Title: Nutritional Status and Quality of Life Among Breast Cancer Patients undergoing
treatment in Addis Ababa, Ethiopia
Version: 1 Date: 20 May 2023
Reviewer:  Diriba Alemayehu Gadisa
Reviewer's report:
The detail comments given should be addressed,and the manuscript needs English language
editions for a lots of grammatical and punctuation errors.
//
Overall, I want to thank the authors since they tried to address areas that not well researched.
And I believed that the manuscript will become more influential provided that comments given
are well addressed.
Abstract
Background: Background should be shortened. The aim of the study should be removed from
background since it is already stated under objectives.
Methods: the study period should be written in interval form (i.e., from this date to this date)
since May 2020 cannot be the study period. It is Ok still using the main module that was common
for all cancer types. However, there is supplementary module that is specific to breast cancer,
i.e., EORTC QLQ C-45 that comprehensively assess the HRQoL of patients with breast cancer
on different treatment modality (chemotherapy, hormonal therapy, different targeted therapy
such as immunotherapy and RTKI therapy, breast conserving therapy, mastectomy etc). Why
the authors did not use this supplementary module to have a complete picture of the patients
HRQoL?
Results:
# ….(mean age =44.4 (± sd), 11.47 years….. correct it to….. (mean age =44.4 (± 11.47 years)….
# Malnutrition and under nutrition are not the same. Therefore, use one words consistently. Both
under nutrition and over nutrition would be malnutrition, so the authors need to specify which
type they want to address and , need to be operationalized or need to use standard definition. ….
# -----'Malnutrition also showed negative associations with all domains of functional status
and strong positive associations with symptom scores covered in the EORTC QLQ C-30 (P <
0.05)’……….. it should be explained by AOR as the other.
Introduction
1. Paragraph 1:-----In Africa, breast cancer causes an estimated 168,690 cases and 74,072 deaths
(2). In Ethiopia, breast cancer is the most common cancer type accounting for 34% of all female
cancer cases….. better if it is reported as in Worldwide, i.e., % of the cases and the rank for easy
understandability for both at region level and ETHIOPIA  level.
2. Paragraph 3: ‘Also, prolonged fasting periods after chemotherapy is common in breast
cancer patients’…. It would be interesting if the authors scientifically elaborate a little bit why
prolonged fasting after chemotherapy among patients with breast cancer?
3. Paragraph 3: ,… ‘Furthermore, these days, because of the critical rise of obesity, breast
cancer patients are facing sarcopenic obesity a condition where loss of lean mass is veiled
by adiposity\fluid retention making it harder for conventional screening methods like BMI to
identify nutritional deficit’   it needs reference/citation.
4. … ‘In addition, there are only a few studies (18, 21, 22) evaluating the quality of life of cancer
patients in Africa and specific information on the nutritional status among breast cancer patients
undergoing both radiotherapy and chemotherapy is notably lacking Ethiopia.’… however, now
there is some sort evidences on nutritional status of adult patients with cancer, in Ethiopia (please
refer to: doi: 10.1155/2022/8740272.). Therefore, modify accordingly.
Methods
1. … ‘taking 40.1% prevalence of malnutrition from a study done in Philippines on quality of
Life and nutritional status Among cancer patients on chemotherapy (34)’… why Philippines
was selected? Did their life standards closer to Ethiopians than the African countries Algeria
(reference number 21) and Libiya (reference number 22) though nothing in East Africa and
around? Why not 50%, assuming the authors had no previous ‘P’ of malnutrition/under-nutrition
in Ethiopia and sorrounding?
2. …. ‘It was tested using the Amharic version of the EORTC QLQC30, which was found to be
accurate and valid for evaluating QOL among cancer patients (24).’ …. It is recommended if the
author used the Amharic version of EORTC QLQ C-30 that specifically validated for patients
with breast cancer. (please refer to:DOI: 10.1186/s12955-019-1257-z ).
Moreover, reference 24 is not talking about the Amharic version of EORTC QLQ C-30, it seems
it is wrong citation. Therefore, correct it accordingly.
3. …. ‘The scoring was done according to the QOL questionnaire-C30 manual (25).’  Still
reference number 25 is not EORTC QLQ C-30 scoring manual. It seems it was wrongly cited
with some one article. Therefore, it needs correction for this and for others throughout the
manuscript.
4. …. ‘Data was collected over 3 and a half months’ duration from May to August 2020.’.. Data
collection period should be specified well. The date should be included.
5. …  ‘Prior to data collection pre-test was conducted at both data collection centers and subjects
that were included in pre-test study were excluded from the actual study.’ On how many patients
the tools was piloted /pretested, and why the piloting was needed since the authors were going
to use the validated Amharic version of the tools.
6. … ‘physical assessment was taken in private examining rooms as well as weight
measurement.’  In general, who under take data collection, i.e., data collectors? The authors
themselves or somebody was recruited? Who undertaken physical assessment, for example for
edema, ascites etc. those things should be clearly explained.
