Poor Muscle Status, Dietary Protein Intake, Exercise Levels, Quality of Life and Physical Function in Women with Metastatic Breast Cancer at Chemotherapy Commencement and during Follow-Up

Round 1

Reviewer 1 Report

The article is very interested and could be worth publishing it after some minor comments:

Title: Should better reflect the findings of the study

Introduction: Line 38. Is there any explanation why OW and OB would be protective in metastatic disease? Authors can add some addiotnal information on that.

Line 58: Write the full name of ESPEN

Methods: The mean age of participants was 53y. Did the subject have a normac menstuation cycle? Estrogen plays a vey important role and could possible effect all assessments and your results. The authors should comment on that in detail and if neccessary could add this information on the inclusion or exclusion criteria.

Line 133- Needs reference

Discussion: Line 326-328 How the authors can explain these findings? 

Line 329-331. the findings should be better reflected in the title

 

 

 

Author Response

The article is very interested and could be worth publishing it after some minor comments:

 

Title: Should better reflect the findings of the study

Thank you for the suggestion, we adapted the title as follows:

“Poor muscle status, dietary protein intake, exercise levels, quality of life and physical function in women with metastatic breast cancer at chemotherapy commencement and during follow-up”

 

Introduction: Line 38. Is there any explanation why OW and OB would be protective in metastatic disease? Authors can add some additional information on that.

We added additional information and references on this in line 37-52. We described the mechanism causing cancer growth in overweight and obese women, described the evidence around a potential protective effect of overweight in metastatic breast cancer.

 

Line 58: Write the full name of ESPEN

We have written the name in full: the European Society for Clinical Nutrition and Metabolism

 

Methods: The mean age of participants was 53y. Did the subject have a normac menstuation cycle? Estrogen plays a vey important role and could possible effect all assessments and your results. The authors should comment on that in detail and if neccessary could add this information on the inclusion or exclusion criteria.

We recruited women with metastatic breast cancer and did not select for pre- or postmenopausal status, nor did we record menopausal status at the time of the study. Therefore, we added the following text to the discussion section, lines 467-473.

“Both pre- and post-menopausal women were recruited in order to expand recruitment opportunity. Unfortunately, menstruation status was not recorded for patients included in the study. As menopause is associated with a decline in oestrogen levels which may contribute to sarcopenia, future studies considering menstruation cycles should be explored.”

 

Line 133- Needs reference.

We inserted references for the MST and PG-SGA.

Discussion: Line 326-328 How the authors can explain these findings? 

These lines discuss the following:

“This study found a low prevalence of malnutrition and sarcopenia and a poor quality of life at the start of a new chemotherapy regimen in a small group of women with MBC. After 1 year of treatment, the majority of women had not lost weight, had no sarcopenia, and were well-nourished.”

We interpret these findings as follows, and added this to the discussion text, line 374-375:

“These findings indicate long term suboptimal physical function, quality of life and nutritional intake in this small sample of women with MBC, and correspond to those of the few similar studies that have been performed in this population [20, 44].”

 

Line 329-331. the findings should be better reflected in the title.

As suggested by the reviewer, we adapted the title and added ‘at chemotherapy commencement and during follow-up':

Poor muscle status, dietary protein intake, exercise levels, quality of life and physical function in women with metastatic breast cancer at chemotherapy commencement and during follow-up.

Reviewer 2 Report

This interesting manuscript describes a study investigating nutritional status, muscle health and functional performance and quality of life before the start of a second chemotherapy regimen and after 52 weeks in women with metastatic breast cancer. Markers of malnutrition, sarcopenia, myosteatosis, reduced physical function, and QoL were present in 20-65% of the patient group at baseline but only QoL further deteriorated during the 52 week follow-up period. Although the sample size was small and no comparison group was used (e.g., breast cancer patients without metastasis), the study is certainly of interest due to the 1 year of follow-up.

