Reviewer’s report
Title: 
SOCIAL SUPPORT IN EARLY-STAGE BREAST CANCER PATIENTS
WITH FATIGUE
Version: 
0 
Date: 
08 Apr 2019
Reviewer: 
NEHAD AYOUB
Reviewer's report:
The manuscript by Sørensen et al. is describing Cancer Related Fatigue (CRF) in
a group of patients diagnosed with early stage breast cancer. The authors further
describe associations between CRF and social support.
The manuscript is providing new insights to CRF in this group of patients. The
followings are my comments for consideration by authors. 
Major comments
Authors are highly encouraged to review the manuscript for language and
editing.
Abstract
Describe in Methods that this study is a cross-sectional.
Provide quantitative data in abstract and expand description of study results.
Background
If you can provide some statistical data from your local national registries about
incidence, prevalence, and other relevant breast cancer statistics would be
appropriate to include in the background.
Line 3-4 'Breast cancer is the most frequent form of cancer for women in
Norway, and has a good prognosis.'
Prognosis of breast cancer is dependent on many factors including tumor stage,
grade, molecular subtype and other patient factors. I think this statement is not
very precise and suggest rephrasing.
Line 5 '...hormonal treatment in various combinations'
Suggest changing to targeted treatments as not all breast cancer patients are
eligible to endocrine therapy is their tumors do not classify as hormone-
dependent.
Line 5-7 'In recent years improvements in diagnostics and treatment have
yielded increased recovery rates, but the complexities of treatment have at the
same time resulted in challenges related to side effects'
A large part of improved outcomes is also due to advances in cancer screening
which enable earlier diagnosis and improved survival. Please add this to the
statement indicated.
Add more details describing cancer related fatigue (CRF), which is known to be
different in nature from other types of fatigue. For example, CRF is not relieved
by sleep or rest and it usually lasts for longer duration and accompanied by high
level of distress. Also, provide more details about the adverse effects of CRF in
terms of life style and daily activities along with impact on work. The following
references would be helpful:
1. Bardwell WA, Ancoli-Israel S. Breast Cancer and Fatigue. Sleep Med Clin.
2008 Mar;3(1):61-71.
2. Kapoor A, Singhal MK, Bagri PK, Narayan S, Beniwal S, Kumar HS. Cancer
related fatigue: A ubiquitous problem yet so under reported, under recognized
and under treated. South Asian J Cancer. 2015 Jan-Mar;4(1):21-3.
Methods
Provide data about menopausal status for breast cancer patients if available.
Why women with advanced breast cancer stage III and IV were not included in
the study?
What is the basis to decide that patients must have a minimum of 2.5 points on
fatigue score for inclusion in the study? Please justify in text.
Method must include a detailed description for the recruitment of participants.
How patients were approached? Who interviewed these participants? Were
patients selected through convenience sampling? Where and when the patients
were interviewed? Did patients self-administer the questionnaire? How was the
questionnaire distributed to patients?
It is my understanding that this is a cross-sectional descriptive study. If correct,
please indicate this in Methods.
Were all the data reported by patients or were any of the relevant data retrieved
from medical archives or electronic data bases? Please describe in text.
Among demographic data, it is essential to report co-morbidities which are
potential factors to influence the level of fatigue among breast cancer patients.
Similarly, treatments for co-morbid conditions must be considered.
For fatigue questionnaire, what was the language of the questionnaire?
Did you consider a pilot group analysis for the demographic part before
distributing the questionnaire?
Provide appropriate citation for the statistical software SPSS according to
manufacturer recommendation.
Indicate the duration during which patients were recruited to the study.
Results
Line 117 'One hundred and sixty women participated in the study, giving a
response rate of 60.2%'
A total of 160 women are eligible to participate according to Methods, and so, if
all provided response this would ideally made the response rate 100% rather than
60%, as the rest of patients were not actually recruited to this study. At the
limitation part, this is better explained, so please rephrase to match what is
mentioned in limitations.
