Reviewer’s report
Title: 
Initial results from a multi-center population-based cluster randomized trial of esophageal and
gastric cancer screening in China
Version: 
0 
Date: 
13 Jul 2020
Reviewer's report:
This study investigated the efficacy of upper endoscopic screening in reducing mortality of esophageal
cancer and gastric cancer in high-risk areas and in non-high-risk areas of China. Three high-risk areas and
four non-high-risk areas were selected as screening centers. Clusters (villages/communities) were
randomly assigned into the intervention group or control group. In the intervention group, participants
from high-risk areas were automatically invited to receive upper endoscopy. Participants from non-high-
risk areas, only subjects who were identified as high-risk individuals using a questionnaire were invited to
receive endoscopy. The detection rates and early detection rates of esophageal cancer and gastric cancer
were evaluated. The detection rates was of both esophagus and stomach were higher in high-risk areas than
in non-high-risk areas, even though only high-risk individuals were screened in non-high-risk areas.
There are several points to be addressed.
1. Three high-risk areas were defined by higher mortality rate based on National survey. The higher
detection rate in high-risk areas is a matter of course.
2. Comparing participants automatically identified as high-risk individuals in high-risk areas and
participants identified as high-risk individuals using the questionnaire in non-high-risk areas is not
accurate. The effectiveness of screening endoscopy for non-high-risk individuals in high-risk areas
identified using the questionnaire should be shown.
3. The early-detection rate was lower in non-high-risk areas than in high-risk areas. This means that the
questionnaire was not effective for identifying high-risk individuals in non-high-risk areas. The
questionnaire was not found in the reference 10. The questionnaire should be shown as a supplement. 
4. Contrary, detection rates of non-early-stage esophageal cancer were 17/26633 (0.0006) in high-risk
areas and 7/11289 (0.0006) in non-high-risk areas. Detection rates of non-early-stage gastric cancer were
70/26633 (0.0017) in high-risk areas and 24/11289 (0.0021) in non-high-risk areas. Detection rates of
non-early-stage cancer were not so different. These results were quite interesting but not discussed in the
manuscript.
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Yes
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you recommend an additional
statistical review?
If an additional statistical review is recommended, please specify what aspects require further assessment
in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this manuscript,
either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an organization that holds or has
applied for patents relating to the content of the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this paper?
If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your
reply is yes to any, please give details below.
I declare that I have no competing interests.
Reviewer Publication Consent.
 I agree for my report to be made available under an Open Access
Creative Commons CC-BY License (
 http://creativecommons.org/licenses/by/4.0
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
Reviewer’s report
Title: 
Initial results from a multi-center population-based cluster randomized trial of esophageal and
gastric cancer screening in China
Version: 
0 
Date: 
13 Jul 2020
Reviewer's report:
This study investigated the efficacy of upper endoscopic screening in reducing mortality of esophageal
cancer and gastric cancer in high-risk areas and in non-high-risk areas of China. Three high-risk areas and
four non-high-risk areas were selected as screening centers. Clusters (villages/communities) were
randomly assigned into the intervention group or control group. In the intervention group, participants
from high-risk areas were automatically invited to receive upper endoscopy. Participants from non-high-
risk areas, only subjects who were identified as high-risk individuals using a questionnaire were invited to
receive endoscopy. The detection rates and early detection rates of esophageal cancer and gastric cancer
were evaluated. The detection rates was of both esophagus and stomach were higher in high-risk areas than
in non-high-risk areas, even though only high-risk individuals were screened in non-high-risk areas.
There are several points to be addressed.
1. Three high-risk areas were defined by higher mortality rate based on National survey. The higher
detection rate in high-risk areas is a matter of course.
2. Comparing participants automatically identified as high-risk individuals in high-risk areas and
participants identified as high-risk individuals using the questionnaire in non-high-risk areas is not
accurate. The effectiveness of screening endoscopy for non-high-risk individuals in high-risk areas
identified using the questionnaire should be shown.
3. The early-detection rate was lower in non-high-risk areas than in high-risk areas. This means that the
questionnaire was not effective for identifying high-risk individuals in non-high-risk areas. The
questionnaire was not found in the reference 10. The questionnaire should be shown as a supplement. 
