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Academic Editor

PLOS One

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[Deanship of Research and Graduate Studies at King Khalid University for funding this work through the Large Research Project under grant number RGP2/676/46].

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[The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through the Large Research Project under grant number RGP2/676/46]

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[Deanship of Research and Graduate Studies at King Khalid University for funding this work through the Large Research Project under grant number RGP2/676/46]

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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?

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

The study is well-designed and methodologically solid, but some aspects need further clarification or improvement. The research question is relevant and addresses essential gaps in the psychosocial aspects of breast cancer care. The focus on marital and parental status as factors influencing QoL and psychological outcomes is innovative and provides a valuable perspective to existing literature. The sample size is adequate for a cross-sectional study and should allow general conclusions within the study's context. The use of validated instruments is a strength, as it guarantees reliable measurement of the variables.

The manuscript lacks a detailed explanation of how the sample size was determined. Given that this is a cross-sectional study, it would be helpful to include a justification for the sample size, based on power analysis or similar statistical reasoning.

The study doesn’t sufficiently discuss potential confounders, such as socioeconomic status, education, or other personal factors that could influence the results. For example, factors such as income, employment, or healthcare access may also play a significant role in the observed outcomes. If this is not addressed, it must be acknowledged as a limitation of the work. The conclusions are well-supported by the data, but the discussion needs to integrate these findings with existing literature on marital and parental status in breast cancer patients.

Also, many figures were not added and this should be addressed and added.

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

Yes, the statistical analysis appears rigorous, but a few points need to be addressed. The regression analysis should be better described. Authors need to explain which variables were included in the regression model and the rationale behind the selection.

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

The manuscript includes data availability statements that align with PLOS ONE’s data-sharing policies.

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

The manuscript is well-organized, but several areas could be clarified and improved in grammar and flow. It has a logical structure, making it easy to follow the progression between sections.

Some sentences need more clarity. For example, in the "Results" section, phrases like "psychological discomfort was most pronounced in mothers" could be clearer. Consider using “mothers, particularly those with multiple children, experienced greater psychological distress.” There are some minor grammatical errors and awkward phrasing that should be proofread and fixed.

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

The study is well-designed and methodologically solid, but some aspects need further clarification or improvement. The research question is relevant and addresses essential gaps in the psychosocial aspects of breast cancer care. The focus on marital and parental status as factors influencing QoL and psychological outcomes is innovative and provides a valuable perspective to existing literature. The sample size is adequate for a cross-sectional study and should allow general conclusions within the study's context. The use of validated instruments is a strength, as it guarantees reliable measurement of the variables.

The manuscript lacks a detailed explanation of how the sample size was determined. Given that this is a cross-sectional study, it would be helpful to include a justification for the sample size, based on power analysis or similar statistical reasoning.

The study doesn’t sufficiently discuss potential confounders, such as socioeconomic status, education, or other personal factors that could influence the results. For example, factors such as income, employment, or healthcare access may also play a significant role in the observed outcomes. If this is not addressed, it must be acknowledged as a limitation of the work. The conclusions are well-supported by the data, but the discussion needs to integrate these findings with existing literature on marital and parental status in breast cancer patients.

Also, many figures were not added and this should be addressed and added.

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

Yes, the statistical analysis appears rigorous, but a few points need to be addressed. The regression analysis should be better described. It would be helpful to explain which variables were included in the regression model and the rationale behind the selection.

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

The manuscript includes data availability statements that align with PLOS ONE’s data-sharing policies.

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

The manuscript is well-organized, but several areas could be clarified and improved in grammar and flow. It has a logical structure, making it easy to follow the progression between sections. Generally, the writing is clear, and the abstract effectively summarizes the study.

Some sentences need more clarity. For example, in the "Results" section, phrases like "psychological discomfort was most pronounced in mothers" could be clearer. Consider using “mothers, particularly those with multiple children, experienced greater psychological distress.” There are some minor grammatical errors and awkward phrasing that should be proofread and fixed.