Provide standard deviation for age of patients.
Provide range (maximum-minimum interval) for each of calculated scores TF,
PF, and MF.
I wonder why data for social scores are presented as medians and range of
minimum and maximum rather than means. If to be given as medians, I highly
suggest calculating quartiles and presenting the scores as boxplots rather than bar
charts of median, minimum, and maximum values as in Figure 1.
The study describes fatigue and social support for patients with early stage breast
cancer during treatment. For this, I would recommend having more details about
the treatment being provided in terms of the type of chemotherapy administered,
the average duration for patients receiving chemotherapy, the average number of
cycles, the number of patients who receive palliative treatments for pain and
emesis, if any, and so on, which collectively can impact the fatigue score and the
level of social support provided to these patients.
I would like to suggest stratifying the data analysis by variables that could
impact the outcomes in terms of the stage of disease, age of patient, and type of
treatment administered, if doable. 
Discussion
Clearly indicate that these findings apply to breast cancer patients with early
stage local disease.
Would it be possible that surrounding hospital settings, such as the level of co-
operation of medical staff, to influence the level of social support and fatigue
experienced by breast cancer patients? Please describe if relevant.
Would factors such as coverage by health insurance impact results in this case?
Please discuss in relation to findings in literature if such data is available.
The following reference papers are related to the work done, please add and
discuss within the context of your findings:
1. Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P, Morrow GR.
Cancer-related fatigue: the scale of the problem. Oncologist. 2007;12 Suppl 1:4-
10.
2. Tabrizi FM, Alizadeh S. Cancer Related Fatigue in Breast Cancer Survivors:
in Correlation to Demographic Factors. Maedica (Buchar). 2017 Jun;12(2):106-
111.
3. Wright F, Hammer MJ, D'Eramo Melkus G. Associations between multiple
chronic conditions and cancer-related fatigue: an integrative review. Oncol Nurs
Forum. 2014 Jul 1;41(4):399-410.
References 
Update the list to include more recent published papers.
Table 1
Does "no response" indicates a missing data? Please verify and would be better
to describe in the Footnote of the Table. 
For the scores, n represents the number of patients who completed each scale?
Please verify.
Minor comments
Abstract, line 29 'A significant association were found ...'
Change to 'A significant association was found ...'
Abstract, line 34 'In addition, association were found ...'
Change to 'In addition, association was found ...'
Abstract, line 39 'the breast cancer...'
Delete 'the'
Abstract, line 49 'living with someone is significant for the experience ...'
Change to 'living with someone is mandatory for the experience ...'
Abstract, line 51-53 'Clinicians need to evaluate breast cancer patients with
fatigue's social support and their demographic characteristics.'
The statement is not clear. Please rephrase.
Background, line 3 'of cancer for women ...'
Change to 'of cancer among women ...'
Background, line 11-12 'and to many this is at its most troublesome during
chemotherapy'
Rephrase
Background, line 12 'Cancer related fatigue ...'
Use the abbreviation CRF and kindly apply to whole manuscript
Background, line 16-18 'Several factors, such as different demographics, medical
status, psychosocial and biological factors as well as our behaviour, affect the
way we experience cancer related fatigue'
Rephrase and use abbreviated term CRF
Background, line 43-45 'The results show that the women have a relatively high
degree of social support and score the lowest on the provision «nurturance».'
Rephrase
Background, line 48 'wholly'
Change to 'fully'
Background, line 54-55 'In addition, to explore the associations between social
support and demographic and treatment characteristics.'
Rephrase
Methods, line 93 'scale of from ...'
Remove 'of'
Methods, line 95 'of between 16 and 64, a high score indicating a high degree of
social support'
Change to 'between 16 and 64 in which higher scores indicate a greater level of
social support'
Table 3
Correct the variable under education level
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
No
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
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 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, 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 the future?
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gain or lose financially from the publication of this manuscript, either now
or in the future?
3
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Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
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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
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Do you have any other financial competing interests?
6
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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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