Effect of a 4-Week Internet-Delivered Mindfulness-Based Cancer Recovery Intervention on the Symptom Burden and Quality of Life of Patients With Breast Cancer: Randomized Controlled Trial

Background Mindfulness-based interventions (MBIs) can improve the symptoms and psychological well-being of patients with breast cancer. However, standard MBIs are an 8-week program delivered face-to-face, which may be inconvenient for patients with cancer. Many attempts have been made to adapt MBIs to increase their accessibility for patients with cancer while maintaining their therapeutic components and efficacy. Objective This study aimed to investigate the effectiveness of a 4-week internet-delivered mindfulness-based cancer recovery (iMBCR) program in reducing symptom burden and enhancing the health-related quality of life (HRQoL) of patients with breast cancer. Methods A total of 103 postoperative patients with breast cancer (stages 0 to IV) were randomly assigned to an iMBCR group (4-week iMBCR; n=51, 49.5%) or a control group (usual care and 4-week program of health education information; n=52, 50.5%). The study outcomes included symptom burden and HRQoL, as measured by the MD Anderson Symptom Inventory and the Functional Assessment of Cancer Therapy-Breast scale. All data were collected at baseline (T0), after the intervention (T1), and at 1-month follow-up (T2). Data analysis followed the intention-to-treat principle. Linear mixed models were used to assess the effects over time of the iMBCR program. Results Participants in the iMBCR group had significantly larger decreases in symptom burden than those in the control group at T1 (mean difference –11.67, 95% CI –16.99 to –6.36), and the decreases were maintained at T2 (mean difference –11.83, 95% CI –18.19 to –5.46). The HRQoL score in the iMBCR group had significantly larger improvements than that in the control group at T1 and T2 (mean difference 6.66, 95% CI 3.43-9.90 and mean difference 11.94, 95% CI 7.56-16.32, respectively). Conclusions Our preliminary findings suggest that the iMBCR program effectively improved the symptom burden and HRQoL of patients with breast cancer, and the participants in the iMBCR group demonstrated good adherence and completion rates. These results indicate that the iMBCR intervention might be a promising way to reduce symptom burden and improve HRQoL of patients with cancer. Trial Registration Chinese Clinical Trial Registry ChiCTR2000038980; http://www.chictr.org.cn/showproj.aspx?proj=62659

The CONSORT-EHEALTH checklist is intended for authors of randomized trials evaluating web-based and Internet-based applications/interventions, including mobile interventions, electronic games (incl multiplayer games), social media, certain telehealth applications, and other interactive and/or networked electronic applications. Some of the items (e.g. all subitems under item 5 -description of the intervention) may also be applicable for other study designs.
The goal of the CONSORT EHEALTH checklist and guideline is to be a) a guide for reporting for authors of RCTs, b) to form a basis for appraisal of an ehealth trial (in terms of validity) CONSORT-EHEALTH items/subitems are MANDATORY reporting items for studies published in the Journal of Medical Internet Research and other journals / scientific societies endorsing the checklist.
As the CONSORT-EHEALTH checklist is still considered in a formative stage, we would ask that you also RATE ON A SCALE OF 1-5 how important/useful you feel each item is FOR THE PURPOSE OF THE CHECKLIST and reporting guideline (optional).
