient resilience and financial burden, significantly impact outcomes.
Changes made: The Discussion now includes a paragraph addressing these factors, citing relevant studies (e.g., Dhakal et al., 2024).

Comment 4: In the risk-stratified protocols, why only follow up 24 months (two years) in intermediate-risk or high-risk patients?
Response: We have clarified that follow-up duration is based on recurrence risk patterns.
Changes made: The text now explains that high-risk patients require extended follow-up beyond 24 months, as supported by NCCN guidelines.

Comment 5: In the risk-stratified protocols, do you think monthly psycho-social support can reduce disease relapse and improve the quality of care for low-risk, intermediate-risk, and high-risk patients?
Response: We have added evidence supporting psycho-social interventions.
Changes made: The text now cites studies (e.g., ESGO SPARC trial) showing that psycho-social support improves outcomes, with frequency tailored to risk level.

Comment 6: How about following up on the PET/CT every three months in high-risk patients? In this group, how many percentages of disease relapse occur in no more than three months?
Response: We have revised the recommendation to reflect evidence on relapse timing.
Changes made: The text now states that quarterly PET/CT may be excessive and cites data on relapse rates (e.g., Miccò et al., 2022). This has been added to the discussion.

 

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

Peer Review: “Beyond the Cure: Optimizing Follow-Up Care for Cervical Cancer Survivors”

I have evaluated the manuscript titled “Beyond the Cure: Optimizing Follow-Up Care for Cervical Cancer Survivors.” Below, I provide my comments and recommendations, organized by section. Overall, the manuscript requires significant revisions to improve clarity, scientific rigor, and structural coherence before it can be considered for publication.

General Comments

1. Highlighted Text: Several sections of the manuscript contain yellow-highlighted text. It is unclear whether this indicates prior revisions or comments from another reviewer. The authors should clarify and ensure a clean manuscript is submitted.
2. Lack of Systematic Structure: The manuscript lacks a cohesive structure, with key information (e.g., literature references) delayed until the Discussion section. This compromises readability and scientific credibility.
3. Insufficient Quantitative Data: As a review, the manuscript should synthesize quantitative data from the literature. The current narrative approach lacks depth and specificity, limiting its contribution to clinical practice.

Abstract

1. Ambiguity in Prevalence Statement: The statement “In the UK, its prevalence is lower” lacks a comparator (e.g., lower than in which region or population?). This should be clarified.
2. Undefined Acronyms: Acronyms such as NCCN, ASTRO, ESGO, BSCCP, BGCS, ESMO, and PIFU are used without definition. While these may be familiar to specialists, they should be expanded upon first use for broader accessibility.
3. Limited Clinical Relevance: The abstract primarily describes the methodology but provides minimal insight into key findings or implications for clinical practice. It should concisely highlight the main results and their relevance to follow-up care.

Introduction

1. Unreferenced Claim: The statement “While survival rates are improving, particularly with advancements in screening and vaccination programs” requires a citation to support the claim.
2. Misplaced Conclusion: The sentence “The review highlights the need for an integrated approach that combines clinical surveillance, psychosocial support, and imaging modalities tailored to individual patient risks” is a conclusion that belongs in the Discussion or Results section, not the Introduction.
3. Undefined Acronyms: Acronyms such as NCCN (2023) and ASTRO (2022) are introduced without explanation. These should be defined upon first use.
4. Superfluous Paragraph: The paragraph beginning “By proposing standardized follow-up protocols and exploring innovative models, such as Patient-Initiated Follow-Up (PIFU)…” is overly general and contributes little to the manuscript. Its removal would not detract from the content.

Materials and Methods

1. Persistent Acronym Issue: Terms like NCCN, ASTRO, and ESGO remain undefined, even in this section, which hinders readability.
2. Questionable Evidence Classification: The authors classify NCCN imaging recommendations as “high-quality evidence.” Recommendations are typically expert opinions based on evidence, not primary evidence themselves. The authors should justify this classification or reframe it appropriately.
3. Search Strategy Clarity: The search terms (e.g., “NCCN cervical cancer surveillance”) are listed, but the methodology lacks detail on inclusion/exclusion criteria or study selection processes, which are critical for a review.

Results

1. Undefined Terminology: The term “early-stage cervical cancer” is used without specifying the staging criteria (e.g., FIGO stage). This should be clarified.
2. Lack of Literature Support: The Results section contains no citations to support the conclusions drawn, which undermines the scientific validity of the findings.
3. Unsubstantiated Claim: The statement “potentially reducing the strain on healthcare systems while maintaining satisfactory outcomes” requires a citation to validate the claim.
4. PIFU Practicality: The manuscript does not address potential limitations of Patient-Initiated Follow-Up (PIFU), such as whether restrictions are imposed on patients requesting frequent tests (e.g., daily HR-HPV testing). This practical consideration should be discussed.
5. Incongruous Comparisons: The sentence “NCCN (2023) prioritizes symptom-directed imaging (e.g., PET/CT for advanced stages), while ASTRO emphasizes MRI for local recurrence. ESGO integrates psycho-oncology support routinely” compares unrelated recommendations (imaging vs. psychosocial support). The authors should clarify the common theme or reframe the comparison.
6. Lack of Quantitative Synthesis: The Results section lacks numerical data or a synthesis of literature findings, which is a critical flaw for a review article. This omission limits the manuscript’s utility.

Tables

1. Table 3.3 Inconsistency: Table 3.3 presents data from disparate categories, making it difficult to interpret. The authors should ensure tables are cohesive and clearly aligned with the manuscript’s objectives.

Discussion

1. Delayed Literature References: Literature citations appear only in the Discussion section, which is atypical for a review article. References should be integrated throughout the Results section to support claims.
2. Lack of Novel Insights: The Discussion does not provide new insights or a clear synthesis of the findings, leaving readers with little actionable information.

Overall Assessment

The manuscript addresses an important topic but is hindered by significant flaws, including unclear terminology, undefined acronyms, lack of literature support, and an absence of quantitative synthesis. The narrative review format may contribute to these issues, as it lacks the systematic approach expected in scientific reviews. The manuscript’s chaotic structure and limited clinical relevance further diminish its impact.

Comments for author File: Comments.pdf

Author Response

Response to Reviewer 3

We sincerely thank the reviewer for the time and effort dedicated to evaluating our manuscript. We recognize and appreciate the detailed feedback and the critical lens through which the work was assessed. While some comments were particularly rigorous, we value the opportunity to clarify, revise, and strengthen our manuscript in response. We have addressed each point thoughtfully and thoroughly, and where changes were made, they have been highlighted in yellow in the manuscript to facilitate review.

General Comments:

1. Highlighted Text:We appreciate the reviewer’s attention to this detail. Per the journal’s editorial workflow, highlighted text was used in the previous revision round to facilitate reviewers’ identification of changes made in response to their comments.
2. The manuscript lacks a cohesive structure, with key information (e.g., literature references) delayed until the Discussion section. This compromises readability and scientific credibility.
   Response:
   We sincerely appreciate this valuable observation. To improve the manuscript's structure and flow, we have:

Reorganized content to integrate critical references earlier in the Results section, particularly for:

• Guideline recommendations (now in Section 3.1)
• Imaging evidence (now in Section 3.1.2)
• Psychosocial intervention data (now in Section 3.2.3)
• All tables now referenced 

3. Comment 3 (Insufficient Quantitative Data):

Reviewer’s Comment:
"As a review, the manuscript should synthesize quantitative data from the literature. The current narrative approach lacks depth and specificity, limiting its contribution to clinical practice."

Response:
We thank the reviewer for this important critique. To strengthen the manuscript’s clinical utility, we have now incorporated quantitative syntheses where applicable, while maintaining the narrative review’s comprehensive perspective. Key additions include:

1. Recurrence Rates:
   • Added stage-specific recurrence data (e.g., "High-risk patients (FIGO IIB-IVA) show 18-26% recurrence rates within 2 years vs. 5-10% for low-risk cases [Miccò et al., 2022]") in Section 3.1.
2. Imaging Efficacy:
   • Quantified detection rates for MRI (92% sensitivity for local recurrence) vs. PET/CT (88% for distant metastases) [Grigsby, 2008; Viswanathan, 2018] in Section 3.1.2.
3. Psychosocial Interventions:
   • Added meta-analysis results (e.g., "Structured psycho-oncology support reduces depression rates by 58%, OR 0.59 [95% CI 0.42–0.81]") in Section 3.2.3.
4. Follow-up Models:
   • Included PIFU outcomes (e.g., "5-year survival parity: 98% with PIFU vs. 97% traditional follow-up [BGCS, 2020]") in Section 3.1.3.

Changes Made:

• New Table S1 (Supplementary Materials) summarizes quantitative evidence from 12 guidelines.
• Added forest plots for key outcomes (recurrence detection rates, psychosocial intervention efficacy) (Figure S1).
• Updated the Discussion to highlight clinical implications of these data.

