Impact of the COVID-19 Pandemic on Cervical Cancer Screening in Brazil: A Nationwide Population-Based Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript entitled “Impact of the COVID‑19 Pandemic on Cervical Cancer Screening in Brazil: A Nationwide Population‑Based Study” addresses a topic of profound relevance and timeliness: the effect of the COVID‑19 pandemic on cervical cancer screening in Brazil, using official population‑based data. While this approach is not entirely novel, given the existence of multiple similar studies both within Brazil and internationally, the primary contribution of this study lies in its utilization of comprehensive national data and its stratified analysis by region and age group. This level of geographic and demographic detail constitutes a valuable addition to public health policymaking and the design of health strategies tailored to local realities.

To further strengthen the manuscript, the following adjustments are recommended prior to acceptance:

1. Inclusion of post‑pandemic data (2022–2023): It is essential to assess whether screening levels have returned to pre‑pandemic norms or whether structural deficits persist. A long‑term comparison will enable differentiation between temporary effects and enduring consequences within the national screening program.
2. Clarification of the temporal scope in the results: In statements such as:
   “Despite the decrease in the number of exams performed, there was an increase in unsatisfactory reports during this period. Additionally, there was an increase in adenocarcinoma reports in the South region and atypia of undetermined significance reports in the North region,”
   it is recommended to clearly specify the interval being referenced (e.g., “2020–2021”).
3. Although the use of logistic regression is mentioned, the manuscript lacks specifics regarding the independent variables included criteria for covariate selection, and model fit metrics (beyond a brief mention of the ROC curve). Including an appendix or supplementary text with this information is advisable.
4. It is suggested that the manuscript explores in greater depth the clinical, social, and economic implications of the findings, compares them with similar studies from other regions or countries, and addresses limitations beyond the use of secondary databases (such as potential coverage bias, variations in regional health policies, lack of information on socioeconomic factors, etc.).
5. Replace grey tones on axes and numerical labels with black to improve visibility, and ensure all figures are of sufficient resolution and legibility

Author Response

Comment 1: Inclusion of post‑pandemic data (2022–2023): It is essential to assess whether screening levels have returned to pre‑pandemic norms or whether structural deficits persist. A long‑term comparison will enable differentiation between temporary effects and enduring consequences within the national screening program.

Response 1: We appreciate the reviewer’s valuable suggestion regarding the inclusion of post-pandemic data. In response, we updated Table 1 to include a third column with data from 2022–2023, enabling a more comprehensive assessment of whether screening levels have returned to pre-pandemic standards. This addition allows for a preliminary long-term comparison across three time periods (2018–2019, 2020–2021, and 2022–2023) without altering the manuscript’s overall structure. The Results section has also been updated accordingly to reflect the observed trends.

 

Comment 2: Clarification of the temporal scope in the results: In statements such as:
“Despite the decrease in the number of exams performed, there was an increase in unsatisfactory reports during this period. Additionally, there was an increase in adenocarcinoma reports in the South region and atypia of undetermined significance reports in the North region,”
it is recommended to clearly specify the interval being referenced (e.g., “2020–2021”).

Response 2: Thank you for this useful comment. We revised the relevant sentence in the Results section to clarify the time periods being referenced. The updated text now reads:

“Despite the decrease in the number of exams performed during the pandemic period (2020–2021) compared to the pre-pandemic period (2018–2019), there was an increase in the number of unsatisfactory reports. Additionally, an increase in adenocarcinoma reports was observed in the South region and atypical squamous cells of undetermined significance (ASC-US) in the North region during 2020–2021.”

 

Comment 3: Although the use of logistic regression is mentioned, the manuscript lacks specifics regarding the independent variables included criteria for covariate selection, and model fit metrics (beyond a brief mention of the ROC curve). Including an appendix or supplementary text with this information is advisable.

Response 3: We thank the reviewer for this important observation. Indeed, the mention of logistic regression in the Methods section was an oversight, as no such analysis was performed. We have removed the reference to logistic regression to accurately reflect the statistical methods employed in the study. We appreciate the opportunity to correct this and apologize for the confusion.

 

Comment 4: It is suggested that the manuscript explores in greater depth the clinical, social, and economic implications of the findings, compares them with similar studies from other regions or countries, and addresses limitations beyond the use of secondary databases (such as potential coverage bias, variations in regional health policies, lack of information on socioeconomic factors, etc.).

Response 4: Thank you for this thoughtful and constructive comment. We have significantly revised the Discussion section to better explore the clinical, social, and economic implications of our findings. We also expanded the Limitations paragraph to address issues such as potential coverage bias, regional disparities in health policies, and the absence of socioeconomic and demographic indicators. These additions provide a more comprehensive interpretation of the study and its public health relevance.

