Title: Beyond the scars: A qualitative study on the experiences of mastectomy among young
women with breast cancer in a country with crisis
Version: 1 Date: 17 Sep 2023
Reviewer's report:
Thank you for the opportunity to review this well-written manuscript, “Beyond the scars: a
qualitative study on the experiences of young breast cancer women with mastectomy in a
country with crisis.”  The authors present an original view of women’s mastectomy experiences
within the context of a war-torn country. It is an important contribution to the literature. The
methodology is sound, using Braun & Clarke’s thematic analysis. It also describes the findings
within the context of Bronfenbrenner’s (1977) Socio-Ecological Model addressing personal,
family, community, and the social determinants of health and illness.
Although there are various strengths to the manuscript, this reviewer recommends several
revisions to improve the quality of this work.
Reviewer Recommendations:
In General:
1. Several grammatical revisions are needed throughout the manuscript. Consider running the
manuscript through grammar software like “Grammarly.”
A few examples:
• Would change: the word commonest to most common
• Would change: no report has been published ever since to no report has been published since
• Would change: deteriorated after the start to deteriorate since the start
2. Please check the grammar/spelling within the women’s individual quotes as well.
3. Please avoid identifying patients by their diagnosis. I would use “women with breast cancer”
or “patients with cancer” as opposed to “breast cancer women” or “cancer patients.” This
verbiage was found in the title, abstract, and throughout the manuscript.
Background Section:
4. women in Syria with 4388 new cases
Is this 4388 new cases in 2020? Please clarify the time frame.
5. You talked about the Stigma of cancer in the Arabic culture. It would be informative to add
a little information about the Stigma associated with mastectomy in general.
6. Would change: a meta-analysis by (16) to a meta-analysis (16).
The word “by” is not needed.
7. This is a really long sentence. Dividing it into 2 sentences would make it easier to read.
Indeed, the Syrian crisis has resulted in many challenges affecting the quality of care and life
of cancer patients including the unavailability of multidisciplinary team approach to cancer
care, the high cost of different types of treatment, the insufficiency of health staff training for
diagnosis, treatment, palliative care, and psychological care of cancer patients as well as lack of
the educational programs designed for patients and oncology health professionals (4).
Methods Section:
8. Please provide more details on where and how the women were recruited. Was this through
a clinic, the hospital, or were they identified through chart review? How were they approached
– by phone/in person?
9. Were the interview questions developed by the team or the 1st author?
10. You said that data were collected using interviews at the Hospital then in the next sentence
you say interviews were done in the participant’s home.  Please clarify the location of the
interviews. If there was additional data that was collected at the hospital, please specify.
Data were collected using in-depth, interviews between June and December 2022 at Tishreen
University Hospital. The interviews were conducted by the first author in a confidential setting
at the participant’s home.
11. The following 2 sentences could be shortened to 1 sentence to be more succinct.
Current: The participants were interviewed using a set of questions pertaining to mastectomy,
developed based on the existing literature (7, 18-20). These questions are listed in table 1.
Revised: The participants were interviewed using a set of questions (see Table 1) pertaining to
mastectomy, developed based on the existing literature (7, 18-20).
12. It appears based on the results that you obtained demographic information. I would include
how you obtained your demographic data (ex: survey) within your data collection section.
13. I suggest providing the interview time range in addition to the average interview time. This
helps readers to understand variability in interview length (and, perhaps, depth).
14. Please speak to how you addressed methodologic rigor for trustworthiness for qualitative
research. You spoke to Investigator Triangulation (using 2 author independent analysis). Were
there any additional steps you took to promote trustworthiness (? Validation interviews with
any of the participants, reflexive journaling, etc). Adding this component should improve the
validity of your study.
Results Section:
15. I would prefer to see your demographic information in a Table. It would be easier to view.
What was the mean age and standard deviation?
16. As some readers may not be familiar with Syria’s educational levels, clarification here would
be helpful.
