Title: Body image dissatisfaction and lower self-esteem as major predictors of poor sleep quality
in gynecological cancer patients after surgery: Cross-sectional study
Version: 4 Date: 10 Jan 2021
Reviewer's report:
Comments to Authors:
The authors presented a cross-sectional on the prevalence of sleep disorders and their predictors
in a sample of post-operative gynecological cancers patients in Morocco.
I believe that the topic of the article is very actual and interesting. In my opinion, the study is
well conducted, and all the sections of the article are well explained.
I enclose only some suggestions.
Background:
•       Lines 100-104: "The purpose of this study was to investigate the prevalence of sleep
disorders in a sample of post-operative gynecological cancers patients in Morocco, and in
particular to determine the predictors of these disorders in this category of patients, in order to
help nurses and oncology professionals to assess and manage sleep disorders and to improve
the quality of life of these patients."
In my opinion, this sentence is too long and this makes it difficult to be read; I would suggest to
separate into two shorter sentences. For example: "The purpose of this study was to investigate
the prevalence of sleep disorders in a sample of post-operative gynecological cancers patients
in Morocco, and in particular to determine the predictors of these disorders in this category of
patients; indeed, the ultimate goal of our study is to help nurses and oncology professionals to
assess and manage sleep disorders and to improve the quality of life of these patients."
Methods
•       Lines 112-116: “The inclusion criteria were as follows: women over 18 years old with
a confirmed diagnosis of primary gynecological cancers (cervical, body uterus or ovarian), …
with T1–T3 tumor stages and who had undergone hysterectomy/oophorectomy for more than 3
weeks and not more than 6 months.”
You state to include in your study patients "who had undergone hysterectomy / oophorectomy
for more than 3 weeks and not more than 6 months", however later in the text and in table 1,
you divide the patients according to "time since diagnosis" as follows: "<1 an, #1 an".
"An" Did you mean "year"?
Could you explain the reason of this temporary discrepancy between time of diagnosis and
surgery for patients included in the group with time since diagnosis #1 year?
•       Lines 122-123: “Oncologists (were randomly inviting: not correct) randomly invited women
who consulted for a check-up to take part of the study.”
•       Lines 123-124: “The researcher verbally presented the study to the patients and (woman
who do not wished: not correct) women who did not wish to participate were excluded.”
•       Line 126 "Patients were recruited consecutively until the sample size was sufficient."
I suggest to report the process performed for the calculation of the sample size of your study
to make more understandable how you have considered that "the sample size was sufficient",
this is mandatory.
•       Line 133: “…(aducational: error) educational level…”
•       Line 134: “…Working status [Housewifes: not correct) housewives/Retired, (working:
not correct) workers] …”
•       “Socio-demographic and medical characteristics”. It would be very interesting to specify
also the type of cancer of the patients because of age at diagnosis, survival and impact on quality
of life differ from one disease to another.
•       Line 179: “…Cronbach’s # for this study is 0.98 which demonstrated a very (a:please
remove this) good reliability of the used questionnaire…”.
•       Lines 184-185: "... Subsequently, a pilot study was conducted on a group of 30 cancer
patients excluded from the study ..."
I suggest to better state the objective of the pilot study, provide a brief description of how it was
conducted and, also explain the reasons for exclusion of the 30 patients from the current study
and why they were eligible for the pilot study.
•       Lines 199-202: "... To determine the unique impact of mental health variables on sleep
quality, three sets of predictors: demographic (age), social (medical coverage system) and mental
(anxiety, depression, body image dissatisfaction, self-esteem) have been introduced in stages in
a hierarchical multiple regression model..."
I suggest to reformulate this sentence as follows:
"...To determine the unique impact of mental health variables on sleep quality, three sets of
predictors have been introduced in stages in a hierarchical multiple regression model; these sets
of predictors were: demographic (age), social (medical coverage system) and mental (anxiety,
depression, body image dissatisfaction, self-esteem)...”
•               Line 183 "...committee (in: not correct) of Moroccan universities experts..."
•       Lines 194-196: “…non-parametric tests were used: Fisher’s exact bilateral test to compare
percentages (.) ; the Spearman rank correlation coefficient to study the correlation between two
quantitative variables..."; please replace the period with semicolon.
Results:
•       Lines 213-214: “…This study shows that 66% of the patients (suffer: not correct) suffered
from proven anxiety and more than half of the patients (59%) (suffer: not correct) suffered from
severe depressive disorders, while body image problems were found in 54% of the patients.”
Discussion:
•       Line 240: “As mentioned in Material and method section, the current study had three main
objectives…”;
I suggest start your discussion without this sentence because it seems superfluous. You can start
your discussion directly with the sentence "The current study had three main objectives ...".
•               Given that your study focuses on a population of patients who received surgery, I suggest
to report in your discussion the impact of the type of surgery (laparoscopy, laparotomy) and
perioperative care on the quality of life and psychological status of patients undergoing surgery
for gynecological cancers; in particular, I suggest to mention the impact of the application of the
ERAS protocols in these patients, because the reduced used of opioid can impact short and long
term outcomes. Here are two studies that you can cite in the discussion https://doi.org/10.1097/
AOG.0000000000002735 and https://doi.org/10.1016/j.ajog.2020.07.003 to put in place the
correct problem.