Reviewer’s report
Title: Colorectal cancer screening behaviors of general surgeons and first-degree family members: a
survey-based study
Version: 0 Date: 21 Apr 2019
Reviewer: Nancy N. Baxter
Reviewer's report:
This is a study collecting data through a cross-sectional survey from general surgeons regarding their
colorectal cancer screening practices and those of their first-degree relatives. The authors report a high
response rate (95.8%, N=530) among respondents, who were divided into those aged less than 50
(n=374) and those older than 50 (n=156). Some additional information and details are required about
the study methodology, including recruitment process, the survey instrument used to collect the data
and how variables were defined and measured. The discussion section could be strengthened through a
more  in-depth  discussion  of the  study results  in light  of available  evidence.  In  addition,  several
limitations outlined in the comments below need to be addressed.   
Comments:
1.Methods section /individuals - please do not include study results in the methods section - the
number of respondents to the survey and number of surgeons in each group should be a part of the
results section. 
2.Methods section/individuals - What would be helpful for the methods section is to include some
more information about who typically attends the National Surgical Congress in Antalya where the data
was collected. Is it only attended by general surgeons or other specialists and providers as well? Is it a
national or international meeting? More information on this would be helpful. 
3.Methods section - please clarify whether the survey was paper-based or was it an e-survey?
4.Methods section - please include some details on the recruitment process. How were individuals
approached to participate in the study? Was it at a particular point/event throughout the meeting? Who
did the recruitment? If the survey was completed electronically, please provide details on when the
survey was sent to potential participants and whether any reminders followed. 
5.Methods section - was there any testing of the questionnaire done prior to use? (i.e. face or
content validity etc.) Please clarify.
6.Methods  section  - it  would  be beneficial  to  have  some  information  on the  actual  survey
instrument and how certain variables were measured. Are the authors able to provide a copy of the
surveys in an appendix/supplemental file? If not, some additional details in the methods section about
how each variable was measured would be beneficial. For example how was "screening options"
measured? Did this refer to screening options available to survey respondents for their own screening
or screening options they recommend to their patients? Please clarify. How was attitudes related to
screening or barriers to CRC screening measured? It would be helpful to know what the multiple-
choice options were for the variables mentioned. 
7.Methods section - similar to comment above it would be useful to provide some details on the
demographic data collected (age, sex, workplace, etc.). Please add these details to the methods section.
How is screening status being defined? (i.e. based on USPSTF guidelines? had a colonoscopy within
the last 10 years, flex sig within 5 years...etc) Please clarify. 
8.Methods section - how was first-degree relative defined for your study? If surgeons had some
first-degree relatives that had been screened and some that had not - how was this handled? (i.e. did
ALL first degree relatives need to be up to date with screening to answer YES or only some?) 
9.Methods section - please address how missing data was handled if applicable.  
10.Results/Discussion - why was 25 CRC cases chosen as the threshold for your analysis? Have
other papers used a similar threshold for defining high-volume surgeons? You should address this in the
discussion section of your paper.
11.Results section/page 7 lines 144-146. You mention here that high-volume surgeons were more
likely to recommend a CRC screening option to their first-degree relatives than low-volume surgeons
(64.1% vs. 51.9%, p=0.023) based on the data reported in Table 1. Is table 1 not reporting on the CRC
screening  status  of  first-degree  relatives  rather  than  surgeons  recommendations  to  first-degree
relatives? My interpretation of this finding would be that first-degree relatives of high volume surgeons
are more like to be up to date with screening. Please clarify. 
12.Discussion section/page 9 lines 200-201. Also related to the last comment, you mention that
high-volume surgeons were more likely to provide CRC screening to their first-degree relatives. This
further adds to the confusion as to what was measured - please clarify what exactly was measured in
regards to first-degree relatives of those under 50 (surgeons providing screening to relatives, surgeons
recommending a CRC screening option to relatives or CRC screening status of first-degree relative?)
