Identifying Optimal Candidates for Trimodality Therapy among Nonmetastatic Muscle-Invasive Bladder Cancer Patients
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
Overall Impression:
The manuscript addresses a critical question in the field of uro-oncology, aiming to distinguish between patients with non-metastatic MIBC who would benefit from Radical Cystectomy (RC) versus those for whom Trimodal Therapy (TMT) would be more appropriate. The authors’ effort to develop a nomogram for aiding this decision-making process is commendable and shows potential. However, the manuscript could benefit significantly from revisions aimed at addressing inherent biases, providing additional information on modern treatment modalities, and improving the clarity and consistency throughout the text.
Abstract:
The abstract succinctly summarizes the main objectives, methodology, and findings of the study. To enhance its quality, it is crucial to ensure that acronyms are clearly defined and used consistently, and to provide more specific information regarding the patient population under study. The key results derived from the predictive model should be prominently featured, given their central role in the study’s objectives.
Introduction:
The introduction provides a solid background and rationale for the study, yet there are areas where improvements can be made. A clear articulation of the research question or hypothesis is needed, and the importance of identifying optimal candidates for TMT warrants stronger emphasis.
Methods:
The manuscript would benefit from a more detailed description of the patient selection criteria and data collection methods. The development, validation, and performance assessment of the nomogram should be thoroughly described. The authors must also address potential biases inherent in the study design and discuss the steps taken to mitigate them.
Results:
The presentation of results necessitates a higher degree of clarity, structure, and detail to enhance the manuscript's comprehensiveness and reliability. The key findings derived from the predictive model need to be distinctly highlighted, providing readers with a clear understanding of their implications for clinical practice. A critical evaluation of the data sources used in the study is required, addressing potential biases stemming from the observational study design, and discussing their possible impacts on the study's conclusions.
The manuscript should highlight the key findings from the predictive model, and discuss any limitations of the data used and their potential impact on the results.
Discussion:
While the discussion offers a comprehensive overview of the study’s findings in relation to existing literature, it needs a more critical analysis of the study’s limitations, including biases and the absence of information on certain treatment modalities. The clinical implications of the findings and their contribution to the existing body of knowledge should be articulated more clearly, and the discussion should outline potential future directions for research in this area.
By addressing these issues in detail, the manuscript can achieve a higher level of rigor, clarity, and impact, making a significant contribution to the field.
Comments on the Quality of English Language
English is ok
Author Response
English editing services have been performed on our manuscript. Please see the attachment in detail.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for Authors
The authors aimed to identify the selected candidates for trimodality therapy (TMT) or radical cystectomy (RC) by a predictive model. They concluded a predictive model with excellent discrimination and clinical application value was established to identify the optimal patients for RC or TMT among non-metastatic MIBC patients.
Well written.
This report is very interesting and easy to read.
The results obtained in this study may have a great impact on future research.
Author Response
Please see the attachment in detail.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for Authors
The authors provide a predictive model aimed at identifying the most optimal treatment for patients with muscle-invasive bladder cancer (MIBC), specifically comparing TMT with RC. The model is developed using data from the Surveillance, Epidemiology, and End Results (SEER) database.
The fundamental flaw of this study is the reliance on overall survival (OS) as the primary outcome measure, rather than cancer-specific mortality. Additionally, the study did not adequately consider other potential causes of mortality within elderly, which is particularly crucial when examining the senior population. Moreover, it is evident that the individuals who had TMT exhibited a considerably higher age, and even when controlling for age, it is reasonable to infer that these patients had a greater number of comorbidities. Furthermore, this study fails to consider the perioperative mortality associated with radical cystectomy (RC). The determination of the N stage for TMT relies on imaging techniques. Is the N stage for RC patients determined by imaging techniques or through pathological findings obtained after lymph node dissection? There exists a significant disparity between the two. There exist a number of small limitations, such as: Introduction –“Without treatment, 41% 37 of MIBC patients would die in six months” . Paradoxically, next sentence states: “35% of untreated MIBC patients within 12 months progressed to distant metastasis
Author Response
Please see the attachment in detail.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for Authors
Thank you for your revision
Reviewer 3 Report
Comments and Suggestions for Authors
In a randomized clinical trial (RCT) evaluating an experimental treatment, the measure of overall survival (OS) is typically considered the most pertinent indicator of clinical efficacy, particularly when controlling for potential confounding factors related to patients' characteristics. However, given that selection bias is a potential issue with trimodal therapy in actual clinical settings, I believe that OS endpiont is inadequate. The study did not account for comorbidities and suggested that trimodal therapy would be preferable for the elderly population. However, it could be that achieving the same outcome without any therapy could potentially be possible when overall survival is utilized as an endpoint.