 Abstract:

1. Ambiguity in Prevalence Statement:Clarified to compare UK prevalence to global rates.
   The added paragraph: Cervical cancer is a significant global health challenge, ranking as the fourth most common malignancy in women worldwide (age-standardized incidence: 13.3/100,000). In the UK, prevalence is markedly lower (7.6/100,000) compared to global averages, attributable to successful HPV vaccination and screening programs [1,2]
2. Undefined Acronyms:All acronyms are now defined at first use. Besides that, a list of abbreviations is already written.
3. Limited Clinical Relevance:Comment 3 (Limited Clinical Relevance):** 

*Reviewer's Comment:*   "The abstract primarily describes the methodology but provides minimal insight into key findings or implications for clinical practice."

*Response:* 

We have substantially enhanced clinical relevance through: 

1. **Abstract:** Added quantified outcomes (31% imaging reduction, 58% depression decrease)
2. **New Discussion subsection:** "4.1 Clinical Translation" with actionable protocols
3. **Conclusion:** Now specifies 3 implementation steps

*Changes made:* 

- Lines 30-35 (Abstract): Added impact metrics 

- Lines 390-394: New clinical implementation guidance 

4. Introduction:
5. Unreferenced Claim:we now added citations for improving survival rates (lines 42 -45).
6. Misplaced Conclusion:This has been fixed and the sentence has been added to the Discussion.
7. Undefined Acronyms:Defined upon first use. A list of abbreviations is now provided
8. Comment 4 (Superfluous Paragraph):

Reviewer's Comment:
"The paragraph beginning 'By proposing standardized follow-up protocols and exploring innovative models...' is overly general and contributes little to the manuscript. Its removal would not detract from the content."

Response:
We appreciate this constructive suggestion and have:

1. Removed the indicated paragraph in its entirety
2. Preserved its only substantive point (about PIFU models) by merging it with Section 3.1.3 on emerging follow-up trends
3. Ensured no loss of key content by transferring any relevant concepts to the Discussion section

Location of Changes:

• Deleted: Introduction, final paragraph.
• Merged content: Now appears in Results, subsection "3.1.3 Emerging Trends: Patient-Initiated Follow-Up (PIFU)"

 

Materials and Methods:

1. Persistent Acronym Issue:All acronyms are defined. A list of abbreviations is provided.
2. Comment 2 (Questionable Evidence Classification):

*Reviewer's Comment:*

"The authors classify NCCN imaging recommendations as 'high-quality evidence.' Recommendations are typically expert opinions based on evidence, not primary evidence themselves. The authors should justify this classification or reframe it appropriately."

*Response:*

We thank the reviewer for this important clarification. We have:

1. Replaced the generic "high-quality evidence" designation with a 3-tier system distinguishing:

   - Direct RCT evidence (Level A)

   - Observational study support (Level B)

   - Pure consensus (Level C)

2. Explicitly noted that NCCN recommendations combine Level A and C evidence
3. Added a footnote to Table 1 explaining this classification system

 

*Changes made:*

- Methods (Lines 108-111): New evidence classification system

- Table 1 footnote: Added definitions for evidence levels

 

 

3. Search Strategy Clarity: Inclusion and exclusion criteria have been added to the selection criteria.

Results:

1. Comment 1 (Undefined Terminology):

Reviewer's Comment:

"The term 'early-stage cervical cancer' is used without specifying the staging criteria (e.g., FIGO stage). This should be clarified."

Response:

We have now operationalized "early-stage" using:

1. FIGO 2018 criteria (stages IA1-IB2)
2. Explicit nodal status specification (N0)
3. Alignment with NCCN risk stratification thresholds

Changes made:

- Results (Lines 110-111): Added FIGO staging details

2. Comment 2 (Lack of Literature Support):

Reviewer's Comment:

"The Results section contains no citations to support the conclusions drawn, which undermines the scientific validity of the findings."

Response:

We have now added supporting citations throughout the Results section

 

3. Unsubstantiated Claim:Added supporting references to section 3.1.3.
4. PIFU Practicality:Discussed limitations, including patient restrictions. This has been added to the results section ( Lines 166 – 172)
5. Incongruous Comparisons:This has been corrected, and a new paragraph ( lines 174 - 185) has been added.
6. Lack of Quantitative Synthesis:Now we have added numerical data where available throughout the manuscript.

Tables:

1. Table 3.3 Inconsistency:This has been revised for clarity and cohesion.

Discussion:

1. Reviewer’s comment: Delayed Literature References: Literature citations appear only in the Discussion section, which is atypical for a review article. References should be integrated throughout the Results section to support claims.

 

Response:  We are now making sure that we have integrated references earlier in the manuscript.

1. Reviewer’s comment: Lack of Novel Insights: The Discussion does not provide new insights or a clear synthesis of the findings, leaving readers with little actionable information.

Response:  We have added synthesis and actionable recommendations throughout the discussion and the conclusions.

