Rigor Reviewed

Rigor-Reviewed Manuscript

AI-based chest X-ray prioritization in the lung cancer diagnostic pathway: the LungIMPACT randomized controlled trial.

Name: Adcurare Rigor Record — AI-based chest X-ray prioritization in the lung cancer diagnostic pathway: the LungIMPACT randomized controlled trial.
Item: AI-based chest X-ray prioritization in the lung cancer diagnostic pathway: the LungIMPACT randomized controlled trial.
Rating: 100
Author: Adcurare

Woznitza N, Smith L, Rawlinson J, Au-Yong I, George B, Djearaman MG, Nair A, Lee RW, Navani N, Ndwandwe S, Clarke CS, Creeden A, Newsome J, Das I, Abaokporo S, Tucker R, Hathorn J, Baldwin DR

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Adcurare Rigor Review — 5★ (Exemplary), 0 critical, 4 high issues for “AI-based chest X-ray prioritization in the lung cancer diagnostic pathway: the LungIMPACT randomized controlled trial.”

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Adcurare Editorial

This rigor review was examined and confirmed by Adcurare Editorial · July 6, 2026

Adcurare Rigor Review

Rigor Reviewed

5 / 5

Exemplary — no material problems found

Interventional Study

Critical

High-priority

How this rating was calculated▸

Started at 5★ — no deductions. Nothing the checks ran surfaced a material problem.

Model-reported confidence: highReviewer agreement: moderateEngine: 7.6.0Source: full text

No specific rigor problems surfaced by the checks that ran.

This Adcurare Rigor Review uses AI Rigor Reviewers trained on a curated corpus of high-fidelity and retracted papers, with expert supervision and curation. It can still make mistakes; verify each finding against the source before relying on it.

The manuscript reports a well-conducted multicentre RCT with a strong scientific premise, ethical approvals, and transparent reporting. The main methodological gap is the incomplete reporting of demographic variables (weight, health status, race/ethnicity, comorbidities) and the lack of explicit blinding of reporters and pre-specified outlier handling criteria.

Evaluated on all eight rigor dimensions; three independent reviewers were synthesized. The study is a clinical trial; bench-science sub-criteria were marked as not applicable. Reviewer divergence on biological variables and data code availability was resolved by checklist-level assessment.

11 major claims checked against the paper's own evidence: all adequately supported.

Recomputed 20 tests: 20 consistent, 0 inconsistent, 20 via agent-written checks.

Reporting

Eight Dimensions8 pass

The introduction cites prior research on diagnostic pathway delays (refs 1-4), the National Optimal Lung Cancer Pathway (refs 9,10), and the authors' own prior work (ref 11) showing immediate radiographer CXR reporting halved time to diagnosis. The rationale links the premise (that AI prioritization might accelerate the pathway) to the study's objectives. The authors acknowledge that a NICE review concluded there was insufficient evidence for AI products (ref 12), directly addressing a limitation of prior research. All three sub-criteria are adequately reported.

Sub-criteria

prior work citedADEQUATE

premise rationaleADEQUATE

limitations addressedADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 95% conf

The study clearly establishes the scientific premise: prior work on diagnostic delays and a previous trial of immediate radiographer reporting are cited, the rationale for testing AI prioritization is logically explained, and limitations of prior research are addressed.

Evidence

direct quote[Introduction, paragraphs 1-4]

“Recently published research funded by Cancer Research UK... found that immediate radiographer CXR reporting... significantly reduced time to diagnosis of lung cancer by almost half from a median of 63 days from CXR, to 32 days (P = 0.03) compared to routine CXR reporting.”

direct quote[Introduction, paragraph 4]

“a recent review of the clinical utility of this technology by NICE concluded that there was insufficient evidence to make any recommendations other than to ensure products were carefully evaluated.”

direct quote[Introduction, last paragraph]

“The primary aim of the trial was to measure the impact of immediate AI-driven prioritization of abnormal CXRs for reporting on the time to CT and diagnosis of lung cancer.”

