Functional State and Rehabilitation of Patients after Primary Brain Tumor Surgery for Malignant and Nonmalignant Tumors: A Prospective Observational Study

Round 1

Reviewer 1 Report

In this study, Krajewski et al, provides an insightful report through a single-center, prospective, observational controlled study on functional state and rehabilitation of patients after primary brain tumor surgery for malignant and non-malignant tumors. Brain tumors are one of the most difficult to treat cancers. Despite the progress in modern medicine, there has been no successful therapy in recent years to treat brain tumors. Therefore, surgical removal of the brain tumor tissue remains a critical component of treatment for these patients. This treatment is often associated with considerable morbidity, poor quality of life and socio-economic impact on patient lives. In this study, authors have examined post-surgical changes on functional state and rehabilitation of brain tumor patients assessing the impact of surgery on the outcome of various survival needs required to maintain the appropriate rehabilitation of these patients.

The methodology used for acquiring data is appropriate and authors have provided sufficient literature to cover the important background information in brain tumor area. The study design and statistical methods to analyze the data are appropriate for this study.  Authors have made sure to maintain the flow of information systematically making it appealing and intriguing for a wide range of audience.

Overall, this study addresses the gap in the knowledge regarding post-surgical rehabilitation process associated with non-malignant and malignant brain tumor patients. This study explores other important factors that contribute to rehabilitation such as functional states and basic motor skills. This study delivers an important take home message to practicing clinicians  that “non-malignant” is not equivalent to lesser physical and mental rehabilitation needs in the vulnerable brain tumor patients, therefore harmonizing the need for holistic care of all types of brain tumor patients. I recommend the following suggestions, critical for the publication of this manuscript.

Specific Comments:

1)     This study uses a number of criteria for patient assessment such as Barthel index (BI), Karnofsky performance status scale (KPS), modified Rankin scale (MRS) and Landriel Ibanez classification. However, no rationale was provided for using these specific guidelines. It is important to justify why these established guidelines were used over others and their significance in the context of this observational study.

2)     Authors acknowledge one of the limitations for this study was the low samples size for this study. It is noteworthy that the study is focused on patients from a single center and low sample size. Authors should discuss this major limitation as an increase in the patient sample size may have impact on the outcome of this study.

3)     Another limitation of the study is authors do not provide data on ethnicity, co-morbidity and socio-economic parameters of patients consented for this study. It is likely that these parameters will have a major impact on the length of the stay in the hospital, ultimately impacting the conclusions of this study. The reasons for not including this information should be discussed.

Minor comments:

11)  Figure 2, These graphs need to be revised. The axis lines are thin, and colors of the middle bar need to change as error bars in the middle bar are not visible. The comparison lines should be made smaller (covering the center of the bars only).

22)   Throughout the text, inconsistent formatting is observed. Gaps between the two sentences should be made consistent.

33)   Table 2, Age (mean +/- SD), should be re-written for clarity. Mean +/- SD should be included in the legend/footnote.

Author Response

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Reviewer 2 Report

This reads well. I do think that there needs to be an acknowledgement of the consistency of neurosurgical approaches. For example, did some of these patients have awake craniotomies, was image guidance used for brain mapping? Or did all have the same neurosurgical interventions?

Authors may also want to cite this article Curr Treat Options Neurol (2016) 18:22 DOI 10.1007/s11940-016-0406-5 Neurocognitive Deficits and Neurocognitive Rehabilitation in Adult Brain Tumors 

It is well written - eloquent, clear and well structured. I have one query over the language used around benign and non malignant. The WHO organisation categorises grade 1 brain tumours as benign but there is a wider shift to referring to these tumours as non malignant. This article  interchanges the terms. Line 37 states 'benign or malignant' whereas l 16 refers to malignant and non-malignant. The preferred terminology by the patient community is non malignant. 

There is also a typographical error on the graphic on page 3 in the third box on the RH side - it should read refused to participate and not refussed. 

Author Response

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Reviewer 3 Report

I appreciate the opportunity to review the manuscript “ Functional state and rehabilitation of patients after primary brain tumor surgery for malignant and non-malignant tumors: a prospective observational study”. curroncol-2354797

General comments:

The manuscript is very interesting and contains many important aspects. Few papers so far attempts to develop rehabilitation programs for patients with poor quality of life. Some studies did not take tumor type into account. The impact of the operation itself has also only rarely been studied, i.e., the functional status immediately before the procedure and in the early postoperative period, which is the often the starting point for rehabilitation. Therefore, the topic taken up by the researchers seems to be very important. Determining the functional status throughout postoperative recovery would help to understand the dynamics and effectiveness of rehabilitation, and taking tumor type into account may help to preselect patients for rehabilitation.

Strong points of the paper: topicality of the subject, the social utility.

In my opinion, it would be worth correcting the Y-axis in all graphs. It should start with a value of 0. If the SD values do not fit on the scale, you can only present a positive-upper value or enter the SEM value.

Author Response

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