Title: Validation of the Swedish version of the EORTC LMC-21, the disease-specific
questionnaire for assessing health- related quality of life in patients with colorectal liver
metastases
Version: 5 Date: 09 Aug 2024
Reviewer's report:
This is a translation and validation of an existing questionnaire for patients treated for liver
metastases from colorectal cancer. The EORTC questionnaires are widely used and therefore it is
very reasonable to have a Swedish version. The translation and validation process seem to have
been performed thoroughly. I commend the authors for the work and think that this translation
is a potentially useful tool in scientific evaluation of patients treated for liver metastases.
I have some questions and comments though.
• In the introduction it is stated that “Surgical treatment of liver metastases is the only potentially
curative treatment”. Are ablative methods included in “surgical treatment”? To my knowledge
there is mounting evidence that ablation can have the same effect on oncological outcome as
resectional surgery, in selected cases. Or is this questionnaire only intended for patients who
undergo surgical liver resection? Why would it be reasonable to exclude the increasing number
of patients undergoing ablation? It seems to me that it would be very important to evaluate
HRQoL in patients who have undergone resectional surgery as compared to ablative methods.
• An expected survival “of more than 4 weeks” seems very short as an inclusion criteria. Would
the authors really include patients with an expected survival of 2-3 months as study persons?
• The discussion states that “Patient-reported outcomes have been shown to increase person-
centred care and may also have a prognostic value for survival, and they are a valuable tool
for monitoring the patient's clinical status in routine care”. Although this is true, it is certainly
not true for the EORTC questionnaires. These are developed for research purposes and are
notoriously known for being quite useless in the clinical situation.
• The Discussion repeats results. This is unnecessary and irritates me as a reader – I just read the
results and I do not want to read them again, but a discussion and reflections around the results.
The reader does also not need to get the details around exact adjustments of specific questions
after input from the patients.
• In the Discussion, it is stated “To evaluate the instrument’s ability to distinguish between
subgroups of patients in different disease stages…..”. But all of the patients with liver metastases
are in stage IV. What kind of stages do the authors refer to? Patients treated with curative
intent have the same stage as patients who undergo palliative treatment. The word the authors
are looking for must be something else than “stage”. Or do the author mean T stage? That is
something completely different . Tumour stage and T stage are completely different things.
Please clarify what you are talking about.
• In Table 1, the T stages are presented as 2a/b and 3a/b. What is this? T2 has no subclasses. T3
has subclasses a,b,c,d. I don’t understand. Why are subclasses of T2 (that does not exist) and
T3 tumours (that has classes c and d as well) mentioned while subclasses of T1 and T4 tumours
are not mentioned. What is the rationale? It does not affect the colorectal surgery performed
whether a colorectal primary tumour is a T3a or T3c, but it can be of great importance if it is a
T4a orT4b since T4b prerequisites extended, sometimes multiorgan, resections. Please explain.
• In table 1 it is stated that a proportion of patients had their liver metastases discovered due to
symptoms. I am curious as of how the authors have this information, since that is not available
from the Swedish Colorectal Cancer Registry. Is it through reading medical reports? Are these
data reliable?
• According to Table 2, the physical function is significantly better after hepatectomy than
before, while almost all other functional scales show a deterioration postoperatively. This is a
remarkable finding. Is it correct? It should in that case be discussed why that is.
• Is “higher correlation”, as used in the Results and Discussion, correct? I would think that “better
correlation” would be more reasonable.
•  It is stated about concurrent validity that “the correlations were weak between the QLQ-C30
and QLQ-LMC21”. But there is no discussion as to why this is so. I think this needs to be
addressed in the discussion, and not only that it was consistent with the original study.
• If you want the reviewer to be happy when reviewing your manuscript, don’t send such
unfinished tables, where tabs are completely missing and the hyphenation is crazy. It makes the
reviewer irritated.
