Reviewer’s report
Title: 
Lifestyle modifications after the diagnosis of gynecological cancer
Version: 
2 
Date: 
09 Dec 2020
Reviewer's report:
Comments to Authors:
The authors presented a study on lifestyle modifications after the diagnosis of
gynecological cancer. I believe that the topic of the article is very actual and
interesting. In my opinion, the study is well conducted and both its results and
the comparison of these with current literature data, in the discussion, are well
presented. I suggest to provide more detail in "materials and methods" section
and a clearer explanation of the objective of the study. I enclose some
suggestions.
Abstract:
* I suggest to more clearly explain the purpose of the study in the background.
* Line 22: "…All patients with a gynaecological malignancy who underwent
surgery for this malignancy…"; I suggest not to repeat the word "malignancy" in
the same sentence.
Background:
* Lines 75-76-77: "…Some data suggest that 58% of long-term cancer survivors
are overweight, 25% continue to smoke, 50% exercise and less than 20% report
a sufficient fruit and vegetable consumption…"; please report the source of the
data.
* I suggest to clearly explain the purpose of this study at the end of the
background with a sentence as "the aim of the study is..."
Materials and methods:
* I suggest briefly specifying the nature of the study at the beginning of this
section.
* "Study population": I suggest to specify on which occasion the consent of the
patients to participate in the study was obtained
* Line 166: "…the mental capacity to understand the questionnaire…"; can you
specify in more detail what you mean and how this parameter was evaluated?
* "Questionnaire": 
at the beginning of this section I would explain how the
questionnaire was developed: were there any previous questionnaires in the
literature that were scientifically validated on the subject that inspired the
authors? otherwise I would state that there are no previous sources; I also suggest
explaining in detail the process by which the questionnaire was created. Please
consider this https://doi.org/10.3389/fpubh.2018.00149 as help
Results:
* It would be interesting to specify the minimum and maximum time elapsed
between surgery / cancer diagnosis and the interview. To indicate the minimum
time between surgery and interview could give us some insights about the role of
surgery on lifestyle changes.
* Would it be possible to describe how patients are divided by gynecological
malignancy? And their stage/prognosis?
* Line 233: "…Four patients reduced their tobacco intake und and eight
patients…"
* I would report in a more precise or homogeneous way the references to figures
and tables in the text, in particular the references to figure 1, table 1, table 3,
table 5, figure 2, are not reported in the text;
* Data reported in table 2 ("Lifestyle changes in relation to several variables")
are erroneously reported as "table 3" in the text relating to the comment of the
results from line 219 to line 228. 
* "Fruits/ vegetables" Line 260: "…the recommended five servings of fruits/
vegetables per day...", please cite here or in the materials and methods section
the source of this criteria. 
* "Consumption of meat" Lines 266-267: "…Assuming 125-150g meat per
serving, eating meat is recommended to be limited to a maximum of two times
per week…", please cite here or in the materials and methods section the source
of this criteria.
* "Fast food/ sweets": Line 274: "…There are no clear recommendations
regarding the daily or weekly intake of fast food/ sweets…", please cite here or
in the materials and methods section the source of this sentence.
* Line 316-317-318 "Patients who managed to increase their physical activity
after diagnosis ... had a higher education level" ; it does not seem possible to
draw this conclusion from the values shown in table 7; although these statements
were also drawn from the values reported in tables 2 and 6, in the latter, even in
the absence of statistical significance, the careful comparison of the data could
allow us to draw conclusions of this type; I do not believe however that this
same conclusion can be drawn with regard to the education level on the basis of
the data reported in table 7.
* "Level of stress": I would suggest describing the way in which the level of
stress (self-assessment and ordinal scale) was evaluated, in the materials and
methods section and subsequently only present the results obtained.
Discussion:
* Line 456: "…Current and prior smoking habits were recorded in order to
assess potential changes in smoking...": here I would insert "in our study" to
better make the reader understand that you are now talking about your results.
* From line 479 to line 490 it is not obvious to the reader whether you are
referring to your own data.
* In this section I would also suggest to underline the importance of the ERAS
programs which in the preoperative phase promote the cessation of smoking and
alcohol as well as paying particular attention to the evaluation of patients'
satisfaction and their psychological state. The ERAS protocols also promote a
preoperative nutritional screening and, in those who are most at risk of
malnutrition, as patients affected by cancer of the ovary, support during all
stages of the care process. Please consider to cite this article
https://doi.org/10.1016/j.ajog.2020.07.003 to provide optimal overview.
* I would add a section that sets out the limitations (eg retrospective nature) and
strengths of your study.
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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?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes