Title: Impact of anticancer therapy on the quality of life of Sudanese patients with breast cancer
at Khartoum oncology hospital
Version: 2 Date: 19 Sep 2022
Reviewer's report:
The purpose of the article by Mawada Aldaak et al, is to evaluate the QOL of Sudanese women
with breast cancer.  Breast cancer mortality and morbidity burden in Africa is higher compared
to other countries  expecially due to late diagnosis .The evaluation of therapies-related QOL has
an increasing importance, and it is interesting to evaluate it by referring to different areas of the
world, with different accessibility to treatments and with a low global health status. There is
literature regarding breast cancer survival in this area and the impact of the lack of screening,
but QOL of breast cancer  survival has not been investigated before.
The strengths of the paper are certainly:
- The scientific validity of the tools used for QOL assessment
- The accurate statistical analysis
- It represents the first QOL study on Sudanese women with breast cancer, interesting despite
the small sample due to the lack of cancer registry programs. In fact data collection is often
difficult in these areas.
- The bibliography and the sources cited are absolutely valid
-The results are in accordance with literature data
However, authors need to be bolder and more analytical on some important aspects.
- First, the paper does not specify whether the therapies were administered before or after
surgery.
- Furthermore, it is not specified what type of surgery  on breast /axilla is performed. Many
studies in the literature report the worst impact that demolition surgery has on patients' quality
of life, especially for young patients. It would be interesting for the authors to deepen this aspect
in the analysis of the data.
- The abstract reports that 54% of patients start therapy from compromised health conditions.
This is in contrast with data reported in Tab2 where patient without comorbidities are the most
representive.
- Another possible criticism could concern the non-homogeneous distribution of therapies
administered to patients. The authors explain this point specify the difficult access to all types
of treatments available, but it would be useful to provide a more representative sample.
- Page 3:
"The decision on systemic treatment is generally based on ER \ PR and HER2 assessment."
This is absolutely correct, but currently the decision on adjuvant and / or neoadjuvant therapies
is also made on the basis of other factors (age, life expectancy, genetic mutations).
It is probably not customary in Sudan to perform assessments such as geriatric evaluation and
genetic testing. In any case, the selection of patients for treatment should be specified more
accurately.
Other minor detailed comments:
- The QOL is not properly considered an indicator of the "efficacy" of the therapy as reported
in the abstract. In fact, the goal that establishes the effectiveness of a neoadjuvant treatment
remains only the complete response of the tumor. QOL is an important outcome but does not
determine efficacy of treatment.
- Citing the excellent source (7) the authors should also mention the third tumor phenotype
TNBC, which is one of the phenotypes that require chemotherapy wherever possible.
- The whole paper needs quick editing of the copy. There are some minor typos.
- The detailed description of the hospital where the data was collected is appreciable but
excessive. It should probably be shortened, making easier focusing on the important aspects.
In conclusion, despite the strong and valid points mentioned, the article must be reviewed in
terms of content and form.