Awareness regarding breast cancer amongst women in Pakistan: A systematic review and meta-analysis

Muhammad Abdul Rehman; Erfa Tahir; Huzaifa Ghulam Hussain; Ayesha Khalid; Syed Mohammad Taqi; Eilaf Ahmed Meenai

doi:10.1371/journal.pone.0298275

Peer Review History

Original SubmissionNovember 26, 2023
27 Dec 2023 Decision Letter - Sina Azadnajafabad, Editor PONE-D-23-38477Awareness Regarding Breast Cancer Amongst Women in Pakistan: A Systematic Review and Meta-AnalysisPLOS ONE Dear Dr. Abdul Rehman, 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 revise your manuscript in accordance with the reviewers' comments and suggestions to enhance its clarity, rigor, and overall quality. Please submit your revised manuscript by Feb 10 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. 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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: Dear Authors Thank you for submitting the article for the possible consideration for publication. The area of your research was interesting and may contribute to the available knowledge of breast cancer which is one of the prevalent and high risks for most of women in the world. However, the following concerns are raised to improve the article. Comments by sections 1. Title Awareness Regarding Breast Cancer amongst Women in Pakistan: A Systematic Review and Meta-Analysis. -Better to use status/level of awareness? 2. Abstract -Not use abbreviation on abstract part -Is knowledge and awareness similar? Your title was awareness but the associated factors mentioned for awareness. Make them consistent -It lacks recommendation Introduction • I think you have three objectives. But, nothing mentioned on your introduction parts regarding your objectives. For example, regarding risk factors, treatment, attitude, screening practices. • Please re-write the introduction parts magnitude, burden, risk factors, possible interventions and major gaps. Materials and methods Inclusion and exclusion criteria • What about knowledge of breast cancer. Were they excluding form the search? • Why you exclude the medical students/ physician. You are searching for awareness of BCa. Please elaborate the reason. • On your document you used knowledge and awareness interchangeably. Please make it consistent. • You said observational studies. Which means your study include case-control, cohort and cross-sectional. Please specify observational. Discussion • Please see again your discussion parts .it only focus on magnitude rather than factors. Reviewer #2: Thank you for your interesting and informing manuscript. 1-I will appreciate it if you could explain more about the method of weight assigning which is described in statistical analysis. 2- What are your suggestions to improve breast cancer knowledge in women in Pakistan? ****** 6. 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 ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. 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Revision 1
8 Jan 2024 Author Response PONE-D-23-38477 Awareness Regarding Breast Cancer Amongst Women in Pakistan: A Systematic Review and Meta-Analysis Response to Reviewers’ Comments 5th of January, 2024 I would first like to thank the reviewers for their valuable comments, and their willingness to dedicate their time towards our work. Secondly, I would like to convey a description of the format of this document so as to make it easy, convenient, and smooth for the editor and the reviewers to understand how the comments have been addressed. Each reviewer’s comment is followed by a response. The answers highlight line numbers, and in quotations, the change that was made. I have also made use of evidence through links to support my responses where necessary. Responses to Comments by the Editor [1] In regard to the geographical map in our study, I would like to inform the editorial team that the original figure is freely available under the Creative Commons Attribution-Share Alike 4.0 International license and is available here: https://en.m.wikipedia.org/wiki/File:Pakistan_provinces_2018_HDI_map.svg I have updated the source of the original figure in the section Method>Illustrations. We feel that because this figure is publicly available, it does not require a signed consent. However, I may be mistaken given the technicalities of the license etc. If that is so, do let us know so we may make the appropriate changes. [2] The revised manuscript has been formatted according to Plos One's style. All associated files have been as well. Responses to Comments by Reviewer #1 Comment 1 ”1. Title: Awareness Regarding Breast Cancer amongst Women in Pakistan: A Systematic Review and Meta-Analysis. -Better to use status/level of awareness?” Response 1 When drafting the title for our manuscript, we put forward several recommendations, including the ones suggested by the reviewer. Upon subsequent revisions, and proofreading, we shrunk the title to keep it concise, to the point, and pertinent. While “Status of awareness…” or “Level of awareness…”, are also correct when it comes to grammar and written