Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis

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Late diagnoses are often linked to poorer outcomes, highlighting the need for prevention, early detection, and effective treatment programs. Raising public awareness of cancer symptoms is thought to promote earlier health-seeking behaviour and diagnosis. Despite the availability of various awareness-raising interventions, their effectiveness on outcomes is not well established. This protocol describes a strategy for addressing this knowledge gap by developing a current, comprehensive review of the evidence on the effectiveness of public-facing interventions aimed at increasing cancer symptom awareness. Methods Our approach will incorporate four distinct study designs—an inductive thematic analysis, a bibliometric analysis, a systematic review, and a network meta-analysis. These evidence synthesis methodologies will be employed following a systematic search of the relevant databases to identify interventions to increase awareness of cancer symptoms with the intent to promote earlier presentation. Only comparative study designs will be considered eligible, but this will include both randomised and nonrandomised studies of interventions, in addition to before-and-after single-arm studies. The outcomes of interest will be cancer-specific mortality and stage-at-diagnosis; however, it is anticipated that these will rarely be reported. Thus, we plan to produce a classification system for all reported outcomes via an inductive thematic analysis guided by Braun & Clarke’s six-phase approach to thematic analysis. This classification schema will facilitate comparison between studies reporting similar outcomes, and thereby the production of a bibliometric analysis, systematic review and network meta-analysis, all of which will be guided by the Cochrane Handbook for Systematic Reviews of Interventions and will be reported according to PRISMA-NMA checklist. Implications The bibliometric analysis will illustrate which interventions, and which outcomes have predominantly been studied, enabling a redirection of the research effort, if appropriate. The systematic review and network meta-analysis will enable policymakers to compare different intervention types, providing a foundation for developing policies and allocating resources towards cancer awareness initiatives. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-2", "name": "Evaluating interventions to enhance public awareness of cancer symptoms:..." } } ] } Home Browse Evaluating interventions to enhance public awareness of cancer symptoms:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Verlaque L, Jacob B, Sharma R et al. Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.12688/hrbopenres.13971.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] Logan Verlaque https://orcid.org/0009-0005-2549-7193 1 , Benjamin Jacob https://orcid.org/0000-0003-1119-064X 1 , Riya Sharma https://orcid.org/0009-0003-8117-0879 1 , [...] Yousef Juha https://orcid.org/0009-0005-8648-7351 1 , Joel Nordstrom https://orcid.org/0009-0008-0480-8484 1 , Laranya Kumar 1 , Sam McGlynn 1 , Rebecca Trower https://orcid.org/0000-0002-0609-2618 2 , Kate Hamilton-West 3,4 , Heather Burns 5 , Patrick Redmond 1 Logan Verlaque https://orcid.org/0009-0005-2549-7193 1 , Benjamin Jacob https://orcid.org/0000-0003-1119-064X 1 , [...] Riya Sharma https://orcid.org/0009-0003-8117-0879 1 , Yousef Juha https://orcid.org/0009-0005-8648-7351 1 , Joel Nordstrom https://orcid.org/0009-0008-0480-8484 1 , Laranya Kumar 1 , Sam McGlynn 1 , Rebecca Trower https://orcid.org/0000-0002-0609-2618 2 , Kate Hamilton-West 3,4 , Heather Burns 5 , Patrick Redmond 1 PUBLISHED 08 Jan 2025 Author details Author details 1 Department of General Practice, The Royal College of Surgeons (RCSI), Dublin, Ireland 2 School of Psychology, The University of Galway, Galway, Ireland 3 University of Kent, Kent, UK 4 Cancer Research UK, London, UK 5 National Cancer Control Programme, HSE, Dublin, Ireland Logan Verlaque Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Benjamin Jacob Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Review & Editing Riya Sharma Roles: Data Curation, Methodology, Writing – Review & Editing Yousef Juha Roles: Data Curation Joel Nordstrom Roles: Data Curation Laranya Kumar Roles: Data Curation Sam McGlynn Roles: Data Curation, Supervision, Writing – Review & Editing Rebecca Trower Roles: Supervision, Writing – Review & Editing Kate Hamilton-West Roles: Supervision, Writing – Review & Editing Heather Burns Roles: Supervision, Writing – Review & Editing Patrick Redmond Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Cancer persists as one of the leading causes of death worldwide as it is responsible for nearly 10 million deaths annually. Late diagnoses are often linked to poorer outcomes, highlighting the need for prevention, early detection, and effective treatment programs. Raising public awareness of cancer symptoms is thought to promote earlier health-seeking behaviour and diagnosis. Despite the availability of various awareness-raising interventions, their effectiveness on outcomes is not well established. This protocol describes a strategy for addressing this knowledge gap by developing a current, comprehensive review of the evidence on the effectiveness of public-facing interventions aimed at increasing cancer symptom awareness. Methods Our approach will incorporate four distinct study designs—an inductive thematic analysis, a bibliometric analysis, a systematic review, and a network meta-analysis. These evidence synthesis methodologies will be employed following a systematic search of the relevant databases to identify interventions to increase awareness of cancer symptoms with the intent to promote earlier presentation. Only comparative study designs will be considered eligible, but this will include both randomised and nonrandomised studies of interventions, in addition to before-and-after single-arm studies. The outcomes of interest will be cancer-specific mortality and stage-at-diagnosis; however, it is anticipated that these will rarely be reported. Thus, we plan to produce a classification system for all reported outcomes via an inductive thematic analysis guided by Braun & Clarke’s six-phase approach to thematic analysis. This classification schema will facilitate comparison between studies reporting similar outcomes, and thereby the production of a bibliometric analysis, systematic review and network meta-analysis, all of which will be guided by the Cochrane Handbook for Systematic Reviews of Interventions and will be reported according to PRISMA-NMA checklist. Implications The bibliometric analysis will illustrate which interventions, and which outcomes have predominantly been studied, enabling a redirection of the research effort, if appropriate. The systematic review and network meta-analysis will enable policymakers to compare different intervention types, providing a foundation for developing policies and allocating resources towards cancer awareness initiatives. READ ALL READ LESS Keywords Systematic review; cancer awareness; early detection; diagnostic delay; education campaigns; patient awareness Corresponding Author(s) Logan Verlaque ( [email protected] ) Close Corresponding author: Logan Verlaque Competing interests: No competing interests were disclosed. Grant information: Sam McGlynn’s involvement was supported by a grant from the HSE National Cancer Control Programme grant code is SDAP-2023-033. Logan Verlaque’s involvement was supported the the 2024 RCSI Reseach Summer School and StEP (Student Engagement Programme) Level 2 funding. Riya Sharma’s involvement was supported by StEP (Student Engagement Programme) Level 2 funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Verlaque L et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Verlaque L, Jacob B, Sharma R et al. Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.12688/hrbopenres.13971.1 ) First published: 08 Jan 2025, 8 :2 ( https://doi.org/10.12688/hrbopenres.13971.1 ) Latest published: 08 Jan 2025, 8 :2 ( https://doi.org/10.12688/hrbopenres.13971.1 ) Introduction Background Globally, there are approximately 20 million new cases and nearly 10 million deaths due to cancer each year 1 . The GLOBOCAN database highlights that in countries with a very high Human Development Index (HDI), the reported cancer mortality rates are 118.3 per 100,000 for men and 78.5 per 100,000 for women, figures that are higher than in countries with a lower HDI 1 . Moreover, cancer is the second-leading cause of premature death in 127 countries and is expected to overtake cardiovascular disease as the leading cause of death within this century 2 , 3 . Cancer detected at an earlier stage is associated with improved outcomes, including reduced mortality 4 , 5 , lower morbidity 4 , enhanced patient quality of life 4 , and reduced cost 6 – 10 . Interventions to promote earlier detection of cancer can be classified into two broad categories: interventions to detect cancer in an asymptomatic population—(i.e. “cancer screening”) and interventions to shorten the time from symptom onset to diagnosis (often referred to as “early diagnosis” initiatives) 11 . While cancer screening attempts to detect cancer before symptoms develop, only a minority of cancers are detected through screening, despite the presence of multiple screening programmes in breast, cervical, colorectal and most recently lung cancer 12 – 14 . In Ireland, between 2017–2019, 25% of breast, 32% of cervical and 6% colorectal diagnoses in Ireland were screen-detected, which equates to approximately 5% of overall invasive cancer cases 5 . Since the route to diagnosis will start with a symptom in over 90% of patients, interventions to promote the early detection of symptomatic cancer are of paramount importance. Early detection initiatives, which aim to reduce the time from symptom-onset to diagnosis, can be subdivided into those that raise symptom awareness in the public, those that alter clinician practice, those that focus on tackling any of several barriers to early help-seeking (including symptom awareness, fear, stigma, negative beliefs about cancer), and those that optimise clinical care pathways. Initiatives focused on raising symptom awareness encourage individuals to recognise potential signs of cancer and seek medical advice promptly 15 . Efforts targeting healthcare professionals, particularly general practitioners, aim to enhance their awareness of cancer symptoms and facilitate timely referrals. Lastly, the effective design of clinical care pathways, which may include intermediate testing or referral to secondary care, streamlines the process from initial suspicion to diagnosis, ensuring that patients are seen by specialists within an appropriate timeframe. Each of these broad intervention categories aims to reduce unnecessary delays and improve outcomes via earlier diagnosis and treatment initiation 16 . Existing literature The existing literature on increasing cancer symptom awareness in the general public is extensive and comprises a vast array of approaches 17 . These approaches range from large-scale national campaigns to more targeted efforts focused on specific communities or opportunistic interventions during healthcare visits. At the national level, strategies include mass media campaigns, public service advertisements, advertisements 18 and large-scale educational initiatives 19 . Community-level efforts often involve distributing informational materials such as booklets 20 , decision aids 6 , 21 , hosting local workshops, or collaborating with community leaders to promote awareness. At the individual level, interventions may include opportunistic conversations during healthcare visits, telephone consults 22 , 23 , or personalized decision aids. Many studies have reported positive findings that these interventions increase cancer awareness 15 , 17 , 24 – 26 . However, raising awareness does not consistently lead to behaviour change 27 . Help-seeking behaviour is influenced by a range of other factors beyond awareness, such as socioeconomic limitations, concerns about burdening health providers, fears about symptoms not being taken seriously, difficulty getting an appointment, and anxiety about potential diagnoses 3 , 28 , 29 . Thus, while awareness is a crucial first step, it alone may not be sufficient to prompt individuals to seek medical attention. Even when behaviour does change, it may not always lead to earlier diagnosis. Awareness campaigns such as "Be Clear on Cancer" (BCoC) in the UK successfully increased primary care visits and urgent referrals for suspected cancer, as well as influenced diagnosis patterns, including incidence and stage at diagnosis 28 , 30 . However, changing help-seeking behaviour and increasing referrals do not automatically translate into a higher rate of early diagnoses, as factors like access to diagnostic services and healthcare provider response also play a role 31 , 32 . Furthermore, even when earlier diagnosis is achieved, it does not necessarily result in improved survival outcomes. For instance, despite the changes in diagnosis patterns following the BCoC campaigns, no clear improvements in survival rates were observed 30 . This could be due to various reasons, such as the complexity of cancer progression, the time lag required to observe survival benefits, or the limitations of survival as a metric for campaign effectiveness 30 . Some studies, such as an ecological comparison across geographical regions, have found an association between awareness and survival, but such findings are context-dependent and not directly tied to awareness campaigns 33 . Knowledge gap, rationale, and aim If public awareness interventions drive timely help-seeking earlier diagnosis and improve cancer outcomes for symptomatic patients, health services could justify implementing such campaigns at a national level. However, the incumbent systematic review in this area was conducted in 2009 and highlighted the scarcity of studies rigorously evaluating the impacts of such campaigns 15 . Although a more recent systematic review focusing on lung cancer awareness and help-seeking was published in 2021 26 the aim of this review is to provide an updated synthesis of evidence on the effectiveness of interventions designed to increase public awareness and encourage help-seeking for earlier cancer diagnosis in general and improved outcomes. Objectives We will achieve this aim through the completion of the following specific objectives: 1. To systematically identify relevant studies in the literature; 2. To categorise the identified studies according to awareness-raising modality and, where available, the underpinning theoretical framework of behavioural change; 3. To collate the outcome data from each study; 4. To develop a schema for classifying the reported outcomes, utilising or modifying an existing schema, where possible; 5. To publish a bibliometric analysis of the identified studies; 6. To compare between interventions, where possible, by examining cancer mortality and cancer stage at diagnosis between the intervention and comparison groups; 7. To produce a pooled estimate of relevant outcomes for comparable interventions, and if possible, to produce a network meta-analysis enabling comparison of multiple interventions. Methods This protocol will describe the proposed methods for a systematic review supplemented by a thematic analysis and network meta-analysis. In addition to the present protocol, we plan to publish the following four outputs: (1) "Development of a classification schema for outcomes used in studies of cancer symptom awareness intervention using inductive thematic analysis”, (2) “A bibliometric analysis of studies of interventions to raise awareness of cancer symptoms”, (3) “A systematic review of interventions to raise awareness of cancer symptoms”, and (4) “A network meta-analysis of interventions to raise awareness of cancer symptoms”. The inductive thematic analysis will be conducted according to Braun & Clarke’s six-phase approach to thematic analyses 34 and in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) 35 . The systematic review, bibliometric analysis and network meta-analysis will adhere to the guidelines established by the Cochrane Handbook for Systematic Reviews of Interventions 36 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA) guidelines 37 . Eligibility criteria The following eligibility criteria will be used to operationalise our research question: Table 1 : Eligibility Criteria. Table 1. Eligibility Criteria. Concept Inclusion Exclusion Population Adults (>18yo) Children and adolescents (<18 years old) Intervention Any intervention to increase awareness of cancer symptoms, with the intent to promote earlier presentation Screening interventions for asymptomatic individuals (e.g. interventions to promote screening/increase screening uptake) Comparison The absence of the stated intervention / “standard” public health practice Non-comparative studies Outcomes Any outcome comparing the intervention to some control group (including a before-and-after control) Any outcome without a comparison group Study design Comparative studies (interventional and observational), including before-and-after studies Research designs without a comparison group Additional Publication year: since November 2008 Studies not published in English Search strategy A comprehensive search will be conducted in the following databases MEDLINE, EMBASE, PsycINFO, Scopus, Web of Science, ProQuest, Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search strategy will include MeSH terms and keywords related to: (1) cancer awareness, (2) early presentation, (3) interventions. These are demonstrated in Table 2 . The approach to this search will be customized to meet the unique specifications of each database, using filters to locate primary studies as needed. The search will be limited to studies published in English from November 2008 to April 22, 2024. References of included studies and relevant reviews will be hand searched to identify additional studies not captured by electronic searches. Full details of the search strategy, designed in consultation with an information specialist, will be outlined on the Open Science Framework. Table 2. Screening Algorithm including Exclusion Criteria. Step Concept Question Exclusion label 1 Cancer Does this paper deal with cancer? “NotCancer” “NotPrimaryCancer” 2 Interventions Does this paper look at interventions? “NotIntervention” 3 Cancer awareness/ Early presentation Does the intervention seek to (a) improve awareness of cancer symptoms, or (b) promote early presentation? “NotSymptomAwareness” “NotEarlyPresent” 4 (INCLUDE) If positive to all the above, then include n/a Study selection Screening of titles and abstracts for eligibility will be done by two reviewers independently, within “Rayyan”, an online tool for collaborative systematic