Early Diagnosis and Prognostic Prediction of Colorectal Cancer through Plasma Methylation Regions

Reviewer #1 (Public review):

Summary:

Colorectal cancer (CRC) is the third most common cancer globally and the second leading cause of cancer-related deaths. Colonoscopy and fecal immunohistochemical testing are among the early diagnostic tools that have significantly enhanced patient survival rates in CRC. Methylation dysregulation has been identified in the earliest stages of CRC, offering a promising avenue for screening, prediction, and diagnosis. The manuscript entitled "Early Diagnosis and Prognostic Prediction of Colorectal Cancer through Plasma Methylation Regions" by Zhu et al. presents that a panel of genes with methylation pattern derived from cfDNA (27 DMRs), serving as a noninvasive detection method for CRC early diagnosis and prognosis.

Strengths:

The authors provided evidence that the 27 DMRs pattern worked well in predicting CRC distant metastasis, and the methylation score remarkably increased in stage III-IV.

Weaknesses:

The major concerns are the design of DMR screening, the relatively low sensitivity of this DMR pattern in detecting early-stage CRC, the limited size of the cohorts, and the lack of comparison with the traditional diagnosis test.

Reviewer #2 (Public review):

This work presents a 27-region DMR model for early diagnosis and prognostic prediction of colorectal cancer using plasma methylation markers. While this non-invasive diagnostic and prognostic tool could interest a broad readership, several critical issues require attention.

Major Concerns:

(1) Inconsistencies and clarity issues in data presentation

a) Sample size discrepancies
- The abstract mentions screening 119 CRC tissue samples, while Figure 1 shows 136 tissues. Please clarify if this represents 119 CRC and 17 normal samples.
- The plasma sample numbers vary across sections: the abstract cites 161 samples, Figure 1 shows 116 samples, and the Supplementary Methods mentions 77 samples (13 Normal, 15 NAA, 12 AA, 37 CRC).

b) Methodological inconsistencies
- The Supplementary Material reports 477 hypermethylated sites from TCGA data analysis (Δβ>0.20, FDR<0.05), but Figure 1 indicates 499 sites.
- The manuscript states that analyzing TCGA data across six cancer types identified 499 CRC-specific methylation sites, yet Figure 1 shows 477. Please also explain the rationale for selecting these specific cancer types from TCGA.
- "404 CRC-specific DMRs" mentioned in the main text while "404 MCBs" in Figure 1, the authors need to clarify if these terms are interchangeable or how MCBs are defined.

(2) Methodological documentation

- The Results section requires a more detailed description of marker identification procedures and justification of methodological choices.
- Figure 3 panels need reordering for sequential citation.

(3) Quality control and data transparency

- No quality control metrics are presented for the in-house sequencing data (e.g., sequencing quality, alignment rate, BS conversion rate, coverage, PCA plots for each cohort).
- The analysis code should be publicly available through GitHub or Zenodo.
- At a minimum, processed data should be made publicly accessible to ensure reproducibility.

Reviewer #3 (Public review):

Summary:

This article provides a model for early diagnosis and prognostic prediction of Colorectal Cancer and demonstrates its accuracy and usability. However, there are still some minor issues that need to be revised and paid attention to.

Strengths:

A large amount of external datasets were used for verification, thus demonstrating robustness and accuracy. Meanwhile, various influencing factors of multiple samples were taken into account, providing usability.

Weaknesses:

There are notable language issues that hinder readability, as well as a lack of some key conclusions provided.