Reviewer ’s report  
 
Title: Preliminary Study on the Effects of Treatment for Breast C ancer: Immunological Markers 
as they relate to Quality of Life and Neuropsychological Performance  
 
Version: 0 Date: 05 Jun  2019  
 
Reviewer: Leah Pyter  
 
Reviewer's report:  
 
This ma nuscript describes a pilot study examining the relationship between breast cancer 
treatment and lymphocyte/NK populations and quality of life/spiritual well -being in patients and 
relative to survivors.  While there is likely some modest new information to be gleaned from this 
experiment, the manuscript preparation requires work and the interpretation of the results needs 
to be clarified.  
 
 
Main Points:  
 
1. The manuscript is incomplete in its current form. There are no figure legends, the figures 
have no panel numbers/informative axis labels, etc., there are multiple methods that are 
not included in the Results/Discussion (pre/post stressor blood comparison, cortisol, etc.).  
A clear and specific hypothesis needs to be stated and supported by the literature. It is not 
clear to me how a biomarker for quality of life would be helpful. Specifying the 
importance of this would benefit the introduction section.  
 
2. Data interpretation would be enhanced by advice from immunologist or 
psychoneuroimmunologist. In its current form, discussion about "immune response" is 
generic (adaptive vs. innate) and the rationale is not clear. If basal cell counts are 
measured, this i s not considered an immune "response." Similarly, NK "activity" was not 
assessed here. The references cited in this regard are weaker than they could be. What is 
the rationale for using absolute vs. percent immune cell counts? Where are all the other 
immun e data that were collected (based on the methods)? For the results, some additional 
analyses that might produce interesting findings were not conducted and/or reported. For 
instance, did the results of the questionnaires change before, during, and after tr eatment 
in the treated group? Did the lymphocyte/NK cell counts change before, during, and after 
treatments? You reported differences in CD8 between patients who underwent chemo 
and radiation vs. radiation only. Did any of the other biomarkers differ? Comp arisons 
were not made between the treated group and non -treatment group. Were there direct 
differences between the groups? There are likely many more analyses that could be 
conducted. The results of these analyses should be reported even if there are no 
differences.  
 
3. The conclusions are weakened by the fact that CD8 cells declined with treatment, 
however, poor QoL, sleep, and cognitive function were instead correlated with higher 
CD8 counts. There is confusion throughout the manuscript as to whether the authors 
interpret the literature on adaptive immunity.  
 
4. There are grammar/typos throughout.  
 
 
Minor Points  
 
5. Presumably these survivors were chosen as a control because they all received radiation? 
If powered to do so, can the survivors that received ch emo serve as controls for the 
patients that also received chemo?  
 
6. How long did the ANAM take to administer (mean and range)? This is relevant if it is to 
be used as a stress challenge.  
 
7. The rationale for some of the endpoints in the Methods (but not i n Results) is unclear, 
how do they relate to the hypothesis (e.g., TxPA, lipid density)?  
 
8. Methods for flow cytometry are incomplete, which markers/labels were used and where 
were the antibodies purchased.  
 
9. Similarly more details are necessary about ho w the different types of data were analyzed.  
 
10. "Usually" needs to be clarified with specifics (line 29 p. 8)  
 
11. Was the treatment paradigm/timing identical in all the breast cancer patients? More detail 
on the patients' treatment regimens would be help ful. For instance, what type of 
chemotherapy was used? Are these patients undergoing any hormonal therapy along with 
the treatments? Are the women in the non -treatment group undergoing any long -term 
hormonal treatment?  
 
12. P. 8 lines 39 -43 conflict with ea ch other.  
 
13. P. 8 line 56, was all blood drawn after assessments or before/after ANAM? Conflicts with 
earlier methods.  
 
14. Appropriate caution was included in Discussion, however, based on power analyses, is 
there sufficient N to compare radiation only vs. radiation + chemo?  
 
15. Why are only CD4, 8, 16 reported? What is rationale.  
 
16. P. 9 line 48, what is "CD4 on QoL total"?  
 
17. P. 10 line 5, are these FSI data not shown?  
 
18. Confusing to refer to a group as "comparison group" please be specific.  
19. The Discussion section needs to focus more on your results and their implications to the 
breast cancer patient population.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your  comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please  explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects requ ire further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain  or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future? 
 
3.  Do you hold or are you currently applying for any patents  relating to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds  or has applied for patents relating to the content of  the manuscript?  
5.  Do you have any other financial competing interests?  
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
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