Reviewer ’s report  
 
Title: Tumor Characteristics and Treatment Outcomes of Older Patients with Breast Cancer in  
Jordan  
 
Version: 0 Date: 10 Dec 2019  
 
Reviewer: Melissa Edwards  
 
Reviewer's report:  
 
Thank you for the opportunity to review this manuscript.  
 
Methods  
Line 70: "Patients who lack appropriate follow up…were excluded." This is inappropriate and 
requires further clarification. What was the definition of inappropriate follow -up? How many 
patients were excluded in consequence? In addition to disease outcomes,  clinical presentation, 
tumour characteristics and treatment were objectives of the study, which do not require follow -
up data to be assessed. While absolute 5 -year survival rates would not include those with shorter 
follow -up, such individuals would contr ibute to all other methods of survival analysis (with 
censoring at loss to follow -up) and should be included.  
 
The multivariate analysis requires further explanatory detail. Which covariates have been 
adjusted, and the theory underlying their selection is unclear. Are we to assume that all variables 
listed in Table 2 (and no others) have been adjusted for? If the objective is to explore tumour 
characteristics associated with mortality in this population, covariate selection requires some 
justification. For instance, why is nodal status included but not tumour size (or, more 
expansively, tumour stage)? Any why was triple negative status selected in the absence of the 
other molecular subtypes?  
 
Kaplan Meier plots: Please add the numbers still at risk. The 5 -year survival rates also require 
confidence limits.  
 
It is also convention to round P values to no more than 3 decimal places (ie p &lt;.001).  
 
Controls  
This is a retrospective cohort study of older Jordanian women with breast cancer. There are no 
controls for comparison however the authors use comparative language. Presumably this is with 
reference to Jordanian women younger than 65 however this is unclea r with no reference to 
previously published or concurrent data. For example, line 134: "…and axillary dissection was 
performed less often than younger patients."  
 
Conclusions  
Line 127: "However, data on whether patients' age at diagnosis is also related to  breast cancer 
treatment outcomes and survival in our region is lacking." This is the key to the paper yet it has 
not been addressed as there is no comparison with younger Jordanian women.  
 
Line 130: "Our data presented in this paper shows that a significa nt proportion of our patients, 
especially those with metastatic disease, were not treated aggressively with chemotherapy or 
surgery". Firstly, metastatic disease is not typically treated with surgery. Secondly, only 6.6% of 
patients with non -metastatic dis ease did not receive surgery - that would be reasonable in an 
elderly population even in a high HDI country. Thirdly, while a low proportion of metastatic 
patients received chemotherapy, all hormone receptor positive cancers received endocrine 
therapy, whi ch would be considered appropriate first line therapy.  
 
Line 168: "Older women with breast cancer in developing countries present with more 
aggressive features and advanced -stage disease." I'm not sure it is fair to say the cohort had more 
aggressive disea se features; the majority were hormone receptor positive, HER2 negative 
tumours, as would be expected in an elderly cohort. The observed advanced stage of disease is 
therefore likely to be related to delays in presentation rather than any biological differ ences 
relating to Jordanian ethnicity.  
 
 
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.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
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 in terests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in t he future?  
 
2. Do you hold any stocks or shares in an organisation that 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 th e 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 y ou 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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