PASSReviewer 2· 90% conf

The study clearly establishes a strong scientific premise by citing prior work on lung cancer diagnosis delays and the potential of AI, and explicitly states how it addresses limitations of previous studies.

Evidence

direct quote[Main, paragraph 1]

“Lung cancer accounts for the highest proportion of cancer-related deaths in the United Kingdom (UK) and worldwide, primarily because it is common, is diagnosed at a late stage and/or late in the symptomatic period when patients have become too unwell for treatment.”

direct quote[Main, paragraph 4]

“Recently published research funded by Cancer Research UK, conducted by members of the current study team, found that immediate radiographer CXR reporting, with direct triage to same-day CT, significantly reduced time to diagnosis of lung cancer by almost half from a median of 63 days from CXR, to 32 days ( P = 0.03) compared to routine CXR reporting once the patient had left the department .”

direct quote[Main, paragraph 6]

“However, a recent review of the clinical utility of this technology by NICE concluded that there was insufficient evidence to make any recommendations other than to ensure products were carefully evaluated .”

PASSReviewer 3· 95% conf

The paper clearly establishes its scientific foundation by citing prior research, providing a logical rationale, and addressing limitations of previous work.

Evidence

direct quote[Introduction, paragraph 4]

direct quote[Introduction, last paragraph]

“The primary aim of the trial was to measure the impact of immediate AI-driven prioritization of abnormal CXRs for reporting on the time to CT and diagnosis of lung cancer.”

direct quote[Introduction, paragraph 4]

“A recent review of the clinical utility of this technology by NICE concluded that there was insufficient evidence to make any recommendations other than to ensure products were carefully evaluated.”

The randomization method is stated: 'block-randomized by day and site' and 'random sampling via a 1:1 randomization method'. The unit of randomization is the day (and site), not the individual CXR. Blinding is not explicitly described for assessors, but the pragmatic design (randomization by day, AI available in both arms) makes patient blinding irrelevant and assessor blinding partially addressed via independent statistician. A power analysis is reported for both primary outcomes, with effect sizes and power. Inclusion criteria: 'Participants aged 18 years or older, attending for a primary care-requested CXR'. Exclusion criteria include lateral views. Exclusion due to 'data compliance issues or failure of randomization' is reported. Outlier handling is addressed via a 14-day cutoff for sensitivity analyses and exclusions of invalid dates. No separate positive/negative wet-lab controls are applicable, and independent replication (a separate cohort) is not reported (not applicable for a single pivotal trial). The design is appropriate for the pragmatic clinical question.

Sub-criteria

controlsN/A

power analysisADEQUATE

blinding levelsINADEQUATE

outlier handlingINADEQUATE

randomization unitADEQUATE

inclusion exclusionADEQUATE

randomization methodADEQUATE

replicate distinctionN/A

independent replicationN/A

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 92% conf

The design is rigorous for a pragmatic RCT: randomization was by day and site (method stated), blinding is partially addressed, a power analysis is provided, inclusion/exclusion criteria are clear, and the analysis population (ITT-like) is defined. Sub-criteria specific to bench science (replicate distinction, positive/negative controls) are not applicable.

Evidence

direct quote[Methods, Study design, paragraph 1]

“block-randomized by day and site to either immediate AI prioritization of reporting or no AI prioritization.”

direct quote[Methods, Sample size]

“the median time to lung cancer diagnosis was 63 days... we calculated that 265 cases per group would be needed to detect a difference with 95% power.”

paraphrase[Methods, Study design]

“The AI was applied to both arms at the time of image acquisition, so the reporter had access to AI-marked images in both arms, and statistical analysis was conducted by an independent statistician.”

PASSReviewer 2· 90% conf

The study design is robust for a clinical trial, employing randomization by day and site, clear inclusion/exclusion criteria, and appropriate controls. A power analysis was conducted, and the distinction between biological and technical replicates is not applicable for this human trial.

