Title: The effectiveness of group problem-solving therapy on women's sexual function and
satisfaction after mastectomy surgery
Version: 2 Date: 02 Jul 2021
Reviewer's report:
Thank you for the opportunity to review this manuscript, which describes an open trial of an 8
session sexual dysfunction intervention for women with breast cancer in Tehran. The authors
should be commended for their work in this important area; however, there are a number of
issues that need to be addressed. Notably, the manuscript requires extensive English language
editing. My review focuses on content; I refrained from commenting on language issues.
Title:
- The title is a little wordy and unclear. I recommend a change to “The effectiveness of
group problem-solving therapy on women’s sexual function and satisfaction after mastectomy
surgery”.
Abstract:
- Line 30: Which problems are being referenced? Please clarify.
- Line 31: Please remove “quantity” or clarify what “quantity of patients’ life” refers to.
- Line 39: I might briefly mention a few key components of the intervention – was it entirely
problem-solving?
- Lines 46-48: Rather than including the raw numbers, please include the statistics and associated
p values.
- Lines 51-55: The authors seem to be undercutting their findings at the very outset of the
conclusions. I might rephrase to indicate that the open trial of the intervention led to significant
improvements in both sexual function and sexual satisfaction, then note that, even with the
significant improvements, sexual function scores still fell below the clinical cut-offs. I would
also reference the lack of a control group as a limitation.
Background:
- Lines 64-69: These sentences are fairly repetitive. I would pare down the text here and move
more quickly into incidence of breast cancer in Iran.
- Lines 74-75: The authors state that “losing this organ is mostly interpreted as losing the female
identity”. I’m not sure that this is universally true; if this is the prevailing sentiment in Iran,
could the authors include some relevant citations? The same is true for the sentence that starts
on line 82 – seems like an overgeneralization.
- Lines 64-83: There is a lot going on in this paragraph. For clarity, I would break it down into
two paragraphs: (1) one that highlights the prevalence of breast cancer in the world/Iran and
discusses associated psychosocial challenges, and (2) one that discusses surgical options and
points to the identity/spiritual implications of those options.
- Lines 84-87: This is an incomplete definition of sexual dysfunction – please also address
arousal and satisfaction. There are numerous papers that might be helpful here (e.g., McCabe et
al., 2016; Derogatis et al., 2016; Parish et al., 2016; Parish et al., 2019).
- Lines 91-93: It is unclear what is meant by “sexual changes affecting sexual function”, as many
of the changes mentioned are aspects of sexual function.
- Line 101: “Multilateral” is likely not an appropriate word here – “complex” or
“multicomponent” might work better. Similarly, “bilateral” in line 106 does not convey the
meaning that the authors likely intend to convey.
- Lines 109-110: What types of counseling programs have been shown to improve sexual
function and satisfaction among women with breast cancer? Have problem-solving approaches
been used with success before? The authors need to provide a stronger and clearer rationale for
their approach.
- Lines 111-115: Please clarify what problem-solving therapy entails. How does it incorporate
or reflect cognitive behavioral principles?
- Lines 123-126: Please cite appropriate Iran-based references here.
Methods:
- Line 135: The study is empirical, not semi-empirical. It is, however, not experimental given
that it is not randomized by design.
- Line 139: How were participants selected for invitation?
- Lines 147, 150: Please justify the choice of age range and the marital status requirement.
- Lines 169-170: Please include appropriate references for the FSFI and the Larson measure.
Have both been validated in Farsi? Line 185 – is 28 the cutoff for the version of the FSFI that
has been validated in the local language? Please clarify.
- Table 1: Based on the content included in this table, it is evident that the program was
much more than a problem-solving intervention. There were psychoeducational components,
relaxation techniques, communication strategies, examinations of sexual schemas…these
components need to be reflected in the description of the intervention and consistently
throughout the manuscript.
Results:
- Line 240: By “sexual stimulation”, are the authors referring to “sexual arousal”? Unless the
domains of the FSFI differ in the Iranian version of the measure, sexual stimulation is not a
domain.
- Line 244: Please include relevant statistics here.
- Table 4: What is “motivation sexual”? Should be arousal, I believe.
Discussion:
- Lines 267-269: Are these figures specific to Iran? Please include appropriate citations.
- General comment: I would break down the discussion into the following categories/paragraphs
to help tell the story of the findings to the reader. Some of this content is already in the discussion,
but it needs to be clarified and/or succinctly summarized:
o (1) Summarize key findings
o (2) Review the ways in which key findings either align with or deviate from previous research
on populations of women with cancer, either in Iran (if data are available) or elsewhere. I would
limit this section to brief comparisons to 2-3 other studies, at most. The authors currently review
many studies, in excessive detail, in very long paragraphs that are difficult to read.
o (3) Hypotheses around key mechanisms: why did the intervention work (or not work)? What
were the ingredients of success?
o (4) Limitations of the study and its analyses
o (5) General conclusions