Reviewer ’s report  
 
Title: Interactive Decision Support for Esophageal Adenocarcinoma Screening and Surveillance  
 
Version: 0 Date: 06 Mar 2019  
 
Reviewer: Julia van Tol -Geerdink  
 
Reviewer's report:  
 
The authors have developed a model to more precisely estimate the risk of developing EAC 
using large datasets from cancer registries and studies. Different models were made for patients 
with or without Barrett's esophagus. Based on these models, they p roduced a tool to visualize the 
calculated 10 year risk of individual patients.  
 
Comments:  
The goal of this study, to improve risk estimates for EAC, is a relevant aim. The authors have 
done extensive analyses on large datasets and have justified the ass umptions they made for the 
effect of age, sex and race. This resulted in an interesting tool to aid decision making.  
However, some issues still need to be clarified.  
1. The message of the paper is somewhat confusing. Authors suggest that the threshold c an 
be raised compared to current guidelines; "more stringent thresholds that might be used" 
(Background, p.3), "to reduce false positives" (Results, p.7), "unnecessary procedures 
could be reduced" (Conclusion, p.9). This all refers to preventing unnecessar y additional 
tests. However, to find out whether preventive actions should be taken, lower thresholds 
may be more appropriate. Do the authors want to alter the threshold guidelines or 
abandon the use of thresholds all together?  
 
2. The decisions on a) pre ventive action and b) additional diagnostic testing should be 
distinguished and discussed. Are both guideline -driven currently?  
 
3. How do the authors envision the use of this tool? They seem to aim at shared decision 
making (SDM) between patients and the ir care providers, since the layout is specifically 
tailored to patients. Usually, SDM is used to choose between two equivalent options that 
have both have pros and cons. In those cases, information is shared with patients to make 
a personal tradeoff betwe en risk and harms. However, in this case the harms from 
additional tests will be more on the providers side (waist of limited resources), whereas 
some patients may take the inconvenience for granted to get more certainty. Is the aim 
SDM or is the tool actu ally meant for the care provider to illustrate his professional 
decision to the patient, e.g. that additional tested are not warranted?  
 
4. Both incidence and mortality of EAC are imported in the model, but only incidence is 
presented as outcome of the too l. Why? Instead of showing incidence in two formats, you 
could show incidence and disease specific mortality, for example with two colors in the 
icons.  
 
5. The presentation of the estimated risk in the icons (number out of 1000 patients) is clear 
and bala nced, showing both the patients with and without EAC.  The "thermometer", 
however, is somewhat bothersome.  
* It's log scale is hard to interpret for patients. Moreover, it visually augments small risks in 
comparison to larger risks.  
* The thermometer compares the incidence of EAC with the mortality of other causes. This 
is inconsistent. Having EAC is not the same as dying from it. This again may cause patient to 
overestimate the risk of EAC. In addition, the comparison may be wrong as  the mortality of other 
causes is "not corrected for non -demographic risk factors"(such as smoking, obesity?) and the 
EAC risk is.  
* The only added value I can see is the presentation of the uncertainty, but does this justify 
the use of the thermometer?  
 
Minor points  
1. Add HGD to the list of abbreviations  
 
2. Horizontal axis in Figure 2 should state per 1000 instead of x1000  
 
3. Why is the incidence of EAC "assumed to vary ..with 1.04 per year of age" (2nd para, p. 
4) when both studies that they refer to (re f. 17 and 18) mention 1.03 per year?  
Are the methods appropriate and well described?  
If not, please specify what is requir ed in your comments to the authors.  
 
Yes 
 
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 e xplain in your comments to the authors.  
 
Yes 
 
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 recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of compe ting 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 relatin g 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 h ave no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. 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/ ). I understand that any comments  
which I do not wis h to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Interactive Decision Support for Esophageal Adenocarcinoma Screening and Surveillance  
 
Version: 0 Date: 06 Mar 2019  
 
Reviewer: Julia van Tol -Geerdink  
 
Reviewer's report:  
 
The authors have developed a model to more precisely estimate the risk of developing EAC 
using large datasets from cancer registries and studies. Different models were made for patients 
with or without Barrett's esophagus. Based on these models, they p roduced a tool to visualize the 
calculated 10 year risk of individual patients.  
 
Comments:  
The goal of this study, to improve risk estimates for EAC, is a relevant aim. The authors have 
done extensive analyses on large datasets and have justified the ass umptions they made for the 
effect of age, sex and race. This resulted in an interesting tool to aid decision making.  
However, some issues still need to be clarified.  
1. The message of the paper is somewhat confusing. Authors suggest that the threshold c an 
be raised compared to current guidelines; "more stringent thresholds that might be used" 
(Background, p.3), "to reduce false positives" (Results, p.7), "unnecessary procedures 
could be reduced" (Conclusion, p.9). This all refers to preventing unnecessar y additional 
tests. However, to find out whether preventive actions should be taken, lower thresholds 
may be more appropriate. Do the authors want to alter the threshold guidelines or 
abandon the use of thresholds all together?  
 
2. The decisions on a) pre ventive action and b) additional diagnostic testing should be 
distinguished and discussed. Are both guideline -driven currently?  
 
3. How do the authors envision the use of this tool? They seem to aim at shared decision 
making (SDM) between patients and the ir care providers, since the layout is specifically 
tailored to patients. Usually, SDM is used to choose between two equivalent options that 
have both have pros and cons. In those cases, information is shared with patients to make 
a personal tradeoff betwe en risk and harms. However, in this case the harms from 
additional tests will be more on the providers side (waist of limited resources), whereas 
some patients may take the inconvenience for granted to get more certainty. Is the aim 
SDM or is the tool actu ally meant for the care provider to illustrate his professional 
decision to the patient, e.g. that additional tested are not warranted?  
 