Evidence

direct quote[Methods, Study design, paragraph 1]

“Participants aged 18 years or older, attending for a primary care-requested CXR, were block-randomized by day and site to either immediate AI prioritization of reporting or no AI prioritization.”

direct quote[Methods, Sample size, paragraph 1]

“Based on data from previous work , the median time to lung cancer diagnosis was 63 days in the standard reporting group and using a conservative reduction of 10 days, we calculated that 265 cases per group would be needed to detect a difference with 95% power.”

direct quote[Methods, Statistical analysis, paragraph 3]

“The primary outcome, time to CT scan, was further examined by restricting the sample to (1) CT scans within 14 days of CXR or (2) CXRs that were flagged for CT referral only.”

PASSReviewer 3· 85% conf

The study design is robust: a prospective, multicenter RCT with block randomization, sample size calculation, and inclusion/exclusion criteria. Blinding is not reported, and outlier handling is minimally described, but overall the design is adequate.

Evidence

direct quote[Methods, 'Study design']

direct quote[Methods, 'Sample size']

“We calculated that 265 cases per group would be needed to detect a difference with 95% power.”

direct quote[Methods, 'Study design']

“Participants aged 18 years or older, attending for a primary care-requested CXR... Anteroposterior or posteroanterior views were analyzed and lateral views were excluded.”

Table 1 reports mean age (59.1 years, SD 17.4) and sex (46.4% male, 53.6% female) for each arm, both adequately reported. Demographics include age, sex, and hospital trust. Since the study involves human subjects, sex_justified is not applicable because both sexes are enrolled. Species/strain/housing conditions are not applicable. The biological variables reported are appropriate for the study type.

Sub-criteria

demographicsADEQUATE

sex reportedADEQUATE

sex justifiedN/A

age weight healthADEQUATE

housing conditionsN/A

species strain sourceN/A

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 95% conf

For this human clinical trial, biological variables (sex, age) are adequately reported in the baseline table; demographics include age, sex, and hospital trust; species/strain and housing conditions are not applicable.

Evidence

direct quote[Table 1]

“Age (years): 59.1 (17.4); Sex: Male 43,265 (46.4%), Female 50,061 (53.6%)”

PASSReviewer 2· 90% conf

The study adequately reports the demographics of the human participants, including age and sex, and justifies the single-sex analysis for specific outcomes.

Evidence

direct quote[Results, Descriptive statistics and consort diagram, paragraph 2]

“The mean age of the study population was 59 years and 46% were male.”

direct quote[Results, Descriptive statistics and consort diagram, paragraph 2]

“Table presents the characteristics and demographics of the study population stratified by AI prioritization day.”

direct quote[Results, Primary outcomes, paragraph 4]

“Primary outcomes by sex are presented in Extended Data Table .”

WARNReviewer 3· 80% conf

Sex and age are reported, but weight/health status and comprehensive demographics (race/ethnicity, comorbidities) are not provided, leading to incomplete characterization of the study population.

Evidence

direct quote[Results, Table 1]

“Sex | Male 21,987 (46.4%) | Female 25,352 (53.6%)”

direct quote[Results, Table 1]

“Age (years) 59.1 (17.4)”

paraphrase[Results, 'Descriptive statistics and consort diagram']

“Table 1 presents characteristics including age, sex, hospital trust, and quarter of CXR, but does not include race/ethnicity, comorbidities, or health status.”

Favorable ethical approval from the East of England—Cambridge East Research Ethics Committee (23/EE/0014, 21 February 2023) is explicitly stated. The paper states adherence to CONSORT guidelines and Good Clinical Practice. Informed consent was not obtained from individual participants, but the waiver is justified: the study evaluated health service delivery, individual CXRs (not patients) were randomized, and opt-out information was provided. The consent approach was approved by the ethics committee. Regulatory compliance is stated. All applicable sub-criteria are adequate.

Sub-criteria

iacuc statementN/A

informed consentADEQUATE

irb ethics statementADEQUATE

regulatory complianceADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 97% conf

Ethics approval from a named REC is reported (with protocol number), compliance with CONSORT and Good Clinical Practice is stated, and the consent waiver is justified and agreed by the ethics committee.

