Title: The assessment of risk factors and risk perception status of breast cancer in Northern Iran
Version: 0 Date: 27 Jan 2023
Reviewer's report:
Methods
Is it possible for the authors to indicate the total population of women and study population in
the regions of Babol from where samples were drawn
It will also be helpful if they can include a flow chart describing the multistage sampling process
either in the main document or in a supplementary file
How was the participants consent obtained?
How did the authors adjust the questionnaire. Was the instrument pretested?
Concerning inclusion /exclusion criteria, why did the authors restrict the participants to ages
35-70 years. How was incompleteness defined?
The authors need to clearly state which variables were described as quantitative and the one
described as qualitative. How were these variables measured. For example, obesity, physical
activity etc.
The authors should clearly indicate where t-test, chi square and one-way anova were used as
a footnote below the tables. Apart from age and BMI most of the variables were nominal/
categorical variables. I did not see the rationale for comparison of means and standard deviations.
I think chi square could have been more appropriate.
RESULTS
“Diploma (P <0.001), undergraduate (P <0.001) and illiteracy (P <0.001) were significantly
higher.”
Higher than what?
What did the authors mean by ‘371 (92.8%) had previously been trained in BC’ and where is
the result?
According to the authors, ‘the frequency distribution of the subjects in terms of age group and
lack of exposure to risk factors are shown in Table 3’. Does riskfactors refer to all the riskfactors?
DISCUSSION
‘The results of the present study showed that the most common risk factors associated with #BC
were old age, obesity, history of radiation, and history of BC in the #family and first-degree
relatives, respectively’
What did the author mean by respectively in the above sentence?
‘The prevalence of BC risk factors has #been reported differently in similar studies [2, 20, 22].#'
What did those studies report differently
‘Regardless of old age, an unavoidable risk factor, obesity was the most common risk #factor
for BC in the present study’
This statement contradicts the authors initial statement that old age was the most common risk
factor
The discussion on the risk of postmenopausal breast cancer seems unnecessary and could be
deleted
‘The results of the present study showed that the mean score of BC risk perception #was
moderate.’ How did the authors determine moderate perception?
‘Understanding the low risk of breast #cancer in the student population may be because most
participants were under 30 years of age #and may have believed that BC occurs in older women’.
What was the basis for this statement?
‘Contrary to the results of the #present study and the studies mentioned above, the results of
a study conducted on healthy #volunteers in Kerman showed that people who had a level of
primary education in comparison #to People with higher levels of education were more likely
to have a breast self-examination and #had a higher self-examination score [30]’. How similar
was your study population with that referenced above. This is important given that the findings
of that study seemed to differ from your expectation considering the findings of other studies
you referenced
‘Therefore, it is necessary to refrain from receiving radiation except in cases of #necessity’.#
Although the above recommendation is okay, it does not seem to be supported by the study
findings given that the direction of the relationships assessed cannot not be determined by
the type of analyses used. That 10% had a history of radiation does not necessarily show that
history of radiation was a risk factor in this case. It could be a reverse causation associated with
socioeconomic bias.
Although the authors observed that risk perception was higher among older women contrary to
others studies, they made a stronger case for a higher risk perception in younger women than
older women. I suggest that they should identify the possible sources of bias that might have
affected their findings.
It was difficult to appreciate the relevance of some of the literature cited/ arguments made. For
examples
Although the high-risk perception of disease is considered #an important determinant of health-
related behaviors, increasing risk perception of a disease #can sometimes led to behaviors such
as mammography. For example, in a qualitative study, #one of the barriers to mammography
was the fear of BC [32]’.#
‘The present study showed that 60 to 70 years old had the highest #exposure to BC risk factors.
This can be explained by the fact that the older person #has more risk factors, which probably
increases the chances of #developing BC with age. In the study of Rohparvarzadeh et al., The
highest #number of women exposed to risk factors were 35 to 39 years old ##(44%) [21]’.#
The article discussion is unnecessarily long. Sometimes  the force of the  arguments/conclusion
tended to depend too much on the cited studies than the study findings.
The assessment of the association was based on chi square which does not tell the direction of
the association or cause effect relationship. Hence, the findings should not be over interpreted
The authors should include the strength and limitations of their study.
The limitation placed after the conclusion is not proper, and need to placed before the conclusion.
Moreover, in my opinion most of the things stated as limitations such as limited time, lack
of cooperation of some participants in completing the questionnaires accurately, incomplete
information of some participants, and lack of access to some participants to complete the
information cannot be pass as limitations without the authors identifying how they could
potentially affect the validity of their findings. They may also need to quantify how many of
the participants have incomplete information and possibly include number of missing values in
the tables