Title: Effects of Mindfulness-Based Stress Reduction Training on Rumination in Patients with
Breast Cancer
Version: 2 Date: 18 Aug 2022
Reviewer's report:
Thank you for the opportunity to review this randomized controlled trial of MBSR for women
with breast cancer. The aim of the study was to evaluate the effect of MBSR on rumination.
The study is interesting and addresses an important concern of not only women with breast
cancer, but other people who have been diagnosed with and treated for cancer. I have suggestions
that may clarify the writing, introduction, design and intervention, as well as the results for any
future readers.
Major revisions
1. The overall writing needs to be improved (i.e., flow). It is difficult to read and contains various
grammatical and typographical errors throughout the entire manuscript.
Introduction
1. I would suggest re-phrasing the first paragraph of your introduction as it is quite repetitive.
a. For the following sentence: ‘Ruminant is a negative metacognitive state that threatens mental
health and can disrupt the treatment process and negatively affect it” – Please change ruminant
to rumination. Please clarify what “it’ is.
2. “Therefore, in addition to medication therapy, cognitive-behavioral interventions may be
necessary for these patients [14]’. I am confused why you are introducing CBT when the
intervention is MBSR.
Study's patient population and sampling
1. Writing needs to be improved.
2. You say 70 volunteered, 10 did not meet the criteria and 8 refused with an overall 56
participants. This does not add up, please correct.
MBSR Intervention
1. Please provide more information about the MBSR program itself. What did it entail? You
provide a general description but not the specifics of the content used.
2. Can you please synthesize data from previous studies to provide a clear definition of
mindfulness and why it is used?
3. Please clarify if any adaptations were made to the MBSR program. Did the participants
complete homework? Did you measure adherence?
4. Who is “the tutor”? Is this a trained professional certified to deliver MBSR? What are their
experiences with MBSR?
5. Can you explain what is meant by a “silent place” for the intervention?
Results/Analysis
1. “There was not a statistically significant difference between the mean age (P= 0.06, Z=
-1.884)” – Why did you use a z-score? Would a t-test be more appropriate?
2. You have 54 participants in your results but indicated 56 were randomized. Please clarify
what happened to the 2 other participants.
3. “In total, 54 patients were recruited, of whom two cases from the control group and 4 cases
from the intervention group refused to continue the study and the analysis was performed on
46 individuals”
a. Again, the math does not add up. Please,
4. Why are you reporting p-values on comparisons between groups for age , insurance, surgery,
etc? What hypothesis were you testing for the demographic variables?
5. Figure 1 does not match up with what you are reporting in the manuscript. Please revise and
correct.
Discussion
1. I would tone down this conclusion ‘The results of the present study, in which rumination is
average, showed that if not any intervention is done for decreasing rumination for patients with
BC, the level of rumination goes up.’
2. you talk about spouses unwilling to participate, though this is nowhere mentioned in the study
as an objective or hypothesis.
3. “The subjects in the intervention group were more successful in avoiding rumination than
those in the control group”. I don’t think “avoiding” is the proper word. Maybe replace with
coping with.
Minor Comments.
1. Consider removing the acronym EMR as it is only used once after introducing it.