Title: Racial Disparities Between Measures of Area Deprivation and Financial Toxicity, and
Uterine Volume in Myomectomy Patients
Version: 1 Date: 11 Sep 2023
Reviewer's report:
Summary: The authors examined the relationship between two sociodemographic measures,
financial toxicity and area deprivation, and uterine volume as potential explanations for why
Black women tend to have larger uteri at the time of presentation for fibroid treatment, compared
to white women. This difference in uterine volume has implications for choice of treatment
modality and, subsequently, clinical and patient-reported outcomes, contributing to ongoing
harms and disadvantages Black women experience when seeking health care. This study is a
secondary analysis of an established cohort and builds on prior publications. Race was self-
reported and reported separately from Hispanic ethnicity. Financial toxicity and area deprivation
were based on validated measures used frequently in clinical and epidemiologic research. The
manuscript is clear, well written, and easy to follow.
Major Comments:  More explanation is needed to justify how these specific sociodemographic
measures help identify avenues to address barriers to care and equitable participation in shared
decision making for Black women. There is a notable gap between the study objectives, main
analysis and presentation of results, and the conclusions. Because prior work is cited, especially
Wegienka et al. in reference #20, the present analysis should stand out more. Of note, race itself
is not really addressed in the regression analysis aside from inclusion as a clustering variable,
which is an unusual approach requiring more explanation. Tables 2 and 3 and the accompanying
text results are rather limited. This part of the paper reads as though something else more
comprehensive was planned and either forgotten inadvertently or omitted.
Specific comments addressing these concerns and minor comments are below.
1. Abstract – Results: Include the 95% CIs for the percent change effect estimates.
Introduction:
2. Lines 75-76: “Black women are more likely than White women to schedule uterine-sparing
treatments.” Consider more detail for those unfamiliar with fibroid treatments (myomectomy,
UAE vs. hysterectomy) and perhaps cite reference #20 here.
3. Lines 96-102: Not all readers will readily understand the concept of financial toxicity nor be
familiar with the ADI. While these are described in the methods, consider adding more detail
on how these concepts/measures are useful in assessing sociodemographic factors’ impact on
both access to care and life stressors contributing to worse outcomes. If space is a constraint,
remove some of the registry and uterine volume measurement details as these are described in
the methods.
Materials and Methods:
4. Line 105: Consider a comma here: “single longitudinal cohort, COMPARE-UF”
5. Line 107: Consider removing a comma here: “eight clinical sites and two additional”
6. Lines 115-116: Explain why the UAE group was omitted from the study and why
myomectomy approach (open vs. minimally invasive) was not considered as a secondary
outcome.
7. Lines 144-145: Please clarify if the Wilcoxon rank-sum/Mann-Whitney-U test was used
to compare continuous/ordinal variables. While the description here was used in a previous
publication by the research group, using a more standard test (or description thereof) is preferred
and more accessible to readers with limited statistical knowledge. Note, Stata documentation
does not appear to use this terminology either.  Also, if the distributions deviated from a
normal distribution, the median and interquartile bounds would be more meaningful for both
independent variables and the dependent variable.
8. Lines 147-150: The results section on line 168 mentions adjustment, so describe both
unadjusted and adjusted models, and why those covariates were chosen. Please provide
references to justify use of robust SEs clustered by race. This approach seems at odds with
the study objectives. Race as an effect measure modifier/moderator of the associations between
financial toxicity, ADI, and uterine volume would be more appropriate, with robust SEs to
accommodate remaining deviations from normality after log transformation of uterine weight.
At present, race is not contributing to the analysis aside from adjusted variance estimates.
Additionally, assess whether the assumption of linearity was feasible for financial toxicity and
ADI. This is a major limitation of the paper that needs to be addressed.
Results, Tables, and Figures:
9. Figure 1: List non-myomectomy treatments other than hysterectomy. Were they all UAE?
10.Figure 2: The y-axis is density not percentage. It would be helpful to include two other plots
to show the distributions of financial toxicity and state-level ADI by race.
11. Table 1: Enclose SDs in parentheses to make this easier to read. Or, replace with medians and
interquartile bounds as suggested in the methods comment. Note the possible range for Financial
Toxicity Score and ADI in the footnotes next to the interpretation. Confirm the top age group is
up to 55 and not 54 as listed in the methods study population description.
12. Lines 162: Why not add the breakdown by myomectomy approach and uterine sizes by race
(see item #6)? It’s mentioned in the introduction, discussion, and conclusion, so even if the
numbers are small, reporting it is sensible.
13. Lines 167-168: Include details of adjusted regression in the methods (see item #8) and add
to the combined tables 2 & 3 (item #14).
14.Table 2: This table is incomplete and would benefit from combination with Table 3 and
better organization. Include both the model betas and percent change, along with 95% CIs
and one p-value (will be the same). Note, percent change is 100 x exp(beta) – 1. Include the
unadjusted and adjusted models, as well as any stratified or stratified contrasts by race. See
analysis recommendations in item #8.
15. Table 3: Combine with Table 2 and expand.
Discussion:
16.Lines 186-193: Address why this study didn’t examine these associations in other fibroid
treatment groups.
17. Lines 202-203: Comment, if possible, on the relationship between financial toxicity, area
deprivation, and other health outcomes for Black or other marginalized people. It would put this
study in context.
18. While the authors note that causal interpretations are not possible, reviewing the causal
inference literature on studying racial disparities may be helpful. One example: Chanelle J
Howe, Zinzi D Bailey, Julia R Raifman, John W Jackson, Recommendations for Using Causal
Diagrams to Study Racial Health Disparities, American Journal of Epidemiology, Volume 191,
Issue 12, December 2022, Pages 1981–1989, https://doi.org/10.1093/aje/kwac140
References:
19. Please check for consistency and completeness of citations in the reference list. For example,
there are duplicates for the COST reference (#11 and #17) and the COMPARE-UF’s design
reference (#10 and #21).