Outcomes of Complex Decongestive Therapy in Managing Upper Limb Lymphedema in Female Breast Cancer Patients at a Palliative Care Unit of a Tertiary Care Hospital in Bangladesh

PLOS ONE

Dear Dr. Alam,

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.

We have invited more than 20 experts to review the ms. Of them only two responded. One of the reviewers raised several comments on the technical aspects of the study, which indicate that the methodology needs substantial revision of the ms. I would request the authors, in addition to the minor points, to focus on the methodological issues raised by Reviewer 2.

Please submit your revised manuscript by May 12 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,

Swaminathan Subramanian, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please note that funding information should not appear in any section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript.

Additional Editor Comments:

NIL

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

Reviewer #1: The aim of this study is to evaluate the effectiveness of CDT for breast cancer patients with upper limb

lymphedema and aims to assess the benefits of this treatment despite the challenges

and constraints in resource-limited settings. It is well structured in all parts. Only the language must be reviewed.

Reviewer #2: It is a well-written manuscript. However there are a few clarifications and suggestions which the authors can address for better clarity.

1. It is not clear in the methodology if the upper limb lymphedema (LE) is unilateral or bilateral. Based on the Results it can be presumed to be bilateral LE.

2. How LE was graded as moderate or severe can be mentioned in the Methodology

3. In line 122, it is mentioned that data collection was done between 1 May 2023 and 30 Sep 2023. Does it mean the recruitment was stopped or it implies that the final 6 weeks follow-up post treatment (CDT) was completed for all participants on 30 Sep 2023. Rephrase the sentence for better clarity.

4. Lines 162 -165: provide reference

5. Line 168: What is the interpretation for the colour domains mentioned: Normal, red, pink, brown?

6. Line 169: Skin thickness can be either normal, thin or thick (stemmer's sign can be mentioned). However, edema can be a separate assessment domain and needn't be mixed with skin thickness.

7. Line 177-178: Mention that the CDT was provided for 6 weeks

8. Lines 197, 200, 202: Ensure either one or two decimal points is provided uniformly in the text as well as in the tables (Table 1 Percentage% check the decimals)

9. Was there any association between stage of cancer and improvement of LE?

10. Table 2: Volume of left limb it is mentioned 3505.69+- 3307.87- please recheck value

11. Table 2: the baseline volume for left limb is observed to be greater compared to the right limb. Is it because left limb LE was more common among the participants?

12. Lines 222-223: Can improvement in skin condition be attributed to CDT?

13. Table 4: Skin thickness and edema can be two separate domains

14. Lines 262-264: The factors discussed were not assessed in the present study. Its relevance here is not clear

15. Line 267: Skin thickness and edema to be discussed separately.

16. Line 295: Lower limb LE was excluded and not relevant here

17. Lines 65 & 301:" early referral..."- the study did not record the delay in accessing treatment (CDT) by patients. Justify the statement provided here.

**********

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

**********

[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.

Dear Dr. Alam,

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.

Both reviewers recommended for a minor revision. However, one of the reviewers raised several minor comments which needs to be addressed. For example the data provided in Tables 3 and 4 do not match with Results presented. Also make appropriate changes as indicated in the attached Comments to Authors. 

Please submit your revised manuscript by Jun 21 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,

Swaminathan Subramanian, Ph.D.

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.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: No

**********

Reviewer #1: This study seeks to evaluate the effectiveness of CDT for breast cancer patients with upper limb

lymphedema and aims to assess the benefits of this treatment despite the challenges

and constraints in resource-limited settings. The paper is well structured but the English must be improved.

Reviewer #2: The authors have addressed most of the comments that were raised during the previous review. However, there are few more additional comments that needs to be addressed by them:

1. The authors responded that all 42 patients had unilateral (U/L) upper limb lymphedema (LE). Whether U/L LE was one of the inclusion criteria? If so, it may be mentioned in the 'Methods' section in both Abstract and Main text of the manuscript (MS).

2. Line 56: "Significant volume reduction in both right and left upper limbs.." This is quite misleading as all cases had unilateral LE. The sentence shall be reframed for clarity.

3. Lines 61-62 and 67, 314: Tightness, heaviness and pain are more subjective responses. It is understood that no validated scale to assess quality of life (QoL) was used in the study and hence the term QoL may be avoided.

4. Line 125: Correct the spelling of 'massive'

5. Line 135: Ref 12 has used LE grading by International Society of Lymphology (ISL), the same shall be mentioned in the MS. These grades are found nowhere else other than the Methods. Information on classification of study participants based on these grades needs to be included in the MS. Were these LE grades not considered for the analysis?

6. Line 172: Please correct the tense (Limb volume changes were...)

7. Line 173-174: '...using a measuring tape along with the fixed designated point...' It is not clear. Rephrase the sentence for clarity

8. Table 1: Write Age (years) with Mean (SD): 50.2+-8.6 and remove years in the rows.

9. Table 1: Performance status- Correct the decimal points (one decimal) for uniformity. Stage I - III is used which is confusing. Please mention it as the Stage of breast cancer for clarity. Further there is no mention of these stages in the Methods.

10. Table 2: Correct decimal points for the volume mentioned (2492.4981, 2691.70 etc...)

11. Line 230-231: Table 3 information cited doesn't match with the sentence provided.

12. Table 3, 4: Title and information provided in tables do not match

13. Table 3: Ensure uniform font size

14. Lines 236-243: Table 4 is cited wrongly in the text

15. Line 248: Tightness, heaviness and pain...these are more subjective symptoms and supposedly assessed orally (using questionnaire). It may be clarified that these symptoms were self-reported perceptions by the patients.

16. Line 258: Check for grammatical error

17. Line 270: Correct the decimal points

18. Previous comment: The authors have replied that no association was found between stage of cancer and improvement of LE. The same shall be mentioned in the Results. Also was there any association found between the LE grades and improvement in LE? If so, please mention in the MS.

Kindly check the MS for grammatical errors once again

**********

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

**********

[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

Outcomes of Complex Decongestive Therapy in Managing Upper Limb Lymphedema in Female Breast Cancer Patients at a Palliative Care Unit of a Tertiary Care Hospital in Bangladesh

PONE-D-24-46999R2

Dear Dr. Alam,

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.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

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,

Swaminathan Subramanian, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

I would request the authors tio revise the ms incorporating the suggestions against comment no. 8 (on Revision 1) and Table 1 (please see comments of Reviewer 2 below for more detail)

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

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

Reviewer #2: (No Response)

**********

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

Reviewer #2: (No Response)

**********

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

The PLOS Data policy

Reviewer #2: (No Response)

**********

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

Reviewer #2: (No Response)

**********

Reviewer #2: The authors have addressed all the comments. However, with regard to comment no:8, authors have wrongly interpreted and deleted the age classes in Table 1 along with relevant text in results section. This may be reincluded.

In Table 1, write as follows:

Age class in years (Mean±SD 50.2±8.6)

Min age-49 10 45.2%

50-Max age 23 54.8%

**********

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

**********