Title: Prevalence and associated factors of baseline anemia among cervical cancer patients in
Tikur Anbesa Specialized Hospital, Ethiopia.
Version: 5 Date: 17 Dec 2020
Reviewer's report:
Dear Editor – BMC Women's Health,
Thank you for the opportunity to revise the corrected manuscript.
The Authors didn’t address all the points raised during the first revision and in this way the
manuscript is not suitable for publication. The manuscript still requires major modifications in
order to be suitable for publication.
Abstract: the comments and respective changes done across the manuscript have not been
reflected to the abstract!
Background: The background is still reporting unnecessary details. It seems like the manuscript
has not been revised by an English speaker and the background still requires major language
modifications to make it clearer and shorten. Examples are reported below.
P.3-4, paragraph 2, 3 & 4: in this paragraph the Authors should directly talk about the relation
of anemia in cancerous conditions (general) and then in cervical cancer and then the negative
consequences on anemia. Please re-write accordingly taking into consideration the comment
below too.
“It is the disease of immune driven…”: needs rephrasing
“Significantly, cancer patients regarded fatigue as having a larger….”: the word “regarded”
should be changed
“….. larger harmful influence on their daily lives than many other or cancer treatment related
complications”:  many other of what?
“Anemia of chronic disease, the second most prevalent anemia, is caused by iron deficiency
which happens in patients with acute or chronic immune activation. It is the disease of immune
driven in which cytokines and cells of the reticuloendothelial system make changes in iron
homeostasis.”: why is this relevant here?
“Cancer patients with anemia(causes fatigue) are facing….”: remove (causes fatigue)
“About 40% to 64% of patients presenting for cancer therapy were anemic……”: this has been
already mentioned before (Almost one patient with malignancy in two is anemic, with the
consequence of poorer treatment outcome and quality of life.)
P.4, paragraph 5:
“The study done in Korea on the association between preoperative anemia and poor prognostic
factors….” You mention this study such as it’s already known to the readers. Please rephrase
the sentence (ex. A study conducted in Korea investigated the association…..)
N.B: this should be applied to the rest of the background.
P.4, paragraph 6 & 7: The Korean study has been addressed to much in details in the
introduction…this might be reserved for the discussion.
“Age <50, advanced stage, non-squamous cell carcinoma , larger tumor size, deeper stromal
invasion, and lymph node metastasis were significant factors affected preoperative anemia in
this study[8].
The median pretreatment hemoglobin level was 12.8 g/dl and 12.3% of patients had pretreatment
anemia. It was significantly associated with large tumor size, advanced clinical stage and
parametrial invasion.” Higher pretreatment hemoglobin level involved better prognostic
significance in disease free survival on the study conducted in Korea. Hemoglobin level less
than 10 g/dL during radiation therapy of cervical cancer was significant and it was correlated
with lower survival of the patients. It this still related to the same study? Where is the reference?
AIM: “Therefore, the aim of this study was to assess the prevalence and major factors associated
to baseline anemia among cervical cancer patients in TASH, Ethiopia.”: the aim is not well
connected to the previous paragraphs. The background should lead the readers to the aim and
this is not happening here.
Methods: when applying the age as continuous variable it can be included in the logistic
regression with all the other categorical variables.
Can the Authors provide an estimate of the proportion of cervical cancer patients refereed to
TASH from the total patients in the country?
Previous comment: “Make it clearer in the abstract that this is 3-years retrospective study
(2014-2016).”: this should be also addressed in the methodology.
“Religion” was one of the sociodemographic characteristics mentioned in the methodology but
never showed later.
Results: Table 4: The Authors didn’t fulfil the request to provide the univariate analysis per
each variable.
The Authors should address within the manuscript the criteria for choosing the variable that
have been included in the logistic regression.
Authors: “The variables found in the Table 4 are all significant variables with p-value less than
0.2 in univariate analysis and analyzed with multivariate analysis.”: this should be addressed
in the manuscript.
Discussion:
The Authors didn’t amplify the discussion as per request. They justified this was due to the lack
of previous data. However, while performing some search I could find interesting articles that are
worth mentioning in the discussion of the manuscript for comparison. Below are few example:
• Harrison LB, Shasha D, Homel P. Prevalence of anemia in cancer patients undergoing
radiotherapy: prognostic significance and treatment. Oncology. 2002;63 Suppl 2:11-8. doi:
10.1159/000067147. PMID: 12466640.
• Ludwig H, Van Belle S, Barrett-Lee P, Birgegård G, Bokemeyer C, Gascón P, Kosmidis P,
Krzakowski M, Nortier J, Olmi P, Schneider M, Schrijvers D. The European Cancer Anaemia
Survey (ECAS): a large, multinational, prospective survey defining the prevalence, incidence,
and treatment of anaemia in cancer patients. Eur J Cancer. 2004 Oct;40(15):2293-306. doi:
10.1016/j.ejca.2004.06.019.
• Shintaro Yanazume, Noriko Karakida, Ryutaro Higashi, Mika Fukuda, Shinichi Togami,
Masaki Kamio, Shunichiro Ota, Hiroaki Kobayashi, Tumor bleeding requiring intervention
and the correlation with anemia in uterine cervical cancer for definitive radiotherapy, Japanese
Journal of Clinical Oncology, Volume 48, Issue 10, October 2018, Pages 892–899, https://
doi.org/10.1093/jjco/hyy113
• Prevalence of anemia and compliance to the National Comprehensive Cancer Network
guidelines for workup and treatment of anemia among patients with gynecologic malignancies.
Demetra Hufnagel, Sumit Mehta, Chinyere Ezekwe, Alaina J. Brown, and Lauren S. Prescott
Journal of Clinical Oncology 2019 37:27_suppl, 32-32
Previous comment: “Can the higher prevalence of anemia in the study population be due to well-
known risk factors such as HPV?”: This still need to be addresses in the manuscript discussion/
limitations.
Previous comment: “In the “operational definitions”, the Authors define “substance”. I however
suggest to make the meanings of “substance” and “region” clearer, particularly in the Abstract.
When first read, the exact meaning for both “substance” and “region” is not clear enough.”: this
has not been fulfilled.