PONE-D-23-43325Effect of inspiratory muscle training in esophageal cancer patients receiving esophagectomy: a meta-analysis of randomized controlled trials

PLOS ONE

Dear Dr. Yu,

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PLOS ONE

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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: Partly

Reviewer #2: Yes

Reviewer #3: No

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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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: No

Reviewer #2: No

Reviewer #3: 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: No

Reviewer #3: 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: The manuscript needs language revision by a native English-speaking editor. Some section read well, but others need attention.

Introduction:

This should include the effect of IMT on esophageal cancer patients. What is the gap in the study? In addition, using IMT is not common in esophageal cancer, why did you decide to review it? what was the importance of the study?

Please provide the questions address by the review.

Materials and methods:

Please define IMT (e.g., type), and other outcomes (i.e., postoperative complications; how did you report or measure it).

Results:

Table 1; please provide types of IMT in Table 1.

Discussion:

Page 7, Line 17: you stated that "Cordeiro ALL included seven studies ..." Please check this sentence? that might be a typing error.

Page 8, line 7: you stated that " ... and the study by Guinan et al. showed no significant value of IMT.." Please provide the reference.

line 12-13: you stated that "Secondly, the clinical outcome measures analyzed in the three foreign studies were generally limited." Please provide further details.

Line 19-26; this might also be discussed in terms of frequency, type of IMT, and duration of IMT.

Overall, the conclusion is certainly vague. In addition, the discussion part need to revised.

Reviewer #2: Dear authors,

I had the opportunity to review the paper entitled “Effect of inspiratory muscle training in esophageal cancer patients receiving esophagectomy: a meta-analysis of randomized controlled trials”

After reading the manuscript I have some concerns that should be resolved:

-Proofreading is crucial to catch typographical errors and ensure the professionalism of the manuscript.

Abstract:

The abstract provides a brief overview of the study.

Introduction:

-The sentence "Although minimally invasive approaches have become increasingly prevalent in the surgical treatment of esophageal cancer in recent decades, surgery still results in significant trauma" is somewhat awkward. Consider rephrasing for better clarity, such as "Despite the increasing prevalence of minimally invasive approaches in recent decades, esophageal cancer surgery continues to result in significant trauma."

-In the sentence "The conventional respiratory training methods currently used in clinical practice 16 mainly include diaphragmatic breathing, blowing up balloons, and lip puckering breathing," it might be clearer to say "commonly" instead of "mainly" for smoother phrasing.

-The mention of "Several relevant randomized controlled trials (RCTs) explored the clinical effect of IMT in esophageal cancer patients receiving esophagectomy, but they have shown significant differences in their results" could be more specific. What kind of differences are being referred to? Clarity here will better prepare the reader for the objective of the meta-analysis.

Materials and Methods:

-The inclusion of specific databases in the literature search is comprehensive. However, the abbreviation "CNKI" is used without explanation. Consider providing the full name on the first mention, e.g., "China National Knowledge Infrastructure (CNKI)."

-In the inclusion criteria, the phrase "patients received the esophagectomy and were diagnoses with primary esophageal cancer" contains a grammatical error ("diagnoses" should be "diagnosed"). Consider revising for accuracy: "patients received esophagectomy and were diagnosed with primary esophageal cancer."

-Consider providing a language preference for the inclusion criteria.

-The exclusion criteria are clear, but you might want to elaborate on what is meant by "low-quality studies" described below, or provide specific criteria for defining low quality.

-The information extracted from each study is comprehensive. However, the sentence structure could be improved for clarity. For instance, "and detailed data about observation endpoints" might benefit from clarification or rephrasing.

-Consider using Cochrane risk of bias assessment (RoB 2.0, Cochrane, London, UK) for risk of bias assessment.

-The clarification on how discrepancies were resolved during the literature search, selection, data collection, and quality assessment is good practice. It demonstrates transparency and reliability in the review process.

Result:

- More information about included the number of articles retrieved initially and the number included after screening is necessary.

-Did you use the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA 2020) flow diagram?

-In the sentence "Most include studies were from China," there's a minor grammatical error. It should be "Most included studies were from China."

-Consider to give more information about interventions.

-In the sentence "Similarly, IMT played a role in 1 improving the pulmonary function...," there's a typographical error. It should be "Similarly, IMT played a role in improving pulmonary function."

-In the sentence "In this meta-analysis, the 6MWT and Borg index were applied to assess the exercise performance status," it would be beneficial to briefly explain why these specific metrics were chosen.

-The organization of the section on postoperative complications is clear, but you could add a brief statement about why assessing these complications is relevant in the context of the study.

-Provide a brief information about Heterogeneity.

Discussion:

-In the sentence "Therefore, perioperative IMT could significantly improve clinical outcomes...," consider specifying the particular clinical outcomes that are significantly improved. It adds clarity and helps the reader understand the impact of IMT.

-The comparison with previous meta-analyses is valuable, providing context and support for the current study. However, it would be beneficial to briefly discuss any differences in methodologies, populations studied, or outcomes assessed between your study and the referenced meta-analyses.

-Consider providing a brief explanation for the cited meta-analyses' methodologies and populations studied, especially for readers who may not be familiar with these studies.

-In the sentence "Thus, IMT may also have significant clinical value in esophageal cancer surgery...," consider specifying the aspects of esophageal cancer surgery where IMT demonstrates clinical value.

-The acknowledgment of differences between domestic and foreign studies adds depth to the discussion. However, it would be helpful to provide a bit more detail on the potential reasons for these differences, perhaps exploring the variation in healthcare practices, patient characteristics, or study methodologies.

-The speculation about the combination of preoperative and postoperative training yielding better results is interesting. However, you might want to phrase it as a hypothesis and suggest it as a direction for future research rather than stating it as a conclusion.

-The discussion about the limitations is essential. However, it's recommended to provide potential solutions or suggestions for mitigating these limitations, such as advocating for larger sample sizes in future studies.

-The point about the optimal timing and training regimen is crucial. Consider expanding on the existing literature or theories that discuss these aspects to provide more context and rationale.

-In the conclusion, you state, "and might be widely applied in clinics." Consider reinforcing this statement with a brief summary of the key findings that support the widespread application of IMT in clinical settings.

-The conclusion could benefit from a more explicit restatement of the study's main contribution or novelty, emphasizing why these findings are important for the field.

Reviewer #3: Dear authors,

Thank you for submitting the manuscript "Effect of inspiratory muscle training in esophageal cancer patients receiving esophagectomy: a meta-analysis of randomized controlled trials".

What are the Major Strengths of the Paper: The major strengths of the paper is summarize studies using inspiratory muscle training.

Major Recommendations:

METHODS

- Informations about Study Selection and research strategy are necessary.

- Additionally, how many researchers participated in data extraction and study selection?

- Is important highlighted: No record of the research protocol was considered. Has the current research protocol been registered on the Prospero platform?.

-

RESULTS

- Despite the statistical difference observed, it is worth highlighting that: 1. most results appear to be below the MCID; 2. there is a great imprecision for the most encouraging result, which would be that of the 6-minute walk test, thus reducing confidence in the finding; 3. heterogeneity is high for most results, thus reducing confidence in the finding.

DISCUSSION

- The discussion needs to critically analyze the results reported: MCID (how much the statistical difference is reflected in the real clinical difference) grade (how much these included studies give me strength to trust this statistical difference), diversity of training protocols and the fact that the control group was not subjected to any type of physical intervention.

- Based on what was observed, it is relevant to discuss what the authors believe may have contributed to the high heterogeneity of some findings.

CONCLUSION

- Another important point: the conclusion goes beyond what the results can say. Considering that the MCID for none of the outcomes was mentioned and the level of evidence was not assessed by GRADE

-Finally, I highlight that given the weaknesses on the subject (which can be seen mainly by small effect magnitudes, high imprecision and great heterogeneity), a more considered conclusion about the effects of inspiratory muscle training is appropriate

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Effect of inspiratory muscle training in esophageal cancer patients receiving esophagectomy: A meta-analysis of randomized controlled trials

PONE-D-23-43325R1

Dear Dr. Yu,

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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Kind regards,

Fatma Abdelfattah Hegazy, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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: All comments have been addressed

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

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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: Yes

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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

**********

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: (No Response)

Reviewer #2: The authors have responded to my comments before. No further questions to the authors about manuscript.

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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: No

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