literature reviews 38 . The screening algorithm is outlined in Table 2 . Discrepancies will be resolved through consensus or with an additional reviewer (B.J.). Full texts of potentially eligible studies will then be reviewed for inclusion based on the eligibility criteria. Data collection Relevant data items will be extracted from the full text of included articles using a pre-piloted pro forma. The extraction will be conducted independently by one reviewer and reviewed by another for accuracy. Data items to be extracted are outlined in Table 3 . Table 3. Extracted Study Items. Data Item Sub-items Publication Details Authors Year of publication Study context Study location Study population (sociodemographic) Year the study was conducted Intervention details Cancer type(s) Intervention modality Duration Underpinning behavioural change theory and targeted behavioural change construct Study details Study design Comparison intervention Sample size Outcomes All reported outcomes Additional information Reported limitations Reported patient experience Intervention Modality. Interventions will be classified into various categories based on their delivery method. These intervention categories include Community Education Sessions; Individual Health Education Sessions; Print Media Initiatives; Digital Media Interventions; Broadcast and Outdoor Media Campaigns; Dual-approach Interventions; Multi-faceted Intervention Programs; Miscellaneous Awareness Strategies. We will adapt this where necessary, and should the schema be inadequate we will develop a schema using thematic synthesis. Targeted Behavioural Change Construct. To capture and understand how interventions are designed to modify behaviour, we will categorise interventions based on underlying behavioural theories in two ways. Firstly, in the bibliometric analysis, we will report whether the authors reported, and frameworks used. Secondly, we will conduct a framework analysis of the methods section of the included papers, utilising the Theoretical Domains Framework to categorise the aspects of behavioural change targeted by the intervention 39 . This categorisation will help in understanding the theoretical basis of the interventions and their potential mechanisms of action. Outcomes. The outcomes are structured in a hierarchy to reflect their logical progression from intervention to impact. Clinical outcomes (1–6) are at the top, as they represent the ultimate measures of success in terms of mortality and cancer stage. Healthcare utilization outcomes (7–10) follow, indicating how the intervention changes healthcare-seeking behaviour, which is necessary for clinical improvements. Measures of intent, attitude, or knowledge (11–12) come next, as these are precursors to behavioural change. Finally, campaign reach (13) is positioned at the base, as it represents the foundation upon which all other changes depend. This order is necessary to demonstrate the pathway from awareness to measurable health outcomes. The outcomes of interest will be: 1. All-cause mortality 2. Cancer-specific mortality 3. Stage III/IV cancer incidence (as defined by standard staging criteria, e.g., TNM classification) 4. Proportion of cancers diagnosed in Stage III/IV 5. Cancer incidence 6. All other clinical outcomes 7. Rate of cancer referral 8. Rate of other referrals or investigation requests 9. Rate of GP attendances with a relevant symptom 10. All other measures of healthcare utilization 11. Any measure of behavioural intention 12. Any measure of relevant healthcare knowledge 13. Any measure of campaign reach It is anticipated that most studies will not report clinical outcomes, and thus all reported outcomes will be further synthesized in our systematic review. However, our synthesis will specifically mention the outcomes listed above wherever possible ( Figure 1 ). Figure 1. A working theoretical model for cancer awareness interventions, illustrating the causal flow from campaign reach through increased awareness, behavior change, earlier diagnosis, and improved clinical outcomes. This approach draws on behaviour change frameworks like the Health Belief Model and CRUK's "Waterfall" diagram for early diagnosis initiatives. Inductive Thematic Analysis of Outcome Data. Due to the anticipated large number of included studies, an inductive thematic analysis of the reported outcomes will be utilised to produce a classification schema which will be employed in the systematic review and meta-analysis results, leading to data that are more interpretable and manageable for analysis. This will be completed using Braun & Clarke’s approach to thematic analysis 34 , whereby each step will be conducted by the lead author and at least one other co-author. During the data extraction phase, the authors involved read and extract excerpts from the “Results” sections of included studies. Each excerpt will be comprehensive enough to cover all reported outcomes. This ensures that all relevant data from the studies are captured accurately. To enable the thematic synthesis, the excerpt will be loaded into either “ NVivo ”, a qualitative data analysis software 40 or “ Taguette ”, an open-source alternative 41 . Step 1 (Familiarisation with data): During this step, all authors involved in the thematic synthesis will familiarise themselves with these excerpts by reading and re-reading them to gain an understanding of the content. Step 2 (Generating initial codes): As outlined above, for each paper, two authors will code each reported study outcome in the excerpt. Step 3 (Searching for themes): Collaborative discussions between all authors will take place to review and segregate the initial codes into larger groups that share common features. Step 4 (Reviewing themes): This step will involve refining the themes synthesised in the previous phase. Authors will review each theme against the coded data to ensure it accurately represents the data. This process may involve combining, splitting, or discarding themes as necessary to ensure they comprehensively and accurately capture the nuances of the data. Step 5 (Defining and naming themes): An attempt will be made to define each theme clearly and, where applicable, identify sub-themes. This process will involve developing detailed descriptions for all themes to ensure they comprehensively capture the essence of the