* One of the inclusion criteria was commencing a new chemotherapy regimen where a minimum 2 cycles of chemotherapy were scheduled. I assume that in table 2, the chemotherapy agents are listed that were used prior to the baseline assessment? As the response in time is influenced by the type of chemotherapy and their side effects during the 12 months of assessment period, please also provide this information.  

* The subjects were well described for their baseline measurements in Table 1-4, however the most important data (the responses in time) were described only in Table 5 and the rest in the text of the Results section. I would prefer figures showing the responses of skeletal muscle mass, visceral adipose tissue, muscle strength, and quality of life until 1 year follow-up.

* In line with this, 5 subjects were at malnutrition risk using the MST at baseline. Did this group respond differently in time? Same for the 7 people with presence of myosteatosis as assessed by skeletal muscle radiodensity below cut-off.  If so, this may suggest a potential role as prognostic marker.

* Same also to identify the baseline characteristics of the group with reduced quality of life at 12 month period. In other words, do these patients or the ones with the highest QOL reduction have a certain baseline profile?

* Table 1 could be in the supplemental material

Author Response

Comments and Suggestions for Authors

 

This interesting manuscript describes a study investigating nutritional status, muscle health and functional performance and quality of life before the start of a second chemotherapy regimen and after 52 weeks in women with metastatic breast cancer. Markers of malnutrition, sarcopenia, myosteatosis, reduced physical function, and QoL were present in 20-65% of the patient group at baseline but only QoL further deteriorated during the 52 week follow-up period. Although the sample size was small and no comparison group was used (e.g., breast cancer patients without metastasis), the study is certainly of interest due to the 1 year of follow-up.

 

Thank you for your positive feedback.

 

* One of the inclusion criteria was commencing a new chemotherapy regimen where a minimum 2 cycles of chemotherapy were scheduled. I assume that in table 2, the chemotherapy agents are listed that were used prior to the baseline assessment? As the response in time is influenced by the type of chemotherapy and their side effects during the 12 months of assessment period, please also provide this information.  

We agree with the reviewer that the response in time is influenced by the type of chemotherapy. Therefore, we chose to report the agent people were going to start right after the baseline assessment, as this agent would mostly determine changes in the outcome parameters of interest over 52 weeks of follow up.

 

* The subjects were well described for their baseline measurements in Table 1-4, however the most important data (the responses in time) were described only in Table 5 and the rest in the text of the Results section. I would prefer figures showing the responses of skeletal muscle mass, visceral adipose tissue, muscle strength, and quality of life until 1 year follow-up.

Thank you for this suggestion. We added figures 2, 3, 4 and 5 showing the responses of skeletal muscle mass, visceral adipose tissue, muscle (handgrip) strength and quality of life until 1 year follow up.

 

* In line with this, 5 subjects were at malnutrition risk using the MST at baseline. Did this group respond differently in time? Same for the 7 people with presence of myosteatosis as assessed by skeletal muscle radiodensity below cut-off.  If so, this may suggest a potential role as prognostic marker.

Thank you for your valuable feedback. We investigated differences in responses between 5 subjects at malnutrition risk at baseline, compared to those who were not at malnutrition risk at baseline. We summarised our findings in paragraph 3.5 Prognostic impact of malnutrition risk at baseline.

 

* Same also to identify the baseline characteristics of the group with reduced quality of life at 12 month period. In other words, do these patients or the ones with the highest QOL reduction have a certain baseline profile?

As above, we discussed this in the new discussion subparagraph: 3.5 Prognostic impact of malnutrition risk at baseline.

 

* Table 1 could be in the supplemental material

As suggested by the reviewer, we placed table 1 in the supplemental material (Online supporting material 1).

In addition, we adapted it as we noticed an error in the third line: Severe Sarcopenia is present in case of confirmed low muscle mass AND low physical function, whereas Sarcopenia could be present in case of low muscle mass OR low physical function.

Round 2

Reviewer 2 Report

My comments have been addressed adequately by the authors.