Title: Expression of inflammatory states in response to psychological distress in breast cancer
survivors and its relationship to subjective memory function complaints
Version: 4 Date: 14 Jan 2025
Reviewer's report:
The authors have carefully addressed many of the issues raised by the reviewers. However, a
few points still need to be addressed before the manuscript is suitable for publication.
1. Terminology regarding PRMQ: While the authors have added references to the PRMQ, it is
important to note that this is not an objective measure. Consequently, terms like ‘dysfunction’
should be avoided and replaced by terms such as ‘complaints’ or ‘experience’,  or ‘subjective
memory decline’. This adjustment would better align the language with the limitations of the
tool used.
2. Mediation analysis: The authors have acknowledged the limitation of performing mediation
analysis with a cross-sectional design in the discussion section. However, the limitations
of performing mediation analyses should be explicitly mentioned in the methods section.
This is particularly important because mediation analysis requires a temporal sequence of
variables, which is not possible with cross-sectional data. Highlighting this limitation early in
the manuscript would strengthen the methodological transparency. We recommend emphasizing
that these mediation analyses are of an explorative nature to investigate underlying mechanisms.
3. Causal language: Causal language persists in several parts of the manuscript. Given the nature
of this study, the language should focus on associations rather than causality. Specific sections
that require revision include, but may not be limited to:
a. Title of the manuscript
b. Aim of the study in both the abstract and introduction
c. Introduction: The statement, “Findings from this study were expected to provide an evidence-
based foundation for early psychological interventions and strategies to improve the mental
health of BC survivors,” is overly strong for a cross-sectional study. Rephrasing this to
emphasize ‘preliminary results’ or ‘exploratory findings’ would provide a more accurate
representation of the study's scope.
d. Section 2.1: The phrase “This cross-sectional study was designed to assess the impact of
psychological distress on memory function” implies causality. It should be revised to reflect that
the study examines associations between these variables.
e. Section 3.4: The statement “DT was able to significantly and positively influence both
RM (#=0.663, p<0.001) and PM (#=0.506, p<0.001)” is inappropriate for the study design.
Rephrasing it to describe associations would make it more methodologically accurate.
f. Table 3 title: The phrase “the effect on” in the table title should be replaced with less causal
language. Additionally, include ‘DT’ in the title for clarity.
Additional adjustments:
4. Introduction: Adjust the following sentence to avoid implying longitudinal measurements,
as ‘changes’ suggests multiple measurement points: “This study sought to investigate whether
changes in inflammation levels are a potential mechanism linking psychological distress to
cognitive dysfunction in BC survivors.”
5. Table 1: Include the definition of the abbreviation ‘KPS’ below Table 1 for clarity.
6. Section 3.2, and Table 2: There seems to be a discrepancy in the reported results: “Differences
in TNF-##65.48±4.98 vs. 58.85±2.88, z=-0.481, p=0.630).” The reported means and standard
deviations do not seem to align with the z and p-values. Please review these numbers.
7. Figure 1: There are spelling errors in the figure: ‘inclusion’ and ‘exclusion’ are misspelled.
Please correct these.
8. Covariates in the Analysis: It appears that no covariates (e.g., sex and age) were included in the
analysis. This omission is concerning and should at least be discussed in the discussion section.
If covariates were included, please clarify this in section 2.4. Additionally, if only women were
included in the study, revise section 2.1 to explicitly state that the analyses are limited to women.
9. Section 3.4: The following sentence appears incomplete and should be clarified:“Bootstrap
program was used to analyze the mediating effects of the The results are shown in Tables 6 and
7, mediation analysis revealed that IL-1# partially mediated the relationship between DT and
RM#effect value=0.128, 95% CI [0.021 to 0.256]#.”
10. Discussion: The first paragraph of the discussion should be revised for accuracy. If
significant results were found only with the PRMQ, which assesses memory complaints rather
than cognitive dysfunction, ensure this distinction is clear.
11. Discussion: Adjust the following sentence to avoid implying longitudinal measurements:
“In this study, the changes in systemic inflammatory markers and cytokines in BC survivors
with psychological distress and their association with altered memory function.”