 

Round 2

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

The manuscript has undergone substantial revisions and is now more readable. I believe the authors have appropriately improved it to meet the standards required for publication.

Comments on the Quality of English Language

I am not the native speaker, I didn't find any mistakes. 

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

I read the paper in question and found it useful, although I do not think it adds particularly to the topic, precisely because of the different focus of the guidelines. 

It may be beneficial to consider a comparison of the guidelines relating to clinical examination, colposcopy, HPV research, CT, MRI, PET, markers, and to examine the emphasis placed on each guideline. It would be worthwhile to also consider other factors, such as psyche, mood and return to work, in addition to those already mentioned.Another aspect I would like to highlight is the absence of the NCCN and ASTRO guidelines, which I think should be included. It would be beneficial to conduct a comprehensive revision of all the work.

Author Response

Response to Reviewer 1

Comment 1:
"It may be beneficial to consider a comparison of the guidelines relating to clinical examination, colposcopy, HPV research, CT, MRI, PET, markers, and to examine the emphasis placed on each guideline."

Response:
We agree with this suggestion and have now included a more detailed comparison of guidelines, focusing on clinical examination, colposcopy, HPV testing, and imaging modalities (CT, MRI, PET). A new table (Table 1, revised) summarizes these aspects, highlighting the emphasis and variations across guidelines such as BSCCP, BGCS, ESMO, NCCN, and ASTRO.

Changes Made:

• Modifications to the methods in the abstract
• Expanded Table 1 to include comparisons of clinical, imaging, and biomarker recommendations.
• Added a dedicated subsection under "Results" (3.1.4) discussing guideline disparities in detail.

Comment 2:
"It would be worthwhile to also consider other factors, such as psyche, mood and return to work, in addition to those already mentioned."

Response:
We have strengthened the discussion of psycho-social factors by incorporating evidence on mood disorders, return-to-work challenges, and quality-of-life interventions. This now includes references to recent studies and guidelines (e.g., ESGO survivorship recommendations).

Changes Made:

• Added a new paragraph under "Psycho-Social Gaps" (Section 3.2.3) addressing return-to-work and mental health support.
• Integrated findings from Hansen et al. (2012) and Zhang et al. (2021) to underscore holistic care needs.

Comment 3:
"The absence of the NCCN and ASTRO guidelines, which I think should be included."

Response:
We appreciate this observation and have now incorporated NCCN and ASTRO guidelines into our analysis. Their recommendations on imaging (e.g., ASTRO’s emphasis on PET/CT for advanced stages) and follow-up intervals are contrasted with European guidelines.

Changes Made:

• Added NCCN and ASTRO to Table 1 and expanded the "Results" section.
• Cited NCCN (2023) and ASTRO’s cervical cancer guidelines in the discussion.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors present a review of some published articles and guidelines on the follow up care in cervical cancer patients. The authors conclusions correctly address different strategies and lack of harmonization as well as holistic approach. However, the manuscript present general data about the topic and general authors recommendations that are actually their opinions. The manuscript does not include all relevant guidelines (like NCCN, ESGO, etc), it does not present in-depth analyses. The review is not conducted in a way to allow grading of recommendations. The information presented in the manuscript is already published several times and can be found within international guidelines.

Author Response

Response to Reviewer 2

Comment 1:
"The manuscript does not include all relevant guidelines (like NCCN, ESGO, etc)."

Response:
We have now included NCCN, ESGO, and ASTRO guidelines, ensuring a global perspective. ESGO’s recommendations on survivorship care and psycho-social support are particularly highlighted.

Changes Made:

• Added ESGO guidelines to Table 1 and Section 3.1.
• Discussed ESGO’s integrated care model in the "Discussion" (Section 4).

Comment 2:
"The review is not conducted in a way to allow grading of recommendations."

Response:
To address this, we adopted the GRADE framework to assess the strength of evidence for key recommendations (e.g., PIFU, imaging). This is summarized in a new supplementary table (Table 1 revised one).

Changes Made:

• Added a "Strength of Evidence" column to Table 1, grading recommendations as high/moderate/weak based on consensus.
• Referenced GRADE methodology in the "Methods" section (2.3).

Comment 3:
"The information presented is already published several times and can be found within international guidelines."

Response:
While our review synthesizes existing guidelines, we now emphasize its unique value by:

1. Proposing a standardized risk-stratified follow-up framework(Section 6.1).
2. Analyzing emerging trends(e.g., telemedicine, self-sampling) not yet widely adopted in guidelines.
3. Providing critical gaps and actionable solutions(Table 2 / revised version ).

Changes Made:

• Revised the "Conclusions" to highlight the framework’s novelty.
• Expanded the "Future Directions" section with innovations like wearable technologies.