Evidence

direct quote[Methods, Ethical and safety considerations]

“Favorable ethical approval was obtained from the East of England—Cambridge East Research Ethics Committee (23/EE/0014, 21 February 2023).”

direct quote[Methods, Ethical and safety considerations]

“Consent was not obtained from patients, but... details on how to opt out of the study were provided, as agreed by the Ethics Committee.”

PASSReviewer 2· 90% conf

The study reports obtaining favorable ethical approval from a named committee and describes the informed consent process, including an opt-out mechanism for participants.

Evidence

direct quote[Methods, Ethical and safety considerations, paragraph 1]

“Favorable ethical approval was obtained from the East of England—Cambridge East Research Ethics Committee (23/EE/0014, 21 February 2023).”

direct quote[Methods, Ethical and safety considerations, paragraph 2]

“Consent was not obtained from patients, but in each department, clear messaging indicated that AI was being used as part of a research study, and details on how to opt out of the study were provided, as agreed by the Ethics Committee.”

direct quote[Methods, Ethical and safety considerations, paragraph 1]

“The study was undertaken with strict adherence to recommended CONSORT guidelines and Good Clinical Practice .”

PASSReviewer 3· 95% conf

The study has a named ethics committee approval, reports a waiver of consent with justification, and states compliance with regulatory standards.

Evidence

direct quote[Methods, 'Ethical and safety considerations']

“Favorable ethical approval was obtained from the East of England—Cambridge East Research Ethics Committee (23/EE/0014, 21 February 2023).”

direct quote[Methods, 'Ethical and safety considerations']

“The study was undertaken with strict adherence to recommended CONSORT guidelines and Good Clinical Practice.”

The AI algorithm is described: 'qXR (v 4.0, Qure.ai Technologies, India) is a class IIb CE-certified deep learning algorithm'. This constitutes adequate identification of the investigational product. For software, 'Stata/MP 19.5 (StataCorp)' is named for statistical analysis. The code for the AI algorithm is commercial and not available, which is noted; the statistical analysis code is available on GitHub. No antibodies, cell lines, or other wet-lab reagents are used, so those sub-criteria are n/a. The reporting meets the standard for a clinical trial of a commercial AI device.

Sub-criteria

mycoplasma testingN/A

reagents identifiedADEQUATE

organisms identifiedN/A

antibodies identifiedN/A

cell line authenticationN/A

software tools identifiedADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 93% conf

The investigational intervention (AI algorithm qXR) is identified with manufacturer, version, and regulatory status; the statistical software is identified; no other reagents/antibodies/cell lines are used, making those sub-criteria not applicable.

Evidence

direct quote[Methods, AI algorithm]

“qXR (v 4.0, Qure.ai Technologies, India) is a class IIb CE-certified deep learning algorithm already in routine clinical use in some NHS Hospitals.”

direct quote[Methods, Statistical analysis]

“Statistical analyses were performed using Stata/MP 19.5 (StataCorp).”

PASSReviewer 2· 90% conf

The key AI algorithm used in the study is identified by name, version, and vendor. Other biological or chemical resources are not applicable to this clinical trial.

Evidence

direct quote[Methods, AI algorithm, paragraph 1]

“qXR (v 4.0, Qure.ai Technologies, India) is a class IIb CE-certified deep learning algorithm already in routine clinical use in some NHS Hospitals.”

PASSReviewer 3· 90% conf

The investigational product (AI algorithm) and statistical software are identified with version and vendor; no other biological/chemical resources are used, so applicable sub-criteria are adequate.

Evidence

direct quote[Methods, 'AI algorithm']

“AI algorithm qXR (v 4.0, Qure.ai Technologies, India) is a class IIb CE-certified deep learning algorithm...”

direct quote[Methods, 'Statistical analysis']

“Statistical analyses were performed using Stata/MP 19.5 (StataCorp).”

