Mindfulness-Based Interventions for Fear of Recurrence in Patients with Breast Cancer: A Meta-Analysis

Mindfulness-Based Interventions for Fear of Recurrence in Patients with Breast Cancer: A Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Mindfulness-Based Interventions for Fear of Recurrence in Patients with Breast Cancer: A Meta-Analysis Xinyu Wang, Man Yuan, Xian Ma This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8587364/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Fear of cancer recurrence (FCR) is a prevalent psychological distress among breast cancer survivors. Although mindfulness-based interventions (MBIs) are increasingly used in cancer care, their efficacy remains inconclusive, and the influence of cultural background on outcomes is unclear. This heterogeneity hinders the development of personalized clinical strategies. Objective: We aimed to systematically evaluate the overall efficacy of MBIs in terms of FCR in people with breast cancer through meta-analysis, and to examine the moderate effects of factors, such as geographic area, length of intervention, and measurement instruments. This study intends to yield evidence supporting the creation of individualized intervention in clinical settings. Methods: We searched relevant databases in Chinese and English, including PubMed, Web of Science, Scopus, Cochrane Library, the China National Knowledge Infrastructure (CNKI), WanFang Data, and VIP Journal (CQVIP) for articles that published from inception through Aug 30 2025, which compared MBIs with control groups to determine the effects of MBIs on FCR of breast cancer patients. We used the Cochrane Risk of Bias tool (RoB 2.0) to assess the methodological qualities. The combined analysis was based on a random-effects model using Hedges’s g to yield the effect size. Subgroup analysis was used to explore sources of heterogeneity. We used funnel plot and Egger’s test to analyze for publication bias. Results: The initial search yielded 264 records. Following a stepwise screening process, 10 RCTs were included. Sensitivity analysis identified one outlier study. After its exclusion, the analysis was based on the remaining 9 studies (involving 896 patients). The results showed that MBIs significantly reduced FCR levels in breast cancer patients, with a pooled effect size of Hedges’s g = -0.56 (95% CI: -0.83 to -0.29, P < 0.001). However, substantial heterogeneity was observed among studies ( I² = 73.83%). Subgroup analysis indicated: 1) Region significantly moderated the efficacy, with MBIs showing a pronounced effect in Chinese patients (g = -0.71, 95% CI: -0.90 to -0.44, P < 0.001), while the effect was not statistically significant in patients from other countries (g = -0.26, 95% CI: -0.56 to 0.04, P = 0.08); 2) Intervention duration (<8 weeks vs. ≥8 weeks) had no significant effect on efficacy ( P = 0.99); 3) Different assessment tools (CARS, FCRI, FoP-Q-SF) all confirmed the effectiveness of MBIs (all P < 0.05), with no difference in efficacy between tools ( P = 0.88). Egger’s test ( P = 0.03) suggested potential publication bias. Conclusion: Mindfulness-based interventions can effectively reduce fear of cancer recurrence in breast cancer patients, and their efficacy is moderated by cultural background, with more pronounced effects observed in Chinese populations. For clinical practice, we strongly recommend developing culturally adapted mindfulness programs, especially for Chinese patients, to maximize therapeutic benefits. Future research requires larger sample sizes and higher-quality studies to verify long-term efficacy and explore core mechanisms of action. Breast cancer Fear of recurrence Mindfulness Meta-analysis Randomized controlled trial Cultural differences Cultural adaptation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 1. Background Breast cancer (BC) was the most common cancer throughout 169 countries or regions and regions in the whole world. It has become one of the most important malignant tumors that threatened the life and health of human beings, and has become the primary cause of death among women and seriously affected the overall quality of living of all women across the globe in recent years [ 1 ] . Data released in recent years show that the burden is gradually increasing [ 2 ] . The recurrence rate of breast cancer is high, and 30% to 40% of women still have a recurrence or metastasis even 15 to 20 years after operation [ 3 , 4 ] . In recent years, fear of cancer recurrence(FCR) refers to anxiety, worry and/or uneasiness towards risk of cancer returning or worsening [ 5 ] . FCR includes not only the simple fear but also the complex process of cognitive emotional and behavioral co-existence simultaneously, its neurobiology foundation is gradually revealed [ 6 ] . As an emerging psychological intervention, mindfulness interventions show significant promise in