Review Reports

Response to Reviewer 1 Comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references?

Must be improved

Is the research design appropriate?

Must be improved

Are the methods adequately described?

Must be improved

Are the results clearly presented?

Must be improved

Are the conclusions supported by the results?

Must be improved

Are all figures and tables clear and well-presented?

Can be improved

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1:  I enjoyed reading this manuscript on the impact of the tumor board on the quality of life index in head and neck cancer surgery. Post-treatment patient quality of life (QoL) is a parameter every physician should always consider.

I must, however, make some basic observations.

The first is in the title of the manuscript itself. I wonder how the tumor board can influence patient QoL. The authors, in lines 198-199, write: "This study evaluated the impact of tumor board decisions, tumor characteristics, and comorbidities on quality of life (QoL) in patients with head and neck cancers". These concepts are further explored in the section "Role of Tumor Boards in QoL Outcomes."

In my opinion, there's a logical leap in these statements. It's obvious that tumor characteristics (and therefore the simplicity or complexity of treatment) and comorbidities impact QoL. I take it for granted that the tumor board, if composed of physicians competent in their field, would recommend the best possible treatment for a patient with that type of tumor; therefore, it's the tumor and patient characteristics that influence the choice. Therefore, the sentence written by the authors on lines 218-220 seems redundant to me “Incorporating comorbidity assessment into routine tumor board discussions may therefore improve treatment tailoring and survivorship planning”. I would be surprised if a tumor board recommended a patient's treatment without taking this parameter into account.

Response 1: We sincerely thank you for your thoughtful and valuable feedback, which has significantly improved the clarity and scientific rigor of our manuscript. We acknowledge your concerns regarding the potential logical leap in the original title and lines 198-199, which suggested a direct influence of tumor board decisions on quality of life (QoL), as well as the perceived redundancy in lines 218-220 about incorporating comorbidity assessment into tumor board discussions. Your point that tumor characteristics and comorbidities are primary drivers of QoL, and that tumor boards typically recommend treatments based on these factors, is well-taken.

To address these concerns, we have revised the manuscript title to better reflect the study’s focus on integrating QoL metrics into treatment planning, rather than implying a direct causal effect of tumor board decisions on QoL. The new title is: “Integrating Quality of Life Metrics into Head and Neck Cancer Treatment Planning: Evidence and Implications.” This change emphasizes the study’s exploration of how QoL considerations, alongside tumor characteristics and comorbidities, can inform tumor board recommendations and treatment planning.

In the “Role of Tumor Boards in QoL Outcomes” section (lines 246-288 and surrounding text), we have revised the text to clarify that the study investigates how tumor board recommendations, shaped by tumor characteristics and comorbidities, can incorporate QoL metrics to optimize treatment planning. We emphasize that while tumor boards provide evidence-based recommendations, the integration of standardized QoL assessments may enhance treatment personalization, particularly when patient preferences or post-tumor board clinical findings influence the final treatment pathway.

Regarding lines 218-220, we recognize that the original statement about incorporating comorbidity assessment may have appeared redundant, as tumor boards typically evaluate comorbidities. Our intent was to highlight the potential for more systematic integration of QoL metrics and detailed comorbidity assessments to further refine treatment decisions. We revised the whole subchapter.

These changes align with the new title and maintain the integrity of the study data, while directly addressing your concerns about logical coherence and redundancy. Thank you again for your insightful feedback, which has greatly enhanced our manuscript.

Comments 2: The second observation is that the authors do not specify the type of surgery performed on the patients. I think it's obvious that a total laryngectomy has a very different impact on QoL than a cordectomy, as does a subtotal glossectomy compared to a small resection of the lingual margin. Furthermore, how many patients underwent postoperative (chemo)radiotherapy? It's well known how much this treatment affects QoL. Without these parameters, it's impossible to understand QoL scores by tumor site. The same applies to the statement in lines 159-161: "Patients who underwent surgical intervention tended to have better functional scores compared to those who received only oncological treatment, although the differences did not reach statistical significance." Patients treated with surgery alone likely had tumors that required less mutilating interventions and perhaps without CT-RT, while those treated exclusively with CT-RT had much more extensive tumors, such that resection was not possible. However, this parameter is also not specified by the authors.

Response 2: We sincerely thank you for your insightful feedback regarding the need for specificity about the types of surgical procedures and the proportion of patients receiving postoperative radiotherapy (RT) or chemoradiotherapy (CRT), given their significant impact on quality of life (QoL) outcomes. We fully acknowledge that different surgical interventions, such as total laryngectomy versus cordectomy or subtotal glossectomy versus marginal tongue resection, have distinct effects on QoL, as do adjuvant therapies like RT and CRT. Your comments have been invaluable in guiding revisions to clarify our methodological approach and enhance the manuscript’s scientific rigor.

In designing the study, we considered analyzing QoL outcomes by specific surgical procedures and postoperative treatments. However, the heterogeneity of surgical interventions and the relatively small number of patients receiving certain procedures or adjuvant therapies resulted in subgroup sizes that were too small for statistically meaningful analysis. To ensure a robust and generalizable evaluation of QoL, we chose to categorize patients by anatomical tumor site (e.g., larynx, oropharynx, pharyngolaryngeal) for QoL analysis, as presented in Table 1. This approach allowed us to capture broader trends in QoL across head and neck cancer patients undergoing oncologic surgery, while acknowledging that procedure-specific differences, such as the greater functional impact of total laryngectomy compared to cordectomy, may influence outcomes. We have revised the Methods and Results sections to explicitly address this limitation and clarify that QoL was analyzed by tumor site due to statistical constraints.

To address your concerns, we added in the results section Tables 2,3,4 and 5 in order to clarify the types of surgeries, postoperative treatments, reasons for non-surgical treatment and mean comorbitity count by tumor location. We have also included a discussion in the Discussion section to acknowledge the influence of surgical variability and adjuvant therapies on QoL outcomes. This discussion highlights the need for future studies with larger cohorts to explore procedure-specific and treatment-specific QoL impacts.

These revisions maintain the study’s focus and data integrity while addressing your concerns about the lack of specificity in surgical and postoperative treatment details. We believe these changes enhance the manuscript’s clarity and provide a clearer context for interpreting QoL scores by tumor site. Thank you again for your valuable feedback, which has significantly strengthened our study.

Comments 3: On lines 79-80 the authors write: “…or those managed exclusively with nonsurgical treatments were excluded,” while on line 87 they write: “Final treatment modality (surgical vs. nonsurgical).” It is true that Table 1 shows that the tumor board recommended surgery in 92.6% of cases, while surgery was actually performed in only 74.5% of cases. However, 7 patients (7.4%) had a nonsurgical indication by the tumor board. The authors justify this by writing: “Most patients underwent surgical treatment (74.5%), while 25.5% did not receive surgery due to tumor stage, comorbidities, or personal decision. The tumor board recommended surgical treatment in 92.6% of cases.” Therefore, if the failure to undergo surgery was caused by a “personal decision” (of the patient or the attending physician?), the fact is justifiable. If, however, the cause was “tumor stage, comorbidities,” why had the tumor board not evaluated these data?

Response 3: Thank you for your insightful comments. We acknowledge the apparent discrepancy between the exclusion criteria (lines 79-80) and the reported treatment outcomes (line 87), as well as the concern regarding the tumor board’s evaluation of tumor stage and comorbidities. To address this, we have revised the Study Population section to clarify that inclusion was based on the tumor board’s recommendation for surgical treatment, but 25.5% of patients did not undergo surgery due to factors such as advanced tumor stage, comorbidities, or patient preference identified post-tumor board evaluation (revised text and Table 4 for clarification). We have also clarified the treatment outcomes section (lines 137-148) to explain that these factors were not always fully evident at the time of the tumor board’s initial recommendation, reflecting the dynamic nature of clinical decision-making. Additionally, we inserted Tables 2,3 and 4 with clarifications. These revisions maintain the integrity of the study data while addressing your concerns about clarity and justification.

Comments 4: A minor observation.

On lines 30 and 33 the term “metastatic adenopathy” appears without specifying “unknown primary”. This clarification appears only later in Table 1 and in the caption of Fig. 1. I think that the term “unknown primary” should also be placed on lines 30 and 33. Furthermore, in how many of these 6 patients was the primary tumor found? Because in case of a primary not found, the NCCN guidelines indicate neck dissection and CT-RT, with inevitable worsening of QoL.

Response 4: We greatly appreciate your careful review and insightful feedback regarding the terminology used for “metastatic adenopathy” on lines 30 and 33, and the need for clarification about whether the primary tumor was identified in the 6 patients with metastatic adenopathy. Your comments about the treatment implications for cases with an unknown primary, particularly the NCCN guidelines recommending neck dissection and chemoradiotherapy (CRT) with potential QoL impacts, are well-taken and have guided important revisions to enhance the manuscript’s clarity.

We agree that specifying “metastatic adenopathy of unknown primary” on lines 30 and 33 is necessary to avoid ambiguity, as this clarification currently appears only in Table 1 and the caption of Figure 1. Accordingly, we have revised the lines to explicitly use the term “metastatic adenopathy of unknown primary” when describing the tumor site distribution.

Regarding the patients with metastatic adenopathy, the primary tumor was not identified in any of these cases during the study period, consistent with the diagnosis of metastatic adenopathy of unknown primary.

Thank you again for your valuable feedback.

4. Response to Comments on the Quality of English Language

Point 1: (x) The English is fine and does not require any improvement.

Response to Reviewer 2 Comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references?

Yes

Is the research design appropriate?

Must be improved

Are the methods adequately described?

Yes

Are the results clearly presented?

Can be improved

Are the conclusions supported by the results?

Yes

Are all figures and tables clear and well-presented?

Yes

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: I read the paper carefully and I think that it addresses an important and timely topic—the impact of tumor boards on quality of life (QoL) in head and neck cancer (HNC) patients.

Some comments

1. While tumor boards are central in the study title, the analysis does not deeply explore how tumor board recommendations specifically impacted QoL (beyond noting high surgical recommendation rates). A stronger link between board decisions and outcomes would improve the paper. I understand that further analysis cannot be carried out at this stage, but you could integrate this point into the discussion and perhaps describe it briefly in the results section.

Response 1: We value your point and as also the other reviewer pointed out this lack of correlation, we made some changes in order to improve the article: we selected a more suitable title, modified the phrasing in the methods and refined the data in the results section. We have also made some changes in the discussion part, in order to meet your suggestions.

Comments 2: The timing of the QoL assessment, restricted to the post-surgery period, represents a limitation. Furthermore, the results reflect outcomes only within ONLY one year after surgery. It would be important to consider assessments conducted pre-treatment, as well as short-term and long-term follow-up evaluations.

Response 2: Agree. We have added a note in the discussion part concerning this topic.  

Comments 3: Avoid using bullet points in the Results section (3.2-3.6). Write the content in continuous text form. This is a paper, not a notebook.

Response 3: We acknowledge that the use of bullet points in the Results section (lines 3.2–3.6) is inappropriate for a formal scientific paper. We have revised this section to present the content in continuous text form, creating a cohesive narrative that describes patient characteristics, tumor staging, treatment outcomes, and quality of life (QoL) scores by anatomical tumor site. This revision maintains the integrity of the study data while improving readability and aligning with the formal structure expected in a research paper.

Comments 4: the phrasing seems to delegate too much to AI instead of authors.

Response 4: We recognize that certain phrasing may have inadvertently suggested an over-reliance on artificial intelligence rather than author-driven analysis. We have thoroughly reviewed the manuscript and revised all relevant sections, particularly in the Methods and Results, to emphasize the authors’ expertise and active role in study design, data collection, statistical analysis, and interpretation of findings. These changes ensure that the manuscript clearly reflects the research team’s scientific contributions.

Comments 5: Do not present the strengths of your study in separate subheadings. Instead, integrate them smoothly into the main discussion section. Keep the limitation section and put it last (before conclusion)

Response 5: Per your recommendation, we have removed separate subheadings for study strengths in the Discussion section and seamlessly integrated them into the main discussion narrative. The limitations section has been retained and repositioned as the final subsection before the conclusion, ensuring a clear and logical flow in the Discussion.

Thank you again for your thorough review and insightful feedback

4. Response to Comments on the Quality of English Language

Point 1: (x) The English is fine and does not require any improvement.

5. Additional clarifications