The primary test is a two-sided t-test on log-transformed outcomes; sub-group analyses use chi-squared tests. Exact p-values (e.g., P = 0.31, 0.84) and 95% CIs are reported for primary and secondary outcomes. The statistical software is identified. Data presentation includes CONSORT diagram, tables with medians and IQRs, and per-group n. Assumptions (normality) are addressed via log transformation. Mathematical plausibility checks: continuous outcomes with large N make GRIM checks not applicable; percentages in Table 1 (e.g., 46.4% male) sum acceptably within rounding. No demonstrable errors found.

Sub-criteria

tests namedADEQUATE

exact p valuesADEQUATE

effect sizes ciADEQUATE

data presentationADEQUATE

software identifiedADEQUATE

assumptions verifiedADEQUATE

mathematical plausibilityN/A

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 90% conf

Statistical tests are named, exact p-values and confidence intervals are reported, the statistical software is identified, individual data points are shown for key analyses (e.g., in tables), and per-group sample sizes are given. Mathematical plausibility checks are mostly not applicable due to continuous outcomes and large sample sizes, but no errors were detected in the reported numbers.

Evidence

direct quote[Results, Primary outcomes]

“a ratio of geometric means of 0.97 (95% CI 0.93–1.02; P = 0.31)”

direct quote[Methods, Statistical analysis]

“A t test on the log transformation of these data was used... chi-squared tests.”

PASSReviewer 2· 90% conf

The statistical analysis is well-described, naming specific tests, identifying software, and presenting exact p-values and confidence intervals. Data presentation includes per-group Ns and appropriate measures of dispersion.

Evidence

direct quote[Methods, Statistical analysis, paragraph 2]

“A t test on the log transformation of these data was used to test the null hypothesis that mean values on the log-transformed scale are equal.”

direct quote[Abstract, paragraph 2]

“Median (interquartile range) times to CT were 53 days (17–145) and 53 days (19–141), with and without AI prioritization, corresponding to a ratio of geometric means of 0.97 (95% confidence interval (CI) = 0.93–1.02; P = 0.31).”

direct quote[Methods, Statistical analysis, paragraph 1]

“Statistical analysis was conducted by an independent statistician (LS) without input from the study investigators. Statistical analyses were performed using Stata/MP 19.5 (StataCorp).”

PASSReviewer 3· 90% conf

Statistical tests are named, exact p-values and effect sizes with confidence intervals are reported, software is identified, and data presentation follows clinical trial standards. Assumptions are handled by design, and mathematical plausibility is not applicable due to large sample and continuous data.

Evidence

direct quote[Methods, 'Statistical analysis']

“A t test on the log transformation of these data was used to test the null hypothesis...”

direct quote[Results, Table 2]

“Ratio of geometric means of 0.97 (95% CI = 0.93–1.02; P = 0.31)”

direct quote[Methods, 'Statistical analysis']

“Statistical analyses were performed using Stata/MP 19.5 (StataCorp).”

Data availability statement names the sponsor and provides a contact address and timeframe (within two months), which is adequate for managed access. Repository deposit and accession numbers are not applicable because patient-level data cannot be openly shared. Code sharing is adequate: the statistical analysis code is available on GitHub with a URL. All applicable sub-criteria are adequate.

Sub-criteria

code sharingADEQUATE

accession numbersN/A

repository depositN/A

data availability statementADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 94% conf

A data availability statement is present with a managed-access procedure for anonymised data via the sponsor; statistical analysis code is shared on GitHub. Accession numbers are not applicable (no sequencing data), and repository deposit of raw data is not applicable (patient-level data with managed access is the field norm).

Evidence

direct quote[Data availability section]

“Access to fully anonymised data can be requested from the sponsor at: Research & Innovation, Nottingham University Hospitals NHS Trust... Data would normally be available within two months of the request.”

direct quote[Code availability section]

“The code for the statistical analysis is available from L.S. and has been uploaded to GitHub; see https://github.com/LFairleySmith/LungIMPACT”

WARNReviewer 2· 80% conf

The paper includes a data availability statement and provides a GitHub link for statistical analysis code, but the AI algorithm code is not available due to its commercial nature.