17. I felt like there was some overlap with some of the concepts/women’s statements.
18. This is part of a quote under Psychological Impacts of Mastectomy. I feel like this part of
the quote would be better under Body Image and Clothing.
I keep saying how am I going to wear a wedding dress in the future? How would I look like when
I do not have a breast? When my family showed me a wedding dress the first thing, I glanced
at the chest. I guess in life, one looks for what is missing.”- W
19. I am curious to know if other women commented on difficulty with mirror-viewing. If so,
I feel this could be an individual theme under Psychological & Emotional Well-being. It could
be called: “Altered Mirror-Viewing” or “Mirror-Viewing Trauma.”
If you choose to create a mirror-viewing category, I recommend the following articles:
Paraskeva, N., Herring, B., Tollow, P., & Harcourt, D. (2019). First look: A mixed methods
study exploring women’s initial experiences of their appearance after mastectomy and/or breast
reconstruction. Journal of Plastic. Reconstructive & Aesthetic Surgery, 72(4), Article 539547.
https://doi.org/10.1016/j. bjps.2019.01.012
Freysteinson, W. M. (2020). Demystifying the mirror taboo: A neurocognitive model of viewing
self in the mirror. Nursing Inquiry, 27(4), Article e12351. https://doi.org/10.1111/nin.12351
Tyner TE, Freysteinson WM. The mirror viewing experience of women undergoing a
mastectomy: An integrative review. J Adv Nurs. 2023 Jun;79(6):2081-2097. doi: 10.1111/
jan.15574. Epub 2023 Mar 6. PMID: 36876727.
20. “Other Psychological Impacts of Mastectomy” seems like a catch-all category for quotes that
didn’t quite align under another category. I wonder if you could change this to: “Psychological
Distress associated with Mastectomy” or something similar. It sounds like these women
experienced distress so having a category that specifically states that would be appropriate. I
feel all the quotes under it would apply as they each discuss the psychological distress their
mastectomy inflicted upon them.
21. Since your header says “Insufficiency of Psychological Care,” I think you should have
additional participant comments illustrating the lack of this service if that is the problem. You
currently have 1 comment that says they need more psychological care services and another
comment that says there are psychological care services.
Otherwise, it might be better to call the header “The Need for Psychological Care,” indicating
that patients need this service regardless of whether it is offered.
22. Under The Dilemma over Reconstruction Decision, you say: participants said, indicating
more than 1 participant comment, but I only see 1 comment. Please change to participant (remove
the s) or add an additional comment.
For example, the following participants said:
“No, I don't think of doing plastic surgery because I am afraid of the side effects later on….
23. Theme 2, “Access to Knowledge and Support Services” seems a little broad given your
quotes are concentrated on the lack of access to prosthetic information/services. Consider
narrowing this sub-theme.
24. Regarding Theme 4:
Based on the comments women made, I question whether the participants fully “accepted their
situations” (as the subtheme states) or if they were instead learning to cope with their altered
bodies through 1) family support, 2) faith in God, 3) comparing their situation to others, and 4)
use of prosthetics. I wonder if these could be 4 individual sub-themes under a main theme of
Coping or Learning to Cope with their Mastectomy.  Or, if the subtheme title should be modified
to reflect their coping and body acceptance as an ongoing process. Just something to consider. If
you choose to modify this section, do not forget to modify the “Individual” section of Figure 1.
Discussion Section:
25. You might consider adding some clinical implications and feasible interventions (that can
be realistically implemented in a war-torn country) to address some of the obstructive factors
you cited or ways to reduce psychological distress for these women.
• Consider adding some information about mirror viewing and ways to improve mirror comfort,
thus reducing psychological distress.
Freysteinson, W. M. (2020). Demystifying the mirror taboo: A neurocognitive model of viewing
self in the mirror. Nursing Inquiry, 27(4), Article e12351. https://doi.org/10.1111/nin.12351
• If known, consider highlighting ways to improve access to psychological resources, prosthetics,
or funding options that may be available for women seeking reconstruction in Syria.
26. Please include limitations to your study and areas for future research.