Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan

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Lifestyle, reproductive and sociodemographic factors are among the influential parameters that may significantly affect the risk of ovarian cancer and its mortality rate. However, the epidemiological investigations have shown that the risk of ovarian cancers associated with these factors is different in varied geographical distributions. Lifestyle and reproductive factors have not been investigated thoroughly across a wide cultural diversity. The objective of this study is to investigate the association of these factors with ovarian cancer in Pakistan. This investigation will focus on the lifestyle effects of fat intake, intake of tea, habitual exercise, use of talc, personal hygiene, habit of holding urine for long time, obesity on ovarian cancer among Pakistani women. Reproductive variables will include age at menarche, natural menopausal age, parity, nulliparity (miscarriages, abortion, stillbirths), infertility, fertility treatment, tubal ligation, oral contraceptive use, and family history of breast or ovarian cancer. Sociodemographic variables will include effect of age, income, education, and geographical location. A case-control study will be conducted in the major cancer hospitals of Pakistan and the patients will also be interviewed. The controls will be recruited outside the hospital. For controls the same age limit and residency requirements will be applied. The information gained from this research will be an important contribution to develop programs for health promotion, with a focus on ovarian cancer prevention and women’s health. The findings could be used for health policies and planning to prevent ovarian cancer. The research will pave the way for a public policy and interventions to reduce the burden of ovarian cancer in Pakistan." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/9-901", "name": "Lifestyle and reproductive health: the aetiology of ovarian cancer..." } } ] } Home Browse Lifestyle and reproductive health: the aetiology of ovarian cancer... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Alvi Q, Baloch GM, Chinna K and Dabbagh A. Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.12688/f1000research.24866.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] Qurratulann Alvi https://orcid.org/0000-0002-5582-0423 1 , Gul Muhammad Baloch 2 , Karuthan Chinna 2 , Ali Dabbagh 2 Qurratulann Alvi https://orcid.org/0000-0002-5582-0423 1 , Gul Muhammad Baloch 2 , Karuthan Chinna 2 , Ali Dabbagh 2 PUBLISHED 04 Aug 2020 Author details Author details 1 School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Kualalampur, Selangor, 47500, Malaysia 2 School Of Medicine,Faculty of Health and Medical Sciences, Taylor's University, Kualalampur, Selangor, 47500, Malaysia Qurratulann Alvi Roles: Conceptualization, Investigation, Writing – Original Draft Preparation Gul Muhammad Baloch Roles: Project Administration, Supervision, Writing – Review & Editing Karuthan Chinna Roles: Methodology, Software, Writing – Review & Editing Ali Dabbagh Roles: Formal Analysis, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Oncology gateway. Abstract Ovarian cancer is a fatal gynaecological cancer and eighth most common cancer in women globally. Lifestyle, reproductive and sociodemographic factors are among the influential parameters that may significantly affect the risk of ovarian cancer and its mortality rate. However, the epidemiological investigations have shown that the risk of ovarian cancers associated with these factors is different in varied geographical distributions. Lifestyle and reproductive factors have not been investigated thoroughly across a wide cultural diversity. The objective of this study is to investigate the association of these factors with ovarian cancer in Pakistan. This investigation will focus on the lifestyle effects of fat intake, intake of tea, habitual exercise, use of talc, personal hygiene, habit of holding urine for long time, obesity on ovarian cancer among Pakistani women. Reproductive variables will include age at menarche, natural menopausal age, parity, nulliparity (miscarriages, abortion, stillbirths), infertility, fertility treatment, tubal ligation, oral contraceptive use, and family history of breast or ovarian cancer. Sociodemographic variables will include effect of age, income, education, and geographical location. A case-control study will be conducted in the major cancer hospitals of Pakistan and the patients will also be interviewed. The controls will be recruited outside the hospital. For controls the same age limit and residency requirements will be applied. The information gained from this research will be an important contribution to develop programs for health promotion, with a focus on ovarian cancer prevention and women’s health. The findings could be used for health policies and planning to prevent ovarian cancer. The research will pave the way for a public policy and interventions to reduce the burden of ovarian cancer in Pakistan. READ ALL READ LESS Keywords Ovarian Cancer, Reproductive Health, Lifestyle, Miscarriage, Pakistan Corresponding Author(s) Gul Muhammad Baloch ( [email protected] ) Close Corresponding author: Gul Muhammad Baloch Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2020 Alvi Q et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Alvi Q, Baloch GM, Chinna K and Dabbagh A. Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.12688/f1000research.24866.1 ) First published: 04 Aug 2020, 9 :901 ( https://doi.org/10.12688/f1000research.24866.1 ) Latest published: 04 Aug 2020, 9 :901 ( https://doi.org/10.12688/f1000research.24866.1 ) Introduction Ovarian cancer is one of the most frequently fatal gynaecologic cancers ( Jayson et al. , 2014 ; Tworoger & Huang, 2016 ). According to the American Institute for Cancer Research report, in 2018 ovarian cancer globally accounted for 3.6% of all forms of cancers and the eighth leading cause of death among women globally ( Merritt et al. , 2018 ). Only 46% of ovarian cancer patients survive beyond 5 years ( Kathawala et al. , 2018 ). The high mortality associated with ovarian cancer is due to late diagnosis and resistance to treatment, ( Carollo et al. , 2019 ; Nunes et al. , 2019 ). According to a 2018 report by World Cancer Research Fund, the diagnosed cases of ovarian cancer are 295,414. The estimated age-standardized incidence and mortality rates of ovarian cancer in 2018 were 6.6 and 3.9, respectively ( Bray et al. , 2018 ) and this number is expected to reach at 434,184 by 2040 . The incidence, prevalence, and mortality of ovarian cancer varies across geographical locations and countries ( Coburn et al. , 2017 ). Globally, the highest incidence and mortality for ovarian cancer was reported in Serbia (16.6 and 6.8, respectively) and lowest in Gambia (0.6 and 0.43, respectively); in Europe itself, figures were highest in Serbia and lowest in Ireland (11.4 and 6.4, respectively); in Asia, rates are highest in Brunei (16 and 6.2, respectively) and lowest in Yemen (2.6 & 2.1, respectively) ( https://gco.iarc.fr/today/online-analysis-table ). The epidemiological diversity could be linked to different risk factors for ovarian cancer ( Hunn & Rodriguez, 2012 ). Poole et al. (2013) called for identifying modifiable risk factors. Jammal et al. (2017) believe that ovarian cancer prevention can be accomplished with clinical approaches. The aetiology of ovarian cancer cannot be defined by single mechanism ( Terry & Missmer, 2017 ). Hence understanding of risk factors is important ( Webb & Jordan, 2017 ). Clinical evidence shows that by eliminating and decreasing the risk factors, the ovarian cancer cases can be prevented ( Bray et al. , 2018 ). Lifestyle modifications can minimize cancer burden ( Song & Giovannucci, 2016 ). Ali (2018) noted that knowledge on ovarian cancer might increase survival rate. This can help women at risk of ovarian cancer to take special precautions ( Li et al. , 2015 ; Torre et al. , 2018 ); thus, help reduce ovarian cancer risk ( Momenimovahed et al. , 2019 ). Schildkraut et al. (2019) reported obesity and family history of breast cancer to be major risk factors for ovarian cancer and Abbott et al. (2016) reported inadequacy of physical activity to be a risk factor. Gabriel et al. (2019) found the use of talc in genital areas to be a risk factor for ovarian cancer in England. In a Canadian study, Koushik et al. (2017) showed strong inverse association between parity and ovarian cancer. Harris et al. (2017) reported oral contraceptive and family history as the main risk factors in an American population. Lee et al. (2013) showed that consumption of green tea increases ovarian cancer risk in a Chinese population. Other risk factors include infertility ( Rasmussen et al. , 2017 ), miscarriages ( Moorman et al. , 2016 ) and age at menopause. Doherty et al. (2017) suggests role of ethnically differing populations. Endpoints must represent the disease agent involved and rely on the quality of life ( Wilson et al. , 2017 ). Responsive and timely health care facilities that use relational communication, could enhance women's health experience with ovarian cancer ( Jelicic et al. , 2019 ). Study objective This study explores lifestyle (use of talc, obesity, pattern of weight change), reproductive health (miscarriages, age at menarche, menopausal age, parity, nulliparity) and socio-demographic factors (age, income, and geographical location) associated with ovarian cancer in Pakistan. Methods The research is now at an advanced stage after a development of a literature review, methodology and preparation of a validated questionnaire. The study will be conducted from July 2020 to December 2020. Data collection will start in July 2020. Study design This will be a case-control study. The cases will be ovarian cancer patients registered at cancer hospitals in Pakistan. Hospitals are selected based on receiving approval from the hospital administrations. The controls will be recruited from the general population, using random digit dialling of individuals in the vicinity of the selected hospitals, since this was what the participating hospitals wanted. Cases and controls will not be matched. In the analysis, the outcome variables will be corrected for all the variables. We do not have the ability to mitigate many sources of bias as we must comply with the hospital’s’ requirements. Instrument A validated questionnaire (validated by a panel of experts, each with doctorates and many years’ experience in biostatistics, public health and biomedicine) will be used to elicit information on following parameters. 