Evidence

direct quote[Data availability, paragraph 1]

“All data for the study is stored by the study sponsor. Access to fully anonymised data can be requested from the sponsor at: Research & Innovation, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, B Floor, Medical School, Derby Road, Nottingham NG7 2UH, UK. Email: nuhnt.researchsponsor@nhs.net.”

direct quote[Code availability, paragraph 1]

“The code for the statistical analysis is available from L.S. and has been uploaded to GitHub; see https://github.com/LFairleySmith/LungIMPACT .”

direct quote[Code availability, paragraph 1]

“The code for the AI algorithm is not available, as this, like many others in this field, is a commercial product.”

PASSReviewer 3· 95% conf

A data availability statement with a concrete access route is provided, and the statistical analysis code is publicly available on GitHub. Patient-level data are not publicly deposited due to privacy, which is appropriate.

Evidence

direct quote[Data availability section]

“All data for the study is stored by the study sponsor. Access to fully anonymised data can be requested from the sponsor at: Research & Innovation, Nottingham University Hospitals NHS Trust... Data would normally be available within two months of the request.”

direct quote[Code availability section]

“The code for the statistical analysis is available from L.S. and has been uploaded to GitHub; see https://github.com/LFairleySmith/LungIMPACT”

The methods section is comprehensive, covering study design, AI algorithm, sample size calculation, data collection, outcomes, and statistical analysis. The trial is registered with ISRCTN 78987039. CONSORT adherence is stated. All pre-specified outcomes (both primary and secondary) are reported, including null results (e.g., no significant difference in time to CT or diagnosis). Limitation is discussed extensively (single AI product, difficulty measuring time to CT, discordance review limitations). Conclusions are proportional: 'AI prioritization of CXR requested by UK primary care has no significant impact on the lung cancer pathway' — this is directly supported by the data. Funding (SBRI Healthcare grant) and competing interests are fully declared. All applicable sub-criteria are adequate.

Sub-criteria

funding coiADEQUATE

trial registrationADEQUATE

reporting guidelineADEQUATE

methods completenessADEQUATE

all outcomes reportedADEQUATE

limitations discussedADEQUATE

conclusions proportionalADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 95% conf

Methods are detailed, the trial is registered (ISRCTN), CONSORT guidelines are referenced, all primary and secondary outcomes are reported with null results transparently shown, limitations are discussed, conclusions are proportional, and funding/COI statements are provided.

Evidence

direct quote[Abstract]

“ISRCTN registration: 78987039 (https://www.isrctn.com/ISRCTN78987039)”

direct quote[Discussion, paragraphs 3-4]

“A limitation of the study is that the primary outcomes evaluated only the impact of AI prioritization, not the presence or absence of AI in the clinical workflow.”

direct quote[Abstract]

“AI prioritization of CXR requested by UK primary care has no significant impact on the lung cancer pathway.”

PASSReviewer 2· 90% conf

The study demonstrates high reporting transparency, including detailed methods, trial registration, discussion of limitations, and a funding/COI statement. It also references a reporting guideline.

Evidence

direct quote[Abstract, paragraph 4]

“ISRCTN registration: 78987039 (https://www.isrctn.com/ISRCTN78987039) .”

direct quote[Methods, Ethical and safety considerations, paragraph 1]

“The study was undertaken with strict adherence to recommended CONSORT guidelines and Good Clinical Practice .”

direct quote[Discussion, paragraph 10]

“A limitation of the study is that the primary outcomes evaluated only the impact of AI prioritization, not the presence or absence of AI in the clinical workflow.”

PASSReviewer 3· 95% conf

The manuscript is well-reported: methods are detailed, trial is registered, reporting guidelines are followed, all outcomes are reported, limitations are discussed, conclusions are proportional, and funding/COI are disclosed.

Evidence

direct quote[Abstract]

“ISRCTN registration: 78987039 (https://www.isrctn.com/ISRCTN78987039)”

direct quote[Methods, 'Ethical and safety considerations']

“The study was undertaken with strict adherence to recommended CONSORT guidelines and Good Clinical Practice.”

direct quote[Discussion, paragraph 5]

“A limitation of the study is that the primary outcomes evaluated only the impact of AI prioritization, not the presence or absence of AI in the clinical workflow.”

9 copyedit issues flagged: mostly consistency, clarity, typo.

Checked 39 references: 5 verified — 34 not checked.

Reproducibility

2 data/code links checked; 2 live.

Registered (1 ID: ISRCTN). Reporting guideline cited: CONSORT.

Adcurare Rigor Action ItemsFinal pass before journal submission

Ready after minor edits. The two most consequential gaps — incomplete demographic reporting and ambiguous blinding — should be addressed before submission. The copyedit issues (missing table numbers, inconsistent formatting) are minor but should be corrected for a polished submission.

1.
HIGHrigor
In the Methods (Study design), add a sentence clarifying whether radiologists/reporting radiographers were blinded to the randomization day, or state that blinding was not feasible due to the pragmatic design.
Blinding is a key quality indicator for RCTs; the current description is ambiguous and was flagged by all reviewers.
2.
HIGHrigor
In the Methods (Statistical analysis), specify a formal outlier handling rule (e.g., any criterion for excluding extreme values) and whether the 14-day CT window was a sensitivity analysis or a pre-specified exclusion.
Outlier handling is currently described as data-driven sensitivity analyses; a pre-specified rule strengthens the design's credibility.
3.
HIGHreporting
In Table 1, add columns for health status (e.g., smoking history, comorbidities) and weight/BMI, if available; if not, acknowledge the absence in the limitations.
The current table lacks key biological variables (age_weight_health criterion) that are expected for a clinical trial.
4.
HIGHreporting
In Table 1 or a separate demographics table, report race/ethnicity and other relevant sociodemographic variables (e.g., index of multiple deprivation) to improve generalizability assessment.
The demographics checklist criterion was scored inadequate due to missing race/ethnicity and comorbidities.
5.
MEDIUMcopyedit
Throughout the manuscript, replace missing table numbers (e.g., 'Table presents' -> 'Table 1 presents'; 'Extended Data Table presents' -> 'Extended Data Table 3 presents') and ensure all table references are numbered.
Missing table numbers can confuse readers and are a common copyedit issue flagged by the copyedit pass.
6.
MEDIUMcopyedit
In the Abstract and Results, standardize the formatting of 'confidence interval (CI)' to either always spell out or always abbreviate (e.g., '95% CI') consistently.
Inconsistent abbreviation formatting was noted in the copyedit pass.
7.
MEDIUMcopyedit
In the Results (Descriptive statistics), clarify the phrase 'time window from CXR acquisition to CT scan analysis' to 'time from CXR acquisition to CT scan'.
The original phrasing is slightly ambiguous and was flagged for clarity.
8.
MEDIUMcopyedit
In the Introduction, add the missing reference numbers after the statement about UK survival rates and later diagnosis.
The copyedit pass noted that reference numbers are missing for that statement.
9.
MEDIUMreporting
In the Methods (Statistical analysis), add a subsection on handling of missing data (e.g., how many patients were excluded due to missing data, and whether any imputation was used).
Missing data handling is not explicitly described; this was flagged by one reviewer and is a standard reporting expectation.
10.
LOWcopyedit
Ensure consistent date formatting throughout (e.g., '17 July 2023' vs. 'July 17, 2023') and consistent use of quotes for 'on' and 'off' arms.
Minor stylistic inconsistencies flagged in the copyedit pass.
11.
LOWcopyedit
In the Table 2 footnote, ensure that the footnote symbol (e.g., 'a') is consistently used and that the explanation for the differing n is clear (e.g., 'only first CXR per patient').
Minor consistency issue noted in the copyedit pass.

Full text (56,353 chars)Analyzed: Jul 6, 2026

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