Quality of Life after Mastectomy with or without Breast Reconstruction and Breast-Conserving Surgery in Breast Cancer Survivors: A Cross-Sectional Study at a Tertiary Hospital in Ghana

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Authors present a work addressing: ‘.Quality of life after mastectomy with or without breast reconstruction and breast conserving surgery in breast cancer survivors; a cross-sectional study at a tertiary hospital in Ghana ’. Authors compared outcomes in QOL in BC survivors who had mastectomy with or without breast reconstruction surgery and breast conserving surgery using the EORTC QLQ-C30 and EORTC QLQ-BR23 QOL tools. The general conclusion demonstrates that there is a need to develop support systems tailored at improving the QOL of breast cancer survivors taking into consideration the type of surgery performed. I would like to thank the authors for introducing a number of modifications to the article and significantly improving it compared to the original version.

Major:
1. What is the novelty of this study? and how your outcomes can help further studies in this area. Please add a brief explanation of the novelty of this study in the introduction section.
2. Based on the reference list, the novelty of the study can be doubted, as only 6 (23 %) (6 out of 26) references are from the last 5 years, while 8 (30%) references are published before 2015. Additionally, the article contains only 26 references including 5 website links.
3. Discussion section: Please use updated papers to discuss and compare your results with the available literature.
4. Please in discussion section add paragraph related to how we can applicate your results into practice?, why your work is valuable in the field? and how can we generalize the results?

Comments on the Quality of English Language

Minor editing of English language required.

Author Response

Please see attachment

Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

With advances in breast cancer treatment and improvement in survival, quality of life becomes as important as treatment of the disease.

This paper compares the postoperative outcomes in quality of life in breast cancer survivors who had mastectomy with or without breast reconstruction surgery and breast conserving surgery. A total of 253 survivors consented to participate in the study. Of the 253 study participants, 162 (64.0%) had mastectomy without breast reconstruction (M), 24 (9.5%) had mastectomy with breast reconstruction (BRS) and 67 (26.5%) had breast conserving surgery (BCS).

One of the objections to the study is that the number of patients with breast reconstruction surgery is smaller than number of patients treated with mastectomy or breast conserving surgery, but this is a reflection of the low prevalence of this surgical option in low to middle income countries like Gana, and the authors clearly stated that this is of the limitations of the study.

The theme of presented article is valuable since there is the need for more research to understand the outcomes of breast cancer treatment within the specific cultural contexts.

The results are interesting, since there was no difference in Global Health Status between surgery groups which means a good quality of life can be achieved irrespective of the type of surgery which is important especially in low to middle income countries where the cost of breast reconstruction surgery is not always covered by the National Health Insurance.

The study is well organized, the discussion is well written, the reference list covers the relevant literature with recently published articles.

Author Response

Dear Sir/Madam,

Thank you for your comments which have helped improve the manuscript

Round 2

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

I accept the manuscript in its current form.

Author Response

Thank you for your review 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

With advances in BC treatment and improvement in survival, quality of life (QOL) becomes as important as treatment of the disease. This paper compares the postoperative outcomes in QOL in BC survivors who had mastectomy with  or without breast reconstruction surgery and breast conserving surgery. A total of 253 survivors consented to participate in the study.

 

The study is well organized, the theme is valuable, the results are interesting, the discussion is well written. The reference list covers the relevant literature with recently published articles.

 

Reviewer 2 Report

Comments and Suggestions for Authors

First of all, I would like to thank you for inviting me to review the manuscript entitled: 'Quality of Life after Mastectomy with or without Breast Reconstruction and Breast Conserving Surgery in Breast Cancer Survivors; A Cross-Sectional Study at a Tertiary Hospital in GHANA’. The aim of the study was to compare the postoperative outcomes in quality of life (QOL) in breast cancer survivors who had mastectomy with or without breast reconstruction surgery and breast conserving surgery using the EORTC QLQ-C30 and EORTC QLQ-BR23. Authors concluded their paper that there is a need to develop support systems tailored at improving the QOL of breast cancer survivors taking into consideration the type of surgery performed.
The weak side of the paper is the No of patients recruited to such analysis because it decreased the power of statistical tests. Thus, the data presented in this article were not convincible due to the small sample size and not well-designed study. I would recommend the authors re-organize all the tables and re-calculate the data. I would reject this manuscript as present. I will consider endorsement the publication of this article if the authors incorporate the following suggestions:
Major:
1. The authors use two explanations for the same abbreviation: QOL: quality of health (line 17) and quality of life (line 41).
2. I believed that the introduction is too short.
3. In methodology section authors should provide general study design as a first paragraph, and than inclusion and exclusion criteria, patient follow-up, etc.
4. I don't understand the data in tables 1 and 2, how is it possible that the IQR is the same in practically all calculations.
5. What statistical test was used to calculate the data in Table 2?
6. How do the authors explain the presence of 0 in Table 3.
7. If QLQ-C30 Global Health status does not differ between groups, what do the results contribute to the field of oncology?
8. I don't understand how the authors in the context of Upset by Hair Loss received only zeros in each subgroup.
9. Also, in discussion section please add paragraph related to clinical and practical aspects of the study. How we can applicate your results into practice?, why your work is valuable in the field?
10. Please, provide limitations and strengths of the study, especially in context of study design. I suggest that this information be included in the last paragraph of the discussion as a continuation of this part.
11. In discussion section the number of references should be extended.

Comments on the Quality of English Language

Extensive modification of the grammar and punctuation is required.

Author Response

Please find the attached file

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This is a comparative study, regarding the postoperative outcomes in terms of quality of life in BC survivors who had either mastectomy with or without breast reconstruction surgery or breast conserving surgery using relevant questionnaires. (EORTC QLQ-C30 and EORTC QLQ-BR23).

The study has several methodological flaws. First of all, a sample size calculation was missing and thus the power of the study to detect significant differences in terms of the outcomes of interest is low and rather a matter of luck. In addition, the 3 groups, and especially the breast reconstruction group has too few patients for the statistical analysis.

This is perhaps the ground for the results reported, namely no difference in overall QOL between M, BRS and BCS groups and that the BRS group scored significantly lower in the functional outcomes compared to the other 2 groups.

The Breast-Q, which is a well-known and usable questionnaire was not used, which precludes any results comparison with other relevant studies in the literature.  

The study lacks also in originality, generalizability and overall merit, and thus I should reject it from publication.  

Author Response

Please find the attached file

Author Response File: Author Response.pdf