psycho-oncology. Rooted in Eastern contemplative traditions, mindfulness emphasizes present-moment awareness with an attentive and non-judgmental attitude [ 7 ] . Mindfulness-based interventions (MBIs), such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), enhance patients’ awareness and acceptance of their mental and physical states through targeted practices like body scans, sitting meditation, and mindful yoga [ 8 ] . Neuroimaging studies further confirm that mindfulness practice can modulate brain network activity associated with emotion regulation and self-referential processing [ 9 ] . Theoretically, MBIs may benefit FCR in multiple ways. FCR is an anticipatory, chronic, catastrophized kind of rumination [ 10 ] , and mindfulness training intervenes this kind of recurrent, negative thoughts by grounding attention in the here and now [ 11 ] . It trains patients to see and frame recurrence-related thoughts as thoughts (mental event), not facts, and creates a decentered, non- evaluative relationship with the thoughts, i.e., the MBI induces a coping attitude [ 11 ] . Previous studies have shown MBIs are beneficial and efficacious in reducing anxiety, depression, fatigue, and improving sleep and quality of life in cancer patients generally [ 12 , 13 , 14 ] . Despite many randomized controlled trials conducted to explore mindfulnessbased interventions (MBIs) effects on fear of cancer recurrence (FCR) in breast cancer patients, the results are sometimes incompatible. These variations in research design factors, including difference in the format of the interventions (online versus offline), dose, culture and variability in FCR scales are considered the reasons of the incongruent findings [15、16] . Amongst these factors, culture, has a notable effect since it considerably influences patients’ willingness to practice mindfulness and achieve the expected outcomes of the intervention [ 17 ] . This mosaic of contradictory evidence does not help to apply it clinically. Although neuroimaging research shows that mindfulness can modulate the emotional regulation circuits [ 9 ] , it is unknown yet how it can affect the underlying neurocognitive circuits for the phenomenon fear of cancer recurrence in different cultures. Therefore, it is necessary to perform a systematic review and a meta-analysis in order to integrate this existing controversial evidence, assess the general effectiveness of mindfulness interventions on fear of cancer recurrence of breast cancer patients and provide a possible explanation for its variability to establish a theoretical frame more homogeneous and reliable to support evidence-based practice. 2. Methods 2.1 Study Design and Registration This study presents the systematic review and meta-analysis of the impact of the mindfulness-based interventions on cancer recurrence concern among breast cancer patients. The research design was previously registered in PROSPERO (Registration number: CRD420251127306). We planned, conducted, and documented this study in accordance with the PRISMA guidelines as strictly as possible [18] . The protocol can be viewed at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251127306 2.2 Literature Search Strategy We searched Chinese and English databases including PubMed, Web of Science, Scopus, Cochrane Library, China National Knowledge Infrastructure(CNKI), WanFang Data and VIP Journal (CQVIP). We searched each database until August 30, 2025, and used a subject headings and free-text keywords combination-based search strategy. The English search terms were: (“breast cancer” OR “breast neoplasm*” OR “breast tumor” OR “breast carcinoma” OR “breast cancer patients” OR “patients with breast cancer” OR “breast neoplasm patients”) AND (“mindfulness-based intervention” OR “mindfulness therapy” OR “mindfulness training” OR “mindfulness-based stress reduction” OR “mindfulness-based cognitive therapy” OR “mindfulness meditation”) AND (“fear of recurrence” OR “fear of cancer recurrence” OR “cancer recurrence fear” OR “fear of relapse” OR “recurrence fear” OR “fear of cancer relapse” OR “Fear of Cancer Recurrence Inventory”). The Chinese search terms were: (“乳腺癌” OR “乳癌” OR “乳腺恶性肿瘤” OR “乳腺癌患者” OR “乳腺肿瘤患者” OR “乳腺癌幸存者” OR “乳腺肿瘤幸存者”) AND (“正念疗法” OR “正念减压” OR “正念冥想” OR “正念训练” OR “正念认知疗法” OR “正念减压疗法” OR “正念基础干预” OR “正念行为疗法”) AND (“复发恐惧” OR “恐惧复发” OR “癌症复发恐惧” OR “对复发的恐惧” OR “肿瘤复发恐惧” OR “复发担忧” OR “害怕复发” OR “癌症复发焦虑”). Additionally, to minimize omissions, we manually searched the reference lists of relevant reviews to supplement potential literature. 