Title:  Assessing the factors associated with body image perception and quality of life of
Palestinian women undergoing breast cancer treatment: A cross-sectional study
Version: 2 Date: 21 Jun 2024
Reviewer:  Angelo B. Hooker
Reviewer's report:
Assessing the factors associated with body image perception and quality of life of Palestinian
women undergoing breast cancer treatment.
Reviewer statement:
Breast cancer is the most commonly diagnosed malignancy worldwide, a significant public
health concern. Breast cancer poses a significant burden on the health and quality of life of
women and can lead to significant physical burden and significant psychological problems,
including distress, anxiety, depression, and sexuality-related problems, including body image.
In women with breast cancer, treatment influences body image, leading to a negative body
perception with a negative influence on quality of life. Little research was conducted to assess the
perceptions of Palestinian women with breast cancer of their body image. The authors conducted
a cross-sectional study to assess how women diagnosed with, treated, and/or ongoing treatment
for breast cancer perceived their body image, which is interesting and clinical relevant. This
information could guide further research and clinical practice.
Title:
The title chosen reflects the study being reported and is considered adequate.
1. The authors should add the study type to the title, reflecting on the type of study conducted.
This helps the reader in understanding the study being reported.
Overall:
The article was pleasant to read with overall good English grammar.
Abstract
The abstract section is well written. The abstract should be adapted based on the provided
comments and suggestions.
Introduction
The introduction section is well written, stating the background of performing study. It was
pleasant to read, explaining well the background and the reason for conducting this study.
No comment on this section.
Methods
This section is well written and good to understand. Nevertheless, some important points need
clarification and/ or explanation.
2. The authors state in line 76-78 the following: “The study was conducted in different hospitals
and outpatient clinics where women with breast cancer received their treatments or visited for
follow up care.” The authors should provide precise information concerning the number of
hospitals and outpatients clinics which were involved in the current study. Please report.
3. In the methods section the authors should report the details of the recruitment process.
Unfortunately, important details concerning the recruitment process are not reported in this
section. How were eligible participants identified and recruited. Please provide more details
concerning the recruitment process.
4. When was the study conducted?
5. The authors state in line 87 the following: “Raosoft sample size calculator was used to
calculate the sample size for this study.” The authors should report how the sample size was
derived, in other words what was the relevant outcome on which the sample size was derived?
This remains unclear. Please provide additional and thorough information to the reader.
6. The authors report the use of a questionnaire that was developed for this study which  collected
the demographic and clinical variables of the patients. The reported variables do not include the
type of treatment received. This is particular as the authors report in line 64-67 that the treatment
received influences body image perception. Please elucidate thoroughly on this point.
7. When reading the line 98-101, it remains unclear when and which patients received a face-
to-face interview.
8. The authors report in line 92 that the” questionnaire that was developed for this study” and
in line 103: “ The validity of the questionnaire was previously established using the Delphi
technique among experts who were academicians or clinical staff who cared for breast cancer
patients.” Were patients included I the development of the questionnaire?
9. The validity of the questionnaire was based on what relevant items/ outcomes?
Results
The result section is well written but was not very pleasant to read. There are some important
points needing clarification and/ or explanation.
10. Nothing is reported in this section on the recruitment process. Please provide more
information. How many eligible women were there?  How many women refused and how many
questionnaire were excluded? These are essential information of the reader.
11. The use of a flow diagram is urgently advised.
12. Is income satisfaction a relevant sociodemographic characteristics? Please explain the
relevance to the reader.
13. The result section was not very pleasant to read because of the magnitude of tables. The
result should be presented in a way  that facilitates the reader. Instead of several different tables,
tables 3- 9 could be merged in a way that facilitates the reader, while the important results are
presented, as the  details are shown in supplemental tables. Please adjust this section.
Discussion
This discussion section is well written and was pleasant to read. Despite, the section should be
modified as crucial and important factors, including limitation are not discussed.
14. The authors state in line 232-234 the following: “ The findings of this study revealed that the
Palestinian women with breast cancer were concerned about their body image.” As a reader, this
is not a surprising results. As the authors report themselves, in line 240-241: “ These findings
were consistent with those reported among women with breast cancer elsewhere [12-14].” The
authors should elucidate whether the reported results are in line with the results elsewhere. What
is the same or what is different ?
15. In line 257-259 the authors report: “ These findings indicate the healthcare providers should
consider counseling breast cancer patients about the available therapeutic approaches.” As a
reader, this cannot be concluded based on the presented results. I suppose, that best therapeutic
approach is always available for the patients. Please elucidate on this point.
16. In line 272 the word Out should be replaced by our.
17. The authors should elucidate of the effect of treatment on the represented results as a higher
dissatisfaction is reported in more radical surgeries, chemotherapy and radiation therapy and  in
more advanced stage cancers (line 254-257).
18. Furthermore, the association the received treatment has not been included in the current
analysis. In line of the statements in line 254-257, as a reader , the authors should explain why
this was not included.
19. The same applies on the time between diagnosis and the reporting of the results.
20. How is the body dissatisfaction in other cancers? Do we see the same trends. In other words,
are the results specific for breast cancer or does the diagnosis cancers a relevant factor?
Figures  and tables:
Tables should be merged.