Mandatory reporting items are marked with a red *. In the textboxes, either copy & paste the relevant sections from your manuscript into this form -please include any quotes from your manuscript in QUOTATION MARKS, or answer directly by providing additional information not in the manuscript, or elaborating on why the item was not relevant for this study. yes: all primary outcomes were significantly better in intervention group vs control partly: SOME primary outcomes were significantly better in intervention group vs control no statistically significant difference between control and intervention potentially harmful: control was significantly better than intervention in one or more outcomes inconclusive: more research is needed 其他: not submitted yet -in early draft status not submitted yet -in late draft status, just before submission submitted to a journal but not reviewed yet submitted to a journal and after receiving initial reviewer comments submitted to a journal and accepted, but not published yet published 其他: not submitted yet / unclear where I will submit this Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if offline products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms.  e  a  t  u  r  e  s  /  f  u  n  c  t  i  o  n  a  l  i  t  i  e  s  /  c  o  m  p  o  n  e  n  t  s  o  f  t  h  e  i  n  t  e  r  v  e  n  t  i  o  n  a  n  d  c  o  m  p  a  r  a  t  o  r  i  n  t  h  e  M  E  T  H  O  D  S  s  e  c  t  i  o  n  o  f  t  h  e  A  B  S  T  R  A  C  T Mention key features/functionalities/components of the intervention and comparator in the abstract. If possible, also mention theories and principles used for designing the site. Keep in mind the needs of systematic reviewers and indexers by including important synonyms. Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study

清除所选内容
Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any).  t  o  -f  a  c  e  a  s  s  e  s  s  m  e  n  t  s  i  n  t  h  e  M  E  T  H  O  D  S  s  e  c  t  i  o  n  o  f  t  h  e  A  B  S  T  R  A  C  T Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study No, not in the abstract but in the paper Report number of participants enrolled/assessed in each group, the use/uptake of the intervention (e.g., attrition/adherence metrics, use over time, number of logins etc.), in addition to primary/secondary outcomes.  I  N  T  R  O  D  U  C  T  I  O  N   2  a  )  I  n  I  N  T  R  O  D  U  C  T  I  O  N  :  S  c  i  e  n  t  i  f  i  c  b  a  c  k  g  r  o  u  n  d  a  n  d  e  x  p  l  a  n  a  t  i  o  n  o  f  r  a  t  i  o  n  a  l  e   D  o  e  s  y  o  u  r  p  a  p  e  r  a  d  d  r  e  s  s  s  u  b  i  t  e  m  1  b  -i  v  ? Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study No, not in the abstract but in the paper Conclusions/Discussions in abstract for negative trials: Discuss the primary outcome -if the trial is negative (primary outcome not changed), and the intervention was not used, discuss whether negative results are attributable to lack of uptake and discuss reasons. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The diagnosis of cancer and treatment is a highly stressful experience that causes patients to suffer a range of physical or psychological symptoms. Such symptom burdens negatively impact their health-related quality of life (HRQoL)" "It has been suggested that non-pharmacologic interventions such as mindfulness-based interventions (MBIs) can be used as adjuvant psychosocial therapy to manage the symptoms of cancer patients." "This study aimed to investigate the effectiveness of an 4-week iMBCR program in reducing symptom burden and enhancing HRQoL of breast cancer patients. Compared with the traditional 8-week face-to-face MBIs, 4-week iMBCR program may be more acceptable to cancer patients and could save time, and human resources." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "This study aims to investigate the effects of the 4-week iMBCR program on symptom burden and HRQoL among breast cancer women. We hypothesized the following: (1) women allocated to the iMBCR groups would report greater improvements in symptom burden and HRQoL at the post-intervention and 1-month follow-up compared with the control group (2) 4-week iMBCR program would elicit greater adherence and intervention completion rate than the traditional 8-week MBCR program." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Our study used the following inclusion criteria: (1) women aged between 18 and 70 years; (2) having a prior diagnosis with stage 0-Ⅳ breast cancer and aware of their cancer diagnosis; (3) within 1 to 24 months after the completion of surgery; (4) with normal cognitive capacity and functional status (Mini-Mental State Exam score≥ 27 points, and Karnofsky performance status score > 60 points), and (5)  Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "able to operate a smartphone and WeChat (the most popular smartphone application used for online communication in China)." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Recruitment was primarily conducted through referrals from ward nurses and research posters displayed in the gynecological clinic and wards." "Baseline data were collected using written questionnaires in the wards of the hospitals. Post-intervention and 1-month follow-up results were collected through online questionnaires." "All participants were invited to scan a quick-response code to join a WeChat group. This group was mainly used to send links to online courses, intervention materials, and instant interactive communication. Participants were invited to attend online courses on Saturday morning through an online video-conferencing application (Tencent) extensively used in China. " Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results.
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Recruitment was primarily conducted through referrals from ward nurses and research posters displayed in the gynecological clinic and wards. We contacted interested participants to screen for eligibility. Next, we contacted the eligible participants and provided further information about our study to them. Participants were given the choice to participate or decline and were informed that they had the right to withdraw at any time without reprisal. " Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Participants were recruited at the breast cancer wards of a 3 tertiary hospital (Changsha, China) from October 2020 to August 2021." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Baseline data were collected using written questionnaires in the wards of the hospitals.