• I think the questionnaire should be included as a supplement
Title: Validation of the Swedish version of the EORTC LMC-21, the disease-specific
questionnaire for assessing health- related quality of life in patients with colorectal liver
metastases
Version: 5 Date: 09 Aug 2024
Reviewer's report:
This is a translation and validation of an existing questionnaire for patients treated for liver
metastases from colorectal cancer. The EORTC questionnaires are widely used and therefore it is
very reasonable to have a Swedish version. The translation and validation process seem to have
been performed thoroughly. I commend the authors for the work and think that this translation
is a potentially useful tool in scientific evaluation of patients treated for liver metastases.
I have some questions and comments though.
• In the introduction it is stated that “Surgical treatment of liver metastases is the only potentially
curative treatment”. Are ablative methods included in “surgical treatment”? To my knowledge
there is mounting evidence that ablation can have the same effect on oncological outcome as
resectional surgery, in selected cases. Or is this questionnaire only intended for patients who
undergo surgical liver resection? Why would it be reasonable to exclude the increasing number
of patients undergoing ablation? It seems to me that it would be very important to evaluate
HRQoL in patients who have undergone resectional surgery as compared to ablative methods.
• An expected survival “of more than 4 weeks” seems very short as an inclusion criteria. Would
the authors really include patients with an expected survival of 2-3 months as study persons?
• The discussion states that “Patient-reported outcomes have been shown to increase person-
centred care and may also have a prognostic value for survival, and they are a valuable tool
for monitoring the patient's clinical status in routine care”. Although this is true, it is certainly
not true for the EORTC questionnaires. These are developed for research purposes and are
notoriously known for being quite useless in the clinical situation.
• The Discussion repeats results. This is unnecessary and irritates me as a reader – I just read the
results and I do not want to read them again, but a discussion and reflections around the results.
The reader does also not need to get the details around exact adjustments of specific questions
after input from the patients.
• In the Discussion, it is stated “To evaluate the instrument’s ability to distinguish between
subgroups of patients in different disease stages…..”. But all of the patients with liver metastases
are in stage IV. What kind of stages do the authors refer to? Patients treated with curative
intent have the same stage as patients who undergo palliative treatment. The word the authors
are looking for must be something else than “stage”. Or do the author mean T stage? That is
something completely different . Tumour stage and T stage are completely different things.
Please clarify what you are talking about.
• In Table 1, the T stages are presented as 2a/b and 3a/b. What is this? T2 has no subclasses. T3
has subclasses a,b,c,d. I don’t understand. Why are subclasses of T2 (that does not exist) and
T3 tumours (that has classes c and d as well) mentioned while subclasses of T1 and T4 tumours
are not mentioned. What is the rationale? It does not affect the colorectal surgery performed
whether a colorectal primary tumour is a T3a or T3c, but it can be of great importance if it is a
T4a orT4b since T4b prerequisites extended, sometimes multiorgan, resections. Please explain.
• In table 1 it is stated that a proportion of patients had their liver metastases discovered due to
symptoms. I am curious as of how the authors have this information, since that is not available
from the Swedish Colorectal Cancer Registry. Is it through reading medical reports? Are these
data reliable?
• According to Table 2, the physical function is significantly better after hepatectomy than
before, while almost all other functional scales show a deterioration postoperatively. This is a
remarkable finding. Is it correct? It should in that case be discussed why that is.
• Is “higher correlation”, as used in the Results and Discussion, correct? I would think that “better
correlation” would be more reasonable.
•  It is stated about concurrent validity that “the correlations were weak between the QLQ-C30
and QLQ-LMC21”. But there is no discussion as to why this is so. I think this needs to be
addressed in the discussion, and not only that it was consistent with the original study.
• If you want the reviewer to be happy when reviewing your manuscript, don’t send such
unfinished tables, where tabs are completely missing and the hyphenation is crazy. It makes the
reviewer irritated.
• I think the questionnaire should be included as a supplement
Please review this paper.
user
Title: Validation of the Swedish version of the EORTC LMC-21, the disease-specific
questionnaire for assessing health- related quality of life in patients with colorectal liver
metastases
Version: 5 Date: 09 Aug 2024
Reviewer's report:
This is a translation and validation of an existing questionnaire for patients treated for liver
metastases from colorectal cancer. The EORTC questionnaires are widely used and therefore it is
very reasonable to have a Swedish version. The translation and validation process seem to have
been performed thoroughly. I commend the authors for the work and think that this translation
is a potentially useful tool in scientific evaluation of patients treated for liver metastases.
I have some questions and comments though.
• In the introduction it is stated that “Surgical treatment of liver metastases is the only potentially
curative treatment”. Are ablative methods included in “surgical treatment”? To my knowledge
there is mounting evidence that ablation can have the same effect on oncological outcome as
resectional surgery, in selected cases. Or is this questionnaire only intended for patients who
undergo surgical liver resection? Why would it be reasonable to exclude the increasing number
of patients undergoing ablation? It seems to me that it would be very important to evaluate
HRQoL in patients who have undergone resectional surgery as compared to ablative methods.
• An expected survival “of more than 4 weeks” seems very short as an inclusion criteria. Would
the authors really include patients with an expected survival of 2-3 months as study persons?
• The discussion states that “Patient-reported outcomes have been shown to increase person-
centred care and may also have a prognostic value for survival, and they are a valuable tool
for monitoring the patient's clinical status in routine care”. Although this is true, it is certainly
not true for the EORTC questionnaires. These are developed for research purposes and are
notoriously known for being quite useless in the clinical situation.
• The Discussion repeats results. This is unnecessary and irritates me as a reader – I just read the
results and I do not want to read them again, but a discussion and reflections around the results.
The reader does also not need to get the details around exact adjustments of specific questions
after input from the patients.
• In the Discussion, it is stated “To evaluate the instrument’s ability to distinguish between
subgroups of patients in different disease stages…..”. But all of the patients with liver metastases
are in stage IV. What kind of stages do the authors refer to? Patients treated with curative
intent have the same stage as patients who undergo palliative treatment. The word the authors
are looking for must be something else than “stage”. Or do the author mean T stage? That is
something completely different . Tumour stage and T stage are completely different things.
Please clarify what you are talking about.
• In Table 1, the T stages are presented as 2a/b and 3a/b. What is this? T2 has no subclasses. T3
has subclasses a,b,c,d. I don’t understand. Why are subclasses of T2 (that does not exist) and
T3 tumours (that has classes c and d as well) mentioned while subclasses of T1 and T4 tumours
are not mentioned. What is the rationale? It does not affect the colorectal surgery performed
whether a colorectal primary tumour is a T3a or T3c, but it can be of great importance if it is a
T4a orT4b since T4b prerequisites extended, sometimes multiorgan, resections. Please explain.
• In table 1 it is stated that a proportion of patients had their liver metastases discovered due to
symptoms. I am curious as of how the authors have this information, since that is not available
from the Swedish Colorectal Cancer Registry. Is it through reading medical reports? Are these
data reliable?
• According to Table 2, the physical function is significantly better after hepatectomy than
before, while almost all other functional scales show a deterioration postoperatively. This is a
remarkable finding. Is it correct? It should in that case be discussed why that is.
• Is “higher correlation”, as used in the Results and Discussion, correct? I would think that “better
correlation” would be more reasonable.
•  It is stated about concurrent validity that “the correlations were weak between the QLQ-C30
and QLQ-LMC21”. But there is no discussion as to why this is so. I think this needs to be
addressed in the discussion, and not only that it was consistent with the original study.
• If you want the reviewer to be happy when reviewing your manuscript, don’t send such
unfinished tables, where tabs are completely missing and the hyphenation is crazy. It makes the
reviewer irritated.
• I think the questionnaire should be included as a supplement
assistant