13.Discussion section - First two paragraphs of the discussion section are very general about the
incidence/mortality of CRC and importance of screening. However, most of the discussion should be
about your results and the implications these have for practice, how they measure up with other studies
etc. I would recommend combining the two paragraphs and linking these to your actual results rather
than just general information about CRC incidence/mortality and screening. You should also consider
discussing your findings regarding barriers to undergoing CRC screening in light of other evidence -
are the barriers identified in your study similar to what has previously been reported or do they add
something new?
14.Discussion section - in addition to the limitations you have identified, you should also add recall
bias as surgeons had to recall whether their first-degree relatives were up to date with screening or
recall about their own screening practices. If the survey did not undergo any content or face validity or
pilot testing prior to use this should also be addressed in the limitations section.  Also address the
arbitrary threshold chosen for high-volume surgeons (<25 vs. ≥25 cases). 
15.Discussion section/page 9-10 lines 210-213 - the authors mention here that "this study was not
focused on screening options, but it only evaluated whether surgeons or their relatives were up-to-date
with CRC screening recommendations  and did not focus  on potential provider-related barriers  to
screening". However, in your methods section and results you mention that your survey measured
screening options and barriers to CRC screening (those older than 50). Please clarify this discrepancy.
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.
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 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.
No conflict
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 wish 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: Colorectal cancer screening behaviors of general surgeons and first-degree family members: a
survey-based study
Version: 0 Date: 21 Apr 2019
Reviewer: Nancy N. Baxter
Reviewer's report:
This is a study collecting data through a cross-sectional survey from general surgeons regarding their
colorectal cancer screening practices and those of their first-degree relatives. The authors report a high
response rate (95.8%, N=530) among respondents, who were divided into those aged less than 50
(n=374) and those older than 50 (n=156). Some additional information and details are required about
the study methodology, including recruitment process, the survey instrument used to collect the data
and how variables were defined and measured. The discussion section could be strengthened through a
more  in-depth  discussion  of the  study results  in light  of available  evidence.  In  addition,  several
limitations outlined in the comments below need to be addressed.   
Comments:
1.Methods section /individuals - please do not include study results in the methods section - the
number of respondents to the survey and number of surgeons in each group should be a part of the
results section. 
2.Methods section/individuals - What would be helpful for the methods section is to include some
more information about who typically attends the National Surgical Congress in Antalya where the data
was collected. Is it only attended by general surgeons or other specialists and providers as well? Is it a
national or international meeting? More information on this would be helpful. 
3.Methods section - please clarify whether the survey was paper-based or was it an e-survey?
4.Methods section - please include some details on the recruitment process. How were individuals
approached to participate in the study? Was it at a particular point/event throughout the meeting? Who
did the recruitment? If the survey was completed electronically, please provide details on when the
survey was sent to potential participants and whether any reminders followed. 
5.Methods section - was there any testing of the questionnaire done prior to use? (i.e. face or
content validity etc.) Please clarify.
6.Methods  section  - it  would  be beneficial  to  have  some  information  on the  actual  survey
instrument and how certain variables were measured. Are the authors able to provide a copy of the
surveys in an appendix/supplemental file? If not, some additional details in the methods section about
how each variable was measured would be beneficial. For example how was "screening options"
measured? Did this refer to screening options available to survey respondents for their own screening
or screening options they recommend to their patients? Please clarify. How was attitudes related to
screening or barriers to CRC screening measured? It would be helpful to know what the multiple-
choice options were for the variables mentioned. 
7.Methods section - similar to comment above it would be useful to provide some details on the
demographic data collected (age, sex, workplace, etc.). Please add these details to the methods section.
How is screening status being defined? (i.e. based on USPSTF guidelines? had a colonoscopy within
the last 10 years, flex sig within 5 years...etc) Please clarify. 
