Reviewer ’s report  
 
Title: The Alpha -fetoprotein Serum is still Reliable as a Bi omarker for the Surveillance of 
Hepatocellular Carcinoma in Indonesia  
 
Version: 1 Date: 29 Apr 2020  
 
Reviewer's report:  
 
The diagnosis of HCC iin Dr. Cipto Mangunkusumo General National Hospital, Jakarta 
(RSCM)RSCM and Dharmais National Cancer Hospital, Jakarta (RSKD), was made from 
patients with positive surveillance results of either elevate d AFP ≥10 ng/ml or positive 
ultrasound,  
 
Thank you for giving me the opportunity to re review this interesting paper. The amended 
version of this paper has clearly gained  - however I still have some major concerns:  
 
* The vast majority of the cases are ver y advanced cases 85% of al cases had an tumour 
size &gt; 5cm 
 
* Only 10 % of the cases had a BCLC Stage A  
 
Just taking into account those two facts is seems clear the AFP gains diagnostic accuracy in the 
advanced stages, however we must emphasises the fact that our main intention is to detect early 
stages A  
 
Also, the fact that all(?) HCC have been seen on ultrasound reflects again the fact that the vast 
majority where advanced cases. Normally ultrasound has a sens of about 60 - 70 %.  
 
The authors must stat a statement that adding AFP into the screening algorithm will clearly 
increase the need of CT and MRI scans as the number of false pos was over 50 in this cohort.  
 
The authors stated that they would have seen all HCC on ultrasound - so one might raise the 
question what the additive value of AFP in this cohort is? Again I believe it is the number of 
advanced HCC in this cohort  - for sure detecting advanced stages mostly is unlikely to improve 
survival an it is well known that AFP increased with tumour size.  
 
Are the methods appropriate and well described?  
If not, please specify what is required 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.  
 
No 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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 manuscri pt: 
 
Needs some language corrections before being published  
 
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, fundi ng, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from t he 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, wr ite '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 edi torial office 
befor e completing the review.  If you wish, you can include your name in your publish ed 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 no t be able to 
publish your name.  
 
I agree to the terms of the CC -BY 4.0 license; please do not publish m y name with my report.  
(default)  
Reviewer ’s report  
 
Title: The Alpha -fetoprotein Serum is still Reliable as a Bi omarker for the Surveillance of 
Hepatocellular Carcinoma in Indonesia  
 
Version: 1 Date: 29 Apr 2020  
 
Reviewer's report:  
 
The diagnosis of HCC iin Dr. Cipto Mangunkusumo General National Hospital, Jakarta 
(RSCM)RSCM and Dharmais National Cancer Hospital, Jakarta (RSKD), was made from 
patients with positive surveillance results of either elevate d AFP ≥10 ng/ml or positive 
ultrasound,  
 
Thank you for giving me the opportunity to re review this interesting paper. The amended 
version of this paper has clearly gained  - however I still have some major concerns:  
 
* The vast majority of the cases are ver y advanced cases 85% of al cases had an tumour 
size &gt; 5cm 
 
* Only 10 % of the cases had a BCLC Stage A  
 
Just taking into account those two facts is seems clear the AFP gains diagnostic accuracy in the 
advanced stages, however we must emphasises the fact that our main intention is to detect early 
stages A  
 
Also, the fact that all(?) HCC have been seen on ultrasound reflects again the fact that the vast 
majority where advanced cases. Normally ultrasound has a sens of about 60 - 70 %.  
 
The authors must stat a statement that adding AFP into the screening algorithm will clearly 
increase the need of CT and MRI scans as the number of false pos was over 50 in this cohort.  
 
The authors stated that they would have seen all HCC on ultrasound - so one might raise the 
question what the additive value of AFP in this cohort is? Again I believe it is the number of 
advanced HCC in this cohort  - for sure detecting advanced stages mostly is unlikely to improve 
survival an it is well known that AFP increased with tumour size.  
 
Are the methods appropriate and well described?  
If not, please specify what is required 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.  
 
No 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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 manuscri pt: 
 
Needs some language corrections before being published  
 
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, fundi ng, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from t he 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, wr ite '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 edi torial office 
befor e completing the review.  If you wish, you can include your name in your publish ed 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 no t be able to 
publish your name.  
 
I agree to the terms of the CC -BY 4.0 license; please do not publish m y name with my report.  
(default)  
Please review this paper.
user
Reviewer ’s report  
 
Title: The Alpha -fetoprotein Serum is still Reliable as a Bi omarker for the Surveillance of 
Hepatocellular Carcinoma in Indonesia  
 
Version: 1 Date: 29 Apr 2020  
 
Reviewer's report:  
 
The diagnosis of HCC iin Dr. Cipto Mangunkusumo General National Hospital, Jakarta 
(RSCM)RSCM and Dharmais National Cancer Hospital, Jakarta (RSKD), was made from 
patients with positive surveillance results of either elevate d AFP ≥10 ng/ml or positive 
ultrasound,  
 
Thank you for giving me the opportunity to re review this interesting paper. The amended 
version of this paper has clearly gained  - however I still have some major concerns:  
 
* The vast majority of the cases are ver y advanced cases 85% of al cases had an tumour 
size &gt; 5cm 
 
* Only 10 % of the cases had a BCLC Stage A  
 
Just taking into account those two facts is seems clear the AFP gains diagnostic accuracy in the 
advanced stages, however we must emphasises the fact that our main intention is to detect early 
stages A  
 
Also, the fact that all(?) HCC have been seen on ultrasound reflects again the fact that the vast 
majority where advanced cases. Normally ultrasound has a sens of about 60 - 70 %.  
 
The authors must stat a statement that adding AFP into the screening algorithm will clearly 
increase the need of CT and MRI scans as the number of false pos was over 50 in this cohort.  
 
The authors stated that they would have seen all HCC on ultrasound - so one might raise the 
question what the additive value of AFP in this cohort is? Again I believe it is the number of 
advanced HCC in this cohort  - for sure detecting advanced stages mostly is unlikely to improve 
survival an it is well known that AFP increased with tumour size.  
 
Are the methods appropriate and well described?  
If not, please specify what is required 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.  
 
No 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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 manuscri pt: 
 
Needs some language corrections before being published  
 
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, fundi ng, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from t he 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, wr ite '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 edi torial office 
befor e completing the review.  If you wish, you can include your name in your publish ed 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 no t be able to 
publish your name.  
 
I agree to the terms of the CC -BY 4.0 license; please do not publish m y name with my report.  
(default)  
assistant