English, restricting the title to “Awareness…” avoids the superfluous use of words. This was our rationale for not choosing “Level of awareness…” in the title. Furthermore, there are several published articles in high-impact factor journals that make use of similar titles, which highlights the scientific, and grammar-related accuracy of the title. Some examples are as follows: A) https://pubmed.ncbi.nlm.nih.gov/34227943/ - Awareness and prevalence of needle stick injuries among cleaners and health-care providers in Gaza Strip hospitals: a cross-sectional study B)https://pubmed.ncbi.nlm.nih.gov/10703802/ - Awareness during anaesthesia: a prospective case study Comment 2 2.Abstract -Not use abbreviation on abstract part Response 2 Firstly, I would like to respond to this comment by highlighting the limited word count that is universally kept for all abstracts. Therefore, it is not feasible to not use acronyms, as it eats away at the total word count which can be used to convey the scientific information that an abstract needs to convey. I presume this is the reason why Plos One allows the use of abbreviations where they can not be avoided (Plos One guide: https://journals.plos.org/plosone/s/submission-guidelines#loc-manuscript-organization). Secondly, all the abbreviations used in the abstract have already been defined at their first use. Thirdly, although abbreviations that are universally known, often do not require an expanded mention in the title or the abstract, which is in consideration of the limited word count. Yet, we have chosen to expand the following abbreviations: “PRISMA” is now “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (Line 18-19); “NIH” is now “National Institutes of Health” (Line 23). Some examples of abstracts in published literature where abbreviations have been used and not defined at first use are: A)https://pubmed.ncbi.nlm.nih.gov/35247352/ - Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts [CI is not defined at all] B)https://pubmed.ncbi.nlm.nih.gov/33635310/ - Association of Convalescent Plasma Treatment With Clinical Outcomes in Patients With COVID-19: A Systematic Review and Meta-analysis [COVID, CI not defined at all] Comment 3 -Is knowledge and awareness similar? Your title was awareness but the associated factors mentioned for awareness. Make them consistent Response 3 Because the objective of our study was to evaluate the prevalence of knowledge and practice (Lines 16-17, Lines 68-71), we chose an overarching, umbrella synonym that covers both knowledge and practice. Similarly, our abstract goes on to report results which are consistent with these objectives (Lines 25-31). I appreciate this comment, and would like to point out that to make the distinction between “awareness” and “knowledge”, and to highlight the overarching nature of the word “awareness”, the manuscript already contains an explanatory sentence in the Method section (Lines 105-106: “The following data regarding BCa awareness were sought: 1) knowledge about BCa, 2) attitude towards BCa, 3) practice towards BCa.”) Lastly, we have changed “…low levels of BCa awareness: risk factors, 42.7%…” to “…low levels of BCa knowledge: risk factors, 42.7%…” (Line 26). Comment 4 -It lacks recommendation Response 4 I would like to point out that the PRISMA 2020 for Abstracts checklist (which can be found here: http://www.prisma-statement.org/extensions/Abstracts) does not list adding recommendations as one of its components. Similarly, the Plos One guide (which can be found here: https://journals.plos.org/plosone/s/submission-guidelines#loc-manuscript-organization) also does not list adding recommendations to the abstract. Furthermore, the abstract is limited to 300 words, which does not allow us to stray from the guidelines. Comment 5 Introduction I think you have three objectives. But, nothing mentioned on your introduction parts regarding your objectives. For example, regarding risk factors, treatment, attitude, screening practices. Response 5 Our research indeed has three objectives, which is to consolidate data about knowledge, attitude, and practice regarding breast cancer in Pakistan (in short: awareness regarding breast cancer; as is conveyed by the title and the explanation in the Method section). I would like to point out the study design of our work which is a systematic review/meta-analysis, and not a primary study. Our aim is to synthesize evidence which could guide future health policies, and highlight the current situation in Pakistan. Our aim is not to compare one intervention/treatment/risk factor with another; which, if it were, would require that we describe and introduce each intervention. Therefore, we focused our introduction on the overall awareness of breast cancer. Furthermore, while we could certainly quote data regarding awareness in the introduction, we decided that it would be best to keep such information within the confines of the Results section, which satisfies the purpose of our systematic review. In order to satisfy the suggestion, we have added another paragraph to highlight why our research is a timely