Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review

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However, high co-morbidity rates are associated with these regimens and can lead to resultant physical decline. A previous review by this group highlighted that the role of physical function in resectable cancer of the pancreas has been underexplored. This updated systematic review aims to explore the physical functioning of patients with resectable cancer of the pancreas and explore its impacts on disease management. Methods A search strategy encompassing EMBASE, Medline OVID, CINAHL, Cochrane Library and Web of Science was developed and refined in consultation with subject librarians. The review will be conducted using the COVIDENCE systematic review management system. Screening of titles, abstracts, and full texts along with data extraction, risk of bias and GRADE assessment will be conducted by two independent reviewers, with a third reviewer available to resolve disagreements by consensus. Discussion Results of this systematic review will provide clinicians in the field with updated evidence regarding the role of physical functioning in the management of resectable cancer of the pancreas. Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251020095. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-80/v1", "name": "Physical Functioning in Resectable Cancer of the Pancreas – Protocol..." } } ] } Home Browse Physical Functioning in Resectable Cancer of the Pancreas – Protocol... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Brennnan L, Lucey N, Mockler D et al. Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :80 ( https://doi.org/10.12688/hrbopenres.14192.1 ) 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 Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] Lisa Brennnan 1,2 , Niamh Lucey 3 , David Mockler https://orcid.org/0000-0001-6171-8751 4 , Emer Guinan 5,6 , Juliette Hussey 5,6 , Linda O'Neill https://orcid.org/0000-0002-0109-9650 1,2 Lisa Brennnan 1,2 , Niamh Lucey 3 , [...] David Mockler https://orcid.org/0000-0001-6171-8751 4 , Emer Guinan 5,6 , Juliette Hussey 5,6 , Linda O'Neill https://orcid.org/0000-0002-0109-9650 1,2 PUBLISHED 14 Jul 2025 Author details Author details 1 Clinical Research Centre, School of Medicine, University College Dublin, Dublin, Ireland 2 St Vincents UCD Cancer Centre, Dublin, Ireland 3 Library and Information Services, St Vincent's University Hospital, Dublin, Ireland 4 John Stearne Library, Trinity College Dublin, Dublin, Ireland 5 Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland 6 Trinity St James's Cancer Institute, Dublin, Ireland Lisa Brennnan Roles: Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Niamh Lucey Roles: Conceptualization, Methodology, Writing – Review & Editing David Mockler Roles: Conceptualization, Investigation, Methodology, Writing – Review & Editing Emer Guinan Roles: Conceptualization, Investigation, Methodology, Writing – Review & Editing Juliette Hussey Roles: Conceptualization, Writing – Review & Editing Linda O'Neill Roles: Conceptualization, Investigation, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Pancreatic resection in combination with adjuvant chemotherapy is the standard of care for resectable cancer of the pancreas and increasingly neoadjuvant chemotherapy is being utilised for those with borderline resectable disease. However, high co-morbidity rates are associated with these regimens and can lead to resultant physical decline. A previous review by this group highlighted that the role of physical function in resectable cancer of the pancreas has been underexplored. This updated systematic review aims to explore the physical functioning of patients with resectable cancer of the pancreas and explore its impacts on disease management. Methods A search strategy encompassing EMBASE, Medline OVID, CINAHL, Cochrane Library and Web of Science was developed and refined in consultation with subject librarians. The review will be conducted using the COVIDENCE systematic review management system. Screening of titles, abstracts, and full texts along with data extraction, risk of bias and GRADE assessment will be conducted by two independent reviewers, with a third reviewer available to resolve disagreements by consensus. Discussion Results of this systematic review will provide clinicians in the field with updated evidence regarding the role of physical functioning in the management of resectable cancer of the pancreas. Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251020095 . READ ALL READ LESS Keywords Physical Function, Pancreatic Cancer, Pancreatic Resection, Prehabilitation, Rehabilitation Corresponding Author(s) Linda O'Neill ( [email protected] ) Close Corresponding author: Linda O'Neill Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Brennnan L 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: Brennnan L, Lucey N, Mockler D et al. Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :80 ( https://doi.org/10.12688/hrbopenres.14192.1 ) First published: 14 Jul 2025, 8 :80 ( https://doi.org/10.12688/hrbopenres.14192.1 ) Latest published: 14 Jul 2025, 8 :80 ( https://doi.org/10.12688/hrbopenres.14192.1 ) Introduction Pancreatic cancer is exemplar of an aggressive malignancy, with a five-year survival rate of less than 10% 1 , 2 . Surgical resection is the only curative treatment option but is associated with significant morbidity and mortality risk 2 . Increasingly a multimodality approach to treatment is favoured with adjuvant chemotherapy with FOLFIRINOX (fluorouracil, irinotecan, leucovorin, oxaliplatin) considered the standard of care for resectable disease at presentation 3 , 4 . In contrast, neoadjuvant chemotherapy is not considered standard of care, but is increasingly recommended for those with high risk disease 5 as it may eliminate micro metastatic disease, improve candidacy for surgery and lead to improvements in complete resection rates, and reductions in surgical complexity, post operative complications and improve overall survival 3 , 6 . Notwithstanding the survival benefits of this multimodality approach, these regimens coupled with the effects of pancreatic cancer itself can lead to a myriad of side effects including unintentional weight loss, sarcopenia, insulin dependence, need for pancreatic enzyme replacement therapy, gastrointestinal disorders, haematological disorders, neuropathy, and fatigue 7 – 9 . These issues may contribute to a decline in physical functioning defined as ‘ the ability to undertake the physical tasks of everyday living’ 10 . Physical function is a key prognostic indicator in cancer care, with reduced fitness, strength, and activity levels associated with increased postoperative morbidity, mortality, prolonged length of stay (LOS), and impaired tolerance to treatment 11 , 12 . In the context of pancreatic cancer this group conducted a systematic review in 2019 exploring the implications of physical function in resectable hepatopancreaticobiliary cancer 13 , findings from that review highlighted that the relationship between physical functioning and pancreatic cancer resection outcomes such as morbidity, mortality, and LOS was unclear at that time, with anaerobic threshold emerging as the strongest predictor of post-operative outcome. In addition, evidence was lacking at that time with regards to interventions which aim to improve/prevent decline in physical function e.g. exercise based prehabilitation/rehabilitation and our review concluded that high quality investigation of the impact of pancreatic cancer on physical function was required. Since completion of this review, notable progress has been made in the monitoring and management of physical function in cancer care. The integration of commercially available wearable technologies, has enabled real-time tracking of physical activity patterns in patients with cancer, including those undergoing treatment for pancreatic cancer 14 . There has also been a marked shift towards the implementation of prehabilitation strategies aimed at enhancing physiological reserve prior to surgery and/or chemotherapy 15 . Recent studies, including both randomised controlled trials and observational data, support the feasibility and potential efficacy of structured exercise interventions in improving treatment outcomes, quality of life, and functional recovery in pancreatic cancer cohorts 16 , 17 . Given the paucity of evidence described in our previous review 13 and the expanding role of prehabilitation and rehabilitation in pancreatic cancer management, there is now a strong rationale for an update to the original systematic review, which given the expanding number of studies in the field will focus solely on pancreatic cancer. Accordingly, the overall aim of this systematic review is to investigate physical function and its implications in the management of potentially resectable cancer of the pancreas. Specifically, we will aim to explore: 1. Physical function across the pancreatic cancer trajectory 2. The relationship between pre-operative physical function and post-operative outcomes (morbidity, mortality, LOS), 3. The impact of pre/rehabilitative interventions on physical function before and after pancreatic resection. 4. The quality of the current evidence base. Methods Study reporting and registration This protocol is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocol (PRISMA-P) guidelines 18 . The completed PRISMA-P checklist is included as extended data. The systematic review is registered on PROSPERO (PROSPERO registration number: CRD420251020095). Eligibility criteria The eligibility criteria for this systematic review will be derived from the PICO Framework (Population, Intervention, Comparison, Outcome) ( Table 1 ) 19 . Table 1. PICO Framework. Population Patients with a histological confirmed diagnosis of pancreatic cancer Intervention Scheduled for/ or having completed surgical resection of the pancreas Comparator N/A Outcome Objectively measured physical function Population. Studies that include adult patients (≥ 18 years old) with a histological confirmed diagnosis of pancreatic cancer will be included. Intervention. Studies must include patients who were scheduled for/ or having completed surgical resection for pancreatic cancer. Studies where participants receive neoadjuvant/adjuvant chemotherapy/ chemoradiotherapy in addition to surgery will also be included. Outcome. Only studies which include an objective measure of physical function will be included. Specifically, under the Functional Ability Framework developed by Rikli and Jones 20 this review will include objective measures which assess physical functioning in terms of physical parameters (e.g. cardiorespiratory fitness and muscle strength), function (e.g. ones ability to engage in functional activities such as walking), and ability to achieve activity goals (e.g. one’s ability to engaged in physical activity for daily living). Examples of physical functioning measures identified in our previous review 13 which may fall under each of these categories are presented in Table 2 . Table 2. Examples of Physical Functioning Measures. Physical Parameters Function Activity Goals Cardiopulmonary Exercise Test Short Physical Performance Battery Actigraphy Hand Grip Strength Gait Speed Test Maximum Voluntary Isometric Contraction Six Minute Walk Test Knee Extensor Strength Study type. This review will include randomised controlled trials and non-randomised controlled trials of interventions which include patients scheduled for or/ having completed surgical resection for pancreatic cancer and include an objective measurement of physical function as an endpoint. It will also include cohort studies which measure physical function objectively. The exclusion criteria will be (i) where physical function is only measured by subjective means e.g. questionnaire, (ii) article unavailable in English, (iii) systematic reviews, meta-analysis, case studies, letter to the editor, conference proceeding (iv) abstracts not available in full text, and (v) grey literature. No limitations will be placed on publication date or geographic location. Information sources and search strategy The databases EMBASE, Medline OVID, CINAHL, Cochrane Library and Web of Science will be searched. The search strategy was initially devised by subject librarian (DM) for our original review 13 in 2019 and subsequently revised in conjunction with subject librarian (NL) in advance of this new review to focus solely on resectable cancer of the pancreas (Extended Data). The search strategy will include terms relating to pancreatic cancer resection and physical functioning. Study records Data management. Following completion of the final search, references will be downloaded into EndNote 21 Desktop Reference management software and then imported into the Covidence Systematic Review Management System. Removal of duplicates is automated within the Covidence system. Data collection. Titles and abstracts screening will be completed by two independent reviewers, irrelevant articles will be excluded, and any conflicts that occur will be resolved by a third reviewer through the Covidence system. Full texts of remaining articles will be similarly assessed by two independent reviewers and conflicts resolved by a third reviewer. Data extraction. Data extraction will also be performed in duplicate independently by two reviewers and data extracted will be compared for accuracy any discrepancies will be resolved using a data extraction spreadsheet in Microsoft Excel. The authors plan to extract the following data: author, year of publication, patient characteristics (age, gender, and treatment types), physical function results, and details of any exercise interventions. Where further information or clarity is required on a particular study, LON will contact corresponding authors via email to seek further data. Risk of bias assessment. Risk of bias will be assessed in duplicate and any disagreements will be resolved by consensus. The Quality in Prognostic Studies (QUIPS) 21 tool will determine the risk of bias on included prognostic studies. For interventional studies, the RoB 2 (A revised Cochrane risk-of-bias tool for randomised trials) 22 and ROBINS-I tool (Risk of Bias in Non-Randomised Studies of Interventions) 23 will be applied. Each of these measures categorise risk of bias as low, moderate, or high serious. Valid studies are considered to have low risk of bias, moderate risk studies may be susceptible to bias, whereas those categorised as high/serious bias may have significant bias which may invalidate study results 24 . Data analysis and synthesis. Data will be synthesized narratively according