4. Contrary, detection rates of non-early-stage esophageal cancer were 17/26633 (0.0006) in high-risk
areas and 7/11289 (0.0006) in non-high-risk areas. Detection rates of non-early-stage gastric cancer were
70/26633 (0.0017) in high-risk areas and 24/11289 (0.0021) in non-high-risk areas. Detection rates of
non-early-stage cancer were not so different. These results were quite interesting but not discussed in the
manuscript.
Publons Reviewer Recognition
. Springer Nature can send verification of this review directly to Publons
(a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on
the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted to Publons upon
publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt
of this review and update your profile 
as per your settings and their policy. If you are not registered with
Publons, you will receive an email from them asking you to register in order for them to be able to
recognize your review on your new profile page. Publons may use the Review Data to generate derivative
metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such
information. For example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help editors to identify candidate
reviewers. Please find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you recommend an additional
statistical review?
If an additional statistical review is recommended, please specify what aspects require further assessment
in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this manuscript,
either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an organization that holds or has
applied for patents relating to the content of the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this paper?
If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your
reply is yes to any, please give details below.
I declare that I have no competing interests.
Reviewer Publication Consent.
 I agree for my report to be made available under an Open Access
Creative Commons CC-BY License (
 http://creativecommons.org/licenses/by/4.0
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
Please review this paper.
user
Reviewer’s report
Title: 
Initial results from a multi-center population-based cluster randomized trial of esophageal and
gastric cancer screening in China
Version: 
0 
Date: 
13 Jul 2020
Reviewer's report:
This study investigated the efficacy of upper endoscopic screening in reducing mortality of esophageal
cancer and gastric cancer in high-risk areas and in non-high-risk areas of China. Three high-risk areas and
four non-high-risk areas were selected as screening centers. Clusters (villages/communities) were
randomly assigned into the intervention group or control group. In the intervention group, participants
from high-risk areas were automatically invited to receive upper endoscopy. Participants from non-high-
risk areas, only subjects who were identified as high-risk individuals using a questionnaire were invited to
receive endoscopy. The detection rates and early detection rates of esophageal cancer and gastric cancer
were evaluated. The detection rates was of both esophagus and stomach were higher in high-risk areas than
in non-high-risk areas, even though only high-risk individuals were screened in non-high-risk areas.
There are several points to be addressed.
1. Three high-risk areas were defined by higher mortality rate based on National survey. The higher
detection rate in high-risk areas is a matter of course.
2. Comparing participants automatically identified as high-risk individuals in high-risk areas and
participants identified as high-risk individuals using the questionnaire in non-high-risk areas is not
accurate. The effectiveness of screening endoscopy for non-high-risk individuals in high-risk areas
identified using the questionnaire should be shown.
3. The early-detection rate was lower in non-high-risk areas than in high-risk areas. This means that the
questionnaire was not effective for identifying high-risk individuals in non-high-risk areas. The
questionnaire was not found in the reference 10. The questionnaire should be shown as a supplement. 
4. Contrary, detection rates of non-early-stage esophageal cancer were 17/26633 (0.0006) in high-risk
areas and 7/11289 (0.0006) in non-high-risk areas. Detection rates of non-early-stage gastric cancer were
70/26633 (0.0017) in high-risk areas and 24/11289 (0.0021) in non-high-risk areas. Detection rates of
non-early-stage cancer were not so different. These results were quite interesting but not discussed in the
manuscript.
Publons Reviewer Recognition
. Springer Nature can send verification of this review directly to Publons
(a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on
the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted to Publons upon
publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt
of this review and update your profile 
as per your settings and their policy. If you are not registered with
Publons, you will receive an email from them asking you to register in order for them to be able to
recognize your review on your new profile page. Publons may use the Review Data to generate derivative
metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such
information. For example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help editors to identify candidate
reviewers. Please find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you recommend an additional
statistical review?
If an additional statistical review is recommended, please specify what aspects require further assessment
in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this manuscript,
either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an organization that holds or has
applied for patents relating to the content of the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this paper?
If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your
reply is yes to any, please give details below.
I declare that I have no competing interests.
Reviewer Publication Consent.
 I agree for my report to be made available under an Open Access
Creative Commons CC-BY License (
 http://creativecommons.org/licenses/by/4.0
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
assistant