Title: Effects of Mindfulness-Based Stress Reduction Training on Rumination in Patients with
Breast Cancer
Version: 2 Date: 11 Oct 2022
Reviewer's report:
Comments on BMC review 10_10_22
Effects of Mindfulness-Based Stress Reduction Training on Rumination in Patients with Breast
Cancer: A Randomized Controlled Trial   Running title: Effects of Mindfulness-Based Stress
Reduction Training on Rumination
Interesting finding about the increasing rumination in the control group but not in the
intervention group.
References are good. I would recommend this article be edited by an English speaker.
In the introduction: Condense your sentence to “In Iran, BC is the most prevalent disease in
women [4], while the most common cancers were breast, colorectal and stomach in 2016 and
are expected to remain the leading cancers nationally in 2025.”
Describe with a citation what metacognition is and give several examples before discussing
rumination as a negative aspect of metacognition.
“Ruminant” should be changed to “rumination”
You write “Additionally, negative metacognitive beliefs have increased in women with BC who
suffer from a chronic condition” Is BC the chronic condition you are referring to, if so just write
negative cognitive beliefs have increased in women with BC? You need to let us know how
much negative metacognitive beliefs have increased and especially the prevalence of rumination
since the whole study is based on the importance of rumination as a condition that negatively
affects individuals with breast cancer.
You write that there are three theories about rumination and then go on to describe only one
theory. Either roughly describe all three or say that a major theory of rumination is The Response
Styles Theory and just describe that one. Bringing up all three makes the reader want to know
more about all three.
You write “It hurts the general health of patients and disrupt their normal life [6].” A suggestion
for change is “It is harmful to the general health of patients and disrupts their life [6].
You write “It seems that compared to other complications of cancer or related treatments such
as nausea, vomiting, hair loss etc. – the concept of rumination has received less attention from
health care providers.” Get rid of “it seems” and start with “Compared to,” You also need to
back up with citations your assertion that rumination is a growing problem among women with
BC. How prevalent is rumination in this population?
When you wrote “Based on the estimation of WHO, the extent of psychological problems such
as rumination and concerns in patients with cancer is estimated 8 times higher than that in healthy
people” Did the WHO actually use the word  “rumination?” If so fine, if not, then what you
write is misleading and you can only say psychological problems.
You write “It helps individuals become familiar with the dual states of the mind and consciously
use them as a cohesive mind [15]” you need to explain and then cite what the dual states of mind
mean, as the reader may likely not be familiar with that term.
You write “Furthermore, we cannot ignore the cultural and social effects on human behaviors
and consequently the incidence of behavioral and mental disorders, treatment search, and the
effectiveness of psychological interventions [21]” This sentence needs to be rewritten for clarity.
I don’t understand what you are trying to say here.
You should write; Therefore, examining non-pharmacological strategies such as MBSR is
essential for finding interventions to treat or prevent rumination.
You wrote,” The sample included all women with BC referred to the hematology wards of
hospitals and hematology clinics in the city of Bushehr in 2019.” This doesn’t make any sense.
You only had 49 subjects. Were there only 49 women with BC in all of the hematology wards
and clinics in Bushehr in the whole year of 2019? If so ok, if not, re-write.
How exactly did random assignment occur? What method was used?
Ethics-consent process? How was the study presented? How and when did they sign consent?
In exclusion criteria-the, subjects should have been excluded before they consent, not after
they die or refuse to keep participating. That would be attrition and not exclusion. Check your
exclusion criteria.
Under study population, you say that it was all women referred to the hematology clinic or
hospital in 2019. However, under data collection, you say that data was collected in 2018 and
2019.
Were the 90-minute mindfulness training sessions weekly? How were the sessions followed up?
Why were they shared on WhatsApp and with whom? What was shown on WhatsApp. Were
they shared with the members for review? Were all of the subjects expected to come for a live
session? How many sessions could they miss and remain in the study?
You wrote, “the participants of the control group who were willing to take part in the education
program received a pamphlet and CD containing MBSR tutorials and were introduced to the
MBSR training group.” Were all of the individuals in the control group introduced to MBSR
training? You said that the control group received no treatment. It sounds like they received
education on mindfulness. How many received education? You may have contaminated your
control group here by adding education for some but not for others. This is no longer “receiving
nothing” as you said earlier.  You need to explain this and it should also go in the limitation
section.
You wrote: The repeated measures of ANOVA suggested that in the intervention group, the
difference between the mean scores of rumination among three times was not statistically
significant; but in the control group, the difference among three times was statistically significant
(Table 2). The post hoc test demonstrated that the mean scores of rumination increased
immediately and one month after the intervention compared to pre-intervention (P< 0.01).
Moreover, the mean score of rumination in the control group increased significantly one month
after the intervention compared to immediately after the intervention (P= 0.02) (Table 3).
The first part of the sentence doesn't make sense. Please re-write. There was no intervention in
the control group unless it was an educational intervention you didn’t describe fully. The surveys
were given at different points in time, but there was no intervention other than taking a survey.
Table One: Both columns say control group and I don’t see an intervention group
You wrote, “The reason for the difference between the results in the present study and the
study by Heydarian et al. (2016) may be related to the research tools used [25] and the reason
mentioned in the study of Mohammadpour et al. (2016).” What is it about the research tool that
might have made the difference, you need to be less vague? Repeat the reason mentioned by
Mohammadaour in different words (paraphrase).
You wrote, “Furthermore, the results suggest that the intervention is needed in the long term
to bring the rumination below the average.” You really don’t know this to be the case.  The
intervention may have benefited from a longer intervention or exposure period is all that you
can say.
You wrote “This shows ( should write “suggests”) the need for the intervention's continuity; so
that the intervention becomes an integral part of the individual's daily behavior.” This suggests
it would take more to show.
You wrote, “These studies aimed to demonstrate the effectiveness of mindfulness and the
results indicated the positive effect of mindfulness on decreasing rumination in patients with
BC.” Studies should not aim to demonstrate effectiveness, they should aim to determine if an
intervention is effective or not, otherwise, bias arises.
You wrote “It is worth noting that the difference between both groups in the present study results
from the process of aggravating rumination in the control group.  In other words, although there
was a statistically significant difference between the control and intervention groups in terms
of rumination, the reason for the difference was not significant, falling the rumination in the
intervention group and significant increasing rumination in the control group. Consequently, the
intervention group acts well psychologically” This needs to be re-written concisely for clarity.
I do not understand what you are trying to say here.
You wrote “Unwillingness of spouses to participate in the study was yet another limitation.
Spouses are the first and main source of family support for most women with breast cancer, and
provide emotional and practical support to their spouses, and attend to their concerns, including
uncertainty about the course of the illness and fear of losing a partner [30].” That is not a
limitation as it would have been a whole other study design.