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: 
03 Aug 2022
Reviewer's report:
PEER REVIEWER ASSESSMENTS: 
OBJECTIVE - Full research articles: is there a clear objective that addresses a
testable research question(s) (brief or other article types: is there a clear
objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols)
appropriate for the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with technical rigor
to allow confidence in the results?
Not sure - key details are missing from the manuscript
STATISTICS - Is the use of statistics in the manuscript appropriate?
Not sure - I am not able to assess the statistics in this study
INTERPRETATION - Is the current interpretation/discussion of the results
reasonable and not overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work
technically sound? If not, can revisions be made to make the work technically
sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS: 
GENERAL COMMENTS: 
Prospective cohort studies are ambitious and challenging to conduct. The study
seems to have been reasonably well conducted, although important elements of
the methods and results are not well reported. Reporting does not meet STROBE
guidance for cohort studies.
REQUESTED REVISIONS: 
1. The rationale for the study is very brief, and would benefit from a more
considered review of the recent literature. There is a sizeable body of literature
describing and predicting the pattern of adjustment, as well as the longitudinal
trajectory of quality of life, among women diagnosed with breast cancer. This
literature is not included in the background section of the manuscript so it's not
clear how this study seeks to build upon existing knowledge and/or overcome the
limitations or gaps in the literature. 
2. Additional information about the study methods is required to allow an
assessment of scientific quality. It is suggested that the authors refer to the
STROBE checklist: cohort studies (www.equator-network.org/wp-
content/uploads/2015/10/STROBE_checklist_v4_cohort.pdf) for reporting. 
Some examples of issues not adequately described are: 
a. data collection: how were the quality of life measures administered (e.g. self-
report? health care provider-administered?) and what was the mode of
administration (e.g. online? paper-and-pencil?)
b. measures: a very limited range of baseline characteristics (type of surgery,
age, family status, employment status ) were considered. Other studies have
found that characteristics such as income, education, comorbidities, perceived
social support, BMI, physical activity are associated with patterns of
psychosocial wellbeing and emotional functioning. What was the rationale for
the variables selected? This is likely to be a limitation of the study and should be
acknowledged in the discussion.
c. analysis: there is a considerable amount of missing data due to attrition/loss to
follow-up. How many participants completed the survey at each of the data
collection points? Did any participants skip a data collection time point (e.g.
completed baseline, skipped 6 month follow-up but completed 12 month follow-
up). What were the reasons for attrition and how may these bias the data ? How
were missing data dealt with in the analyses? Were those who had complete data
different to those who were lost to follow-up on key characteristics associated
with the outcomes of interest? If there are differences, what is the impact on the
study findings e.g. are they likely to have led to an under- or over-estimate of
functioning and wellbeing? The high rate of attrition should be acknowledged as
a limitation in the discussion section. 
3. While the authors have considered statistically significant changes in scores
over time, it would be relevant to consider clinical significance. For example, do
the changes in scores represent minimal clinically important differences?
Additionally, do the scores reflect 'high' levels of functioning or wellbeing at
baseline? Moreover, do the subsequent changes in scores still place them in the
'high' level of functioning and wellbeing? It would also be relevant to discuss the
scores in the context of reference values given these values exist for both of the
quality of life tools used in this study. The interpretation of the scores and their
changes over time is important for the utility of the findings. 
The utility of having identified characteristics associated with outcomes is not
well covered in the discussion. These characteristics form a profile of patients
who may be targeted with increased psychosocial screening and monitoring, or
indeed early intervention strategies. Ideally, these characteristics would be
amenable to change, however, a limitation of this study is that few
characteristics were examined and half are not amenable to change.
ADDITIONAL REQUESTS/SUGGESTIONS: 
No
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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?
No
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
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Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes