Title: Women’s decision process when actively choosing to ‘go flat’ after breast cancer: a
constructivist grounded theory study
Version: 0 Date: 18 Feb 2024
Reviewer:  Annie Topping
Reviewer's report:
This is a fascinating paper and makes a valuable contribution at a number of levels. Not least
as part of performance management of breast cancer services decision-making is accelerated.
For many women they are dealing with existential treat of the breast cancer diagnosis and what
they may want in terms of body image at some point in the future post what can be a demanding
treatment journey. All set against a context of lots of new information and risks/benefits.
historically in my life time with advances and availability of reconstructive surgery changing
women who choose not to undergo reconstruction are currently  not following recommendations
and possibly perceived as psychological anomalies. Whereas not that long ago  those demanding
reconstruction were seen as overly concerned with appearance  and not dealing with the cancer.
It is interesting that  contemporary recommendations  in many countries are 'women should
be offered reconstruction' but that has somehow been systematised in many health systems  as
women will and these are the options.  The recent paper you cited Johnson et al (2023) captures
some interesting demography about who chooses  or may  choose for other reasons 'to go flat' .
Particularly where choice may be driven by economic necessity to get back to work or resume
other responsibilities.
That aside I would suggest some amendments to improve your manuscript :
1.  Recruitment (p5) You mention 58 women responded to the  call for participants but only 18
were recruited. Can you say anything about those who decided not to participate?
2. In your cohort (P6/Table 1)  you have presented information about age, type of surgery,
socioeconomic status  and education, but nothing about sexual orientation, ethnicity,  and/or
if the participants  carried  an at risk genetic mutation.  This would add greater granularity to
the personhood of informants if available. Possibly say in limitations if not.  It may be given
you interview topic guide dived straight in rather than sought more information about your
participants this may not be available.
3. On page 8 Fig 1 - it says trajector and should say trajectory ?
4.  P9 you say ..."Some women had a diagnosis of a gene mutation with increased risk of breast
cancer, which forced them ....." suggest you change forced to necessitated them - it suggests the
process was less coercive.
5. In the quotes various abbreviations are used such as BRCA and MRI and I do not think they
are explained in full elsewhere. There is a convention of putting in full in brackets within the
quote the explanation.
6. In your discussion you do talk about health care professions when adopting person-
centred approaches need to provide information about all options and include 'going flat'
in any discussion of risk. You might want to discuss the role of different members of the
multidisciplinary team in those discussions. In some contexts options /patient education is
the remit of the breast care nurse/clinical nurse specialists and the decision-making with
breast surgeon/onco-plastic surgeon. It might be worth exploring the complexities of person-
centred interventions and assuring impartial/non-judgemental communication irrespective
which member of the MDT is involved .