Education, Employment, and Financial Outcomes in Adolescent and Young Adult Cancer Survivors—A Systematic Review

Round 1

Reviewer 1 Report

Please refers to the following comments:

1. Introduction:

1.1. My concern is why this SR did not determine the prevalence rate of the outcomes instead of describing the outcomes.

1.2. What is your PICO? Need to provide it here or under the Methods.

2. Methods:

2.1. Please provide PROSPERO information. If this study didn't register in PROSPERO, please explain why?

2.2.  Authors wrote, "Two reviewers each (AA, CB, MK, KR) independently assessed eligibility by first screening titles and abstracts followed by the full texts of the remaining articles." Two or four reviewers?

2.3. Authors wrote, "The quality of each study was independently assessed by two reviewers each (AA, MK, KR) using the JBI critical appraisal tool [28]" What is the reliability of the reviewers? Also, 2 or 3 reviewers?

2.4. I have a reservation on this "A priori, we did not consider a meta-analytic approach because of expected heterogeneity in study design, study period, outcome definition across studies, and differences in educational, labor, and financial contexts across geographic regions" In fact, you can use regression to identify which factors show impact on each outcome by country/region.  For example, there are many articles from the USA.

2.5. Definition of youth and adult needs to provide, you are using their age? If yes, please provide the age range [Min - Max].

3. Results:

3.1. In Table 1, I was surprised that Bhatt, 2021, didn't report "age at study" and "time since diagnosis", but its quality is 100%. Same for Ghaderi, 2013, 3 variables were "not reported," but it is 100% on its quality. Please cross-check again.

Author Response

Reviewer 1

Open Review

( ) I would not like to sign my review report
(x) I would like to sign my review report

Quality of English Language

( ) I am not qualified to assess the quality of English in this paper
( ) English very difficult to understand/incomprehensible
( ) Extensive editing of English language required
( ) Moderate editing of English language required
( ) Minor editing of English language required
(x) English language fine. No issues detected

Comments and Suggestions for Authors

Please refers to the following comments:

1. Introduction:

Comment 1: 1.1. My concern is why this SR did not determine the prevalence rate of the outcomes instead of describing the outcomes.

Response 1: Thank you for this comment. As expected, the reporting of the three outcomes of interest, education, employment, and financial outcomes, varies across the different studies and therefore, the measures presented in our systematic review vary as well. Furthermore, the included studies were heterogeneous regarding study design, study period, outcome definitions, and the educational, labor, and financial contexts across different geographic regions.

Comment 2: 1.2. What is your PICO? Need to provide it here or under the Methods.

Response 2: We have two research questions and the corresponding PICO formats are as follows:

1. i) To describe education, employment, and financial outcomes in AYA cancer survivors:

For articles including a comparison group:

P:           Adults

I:            Survivors of cancer during adolescence or young adulthood (15 to 39 years of age)

C:           Comparison group

O:          Education, employment, and/or financial outcomes

For articles not including a comparison group:

P:           Survivors of cancer during adolescence or young adulthood (15 to 39 years of age)

I:            -

C:           -

O:          Education, employment, and/or financial outcomes

1. ii) To describe determinants for adverse educational, employment, and financial outcomes in AYA cancer survivors:

P:           Survivors of cancer during adolescence or young adulthood (15 to 39 years of age)

I:            Different levels of various characteristics

C:           Different levels of various characteristics

O:          Education, employment, and/or financial outcomes

We have included these PICO formats for our research questions as additional table in the Supplementary Material (Table S3 in the revised version).

Changes (Supplementary Material): Additional table, Table S3 in the revised version.

2. Methods:

Comment 3: 2.1. Please provide PROSPERO information. If this study didn't register in PROSPERO, please explain why?

Response 3: Thank you for this comment. This systematic review was registered in PROSPERO (number: CRD42021262353; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021262353).

Changes (page 2): This systematic review was registered in PROSPERO (number: CRD42021262353) and complies with the PRISMA statement regarding reporting systematic reviews and meta-analyses [27].

Comment 4: 2.2.  Authors wrote, "Two reviewers each (AA, CB, MK, KR) independently assessed eligibility by first screening titles and abstracts followed by the full texts of the remaining articles." Two or four reviewers?

Response 4: In total, four authors were involved in the title and abstract and the full text screening and each article was screening by two of these four authors independently.

Changes (page 3): Two reviewers each independently assessed eligibility by first screening titles and abstracts followed by the full texts of the remaining articles (involved authors: AA, CB, MK, KR). Discrepancies between reviewers were resolved by discussion and consensus or by consulting a third reviewer (LM).

Comment 5: 2.3. Authors wrote, "The quality of each study was independently assessed by two reviewers each (AA, MK, KR) using the JBI critical appraisal tool [28]" What is the reliability of the reviewers? Also, 2 or 3 reviewers?

Response 5: In total, three authors were involved in the quality assessment and each article was assessed by two of these three authors independently. Inter-rater reliability assessed by Kendall’s tau was tau = 0.74 for quantitative studies and tau =0.71 for qualitative studies.  

Changes (page 3-4): The quality of each study was independently assessed by two reviewers each using the JBI critical appraisal tool [28] (involved authors: AA, MK, KR). Discrepancies between reviewers were resolved by discussion and consensus. Inter-rater reliability assessed by Kendall’s tau was tau = 0.74 for quantitative studies and tau =0.71 for qualitative studies. The JBI critical appraisal tool was designed to assess methodological validity and determine the extent to which the study considered possible biases in its design, conduct, and analysis.