LIMITATIONS THAT NEED TO BE INCLUDED

The study's cross-sectional design captures data at a single point in time, limiting the ability to draw causal conclusions or infer long-term trends. Longitudinal studies provide a better understanding of how marital and parental status influence psychological distress, social support, medication adherence, and QoL over time. The study used non-probability sampling from five hospitals in Punjab, Pakistan, possibly causing selection bias and limiting generalizability. Results may not apply to women in rural areas, different cultures, or without healthcare access. The study didn't fully control for confounders like socioeconomic status, education, comorbidities, or treatment type, which could influence psychological outcomes and quality of life. Future research should include these variables to better isolate effects of marital and parental status.

The study's setting in Punjab, Pakistan, may restrict the external validity of the findings. Cultural norms and expectations concerning marriage, family, and caregiving differ significantly across regions. Consequently, the results may not be generalizable to populations in different cultural or geographic contexts. Conducting cross-cultural comparisons would be beneficial in examining how these factors influence women with breast cancer in various settings. Although the study included 503 patients in the final analysis, 110 patients were excluded due to incomplete or missing data. The reasons for missing data are not specified, and the potential impact on the results remains unclear. It should be acknowledged as a limitation.

Reviewer #2: Greetings, thank you for giving me the opportunity to review this manuscript, I have some concerns that I will explain below.

Firstly, in the methods part, exclusion criteria, the authors state the patients with co-morbid life threatening conditions were excluded. What does this sentence mean? An example on such condition should be provided, moreover, an explanation to why authors made this decision, and how is it going to affect the data generated should also be provided in the main text.

Secondly, according to the data released by the World Health Organization, International Agency for Research on Cancer on 24th of FEBRUARY, 2025. ( Globally, most breast cancer cases and deaths occur in individuals aged 50 years and older, who account for 71% of new cases and 79% of deaths ). In this study, the sample included a majority of 181 patients out of 503 that were aged between 25-34, compared to 155 patients aged greater that 45. These numbers contradict the known data regarding the common age of breast cancer, I was hoping to find a part that addresses this issue, even in the discussion section but the authors seemed ignorant of the idea, it was not mentioned as a limitation as well. Such numbers of cases in a young age are strongly linked to family history or genetic mutations like BRCA 1 gene mutation. However, the majority of the responses reported denied having family history of cancer.

This issue is very crucial, and if not properly addressed it may result in an unrepresentative sample and thus a biased study. I kindly ask the authors to investigate why larger numbers of cases in a younger ( unexpected age ) were involved in their study sample. Were all participants from the same geographical area? Are the hospitals included in the study known for treating younger aged patients? What makes these similar\ different from the global population?

Thirdly, line 210-213, if this conclusion is mentioned by other studies in the existing literature, please reference them. Same goes for lines 215-218, 224-225, 229-230.

Fourthly, line 232, it seems like there is a missing part, depression negatively associated with what?

Lines 248-249 contradict what is mentioned in the Indonesian study mentioned in line 247.

Thank you again for your submission, I hope the authors take these points into consideration.

Reviewer #3: The topic is important, but the research needs some critical corrections.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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Attachments

Attachment

Submitted filename: report 1.docx

Dear Dr. Shah,

Please submit your revised manuscript by Apr 01 2026 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.. 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.

• A 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 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 . 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,

Mukhtiar Baig, Ph.D.

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. 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.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

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 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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Minor comments

The sentences in Lines 87-90 should be cited as well as sentences in line 99-102. Line 348 states 'Future longitudinal and cross-cultural studies may further clarify these relationships'. This statement is ambiguous and so there should be a mini section that addresses the future research directions in the area of this research.

Reviewer #2: Thank you for addressing the issues and doing modifications accordingly.

My major concern was the generalizability of the results of a tertiary hospital data, where cases can differ from global estimates and more aggressive disease form are present. Since the authors declared that the data do not provide generalizable data at the moment and more studies are needed, then the main issue has been addressed and paper is ready for publication.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.). 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 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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Association of Marital and Parental Status with Stress, Support, Adherence, and Quality of Life Among Breast Cancer Women

PONE-D-25-55850R2

Dear Dr. Shah,

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,

Mukhtiar Baig, Ph.D.

Academic Editor

PLOS One

Reviewers' comments: