Title: Current status of and barriers to the treatment of advanced-stage liver cancer in China: A
questionnaire-based study from the perspective of doctors
Version: 1 Date: 11 Apr 2022
Reviewer's report:
Comments to the authors
This is an interesting study by Wei et al about provider perspectives on liver cancer treatment
in China. The authors found that liver cancer treatment varied by region, provider type, and
hospitals. Although the findings are interesting, I would recommend the following to strengthen
this paper.
1. It would be important for the authors to be more careful with their word choice as this is a
questionnaire-based study and as they mentioned, a cross-sectional study. For example, please
avoid terms that imply causation. There are also a few different times where the authors state
that patients had advanced stage disease. However, this is incorrect as it was the providers who
provided a percentage of patients with advanced stage disease (the true percentage is unknown).
2. More details are needed within the methods section, particularly related to questionnaire
development and how the questionnaire was administered. Was this a convenience sample? Why
were there only 6 respondents per site? How many sites were there overall? How were the 6
respondents chosen at each site? As questionnaire-based studies are prone to bias, more details
should be provided and when it cannot be addressed, included as a limitation.
3. As the journal will have readers outside of China, it would be helpful to provide more context
related to the Chinese healthcare system and any known perspectives related to liver cancer
diagnosis and treatment in the introduction and/or discussion. This would help readers better
understand the importance of the findings.
Major comments:
Methods – Study population: It will be important to clarify how and why a maximum of 6 people
from each hospital were allowed to participate. How were these providers selected? How were
they invited? Could this have led to bias in the results? Similarly, please clarify what it means
when the doctors “were unable to cooperate with the investigator”. As written, this suggests
there may have been pressure from the investigator to the doctors to participate, which would
be concerning.
Methods – Study population: Please describe how the participating hospitals or providers were
selected. Were provinces selected first? Then hospitals?
Methods – Questionnaire design: As someone who does not provide care in China, it would be
helpful to learn a bit more about the cultural nuances of liver cancer diagnosis, disclosure (for
example, in reference to “disclosure of the patients’ true conditions”, and treatment. This should
be provided within the introduction or in the methods to provide some context as to why certain
questions were asked in the questionnaires.
Methods – Questionnaire design: Please clarify in this section what regions (ex: East, West,
etc), titles, and hospital categories are included in the questionnaire. This will help the reader
understand the results. Please also clarify whether the questions were asked in English or Chinese
so that Table 2 can be interpreted accordingly. Please also clarify how the questions were
developed – were they pre-tested? If so, by who and how many people?
Methods – Data collection: Why did participants need to complete the questionnaire in 10
minutes? Does this mean the questionnaire was administered at the same time across the country?
Methods – Data collection: Either in this section or another section of the methods, please include
if this questionnaire and study was IRB-approved, if required by the journal to include it in the
main text. I do note that the authors included this information under Declarations.
Results: Before providing existing results, it would be helpful to have a paragraph about the
participant characteristics.
Results – 3.1.1: Please revise the first sentence  on lines 112-113 and state what the findings are
and provide the associated P-values. Please clarify what “equipment to determine the nature of
the liver masses” refers to. Please also provide 95% CI for all odds ratios.
Results – 3.1.1: Please clarify the lines 117-119. Do you mean that providers thought that patients
were at higher risk of developing advanced cancer? As written, it makes it seem patients were
actually higher risk but I don’t think there was patient data that was collected.
Results - 3.1.1: What does a “well-known hospitals” mean on line 128?
Results - 3.1.2: What is the difference between tertiary and tertiary first-class hospital?
Secondary and lower hospital?
Results – 3.1.3: Consider revising the first 2 sentences of this section. Either include more
information with P-values in the first sentence, or if limited by words, move this to the end of
the section. For the 2nd sentence, provide P-value.
