Title: How do I deal with Breast Cancer: A qualitative inquiry into the coping strategies of
Iranian women survivors
Version: 1 Date: 25 Jan 2022
Reviewer:  Nadia Rajaram
Reviewer's report:
The authors sought to understand the coping mechanism of Iranian breast cancer survivors,
using an established methodology for data organization and interpretation. The findings of this
study could lead to important information about how public systems and communities can better
support breast cancer patients in Iran.
However, there has been similar research done among breast cancer survivors in Iran, and it is not
clear how this paper adds to that. Furthermore, without grounding this analysis in a behavioural
framework, the authors do not have sufficient depth to describe how women cope with breast
cancer. Also, it would be useful to review the whole manuscript for grammar and formatting.
Specific comments are below:
Introduction:
1. The introduction is very lengthy. Suggest revising to a more concise introduction, with more
emphasis on the current research gaps in Iran or similar populations.
2. Line 46: Remove all commas in this sentence
3. Line 48-51: Some information about the Iranian context of women’s or societies perception
of breasts can enable better understanding of the themes arising in this paper.
4. Line 52-53: This line suggests that 50-83% of women worldwide suffer from psychological
distress, rather than among breast cancer patients. Suggest revising the sentence to reflect the
data more accurately.
5. Line 54: This statement requires a citation.
6. Line 63 “dene” – is this a typo?
7. Line 67 “Escape coping” – previously the term used was avoidant coping. Suggest using the
same terminology to avoid confusion.
Materials and methods
8. Were participants selected from specific clinics? There are only 14 participants, so it would be
good to more specific about where they were recruited from. This will impact how we interpret
and extrapolate of the study findings.
9. It is also helpful to know more about their diagnosis (i.e. stage at diagnosis, time since
diagnosis, type of treatment they had and whether or not they are currently in treatment)
10. How was the questionnaire developed?
11. Were the interviews conducted in English? If not, a description of how the interviews were
conducted then translated is required.
12. The section on “trustworthiness” needs to be better described. If there were steps take to
specifically validate the findings, then this should be described thoroughly. However, it seems
that the sentences here may be more suited to be discussed as strengths or limitations of the
methodology, in Discussion.
Results
13. It would be more meaningful to classify the emerging themes using a behavioural framework,
especially because of the interconnectedness between emotions and behaviour (the two themes
defined here). i.e. the quote for behavioural coping: " I use yellow beef oil myself. It really works.
As soon as I eat Indian rice and liquid oils, my body reacts. I feel very good when I use natural
things.” Here, it appears that behaviour modification leads to better emotional coping. This is
example of how behavioural frameworks are used to described qualitative research among breast
cancer survivor: https://doi.org/10.1111/ecc.13013
14. Please use double quotation marks (“ ”) to denote participant statements, some quotation
marks are missing. Also, the convention for denoting truncated sentences is the ellipsis, which
is 3 dots (…).
15. Line 171: “…” is this a typo?
16. Line 263: It would be helpful to know the distribution of participants by their religious
background, perhaps in Table 1
Discussion
17. The authors use the term emotional and psychological interchangeably, but there are subtle
differences in terminology. Consider what is the most suitable terminology here, and standardize
across the manuscript
18. Suggest authors revise the paragraphs in the Discussion to be more concise. Participant
descriptions that are in the Results section should not be described again in the Discussion.
Rather, authors should try to interpret what this means for Iranian BC survivors. For example,
Line 415:425 is a long description of study findings, that should be in Results, not Discussion.
19. There are many instances of facts or findings from other studies that do not have a
corresponding citation. Please include citations appropriately.
20. Line 322-325: Should this be part of the previous paragraph or other paragraphs? It feels
incomplete as its’ own paragraph.
21. Line 440-441: Suggest adding “in Iran” or something similar, as the strength of this study is
about understanding coping mechanisms among Iranian women.
22. Line 441: Are these other studies in Iran? If so, what is the contribution of this paper?
23. There should be more discussion about the limitations of this study. This includes the small
sample size, which may not be representative of the Iranian population of women (it will help
to give more description about these women and where they were recruited earlier in the paper).
Some discussion on how this might have led to the observed findings is warranted. Furthermore,
if the analysis is not grounded in a behavioural framework, that will serve as a limitation, too.
Conclusion
24. In my opinion, the authors have not provided an “in-depth” understanding of the coping
strategies for Iranian breast cancer survivors. Instead, the authors have described the coping
activities that these women undertake. As a result, the conclusion becomes quite repetitive of the
Results and Discussion section. I encourage the authors to really delve into what their findings
mean for Iranian women with breast cancer, and how these may lead to actionable interventions
for these women. Grounding this work in a behavioural framework might help improve the
interpretation of the findings observed here.