need where we highlight the importance of knowledge about BCa-related interventions/risk factors etc. (Lines 63-70) Comment 6 • Please re-write the introduction parts magnitude, burden, risk factors, possible interventions and major gaps. Response 6 Unfortunately, I fail to grasp why these sections need to be rewritten. Perhaps the reviewer meant that they be added. In order to address this comment I will point out the line numbers of each section: Magnitude and burden: Lines 37-47 Risk Factors: Line 68 Interventions: Lines 65-67 Major Gap: Lines 72-73 Comment 7 Materials and methods. Inclusion and exclusion criteria. • What about knowledge of breast cancer. Were they excluding form the search? Response 7 No, such studies were not excluded. In fact, assessing knowledge is a core objective of our study. The term “awareness” (Line 93) includes studies that assessed knowledge. Comment 8 • Why you exclude the medical students/ physician. You are searching for awareness of BCa. Please elaborate the reason. Response 8 We excluded medical students and physicians because assessing their knowledge and including it in the statistical analysis would significantly skew the results by introducing a massive knowledge bias. This is so because medical students and physicians are taught about breast cancer thoroughly and meticulously which makes an assessment of their knowledge almost irrelevant when gauging the current awareness in Pakistan. Comment 9 • On your document you used knowledge and awareness interchangeably. Please make it consistent. Response 9 As explained previously and in the Method section (Lines 112-113), “awareness” is an umbrella term which is includes knowledge, attitude etc. In our manuscript, we have used them accordingly. The term “knowledge” is used wherever knowledge is calculated or referred to. “Awareness” is used wherever the overall results of our work are referred to. Comment 10 • You said observational studies. Which means your study include case-control, cohort and cross-sectional. Please specify observational. Response 10 We have already specified the type of observational studies in the Methods section (Line 92): “We included observational cross-sectional studies which were…” Comment 11 Discussion • Please see again your discussion parts .it only focus on magnitude rather than factors. Response 11 Firstly, I would like to point out the same response as was given for Comment 5: our aim is to consolidate data and not comment on individual interventions/risk factors/treatments etc. Secondly, the discussion does comment on various pertinent and relevant factors such as self-examination which is a primary screening method that is hailed as cheap and effective (Lines 285-293). Similarly, mammography (Lines 278-283), discussion of factors for poor knowledge (Lines 304-314), comparison with neighboring countries and literature (Lines 316-323), and a discussion of the statistical interpretation (Lines 325-345) have been discussed in detail. This is in addition to the prevalence/magnitude which open the discussion in the introductory paragraph. Responses to Comments by Reviewer #2 Comment 12 1-I will appreciate it if you could explain more about the method of weight assigning which is described in statistical analysis. Response 12 We assigned weights under a random effects model (Line 132) to account for the varying heterogeneity in the data across studies owing to various factors such as geography, socioeconomic status etc., as is conventional for single proportion meta-analyses which pool data from observational studies. In particular, we used the DerSimonian random effects model which was introduced in 1986, accounts for inter-study variance, and has been amongst one of the most widely used models for large data in single proportion meta-analyses. It makes use of inverse weights, which is utilized in meta-analyses calculating prevalence, or similar. Links for further reading and the use of the model in other single proportion meta-analyses can be found here: A)https://pubmed.ncbi.nlm.nih.gov/3802833/ - Meta-analysis in clinical trials B)https://pubmed.ncbi.nlm.nih.gov/16807131/ - Random-effects model for meta-analysis of clinical trials: an update C)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667312/ - A re-evaluation of random-effects meta-analysis D)https://pubmed.ncbi.nlm.nih.gov/36000793/ - Prevalence and risk factors of self-reported psychotic experiences among high school and college students: A systematic review, meta-analysis, and meta-regression E)https://pubmed.ncbi.nlm.nih.gov/33958198/ - A meta-analysis and meta-regression on the prevalence of lipohypertrophy in diabetic patients on insulin therapy F)https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/37131226/ - Malaria prevalence in Mauritania: a systematic review and meta-analysis Comment 13 2- What are your suggestions to improve breast cancer knowledge in women in Pakistan? Response 13 Our recommendations/suggestions to improve breast cancer-related knowledge is primarily through organized awareness campaigns, for which our work lays the stepping stone. We have described their effectiveness in the introduction (Lines 62-70), discussion (Lines 311-315), and conclusion (Lines 361-363). I hope our responses are satisfactory for the reviewers. Incase further explanations are needed or suggestions are available, I would gladly receive them. I want to once again thank both reviewers for their comments. Warm Regards, Dr. Abdul Rehman Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0298275.r002
