Patient-Reported Experiences of Breast Cancer Screening, Diagnosis, and Treatment Delay, and Telemedicine Adoption during COVID-19

Round 1

Reviewer 1 Report

Thank you for giving me the opportunity to review the valuable manuscript. This study was designed to evaluate sociodemographic disparities in breast cancer screening, diagnosis, and treatment delay and telemedicine adoption in COVID-19. Researchers contributed a lot of effort into this research. However, there are several major points that should be further addressed:

1. Introduction (Page 2)

Lines 85-88: There is no adversative relation between this sentence and the previous one. It is suggested to delete "However".

Lines 88-90: The COVID-19 may impact breast cancer screening, diagnosis, and treatment. The breast cancer population in this sentence is not precise. Suggest that replace it with a more precise expression.

2. Methods (Page 3)

Lines 105-107: What is the age range and regions for eligible participants?

Lines 107-108: Does the participant incentive have to be mentioned here?

Lines 121-123: The definition of the delay needs to be defined clearly here.

3. Page 3, lines 128: The definition of the patients’ cancer status needs to be defined clear, since this is the first time it has been mentioned. If the authors mean that no personal history of breast cancer and personal history of breast cancer, then the patient is not precise,

Page 4, lines 152-153: The authors mentioned the delay, rescheduling, interruption, or termination here, but used change, delay, or cancel in the methods. It is suggested that these can be expressed uniformly in the manuscript for easy reading.

Based on the above, I suggest the authors add a table or box in the methods to list the information collected in the survey and define some items.

4. People can participate the survey in three kinds of ways, including clicking a public link distributed via social media. This may lead to a large number of questionnaires being collected. However, the author did not mention how many questionnaires were collected in total in the text of the results.

5. Page 3-4, lines 146-147: Compared to participants without a personal history of cancer, breast cancer patients and were older, and more likely to be white, and have a college degree. This sentence is more appropriate in the discussion. In addition, the “and” in red are redundant.

6. Page 4, lines 163: Please add “(Figure 3)”

7. Page 4, line 165: The number, percent, and estimated odds ratio of cancer care delay…… The statistics used to present the results, including number of people, percentage, odds ratio (OR), confidence intervals (CI), and p-value, should be present in the statistical analysis of the method. Also, if the authors use abbreviations in the manuscript, it is needed to show the full names and abbreviations when they first appear, such as OR and CI.

8. Table 1 is too large, some variables not used in this study can be deleted, such as the time since breast cancer diagnosis.

In addition, Table 1-3 were not presented with the usual three-line table. Is this the requirement of the journal? If not, I think the three-line table will be more appropriate.

9.Figure 1: What does n=2191 mean in the study population?

10. Figure 2: Page 7, line 183: No title.

11. The present results and expression make me confuse whether the analyses in Table 2 and Table 3 univariate logistic regression or multivariate logistic regression is? I think the results so far look more like a univariate logistic regression, including one independent variable at one time. However, the author stated that multivariate logistic regression was used in the method. Please confirm.

12. Table 2 is similar to Table 3 and used the same independent variables, so I think the authors can merge the two tables to save space.

13. The annotation format of references in the methods and the discussion section is inconsistent with that in the introduction section. Please unified.

14. In the discussion, the authors can summarize the main findings of this study in the first paragraph, and then compare these findings with prior studies and find explanations for these results from the second paragraph.

15. In my view, the study may have the selection bias (select people using computers or mobile phones fluently, who have higher SES in general.) and information bias (participant self-report experience). Suggest to add them to the limitations.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

The paper presents the results of research about the assessment of access to screening tests and other diagnostic tests and treatment of women diagnosed with breast cancer during the Covid-19 pandemic and the possibility of use telemedicine. Attention was put to the differences in the availability of tests and treatment due to socio-demographic disproportions in women. It is very important to say that efforts should be made to provide society with equal access to telemedicine. I accept the work at its current form and recommend its publication.

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report

The authors have enhanced our understanding on how the COVID-19 pandemic has influenced the management of breast cancer patients. In addition, they have investigated the utilization of telemedicine during the pandemic.

Overall, this manuscript is well-written, with clear aims and an excellent introductory section. The supporting motivation for the manuscript is clearly outlined. The subject discussed is highly topical and covers an essential subject for the radiation oncology community.

I have a minor suggestion that would improve the general theme of this manuscript. In particular, the absence of any explanation or discussion that highlight the influence of how treatment delay or treatment gaps can influence clinical outcomes.

For instance, page 2 lines 65-66, “Current research suggests cancer patients are more likely to experience 65 worse outcomes due to COVID-19” Why is this (due to tumour repopulation)?

A radiotherapy treatment schedule can be disrupted for various patient- or equipment-/service-related reasons. Having said that, the overall treatment time is a significant factor influencing the efficacy of a radiotherapy treatment. The accelerated repopulation of tumour clonogenic cells with increased treatment time is considered to be a major contributing cause for reduced local control without appropriate radiation dose compensation.  

Please provide few sentences to highlight this issue.

Author Response

Please see the attachment.

Author Response File: Author Response.docx