coded data. Authors will write concise definitions and descriptions for each theme and sub-theme, highlighting their scope and distinguishing characteristics. Consensus discussions among all authors will be conducted to resolve any discrepancies and to ensure agreement on the definitions and descriptions. This step ensures that the themes are well-defined and distinct, facilitating a clearer and more coherent analysis. Step 6: (Creating the classification schema): In this step, we will develop a classification schema for the reported outcomes. First, we will review the themes and sub-themes from previous steps and group similar ones into higher-order categories. We will then arrange these categories into a logical framework to highlight patterns and relationships within the data. Consensus discussions among all authors will refine the schema, ensuring agreement on its structure. Finally, we will finalize and describe the schema, ensuring it accurately reflects the data and enhances the interpretation of study findings. Risk of Bias Assessment. We will critically assess and report the risk of bias in each study using established tools including ROBINS-E, ROBINS-I, and Cochrane RoB2 36 , 42 , 43 . ROBINS-E is used for observational studies of exposure, whereas ROBINS-I is used in observational studies of intervention 42 , 43 , and Cochrane RoB2 is used for assessing bias in randomised trials 36 . This assessment will help in understanding the reliability and validity of the findings reported in the individual studies. Data synthesis The data will be synthesised in three phases. The first phase involves a bibliometric analysis, supported by a thematic synthesis of outcome data into a classification schema. In the second phase, a systematic review will be conducted to catalogue key outcome measures, enabling comparisons between interventions. The final phase will involve a network meta-analysis to further analyse the data. Stage 1 (Bibliometric analysis) : For our bibliometric analysis, we will collect and analyse data in several key categories. We will gather publication details (year, journal, authors, and affiliations) to understand research trends. We will examine the study context, focusing on geographical locations, settings, and populations. Intervention details, including types, duration, and modalities, will be documented to compare different approaches. We will categorise the behavioural theories underlying the interventions to understand their theoretical foundations. Study details such as design, sample size, and methodology will be compiled to assess research robustness. Finally, we will classify the reported outcomes to aid thematic synthesis and create a classification schema for the data. This systematic approach will help identify trends, gaps, and patterns in the research. Stage 2 (Systematic review of efficacy): Our systematic treatment of the literature will allow us to catalogue key outcome measures, enabling detailed comparisons between different interventions. This process will provide a comprehensive overview of the effectiveness of various approaches, and if possible, a subgroup analysis of the impact of these interventions across sociodemographic groups, which will highlight the most effective interventions and areas needing further investigation. Stage 3 (Network meta-analysis): We plan to conduct a network meta-analysis to compare multiple interventions simultaneously. This technique allows us to estimate the relative effectiveness of different interventions by integrating data from various studies. The analysis will help identify the most effective interventions and rank them in terms of efficacy and safety, providing a comprehensive understanding of their performance. However, this is only possible if the included studies are adequate in terms of quality, consistency, and comprehensiveness, as these factors ensure the reliability and validity of the meta-analysis findings. Stage 4 (Overarching synthesis): To conclude, we will attempt to interpret the findings from the bibliometric analysis, systematic review, and network meta-analysis. This synthesis will consider the strengths and limitations of each methodology to generate concise and practical conclusions which are nonetheless rooted in the available evidence. Network meta-analysis Network meta-analysis (NMA) differs from standard meta-analysis as it incorporates direct and indirect comparisons of interventions across multiple studies, forming a network of evidence. The technique provides insights into the comparative effectiveness of all available treatments within the network. To perform any meta-analysis effectively, certain conditions should be met 44 : literature quality should be of high standard; risk of bias of trials as well as publication bias should be analysed; heterogeneity of studies should be identified as well as relevance of studies to the primary research question. Specifically, to perform an NMA, additional considerations are required: homogeneity of evidence, consistency between direct and indirect estimates for the same intervention comparison, and transitivity between studies. We will conduct all analyses using R, specifically the netmeta package 44 , 45 , with a significance level set at p < 0.05. Data will be formatted using the pairwise () function, converting it into a contrast-based format suitable for NMA. The NMA will be conducted with the netmeta() function, integrating direct and indirect evidence. Both fixed-effect and random-effect models will be considered, with between-study variance estimated via restricted maximum likelihood. Meta-regression techniques using the metareg() function will adjust for covariates such as cancer type and intervention type. Heterogeneity and inconsistency will be assessed using Cochran’s Q and I 2 statistics. The decomp.design() and netsplit() functions will be used to explore within-design and between-design heterogeneity and local inconsistency. Sensitivity analyses will include examining the impact of excluding studies with high risk of bias, using different methods for handling zero-event studies, and applying the Mantel-Haenszel method and continuity correction approaches to assess robustness of the findings. Subgroup analyses based on cancer type, stage, and patient characteristics will be performed by conducting separate NMAs for each subgroup. Interventions will be ranked using SUCRA curves and P-scores, calculated with the netrank() function, and rankograms will visually display ranking probabilities. Results will be presented using netgraph() for network plots, forest.netmeta() for forest plots, and netleague() for league tables. Forest plots generated with forest.netmeta() will display the estimated treatment effects and their confidence intervals, while league tables produced with netleague() will summarize all pairwise comparisons, providing a comprehensive overview of the relative effectiveness of each intervention. Publication bias will be assessed using comparison-adjusted funnel plots generated with the funnel.netmeta() function to detect any asymmetry indicative of potential publication bias. Confidence in Cumulative Evidence. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach will be used to assess and rate the strength of the body of evidence for each outcome examined in this review 46 . GRADE provides a systematic method to evaluate the quality of evidence, initially categorising randomised controlled trials as high quality and observational studies as low quality. The evidence will be downgraded based on factors such as risk of bias, inconsistency, indirectness, imprecision, and publication bias. Conversely, it can be upgraded for factors like large effect sizes or a dose-response relationship. This process will result in a final rating of high, moderate, low, or very low quality for each outcome, providing a clear indication of the confidence we can place in the results. Discussion Summary The proposed evidence synthesis work aims to tackle the urgent need for evidence-based interventions to increase public awareness of cancer symptoms thereby facilitating earlier presentation and, consequently, improving cancer outcomes. With a rigorous methodology, this study ensures a thorough analysis of existing literature, providing valuable insights for policy and practice decisions. By synthesising evidence and evaluating interventions critically, it aims to contribute significantly to alleviating the burden of cancer on both individuals and society. Limitations Limitations exist that may affect the interpretation of our findings. First is subjectivity in data extraction in which reviewers analysing and extracting data from studies might introduce subjectivity, which could lead to biases in the synthesis process. The possibility of incomplete data should also be noted. The reliability of the synthesised results may be affected if there are missing or incomplete data due to variations in the quality and reporting of the included studies. For more recent papers the COVID-19 pandemic should also be taken into consideration, with its potential effects on factors such as patient willingness to seek physicians and attend routine GP consultations as well as shift to remote consultations 47 . Publication bias also serves as a limitation as studies with more favourable outcomes are more likely to be published, leading to an overestimation of intervention efficacy. Language bias could also lead to overestimation of efficacy as studies published in languages other than English might be excluded. Implications. The results of this systematic review will have an impact on the public health policy and practice, as well as future research. This review will provide public health professionals with collated evidence on the effectiveness of interventions targeting cancer awareness, early presentation and barriers to cancer seeking diagnosis. The goal of this review is to provide answers to key questions including the degree of positive impact of various interventions and cost-effectiveness of such interventions. This would provide a basis for the development of current health policies to allocate resources towards the chosen cancer awareness and early presentation initiatives. In addition, this review will highlight areas where further research is needed, ensuring the evidence based continues to develop. Specifically, we will collate evidence for the National Cancer Control Programme (NCCP) in Ireland and thus give recommendations that will aid in shaping the field of increasing awareness in cancer. We will work with NCCP policymakers to create a policy brief summarising key findings and recommendations addressing early diagnosis of symptomatic cancer for the NCCP and other health policy stakeholders. Through academic publications, policy briefs, and stakeholder meetings, in addition to a summary report, the results of this systematic review are intended to augment efforts to raise awareness of cancer symptoms and presentations in Ireland. Data availability No data are associated with this article. Extended data OSF: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis, Doi: https://doi.org/10.17605/OSF.IO/BPS3Z 48 This project contains the following extended data: AWARE_Protocol_SearchStrategy.pdf Reporting guidelines OSF: PRISMA checklist for ‘Evaluating Interventions to Enhance Public Awareness of Cancer Symptoms: Protocol for a Systematic Review and Network Meta-Analysis’. https://doi.org/10.17605/OSF.IO/BPS3Z 48 Data are available under the terms of the CC-By Attribution 4.0 International Faculty Opinions recommended References 1. Bray F, Laversanne M, Sung H, et al. : Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024; 74 (3): 229–63. PubMed Abstract | Publisher Full Text 2. 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October, 2024. http://www.doi.org/10.17605/OSF.IO/BPS3Z Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 08 Jan 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of General Practice, The Royal College of Surgeons (RCSI), Dublin, Ireland 2 School of Psychology, The University of Galway, Galway, Ireland 3 University of Kent, Kent, UK 4 Cancer Research UK, London, UK 5 National Cancer Control Programme, HSE, Dublin, Ireland Logan Verlaque Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Benjamin Jacob Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Review & Editing Riya Sharma Roles: Data Curation, Methodology, Writing – Review & Editing Yousef Juha Roles: Data Curation Joel Nordstrom Roles: Data Curation Laranya Kumar Roles: Data Curation Sam McGlynn Roles: Data Curation, Supervision, Writing – Review & Editing Rebecca Trower Roles: Supervision, Writing – Review & Editing Kate Hamilton-West Roles: Supervision, Writing – Review & Editing Heather Burns Roles: Supervision, Writing – Review & Editing Patrick Redmond Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Sam McGlynn’s involvement was supported by a grant from the HSE National Cancer Control Programme grant code is SDAP-2023-033. Logan Verlaque’s involvement was supported the the 2024 RCSI Reseach Summer School and StEP (Student Engagement Programme) Level 2 funding. Riya Sharma’s involvement was supported by StEP (Student Engagement Programme) Level 2 funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 08 Jan 2025, 8:2 https://doi.org/10.12688/hrbopenres.13971.1 Copyright © 2025 Verlaque L et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Verlaque L, Jacob B, Sharma R et al. Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.12688/hrbopenres.13971.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 08 Jan 2025 Views 0 Cite How to cite this report: Busakhala N. Reviewer Report For: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.21956/hrbopenres.15334.r45355 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-2/v1#referee-response-45355 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Feb 2025 Naftali Busakhala , Moi University School of Medicine, Eldoret, Kenya Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15334.r45355 This is an important topic. The authors should indicate validated and recommended tools for assessing impact of cancer campaigns on awareness//knowledge, attitudes, early attendance, early investigation, early diagnosis and better outcome. Which tool will they use and why? ... Continue reading READ ALL This is an important topic. The authors should indicate validated and recommended tools for assessing impact of cancer campaigns on awareness//knowledge, attitudes, early attendance, early investigation, early diagnosis and better outcome. Which tool will they use and why? The references have only 2 or 3 studies measuring impact. The authors should include more studies. Have they considered a software that can be used to measure impact? Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Cancer screening/early detection I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Busakhala N. Reviewer Report For: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.21956/hrbopenres.15334.r45355 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-2/v1#referee-response-45355 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 27 Mar 2025 Logan Verlaque , Department of General Practice, The Royal College of Surgeons (RCSI), Dublin, Ireland 27 Mar 2025 Author Response Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic ... Continue reading Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic behaviours. We will also highlight studies that employ validated tools in our synthesis. However, as measurement tools vary widely across studies, we will also document non-validated but frequently used methods and appraise their reliability and limitations. We will also conduct a more extensive search to identify additional studies that quantify changes in awareness and behaviour following interventions. Lastly, we will explore available software and digital tools that may facilitate the evaluation of campaign impact, noting any applications that have been successfully used in previous studies. Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic behaviours. We will also highlight studies that employ validated tools in our synthesis. However, as measurement tools vary widely across studies, we will also document non-validated but frequently used methods and appraise their reliability and limitations. We will also conduct a more extensive search to identify additional studies that quantify changes in awareness and behaviour following interventions. Lastly, we will explore available software and digital tools that may facilitate the evaluation of campaign impact, noting any applications that have been successfully used in previous studies. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 27 Mar 2025 Logan Verlaque , Department of General Practice, The Royal College of Surgeons (RCSI), Dublin, Ireland 27 Mar 2025 Author Response Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic ... Continue reading Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic behaviours. We will also highlight studies that employ validated tools in our synthesis. However, as measurement tools vary widely across studies, we will also document non-validated but frequently used methods and appraise their reliability and limitations. We will also conduct a more extensive search to identify additional studies that quantify changes in awareness and behaviour following interventions. Lastly, we will explore available software and digital tools that may facilitate the evaluation of campaign impact, noting any applications that have been successfully used in previous studies. Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic behaviours. We will also highlight studies that employ validated tools in our synthesis. However, as measurement tools vary widely across studies, we will also document non-validated but frequently used methods and appraise their reliability and limitations. We will also conduct a more extensive search to identify additional studies that quantify changes in awareness and behaviour following interventions. Lastly, we will explore available software and digital tools that may facilitate the evaluation of campaign impact, noting any applications that have been successfully used in previous studies. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Gil NM. Reviewer Report For: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.21956/hrbopenres.15334.r45354 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-2/v1#referee-response-45354 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Feb 2025 Natalie Maria Gil , University of Surrey, Guildford, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15334.r45354 This protocol seeks to identify and evaluate the available scientific literature on interventions to enhance public awareness of cancer symptoms. This is an important and timely piece of research given global public health priorities and increasing incidence ... Continue reading READ ALL This protocol seeks to identify and evaluate the available scientific literature on interventions to enhance public awareness of cancer symptoms. This is an important and timely piece of research given global public health priorities and increasing incidence and mortality rates of cancer worldwide. There is a pressing need to review existing interventions to improve cancer symptom awareness, especially in vulnerable and marginalised population groups. The protocol provides a detailed overview of proposed steps for a 4-phased review of the literature with several outcomes and objectives. Particularly important is the strategy to document the underpinning behavioural change theory or targeted behaviour change constructs. This will aid in future design and delivery of successful public health interventions. I would make clear whether this review aims to just evaluate interventions to improve cancer symptom awareness or whether the review will also evaluate help-seeking behaviour. The title suggests the measure will be cancer symptom awareness, however behaviour change constructs and behaviour change theory are mentioned throughout, indicating that help-seeking behaviour as a result of increased awareness will also be evaluated. On line 23/24 of the Background, the words 'in Ireland' are repeated in the sentence. Consider restructuring. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health Psychology, Behavioural Science, Early diagnosis of cancer, health inequalities. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gil NM. Reviewer Report For: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.21956/hrbopenres.15334.r45354 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-2/v1#referee-response-45354 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 08 Jan 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 08 Jan 25 read read Natalie Maria Gil , University of Surrey, Guildford, UK Naftali Busakhala , Moi University School of Medicine, Eldoret, Kenya Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Busakhala N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Feb 2025 | for Version 1 Naftali Busakhala , Moi University School of Medicine, Eldoret, Kenya 0 Views copyright © 2025 Busakhala N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is an important topic. The authors should indicate validated and recommended tools for assessing impact of cancer campaigns on awareness//knowledge, attitudes, early attendance, early investigation, early diagnosis and better outcome. Which tool will they use and why? The references have only 2 or 3 studies measuring impact. The authors should include more studies. Have they considered a software that can be used to measure impact? Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Cancer screening/early detection I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 27 Mar 2025 Logan Verlaque, Department of General Practice, The Royal College of Surgeons (RCSI), Dublin, Ireland Thank you for your thoughtful and constructive feedback on our protocol. We will expand our methodology section to discuss established frameworks for measuring awareness, knowledge, attitudes, and early diagnostic behaviours. We will also highlight studies that employ validated tools in our synthesis. However, as measurement tools vary widely across studies, we will also document non-validated but frequently used methods and appraise their reliability and limitations. We will also conduct a more extensive search to identify additional studies that quantify changes in awareness and behaviour following interventions. Lastly, we will explore available software and digital tools that may facilitate the evaluation of campaign impact, noting any applications that have been successfully used in previous studies. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Busakhala N. Peer Review Report For: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.21956/hrbopenres.15334.r45355) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-2/v1#referee-response-45355 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Gil N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Feb 2025 | for Version 1 Natalie Maria Gil , University of Surrey, Guildford, UK 0 Views copyright © 2025 Gil N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This protocol seeks to identify and evaluate the available scientific literature on interventions to enhance public awareness of cancer symptoms. This is an important and timely piece of research given global public health priorities and increasing incidence and mortality rates of cancer worldwide. There is a pressing need to review existing interventions to improve cancer symptom awareness, especially in vulnerable and marginalised population groups. The protocol provides a detailed overview of proposed steps for a 4-phased review of the literature with several outcomes and objectives. Particularly important is the strategy to document the underpinning behavioural change theory or targeted behaviour change constructs. This will aid in future design and delivery of successful public health interventions. I would make clear whether this review aims to just evaluate interventions to improve cancer symptom awareness or whether the review will also evaluate help-seeking behaviour. The title suggests the measure will be cancer symptom awareness, however behaviour change constructs and behaviour change theory are mentioned throughout, indicating that help-seeking behaviour as a result of increased awareness will also be evaluated. On line 23/24 of the Background, the words 'in Ireland' are repeated in the sentence. Consider restructuring. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Health Psychology, Behavioural Science, Early diagnosis of cancer, health inequalities. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Gil NM. Peer Review Report For: Evaluating interventions to enhance public awareness of cancer symptoms: Protocol for a systematic review and network meta-analysis [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :2 ( https://doi.org/10.21956/hrbopenres.15334.r45354) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); }); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fea650ebe9006db',t:'MTc3OTI3MDE4Mg=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();