Title: The assessment of risk factors and risk perception status of breast cancer in Northern Iran
Version: 2 Date: 29 Mar 2023
Reviewer's report:
The authors have done well in addressing most of the concerns. However, there are still some
issues which in my opinion need to be addressed
• The authors indicated that the questionnaire was adjusted but did not state clearly what
adjustment meant. Did they trim down the number of questions or modify the presentation of
the questions. Whatever they did should be stated and the rationale for the adjustment included.
If there was no adjustment following pretesting, then the statement could be deleted.
• The authors should provide references for the key books, articles and scientific journal used
for the development of their questionnaire.
• One of the inclusion criteria as stated by authors was participants without severe mental illness.
What did they mean by severe mental illness? How was that determined?
Exclusion/inclusion criteria
• In my opinion ‘incompleteness’ may be included as a limitation of the study if it affected the
sample size, but not as an exclusion criterion. This is because the participants have already been
included in the study the observation of such ‘incompleteness’. The authors can get clues to
appropriate response by studying their inclusion criteria and providing reason why some people
were excluded
• Risk perception may not be described as a quantitative variable except the authors were
referring to risk perception score. If that was the case, it should be stated as such.
• Monthly income may not be described as a qualitative variable except the authors were
referring to income levels or groups. If that was the case, it should be stated as such.
• How did the authors measure physical activity?
RESULTS
• The 3 tables are quite confusing.
• In my opinion table 1 need to be restricted to the distribution of sociodemographic
characteristics of the participants.
• If part of the objectives of the study was to assess the relationship between risk perception
score and sociodemographic characteristics of the participants. That should be presented clearly
in a different table
• The t-test and ANOVA placed as footnotes below table 1 were confusing as the authors did
not indicate where these statistics were applied in the results.
• What does Mean±SD in table 2 refer to? If it is risk perception, it should be stated as such.
• The relevance of table 3 was not clear to me.
• Important Note: The objectives of this study did not capture the assessment of the relationship
between demographic characteristics, prevalence of potential risk factors and risk perception
scores. If these were part of what the authors had in mind. They should include them as part
of their objectives.
• The p values in table 1 do not compare the significant difference between on specific group
level and the other as interpreted by the authors, they only test the presence of association or
differences across the groups but does not tell you which group is significant compared to the
other. This need to corrected throughout.
• The authors stated that   ‘The low-risk perception of BC in the mentioned studies can be due
to the lack of knowledge of some women about breast cancer or the fact that they did not have
cases of breast cancer in their family and relatives. In Osei et al. study, 73% of the students had
never heard of breast cancer’. For these assumptions to be relevant, the authors need to show
that that knowledge of breast cancer and proportion of participants with family history of breast
cancer in their study were higher than the observations in the studies cited.
• The authors indicated that they included missing values in the result tables. Unfortunately, I
could not see them.
• What do they authors mean by complication in the statement below:
‘The morbidity or mortality of this complication #in married women can seriously affect various
aspects of children and spouses' physical and mental health and even the educational and work
future of children and their #spouses. Therefore, they pay more attention to their health #because
of it and would like to increase their awareness and understanding of the risk factors for this
#complication.#'
• Concerning the discussion on the relationship between breast cancer risk perception and oral
contraceptive pill use,the authors should note that ‘increase in risk perception’ is not the same
as ‘increased risk of breast cancer’ and should not be used interchangeably. This should be
corrected throughout the manuscript. Did the study by Osei etal deal with breast cancer risk
perception or breast cancer risk? The authors recommended that women's counselling is essential
in health care centres and private offices, especially in high-risk cases using #contraceptives’
This recommendation was not supported by their findings. It was rather derived from findings
of other studies. The authors need to provide possible reason why the risk perception was lower
among oral contraceptive pill users compared to observations in other study
• References should be provided for the statement highlighted in the paragraph that discussed
the association between risk perception and radiation exposure
•