Title: The effectiveness of group problem-solving therapy on women's sexual function and
satisfaction after mastectomy surgery
Version: 5 Date: 13 Oct 2021
Reviewer's report:
The revisions did improve the manuscript, but there are still areas that require additional
clarification and modification.
Abstract:
- Would probably refer to this study as an “open pilot”, since there was no randomization, rather
than “semi-experimental”.
- Please clarify what is meant by “clinically progressive” – as in, even after follow up, women
would still be classified as “sexually dysfunctional” based on the clinical cutoff of the FSFI,
which is 26.55? How might the intervention be modified to enhance outcomes? Additional
content? More sessions? Other strategies?
Introduction:
- Pg. 4, lines 65-68: I would soften the language here. Though breasts may be highly meaningful
to conceptualizations of femininity, breast cancer may be linked to fear, anxiety, and depression
for other reasons, beyond or in addition to the breast’s “importance in forming the female
identity”. I commented on this issue in my first round of feedback, asking the authors to clarify if
losing a breast is equivalent to losing the female identity in Iran, and to provide some references.
The authors provided some additional papers in the response to reviews, not in the manuscript
(from what I can tell), and the majority of the references do not speak to Iranian culture.
- Pg. 4, lines 78-79: It seems unlikely that “chemotherapy is the cause of all sexual problems”,
though surely it is a major contributor. Would hesitate to use absolute language here.
- Pg. 5, lines 95-98: This sentence needs to be broken down for clarity.
- Pg. 6, lines 102-110: Great inclusion of problem-solving therapy description. However, the
reference to Gaskell et al seems out of place and/or is not connected back to sexual function
post mastectomy.
Methods:
- Pg. 6, lines 119-120: Please clarify the admission criteria at the institute.
- Pg. 7, line 123: How were the 32 women selected?
- Pgs. 7-8: Please write out the inclusion and exclusion criteria in paragraph form or provide
them in a table.
- Pg. 8, lines 145-149: Please provide a rationale for the dropping criteria. Why did absence from
sessions trigger a drop rather than an exploration of barriers? Why were individuals experiencing
added stress, who could have benefitted from group-based counseling for sexual problems,
dropped?
- I’m copying the same comment on I made on the earlier draft here, relevant to Table
1 and the content of the intervention: Based on the content included in this table, it is
evident that the program was much more than a problem-solving intervention. There were
psychoeducational components, relaxation techniques, communication strategies, examinations
of sexual schemas…these components need to be reflected in the description of the intervention
and consistently throughout the manuscript. In the response to reviewers, the authors did clarify
the structure of the intervention and some sample assignments, they still frame the program as
a problem-solving intervention, which seems to be only one small component of a much larger
treatment package. Problem solving therapy is a very specific treatment modality, typically for
depression (see D’Zurilla & Nezu, 2010 and Bell & D’Zurilla, 2009, among others). I would
frame the intervention as cognitive behavioral, with problem solving as a component.
Results:
- Please ensure that tables adhere to APA style guidelines.
Discussion:
- Pg. 14, lines 241-243: I would frame the results as having statistical significance, noting that
they may not have been clinically meaningful, given that the mean FSFI score following the
intervention was below the clinical cutoff for sexual function.
- Pg. 15: Findings of previous studies are summarized in single sentence paragraphs
(e.g., “Hummel et al designed internet-based cognitive behavioral therapy improved sexual
dysfunctions in women treated for breast cancer, but the final result was not publish”) but not
interpreted in light of current findings. Although the discussion is improved from the previous
draft, it still requires significant work. One of the areas that I had emphasized in my earlier
feedback was hypotheses around key mechanisms – why did the intervention work or not work?
What were the ingredients of success? What elements might need to be modified or adapted to
increase efficacy?