Title: The Mediating Effect of Intrusive Rumination on The Relationship Between Illness
Uncertainty and Fear of Recurrence in Breast Cancer Survivors
Version: 2 Date: 16 Dec 2024
Reviewer's report:
This cross-sectional study of 204 women diagnosed with breast cancer examined rumination
as a mediator of the association between illness uncertainty and fear of cancer recurrence.
The proposed model was supported. The manuscript presents a straightforward and interesting
finding that appears to be supported by theory. However, the writing is a bit difficult to follow
and obfuscates some of the points the authors make. The presence of multiple theories and
writing distracts from the importance of the results or the implications for treatment and future
research. Some specific comments for each section are listed below.
Abstract:
- Conclusion section seems to go beyond the study's data:
o “Planning social support and psychoeducation programs during follow-up to reduce illness
uncertainty may positively affect FCR” (This study did not measure social support, so it is
unclear the connection of this sentence to this particular study).
Introduction
- It is unclear how Leventhal’s Common Sense Model of Disease is connected to the blended
model of fear of cancer recurrence developed by Lebel and colleagues. It would be easier for
the readers to follow if the Common Sense Model of Disease is described more in detail after
elaborating on the blended model of fear of cancer recurrence. Also, a visual for the “Common
Sense Model of Disease” (or the “blended model”) may be helpful if space allows.
- Relatedly, adding background information, or a summary of prior literature on the relationships
between FCR, illness perceptions, and rumination would help bolster the credibility / necessity
for the present study. Are there any studies looking at FCR and IU, or FCR and rumination?
- The reference #11 at the end of the sentence describing the Common Sense Model of Disease
and the blended model appears to be miscited. The more relevant reference would be the
following:
o Lebel, S., Maheu, C., Tomei, C., Bernstein, L. J., Courbasson, C., Ferguson, S., Harris,
C., Jolicoeur, L., Lefebvre, M., Muraca, L., Ramanakumar, A. V., Singh, M., Parrott, J., &
Figueiredo, D. (2018). Towards the validation of a new, blended theoretical model of fear of
cancer recurrence. Psycho-oncology, 27(11), 2594–2601. https://doi.org/10.1002/pon.4880
- In general, the writing style obfuscates the point being made (which does seem to be
theoretically sounds and interesting).
- Would help to end with a clear statement of hypothesis(es). The intro ends stating “aimed to
investigate the effect of rumination on the relationship between IU and FCR” but the specifics/
direction of effect isn’t stated.
Methods
- Was this study preregistered?
- Data analyses: “Relationships between study variables were measured using Pearson
correlation coefficients for continuous scales.” Would help to clarify why these correlations were
conducted. Was this to evaluate a hypothesis? Also, it would be helpful to include information
on the covariates the authors considered for the mediation analysis.
- In the “2.1 Study Design and Participants” section, it would be helpful to clarify whether
participants recruited for this study are patients or survivors. It seems like the authors recruited
cancer survivors for the study since they report descriptives on “time since treatment” in the
Result section but this information is not clear in the methods section.
- In the “Fear of Cancer Recurrence Inventory” paragraph in the “2.3 Variables” section, it would
be helpful to mention that the FCRI Severity subscale is also referred to as the “Fear of Cancer
Recurrence Inventory-Short Form.” Also, what does the “cutoff value” of 12 indicate on the
FCR?
- In the “Mishel Illness Uncertainty Scale” paragraph in the “2.3 Variables” section, the first
sentence does not have a reference. Please add a reference for this sentence.
- In the “2.3 Variables” section, it would be helpful to add information on the range of scores
and the value used in the analysis (e.g., total score vs. subscale scores for the Mishel Illness
Uncertainty scale).
Results
- Table 1 could be formatted in a more concise way (no need for range column and N/% columns
could overlap with M/SD columns).
- It is not clear why this sentence is included in 3.2 rather than the next paragraph, which seems
to be about demographic factors’ association with study variables:
o “When the relationship between the demographic characteristics of the participants and FCR
was examined, no significant difference was found in FCR scores between cancer stage, marital
status, and education level.”
- Paragraph 3.3 examines the differences in clinical/demographic factors with study variables.
It seems that years since diagnosis was not examined. I imagine this could be related to FCR
and so would make a reasonable covariate (this could just be a correlation). Also, age could be
left continuous when examining its association with .
- Were the relevant demographic/clinical characteristics used as covariates in the SEM?
Discussion
- It would be helpful to combine and shorten the paragraphs (e.g., paragraphs 3-6 in the
discussion section) describing the differences in FCR, IU, and intrusive rumination in regards
to sociodemographic and clinical characteristics into 1 paragraph.
- There are several theories and paradigm mentioned in the discussion section, which makes it
difficult for readers to understand how similar/different these findings are compared to previous
findings and what value the findings from the current study adds to the existent literature.
- In the “Limitations” paragraph, please include the use of cross-sectional data when conducting
mediation analyses. Generally, mediation analyses include data collected in at least two different
time points. This study involves cross-sectional data, which precludes the authors from being
able to detect a causal mediation effect.
- General rewording/rephrasing/improving writing as well as grammatical revisions would help
clarify the significance of the findings in the present study. The presence of multiple theories
and related jargon distracts from the importance of the results or the implications for treatment
and future research.