Comment 6: 2.4. I have a reservation on this "A priori, we did not consider a meta-analytic approach because of expected heterogeneity in study design, study period, outcome definition across studies, and differences in educational, labor, and financial contexts across geographic regions" In fact, you can use regression to identify which factors show impact on each outcome by country/region.  For example, there are many articles from the USA.

Response 6: We agree that with a meta-regression, one could potentially identify factors being related to the outcomes of interest. However, also the assessment and reporting of the outcomes varied and therefore, we decided to refrain from conducting meta-analytic analyses.

Comment 7: 2.5. Definition of youth and adult needs to provide, you are using their age? If yes, please provide the age range [Min - Max].

Response 7: The eligible age range at diagnosis has been described under 2.2. Study Selection: “(…) AYA cancer (i.e., at least 75% of participants in the age range of 15-39 years at diagnosis) (…)”.

3. Results:

Comment 8: 3.1. In Table 1, I was surprised that Bhatt, 2021, didn't report "age at study" and "time since diagnosis", but its quality is 100%. Same for Ghaderi, 2013, 3 variables were "not reported," but it is 100% on its quality. Please cross-check again.

Response 8: Thank you for carefully looking at our manuscript. We agree that it would have been nice to be able to extract these information pieces. However, based on the information presented, we were able to decide if to include these articles what is also reflected in the quality assessment rating. We did not have an inclusion or exclusion criteria for age at study and there was still enough information available to use our inclusion and exclusion criteria on time since diagnosis (Bhatt et al., (2021): median time since treatment = 60.6 months, range: 12-121 months; Ghaderi et al. (2013): survivors were followed for mean=13.2 years beginning 5 years after diagnosis (range: 0–39.3 years) (childhood and AYA cancer survivors)).

Author Response File: Author Response.pdf

Reviewer 2 Report

The Authors present a very interesting manuscript related to quality of life of longterm survivors from cancer.

They wrote a complete analysis of the problem divided in the 3 main issues: education, employement and  insurance. A very good and detailed literature review was reported.

I don't have specific concerns but I would like the Authors could complete their paper following the 2 my requests:

1. The tables complete but not easy to read as to me should be removed from the text and added as appendix for making the manuscript less heavy to read.

2. I have a criticism when I read in the Conclusions that "further studies are needed to...." : I ask the Auhotrs please to report even as preliminary considerations "how they think to face the 3 problems reported in a detailed way in the manuscript. What are the take home messages they leave to readers, just not waiting for other many years before having from their experience some practical suggestion (operative modality).

Author Response

Reviewer 2

Open Review

( ) I would not like to sign my review report
(x) I would like to sign my review report

Quality of English Language

( ) I am not qualified to assess the quality of English in this paper
( ) English very difficult to understand/incomprehensible
( ) Extensive editing of English language required
( ) Moderate editing of English language required
( ) Minor editing of English language required
(x) English language fine. No issues detected

Comments and Suggestions for Authors

Comment 9: The Authors present a very interesting manuscript related to quality of life of longterm survivors from cancer.

They wrote a complete analysis of the problem divided in the 3 main issues: education, employement and  insurance. A very good and detailed literature review was reported.

Response 9: Thank you for your appreciative comment.

I don't have specific concerns but I would like the Authors could complete their paper following the 2 my requests:

Comment 10: 1. The tables complete but not easy to read as to me should be removed from the text and added as appendix for making the manuscript less heavy to read.

Response 10: We agree that the tables are quite long. This is due to the fact that we included 35 articles in total and were investigating three outcomes of interest. We would like to keep the tables in the manuscript itself to enable the reader to directly have a look at our results also in a tabular format.

Comment 11: 2. I have a criticism when I read in the Conclusions that "further studies are needed to...." : I ask the Auhotrs please to report even as preliminary considerations "how they think to face the 3 problems reported in a detailed way in the manuscript. What are the take home messages they leave to readers, just not waiting for other many years before having from their experience some practical suggestion (operative modality).

Response 11: We have added more concrete suggestions to the Implications part of the Discussion section.

Changes (page 42): Identifying AYA cancer survivors at risk for adverse educational, employment, and financial outcomes is important for developing tailored support strategies for cancer patients and survivors along their whole cancer trajectory. We found that most survivors returned to school or work after cancer treatment. However, this re-entry was associated with difficulties and hurdles. To enable a successful return to school or work, AYA cancer survivors should be supported in navigating the system [64] and involved key persons such as peers, teachers, or employers and employees should be informed and supported as well [65]. Flexible working conditions might help survivors in successfully return to work [66] and being able to stay in the workforce also in the long term. Survivors in their last years of school or their first years of employment might be especially vulnerable to adverse effects on their education and employment. Individual support options focusing on cancer- and treatment-related impairments but also abilities and potential new directions for their employment should be provided [66].

Although most AYA cancer survivors were able to re-enter education and employment, they reported difficulties with re-entry and delays in their employment pathway. We found some determinants for adverse outcomes, but results were heterogeneous. To facilitate successful re-entry, age- and situation-tailored support services along the cancer trajectory should be developed and implemented to prevent future social inequalities and adverse educational, employment, and financial outcomes in the long-term.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The authors answered all the comments adequately by stating the revised MS's changes.