to the Synthesis Without Meta-Analysis (SWiM) guidelines 25 . If the nature of the data permits a meta-analysis will be conducted using Review Manager (RevMan). A random effects model will be applied in consideration of the likely heterogeneity amongst studies. Statistical heterogeneity will be assessed using the I 2 statistic, with values exceeding 50% indicating substantial heterogeneity. Certainty of the evidence assessment (GRADE). The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) 26 approach will be used to assess the certainty of the evidence. Two reviewers will use the GRADEpro GT tool to consider the certainty of the evidence in consideration of: study limitations, unexplained heterogeneity of inconsistency, imprecision, indirectness and publication bias. Disagreements in rating will be resolved in consultation with a third reviewer. Potential limitations Due to the absence of translation resources, it will not be possible to include papers not available in English. Only peer reviewed published research will be included in this review, potentially yielding a risk of publication bias. Tracked and dated amendments Any updates to this protocol will be documented and presented in a table in the subsequent manuscript detailing the results of the systematic review. Dissemination The findings of this systematic review will be published in a peer-reviewed journal upon completion and presented at appropriate national and international conferences in the field of cancer rehabilitation. Conclusion This updated systematic review will provide a much-needed update to our previous review completed in 2019 13 which highlighted that there was a paucity of literature in this field. Specifically, this systematic review aims to investigate physical functioning in resectable cancer of the pancreas and explore its implication in its management. It will examine the relationship between physical functioning and surgical outcomes, and the applicability of physical functioning as an endpoint to prehabilitative and rehabilitative programmes for patients scheduled for/or having completed surgical resection for cancer of the pancreas. Ethics This systematic review does not require ethical approval due to the absence of human participants. Data availability Underlying data No data associated with this article Extended data The project contains the following extended data ( https://doi.org/10.17605/OSF.IO/4UEQ3 ) 27 : -250522 Search Strategy -250616 PRISMA-P Checklist Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). Acknowledgments The authors would like to acknowledge the assistance and support of the UCD Clinical Research Centre, and for providing the scholarship funding for Ms Lisa Brennan’s doctoral studies. Faculty Opinions recommended References 1. Siegel RL, Miller KD, Fuchs HE, et al. : Cancer statistics, 2022. CA Cancer J Clin. 2022; 72 (1): 7–33. PubMed Abstract | Publisher Full Text 2. Wolfgang CL, Herman JM, Laheru DA, et al. : Recent progress in pancreatic cancer. CA Cancer J Clin. 2013; 63 (5): 318–48. PubMed Abstract | Publisher Full Text | Free Full Text 3. Park W, Chawla A, O'Reilly EM: Pancreatic cancer: a review. 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O'Neill L: Physical functioning in resectable cancer of the pancreas - a protocol for a systematic review. 2025. http://www.doi.org/10.17605/OSF.IO/4UEQ3 Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 14 Jul 2025 ADD YOUR COMMENT Comment Author details Author details 1 Clinical Research Centre, School of Medicine, University College Dublin, Dublin, Ireland 2 St Vincents UCD Cancer Centre, Dublin, Ireland 3 Library and Information Services, St Vincent's University Hospital, Dublin, Ireland 4 John Stearne Library, Trinity College Dublin, Dublin, Ireland 5 Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland 6 Trinity St James's Cancer Institute, Dublin, Ireland Lisa Brennnan Roles: Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Niamh Lucey Roles: Conceptualization, Methodology, Writing – Review & Editing David Mockler Roles: Conceptualization, Investigation, Methodology, Writing – Review & Editing Emer Guinan Roles: Conceptualization, Investigation, Methodology, Writing – Review & Editing Juliette Hussey Roles: Conceptualization, Writing – Review & Editing Linda O'Neill Roles: Conceptualization, Investigation, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, 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: 14 Jul 2025, 8:80 https://doi.org/10.12688/hrbopenres.14192.1 Copyright © 2025 Brennnan L 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 $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Brennnan L, Lucey N, Mockler D et al. Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :80 ( https://doi.org/10.12688/hrbopenres.14192.1 ) 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 14 Jul 2025 Views 0 Cite How to cite this report: Brown M. Reviewer Report For: Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :80 ( https://doi.org/10.21956/hrbopenres.15608.r48515 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-80/v1#referee-response-48515 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 02 Sep 2025 Malcolm Brown , Ulster University, Belfast, UK Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15608.r48515 This systematic review aims to update the evidence on physical functioning in patients with resectable pancreatic cancer. Given the accumulating evidence available since their initial review in 2019, this updated version is warranted. This protocol is well ... Continue reading READ ALL This systematic review aims to update the evidence on physical functioning in patients with resectable pancreatic cancer. Given the accumulating evidence available since their initial review in 2019, this updated version is warranted. This protocol is well prepared, detailed and suitably designed from a methodological standpoint. I expect that once completed this review will provide a comprehensive update on the evidence base as well as potential recommendations for disease management. The authors plan to include the highest calibre of articles (i.e. RCTs), within the systematic review and have a number of measures and guidelines (PRISMA; risk of bias) in place to direct the eventual outcome of this work. Finally, I wish to commend the authors for this important work, especially within this underserved population with poor survival outcomes. 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: Cancer research; supportive care; clinical exercise physiology 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 Brown M. Reviewer Report For: Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :80 ( https://doi.org/10.21956/hrbopenres.15608.r48515 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-80/v1#referee-response-48515 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 Author Response 22 Sep 2025 Linda O'Neill , Clinical Research Centre, School of Medicine, University College Dublin, Ireland 22 Sep 2025 Author Response Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill Competing Interests: No competing interests were disclosed. Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 22 Sep 2025 Linda O'Neill , Clinical Research Centre, School of Medicine, University College Dublin, Ireland 22 Sep 2025 Author Response Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill Competing Interests: No competing interests were disclosed. Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 14 Jul 2025 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 Version 1 14 Jul 25 read Malcolm Brown , Ulster University, Belfast, 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 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Brown M. 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. 02 Sep 2025 | for Version 1 Malcolm Brown , Ulster University, Belfast, UK 0 Views copyright © 2025 Brown M. 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 (1) 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 systematic review aims to update the evidence on physical functioning in patients with resectable pancreatic cancer. Given the accumulating evidence available since their initial review in 2019, this updated version is warranted. This protocol is well prepared, detailed and suitably designed from a methodological standpoint. I expect that once completed this review will provide a comprehensive update on the evidence base as well as potential recommendations for disease management. The authors plan to include the highest calibre of articles (i.e. RCTs), within the systematic review and have a number of measures and guidelines (PRISMA; risk of bias) in place to direct the eventual outcome of this work. Finally, I wish to commend the authors for this important work, especially within this underserved population with poor survival outcomes. 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 Cancer research; supportive care; clinical exercise physiology 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 (1) Author Response 22 Sep 2025 Linda O'Neill, Clinical Research Centre, School of Medicine, University College Dublin, Ireland Dear Dr Brown, Many thanks for taking the time to review our protocol, and thank you for your positive feedback. Kind regards, Linda O'Neill View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Brown M. Peer Review Report For: Physical Functioning in Resectable Cancer of the Pancreas – Protocol for A Systematic Review [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :80 ( https://doi.org/10.21956/hrbopenres.15608.r48515) 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://hrbopenresearch.org/articles/8-80/v1#referee-response-48515 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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