2.3 Literature Inclusion and Exclusion Criteria Inclusion and exclusion criteria were developed based on the PICOS principle: Participants (P): Pathologically confirmed breast cancer patients, regardless of age, cancer stage, or treatment phase. Intervention (I): Structured interventions based on mindfulness, such as Mindfulness-Based Stress Reduction or Mindfulness-Based Cognitive Therapy. Comparison (C): Usual care, waitlist, health education, or other non-mindfulness psychological interventions. Outcome (O): The primary outcome was fear of cancer recurrence, measured using validated scales. Study design (S): Randomized controlled trials.All included RCTs reported ethical approval from an institutional review board. Exclusion criteria: ① Non-Chinese or English literature; ② Full text unavailable or incomplete data even after contacting authors; ③ Duplicate publications. 2.4 Literature Screening and Data Extraction Two investigators independently screened the literature, performed data extraction, and cross-checked the extracted information. Disputes were settled through discussion to consensus or by arbitration from a third investigator. The literatures were firstly de-duplicated by reference management software, preliminarily screened by reading title and abstract, and screened based on full texts reading finally. Data extraction included: ① Basic study information: first author, publication year, and country; ② Participant characteristics: sample size per group, patient age, and disease status; ③ Intervention details: specific intervention method, session duration, frequency, and total intervention dose; ④ Description of control measures; ⑤ Outcome data: mean, standard deviation, and sample size for each group. 2.5 Risk of Bias Assessment The Cochrane Risk of Bias tool (RoB 2.0) was used to appraise the methodologic quality of RCTs included [19] . The review considered domains included: randomisation process, selective exclusion of participants, missing outcome data, outcome assessment and reporting outcome. All the studies were rated by two independent reviewers using the risk of bias as “low risk”, “high risk” or “some concerns”. 2.6 Statistical Analysis All statistical analyses were conducted using Stata 18.0. The effect size, Hedges’s g with its 95% confidence interval (CI), was calculated to correct for potential bias in small sample studies [20] . Heterogeneity across studies was quantified using the I² statistic, with I² ≥ 50% indicating substantial heterogeneity. Given the anticipated clinical and methodological diversity (e.g., variations in cultural backgrounds and intervention formats), a random-effects model was employed, utilizing the DerSimonian-Laird method to estimate between-study variance ( τ² ) [21] . To investigate the sources of heterogeneity, we performed pre-defined subgroup analyses based on Region (China vs. other countries), Intervention format (in-person group vs. online), Intervention duration (<8 weeks vs. ≥8 weeks), and Assessment tool (CARS vs. FCRI vs. FoP-Q-SF). An exploratory analysis was also conducted to examine the distribution of intervention formats within the regional subgroups. Meta-regression was not performed due to the limited number of included studies (<10), in accordance with the recommendations of the Cochrane Handbook [21] . The robustness of the pooled effect size was assessed through a sensitivity analysis using the leave-one-out method. Publication bias was evaluated by visual inspection of funnel plots and Egger’s test [22] . A p-value of < 0.05 was considered statistically significant for all tests [21] . 3. Results 3.1 Literature Screening Process The initial search yielded 264 relevant records. Following a stepwise screening process, 10 randomized controlled trials were ultimately included in this systematic review and meta-analysis. The literature screening process and reasons for exclusion are detailed in the PRISMA flow diagram (Figure 1). 3.2 Basic Characteristics and Risk of Bias Assessment of Included Studies The 10 included studies involved a total of 896 breast cancer patients (Figure 2). Seven studies were conducted in China, and the remaining three were from the United States (2) and Japan (1). The interventions were primarily structured courses based on MBSR or MBCT; control conditions included usual care, health education, or waitlist. For the primary outcome (fear of cancer recurrence), studies used standardized scales such as CARS, FCRI, and FoP-Q-SF. According to the Cochrane Risk of Bias tool (RoB 2.0), all 10 studies were rated as "low risk" (Figure 3). Study (Author, Year) Country Treatment Phase Sample Size (I/C) Mean Age (I/C) years Intervention Type Duration (weeks) FCR Scale Used Follow-up Zhou et al., 2020 [23] China Postoperative chemotherapy 52/52 -/- MBSR 8 FoP-Q-SF No Yang et al., 2024 [24] China Perioperative 35/35 44.85/45.16 Online MBSR 8 FCRI No Wang et al., 2021 [25] China Postoperative 41/43 49.15/51 MBSR 6 CARS No Huang et al., 2025 [26] China Post-treatment 40/40 29.29/29.14 MBSR 6 FoP-Q-SF 12 weeks Wang et al., 2021 [27] China During treatment 30/30 50.83/51.2 Online MBSR 8 FCRI No Lengacher et al., 2012 [28] USA Post-treatment 40/42 57.5/57.5 MBSR 6 CARS No Chu et al., 2020 [29] China