Post-intervention and 1-month follow-up results were collected through online questionnaires. Participants who attended less than two sessions were considered dropouts." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Guided by Barrera's heuristic framework, our team constructed the 4-week iMBCR program using the following steps. (a) information gathering: a cross-sectional study was conducted to explore the relationship between mindfulness, unmet supportive-care needs, and HRQoL among cancer patients in China. Results showed that breast-cancer patients had a high level of supportive-care needs, and a positive relationship existed between the level of mindfulness and HRQoL. Patients were invited to participate in individual semi-structured interviews to fully understand their cancer-related distress and their attitudes toward participation in an 8-week psychosocial intervention. The interviews showed that cancer patients experienced numerous symptoms but lacked strategies for coping with them. Meanwhile, most patients felt that an 8-week intervention course is too long for them. (b) preliminary adaptation design: we translated the language of the 8-week MBCR program into Chinese and organized an expert-panel meeting to discuss the content and delivered format of MBCR in the Chinese cultural context. Combined with the results of the previous phase, we formed the preliminary 8-week online MBCR program. (c) preliminary adaptation tests: we conducted a pilot study to test the feasibility and acceptability of an 8-week iMBCR program in breast cancer patients. Results showed that the online MBCR intervention was well acceptable to the participants, but only 40% (4/10) of the participants completed a fully 8-week session. More than half of the participants felt that the intervention was too long. Interviews with four participants who completed the intervention showed that mindful practice techniques (e.g., mindful breathing, body scanning, and mindful walking) were practical for daily life, but yoga exercises were difficult for some patients to complete. (d) adaptation refinement: according to the problems in the pilot study and participant feedback, we adjusted the duration and content of iMBCR. Five experts were invited to evaluate the content importance and rationality of the 4-week MBCR program. Through two rounds of expert consultation, we constructed the 4-week iMBCR program. Table 1 presents the detailed contents of the iMBCR program." Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial.
Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b). Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We did not change the treatment content during the trial Provide information on quality assurance methods to ensure accuracy and quality of information Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Several strategies were used to ensure intervention fidelity. A treatment manual specifying the content of each course was developed, and the interventions were strictly followed. All the intervention courses video were recorded, and an investigator reviewed the video after each course to ensure proper implementation of the treatment manual. Furthermore, our team would met at the end of each intervention week to discuss the intervention implementation quality." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study All treatment content is available (in chinese) from the authors on request.

-
Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The iMBCR group received a 4-week MBCR program (1.5 h per week) and at least 30 min of daily mindfulness home practice. All participants were invited to scan a quick-response code to join a WeChat group. This group was mainly used to send links to online courses, intervention materials, and instant interactive communication. Participants were invited to attend online courses on Saturday morning through an online video-conferencing application (Tencent) extensively used in China. Our assistant provided systematic training on the use of videoconferencing to ensure that the courses were accessible to participants. Session attendance was recorded, and all courses were recorded by video. The course video would be provided to those who were absent for any reason. A Chinese version MBCR book and some assisted audios were provided to the participants for home practice. Participants were asked to record in the WeChat applet after completing their daily home practice, and researchers also sent a daily tweet to remind them to practice. The intervention was delivered by a therapist who had completed mindfulness training and had 4 years of experience in teaching MBCR, accompanied by an assistant with 2 years of experience in mindfulness practice." "Participants in the control group received usual care and four cancer-themed health education sessions. The content of health education primarily included the following: recognizing stress and managing negative emotions, coping with the adverse effects of therapy, dietary guidance, and exercise guidance, which do not involve any mindfulness component. The number and frequency of online courses were the same as those in the iMBCR group." "Our team adapted and modified the MBCR program guided by Barrera's heuristic framework for the cross-cultural adaptation of interventions. MBCR is a program that aims to reduce stress-related symptoms by developing mindfulness, meaning a non-judgmental, accepting moment-by-moment awareness." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The iMBCR group received a 4-week MBCR program (1.5 h per week) and at least 30 min of daily mindfulness home practice."

