Title: Conservative interventions and clinical outcome measures used in the perioperative
rehabilitation of breast cancer patients undergoing mastectomy: a scoping review.
Version: 1 Date: 07 Jul 2022
Reviewer's report:
Title: Conservative interventions and clinical outcome measures used in the perioperative
rehabilitation of breast cancer patients undergoing mastectomy: a scoping review.
Submission ID: 8b51322a-d10e-41d7-9faa-84a6f5fb5c10
Mathieu and colleagues reported a scoping review to identify the treatments and outcome
measures used for perioperative rehabilitation of patients who are awaiting or have undergone
mastectomy. The research team followed rigorous methods and included 46 papers from 44
original studies. The authors identified heterogeneity in the interventions with limitations in
reporting interventions, and reasons for declining participation and losses to follow-up.
Thank you for the opportunity to review this paper. This is a well written manuscript on an
important area of study. The authors followed rigorous methods and present a thorough overview
of the results both in the main paper and the supplementary files.  There are a few issues which
I believe would improve this manuscript outlined below.
1. The introduction is very well written and compelling, however the rationale for conducting
this scoping review is not clear. On page 5, it appears the team might be setting the review up
as a foundation from which to develop rehabilitation resources for breast cancer patients within
their centre, but the authors do not seem to close the loop on this through the discussion or
conclusion. In addition, it appears there are a number of systematic reviews that already exist
(the authors cite 2 - De Groef and Ribeiro), as such, the paper would benefit from more explicit
rationale for choosing a scoping review in that context.
2. Methods (pg 8 line 114) – can the authors please provide detail on how they decided a study
'did not provide sufficient detail on intervention procedures'? Were specific criteria applied to
determine this or was it objective per the person screening?
3. Methods (pg 8) – in the discussion (pg 22), authors report that breast cancer survivors were
excluded and those studies that did not define survivorship were also excluded – these criteria
should be added to the exclusion criteria in the methods.
4. Results (pg 11) – much of the data here could go into a table including study type,
country of origin, income level, year published (or 5-year or decade groupings), and participant
characteristics (age, cancer stage, type of surgery, etc.).
5. Results – Figure 2 – please provide a legend for the colors and the superscripted a, b, c (if this
is elsewhere and not included for the reviewer, please disregard). The accompanying paragraph
on page 12 would also benefit from explicit reporting of how many studies clearly defined all
three components (unclear if it is 33 (from line 209 on page 13) or 30 as counted on the figure)
6. Results – the idea of ‘prehabilitation’ for those awaiting surgery is interesting and it might be
helpful to pull out a separate paragraph for these studies in the results
7. Results (pg 15) – can the authors provide a summary of the overall number of unique outcome
measures used across studies and the number within each of the three categories for the reader (to
complement Figure 4)? It may also be interesting to note how many studies included measures
from more than one category – was it the norm for studies to utilize multiple measures assessing
different dimensions?
7a. This can then thread through to the discussion where the authors discuss core outcome sets
– for example, how many studies utilized measures that aligned with core outcome sets?
8. Results (pg 16 lines 284-285) – a 2 to 75% decline rate is a massive spread – what was the
distribution for these numbers? I am concerned this could be misleading, for example if there
was only one study with a 75% decline rate that was much higher than any other included study.
Suggest providing more detail to help the reader contextualize these numbers.
8a. This could also come through to the discussion where authors discuss reasons for non-
participation and/or non-adherence – perhaps the authors could provide some insight as to
what they postulate might be driving those very high numbers for a study (i.e., was it a rural
population, did that study (or studies) have much higher complication rates, etc.).
9. The discussion could be streamlined. There is a fair amount of restating of results, particularly
in the patient experiences section.
10. Discussion (pg 21, line 413) – the authors state a “significant proportion of…patients refused
to engage…”. It is important to provide context here for how many studies experienced those
high levels as there may have been specific circumstances in one or two of those studies
contributing to such high numbers. Suggest providing that context (see comment 8 and 8a above)
and consider tempering the language if appropriate.
11.  Discussion (pg 23 lines 444-450) – these are not limitations of the authors’ work, but rather
of the existing literature. Suggest this could be moved above to its own paragraph because it is
an important point to capture. It may also be beneficial to have a short section in the results that
summarizes overall reporting (e.g., did most studies report >50% of TIDieR items or something
similar), what were the most underreported items, etc.
11a. Table S2 title - can the authors please clarify what is meant by “modified based on
TIDieR checklist”? Is the table modified or was the TIDieR checklist modified to fit the authors
extraction?
12. The search is now 18-months old and should be updated to include any current literature
since the original.
13. Minor - suggest using repeating header rows for the tables in Additional File 2 (makes it
easier for the reader to review rather than having to scroll back up pages to remember what
column it is)