Title: Changes in Participation for Young Women after Breast Cancer Diagnosis and Treatment:
A Qualitative Study
Version: 2 Date: 24 Apr 2025
Reviewer's report:
Thank you for the opportunity to review this manuscript: “Changes in Participation for Young
Women after Breast Cancer Diagnosis and Treatment: A Qualitative Study. This is a small,
but elegant study. Strengths include a well-reasoned rationale for phenomenological analysis;
a second interview to present evolving interpretations was conducted and both interviews
were relatively lengthy, suggesting a deep and rich interaction; the analysis is well described,
including a description of the PI’s background; the results ring true and resonate with previously
published studies.
I have a few comments for the authors to consider.
1. Overall: In the abstract, I was particularly intrigued by the goal to explore “how person-
environment interactions mediate young breast cancer survivors’ participation in life” and
“conceptualizations of disability that identify the environment as a major driver of restricted
participation for disabled people.” This is new and fresh- survivorship care research does not
typically overlap with disability studies frameworks. I was very intrigued to see what new
knowledge could be generated with insight from disability studies and a phenomenological
approach. However, the results as presented (particularly themes 1 and 2) echo what has
already been reported in the literature; there is very little that is new here and environment is
not explicitly mentioned or noted in the first two themes. Could the discussion section more
explicitly tie these results to the frameworks and theories in disability literature to help us to
reinterpret these results? Could the role of the environment be more explicitly characterized?
The introduction states this goal (“specific attention to the role of the environment in mediating
participation outcomes for this population.) but it doesn’t feel fully realized throughout the
results and I don’t understand the mediating role of the environment. For that matter, is it truly
a mediator or more of a moderator? It feels like either the purpose needs to be rewritten to de-
emphasize the focus on the environment or the results need to be rewritten to explicitly show
how the purpose was realized in the findings.
2. Along the same lines, it is somewhat counterintuitive (and therefore potentially game-
changing) to focus on the role of the environment in cancer-related disability i.e., when you  say
“conceptualizations of disability that identify the environment as a major driver of restricted
participation for disabled people” in the abstract.  In the world of oncology, it is far more
common to consider disability arising from within the body/person (the treatment side effects
and disease symptoms creating trouble functioning)- this view is both inaccurate and has limited
supportive care and rehabilitation practice and research in that it makes us laser-focused on
symptom management and impairment reduction. Your thesis would be augmented by a more
clear articulation of the person-environment interaction challenges. The paper, as written, hints
at this, but it sounds like what we’re heard before (symptoms and uncertainty make participation
difficult). It would be a bigger contribution to the literature if this study could unpack some of
that and bring the wisdom of disability studies into the world of oncology- it is definitely needed!
3. Introduction: The article mentions AYA population. Other places just describe a “young”
population (those diagnosed prior to when routine screening is initiated. Can you be clear about
the definition of AYA population and the degree to which your sample reflects that definition?
4. Methods: It is unclear as to how purposive sampling was conducted. As written, it appears
that the eligibility criteria were created to identify the people with the perspective needed and
the investigators enrolled a convenience sample of people meeting the criteria. For purposive
sampling I would expect you to selectively recruit or invite people with varying perspectives
(half the sample working, half not working, etc.). If you had a sampling frame a priori or one
that evolved with the analysis, please say more (e.g., how did you select one potential person
over another? How many were identified and not invited). If I am not understanding this, please
provide a citation and description of what you mean by purposive sampling.
5. Methods: Please justify the sample size in the methods section. It is mentioned with a reference
in the analysis section but please say exactly how was it “deemed accurate” i.e., when and by
who? Was this an a priori decision or made as the analysis evolved?
6. Methods: It’s unclear why the characteristics of the women were presented in the methods
section as opposed to the results section.
7. Range: There is a wide range of years since diagnosis. Can you discuss how that may affect
your results and anything you did within the interview to explore this?
8. Results: Can you provide the average, not just range, of interview length?
9. Not clear what is meant by “environment” in theme 3, some of the findings seem similar to
theme 1”.