Reviewer’s report
Title: 
Trends in Emotional Functioning and Psychosocial Wellbeing in Breast
Cancer Survivors: A Prospective Cohort Study Using Patient-Reported Outcome
Measures
Version: 
1 
Date: 
26 Apr 2022
Reviewer's report:
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General
* Interesting study re the trajectories of emotional functioning and breast-related
psychosocial wellbeing in breast-cancer patients. Good sample size, and overall
nicely written. However, I think the paper could be strengthened in a number of
places, as outlined below. 
* Minor point - actual page numbers appear to have dropped off after "page 3";
so I'm going by PDF document page number throughout 
Abstract
* Breast Q - is this the best measure of psychosocial wellbeing? 
* Do the authors differentiate psychosocial wellbeing from EF? 
Introduction
* Page 4, Lines 33-35; 
"Therefore, the current study aimed to find out how levels of emotional
functioning and psychosocial
wellbeing in breast cancer survivors changed as a function of time." The authors
haven't introduced the concepts of 'emotional functioning" or "psychosocial
wellbeing" prior to this (and how they differ or overlap). Given different findings
emerged in this study, I think it's important to define and differentiate them in
the introduction. 
Method
* Measures - it becomes apparent from reading the item descriptions that the
PSWB is very breast-specific; ie., how women feel about their breasts, not a
broader wellbeing measure. 
* Analyses - lots of models conducted - risk of Type 1 error? Should be
discussed in limitations. 
Results
* Page 8 lines 24-29: Sentence "Since only the participants receiving
neoadjuvant chemotherapy were administered the questionnaires at timepoint
T3, and since none enough women reached the timepoint T36 after their
surgeries, these two timepoints were excluded from the analysis so as to not let
small numbers unduly skew the trends." This information should be moved to
methods (when first describing the dataset / data collection), as the authors
initially introduce T3 and T36 but then omit further mention of it until page 8,
when it becomes apparent why this data isn't included in the dataset. Would
make sense to immediately mention this when first discussing the waves of data.
I recommend moving this sentence to page 5, line 21 (immediately prior to
sentence 'As part of the routine care protocol…')
* Average age quite young (52.7). Need to discuss how reflective of general
population this is in the Netherlands, and how this might have impacted on
findings. Especially given that age wasn't a predictor of trajectories. 
* I found the PSWB results confusing - on the one hand it states that "trends
showed improvements towards T24", but then later it states that T12 was chosen
as the primary timepoint for comparing groups because PSWB was not recorded
at T24. So how were the estimated trends extending towards T24? In the
discussion it emerges this was done through modelling given that there was no
T24 data - but this needs to be made clear in the methods/analysis section (i.e.,
that T24 was estimated through modelling, and then describe how). 
○ Related: Table 2 clearly demonstrates that PSWB wasn't collected at T24, but
it hadn't hadn't been clear in the methods that PSWB hadn't been recorded at this
timepoint. Please ensure clarity of presentation (a table / matrix of measures and
data availability would be helpful). 
Discussion
* I think the authors need to make it clearer that this is breast-specific PSWB that
declined (ie., the items were anchored to how they've felt in relation to their
breasts over the past 2 weeks). This is different from more general PSWB. If a
HADS or PANAS or DASS had been administered as a distress / wellbeing
measure, results may have differed and been more consistent with the EF profile
(or perhaps not, but we don't know).
* 
Page 11, lines 14-17 "thus far, emotional functioning and psychosocial
wellbeing have been grouped together…" outside of the PTSD studies you've
cited, I don't think this is accurate, otherwise why would they both be measured?
In the broader psycho-oncology literature, EF and distress/wellbeing are
considered separate (but related) - ie., one is more about symptom
presence/severity (distress/wellbeing outcomes), the other is about symptom
impact (EF). I would recommend the authors cite beyond the 4 PTSD articles
referenced. 
* The fact that T0 was pre-surgery is a major explanatory factor for why breast-
specific PSWB went down after, while EF (which is broader and not anchored to
breast wellbeing) went up. The authors acknowledge this but I think it should be
emphasised. Again, this all relates to the breast-specific nature of the PSWB tool
that was used. 
* Interesting findings re the recon groups having better EF / PSWB than other
groups - however it is a bit speculative to state that this is due to 'differences in
practices regarding patient-centred care' (ie., treatment expectancies), as this
wasn't measured. This needs to be acknowledged and listed as an avenue for
future studies to actually test/confirm. 
* No discussion of age as not being a predictor - this should be discussed. 
* Re the influence of child-partner/social support could be discussed in more
detail - ie., it's good that you've confirmed prior studies' findings, but what
unique contribution did you make and what can we do with that info. Potentially
weaving in some of the clinical implications into this discussion here would
strengthen it. 
* Limitation re systemic treatment - yes this is good to acknowledge, as it was a
likely confound and could explain the lower baseline EF (e.g., if it was
neoadjuvant). 
○ The breast-specific nature of the PSWB measure needs to be acknowledged as
a limitation here (ie., these findings are breast wellbeing specific, and not
necessarily generalisable to broader psychosocial wellbeing). 
Conclusion - Clinical implications
* First 2 sentences don't really add much; I'd consider deleting them. Ie., the
study confirms what was already known, that the biggest impact of cancer occurs
in first 12 months following diagnosis. But this section would be better off
starting off with the unique contribution of this paper; that women who undergo
recon have better psychosocial outcomes and could inform future clinical
practice recommendations towards this (for those who are eligible). 
* Paragraph - 'one of the most significant findings in this paper…' as per my
earlier comment, I think this needs to be somewhat revised, to acknowledge that
many studies have found that distress/wellbeing and QOL differ. (ie., this isn't a
unique finding, but the authors can acknowledge that the current study extends it
by applying it to breast-specific PSWB). 
- The final paragraph of the clinical implications does not really relate to the
findings of the current study. The clinical implications should be specific to the
implications of this study's findings, not about the general importance of
clinicians talking to patients about wellbeing more broadly. I'd revise this
heavily, and instead focus on the takehome message of this paper's findings (ie.,
the importance of screening patients using PROMS, and using the data from this
study to inform treatment recommendations re reconstruction).
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes