The Cardio-Oncology Patients—What They Know and What They Should Know

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This work evaluates the awareness and knowledge on the cardiac toxicity by patients attending a cardio-oncology clinic.

Overall, this work addresses an important issue concerning the health literacy and the evolving role of cardio-oncology in longer leaving patients exposed to cardio toxic treatment.

The document is well written, however a more concise and shorter document, focused on the most relevant background and discussion points could help in reading. I also would like to emphasize and call the authors attention to fully reference all assumptions made, especially in the background and the discussion. This needs a careful review. Also, some care must be taken to review repetitions and sections where instructions were left without editing.

Below I point out some details to further consider.

Simple summary

Please include also some information about results

Abstract

Please review and replace the general guide by 2-3 short sentences to set the important of the research and the gaps that it try to overcome in the background section.

Methods:

Please consider being a bit more clearer and concrete on the methods with simple sentences.

Results

Please review to express only the most relevant and impactful information. Please include the statistics for all affirmations.

Introduction

Quite long and many sentences without proper referencing. I would advise on shortening it, leaving only the most relevant information for the research taken.

Material and Methods

Measurement

When describing the instrument used, I would like to understand which type of responses were possible: open answering or multiple choice, with one or more answers possible and which options were available/possible?

“The response options “no” and “I don’t know” or “I don’t remember” were combined because we wanted to obtain a clear classification of respondents in terms of their knowledge.” – Can you please clarify if you merged them for the statistical analysis or if they were the three in the same answer option? I believe that this whole paragraph could be relocated to results.

Statistical Analysis

The text on this section should be a bit more comprehensive and include the conditions to use each of the mentioned statistical tests.

Results

On the table 1, please confirm if the only systemic treatment that were performed were chemotherapy. It is frequent that patients have also been on hormone therapy, immunotherapy and other targeted therapy.

Discussion

Please include references for all data discussed.

In the discussion I believe that it is missing a point on the fact that the study population was recruited in a cardio-oncology clinic, which could have an impact on the awareness for the cardio toxic effects from treatment, according to literature.

Conclusion

Please consider reviewing the text as it is a copy of the limitations section.

The conclusions should focus on pointing out the main findings and future directions or challenges in face of the results obtained.

Patents

Either remove or state that there are no patents.

Author Response

Please find the attached file

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

I would like to congratulate the authors for this survey which highlights the need to increase patients awareness for cardiotoxicities and cardio-oncology in order to improve their outcomes.

The following points needs to be addressed:

1. Kindly state clearly in the abstract that the survey was conducted in the cardio-oncology outpatient clinic of your hospital.
2. The introduction is too extensive with irrelevant information like the mention about certain doctors e.g. Lenihan
3. Kindly discuss about the 2022 ESC cardio-oncology guidelines for patients that will help to raise awareness about cardio-oncology
4. In the introduction “Patients' knowledge of cardio-oncology remains insufficient, with only a small proportion of oncology patients able to accurately define the field. Awareness is highest among younger individuals, while patients with multiple comorbidities tend to be less familiar with the concept of cardio-oncology”. If these are known, then why did you do this survey? References?
5. In the introduction “Effective health education provided by oncologists or cardiologists enhances patient engagement in care and facilitates the early detection of cardiac side effects.” Reference?
6. You did not present the results of HBS only association with knowledge (?) in table 4.
7. In Table 4 what is correct and incorrect? Not clear
8. In 3.3 “This shows the benefits of health education that a doctor can 216
9. provide in their office. This association may also be related to patients' health literacy. People who had higher health literacy remembered the information provided better and were more involved in the treatment process.” This should be part of the discussion, not of the results.
10. The first page of the discussion is a general overview of cardiotoxicities of different drug categories. This must be limited to 1 paragraph.
11. Kindly avoid to use trade names like Herceptin.
12. In the discussion “Many of them admitted that it was also difficult to determine which disease needed more attention and which symptom should prompt them to see a cardiologist”. Was there such a question in the survey?
13. “In addition, older people are less likely to ask questions of the doctor, assuming that they have no say in the treatment plan.” Reference?
14. Kindly discuss the importance of an organized cardio-oncology clinic in raising awareness about cardiotoxicities.
15. Conclusion is missing. You repeat the limitations.
16. Kindly discuss baseline risk stratification of cancer patients with HFA ICOS risk score that will facilitate the identification of high cardiotoxicity risk score.
17. Kindly add these references

Andres MS, et al. The United Kingdom's First Cardio-Oncology Service: A Decade of Growth and Evolution. JACC CardioOncol. 2024 Feb 6;6(2):310-312.

Farmakis D, et al. How to build a cardio-oncology service? Eur J Heart Fail. 2018 Dec;20(12):1732-1734. doi: 10.1002/ejhf.1336. Epub 2018 Oct 17. PMID: 30328667.

Okwuosa TM, et al. Cancer therapy and the heart; the necessity to calibrate risk. Eur J Heart Fail. 2020 Nov;22(11):1961-1965. doi: 10.1002/ejhf.1999. Epub 2020 Sep 29. PMID: 32892435.

Tocchetti CG, et al. Cardiovascular toxicities of immune therapies for cancer - a scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Council of Cardio-Oncology. Eur J Heart Fail. 2024 Oct;26(10):2055-2076.

