Reviewer's report 
 Delayed presentaion in breast cancer: a study in Iranian women Title: 
Authors: 
Dr Ali Montazeri ( ali@jdcord.jd.ac.ir )
Dr Mandana Ebrahimi ( ebrahimiman@yahoo.com )
Neda Mehrdad ( neda_mehrdad@yahoo.com )
Dr Mariam Ansari ( ali@jdcord.jd.ac.ir )
Akram Sajadian ( asadjadian@yahoo.com )
 1  13 May 2003 Version: Date: 
 Anthony Staines Reviewer: 
 A paper whose findings are important to those with closely related research Level of interest: 
interests 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
This is a good paper, well written and nicely presented. Note that my competence is as a practising 
epidemiologist, and not a specialist in breast cancer treatment research. I have not attempted to 
replicate the analyses reported in this paper. I have some minor suggestions for amendments, and two points which should be clarified. I did not see any explicit statement on consent in the paper - there should be one. Who actually asked the women the questions - did anyone besides the authors 
help, if so they should be specifically acknowledged here also. 
Clarification 1 
203 patients were recruited into this study - how many women presented to the breast clinic or the 
university hospital during the study period? Almost inevitably studies like this miss some of the 
potential patients, and it is important to give your readers clear guidance on the proportion of potential patients actually recruited. 
Clarification 2 
You say that multivariate forward conditional logistic regression was used to analyse the data 'after adjusting for other variable studied'. This is unlikely. Conditional logistic regression is typically used only to analyse matched case-control studies. I suspect that you just used multivariate logistic 
regression, with forward selection of statistically significant variables. This is not usually a good idea. 
Kenneth Rothman devotes a whole chapter of his book 'Modern Epidemiology' to explaining why. 
The presentation here is confusing, and fails to make your main points clear. I recommend that you 
add a further column to Table 2 thus :- 
'Variable' '< 3months' '> 3 months' 'Univariate OR' 'Multivariate OR' 
(95% CI) (95% CI) 
and present there the adjusted values of the associations reported by you. This will be much 
simpler, and will make your key points more elegantly. You could either adjust for all of the other variables, or for a selection justified on some combination of statistical significance, subject matter 
knowledge, prior results etc. 
Minor points 
You use the term 'late stage diagnosis' several times -I suggest 'late stage at diagnosis' 
Abstract 
Nice and clear, well structured. I suggest emending two lines as follows - 
A significant association was also found between delayed presentation and both late stage disease 
(p=0.01) and bigger tumour size (p=0.004). 
The findings suggest that almost one in three women with breast cancer present late, and this has a 
significant effect on their prognosis. (not disease prospects) 
Background 
Para 1 line 2 omit 'the' in 'Moreover the late stage' 
Para 2 line 4 amend 'Delay and late stage diagnosis' to ' Delay in presentation and advanced stage 
at diagnosis' 
Para 3 - Put this incidence figure in context - is it high, low, high for middle eastern populations etc... 
You will find all the information required at http://www-dep.iarc.fr/teh the invaluable IARC cancer 
incidence website. 
Methods 
See clarification 1 above 
Line 7 amend 'Delay was defined as time intervals of more than 12 weeks' to 'Delay was defined as 
a time interval of more than 12 weeks'. Note that three Gregorian calendar months are not often 
equal to 12 weeks, unlike the more regular Islamic calendar. 
Last line amend 'examined as predicting factors' to selected as potential explanatory factors' - this is 
more in line with customary terminology in epidemiology and biostatistics. 
If you used a statistics package you should reference it here. Most packages give explicit directions 
on how they want to be referenced. 
Results 
See clarification 1 and 2 above. 
Para 1 line 3 Give mean age as either 47 years or 47.0 years - 47.03 years is not sensible - likewise 
give the SD as 11.3 years, or even 11 years. Stick to a reasonable number of significant figures 
throughout the paper. 
Para 2 line 1 amend 'univariate regression analysis' to 'univariate logistic regression analysis' 
Para 3 - see clarification 2 above, also tidy up the spacing on the results here, some of the results 
run into each other. 
Discussion 
Para 2 This is a little confusing. Is marital status associated with delayed presentation for treatment 
in the ;literature? I'm not sure after reading this paragraph and I should be... 
Para 3 The points touched on at the end of this paragraph, about cultural issues in health promotion 
are of the highest importance, and would merit a slightly longer discussion if this is possible. 
Para 4 
Para 5 line 8 amend 'most frequent symptom that is non-tender breast mass' to 'most frequent 
symptom, a non-tender breast mass' It would be of interest to know what the other presenting symptoms were in this population. 
Para 6 
Para 7 
Para 8 You could include a power calculation in your methods section, or here, specify for example 
the smallest risk you desired to detect, and the power of your achieved sample for detecting it. 
Tables 
See Clarification 2 
I suggest presenting 'Lump' and 'Other' rather than 'Lump' and 'No Lump' as the labels for the first 
symptom seen in tables 1 and 2. 
Competing interests: 
None declared.