14 Jan 2024 Decision Letter - Sina Azadnajafabad, Editor PONE-D-23-38477R1Awareness Regarding Breast Cancer Amongst Women in Pakistan: A Systematic Review and Meta-AnalysisPLOS ONE Dear Dr. Rehman, 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 Feb 28 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. 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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: 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 #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: Thank you for submitting the article for the possible consideration for publication. The area of your research was interesting and may contribute to the available knowledge of breast cancer which is one of the prevalent and high risks for most of women in the world. All comments were addressed. But, still your manuscript needs some grammar correction issue. • You mentioned on response cross sectional study. But, throughout the manuscript I didn’t seen cross sectional study. So, please specify observational. Reviewer #2: (No Response) ****** 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: Ghazal Daftari ******** [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. Attachments Attachment Submitted filename: Comments for authors - 2.docx https://doi.org/10.1371/journal.pone.0298275.r003
Revision 2
14 Jan 2024 Author Response PONE-D-23-38477 Awareness Regarding Breast Cancer Amongst Women in Pakistan: A Systematic Review and Meta-Analysis Response to Reviewers’ Comments Round Two 15th of January, 2024 Once again, I would like to begin by first thanking the reviewers who dedicated time out of their busy schedules towards our work. Secondly, I would like to convey a description of the format of this document so as to make it easy, convenient, and smooth for the editor and the reviewers to understand how the comments have been addressed. Each reviewer’s comment is followed by a response. The answers highlight line numbers, and in quotations, the change that was made. I have also made use of evidence through links to support my responses where necessary. Responses to Comments by Reviewer #1 Comment 1 Thank you for submitting the article for the possible consideration for publication. The area of your research was interesting and may contribute to the available knowledge of breast cancer which is one of the prevalent and high risks for most of women in the world. All comments were addressed. But, still your manuscript needs some grammar correction issue. • You mentioned on response cross sectional study. But, throughout the manuscript I didn’t seen cross sectional study. So, please specify observational. Response 1 I believe that perhaps some oversight has been made, as this comment was addressed in the first round of revisions. Nonetheless, I will point out the locations where we already specify the type of observational study design that was included In our research in order to provide maximum aid and convenience. We specify the type of observational study design on the following line numbers: 1.Line 91, Methods>Inclusion/exclusion criteria: “We included observational cross-sectional studies that were published in/after 2010…” 2.Line 151. Results>Characteristics of Included Studies: “All included studies were observational cross-sectional studies.” 3.Line 163, Table 1, where each study is specified as having a cross-sectional study design. Responses to Comments by Reviewer #2 No comments have been raised by Reviewer #2 in this round. I hope my responses is satisfactory for Reviewer 1. Incase further explanations are needed, or suggestions are available, I would gladly receive them. I want to once again thank both reviewers for their comments. Warm Regards, Dr. Abdul Rehman Attachments Attachment Submitted filename: Response to Reviewers (Round Two).docx https://doi.org/10.1371/journal.pone.0298275.r004
23 Jan 2024 Decision Letter - Sina Azadnajafabad, Editor Awareness Regarding Breast Cancer Amongst Women in Pakistan: A Systematic Review and Meta-Analysis PONE-D-23-38477R2 Dear Dr. Rehman, 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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, 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, Sina Azadnajafabad, MD, MPH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0298275.r005
Formally Accepted
27 Feb 2024 Acceptance Letter - Sina Azadnajafabad, Editor PONE-D-23-38477R2 PLOS ONE Dear Dr. Abdul Rehman, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Sina Azadnajafabad Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0298275.r006

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