Reviewer ’s report  
 
Title: Motivations for contralateral prophylactic mastectomy as a function of socioeconomic 
status  
 
Version: 0 Date: 19 Oct 2016  
 
Reviewer: Susan Vadaparampil  
 
Reviewer's report:  
 
This is an  interesting paper that provides some insight into the growing trend of CPM in the U.S. 
The study includes 113 patients seen in 4 clinical settings in Indiana. There are several notable 
strengths to the manuscript including the use of a newly developed mea sure that provides some 
insight into various reasons why patients may select CPM, despite clinical evidence suggesting 
minimal benefits in survival when compared to standard treatments such as LRT or mastectomy 
and chemotherapy. However, there are some con cerns with the paper and areas that require 
additional clarification.  
The abstract of the paper implies that the trend of increasing CPM should be stopped and the 
conclusions focus on "dissuading patients from CPM". However, when the literature is reviewe d 
in the introduction section, there is some suggestion that CPM access should be increased for 
minority women. It is possible that patients may base the decision for CPM on their own 
personal preferences and values.  Therefore, the framing of this paper b oth in the introduction 
and in the discussion/conclusion may be better served by considering that there are many factors 
that may go into a woman's decision for CPM including clinical information, but also patient 
values and preferences that should be cons idered?  
At the very least, a limitation of this project is that other variables that may influence the 
decision for CPM are not included such as family history of breast cancer (independent of BRCA 
test results). Other examples may include current number of childr en and a desire for future 
children to avoid chemotherapy. Patient's perception of the provider recommendation for or 
against surgery is another example as is culture which may play into decisions around surgery. 
This issue is demonstrated in the relativel y low R2 values in Table 4.  
It would be helpful to have a better break down of reasons for non -participation.  
Please show the number of participants recruited from each site.  
Were all patients in the study those who were diagnosed with breast cancer fo r the first time?  
In the results, please provide the p -value for results that re reported as statistically significant.  
What was the rationale for splitting the income at 51K?  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any  other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I receive research funding from Myriad Genetics Laboratories that provides clinical testing for  
inherited breast cancer risk. However, patients who had testing were excluded from this  
manuscript, so I do not perceive any conflict of int erest.  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on th e website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal