Reviewer ’s report  
 
Title: Relationships between determinants of adjuvant endocrine therapy adherence in breast  
cancer 
 
Version: 0 Date: 14 Apr 2017  
 
Reviewer: Shoshana Rosenberg  
 
Reviewer's report:  
 
The authors present an interesting conceptual framework and methodological approach to 
evaluate the relationship and interplay between a range of demograp hic, clinical, psychological, 
and endocrine therapy specific factors and adherence to endocrine therapy. Comments regarding 
the manuscript are detailed below:  
 
 
 
Background:  
 
page 2 - "To reduce the risk of recurrence and mortality in women diagnosed with ho rmone 
receptor positive breast cancer, current guidelines generally recommend 5 years of adjuvant 
endocrine therapy (AET)"  
 
- Current ASCO guidelines recommend up to 10 years  
 
 
page 2 - "Early discontinuation or non -adherence to AET leads to increased mortal ity" 
 
- Leads is a very strong word; would change to has been "associated"  
 
page 2 - "The association between AET adherence factors has not been investigated in detail to 
date."  
 
- Can the authors clarify more explicitly how the studies they just cited are different from what 
they are proposing to do? It seems these studies did investigate factors associated with adherence  
 
 
 
Results  
 
Page 6 "A total of 210 women (patients) participated in the study and completed the survey."  
 
 
- Can the authors provide more detail about the response rate, e.g., number of women 
approached vs. ultimately participated. Of women who participated, did all women complete the 
survey? Did the authors collect information about non -participants and how th ese women might 
be different than those who participated?  
 
 
Page 6 - "When a MMAS score of 6.0 or above (MMAS ≥6.0) was used as the cutoff for the 
adherence group…"  
 
 
- Can the authors provide justification for using this cutoff? Is it clinically meaningfu l? Did the 
authors consider any sensitivity analyses using different cutoffs?  
 
 
Higher depression caused higher concerns beliefs, lower self -efficacy, and consequently lower 
adherence to AET.  
 
 
- b/c this was a cross -sectional , cannot determine  
 
 
 
 
Discussion  
 
Page 10 - "The study identified AET regimen type and cancer stage as demographic/medical 
factors of AETadherence, depression as a psychological factor, and belief and self -efficacy as 
ET-specific factors."  
 
- Though the difference in scores is statistically significantly different, can the authors comment 
on whether these differences are clinically relevant?  
 
 
- Also, AET regimen/stage were significant in a descriptive analysis, it's possible in a 
multivariable analysis, they would not be. Also, in the sequenti al effects analysis, stage was not 
significant in any model and ET regimen was only significant in Model 3. Can the authors justify 
their conclusions more robustly (e.g., beyond what they found in the descriptive analysis that 
informed their model selectio n)?  
 
 
Page 11 - "Previous studies suggest that participants who are anxious or depressive in the early 
stages of treatment are likely to be motivated to take medication."  
 
 
- Can the authors provide more evidence for this? Please see the following review/met a analysis 
for a different conclusion. (DiMatteo et al. 2000. Archives of Internal Medicine)  
- 
 
Page 11 "Higher depression caused higher concerns beliefs, lower self -efficacy, and 
consequently lower adherence to AET."  
 
 
- Given the cross -sectional nature of this study, the authors should be careful about inferring 
causation in any findings.  
-  
 
Page 12 - The authors should consider adding an additional limitations about the study sample, 
mainly that it was identified based on women coming to clinic who are li kely a select population 
on some level; if they are engaged in regular medical follow -up than they might be more likely 
to be adherent, e.g., might be more likely to have someone helping them deal with bothersome 
side effects which can affect adherence.  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects req uire further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following qu estions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing i nterests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
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