Fear of Cancer Recurrence and Coping Strategies among Prostate Cancer Survivors: A Qualitative Study

Round 1

Reviewer 1 Report

The sample size and the non-homogeneous characteristics of the population and treatments do not allow to obtain robust and significant results

The sample size and the non-homogeneous characteristics of the population and treatments do not allow to obtain robust and significant results

Author Response

The sample size and the non-homogeneous characteristics of the population and treatments do not allow to obtain robust and significant results

Answer: Thank you for your comment. The sample size in qualitative studies is not determined by statistical power calculations but rather by the concept of data saturation. Data saturation refers to the point in the research process where no new information or themes emerge from additional data collection. Therefore, the sample size in qualitative studies is typically smaller than in quantitative studies and is determined by the research question, the complexity of the phenomenon being studied, and the resources available for data collection and analysis (Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qualitative health research. 2016 Nov;26(13):1753-60.). In the current study, we reached data saturation with 13 PCa survivors.

Furthermore, regarding the comment about the non-homogeneous characteristics of the participants, it should be mentioned that there is a technique in sampling for qualitative studies known as ‘maximum variation’. It is a purposive sampling technique used in qualitative research to ensure that the sample includes participants with diverse characteristics and experiences related to the phenomenon being studied. The goal of maximum variation sampling is to increase the generalizability of the findings and to provide a more comprehensive understanding of the phenomenon. In maximum variation sampling, researchers intentionally select participants who represent a wide range of characteristics such as age, gender, socioeconomic status, ethnicity, and other relevant factors. This approach allows researchers to explore the similarities and differences in participants' experiences and perspectives related to the phenomenon being studied (Patton MQ. Qualitative research & evaluation methods: Integrating theory and practice. Sage publications; 2014 Oct 29.).

Thank you and we hope that the changes meet the journal needs.

Sincerely,

Authors

Reviewer 2 Report

In this study, the authors analyzed the fear of cancer recurrence (FCR) in a series of patients undergoing treatment for prostate cancer and the related coping strategies using a qualitative research method.

The study has several limitations, the most important of which is the small number of men with prostate cancer who were evaluated, and which also limited the analyzes carried out by the authors. However, the manuscript is interesting because in the literature there are only a few studies that analyzed the FCR.

 

The manuscript may be suitable for publication after minor revision:

-         Authors should indicate for each patient assessed the stage and ISUP grade group of prostate cancer and evaluate whether they have modified FCR.

-          Authors should explain the limitations of this study more extensively.

-          In the last decade, active surveillance has been considered the gold standard for the management of low-risk prostate cancer. However, many patients refuse this strategy or leave it early for fear of the neoplasm. The authors should discuss this phenomenon and explain whether there are the same causes that lead to FCR.

Minor editing of English language required

Author Response

In this study, the authors analyzed the fear of cancer recurrence (FCR) in a series of patients undergoing treatment for prostate cancer and the related coping strategies using a qualitative research method.

The study has several limitations, the most important of which is the small number of men with prostate cancer who were evaluated, and which also limited the analyzes carried out by the authors. However, the manuscript is interesting because in the literature there are only a few studies that analyzed the FCR.

Answer: We appreciate your positive feedback and suggestions for further improvement. Your insights have been valuable in helping us to revise and improve the manuscript.

The manuscript may be suitable for publication after minor revision:

1. Authors should indicate for each patient assessed the stage and ISUP grade group of prostate cancer and evaluate whether they have modified FCR.

Answer: We agree that providing information on the stage and ISUP grade group of prostate cancer for each patient would be valuable in understanding the impact of these factors on FCR. We included this information in the revised manuscript (Table 1). Although due to the qualitative nature of the study, a detailed review was not possible in this regard, as those participants whose doctor had given them information about a high Gleason score at diagnosis were more concerned about cancer returning. We included it in the findings (Table 1; line: 222-229).

2. Authors should explain the limitations of this study more extensively.

Answer: We tried to expand the potential limitations of our research (line: 492-501).

3. In the last decade, active surveillance has been considered the gold standard for the management of low-risk prostate cancer. However, many patients refuse this strategy or leave it early for fear of the neoplasm. The authors should discuss this phenomenon and explain whether there are the same causes that lead to FCR.

Answer: According to your comments, we performed a review of literature and discussed about FCR in PCa people undergoing active surveillance and curative treatments. However, the literature available in this field is limited and further in-depth studies are still needed (line: 419-435).

