In reply to: From Diagnosis to Survivorship: How the Tumor Boards Facilitation Forum (TEFF) Shapes the Breast Cancer Journey in Pakistan

Respected Editor,

I read Shaukat F. et al.’s paper about the Tumor Board Establishment Facilitation Forum (TEFF) and its achievements in relation to breast cancer (BCa) awareness. ¹ In Pakistan, where two in five women are aware of BCa symptoms, all possible efforts aiming to curb, and reverse, this statistic are needed. ² However, the purpose of my letter is to express my concern regarding the manuscript, which has omitted essential references and has faltered in multiple aspects. Unless clarified by the authors, readers of their manuscript will remain mis- and under-informed.

First, the authors do not introduce TEFF’s roots. Not in the main text, nor in their references. Although it might seem a trivial oversight - intentional or unintentional, it withholds from the reader essential information. TEFF was first established at the Dr. Ruth K. M. Pfau Civil Hospital in Karachi, Pakistan by medical students under the guidance of mentors. It runs on a low-resource and sustainable model which ensures that it continues to meet its goals. TEFF’s work, and dynamics, at this institute is briefly captured in a correspondence with The Lancet Regional Health - Southeast Asia, which readers can explore. ³

Second, a regrettable error in Shaukat F. et al.’s paper is their wrong use of TEFF’s title. The acronym “TEFF” stands for “Tumor Board Establishment Facilitation Forum” and not “Tumor Boards Facilitation Forum”. Shaukat F. et al use the latter. A curious reader may wonder what the “E” in TEFF stands for. I hope this letter clarifies. References to the accurate use of TEFF’s title can be found in several online resources: TEFF’s Facebook pages, published papers, and conference abstracts.^4,5 An observant eye will notice the correct title in TEFF’s logo present in Shaukat F. et al.’s manuscript.

Third, the authors say, “This study aims to highlight the pivotal role played by tumor boards in Pakistan to enhance awareness and education among women surrounding BCa.” This implies that tumor boards create awareness among women. This is not true. In fact, in most cases, patients are not present in tumor boards, let alone the involvement of laypeople. Tumor boards draft a comprehensive management plan, but they have no direct role in educating the population.

Fourth, I would welcome certain details. The title suggests that the authors’ efforts are present from “Diagnosis to survivorship…”. And so, it was disappointing to see that the manuscript is solely focused on awareness campaigns. It would be interesting for the readers to know how the authors assisted the clinical aspect of BCa at their hospital. I am also interested in learning how frequently the authors conduct their “Self-Breast Examination Workshop”, and if it has created a lasting change.

Lastly, I do not believe the authors are approaching the appropriate age group. The authors say “…100 young girls…”, which is concerning. First, because breast cancer is most commonly diagnosed in the fourth decade in Pakistani women. ⁵ Second, the U.S. Preventive Services Task Force recommended against breast self-examination after labeling it as a Grade D recommendation, fifteen years ago, in its 2009 guidelines. ⁶ Although this may not apply to a low-income country, but when coupled with the former point, the authors’ efforts may be causing psychological harm. ⁶