Reviewer's report
Title:Breast cancer in kurdish women of northern Iraq: incidence, clinical stage,
and case control analysis of parity and family risk
Version: 1Date:11 September 2009
Reviewer: Livia Giordano
Reviewer's report:
Runnak et al. reported the results on breast cancer rates and clinical stage
related to age in a group of Kurdish women and evaluated the risk associated
with parity and family history.
The study is interesting because is one of the few studies performed to
investigate rates and characteristics of breast cancer lesions in this area and
should be encouraged.
Compulsory revisions
Methods Section:
1. Page 5: 539 records of breast cancer patients were considered to estimate the
occurrence of breast cancer in this area (table 1). – but the Hewa Hospital
collects all the cases? It is the Unique Hospital or other Hospitals or Health
Centres are operating in the area? Almost inevitably studies like this miss some
of the potential patients, and it is important to give the readers clear guidance on
the proportion of potential estimate of potential missing patients. The lower
number of cases >= 60 years old is probably related to under reporting. This can
be excluded for younger women?
2. Page 5: The authors state that among 539 patients with a first diagnosis of
breast cancer, 296 had detailed clinical records and consent to be interviewed
and so included in the study. What about the remaining 243 women? How many
did not consent to be interviewed and how many had some missing information?
Did the author investigate the reasons of refuse? And what the characteristics of
their lesions? If present for some, why to exclude them in table 3? If some of
these patients were excluded if their data concerning clinical data were missing,
was it not possible to reassess data already during the interview?
3. “54 controls were patients at ambulatory facilities”. Were
gynaecological/obstetrical ambulatories excluded? Women accessing ambulatory
facilities and matched with cases should be not being selected for conditions
related to parity and fertility. Authors should specify this.
Results Section:
Page 7: There is no correspondence between results described at rows 11-17
and what presented in table 2. Please check it. There is also a missing value in
the table related to the number of patients>= 50y with a history of mother or
sister having breast cancer (last row).
Page 8: The P values reported are P value for the trend? It is not clear.
Discussion Section:
Page 8 – row 17: authors speak about ‘…formal mechanism for collecting
data…in the region’ but in the previous part of the document no references to this
mechanism can be founded. If there is a formal procedure to collect breast
cancer it should be described. The presence or nor of a formal and exhaustive
procedure to collect breast cancer data can strongly influence the
comprehension and evaluation of results.
Page 9- rows 10-11: the point touched on in this part of the document, about
cultural issues in health promotion is of the highest importance, and would merit
a slightly longer discussion if this is possible.
Page 11 – rows 9-11: authors cite clinical breast examination and Magnetic
Resonance Imaging (MRI) as principal alternative screening test (in the general
population?). The evidence now available is strongly insufficient to justify
recommendations for both these two investigations. (Elmore J 2007; Moss S.M
2006)
The American Cancer Society recommends annual magnetic resonance imaging
as an adjunct to screening mammography ONLY in high-risk women 30 years
and older.
Authors should be clearer on this point.
Page 11: At the end of the discussion, authors state: “It will take several years
before meaningful mortality data will be available four our Kurdish population. In
the meantime, reductions in clinical stage might serve as a short-term measure
of interventional programs” In the whole document authors did never refer to
what has been made or is currently made as ‘interventional programs’ in
Sulaimaniyah Governate. It would be considered.
Minor Essential revisions:
Authors use the term 'case control subjects' several times -I suggest 'controls'
Table 1: Authors should include references for the breast cancer data reported
for Israeli Arabs, Jordan, Egypt and USA (references 2 and 3?). I will speak
about ‘estimated’ average annual incidence. The note specified with # should be
moved under the table. The title should become: Estimated age specific
incidence (annual, x 100.000) for breast cancer in Sulaimaniyah Governate and
comparison with other Eastern and Western countries.
Table 2: I propose that the title should be only: Clinical Characteristics of patients
and controls. Table 2 is not easily readable. Try to improve it maybe moving all
the data related to age>= 50 to the right side of the column.
Why data about age of menarche and menopause are not reported in the table?
Please check the correspondence between what assessed at page 7 and what
reported in table 2 (see above).
Table 3: I will add a row with total. The title speaks about clinical stage and
tumour grade but the data concern only the first. The title should be simplified. I
will erase the third column (Age (years).
Reference 14 is very old. It should be replaced by a more updated one (as Sue
M Moss et al., Effect of mammographic screening from age 40 years on breast
cancer mortality at 10 years’ follow-up: a randomised controlled trial. Lancet
2006; 368: 2053–60).
English should be revised by an English spoken person.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
'I declare that I have no competing interests'