PONE-D-24-15694Venous Thromboembolism Risk Assessment in Cancer Patients: A Qualitative StudyPLOS ONE

Dear Dr. Mikhael,

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,

Theresa Ukamaka Nwagha, M.B.B.S., M.P.H., FMCPath, M.Sc., M.D.,

Academic Editor

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: Partly

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

Reviewer #1: No

Reviewer #2: I Don't Know

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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: Yes

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: The study addresses a relevant and underexplored area in oncology practice. The focus on an Iraqi context adds originality and contributes to the global understanding of VTE risk assessment practices. Ethical approval and consent processes are mentioned, but more detail on how confidentiality and participant rights were protected would strengthen the ethical rigor. The manuscript is generally well-written, but minor grammatical errors and redundancies should be addressed to enhance readability.

Suggested Revisions:

1. Provide details on written informed consent and measures to ensure ethical rigor.

2. Clarify the approach to ensuring intercoder reliability.

3. Address minor grammatical errors and improve overall readability.

4. Enhance the discussion of implications for clinical practice and policy.

Reviewer #2: This is a relevant study as it examines perceptions and attitude towards validated methodology for assessing risk in cancer patients. The findings are important for guiding interventions that will improve health care out comes in oncology patients. This is particularly important in settings where there may be a limited number of oncology specialists.

The title is misleading as it is a statement on the methodology or study design rather than the findings of the study.

The author should run a spell check to correct words which have no space between them.

The data and questions in the data tool (Section B) are more related to practice rather than perception. Questions such as How often? How do you assess? What is your action? are not well elaborated. There is much quantitative data and it is not clear how this was obtained. The study appears to have both quantitative and qualitative data. It will be good for the author to elaborate which results focus on practice and which data are for perception, how this was collected and analyzed.

In the results section on Dealing with Cancer patients with high risk of VTE: how did the author assess appropriateness of dosage? Was this part of the objective of the study?

The conclusions are not supported by data from this study. The author concludes that limited competence as the main reason for poor compliance to guidelines for guidelines. How was compliance measured, and how did the author determine that there was poor compliance to thromboprophylaxis guidelines? Again, this as stated in the objective, was a study on perception and practice towards risk assessment for VTE.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review PLOS VTE Cancer.pdf

PONE-D-24-15694R1Determining the Perceptions and Practices of Oncologists Regarding Venous Thromboembolism Risk Assessment in Ambulatory Cancer Patients: A Qualitative StudyPLOS ONE

Dear Dr. Mikhael,

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 Dec 14 2024 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,

Maher Abdelraheim Titi

Academic Editor

PLOS ONE

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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 #2: (No Response)

Reviewer #3: (No Response)

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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 #2: Partly

Reviewer #3: Partly

**********

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

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

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 #2: Yes

Reviewer #3: Yes

**********

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 #2: Yes

Reviewer #3: 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 #2: The data presented in Table 4 is the number of oncologists who identified or selected that particular malignancy as being associated with VTE. The data does not represent the frequency of actual occurrence of VTE in patients with malignancy. The author may want to clarify this in the results.

Reviewer #3: This is a study that aims to understand the perceptions and practices of oncologist regarding risk of VTE in ambulatory cancer patients as well as primary prophylaxis prescription patterns in Baghdad, Iraq.

The question guide was developed and reviewed by a panel of experts with interviews conducted 11/2023 – 1/2024.

Sample size = 31 oncologists

Overall, 64% of the interviewed oncologists do not assess VTE risks; however, 71% have diagnosed VTE in their cancer patients. Of the 58% that have prescribed primary thromboprophylaxis, dosing was inappropriate for most prescriptions.

I have the following concerns related to the study.

1. The conclusion that CAT is prevalent in Iraqi cancer patients is inaccurate based on the data presented. The authors note that 71% of oncologists diagnose VTE in their patients. This suggests that most oncologists in the study have diagnosed VTE in cancer. Not that VTE is prevalent in cancer. To assess prevalence, you would need a denominator of all patients cared for by the 31 oncologists and calculate prevalence. Please revise.

2. The statement that most prophylaxis prescriptions were inappropriate could use data for support in the abstract, especially given this is a conclusion of the study.

3. The introduction Paragraph 1-2 has jumping concepts. Recommended Modification for flow and clarity:

Venous thromboembolism (VTE) is a serious, potentially, life-threatening condition and a major cause of mortality and morbidity [1][6]. Approximately 20% of all newly diagnosed cases of VTE are cancer patients [2] and an estimated 8% of cancer patients develop VTE within one year after diagnosis or progression of their malignancy [4,5]. Therefore, current guidelines recommend primary prophylaxis for VTE prevention in high-risk patients after assessing the competing risk of bleeding [7,8]. The prediction of VTE in cancer patients often involves the use of risk assessment models or scores (e.g., Khorana Score) based on the presence of certain clinical and laboratory factors [9].

Despite available evidence and existing guideline recommendations for VTE risk assessment of ambulatory cancer patients with primary thromboprophylaxis for identified high-risk patients, several studies found limited utilization of both risk assessment and prescription of primary prophylaxis in clinical practice [10,11,12]. However, several questions remain regarding assessment of risk and prescription of prophylaxis. First, understanding clinician knowledge and understanding regarding guideline recommendations. Second, frequency of VTE risk assessment and prescription of primary thromboprophylaxis for identified high-risk patients [10]. Therefore, the current study aimed to explore the practices and perceptions of oncologists working in Baghdad, Iraq, regarding cancer-associated VTE, its risk assessment, and prevention among ambulatory cancer patients.

4. Methods – change “validated by a panel of experts” to reviewed or endorsed by a panel of experts

5. Table 2 can be moved to the supplement

6. For the result section “VTE among Cancer Patients”

a. Did the oncologists participating subspecialize? For example, were there oncologist that focus only on specific types of cancer? This will bias their answers.

b. For example, VTE is less common in patients with prostate cancer, but will be more common in pancreatic cancer etc. If you have a GU oncologist, they may be seeing VTE infrequently.

7. Decrease use of the phrase “on the other hand”

8. For the abstract and results section stating that most patients are prescribed inappropriate dosing of prophylaxis, I recommend changing the result/interpretation to “of oncologists that prescribe primary thromboprophylaxis, most prescribe inappropriate doses compared to those recommended by guidelines or prior randomized controlled trials” (cite guidelines, AVERT, CASSINI).

9. First line of the discussion is not supported by the data. The results stated that: 14 oncologists state that sometimes (not many) their patients develop and 8 stated that their patients commonly develop VTE. Sometimes does not = many. Also, this is not the main purpose of this study. This study is not to determine if VTE is common in cancer. It is to determine knowledge of VTE risk assessment and prophylaxis prescribing patterns, unless I misunderstood. Recommend deleting this sentence/conclusion throughout the paper.

10. Regarding type of cancer associated with VTE, again, this could be baised by the practice composition of the oncologist. I would not make this a key focus of the study. I recommend deleting all of paragraph 1 of the discussion. It is not supported by the study.

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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 #2: No

Reviewer #3: No

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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.

Determining the Perceptions and Practices of Oncologists Regarding Venous Thromboembolism Risk Assessment in Ambulatory Cancer Patients: A Qualitative Study

PONE-D-24-15694R2

Dear Dr. Mikhael,

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,

Maher Abdelraheim Titi

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 #3: 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 #3: Yes

**********

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

Reviewer #3: 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 #3: 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 #3: 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 #3: Thank you for addressing my comments. I have no further concerns at this time. I recommend publication.

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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 #3: No

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