Resilience as a Factor Influencing Psychological Distress Experience in Patients with Neuro-Oncological Disease

Round 1

Reviewer 1 Report

This topic is interesting, but paper needs several revisions:

- "This study examined the impact of resilience on distress in patients with neuro-oncological diseases" It is not clear if this paper reported patients with all kind of brain tumors or only with brain metastasis. Revise

- It seems all kind of brain tumors. So why to report this sentence? "Brain metastases occur in approximately 20% of all patients with cancer [18] " Improve.

- "It could be shown that resilience seems to be an influencing variable on the distress experience in patients with neuro-oncological diseases" Depression and anxiety seems to be correlated with a good muscle mass and temporalis muscle thickness. Look at these papers: -- Pasqualetti F et al. Impact of temporalis muscle thickness in elderly patients with newly diagnosed glioblastoma treated with radio or radio-chemotherapy. Radiol Med. 2022 Aug;127(8):919-924. doi: 10.1007/s11547-022-01524-2. ---  Muglia R et al. Prognostic relevance of temporal muscle thickness as a marker of sarcopenia in patients with glioblastoma at diagnosis. Eur Radiol. 2021 Jun;31(6):4079-4086. 

- Conclusion section should be improved. What does this paper add new to the literature? Please report a take-home message in the discussion section and in the abstract.

- "Meningiomas are usually benign. 30 As a result, even a large proportion of patients did not end up with cancer and are in remission after surgery." What do authors suggest to improve this patients' outcome?

- Figure 1 needs to be explain better. Improve figure legend.

- All references in their section were not reported in the correct way. Revise.

Author Response

Thank you for the valuable comments, which we will gladly implement. We have tried to improve the content.

Ad 1) - "This study examined the impact of resilience on distress in patients with neuro-oncological diseases" It is not clear if this paper reported patients with all kind of brain tumors or only with brain metastasis. Revise

Thank you for this important comment, in this study all patients with neuro-oncological diseases were included. This means that there are patients with primary brain tumors (gliomas, meningiomas, etc.) and also secondary ones, for example metastases. We have tried to formulate this even more clearly.

„The inclusion criterion was needing surgical treatment at inpatient admission for a tumor of neuro-oncological origin (i.e., suspicion of a malignant tumor, recurring tumor or second tumor).”

Ad 2) - It seems all kind of brain tumors. So why to report this sentence? "Brain metastases occur in approximately 20% of all patients with cancer [18] " Improve.

You are right. We tried to write more specific, that many patients with cancer also suffer from a neurological component. In this case, cerebral metastases.

„At the same time, because brain metastases occur in approximately 20% of all patients with cancer, other tumors of primary genesis may also have have a neuro-oncological component.“

Ad 3) - "It could be shown that resilience seems to be an influencing variable on the distress experience in patients with neuro-oncological diseases" Depression and anxiety seems to be correlated with a good muscle mass and temporalis muscle thickness. Look at these papers: -- Pasqualetti F et al. Impact of temporalis muscle thickness in elderly patients with newly diagnosed glioblastoma treated with radio or radio-chemotherapy. Radiol Med. 2022 Aug;127(8):919-924. doi: 10.1007/s11547-022-01524-2. ---  Muglia R et al. Prognostic relevance of temporal muscle thickness as a marker of sarcopenia in patients with glioblastoma at diagnosis. Eur Radiol. 2021 Jun;31(6):4079-4086. 

Thanks for suggesting these highly interesting papers. Of course, there are many variables that moderate the experience of distress. We tried to make this understandable in the article.

Ad 4) - Conclusion section should be improved. What does this paper add new to the literature? Please report a take-home message in the discussion section and in the abstract.

Thank you very much for this very important comment. We have attempted to illustrate how resilience affects distress in this particular patient population. We were able to show that resilience has a significant influence on hospitalization. We are trying to make this take-home-message more clearly.

Ad 5) - "Meningiomas are usually benign. 30 As a result, even a large proportion of patients did not end up with cancer and are in remission after surgery. What do authors suggest to improve this patients' outcome?

Thank you for the important comment. The key message of this statement was that in our studied group also some patients did not have cancer in the end. A tumor diagnosis is initially stressful for all patients. Even for patients who ultimately receive a benign diagnosis and can be cured, support is necessary in this extreme situation.

