Title: Adherence to oral anticancer hormonal therapy in breast cancer patients and its
relationship with treatment satisfaction: an important insight from a developing country
Version: 2 Date: 18 Jan 2023
Reviewer's report:
Dear author,
Thank you for working on improving your manuscript.
Please see the following comments
Abstract
1) Page 2 line 12, Suggest to exclude "and two clinical pharmacists filled in the questions", but
to include “and medical record reviews”
2) Page 2 line 13, Not appropriate to state MARS in the abstract when it is not the full
questionnaire.. suggest to state “adapted”
3) Page 2 line 20 and 24, Suggest to use “adherence score” instead of "MARS score"
Introduction
Suggest to rewrite with the following focus for each paragraph
a)  Breast cancer and hormonal therapy
b)  Hormonal therapy adherence and associated factors
c)  Study gap, and study objective
1) Page 3 line 6, Suggest to change to “based on statistics in the United States”
2) Page 3 line 8-12, Suggest to cite internationally used guidelines such as NCCN
3) Page 3 line 12-15, Suggest to exclude sentence from first paragraph
4) Paragraph 2, Suggest to start paragraph with
a)  Adherence rate to hormonal therapy from studies
b)  Adherence rate in Arabic nation
c)  Factors that affect adherence rate
5) Paragraph 3, Suggest start with
a)  treatment satisfaction identified as an important modifiable factor (please provide citation),
b)  treatment satisaction not known in Palestine,
c)  therefore objective of study
Methodology
1) Page 5 line 4-5, Suggest to exclude pediatric given it is irrelevant to your study population;
Suggest to mention cancer only (hematologic cancer is not relevant to your study population)
2) Page 6 line 6-8, Suggest to rephrase this to state the max point of 7, with 7 being high
likelihood of adherence, and include after sentence in line 11-12  on mentioning the exclusion
of the irrelevant items
3) Page 6 line 13-14, Suggest to exclude sentence
4) Page 7 line 14-18, Suggest moving to section on “Data collection”and removing duplicated
information
5) Page 8 line 16-20, Given the small number of participants, suggest to reduce adherence and
satisfaction questions to binary (high vs low) and conduct a binary logistic regression instead.
E.g. high adherence = score > 5, low adherence = score < 5
High satisfaction = score > 66.67, low satisfaction = score < 66.67 (use median as cut off)
Similar for demographic factors e.g. age and BMI (obese vs non-obese)
Results
Suggest rewrite results section based on new analysis
1) Page 9 line 11 and 14, suggest use “adherence score” instead of MARS score
2) Page 9 line 12, suggest to use "high likelihood of adherence" similar to description in
methodology instead of "fully adherent"
3) Page 10 line 8-17, note when writing this section, the association is towards “higher
satisfaction” in perceived effectiveness, side effect and convenience; not association towards
perceived effectiveness, side effect and convenient
4) Page 10 line 11-12, noted from Table that Postmenopausal patients had higher score.. please
clarify if this shld be higher satisfaction towards side effects (i.e. lower side effect experienced?)
5) Page 10 line 15-17, please state the association, which drug is associated with higher
satisfaction towards effectiveness and global satisfaction
Alternatively suggest to convert type of oral hormonal drug into binary value.. tamoxifen vs
aromatase inhibitor
Discussion
Discussion needs improvement.
Discussion shld be based on what you found in your study.. postulation from results of others’
studies shld be excluded eg page 12 line 1-4
Suggest repeat analysis and rewrite the discussion.
Page 11 line 12, Sentences like this have no relevance to your study
Page 12 line 22-23, Also the questionnaire has been adapted (by the removal of 3 questions)
in your study
Thanks!