Title: Adherence to oral anticancer hormonal therapy in breast cancer patients and its
relationship with treatment satisfaction: an important insight from a developing country
Version: 0 Date: 20 Oct 2022
Reviewer's report:
Thank you for your manuscript. It is certainly interesting to study the correlation of treatment
satisfaction as a modifiable factor for adherence.
Below are some comments for your consideration
The overall manuscript can be written in a more succinct manner. There are too many connectors
and some not used appropriately.
Decimal place for numbers shld be used consistently.
Introduction
Introduction shld be rewritten
Paragraph one is long and confusing as there are many points and do not flow well, e.g.
breast cancer statistics, its treatment options, hormonal therapy, treatment satisfaction; suggested
change: breast cancer is common, hormonal therapy
Paragraph two is also hard to read because it also has many single sentence points that do not
flow, i.e. treatment satisfaction and adherence, adherence (randomly quoted), adherence and
disease-free survival; suggest to reorganize to: adherence to hormone therapy increase disease-
free survival, previous published adherence from systematic reviews, factors affecting adherence
to hormonal therapy
Suggestion for paragraph three: there are limited report on endocrine therapy adherence in
Palestine, therefore study objective (1) determine adherence, (2) study factors associated to
adherence
Basically suggest to keep introduction brief with points that flow well
Citations shld also be improved, for example
1) Suggest to cite worldwide data (such as GLOBOCAN) on breast cancer statistics mentioned
in the first 5 rows of introduction (i.e. reference 1-4 shld be replaced). Current statements are also
a mixture of worldwide data and US data according to citation provided, need to be consistent.
2) Adherence to hormonal therapy is widely published, hence suggest to cite systematic review
instead of random individual study (unless it is specifically for adherence previously studied in
your country or similar setting)
Methods
The methodology is generally ok, however, there is a major flaw in the design where authors used
the Medication Adherence Rating Scale (MARS) which is validated for psychiatric disorder.
Note that MARS is not the Morisky scale, although it was developed with the inclusion 4
questions from the Medication Adherence Questionnaire (MAQ) by Morisky et al. The other
questions are from the Drug Attitude Inventory.
The references cited by author on this (ref 19 and 20) are also not appropriate, where ref 19 is
the use of MARS for pain medication in cancer patient (a symptomatic condition which would
be very different from author’s study subject), and ref 20 is using a different set of 8 questions
relevant to author’s study subject i.e. endocrine therapy adherence in breast cancer patient.
My suggestion to author is to repeat the analysis using only the first 4 questions (basically
Morisky’s MAQ, may need to get permission from Morisky et al) to assess adherence.
Other suggested edits are as follows
1) Page 5, line 10-11, “…women breast cancer patients” is not data, so suggest to change to
“women breast cancer patients’ interviews”
2) Page 5, line 12, “…interviewing all women...” I believe not all women with breast cancer
participated in the study, so suggest to omit “all”, and
3) Page 6, line 2, suggest to add “recommended” before “sample size”
4) Page 6, line 8-10, the sentence is rather hard to read as there are multiple “or”, suggest to
rephrase the sentence
5) Page 6, line 13, what is a “self-selection method”
6) Page 6, line 18-23, there are many variables listed, suggest to include only variables reported
in the results to be listed, or refer readers to table 1
7) Page 6, line 19, typo, shld be “marital status”?
8) Page 7, line 16, suggest to change to “…overall satisfaction using 14 items.”
9) Page 7, line 16-18, may I know how are effectiveness, side effects, convenience and overall
satisfaction “addressed”? isn’t the questionnaire to evaluate these domains as stated in previous
sentence?
10) Page 7, line 19, suggest to change to “…better satisfaction”
11) Page 7, line 21, being used in several publications may not be important, the important thing
is whether it has been validated in Palestine?
12) Page 8, line 18, prob helpful to state why continuous variables were expressed in median
and interquartile range, e.g. “Continuous variables were ??, hence expressed using median
and interquartile ranges” The mention of normality test can be brought forward earlier in the
paragraph
Results
Please repeat analysis of adherence using only item 1-4 of MARS, otherwise this paper cannot
be accepted.
Other comments are.
1) Page 9, line 7, this statement is confusing, “a total of 121 patients participated, and 15 refuse
to participate…” is it that 121 patients were recruited?
2) Page 9, line 9-12, suggest to highlight demographic factors that are the majority e.g. age:
53.8% are aged 45-65, and not all demographic factors need to be highlighted in the text. Readers
can refer to your table.
3) Page 9, line 10, suggest to remove mention of “female” patients, as all included participants
are female, it is confusing when female patient is mentioned because it implies that there are
male patients involved. Same applies to the remaining of the manuscript.
4) Page 9, line 13, suggest to include “other” before “chronic drugs” as hormonal drug is a
chronic drug itself, so here I believe you are referring to other chronic drugs (not including
hormonal drug)
5) Page 10, line 5-7, “median rank” should be typo, it should be “median”
6) Page 10, line 11-12, “there was significant differences…”? should it be “significant
correlation”? “…including…” should be “…for…”?
7) Page 10, line 14, “…had the highest satisfaction scores…” should be “higher”?
8) Page 10, line 21, “The median of each was…” should be “The median score of each domain
was…”?
9) Page 10, line 23, “the menopausal status variable was statistically significant with…” should
be “the menopausal status was significantly correlated with…”?
Discussion
Discussion should also be rewritten
The current version discussed about adherence, treatment satisfaction, demographic factors
associated with adherence, then back to treatment satisfaction. Try to keep the flow simple.
Usually we “answer” our objective in the discussion section. If you take my suggestion from
the introduction, your discussion will start adherence, then demographic factors and treatment
satisfaction associated with adherence. If you would like to include recommendation to improve
adherence (which you did towards the end of the first paragraph of discussion), I suggest you
include that as part of your objective, and include that as your last paragraph of discussion.
Regarding citations
1) Do cite the relevant study if statements are not findings of the study or postulation by the
authors
2) For citing other studies related to adherence, suggest to keep to systematic review only given
there are so many studies on it already. It is not appropriate to cite random individual study from
various countries, unless these are major studies done at national or international level. Citing
of adherence to gonadotropin-releasing hormone analog is also not relevant to the study
3) For citing other studies related to factors associated with adherence/non-adherence, do keep
it to studies relevant to the factors your study evaluated e.g. “changes from brand products to
generic ones” seems irrelevant
Conclusion
Page 14, line 16-18, please review the article cited. I believe the conclusion has to do with lack
of literature on relationship between psychosocial factors and adherence to hormonal therapy in
breast cancer because it differs from the relationship in other chronic condition.
References
Please review your references as I noted reference 21 and 25 are identical references
Tables
Table 1. For “Duration of starting current hormonal therapy”, please define what is > or < 1,
is it 1 year?
Table 2. For “Median [Q1-Q3]”, please use consistent number of decimal place
Thank you!