Ad 6) Figure 1 needs to be explain better. Improve figure legend.

Thank you for the comment regarding our figure. We have tried to add a more detailed description.

“Figure 1 shows three boxplots with the scores for distress in the different resilience-based groups. The upper whisker shows the maximum value and the lower whisker the minimum value, while the lower part of the box shows the first quartile ad the upper part the third quartile. Mean values increased within the three resilience-based groups from 4.89 to 5.67 and to 7.15, respectively.”

Ad 7) All references in their section were not reported in the correct way. Revise.

All references were revised in the correct way.

For example:

„As a life-threatening disease, cancer typically prompts major changes in lifestyle, which can can cause distress. In recent decades, research has indeed shown the traumatic potential of cancer as a source of distress [1].“

[1] Seiler A, Jenewein J. Resilience in Cancer Patients. Front. Psychiatry 2019; 10: 208 [PMID: 31024362]

Author Response File: Author Response.docx

Reviewer 2 Report

This study aims to search for effect of resilience on psychological distress experience of patients with neurooncological diseases in a tertiary cancer clinic. To achieve this purpose, 100 patients with neurooncological tumors were evaluated with several scales for two times in 6 months. They reported that resilience seems to have a significant impact on distress in the acute phase of the disease but not at 6th month. Authors used univariate analysis for the study which they explained minimally and also minimally reported the limitations of study.

Several points should be highlighted in the manuscript

1. The purpose of the study is not clear. While neurooncological disease was mentioned in the title and purpose, only neurooncological tumor was mentioned in the methodology, not these diseases, and the findings were included in the study. This issue should be clarified and consistent.

2. How the sample size was found should be specified and power analysis findings should be included. Likewise, how the sample was collected (sequential, randomized, all cases) should be explained.

3. What the abbreviations T0 and T1 stand for should be stated in the text.

4. As far as I understand the methodology, the first interview was face-to-face and then tests were administered by telephone. Was a psychiatric interview conducted during these interviews? How healthy were the evaluations made 1 to 3 days after the surgery? Who conducted these interviews? What are their competencies? 

5. Is there any information about the cognitive level of the patients at the first interview and 6 months later? How was this situation handled?

6. Was there any information about the stage of the cancers of the patients, which brain region was involved, was there any information about these? The possible effect of this situation on the scale results should be discussed, and if there is data, it should be discussed in the context of these data. 

7. Psychometric properties of the original and adapted versions of the scales used should be included.

8. Why was a scale assessing generalized anxiety used in the study instead of scales assessing situational anxiety? What is the rationale for this?

9. Discussion is not sufficient. Comparison with previous studies should be made and this section should be improved.

10. Limitations of the study should be added to the discussion.

11. In the conclusion section, more meaningful suggestions that will guide further studies should be added.  

Author Response

Thank you for all the helpful comments. We have tried to respond to them in the best possible way. We improved our english via editmyenglish.com.

Ad 1) „The purpose of the study is not clear. While neurooncological disease was mentioned in the title and purpose, only neurooncological tumor was mentioned in the methodology, not these diseases, and the findings were included in the study. This issue should be clarified and consistent.“

Thank you for this very important comment, which we are happy to refer to. Patients with different tumor entities were included in the study. We have now tried to discribe this in more detail in accordance with your recommendation. All included patients had a tumor disease.

“we examined patients who were undergoing surgical tumor therapy in the
Department of Neurosurgery at Tübingen University Hospital”
“The inclusion criterion was needing surgical treatment at inpatient admission for a tumor of neuro-oncological origin (i.e., suspicion of a malignant tumor, recurring tumor or second tumor). By contrast, the exclusion criteria were cognitive deficits (e.g., somnolence and pronounced aphasia...”

Ad 2) „How the sample size was found should be specified and power analysis findings should be included. Likewise, how the sample was collected (sequential, randomized, all cases) should be explained.“

Thank you. We have tried to specify this further. In fact, we tried to include all
patients who were on the unit at the time of screening. We did not perform a power analysis as weh ad no comparable study to estimate expected variance and average values for this power estimation.

Ad 3) As far as I understand the methodology, the first interview was face-to-face and then tests were administered by telephone. Was a psychiatric interview conducted during these interviews? How healthy were the evaluations made 1 to 3 days after the surgery? Who conducted these interviews? What are their competencies?

Thank you for this important comment. T0 stands for the hospital stay and T1 for the time 6 months after surgery. We have tried to illustrate this better in the text. We have now defined this clearly again in the method section.

“We administered a psycho-oncological distress screening via a questionnaire with five instruments 1 and 3 days after neurosurgery and again 6 months later over the phone. The instruments were used to measure distress, need for psychosocial support, and symptoms of anxiety and depression, as described in the following subsections.”

Ad 4) „As far as I understand the methodology, the first interview was face-to-face and then tests were administered by telephone. Was a psychiatric interview conducted during these interviews? How healthy were the evaluations made 1 to 3 days after the surgery? Who conducted these interviews? What are their competencies?“

Thank you for this comment. You are right. No interviews were conducted between T0 and T1. We did not test to assess the fitness of the patients after surgery. The patients were only asked whether they felt healthy enough. Interviews were conducted by the first author. At that time he was still a medical student, now a physician.

Ad 5) „Is there any information about the cognitive level of the patients at the first interview and 6 months later? How was this situation handled?

Cognitive level was measured within the Barthel index at T0. 6 months later, no
measurement was performed, but the patients were subjectively adequate to be
questioned.

Ad 6) „Was there any information about the stage of the cancers of the patients, which brain region was involved, was there any information about these? The possible effect of this situation on the scale results should be discussed, and if there is data, it should be discussed in the context of these data.“

Thank you for this importent comment. Only the first suspected diagnosis was
checked. In addition, it was asked whether it was a first, second or metastatic disease. The localization of the tumor, the final diagnosis and so on were not part of the research question. Thanks for the input, this could be highly interesting for other studies.

„In future studies on the course of distress during patients’ treatment, tumor entities should be measured as a possible primary contributing factor to distress”

Ad 7) Psychometric properties of the original and adapted versions of the scales used should be included.

Thank you for your suggestion. We included the psychometric properties.

For example: „The Resilience Scale 13 (RS-13), an instrument with 13 items for
measuring resilience, is the short form of the RS-25 [20], one with good
psychometric properties [21]. The 13 items address personality traits (e.g.,
“Keeping interested in things is important to me” and “I am determined”) and
are rated on a 7-point Likert scale ranging from 1 (disagree) to 7 (agree), for a
total score subsequently used to calculate the level of resilience.”

Ad 8) „Why was a scale assessing generalized anxiety used in the study instead of scales assessing situational anxiety? What is the rationale for this?“
The GAD-2 is a test instrument to screen for anxiety (not only General Anxiety
Disorder) which is often used in clinical routine due to its simplicity. Also for the
used short form a good validity could be proven. This is why we used GAD-2.

„The GAD-2 is considered to have good psychometric properties in terms of
specificity and sensitivity [31], and its simplicity makes it ideal suited for a briefly
screening for anxiety.“

Ad 9) „Discussion is not sufficient. Comparison with previous studies should be made and this section should be improved.“

Thanks a lot for this comment. We have worked out comparisons to other studies even better. As suggested, we have included even more comparative studies here. The section has been revised.

Ad 10) Limitations of the study should be added to the discussion.

We fully agree with the reviewer and tried to improve this part of the discussion.

“Because we examined only patients with neuro-oncological tumors, our results are limited in their generalizability. Even then, their various tumor entities differed greatly in terms of prognosis and physical limitations, differences that we did not examine as variables potentially affecting experiences with distress. In future studies on the course of distress during patients’ treatment, tumor entities should be measured as a possible primary contributing factor to distress. Last, the group with low resilience was smaller than the other groups in our study.

Ad 11) „In the conclusion section, more meaningful suggestions that will guide further studies should be added.“

We fully agree. We have tried to make even more suggestions for further studies.

“In a future study, a larger sample involving more patients with low levels of
resilience should therefore be evaluated.”

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Good

Reviewer 2 Report

Authors adequately responded to my comments. I have no further suggestions.