Results – 3.2: It would be helpful to provide the N for each category of the 2 groups at the
beginning of this section (and in other sections of the results as applicable). I am also not
sure I understand the sentence in line 170-172, as it refers to a high percentage of patients
diagnosed with advanced-stage disease. How was this information obtained, as this was a survey
of providers? If actually collected, what was the percentage difference?
Results – 3.3: I am not sure I understand what a “complete cure was approved by..” on line 206
means. Do you mean ~50% of doctors hoped for a complete cure?
Discussion: Would recommend clarifying that disclosure of a diagnosis (lines 267-268) remains
debatable or controversial in China (as it is not necessarily the case in other countries).
Table 4: Is there a reason why attending physicians and residents are in the same category?
Normally, I would separate these groups as one group is in training and the other is not so
answers may differ.
Figure 1: The title suggests that this figure shows the difference in variables by provider
satisfaction. However, it is hard to interpret the plot, as it doesn’t seem to include any data by
provider satisfaction. Please revise. Also, it may be informative to provide a separate plot that
includes the univariate analysis.
Figure 2: I found the question asked in section A difficult to understand. Were providers actually
asked which treatments they would approve, meaning if they didn’t select an answer, they would
not approve or use the treatment? If so, it seems strange to me that only 11.7% would approve
of long-term treatment while 89% would approve complete cure, as we currently don’t have
a complete cure for many patients with liver cancer. Could the authors also include the actual
question stem used in the questionnaire to clarify to the providers that these questions were
in reference to the future? It doesn’t seem obvious it is asking about the future, at least in the
questions provided in the appendix.
Minor suggestions:
Abstract: Under methods, I would recommend against using the phrase “caused by” on line 33
as this is a cross-sectional and questionnaire-based study.
Abstract: It is unclear what “hospital of varied levels” on line 36 means. Perhaps this should be
clarified or re-worded for readers from outside of China.
Abstract: I am not sure what “unevenness” on line 40 means. Please clarify or consider revising
word choice.
Introduction: Please update the reference for liver cancer epidemiology. The current reference
is from 2012 (published in 2015) and there is updated data from 2020 (published in 2021) by
Sung et al from the same journal for example.
Introduction: Consider adding a reason (if known) for why liver cancer incidence is higher in
China than in other countries.
Methods – Study population: May be helpful to clarify how many total provinces are in Mainland
China to give the reader a better idea of the representation when 31 provinces are included.
Methods – Study population: Please clarify what “county-level and above” means.
Methods – Data collection: Line 93 as written is redundant, as survey and questionnaire are the
same. Please also explicitly state that the study had a 68% response rate (1021/1500).
Table 1: Please consider revising “No” to something else (such as “Number”).
Title: Current status of and barriers to the treatment of advanced-stage liver cancer in China: A
questionnaire-based study from the perspective of doctors
Version: 1 Date: 11 Apr 2022
Reviewer's report:
Comments to the authors
This is an interesting study by Wei et al about provider perspectives on liver cancer treatment
in China. The authors found that liver cancer treatment varied by region, provider type, and
hospitals. Although the findings are interesting, I would recommend the following to strengthen
this paper.
1. It would be important for the authors to be more careful with their word choice as this is a
questionnaire-based study and as they mentioned, a cross-sectional study. For example, please
avoid terms that imply causation. There are also a few different times where the authors state
that patients had advanced stage disease. However, this is incorrect as it was the providers who
provided a percentage of patients with advanced stage disease (the true percentage is unknown).
2. More details are needed within the methods section, particularly related to questionnaire
development and how the questionnaire was administered. Was this a convenience sample? Why
were there only 6 respondents per site? How many sites were there overall? How were the 6
respondents chosen at each site? As questionnaire-based studies are prone to bias, more details
should be provided and when it cannot be addressed, included as a limitation.
3. As the journal will have readers outside of China, it would be helpful to provide more context
related to the Chinese healthcare system and any known perspectives related to liver cancer
diagnosis and treatment in the introduction and/or discussion. This would help readers better
understand the importance of the findings.
Major comments:
Methods – Study population: It will be important to clarify how and why a maximum of 6 people
from each hospital were allowed to participate. How were these providers selected? How were
they invited? Could this have led to bias in the results? Similarly, please clarify what it means
when the doctors “were unable to cooperate with the investigator”. As written, this suggests
there may have been pressure from the investigator to the doctors to participate, which would
be concerning.
Methods – Study population: Please describe how the participating hospitals or providers were
selected. Were provinces selected first? Then hospitals?
Methods – Questionnaire design: As someone who does not provide care in China, it would be
helpful to learn a bit more about the cultural nuances of liver cancer diagnosis, disclosure (for
example, in reference to “disclosure of the patients’ true conditions”, and treatment. This should
be provided within the introduction or in the methods to provide some context as to why certain
questions were asked in the questionnaires.
Methods – Questionnaire design: Please clarify in this section what regions (ex: East, West,
etc), titles, and hospital categories are included in the questionnaire. This will help the reader
understand the results. Please also clarify whether the questions were asked in English or Chinese
so that Table 2 can be interpreted accordingly. Please also clarify how the questions were
developed – were they pre-tested? If so, by who and how many people?
Methods – Data collection: Why did participants need to complete the questionnaire in 10
minutes? Does this mean the questionnaire was administered at the same time across the country?
Methods – Data collection: Either in this section or another section of the methods, please include
if this questionnaire and study was IRB-approved, if required by the journal to include it in the
main text. I do note that the authors included this information under Declarations.
Results: Before providing existing results, it would be helpful to have a paragraph about the
participant characteristics.
Results – 3.1.1: Please revise the first sentence  on lines 112-113 and state what the findings are
and provide the associated P-values. Please clarify what “equipment to determine the nature of
the liver masses” refers to. Please also provide 95% CI for all odds ratios.
Results – 3.1.1: Please clarify the lines 117-119. Do you mean that providers thought that patients
were at higher risk of developing advanced cancer? As written, it makes it seem patients were
actually higher risk but I don’t think there was patient data that was collected.
Results - 3.1.1: What does a “well-known hospitals” mean on line 128?
Results - 3.1.2: What is the difference between tertiary and tertiary first-class hospital?
Secondary and lower hospital?
Results – 3.1.3: Consider revising the first 2 sentences of this section. Either include more
information with P-values in the first sentence, or if limited by words, move this to the end of
the section. For the 2nd sentence, provide P-value.
Results – 3.2: It would be helpful to provide the N for each category of the 2 groups at the
beginning of this section (and in other sections of the results as applicable). I am also not
sure I understand the sentence in line 170-172, as it refers to a high percentage of patients
diagnosed with advanced-stage disease. How was this information obtained, as this was a survey
of providers? If actually collected, what was the percentage difference?
Results – 3.3: I am not sure I understand what a “complete cure was approved by..” on line 206
means. Do you mean ~50% of doctors hoped for a complete cure?
Discussion: Would recommend clarifying that disclosure of a diagnosis (lines 267-268) remains
debatable or controversial in China (as it is not necessarily the case in other countries).
Table 4: Is there a reason why attending physicians and residents are in the same category?
Normally, I would separate these groups as one group is in training and the other is not so
answers may differ.
Figure 1: The title suggests that this figure shows the difference in variables by provider
satisfaction. However, it is hard to interpret the plot, as it doesn’t seem to include any data by
provider satisfaction. Please revise. Also, it may be informative to provide a separate plot that
includes the univariate analysis.
Figure 2: I found the question asked in section A difficult to understand. Were providers actually
asked which treatments they would approve, meaning if they didn’t select an answer, they would
not approve or use the treatment? If so, it seems strange to me that only 11.7% would approve
of long-term treatment while 89% would approve complete cure, as we currently don’t have
a complete cure for many patients with liver cancer. Could the authors also include the actual
question stem used in the questionnaire to clarify to the providers that these questions were
in reference to the future? It doesn’t seem obvious it is asking about the future, at least in the
questions provided in the appendix.
Minor suggestions:
Abstract: Under methods, I would recommend against using the phrase “caused by” on line 33
as this is a cross-sectional and questionnaire-based study.
Abstract: It is unclear what “hospital of varied levels” on line 36 means. Perhaps this should be
clarified or re-worded for readers from outside of China.
Abstract: I am not sure what “unevenness” on line 40 means. Please clarify or consider revising
word choice.
Introduction: Please update the reference for liver cancer epidemiology. The current reference
is from 2012 (published in 2015) and there is updated data from 2020 (published in 2021) by
Sung et al from the same journal for example.
Introduction: Consider adding a reason (if known) for why liver cancer incidence is higher in
China than in other countries.
Methods – Study population: May be helpful to clarify how many total provinces are in Mainland
China to give the reader a better idea of the representation when 31 provinces are included.
Methods – Study population: Please clarify what “county-level and above” means.
Methods – Data collection: Line 93 as written is redundant, as survey and questionnaire are the
same. Please also explicitly state that the study had a 68% response rate (1021/1500).
Table 1: Please consider revising “No” to something else (such as “Number”).
Please review this paper.
user
Title: Current status of and barriers to the treatment of advanced-stage liver cancer in China: A
questionnaire-based study from the perspective of doctors
Version: 1 Date: 11 Apr 2022
Reviewer's report:
Comments to the authors
This is an interesting study by Wei et al about provider perspectives on liver cancer treatment
in China. The authors found that liver cancer treatment varied by region, provider type, and
hospitals. Although the findings are interesting, I would recommend the following to strengthen
this paper.
1. It would be important for the authors to be more careful with their word choice as this is a
questionnaire-based study and as they mentioned, a cross-sectional study. For example, please
avoid terms that imply causation. There are also a few different times where the authors state
that patients had advanced stage disease. However, this is incorrect as it was the providers who
provided a percentage of patients with advanced stage disease (the true percentage is unknown).
2. More details are needed within the methods section, particularly related to questionnaire
development and how the questionnaire was administered. Was this a convenience sample? Why
were there only 6 respondents per site? How many sites were there overall? How were the 6
respondents chosen at each site? As questionnaire-based studies are prone to bias, more details
should be provided and when it cannot be addressed, included as a limitation.
3. As the journal will have readers outside of China, it would be helpful to provide more context
related to the Chinese healthcare system and any known perspectives related to liver cancer
diagnosis and treatment in the introduction and/or discussion. This would help readers better
understand the importance of the findings.
Major comments:
Methods – Study population: It will be important to clarify how and why a maximum of 6 people
from each hospital were allowed to participate. How were these providers selected? How were
they invited? Could this have led to bias in the results? Similarly, please clarify what it means
when the doctors “were unable to cooperate with the investigator”. As written, this suggests
there may have been pressure from the investigator to the doctors to participate, which would
be concerning.
Methods – Study population: Please describe how the participating hospitals or providers were
selected. Were provinces selected first? Then hospitals?
Methods – Questionnaire design: As someone who does not provide care in China, it would be
helpful to learn a bit more about the cultural nuances of liver cancer diagnosis, disclosure (for
example, in reference to “disclosure of the patients’ true conditions”, and treatment. This should
be provided within the introduction or in the methods to provide some context as to why certain
questions were asked in the questionnaires.
Methods – Questionnaire design: Please clarify in this section what regions (ex: East, West,
etc), titles, and hospital categories are included in the questionnaire. This will help the reader
understand the results. Please also clarify whether the questions were asked in English or Chinese
so that Table 2 can be interpreted accordingly. Please also clarify how the questions were
developed – were they pre-tested? If so, by who and how many people?
Methods – Data collection: Why did participants need to complete the questionnaire in 10
minutes? Does this mean the questionnaire was administered at the same time across the country?
Methods – Data collection: Either in this section or another section of the methods, please include
if this questionnaire and study was IRB-approved, if required by the journal to include it in the
main text. I do note that the authors included this information under Declarations.
Results: Before providing existing results, it would be helpful to have a paragraph about the
participant characteristics.
Results – 3.1.1: Please revise the first sentence  on lines 112-113 and state what the findings are
and provide the associated P-values. Please clarify what “equipment to determine the nature of
the liver masses” refers to. Please also provide 95% CI for all odds ratios.
Results – 3.1.1: Please clarify the lines 117-119. Do you mean that providers thought that patients
were at higher risk of developing advanced cancer? As written, it makes it seem patients were
actually higher risk but I don’t think there was patient data that was collected.
Results - 3.1.1: What does a “well-known hospitals” mean on line 128?
Results - 3.1.2: What is the difference between tertiary and tertiary first-class hospital?
Secondary and lower hospital?
Results – 3.1.3: Consider revising the first 2 sentences of this section. Either include more
information with P-values in the first sentence, or if limited by words, move this to the end of
the section. For the 2nd sentence, provide P-value.
Results – 3.2: It would be helpful to provide the N for each category of the 2 groups at the
beginning of this section (and in other sections of the results as applicable). I am also not
sure I understand the sentence in line 170-172, as it refers to a high percentage of patients
diagnosed with advanced-stage disease. How was this information obtained, as this was a survey
of providers? If actually collected, what was the percentage difference?
Results – 3.3: I am not sure I understand what a “complete cure was approved by..” on line 206
means. Do you mean ~50% of doctors hoped for a complete cure?
Discussion: Would recommend clarifying that disclosure of a diagnosis (lines 267-268) remains
debatable or controversial in China (as it is not necessarily the case in other countries).
Table 4: Is there a reason why attending physicians and residents are in the same category?
Normally, I would separate these groups as one group is in training and the other is not so
answers may differ.
Figure 1: The title suggests that this figure shows the difference in variables by provider
satisfaction. However, it is hard to interpret the plot, as it doesn’t seem to include any data by
provider satisfaction. Please revise. Also, it may be informative to provide a separate plot that
includes the univariate analysis.
Figure 2: I found the question asked in section A difficult to understand. Were providers actually
asked which treatments they would approve, meaning if they didn’t select an answer, they would
not approve or use the treatment? If so, it seems strange to me that only 11.7% would approve
of long-term treatment while 89% would approve complete cure, as we currently don’t have
a complete cure for many patients with liver cancer. Could the authors also include the actual
question stem used in the questionnaire to clarify to the providers that these questions were
in reference to the future? It doesn’t seem obvious it is asking about the future, at least in the
questions provided in the appendix.
Minor suggestions:
Abstract: Under methods, I would recommend against using the phrase “caused by” on line 33
as this is a cross-sectional and questionnaire-based study.
Abstract: It is unclear what “hospital of varied levels” on line 36 means. Perhaps this should be
clarified or re-worded for readers from outside of China.
Abstract: I am not sure what “unevenness” on line 40 means. Please clarify or consider revising
word choice.
Introduction: Please update the reference for liver cancer epidemiology. The current reference
is from 2012 (published in 2015) and there is updated data from 2020 (published in 2021) by
Sung et al from the same journal for example.
Introduction: Consider adding a reason (if known) for why liver cancer incidence is higher in
China than in other countries.
Methods – Study population: May be helpful to clarify how many total provinces are in Mainland
China to give the reader a better idea of the representation when 31 provinces are included.
Methods – Study population: Please clarify what “county-level and above” means.
Methods – Data collection: Line 93 as written is redundant, as survey and questionnaire are the
same. Please also explicitly state that the study had a 68% response rate (1021/1500).
Table 1: Please consider revising “No” to something else (such as “Number”).
assistant