Review Reports - Mortality of Laryngeal Cancer before and during the COVID-19 Pandemic

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The submitted manuscript is a (very) short communication, however as this type of article is also supported by MDPI COVID, it can be accepted after several changes, listed below.

As the manuscript is short, my review will be short too.

My major question is why the Authors haven’t included the period before 2018 in their analysis? This should be clearly stated in the introduction.

The introduction is clear, well written, doesn’t require any corrections.

Figure 1, the y-axis range should be from 0.84 to 0.96

Lines 145-149, the Authors should try to correlate those data with the number of individuals with COVID in the same age group and the same period.

Author Response

My major question is why the Authors haven’t included the period before 2018 in their analysis? This should be clearly stated in the introduction.

ANSWER: We have already explained it in the method section, as follows: “We accessed the last updated version of the CDC WONDER on-line database, which reports mortality data between the years 2018 and 2022 for the US resident population”. This database provide no access to data before the 2018.

Figure 1, the y-axis range should be from 0.84 to 0.96

ANSWER: Done, as suggested

Lines 145-149, the Authors should try to correlate those data with the number of individuals with COVID in the same age group and the same period.

ANSWER: This is already done. This is what the age-adjusted death rate exactly stands for, according to this universal calculation: “= deaths in age group ÷ estimated population of that age group × 100,000”.

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting research article with adequate novelty. However, several point should be addressed.

- In line 62, the statement "... may have represented" should be revised as "...may be considered".

- The Material and Methods section should be split into paragraphs which each of them should have a subheading (for example: study population, participants diagnosis and prognosis, statistical analysis).

- When the authors stated that "The age-adjusted mortality rate ×100,000 for laryngeal cancer was 0.91 (95%CI, 0.84- 97 0.94) in 2018", it is complex to understa what the number 0.91 means. Is it an odd ratio or a relative risk ratio? Please explain.

- Figure 2 should be improved concerning its resolution.

- Could the results of the 2nd paragraph (lines 111-125) be presented into a table. This could be helpful for the readers.

- Since the only significant association was obtained for patients aged 85 years or older, what is the percentage proportion of patients with this age in the study population?

- The auhtor reported in the discussion section that "The most obvious consequence is the delayed detection of some cancers and the diagnosis of some malignancies at a more advanced stage than in the pre-pandemic period." This statement needs more explanation. During COVID-19 pandemic, most people, including mostly the older ones, avoided to go tp hospitals. Thise may be ascribed to their fear to be infected by coronavirus. Is this a possible exlanation for the significant association for older patients?

- In conclusion section, the authors should state the significant association observed for the older patients in a condensed sentence.

- In conclusion section, the authors should add their opinion basd on their experience concerning what future studies could be performed based on the results of the present study.

Comments on the Quality of English Language

Minor editing of English language is recommended.

Author Response

- In line 62, the statement "... may have represented" should be revised as "...may be considered".

ANSWER: Done, as suggested

ANSWER: Done, as suggested

ANSWER: We have further explained the concept of age-adjusted mortality rate (as for referee 1) in the method section, i.e., “= deaths in age group ÷ estimated population of that age group × 100,000”

- Figure 2 should be improved concerning its resolution.

ANSWER: Done, as suggested

- Could the results of the 2nd paragraph (lines 111-125) be presented into a table. This could be helpful for the readers.

ANSWER: Done, as suggested (New table 2)

- Since the only significant association was obtained for patients aged 85 years or older, what is the percentage proportion of patients with this age in the study population?

ANSWER: Done, as suggested (“which represent around 13% of the overall US population”)

ANSWER: Yes, thanks. We have included this explanation in the text of the article, as follows: “which may be attributable to several factors such as fear of infection, healthcare system strain, disruption of diagnostic pathways, and backlog of cases”

- In conclusion section, the authors should state the significant association observed for the older patients in a condensed sentence.

ANSWER: Done, as suggested (“In conclusion, our analysis of real-world data on laryngeal cancer mortality suggests that the impact of the COVID-19 pandemic may have been relatively modest in the general US population, except for the population aged 85 years or older”).

- In conclusion section, the authors should add their opinion basd on their experience concerning what future studies could be performed based on the results of the present study.

ANSWER: Good point, thanks. Done, as suggested: “Further studies are needed to determine whether medium- and long-term mortality from laryngeal cancer will be impacted by the COVID-19 pandemic.”

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for giving me the opportunity to read and comment on the paper titled "Mortality for Laryngeal Cancer before and during the COVID-19 Pandemic" submitted for possible publication in this journal. The authors aim to assess the impact of COVID on the epidemiology of Laryngeal Cancer, looking for possible variations due to both direct and indirect effects of the pandemic.

It is indeed well-known that COVID disrupted health services worldwide, and several diagnostic and therapeutic pathways for various pathologies (including oncological ones) have shown variations in trends. However, analyses that manage to precisely define whether there has actually been an impact on the distribution and frequency of health conditions are those that have conducted analyses in smaller time intervals than annual ones. It is now established that for several conditions that have been impacted (for example, during the major waves), they could then "benefit" from recoveries during subsequent periods. Therefore, analyses conducted over an entire year may not be sensitive enough to appreciate individual changes, as the total sum approximates that of previous/succeeding years.

This consequently leads to the discussions in the submitted work being unfortunately weak due to the difficulty in commenting on data spread over periods when events have changed: even in the USA, the periods of possible impact of COVID and lockdowns varied during the years 2020 and 2021, with different degrees of repercussions on this (as well as other) pathology.

My advice is to apply this methodology to other types of data (i.e., health discharge records from administrative health database) that allow for better evaluation of whether the COVID impact has occurred or not, while acknowledging the bias related to the period.

Comments on the Quality of English Language

My comments are limited to occasional typos that can be dealt with a quick review by an editor.

Author Response

Indeed, the discussions are very generic, limited to describing (lines 127-136) what happened during the pandemic in a generic manner (not their fault or lack of preparation, but simply because it is difficult with this type of data), but there is no specific analysis of the COVID impact on this pathology. My advice is to apply this methodology to other types of data (i.e., health discharge records from administrative health database) that allow for better evaluation of whether the COVID impact has occurred or not, while acknowledging the bias related to the period.

ANSWER: This is a good point, but our search of the Wonder database only allows to retrieve mortality data. However, we acknowledge that this is a possible limitation in our analysis and we have included this sentence at the end of the manuscript: “We acknowledge that mortality data for laryngeal cancer only provides a generic representation of what has happened during the COVID-19 pandemic, but this is the only information available in the CDC Wonder database. Additional analysis could be performed to consider to other types of data (i.e., health discharge records from administrative health database) that allow for a more comprehensive evaluation of the impact of the pandemic on this and other types of cancers”.

My comments are limited to occasional typos that can be dealt with a quick review by an editor.

ANSWER: Thanks for this comment. We have attempted to fix all occasional typos throughout the article.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The Authors have improved and revised their work. Current version can be accepted.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have significantly improved their manuscript.

Comments on the Quality of English Language

Minor editing of English language required

Reviewer 3 Report

Comments and Suggestions for Authors

I have read the authors' kind response and I understand their point of view. However, the issues I raised regarding the methodology and the type of data require a different and more careful approach, which cannot be resolved in three hours as it was done. I confirm what was said in the first round and I believe the work cannot be published. However, it will be up to the editors to consider a different path.

Comments on the Quality of English Language

My comments are still limited to occasional typos.