Reviewer 3 Report

Thank you for the opportunity to review this manuscript. The manuscript's strengths lie in the well structured presentation of findings and sharing findings from the Iranian context. I have a few suggestions/questions to potentially strengthen the manuscript before publication:

1. Introduction: What is the rationale to exclusively focus on FCR in PCa survivors? How are their experiences different or similar to those of other cancer survivors?

2. The presentation of findings remains very descriptive. Can the results be further elevated by employing an appropriate theoretical framework? For a qualitative study this size, we would probably aim for mid-range conceptual contributions.

3. The study design seems to employ a rigorous qualitative design. I encourage the authors to delete any allusions to 'bias' or 'lack of objectivity' for having employed a qualitative design. These are terms borrowed from quantitative studies. Qualitative designs are assessed along different criteria of rigour than quantitative research (as the authors have compellingly done) and the apologetic language suggesting qual research = bias = inferior should have no place here.

4. The authors identify themes around health seeking and lifestyle changes. I encourage a reread/edit of this section, keeping in mind that the evidence base for stress or negative thinking as a causal driver for cancer occurrance/recurrance is limited. Cultural beliefs, however, exist to that effect and shape practices and moralities. The way it reads now feels like it is inviting judgment. (see for example on moralities in cancer aetiologies, Plage & Olson, 2021, Surprise reveals the affective-moral economies in cancer illness narratives, Qualitative Health Research).

Overall, the study appears thorough and has the potential for a significant contribution. I am happy to review a revised manuscript in due course if requested.

 

 

The manuscript is well-structured and signposted. It is easy for the reader to follow and there are only minor errors of expression that can be addressed at the proofing stage, if the manuscript is accepted.

Author Response

Thank you for the opportunity to review this manuscript. The manuscript's strengths lie in the well structured presentation of findings and sharing findings from the Iranian context. I have a few suggestions/questions to potentially strengthen the manuscript before publication:

Answer: Thank you for your thoughtful review of our manuscript. We appreciate your positive feedback and suggestions for further improvement. Your insights have been valuable in helping us to revise and improve the manuscript.

1. Introduction: What is the rationale to exclusively focus on FCR in PCa survivors? How are their experiences different or similar to those of other cancer survivors?

Answer: We agree that it is important to provide a rationale for why we chose to exclusively focus on FCR in PCa survivors. We performed a review of the literature and added some reasons for focusing on people with prostate cancer in the introduction (such as early-stage diagnosis, high five-year relative survival, and certain factors specific to prostate cancer) (line: 64-71).

2. The presentation of findings remains very descriptive. Can the results be further elevated by employing an appropriate theoretical framework? For a qualitative study this size, we would probably aim for mid-range conceptual contributions.

Answer: We acknowledge the potential for further theoretical development of our findings. Although our study was conducted inductively and the findings were extracted from the stories of the participants without using a specific theoretical framework, the findings can contribute to enriching the literature and theories related to the FCR. We developed a paragraph in the discussion section and tried to link the findings to a theoretical framework (line: 477-491).

3. The study design seems to employ a rigorous qualitative design. I encourage the authors to delete any allusions to 'bias' or 'lack of objectivity' for having employed a qualitative design. These are terms borrowed from quantitative studies. Qualitative designs are assessed along different criteria of rigour than quantitative research (as the authors have compellingly done) and the apologetic language suggesting qual research = bias = inferior should have no place here.

Answer: According to your comment, we replaced these words with words correspond to the terminology of qualitative research (line: 128; 143; 493).

4. The authors identify themes around health seeking and lifestyle changes. I encourage a reread/edit of this section, keeping in mind that the evidence base for stress or negative thinking as a causal driver for cancer occurrance/recurrance is limited. Cultural beliefs, however, exist to that effect and shape practices and moralities. The way it reads now feels like it is inviting judgment. (see for example on moralities in cancer aetiologies, Plage & Olson, 2021, Surprise reveals the affective-moral economies in cancer illness narratives, Qualitative Health Research).

Answer: We agree that the evidence base for stress or negative thinking as a causal driver for cancer occurrence/recurrence is limited, and we revised our manuscript to reflect this. We also acknowledge that cultural beliefs may shape practices and moralities related to cancer, and we considered this perspective in our analysis of the themes around health seeking and lifestyle changes. We appreciate your suggestion to read Plage & Olson's (2021) article on moralities in cancer etiologies, and we used relevant insights from this article and cite this article in the results (line: 313-315; 345; 360-362).

 

Thank you and we hope that the changes meet the journal needs.

Sincerely,

Authors

Round 2

Reviewer 3 Report

Thank you for comprehensively addressing comments. Some minor language corrections are still needed.

Minor errors especially in revised text.