8.Methods section - how was first-degree relative defined for your study? If surgeons had some
first-degree relatives that had been screened and some that had not - how was this handled? (i.e. did
ALL first degree relatives need to be up to date with screening to answer YES or only some?) 
9.Methods section - please address how missing data was handled if applicable.  
10.Results/Discussion - why was 25 CRC cases chosen as the threshold for your analysis? Have
other papers used a similar threshold for defining high-volume surgeons? You should address this in the
discussion section of your paper.
11.Results section/page 7 lines 144-146. You mention here that high-volume surgeons were more
likely to recommend a CRC screening option to their first-degree relatives than low-volume surgeons
(64.1% vs. 51.9%, p=0.023) based on the data reported in Table 1. Is table 1 not reporting on the CRC
screening  status  of  first-degree  relatives  rather  than  surgeons  recommendations  to  first-degree
relatives? My interpretation of this finding would be that first-degree relatives of high volume surgeons
are more like to be up to date with screening. Please clarify. 
12.Discussion section/page 9 lines 200-201. Also related to the last comment, you mention that
high-volume surgeons were more likely to provide CRC screening to their first-degree relatives. This
further adds to the confusion as to what was measured - please clarify what exactly was measured in
regards to first-degree relatives of those under 50 (surgeons providing screening to relatives, surgeons
recommending a CRC screening option to relatives or CRC screening status of first-degree relative?)
13.Discussion section - First two paragraphs of the discussion section are very general about the
incidence/mortality of CRC and importance of screening. However, most of the discussion should be
about your results and the implications these have for practice, how they measure up with other studies
etc. I would recommend combining the two paragraphs and linking these to your actual results rather
than just general information about CRC incidence/mortality and screening. You should also consider
discussing your findings regarding barriers to undergoing CRC screening in light of other evidence -
are the barriers identified in your study similar to what has previously been reported or do they add
something new?
14.Discussion section - in addition to the limitations you have identified, you should also add recall
bias as surgeons had to recall whether their first-degree relatives were up to date with screening or
recall about their own screening practices. If the survey did not undergo any content or face validity or
pilot testing prior to use this should also be addressed in the limitations section.  Also address the
arbitrary threshold chosen for high-volume surgeons (<25 vs. ≥25 cases). 
15.Discussion section/page 9-10 lines 210-213 - the authors mention here that "this study was not
focused on screening options, but it only evaluated whether surgeons or their relatives were up-to-date
with CRC screening recommendations  and did not focus  on potential provider-related barriers  to
screening". However, in your methods section and results you mention that your survey measured
screening options and barriers to CRC screening (those older than 50). Please clarify this discrepancy.
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.
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 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.
No conflict
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 wish 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: Colorectal cancer screening behaviors of general surgeons and first-degree family members: a
survey-based study
Version: 0 Date: 21 Apr 2019
Reviewer: Nancy N. Baxter
Reviewer's report:
This is a study collecting data through a cross-sectional survey from general surgeons regarding their
colorectal cancer screening practices and those of their first-degree relatives. The authors report a high
response rate (95.8%, N=530) among respondents, who were divided into those aged less than 50
(n=374) and those older than 50 (n=156). Some additional information and details are required about
the study methodology, including recruitment process, the survey instrument used to collect the data
and how variables were defined and measured. The discussion section could be strengthened through a
more  in-depth  discussion  of the  study results  in light  of available  evidence.  In  addition,  several
limitations outlined in the comments below need to be addressed.   
Comments:
1.Methods section /individuals - please do not include study results in the methods section - the
number of respondents to the survey and number of surgeons in each group should be a part of the
results section. 
2.Methods section/individuals - What would be helpful for the methods section is to include some
more information about who typically attends the National Surgical Congress in Antalya where the data
was collected. Is it only attended by general surgeons or other specialists and providers as well? Is it a
national or international meeting? More information on this would be helpful. 
3.Methods section - please clarify whether the survey was paper-based or was it an e-survey?