1. Socio demographic characteristics 2. Patient clinical data 3. Diagnostic data 4. Lifestyle factors 5. Reproductive health Data collection Patients’ clinical and diagnostic data will be obtained from the respective hospital registries. Written informed consent will be obtained from all participants with the voluntary decision to participate in the study. Interviews will be conducted with questions relevant to the parameters mentioned above. Sample size Power and Sample Size software was used to calculate sample size. The level of significance and power were set as 0.05 and 80%, respectively. Based on results, the minimum required sample size is 387 for cases and 387 for controls. The figures are rounded up to 400 per group. Inclusion criteria for cases • Age 30 to 65 • Confirmed diagnosis of ovarian cancer by hospital or health care facility. Exclusion criteria for cases • Cognitively impaired • Diagnosed with any other form of cancer The inclusion criteria for control will be, age 30 to 65, healthy and cognitively not impaired; and exclusion criteria will be comorbidities, such as diabetes or cardiovascular disease. Data analysis Data will be analysed using SPSS version 25. Qualitative variables will be described as frequencies and percentages, while quantitative variables will be described as means and standard deviations if the variable is normally distributed and as median and interquartile ranges, otherwise. Univariate and multivariate binary logistic regression analyses will be used in testing association between the predictor variables and ovarian cancer. In the univariate analysis, the predictor variables will be tested on at time. The variables that are significant at 0.25 level will be included in the multivariate analysis. Finally, stepwise analysis will be used to determine the significant predictors of ovarian cancer. Ethical consideration Ethical approval for this study will be obtained from the participating hospitals/authorities in Pakistan. Respondents will be briefed, consent obtained and the confidentiality and participants’ right to stop at any point of the study will be assured. Data availability No data are associated with this article. Faculty Opinions recommended References Abbott SE, Bandera EV, Qin B, et al. : Recreational physical activity and ovarian cancer risk in African American women. Cancer Med. 2016; 5 (6): 1319–1327. PubMed Abstract | Publisher Full Text | Free Full Text Ali AT: Towards Prevention of Ovarian Cancer. Curr Cancer Drug Targets. Bentham Science Publishers. 2018; 18 (6): 522–537. PubMed Abstract | Publisher Full Text Bray F, Ferlay J, Soerjomataram I, et al. : Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018; 68 (6): 394–424. PubMed Abstract | Publisher Full Text Carollo E, Paris B, Samuel P, et al. : Detecting ovarian cancer using extracellular vesicles: progress and possibilities. Biochem Soc Trans. 2019; 47 (1): 295–304. PubMed Abstract | Publisher Full Text Coburn SB, Bray F, Sherman ME, et al. : International patterns and trends in ovarian cancer incidence, overall and by histologic subtype. Int J Cancer. Wiley Online Library, 2017; 140 (11): 2451– 2460. 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 04 Aug 2020 ADD YOUR COMMENT Comment Author details Author details 1 School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Kualalampur, Selangor, 47500, Malaysia 2 School Of Medicine,Faculty of Health and Medical Sciences, Taylor's University, Kualalampur, Selangor, 47500, Malaysia Qurratulann Alvi Roles: Conceptualization, Investigation, Writing – Original Draft Preparation Gul Muhammad Baloch Roles: Project Administration, Supervision, Writing – Review & Editing Karuthan Chinna Roles: Methodology, Software, Writing – Review & Editing Ali Dabbagh Roles: Formal Analysis, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 04 Aug 2020, 9:901 https://doi.org/10.12688/f1000research.24866.1 Copyright © 2020 Alvi Q et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Alvi Q, Baloch GM, Chinna K and Dabbagh A. Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.12688/f1000research.24866.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 04 Aug 2020 Views 0 Cite How to cite this report: Bhanbhro S. Reviewer Report For: Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.5256/f1000research.27437.r68704 ) The direct URL for this report is: https://f1000research.com/articles/9-901/v1#referee-response-68704 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Aug 2020 Sadiq Bhanbhro , College of Health and Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK Approved VIEWS 0 https://doi.org/10.5256/f1000research.27437.r68704 This is a well-designed study protocol aimed to investigate the relationships between lifestyle factors, reproductive health, and risk of ovarian cancer in Pakistan. The aims, objectives and study design including sample size and data collection methods are appropriate and sufficiently described. ... Continue reading READ ALL This is a well-designed study protocol aimed to investigate the relationships between lifestyle factors, reproductive health, and risk of ovarian cancer in Pakistan. The aims, objectives and study design including sample size and data collection methods are appropriate and sufficiently described. The authors have cited the current and relevant literature. However, considering the sensitive nature of the topic under study, I would suggest the investigators need to provide more details on the recruitment of the potential study participants and the ethical considerations. For instance, the authors’ need to identify and name the relevant academic ethics review committee that will approve the project. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public health, social sciences, research methods. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Bhanbhro S. Reviewer Report For: Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.5256/f1000research.27437.r68704 ) The direct URL for this report is: https://f1000research.com/articles/9-901/v1#referee-response-68704 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Kumar R. Reviewer Report For: Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.5256/f1000research.27437.r68702 ) The direct URL for this report is: https://f1000research.com/articles/9-901/v1#referee-response-68702 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 07 Aug 2020 Ramesh Kumar , Health Services Academy, Ministry of National Health Services Regulation & Coordination, Government of Pakistan, Islamabad, Pakistan Approved VIEWS 0 https://doi.org/10.5256/f1000research.27437.r68702 This will be an important study proposal and will be helpful for future research evidence. Ovarian cancer is a big problem in Pakistan and researchers are strongly needed to work in this area. Moreover, the author has proposed a case-control ... Continue reading READ ALL This will be an important study proposal and will be helpful for future research evidence. Ovarian cancer is a big problem in Pakistan and researchers are strongly needed to work in this area. Moreover, the author has proposed a case-control study that would explore multiple factors responsible to develop this problem in Pakistan. This is a study protocol developed by the author and the author will collect the data and publish it later on Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kumar R. Reviewer Report For: Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.5256/f1000research.27437.r68702 ) The direct URL for this report is: https://f1000research.com/articles/9-901/v1#referee-response-68702 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 04 Aug 2020 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 04 Aug 20 read read Ramesh Kumar , Ministry of National Health Services Regulation & Coordination, Government of Pakistan, Islamabad, Pakistan Sadiq Bhanbhro , Sheffield Hallam University, Sheffield, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2020 Bhanbhro S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Aug 2020 | for Version 1 Sadiq Bhanbhro , College of Health and Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK 0 Views copyright © 2020 Bhanbhro S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a well-designed study protocol aimed to investigate the relationships between lifestyle factors, reproductive health, and risk of ovarian cancer in Pakistan. The aims, objectives and study design including sample size and data collection methods are appropriate and sufficiently described. The authors have cited the current and relevant literature. However, considering the sensitive nature of the topic under study, I would suggest the investigators need to provide more details on the recruitment of the potential study participants and the ethical considerations. For instance, the authors’ need to identify and name the relevant academic ethics review committee that will approve the project. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Public health, social sciences, research methods. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Bhanbhro S. Peer Review Report For: Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.5256/f1000research.27437.r68704) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/9-901/v1#referee-response-68704 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2020 Kumar R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Aug 2020 | for Version 1 Ramesh Kumar , Health Services Academy, Ministry of National Health Services Regulation & Coordination, Government of Pakistan, Islamabad, Pakistan 0 Views copyright © 2020 Kumar R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This will be an important study proposal and will be helpful for future research evidence. Ovarian cancer is a big problem in Pakistan and researchers are strongly needed to work in this area. Moreover, the author has proposed a case-control study that would explore multiple factors responsible to develop this problem in Pakistan. This is a study protocol developed by the author and the author will collect the data and publish it later on Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Kumar R. Peer Review Report For: Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan [version 1; peer review: 2 approved] . F1000Research 2020, 9 :901 ( https://doi.org/10.5256/f1000research.27437.r68702) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/9-901/v1#referee-response-68702 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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