5
Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The intervention was delivered by a therapist who had completed mindfulness training and had 4 years of experience in teaching MBCR, accompanied by an assistant with 2 years of experience in mindfulness practice." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The study outcomes included symptom burden and HRQoL, as measured by the M.D. Anderson Symptom Inventory (MDASI) and the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B) Scale. All data were collected at baseline (T0), post-intervention (T1), and 1-month follow-up (T2). Data analysis followed the intention-to-treat principle. " Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Sample size was calculated by Power analyses using G*Power software 3.1. According to a previous study that explored the effectiveness of the MBCR program in women with cancer, the effect size for HRQoL scores was 0.66 [30]. Thus, to predict the difference between the two groups at a 5% level of significance and a power of 0.8, 38 participants were required for each group. Allowing for a 20% attrition rate, an additional 10 participants were needed for each group. Thus, the total sample size for this study was 96, with 48 participants in each group." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Patients were randomly divided into the iMBCR group and the control group in a 1:1 ratio according to a list of computer-generated random numbers. " ? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Patients were randomly divided into the iMBCR group and the control group in a 1:1 ratio according to a list of computer-generated random numbers." "To guarantee allocation concealment, an independent researcher who was not involved in the recruitment performed the random assignments by delivering an opaque, sealed envelope to each participant. " Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "Linear mixed models were used to compare groups over time on all outcome variables. The data were hierarchically arranged in a two-level structure with time at level 1 nested within individuals at level 2. Fixed effects were specified for intercept, time, group, and the time × group interaction, while the random effect was the participant. Effect sizes for the mean changes between groups were calculated using Cohen's d, with 0.2, 0.5, and 0.8 considered a small, medium, and large effect size, respectively [35]. We assumed a two-sided p-value of <.05 to be statistically significant.' Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "A total of 103 participants were recruited, there were 51 (49.5%) participants in the iMBCR group and 52 (50.5%) participants in the control group. A total of 100 participants completed all assessments, of which 1 participant was lost from the iMBCR group (dropout rate=2%), and 2 were lost from the control group (dropout rate=3.8%). " All included participants were used in the mixed models analysis.  D  o  e  s  y  o  u  r  p  a  p  e  r  a  d  d  r  e  s  s  C  O  N  S  O  R  T  s  u  b  i  t  e  m  1  3  b  ?  (  N  O  T  E  :  P  r  e  f  e  r  a  b  l  y  ,  t  h  i  s  i  s  s  h  o  w  n  i  n  a  C  O  N  S  O  R  T  f  l  o  w  d  i  a  g  r  a  m  ) * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study recruitment from October 2020 to August 2021 The intervention were four weeks long, and the 1-month follow-up data was collected. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study It ended when all participants who had not dropped out had be given a chance to answer the 1-month follow up a  s  e  l  i  n  e  d  e  m  o  g  r  a  p  h  i  c  a  n  d  c  l  i  n  i  c  a  l  c  h  a  r  a  c  t  e  r  i  s  t  i  c  s  f  o  r  e  a  c  h  g  r  o  u  p   N  P  T  :  W  h  e  n  a  p  p  l  i  c  a  b  l  e  ,  a  d  e  s  c  r  i  p  t  i  o  n  o  f  c  a  r  e  p  r  o  v  i  d  e  r  s  (  c  a  s  e  v  o  l  u  m  e  ,  q  u  a  l  i  f  i  c  a  t  i  o  n  ,  e  x  p  e  r  t  i  s  e  ,  e  t  Report multiple "denominators" and provide definitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at specific pre-defined time points of interest (in absolute and relative numbers per group). Always clearly define "use" of the intervention. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The intention-to-treat analysis was applied. " In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational definitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is defined (e.g., timeout after idle time) [1] (report under item 6a Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "The mean number of attended iMBCR courses was 3.6 (adherence rate=90%). The mean time of mindfulness home practice was 19.62 days (adherence rate=71%)." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study " In the future study, we will consider using more advanced technology to record user logins or the online duration to measure the completion and adherence to interventions. " "Future research should incorporate longer follow-up periods to examine the durability of iMBCR effects." "Future research is warranted to continue the investigation on the mechanisms of change in online short-term MBCR interventions. Researchers should examine the efficacy of the components of mindfulness and emphasize on techniques that are more effective and to what extent. They should also determine how much exposure to the intervention is needed to effectively develop a feasible and effective program that increases its accessibility for a larger number of clinical populations." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study "There were several limitations to this study. First, the completion of mindfulness home practice relied on the self-reporting of the participants and was calculated by days and not specific practice minutes. This setup may affect the accuracy of intervention adherence because self-reporting is subjective. In the future study, we will consider using more advanced technology to record user logins or the online duration to measure the completion and adherence to interventions. Second, the heterogeneity of the sample with regard to cancer stage and time since surgery may affect the symptom burden and HRQoL, which may lead to some bias in the results. However, there was no difference in cancer stage and surgery time existed between the two groups at baseline in this study, which could have reduced the bias to some extent. Third, the patients in this study were followed up for only 1 month. We were unable to determine the medium-or long-term effects of the 4-week iMBCR program on the symptom burden and HRQoL. As such, future research should incorporate longer follow-up periods to examine the durability of iMBCR effects Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study