Letter to the Editor: Cross-Sectional Study for Investigation of the Association Between Modifiable Risk Factors and Gastrointestinal Cancers at a Tertiary Hospital in Ghana

Dear editor,

The work of Boi-Dsane et al in the article titled “Cross-Sectional Study for Investigation of the Association Between Modifiable Risk Factors and Gastrointestinal Cancers at a Tertiary Hospital in Ghana” is commendable. ¹ However, based on the findings of the study and global burden of gastrointestinal (GI) cancers, we would like to raise a few concerns on the methodology.

Firstly, the author has stated the study design as “cross-sectional prospective”; however, cross-sectional studies are not prospective rather conducted at a single point in time. ² In addition, the authors state that the article is compliant to STOBE guidelines ³ ; however, sample size calculation is a component of the guidelines and is not mentioned. The stated objective of the authors was “To determine the association between lifestyle and gastrointestinal cancers.” However, they did not explore major aspects of lifestyle like physical activity, hygiene, occupation, and sexual activity that can also influence development of GI cancers. Therefore, we suggest that the SMART objective ⁴ for this study can be formulated as “To evaluate the association between diet, alcohol consumption, and cigarette smoking with GI cancers in the Ghanaian population visiting Korle Bu Teaching Hospital.” Majority of the recruited participants (89%) belong to urban areas, which raises concern about generalizability of the study findings, as nearly half (41%) of Ghanaian population lives in rural regions. ⁵ Moreover, the collection of dietary information was solely based on participant’s recall, and although the authors mentioned a relatively constant and consistent Ghanaian diet, there is still a possibility of recall bias. Another point to be highlighted is that the study does not address the validation and reliability of the questionnaire or data collection tool used. Whether the paper-based questionnaire was self-administered or interviewer based is not explicitly mentioned. This absence of information is noteworthy because establishing the validity and reliability of such tools is essential for ensuring the accuracy and consistency of the data gathered in the research. A validated tool to collect dietary information includes various essential factors including the number of times the study participants consumed a particular diet, ingredients of the diet, quantity of each meal, and occasional changes in their dietary behavior and pattern, which were not assessed. The study shows an association between red meat consumption and colon cancer with an odds ratio of 0.44, indicating a protective effect of red meat, while the conclusion of the study states that red meat consumption is a modifiable risk factor that predisposes to the incidence of colon cancer. This discrepancy needs to be addressed. Similarly, it’s important to note that there is a statistically significant association between alcohol consumption and upper GI cancer ie. 2.48 [1.07-5.75], even though this crucial information is not included in the study’s result, conclusion, and discussion.

Lastly, the table found in the supplementary material, which directly relates to the study’s objectives, should be moved into the main article. Conversely, Table 3 of the Boi-Dsane et al’s article displays the types of treatments received by participants, which is unrelated to the study’s primary objective. Therefore, it would be appropriate to include that table in the supplementary material. This article is praiseworthy for its potential to generate hypotheses, for future longitudinal studies, and we recommend doing case control studies in future. ⁶ It would give us a better understanding of risk factors associated; besides, we recommend using standard tools like food frequency questionnaires ⁷ or 24-hour dietary recall questionnaire. ⁸