7. .. ‘Nutritional status was assessed by the Subjective Global Assessment (SGA), through
the administration of a questionnaire.’   ….   ‘Interviewer-based questionnaires were used to
assess socio demographic status, nutritional status, quality of life, other disease and clinical
factors’… is that two contradicting statements. Self-administered questionnaire or interviewer-
based questionnaire? The authors should explicitly explain the data collection method.
8. … ‘Weight of the patient before six months was recorded from the patient chart and compared
to the weight the patient currently has to calculate weight loss over six months’… how the
authors were collected the weight of patients that had not completed their 6 months since their
initial diagnosis? Since nothing was stated under inclusion or exclusion criteria about those
patients? Was using 6 months as cut-point for determining the weight loss was a standard or
used arbitrarily? It should be scientifically supported.
9. For patients with time since initial diagnosis was greater than 3-5 yrs (as per table 1), were
they still receiving chemotherapy/any treatment during the data collection or….? How the
authors contacted them? For example, those started 4 cycles AC chemotherapy (i.e., every 21
days) might completed their chemotherapy within three months, and might not stay 6months.
Therefore, how it could be possible to got their weight at the interval of 6 months? And other
physical assessments too? Or were the authors excluded those patients who less than 6 months
since their initial diagnosis? This part should be clearly and explicitly explained.
10. …. ‘We also fitted fifteen separate multiple linear regression models .0and factors potentially
associated with QoL: age, sex, marital status, education level, occupation, family size, lifestyle
factors, wealth status, monthly income, financial support, food security….’.   however, life style
factors, wealth status, monthly income, and financial support’ description were not explained
under table 1 or elsewhere. All should be presented with preferable methods either in table 1 or
in its own table/any preferable method.
11. … ‘The study received ethical approval from the Research Ethical Committee of the School
of Public Health, Addis Ababa University.’   Reference number for the approval of the study
should be included.
Result
1. The some of the frequencies with in some cells in table was not summed to 411. Example
table 2: treatment modality (previous) it summed to 496
2. Table 2: It is not clear about treatment modality (previous) and the treatment modality the
patients were on at the time of data collection? Was it a treatment modality 6 months ago for
the ‘previous’ or something else? The authors should explain it in understandable way.
3. Table 2: for time since diagnosis: the interval between 12-24, and the others are not equal. It
should be equally spaced. And it is better if also reported in form of central tendency in particular
range (mean/median and range).
4. No table/figure for nutritional status. It should be presented in either table or another possible
graph. Besides, since nutritional status assessment by both SGA and weight loss are ‘scale
measurements (i.e., continuous variables)’ , in addition to reporting in the specified range or
cut-point, it would be better if also reported as mean +/- SD. The same requirement for ‘Profile
of quality of life scale scores’
5. Which variables were included in to final multivariate model? Were all variables showed
association on bivariate included into multivariate or something else? It should be well explained
under methods and subsection of data analysis. Furthermore, linear regression is not a preferable
model for this data. Linear regression is used when both the dependent (outcome variable)
and independent (determinant) factors are continuous variable in to 3 (severely malnourished,
moderately malnourished and well nourished). Therefore, consider using ordinal logistic
regression than linear regression that will result in different out-put.
6. … ‘Patients who had primary level, Technical and university level education had more CF
scores than 41 those who had no formal education (# =9.85 p=0.025), (# =14.42 p=0.004) &
(# =16.14 p=0.006) respectively.’ … the impact of other socio-demographic variables on QoL
can be presented in table and can be uploaded as a supplementary file….’. let it be revised
accordingly.
Discussions
1. Paragraph 1… ‘weight gain in these patients hindered the detection of malnutrition’…
however, nothing explained about weight gain in results part. The discussions should be
supported the results. Hence, needs correction accordingly.
2. Paragraph 2…. ‘But, higher than studies done in Brazil (34) that had only 24% of its
participants  moderately and severely malnourished, using SGA tool and a study in France (23)
which revealed that only and 18.3% of the breast cancer patients were malnourished but the
study only used BMI and weight loss as nutritional measurements which are not indicated as
sole nutrition assessment tools for cancer patients (22, 24, 35-37)  as they are prone to be highly
affected by water retention affecting weight or presence of excess body fat masking the loss
of lean body mass sometimes leading to malnourished cancer patients having a normal BMI
despite having 10-20% weight loss in 6 months (22).’ Very long paragraph. Should be broken
down to two or more sentences. The same suggestions will apply to it if any of that throughout
the discussions.
3. In paragraph stating about limitation the study the authors stated that they depend only on
patient reported data, but under methods part they stated ‘physical assessment was taken in
private examining rooms as well as weight measurement’ so what was the purpose of physical
examination?
4. Moreover, drugs like breast cancer chemotherapy or radiation therapy is by far deteriorates
HRQoL by far greater than surgery alone or targeted therapy. And their impact on both QoL and
nutritional status was not assessed. This could be one potential limitation.
5. In general, discussions should be shortened and targeted. Needs revision.
Conclusion and recommendation
It was not concluded based on the finding. Hence, should be revised depending on the objectives
and on the actual finding. And recommendation should be specific.