Author Response

Please find the attached file

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

• While the study addresses an important and underexplored area, the introduction should more clearly define the knowledge gap and justify how this study adds to existing literature. The authors cite limited prior research but do not fully contrast their findings with previous international studies. Strengthening the novelty and positioning of the paper would enhance its impact.
• The sample was recruited from a single center with a convenience approach, which limits generalizability. This limitation is acknowledged, but the methods section could better explain how patients were approached, as well as the response rate.
• The discussion is somewhat descriptive and repeats results rather than critically analyzing them. It should better integrate findings with international literature on patient awareness in cardio-oncology, highlight differences and similarities, and discuss potential reasons for these.
• The implications for clinical practice should also be elaborated.
• The conclusions and limitations sections are repetitive (limitations appear twice, in both Section 5 and Section 6). These could be merged and streamlined.
• Additionally, the abstract contains placeholder text ("A few sentences to place the question addressed…") that must be revised before acceptance.
• The statistical analysis section lists several tests but does not justify their choice or explain how multiple comparisons were handled.
• Some tables (Table 2) are very dense and difficult to interpret.

Author Response

Please find the attached file

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I am submitting a review on a revised version by the authors.

Simple summary still lacks information on the results.

Abstract

Please review punctuation and sentence construction.

Introduction

“Awareness is highest among younger individuals, ...” This whole paragraph requires referencing

Materials and methods

“The response rate was 80%.” This sentence belongs to results and not methods

Results

In table 1 the mark 4 in legend has no identification on the table.

Weren’t there any patients under / that have had hormone therapy?

Radiotherapy should specify f it was delivered to the left chest Wall.

Chemotherapy should state what medicines were taken.

Did patients received anti HER2 therapy?

Table 2 is not formatted in the education line.

“This shows the benefits of health education that a doctor can provide in their office. This association may also be related to patients' health literacy.” – this sentences belong to discussion.

“People who had higher health literacy remembered the information provided better and were more involved in the treatment process.” – which instrument was used to access health literacy?

Discussion

I stress again that all affirmations should be properly referenced.

Line 238 to 288 just gives background support on the importance of cardio-oncology. It is not discussion. Either review introduction to include some information without repetition or remove it.

“It is difficult to determine whether this results from denial of the cancer 300 diagnosis, lack of interest in their health despite the disease, or concomitant depression.” – I believe this is a factor influencing the responses across the whole study not only for these questions. Many other factors can be implicated.

“A higher level of awareness could have 325 been expected, since these patients voluntarily attended the clinic and therefore were po- 326 tentially more aware of the risks than the general population.” – this is a bit tricky as the study didn’t compare results with the non cardio-oncology patients or the general population. To overcome this comparison, literature data, if available, can be introduced with proper referencing. If no literature available, please avoid comparisons that were not performed.

“A higher level of awareness could have 325 been expected, since these patients voluntarily attended the clinic and therefore were potentially more aware of the risks than the general population.” – is this data from the present study or from literature?

“Although not every patient takes an active 340 interest in their treatment, it is surprising that in this group of respondents, as many as 341 46.9% rated their health knowledge as very good or good [26].” – is this data from the present study or from literature?

“such follow-ups at all.” – are this sentence intended to stay?

“A patient may attempt to move on from their cancer diagnosis, but they must remain 396 aware of the potential cardiovascular risks that may still emerge years later.” – this sentence is repeated. Furthermore, it assumes a factor that was not investigated in the study as the cause for lack of awareness of cancer treatment complications.

Please review ref 28 as i tis a narrative review and it doesn’t support information on lines 412-423

“However, the responses differed significantly when the question 435 pertained to the need for cardiac monitoring after radiation therapy.” – was this statistically tested?

Ref 39 , does not support the whole paragraph from lines445-456.

Ref 22 does not support the discussion in lines 458-466, also i tis not from White.

Conclusion:

“the control of modifiable 521 cardiovascular risk factors, such as hypertension, diabetes, and obesity” – this are comorbidities that can be controlled. modifiable risk factors are lifestyle adoption measures.

Author Response

Please see the attached file

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

• Affiliation number 2 is missing.
• kindly replace "heart attacks" with myocardial infarction?
• " Therefore, information on the risk of cardiotoxicity should be a permanent element of patient education during visits to both the oncologist and the cardiologist". This is a very strong sentence.  Patients must be informed at baseline about cardiotoxicity risk and must be aware of the potential cardiovascular complications of their antineoplastic treatment. This is not obligatory in every visit. 
• "The self-developed questionnaire was used. It consisted of 40 questions (including 16 from the Health Behaviour Scale) and 8 additional sociodemographic questions. " A self-developed questionnaires....
• The survey was comprise of 40 questions: 16 from HBS and 8 dditional sociodemographic questions. The rest 16 questions? and you did not present the results of HBS which comprised almost half of the questions of the survey! A second paper to describe the results of HBS is not needed. Kindlly include them in this paper.
•  

Author Response

Please see the attached file

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Authors have now addressed all comments and made appropriate changes.

Author Response

Dear Madam or Sir,

Thank you very much for your kind review.

Yours faithfully,

The Authors

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

I am submmiting a review on a revised manuscript by authors.

All major comment have been improved.

I just so extra suggestions:

Table 1 - legend 4: trastuzumab and sunitinib are not immunotherapy. They are target therapy

Reviewer 2 Report

Comments and Suggestions for Authors

I suggest that I can be published now.

Author Response

Thank you for your kind review.

Yours faithfully,

The Authors