Reviewer’s report
Title: 
Association of education level with the risk of female breast cancer: A
prospective cohort study
Version: 
0 
Date: 
03 Oct 2022
Reviewer's report:
The manuscript presents an interesting research topic and is in the scope of the
BMC Women's Health journal.
In this study, the authors investigated the association between educational level
and the risk of developing female breast cancer. The observed cohort was quite
large (n=20,129 women) and the follow-up was longer than 10 years. In general,
the results found are not sufficient to elucidate the controversies on the subject,
but contribute to the understanding of the issue. 
However, some aspects need to be better explained:
1. In the method, it is not clear whether the entire study population had their
information available in the Tangshan City health insurance system. Is there a
possibility of any participant being diagnosed or treated in another health
insurance system? Also, the information should ideally be extracted from the
Population-Based Cancer Registry, since only participants who had access to
diagnosis and treatment have medical records.
2. Some risk factors that are considered confounders were not considered in the
analyses, such as: use of hormone therapy, age at first pregnancy, number of
children, lactation, age at menopause. How do the authors consider that these
factors might influence the results found? Wouldn't this be a limitation of the
study?
3. In the conclusion it is important to highlight that the results are not
generalizable, and it is not possible to state that the breast cancer risk is higher in
populations with medium and high EL.
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Is the study design appropriate to answer the research question (including the use
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presented?
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from apparent manipulation?
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