PONE-D-24-13898‘‘Mitigating Cancer Pain: What else Matters?”—A Qualitative Study into the Needs and Concerns of Cancer Patients in Sri LankaPLOS ONE

Dear Dr. Edirisinghe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Surangi Jayakody, MBBS, MSc, MD

Academic Editor

PLOS ONE

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2. Thank you for stating the following financial disclosure: 

“This study was funded by the Cancer Research Center, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka (Grant No: 002/2017)”

Please state what role the funders took in the study.  If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" 

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, the article presents valuable insights into the needs and concerns of cancer patients in Sri Lanka regarding pain management. It effectively highlights the significant impact of cancer pain on patients' daily lives and emotional well-being, shedding light on the challenges they face. The use of qualitative methods allows for a deep exploration of patients' experiences, adding depth to the discussion. However, there are areas where clarity and consistency could be improved, as mentioned below related to each component;

Abstract- To enhance the abstract, it would be beneficial to include a sentence on cancer prevalence and trends in Sri Lanka,helping readers understand the significance of this study

Introduction-

The introduction section provides relevant information pertinent to the title "Mitigating Cancer Pain: What Else Matters?—A Qualitative Study into the Needs and Concerns of Cancer Patients in Sri Lanka."

It includes important details on the prevalence and impact of cancer pain, both globally and in Sri Lanka, highlights the need for improved pain management, and justifies the use of a qualitative approach. However, there are areas where clarity and emphasis could be enhanced. Here are some comments and suggestions:

1. Cancer Prevalence and Context:

You have effectively included statistics on cancer prevalence globally and in Sri Lanka. Further, better to give more stastics on increasing cancer trend in sri Lanka based on the Cancer Registry data.

However, it would be beneficial to explicitly connect these statistics to the significance of studying cancer pain specifically in Sri Lanka. For instance, "With 29,604 new cases reported in 2020, the growing burden of cancer in Sri Lanka underscores the urgent need to address cancer-related pain comprehensively.".

2. Impact of Cancer Pain:

The discussion on how cancer pain affects various aspects of life is thorough. However, it might be useful to provide more specific examples relevant to the Sri Lankan context if available. This would help in localizing the problem and emphasizing the need for the study.

3. Challenges in Pain Management:

The paragraph discussing the prevalence of untreated cancer pain in Asia compared to Europe and the USA is very relevant. Consider emphasizing the specific challenges faced by Sri Lanka in this context. For example, "In Sri Lanka, these challenges are exacerbated by limited healthcare resources and inadequate pain management facilities."

4. Holistic and Individualized Pain Management:

The introduction effectively argues for holistic and individualized pain management approaches. It might help to briefly mention any existing gaps in Sri Lanka's healthcare system that this study aims to address. For example, "Despite the recognized need for holistic care, Sri Lanka's healthcare system faces significant gaps in implementing such approaches."

5. Justification for Qualitative Approach:

You have justified the use of a qualitative method well. To strengthen this, you could briefly outline what specific insights you hope to gain through qualitative research.

6. Objective of the Study:

The objective of the study is stated, but it could be made more prominent. Consider explicitly stating the research question or hypothesis. For example, "This study seeks to explore the primary needs and concerns of cancer patients in Sri Lanka regarding pain management, aiming to inform more effective and patient-centered interventions."

7. Relevance to Title:

Ensure that the introduction explicitly ties back to the title "Mitigating Cancer Pain: What Else Matters?" by outlining what additional factors (beyond pain relief) are being investigated. For example, "In addition to pain relief, this study will explore the broader psychosocial needs and concerns that impact the quality of life for cancer patients in Sri Lanka."

Comments on the Methods Section:

1. Section 2.1: Study Design

The phrase "A qualitative descriptive study was conducted approach to delve into" is grammatically incorrect. Consider revising it to "A qualitative descriptive study was conducted to delve into."

The sentence "This study adopts a constructivist perspective, acknowledging the subjective nature of cancer experiencing pain..." is slightly awkward. Consider revising it to "This study adopts a constructivist perspective, acknowledging the subjective nature of experiencing cancer pain..."

2. Section 2.2: Study Setting and Participants-

• Mention the specific reasons for selecting Apeksha Hospital as the study setting to ensure that readers, particularly those from outside Sri Lanka, understand its relevance.

• The process of purposeful selection of study participants is not described adequately. A concise yet vivid description of the participants, site, and researcher is essential to provide readers with a comprehensive understanding of the study context.

Ex: It is unclear whether patients with advanced cancer or palliative patients were included. If both curable cancer patients and those with advanced or palliative cancer are included, the interpretation of pain and their needs may vary.

3. Section 2.3: Study Instruments

o Elaborate on the semi-structured interview guide, including whether probing questions were used and what the opening question was / what kind of questions included

o The sentence "The guide’s concepts and question areas were determined based on a comprehensive literature review and subsequently revised by subject specialists" is clear, but could be more concise. Consider: "The guide’s concepts and questions were based on a comprehensive literature review and revised by subject specialists."

4. Section 2.4: Data Collection

o Procedural rigor should be documented by providing information about the researcher’s credentials and previous experience in interviewing and communication to increase reader confidence.

o Since more than one interviewer was used, it is important to describe measures taken to maintain uniformity in data collection, such as training of data collectors.

o Consider breaking up the sentence "The interviewer introduced herself and described the purpose of the interview" into two sentences for clarity: "The interviewer introduced herself and described the purpose of the interview. The informant was assured that the information would be treated with confidentiality..."

5. Section 2.5: Data Analysis

o The description of data analysis lacks detail, particularly regarding the transcription and translation process.

o The data analysis section appears incomplete and need more details on analysis is required;

Was coding performed on the basis of pre-identified themes or just obtained directly from the interviews? Please specify

It is unclear how the investigators in addition to the primary analyst agreed on the initial coding of the raw data; and how the disagreements if any were addressed

• Using "myself" in academic or professional writing is generally discouraged because it can sound informal or overly personal. It's often better to use more formal language, such as referring to oneself as the author, researcher, or principal investigator. This helps maintain a professional tone and clarity in the writing.

o The phrase "The transcripts were generated codes, subcategories, categories, and themes" is unclear. Consider revising it to "Codes, subcategories, categories, and themes were generated from the transcripts."

6. Section 2.6: Trustworthiness

o This section should be revised to provide a more structured and comprehensive overview of the four components of trustworthiness: credibility, confirmability, dependability, and transferability.

o Rather than being scattered throughout the section, each component should be clearly addressed, detailing the specific actions taken by the research team to ensure the overall rigor of the study.

o This restructuring will enhance clarity and facilitate a better understanding of the methodological approach employed to validate the data.

o The phrase "Internal validity was promptly checked on transcripts" could be clarified. Consider specifying what this process entailed.

Overall, your methods section is thorough and well-organized. Making these adjustments will enhance clarity and readability, ensuring your audience can easily follow the methodology.

while your Introduction and methods section is thorough and well-organized, enhancing the grammatical structure and clarity of certain sentences would improve readability. I recommend revising awkward phrases and simplifying complex sentences to ensure clear communication of the article

Results:

Overall, this section offers valuable insights into the lived experiences of cancer patients in Sri Lanka. However, Improvements in grammar and clarity would enhance readability and precision, addressing occasional instances of awkward phrasing and repetitive language. While direct quotes enrich the results, restructuring some sentences for better coherence would be beneficial. Streamlining language and minimizing repetition present opportunities for enhancing the overall quality of the section.

1st Paragaraph –

Age group 51-60: It is not appropriate to refer to this group as the majority since it only represents 33% of the sample. If you want to refer to a majority, consider using broader categories like 31-70 or at least 41-70.

• Include information on whether participants were working, retired, or had stopped working because of cancer, as this is more relevant to their monthly income.

• Time since diagnosis could be categorized further (e.g., 2-3 years, >3 years) to provide a clearer picture of the duration of suffering among included patients.

Table 2. Theme 1: Changing normal lifestyle

• The quote "I cannot cook now. I do not eat the way I want to..." is more indicative of functional limitations rather than an emotional reaction. Consider categorizing it accordingly.

Discussion

• It seems there's a discrepancy between the methods and the discussion regarding who conducted the interviews. While the methods section states that multiple individuals conducted the interviews, the discussion mentions that the same investigator conducted all interviews for data consistency. This inconsistency raises concerns about the accuracy and reliability of the study's methodology. Clarifying this discrepancy is crucial for maintaining transparency and ensuring the credibility of the research findings.

• The discussion could benefit from further exploration of how the study findings contribute to the existing literature on cancer pain management, particularly in the context of Sri Lanka.

• Additionally, expanding the discussion to include potential implications for healthcare practice in Sri Lanka and future research directions would enhance the article's overall contribution to the field.

Reviewer #2: This qualitative study addresses a critical topic that spans individual and social health. It is a well-conducted study, adhering to qualitative methods. However, the following issues need to be addressed:

*Specify whether participants received any rewards for their involvement in the study

*Elaborate on how nonverbal responses were utilized in the subsequent analysis

*Describe the measures taken to ensure the quality of data analysis

*Confirm whether interview transcripts were reviewed by individuals other than the interviewers

*Identify who performed the transcriptions

*Utilize the demographic characteristics collected during the study to enrich the discussion section

*There are a few grammatical mistakes

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Reviewer #1: No

Reviewer #2: Yes: WDCN Adikaram

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PONE-D-24-13898R1‘‘Mitigating Cancer Pain: What else Matters?”—A Qualitative Study into the Needs and Concerns of Cancer Patients in Sri LankaPLOS ONE

Dear Dr. Edirisinghe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 24 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Surangi Jayakody, MBBS, MSc, MD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

********** 

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I appreciate the authors' effort in addressing the previous review comments and improving the manuscript. The study provides valuable insights, and the revisions made so far have strengthened the overall quality. However, there are still a few areas where further refinement could enhance clarity and precision, as detailed below:

Abstract:

• Clarity and Conciseness: The abstract is mostly clear, though readability could be improved. For example, “patients eighteen years older with cancer-related pain were recruited” could be rephrased to clarify that participants were 18 years

or older. Overall, the abstract is informative but could benefit from minor refinements to enhance clarity and conciseness.

Method of Data Collection: as the method of data collection the word “In-depth interviews” are not clearly mentioned in the abstract and methodology sections.

Administrative Clearance: There is no mention of administrative clearance anywhere in the article.

Specific Language Suggestions:

• Sentence 231 : The term 'multiple sources of data' is misleading, as only patient interviews were conducted. 'Multiple sources' would be appropriate if data were also obtained from healthcare staff, family members, caregivers, or other sources. Please revise to accurately reflect the data sources used in this study

• Sentence 262: Consider replacing “salary” with “income” for accuracy.

• Sentence 478: The use of “triangulation” is unclear; if triangulation was not done, please remove this term.

Results and Discussion: Aim for a more concise, focused presentation of the results and discussion sections, avoiding repetition.

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: WDCN Adikaram

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

‘‘Mitigating Cancer Pain: What else Matters?”—A Qualitative Study into the Needs and Concerns of Cancer Patients in Sri Lanka

PONE-D-24-13898R2

Dear Dr. Nirosha,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Surangi Jayakody, MBBS, MSc, MD

Academic Editor

PLOS ONE