4.Methods section - please include some details on the recruitment process. How were individuals
approached to participate in the study? Was it at a particular point/event throughout the meeting? Who
did the recruitment? If the survey was completed electronically, please provide details on when the
survey was sent to potential participants and whether any reminders followed. 
5.Methods section - was there any testing of the questionnaire done prior to use? (i.e. face or
content validity etc.) Please clarify.
6.Methods  section  - it  would  be beneficial  to  have  some  information  on the  actual  survey
instrument and how certain variables were measured. Are the authors able to provide a copy of the
surveys in an appendix/supplemental file? If not, some additional details in the methods section about
how each variable was measured would be beneficial. For example how was "screening options"
measured? Did this refer to screening options available to survey respondents for their own screening
or screening options they recommend to their patients? Please clarify. How was attitudes related to
screening or barriers to CRC screening measured? It would be helpful to know what the multiple-
choice options were for the variables mentioned. 
7.Methods section - similar to comment above it would be useful to provide some details on the
demographic data collected (age, sex, workplace, etc.). Please add these details to the methods section.
How is screening status being defined? (i.e. based on USPSTF guidelines? had a colonoscopy within
the last 10 years, flex sig within 5 years...etc) Please clarify. 
8.Methods section - how was first-degree relative defined for your study? If surgeons had some
first-degree relatives that had been screened and some that had not - how was this handled? (i.e. did
ALL first degree relatives need to be up to date with screening to answer YES or only some?) 
9.Methods section - please address how missing data was handled if applicable.  
10.Results/Discussion - why was 25 CRC cases chosen as the threshold for your analysis? Have
other papers used a similar threshold for defining high-volume surgeons? You should address this in the
discussion section of your paper.
11.Results section/page 7 lines 144-146. You mention here that high-volume surgeons were more
likely to recommend a CRC screening option to their first-degree relatives than low-volume surgeons
(64.1% vs. 51.9%, p=0.023) based on the data reported in Table 1. Is table 1 not reporting on the CRC
screening  status  of  first-degree  relatives  rather  than  surgeons  recommendations  to  first-degree
relatives? My interpretation of this finding would be that first-degree relatives of high volume surgeons
are more like to be up to date with screening. Please clarify. 
12.Discussion section/page 9 lines 200-201. Also related to the last comment, you mention that
high-volume surgeons were more likely to provide CRC screening to their first-degree relatives. This
further adds to the confusion as to what was measured - please clarify what exactly was measured in
regards to first-degree relatives of those under 50 (surgeons providing screening to relatives, surgeons
recommending a CRC screening option to relatives or CRC screening status of first-degree relative?)
13.Discussion section - First two paragraphs of the discussion section are very general about the
incidence/mortality of CRC and importance of screening. However, most of the discussion should be
about your results and the implications these have for practice, how they measure up with other studies
etc. I would recommend combining the two paragraphs and linking these to your actual results rather
than just general information about CRC incidence/mortality and screening. You should also consider
discussing your findings regarding barriers to undergoing CRC screening in light of other evidence -
are the barriers identified in your study similar to what has previously been reported or do they add
something new?
14.Discussion section - in addition to the limitations you have identified, you should also add recall
bias as surgeons had to recall whether their first-degree relatives were up to date with screening or
recall about their own screening practices. If the survey did not undergo any content or face validity or
pilot testing prior to use this should also be addressed in the limitations section.  Also address the
arbitrary threshold chosen for high-volume surgeons (<25 vs. ≥25 cases). 
15.Discussion section/page 9-10 lines 210-213 - the authors mention here that "this study was not
focused on screening options, but it only evaluated whether surgeons or their relatives were up-to-date
with CRC screening recommendations  and did not focus  on potential provider-related barriers  to
screening". However, in your methods section and results you mention that your survey measured
screening options and barriers to CRC screening (those older than 50). Please clarify this discrepancy.
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.
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 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.
No conflict
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 wish 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