4. Both incidence and mortality of EAC are imported in the model, but only incidence is 
presented as outcome of the too l. Why? Instead of showing incidence in two formats, you 
could show incidence and disease specific mortality, for example with two colors in the 
icons.  
 
5. The presentation of the estimated risk in the icons (number out of 1000 patients) is clear 
and bala nced, showing both the patients with and without EAC.  The "thermometer", 
however, is somewhat bothersome.  
* It's log scale is hard to interpret for patients. Moreover, it visually augments small risks in 
comparison to larger risks.  
* The thermometer compares the incidence of EAC with the mortality of other causes. This 
is inconsistent. Having EAC is not the same as dying from it. This again may cause patient to 
overestimate the risk of EAC. In addition, the comparison may be wrong as  the mortality of other 
causes is "not corrected for non -demographic risk factors"(such as smoking, obesity?) and the 
EAC risk is.  
* The only added value I can see is the presentation of the uncertainty, but does this justify 
the use of the thermometer?  
 
Minor points  
1. Add HGD to the list of abbreviations  
 
2. Horizontal axis in Figure 2 should state per 1000 instead of x1000  
 
3. Why is the incidence of EAC "assumed to vary ..with 1.04 per year of age" (2nd para, p. 
4) when both studies that they refer to (re f. 17 and 18) mention 1.03 per year?  
Are the methods appropriate and well described?  
If not, please specify what is requir ed in your comments to the authors.  
 
Yes 
 
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 e xplain in your comments to the authors.  
 
Yes 
 
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 recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of compe ting 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 relatin g 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 h ave no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. 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/ ). I understand that any comments  
which I do not wis h to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Interactive Decision Support for Esophageal Adenocarcinoma Screening and Surveillance  
 
Version: 0 Date: 06 Mar 2019  
 
Reviewer: Julia van Tol -Geerdink  
 
Reviewer's report:  
 
The authors have developed a model to more precisely estimate the risk of developing EAC 
using large datasets from cancer registries and studies. Different models were made for patients 
with or without Barrett's esophagus. Based on these models, they p roduced a tool to visualize the 
calculated 10 year risk of individual patients.  
 
Comments:  
The goal of this study, to improve risk estimates for EAC, is a relevant aim. The authors have 
done extensive analyses on large datasets and have justified the ass umptions they made for the 
effect of age, sex and race. This resulted in an interesting tool to aid decision making.  
However, some issues still need to be clarified.  
1. The message of the paper is somewhat confusing. Authors suggest that the threshold c an 
be raised compared to current guidelines; "more stringent thresholds that might be used" 
(Background, p.3), "to reduce false positives" (Results, p.7), "unnecessary procedures 
could be reduced" (Conclusion, p.9). This all refers to preventing unnecessar y additional 
tests. However, to find out whether preventive actions should be taken, lower thresholds 
may be more appropriate. Do the authors want to alter the threshold guidelines or 
abandon the use of thresholds all together?  
 
2. The decisions on a) pre ventive action and b) additional diagnostic testing should be 
distinguished and discussed. Are both guideline -driven currently?  
 
3. How do the authors envision the use of this tool? They seem to aim at shared decision 
making (SDM) between patients and the ir care providers, since the layout is specifically 
tailored to patients. Usually, SDM is used to choose between two equivalent options that 
have both have pros and cons. In those cases, information is shared with patients to make 
a personal tradeoff betwe en risk and harms. However, in this case the harms from 
additional tests will be more on the providers side (waist of limited resources), whereas 
some patients may take the inconvenience for granted to get more certainty. Is the aim 
SDM or is the tool actu ally meant for the care provider to illustrate his professional 
decision to the patient, e.g. that additional tested are not warranted?  
 
4. Both incidence and mortality of EAC are imported in the model, but only incidence is 
presented as outcome of the too l. Why? Instead of showing incidence in two formats, you 
could show incidence and disease specific mortality, for example with two colors in the 
icons.  
 
5. The presentation of the estimated risk in the icons (number out of 1000 patients) is clear 
and bala nced, showing both the patients with and without EAC.  The "thermometer", 
however, is somewhat bothersome.  
* It's log scale is hard to interpret for patients. Moreover, it visually augments small risks in 
comparison to larger risks.  
* The thermometer compares the incidence of EAC with the mortality of other causes. This 
is inconsistent. Having EAC is not the same as dying from it. This again may cause patient to 
overestimate the risk of EAC. In addition, the comparison may be wrong as  the mortality of other 
causes is "not corrected for non -demographic risk factors"(such as smoking, obesity?) and the 
EAC risk is.  
* The only added value I can see is the presentation of the uncertainty, but does this justify 
the use of the thermometer?  
 
Minor points  
1. Add HGD to the list of abbreviations  
 
2. Horizontal axis in Figure 2 should state per 1000 instead of x1000  
 
3. Why is the incidence of EAC "assumed to vary ..with 1.04 per year of age" (2nd para, p. 
4) when both studies that they refer to (re f. 17 and 18) mention 1.03 per year?  
Are the methods appropriate and well described?  
If not, please specify what is requir ed in your comments to the authors.  
 
Yes 
 
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 e xplain in your comments to the authors.  
 
Yes 
 
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 recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of compe ting 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 relatin g 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 h ave no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. 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/ ). I understand that any comments  
which I do not wis h to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant