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  1. Evaluation Summary:

    The manuscript by Harper et al. examines the cancer risk perceptions, provider communication behaviors and demographic factors influencing the uptake of both, cervical and colorectal cancer screening among 50- to 65-years-old women. Towards those goals, the authors adapted and administered behavioral questions from the Health Information National Trends Survey to a multiethnic population sample in Southeast Michigan. Self-reported cancer screenings for the tumors (as defined by the USPSTF updated guidelines) served as the variable outcome. The study has public health merit in its identification of distinct predictors for cervical cancer and colorectal cancer screenings. The insights from this work on screening behavior differences among women, the perception of cancer risks and impact of positive provider communication, point to the need for exploring new ways for more holistic and integrated cancer prevention with a targeted focus. The strengths of the study include (i) the identification of an unmet need in public health in a neglected patient population, (ii) the track-record of the seasoned investigators, and (iii) the recognition of two potentially actionable insights obtained from the study. Weaknesses of the work include (i) the descriptive and specialized nature of the manuscript, (ii) the regional setting of the study and the question of how generalizable their conclusions would be in other contexts, and (iii) the relatively incremental advance of the reported findings.

    (This preprint has been reviewed by eLife. We include the public reviews from the reviewers here; the authors also receive private feedback with suggested changes to the manuscript. Reviewer #1 agreed to share their name with the authors.)

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  2. Reviewer #1 (Public Review):

    Harper DM, et al. focus on understanding how cancer risk perceptions and provider communication behaviors influence the uptake of both cervical and CRC screening among multiethnic women 50-65 years old in southeast Michigan.

    They investigate different predictors for CRC and cervical cancer screening together and alone. Their work shows that race, age and physician communication behavior are three independent influencers of completing both CRC and cervical cancer screening.

    Through their modeling and analysis of self-reporting, the authors find that involvement by physician in health care decision-making was one communication behavior significantly associated with women having both screens compared to only cervical cancer screening. They find that women who had completed both screenings were 99 percent more likely to agree that her physician involved her in the decisions about her health care as much as she wanted.

    The authors provide a new insight with reference to age as a screening predictor and show that younger women participate more in the cervical cancer screen and older women participate more in the CRC screen. Understanding the differences for completion of one screen but not another is important to explore opportunities to present options for other screenings and the need for a more holistic integrated prevention approach.

    The study has been also able to show new deficits in screening in women from Middle-East and North Africa (MENA). The work shows that MENA and Black women were significantly less likely than white women to have both the screens and that MENA women are rarely screened for CRC cancer, be it alone or in addition to cervical cancer screening.

    The conclusions of the paper are well-supported by data. However, all outcomes were self-reported with an opportunity to over-report actual screening frequencies and also discrepancies from Arabic language translation. Also, only 9 percent of the 394 respondents in the survey were women from MENA race.

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  3. Reviewer #2 (Public Review):

    Harper and colleagues investigate the potential association between cervical and colorectal screening uptake in a multiethnic sample population of women from 50- to 65-years women from Southeast Michigan with personal risk perceptions, cancer risk perceptions and knowledge along with physician communication behavior. The authors adapted and administered validated behavioral questions sampled from the Health Information National Trends Survey (HINTS) to a multiethnic population sample in Southeast Michigan. The variable outcomes were the self-reported cancer screenings for cervical and colorectal cancer, as defined by the United States Preventive Services Task Force (USPSTF) updated guidelines.

    Harper and colleagues have shown that race, age, and physician communication behavior were different and independent predictors for completing both cervical and colorectal cancer screening. Moreover, by using a self-reporting methodology, the investigators have indirectly shown that involvement by physician in health care decision-making was one communication behavior associated with women having both screens compared to only cervical cancer screening. In particular, Harper and colleagues have again recognized cervical and colorectal cancer screening deficits in women from Middle-East/North Africa (MENA) origin or ancestry. They demonstrate that MENA and Black women were less likely than Caucasian women to undergo cancer screenings for both tumor types and that MENA women. They have also demonstrated that virtually all of the MENA and Black women who had completed both of the recommended cancer screenings were more likely to agree that the physician involved her in the decisions about her health care as much as she wanted. Finally, the current study by Harper and colleagues has provided two potentially actionable insights. First, that positive communication with the provider, which includes the woman in her health care as much as she wants associates with completion of both cervical and colorectal cancer screenings not only relatively to no preventive screening at all but also when compared to cervical cancer-only screening. This finding might perhaps have implications for so-called "primary care physicians" that either do not routinely perform or are reluctant to include pelvic exams in their scope of practice in female patients. Second, the internal age range of the screened population is an apparent outcome predictor with the younger women completing more in the cervical cancer screenings and the older women completing more of the colorectal cancer screenings. While the reason(s) for this evident age-dependent and/or tumor-dependent phenomenon remains unclear at this point, this empiric hypothesis-generating finding might generate further research to address this potentially actionable dichotomy.

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