Abstract
Dear Editor,
We thank Satapathy et al for the thoughtful and constructive feedback on our manuscript.1,2 We are encouraged by the recognition of the study’s clinical relevance and methodological rigor and we appreciate the opportunity to clarify and expand on the interpretation of our findings. Below, we provide detailed responses to each of the concerns raised, noting that many of these issues were already acknowledged in the Discussion and Limitations sections of our publication.
We appreciate the concern regarding the interpretation of the effect sizes. In our study, the reported values correspond to partial eta squared (ηp²) measures. According to Cohen’s widely accepted standards for ηp² where from a statistical perspective, the magnitude of change in the physiological outcomes (VO²peak and time to exhaustion) is considered meaningful. We agree that statistical effect size does not automatically translate into clinical significance. As noted in the Discussion, we did not establish direct links between VO²peak changes and clinically actionable outcomes such as reductions in cardiovascular risk. While even modest absolute gains in VO²peak may express prognostic importance in BC cancer populations or survivors, future studies should explicitly connect these physiological improvements to patient-centered clinical changes.
We accept the concern regarding potential confounding variables such as adjuvant therapy, age, and baseline fitness. As noted in the Discussion, there is currently no established minimal clinically important change for the 6MWT in BC patients or survivors. Age differences (though non-significant) and therapy regimens are explicitly discussed as potential confounders in the Discussion, with an emphasis on the need for future studies with larger sample size incorporating multivariable analyses to explore intervention effects from age- or treatment-related variation. Furthermore, in Limitations chapter we have indicated that the small sample size precludes robust adjustment for confounders. Nevertheless, we statistically controlled for baseline VO²peak and functional capacity when analyzing change scores, which partially mitigates but does not eliminate the risk of residual confounding.
We acknowledge in the Discussion the complex and sometimes inverse relationship between objective fitness improvements and self-reported quality of life parameters related to physical functioning. We have provided potential explanations, including increased awareness of limitations after regaining functional capacity or persistent emotional distress despite physical improvements. In the Limitations, we noted that future studies should incorporate remotely monitored physical activity and use other research approaches (eg, qualitative) to better elucidate the lived experience of BC survivors.
We have addressed the need to monitor physical activity levels during the follow-up period in our Limitations. In Discussion we mentioned that participants from both groups reported that they engaged in low intensity physical activities 1 to 2 times per week that likely contributed to sustaining or even increasing daily physical activity outcomes during follow-up period. As indicated above, we proposed that future investigations integrate objective physical activity tracking (eg, wearable accelerometers) to analyze intervention versus lifestyle-maintained effects, allowing for more precise measures of follow-up physical activity behaviors.
Thank you again for the opportunity provided by Integrative Cancer Therapy to respond to the letter addressing clinical relevance and methodological rigor of our study.
