Title: Prognostic nomograms for breast cancer with lung metastasis: a SEER-based population
study
Version: 1 Date: 15 Nov 2023
Reviewer's report:
Feedback for manuscript titled “Prognostic nomograms for breast cancer with lung metastasis:
a SEER-based population study”
This body of work is promising but requires minor revisions.
Abstract Methods: “We selected 1197 patients diagnosed with breast cancer with lung metastasis
(BCLM) from the SEER database and randomly assigned them to the testing group (n=837) and
the testing group (n=360).” – Please clarify which is the training group
“we evaluate the effects of multiple variables on survival and prognosis” – is there a difference
between survival and prognosis?
Usual convention is to use past tense in academic writing, please correct throughout manuscript.
“COX” is not an acronym and should not be capitalised.
Abstract Results: Several acronyms (HER2, ER, PR) have not been defined.
Disappointed to see a lack of references to support authors’ statements throughout the second
paragraph of the Introduction. Each statement made in the Introduction should be supported by
reference(s).
Introduction: “However, the survival prognostic nomograms of patients with breast cancer lung
metastasis have not been adequately studied, which may be limited to the influence of multiple
factors such as follow-up of the patients” – the wording of the last part of this sentence does
not make sense. Please clarify.
Introduction: “Our study will help clinicians better understand the survival and risk factors of
lung metastases and improving the prognosis by early intervention.” – the manuscript does
not discuss how prognosis can be improved. Either omit this or include a discussion of how
prognosis can be improved.
Please explain why the data used are 8 years old (up to 2015)
Materials and methods section: “The identification performances of the nomogram were
evaluated quantitatively by the Harrell concordance index (C-index) and the area under curve
(ACU)” – acronym should be AUC rather than ACU.
Materials and methods section: “Cox regression analyses were conducted to identify the
significant prognostic factors of OS using the backward stepwise method. Odds ratios (ORs)
with 95% confidence intervals (CIs) were calculated” – Cox regression produces hazard ratios,
not odds ratios.
Results section: Please add the median and range of the follow-up period for the two cohorts
and overall.
Results section: “The consistent and inconsistent characteristics of the training group and testing
group are shown in Table 1.” – If there are inconsistent characteristics between groups please
describe these in the text. Also summarise in the text which characteristics are consistent between
groups, and what the significance is of any inconsistencies.
Results section: “In the training group, the AUC values for the nomograms to predict 1-, 2-,
3-year OS were 0.798, 0.79, and 0.793, respectively” – please be consistent in the number of
decimal places used.
Table 3: the 95% confidence intervals for IDI are missing. P values should be presented for both
the NRI and IDI separately.
Table 3: “The net reclassification improvement and egrated discrimination…” – is “egrated”
an error?
Figure 3: Please add legends for the solid and dashed lines
Figure 4: The appearance of the lines in the legend does not match the appearance of the lines
in the figure.
Discussion section: “In addition, we constructed variable factors related to the prognosis of lung
metastases and verified nomograms to precisely predict the prognosis of BCLM patients.” –
omit “precisely” as AUC values are modest (<0.8)
Discussion section: “The nomogram can completely reflect the individual differences of patients
because it quantifies the risk non-invasively and quantitatively on a macro scale, which makes
the nomogram have better performance in predicting OS than the traditional TNM staging.”
– there are several issues with this statement. i) omit “completely” because as you have
mentioned in the discussion, other variables may be present that are unaccounted for. ii) omit
“non-invasively” because the histopathology results depend on biopsy which is invasive. iii)
what do you mean by “a macro scale”?  iv) Using “quantify” and “quantitatively” in the same
sentence is redundant.
Discussion section: “our nomograms demonstrated that young patients (<35) have a better
prognosis, which is different from previous studies.”
- Two issues: i) you mention multiple previous studies but have only referenced one study. ii) if
there is a difference in findings between your study and other studies, you need to discuss why
this might be the case, taking into consideration the characteristics of these other studies.
Discussion section: “Chemotherapy and neoadjuvant therapy significantly improve the
prognosis of patients with BCLM.” – you need to reference this statement.
Discussion section: “Although some studies do not support neoadjuvant therapy has a positive
effect on the long-term survival of MBC patients, our nomogram suggests that neoadjuvant
therapy is beneficial for the survival of patients with BCLM”
- Two issues: i) you need to add references to these studies. ii) if there is a difference in findings
between your study and other studies, you need to discuss why this might be the case, taking
into consideration the characteristics of these other studies.
Discussion section: “It may be because neoadjuvant therapy can help clinicians transition from
‘clinic-based choice’ to ‘molecular-tailored chemotherapy’” – please explain what the terms
‘clinic-based choice’ and ‘molecular-tailored chemotherapy’ mean.
Discussion section: “we found that the prognosis was worse when a patient was in a relationship
of "divorced" or "widowed" than “married” or “unmarried”.” – change to “relationship status”
rather than “relationship”.