Title: The development and validation testing of a comprehensive frailty assessment in women
with breast cancer
Version: 1 Date: 13 Nov 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
No - there are minor issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Not sure - key details are missing from the manuscript
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Overall impression: This is an interesting study which offers a
considerable amount of information. There are limitations in how the paper is structured,
reported and presented which means there is a lack of information on the development of
the assessment tool, but ample information on the validation testing. I have highlighted these
insufficiencies which I think can be addressed through revision:
Authors done well: The authors have developed an assessment tool and collected pertinent data
which has been robustly analysed to answer the research question.
Ways it does not meet best practice: More information is needed on the literature review and
Delphi activities which underpin the assessment tool's development; there is a need to consider
the reporting of confidence intervals; there is a need to revise paragraph structure and content
to aid interpretation of these findings in the Discussion. A full critique is presented below.
REQUESTED REVISIONS:
Thank you for the opportunity to review this paper. I have identified a number of points which
I hope will further strengthen this interesting work.
Title: I recommend the authors re-structure the title of this paper to improve the clarify. I suggest
“The development and validation testing of a comprehensive frailty assessment in women with
breast cancer” or something to that effect.
Abstract: Background: The authors do not clearly communicate why a frailty score specifically
for people with breast cancer would be different and behave different to a more generic
comprehensive frailty score. I recommend this is briefly explained as would provide an
important rationale for this study, in the abstract.
Abstract: Methods: The authors have clearly reported what they did. I recommend the add in the
number of papers identified in the systematic review and the number of participants and types
of participants i.e. women with breast cancer, clinicians etc who formed the Delphi study. This
would provide more details on the development of the score.
Abstract: Results: I recommend, where available, the authors present 95% confidence interval
data for their validation and reliability analyses. This would improve the reporting and
presentation of precision of findings.
Abstract: Conclusions: These are reasonable and grounded in the evidence. Nothing to add.
Background: Paragraph 1: I recommend the authors review the grammar throughout this paper.
This would improve the reporting of the work. For example, Background Paragraph 2 is a
presentation summarising the various components/elements of frailty assessment. This could
be presented in a clearer, more logical approach and communicated stronger. I recommend a
review of the whole paper, but this is just one example.
Background: Paragraph 1: I recommend the authors review the sentence “Breast cancer women
are significantly more vulnerable than other cancers” – what do the authors mean by ‘vulnerable’
please specify.
Background, Paragraph 3: The rationale and argument for developing a specific comprehensive
frailty assessment for people with breast cancer should be more clearly provided. Do the
authors feel that a single tool would offer greater robustness? Do they feel the breast cancer
population offer multiple domains of frailty and those instruments which already offer this are
not acceptable for some reason? I believe the answer may be within the text in the current
paragraph 2 and 3 but this is not sufficiently clear. I recommend a revision of this section, so
the authors more clearly articulate why a specific measure is needed and how this has not been
completed before. Justification for my validation testing is also needed, would be a valuable
addition too.
Methods: Participants: This section is not logically placed. I recommend the authors provide
an outline of the development of the score first, then, prior to reporting the validation testing,
describe the participants who were involved with that stage of the study. This would improve
the robustness and logic of reporting.
Methods: Stage 1: Scale development: There is insufficient reporting on the literature review.
The authors need to provide more information on this such as the methods used, the results of
the search strategy and the overarching themes reported. If this is prohibited because of word
count, the authors should provide a summary of the literature review as a Supplementary File
and included in the study. Currently this is insufficient information to interpret.
Methods: Stage 1: Scale development: Similar to the literature, there is insufficient information
on the Delphi study such as participant characteristics (only professional background is currently
presented), equally further information on all stages of the Delphi are needed.
Methods: Stage 1: Scale development: The authors need to explain “Initially, a pool of
20 potential items was generated through the aforementioned methods” – what are the
aforementioned methods? These are not clearly communicated.
Methods: Stage 1: Scale development: For the Delphi, it is not clear if the mean score needed to
be 3 or 4 for an item to be included. There is insufficient reporting on what the threshold and cut
points were and whether there was differential inclusion for scores from some members? This
should be clearly stated. As with the literature review, if the authors feel unable to do this in the
paper, a full report should be included as a Supplementary File as this is important information
which should be shared.
Methods: Stage II: Scale validation: The authors have adopted parametric tests but have not
stated how they assessed and determined data distribution. I recommend this is explicitly stated
somewhere in the paper’s Methods section.
Methods: Stage II: Scale validation: There is insufficient information on how the sample size
was determined and that the authors were powered to judge the research questions. There was
no reporting on missing data. There was no reporting on detailed source of participants. These
are important to state in this methods section.
Results: Table 1: This is helpful but there is no information on the breast cancer details and
limited details on comorbidities. For example, stage of breast cancer, location, type, adjunctive
treatment, primary or recurrent, if the patient had metastatic disease. These are really important
data which I recommend the authors consider to add into Table 1 to characterise the cohort.
Results: Validity: There the authors have performed between group comparative test e.g. t-test,
I recommend mean difference and 95% confidence intervals are presented rather than the mean
and standard deviation for each group individually. This would be more helpful in interpreting.
Results: Validity: For the data from Table 2 and 3, I recommend the authors consider presenting
95% confidence intervals for the correlation data and Figure 2, in the text, interpreting the ROC
data. This would allow the reader to understand the precision of the data.
Results: Reliability: The interpretation is correct, but I recommend the authors also present 95%
confidence interval data for the reliability analyses.
Discussion: Paragraph 1: The sentence “The strength of this study is that the initial items
were developed using a literature review and the modified Delphi method with professionals in
Taiwan” should not be presented in the opening paragraph of the Discussion as this paragraph’s
objective is to summarise the findings only and not to reflect on strengths (or limitations).
Discussion, Paragraph 2: The statement “With a dense population and health insurance benefits
for everyone in Taiwan, there is no lack of interaction with cancer women and social frailty is
relatively rare” should be reconsidered as this does not have a citation to support the statement
and I am not sure what the point the authors are trying to make. I therefore recommend this is
reviewed.
Discussion: Paragraph 3: The paragraph starting “In the past, most indicators of psychological
frailty in cancer women have measured the risk of depression or anxiety…” has limited value.
I recommend the authors review this. Are they attributing a strength to their multi-dimensional
score or is there another meaning to this paragraph. I recommend this is re-examined, so the
reader gain more clearly understand the point being made.
Discussion: Paragraph 4: Similar to the last point, there is a need for a ‘take home’ point to
outline what the message of this paragraph is. The authors need to reconsider what the important
point is for this paragraph and then summarise/conclude this at the end of the paragraph. This
would strengthen the interpretation of this Discussion section.
Discussion: Paragraph 5: the authors should consider whether stage of disease or comorbidities
are important as well as whether the cohort was sufficiently large to answer the research
questions.
Conclusions: The authors may consider offering a similar take-home conclusion in their main
paper’s Conclusion to that of the Abstract’s conclusion i.e. for further research. This would be
appropriate given the limitations on external validity.
Figure/Supplementary File: I recommend the authors include a copy of their final assessment
tool so this can be accessed through the paper.
ADDITIONAL REQUESTS/SUGGESTIONS:
Nothing additional"