Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript presents a clinically oriented approach to refining prognostic stratification in muscle-invasive bladder cancer treated with neoadjuvant chemotherapy by integrating a readily available systemic inflammatory marker into a practical nomogram alongside key baseline patient characteristics. The work highlights the value of leveraging routine laboratory and clinical data to identify patients with divergent event-free survival outcomes, thereby supporting more individualized treatment discussions. By focusing on accessible variables and generating a user-friendly risk stratification tool, the study addresses an unmet need in the perioperative setting and provides a foundation for future integration of inflammatory biomarkers with emerging therapeutic strategies, including chemo-immunotherapy.

#1 The introduction mentions the prognostic value of NLR in bladder cancer, but does not explicitly explain why it was included in the line plot rather than other inflammatory markers (such as PLR or SII).

#2 The NLR cutoff (2.78) is based on the median value in this cohort, but the authors do not specify whether other commonly used cutoffs (such as 3 or 5) were tested or whether the Youden index was used for optimization.

#3 The authors mention that chemotherapy combined with immunotherapy has become the new standard in recent years, but this model is based on a pure chemotherapy cohort and does not discuss the model’s applicability in chemo-immunotherapy. Add a section titled “Future Directions” at the end of the discussion to specify:

Propose validation criteria: e.g., the C-index should be ≥0.60, or the 5-year EFS in the high-risk group should be <30%; recommend conducting prospective observational studies or utilizing individual-level data from the control groups of published Phase III trials for validation.

#4  To enhance the breadth of the manuscript, please cite and briefly discuss the following literature in the context of the specific research scenarios of this manuscript, such as Prognostic Significance of Lymph Node Ratio for Overall Survival in Patients with Lymph Node-Positive Bladder Cancer Post-Radical Cystectomy and Chemotherapy: A Multicenter Cohort Analysis PMID: 41637020

Given these considerations, I highly recommend that authors revise their manuscript. Looking forward to receiving your revised version of the manuscript. I will review this manuscript again based on the revised version.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Authors did a good job in study design, data collection and data analysis. I only have a few questions:

1. How did you develop the nomogram-derived risk score? Please provide more details in this manuscript.
2. You mentioned that you used Schoenfeld residuals to check the assumption of Cox proportional hazards model, what is the results?
3. How did you choose 2.78 as the cutoff of NLR.
4. What is the significant level in the backward selection?
5. Can you revise the flowchart to include 203 patients who underwent RC and use in developing the nomogram risk score?

In addition, lines 93 and 99 is a repeat paragraph of the previous one. please remove them.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have made significant revisions and efforts to improve their manuscript and have thoroughly resolved previous concerns. I recommend this manuscript for publication in its current form.