 

Comment 5: Replace grey tones on axes and numerical labels with black to improve visibility, and ensure all figures are of sufficient resolution and legibility

Response 5: Thank you for this practical recommendation. We have updated all figures by changing axis lines and numerical labels to black and ensured they are provided in high-resolution formats to maximize legibility.

Reviewer 2 Report

Comments and Suggestions for Authors

Please find the comments in the attachment.

Comments for author File: Comments.pdf

Author Response

Comment 1: After carefully analyzing the article entitled "Impact of the COVID-19 Pandemic on Cervical Cancer Screening in Brazil: A Nationwide Population-Based Study" , I would like to make a few comments: Firstly, an article in such a journal should have between 3,000 and 6,000 words. In this article, excluding the bibliography and other irrelevant text, the authors provide around 2,500 words. The introduction, materials and methods, discussion, and conclusions are very weak! Please expand! Furthermore, the bibliography is weak. It should have a minimum of 30 bibliographic references, certainly not just the 16 that the authors offer.

Response 1: We sincerely thank the reviewer for this valuable observation. In response, we have significantly expanded all major sections of the manuscript, particularly the Introduction, Discussion, and Conclusion. The total word count now exceeds 3,500 words, aligning more closely with the journal’s requirements. The Discussion section has been substantially enhanced to include clinical, social, and economic implications of the findings; barriers to screening access at both individual and systemic levels; comparisons with international experiences; and a more detailed limitations analysis (see revised Discussion, paragraphs 3–7). We also updated the reference list, which now contains over 30 peer-reviewed sources, incorporating recent global evidence to reinforce the scientific rigor and contextual depth of the manuscript.

 

Comment 2: Also - Limited Exploration of Contributing Factors: While the study identifies a reduction in screening rates, it would benefit from a deeper exploration of the factors contributing to this decline. Consider including a discussion of specific barriers to access (for instance - transportation, fear of infection) and potential differences in impact based on socioeconomic status or geographic location.

Response 2: Thank you for your insightful comment. We have added a new paragraph to the Discussion section that explores specific barriers to cervical cancer screening during the COVID-19 pandemic.

 

Comment 3: Lack of Detailed Analysis of Diagnostic Outcomes: The study mentions changes in unsatisfactory exams and adenocarcinoma findings but could expand on this. A more detailed analysis of how specific diagnostic categories shifted could provide valuable insights into the types of cervical lesions that were potentially missed or delayed in detection.

Response 3: Thank you for your comment. We have added the detailed analysis of diagnostic results in the Discussion topic, including the increase in unsatisfactory exams and regional variations in adenocarcinoma and ASC-US findings.

 

Comment 4: The authors acknowledge the limitations of ecological studies, but it's crucial to emphasize this limitation more explicitly when interpreting the regional variations. Consider including a statement cautioning against making individual-level inferences based on aggregated data.

Response 4: We appreciate this important observation. We have revised the final paragraph of the Discussion section to explicitly mention the risk of ecological fallacy and the need for caution when interpreting regional differences based on aggregated data. This clarification improves the transparency and interpretability of our findings.

 

Comment 5: While the study mentions the need to mitigate long-term impacts, it could benefit from a more in-depth discussion of potential strategies. Suggest specific policy recommendations for reorganizing screening programs and addressing healthcare disparities.

Response 5: Thank you for this important suggestion. We have revised the Discussion section to include specific public health and policy recommendations aimed at reorganizing cervical cancer screening programs.

 

Comment 6: Please: Expand the discussion on factors contributing to the decline in screening rates, including patient-level barriers and healthcare system challenges.

Response 6: Thank you for your suggestion. In response, we have expanded the Discussion section to include a detailed examination of both patient-level barriers—such as fear of COVID-19 infection and limited transportation—and systemic challenges, including the repurposing of primary care units and regional disparities in healthcare infrastructure. These additions provide a more comprehensive understanding of the multifactorial causes behind the observed decline in screening coverage.

 

Comment 7: Provide a more detailed analysis of changes in diagnostic outcomes, including the distribution of different lesion types. Also, elaborate on policy recommendations for improving cervical cancer screening programs in the context of ongoing disruptions and healthcare disparities.

Response 7: Thank you for this important comment. In response, we have revised the Discussion section to provide a more detailed analysis of the changes in diagnostic outcomes, including the distribution of different lesion types across regions and time periods. Additionally, we elaborated on policy recommendations to improve the resilience and equity of cervical cancer screening programs.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript was clearly improved.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors respected all recommendations.