Title: Breast cancer surveillance in BRCA positive Sri Lankan women: health equity for a high-
risk group at a limited resource setting
Version: 1 Date: 14 Aug 2023
Reviewer's report:
This research has looked into the important question of practices and behaviours of at-risk breast
cancer patients in participating in screening programs for breast cancer. While the study team
should be commended for identifying this important research question, the submitted paper
needs to be revised and the questions must be answered by the research team.
Justification for the study:
It is important to understand the practices and behaviours of women at-risk for breast cancer
(BC). However, the article fails to convince the reader the use of the findings from the study. If
no mammographic screening programs are offered to patients in the public sector, how can this
new knowledge help the study population? In other words, what if the benefit of this research
to the community?
Ethics considerations:
I understand the study was approved by a university HREC. However, there are many ethics
concerns in this study. The authors claim that the cancer database maintained at the HGU in the
university of Colombo is anonymised. In this case, how were the individuals diagnosed with BC
identified to be contacted? Have these individuals expressed their willingness to be contacted at
their first consultation for genetic counselling? How were they invited to the study? How was
the consent to participate obtained, during the same telephone interview or before the interview?
Were the participants given adequate time to consider their participation? What measures were
taken to ensure the psychological harm that participants may have had because of the telephone
interview?
Methods:
Methods needs to be adequately described in terms of the study design, study setting, population,
recruitment, data collection instruments with detailed account, data collection process (who
interviewed, when, how the schedule for the interview fixed), what sort of data were collected
and how they were analysed.
Results:
Suggest presenting the results for the practices and behaviour in a table/ graph rather than as
paragraphs.
Discussion:
Rather than repeating the results, authors should discuss the significance of their findings in
relation to the country's situation. What do the finding mean? What are your recommendations
in the light of your findings? Can these recommendations be implemented given the resources
availability in the country? If not, what can be done to improve this situation?
Lines 191-192: The justification provided for the under-diagnosis of the condition cannot be
agreed with. Offering genetic counselling at very few centres may or may not mean under-
diagnosis of the condition.
Indication for referral: Does the country have guidelines/ protocols for referrals? You need to
discuss these findings in the background of available policies.
Majority not done any screening:
The authors need to discuss this finding in the background of if they were educated on the
process. Presenting what is involved during the genetic counselling will be helpful to better
understand the reasons behind the behaviour.
Authors need to discuss why locally adapted national clinical practice guidelines for detecting
individuals at high risk are not available. without this background context, the findings are
difficult to interpret meaningfully. Authors may compare this situation with other countries with
similar socio-economic backgrounds or even with high income countries.
Study limitations:
This study has many limitations which are not identified by the authors. Inquiring health
behaviours through telephone interviews, recall bias, prolonged interviews all are very important
factors that affect the reliability and validity of the study. Authors need to discuss in detail what
measures were taken to mitigate these biases and how they may have impacted the findings.
Minor comments:
please clarify whether you refer to mammographic screening r CBE when you mention screening
program, at each place.
Line 66: mention which countries are relevant for references 2,4, and 5.
Line 84: LI and LMI countries are NOT synonymous with weak health systems. Please revise
the wordings.
Line 99: please provide a reference
Line 110: Please provide reference to say HGU is the principal centre in state sector.
Line 226: what is meant by 'average risk' should be defined/ clarified.
Line 226: please provide reference for mammographic screening services offered by other
resource poor countries in the region.
Line 227: please provide reference for this claim.