Post-surgery 42/42 54.6/54.9 MBCT 8 CARS 12 weeks Peng et al., 2022 [30] China Post-treatment 28/29 -/- Online MBSR 6 FCRI-SF 4 weeks Lengacher et al., 2016 [31] USA Post-treatment 167/155 56.5/57.6 MBSR 6 CARS 12 weeks Park et al., 2020 [32] Japan Non-metastatic breast cancer 38/36 53.21/54.19 MBCT 8 CARS 4 weeks Abbreviations: I/C: Intervention group/Control group; FCR: Fear of cancer recurrence; MBSR: Mindfulness-Based Stress Reduction; MBCT: Mindfulness-Based Cognitive Therapy; CARS: Concerns About Recurrence Scale; FCRI: Fear of Cancer Recurrence Inventory; FoP-Q-SF: Fear of Progression Questionnaire-Short Form. 3.3 Sensitivity Analysis and Study Exclusion A preliminary meta-analysis revealed high heterogeneity among studies ( I² > 90%, Figure 4). Leave-one-out analysis revealed that the study by Huang (2025) had the most significant impact on overall heterogeneity. After excluding this study, heterogeneity decreased significantly from >90% to 73.83%, and the direction and statistical significance of the pooled effect size did not change, indicating relatively robust overall results. Considering that the effect size reported by Huang (2025) was substantially larger than in other studies ( Hedges’s g = -3.56), its extreme effect size may be attributable to unique intervention protocols, assessment tools, or population characteristics. To prevent this study from unduly influencing the overall estimate, we decided to exclude it from subsequent analyses. Therefore, all following analyses are based on the remaining 9 studies. 3.4 Meta-Analysis Results 3.4.1 Overall Effect The meta-analysis results based on the random-effects model (Figure 5) showed that compared to the control group, mindfulness interventions significantly reduced fear of cancer recurrence levels in breast cancer patients, with a pooled effect size of Hedges’s g = -0.56 (95% CI: -0.83 to -0.29, P < 0.001). Substantial heterogeneity was observed among studies ( I² = 73.83%, τ² = 0.12, P < 0.01), indicating a need to further investigate sources of heterogeneity. 3.4.2 Subgroup Analysis To explore sources of heterogeneity, we conducted subgroup analyses. The results showed that region was an important factor influencing the effect size (between-group difference P = 0.03) (Figure 6).In the Chinese population, mindfulness interventions had a moderate and significant effect on reducing fear of cancer recurrence (Hedges's g = -0.71, 95% CI: -0.90 to -0.44, p < 0.001), with moderate heterogeneity within this subgroup ( I² = 52.30%, p = 0.06). In populations from other countries, the intervention effect was small and did not reach statistical significance (Hedges's g = -0.26, 95% CI: -0.56 to 0.04, p = 0.08), with moderate heterogeneity within the subgroup ( I² = 52.03%). Subgroup analysis based on intervention duration (<8 weeks vs. ≥8 weeks) (Figure 7) showed that both short (<8 weeks: Hedges’s g = -0.57, 95% CI: -1.09 to -0.06, P = 0.03) and long (≥8 weeks: Hedges’s g = -0.57, 95% CI: -0.83 to -0.31, P < 0.001) interventions had significant effects, with no significant difference between the groups (between-group difference P = 0.99). Notably, the <8 weeks subgroup had high heterogeneity ( I² = 85.62%), while the ≥8 weeks subgroup had lower heterogeneity ( I² = 39.82%). Subgroup analysis based on different assessment tools (Figure 8) showed that studies using the CARS scale (Hedges's g = -0.56, 95% CI: -0.97 to -0.15, p = 0.01), FCRI scale (Hedges's g = -0.54, 95% CI: -1.00 to -0.08, p = 0.02), and FoP-Q-SF scale (Hedges's g = -0.68, 95% CI: -1.07 to -0.29, p < 0.001) all reported significant mindfulness intervention outcomes. There was no significant difference in effect sizes between the different assessment tool subgroups (between-group difference p = 0.88). However, high heterogeneity existed within the subgroup using the CARS scale ( I² = 82.75%). 3.4. 3 Sensitivity Analysis of Follow-up Data Among the included studies, three reported follow-up data at 12 weeks [26, 28, 31] . A qualitative synthesis of these studies suggested that the beneficial effects of MBIs on FCR were maintained at short-term follow-up. However, due to variations in reporting formats, a quantitative meta-analysis of follow-up effects was not feasible. This highlights a need for standardized long-term outcome reporting in future trials. 3.5 Publication Bias After excluding the study by Huang et al. (2025), publication bias was assessed for the remaining 9 studies. Visual inspection of the funnel plot showed asymmetry (Figure 9), suggesting possible publication bias [33] . 4. Discussion This meta-analysis demonstrates that mindfulness interventions significantly reduce the fear of cancer recurrence among breast cancer patients ( Hedges’s g = -0.56). Our findings build on foundational work in psycho-oncology, such as the definition of FCR [5] and the established role of mindfulness in cancer care [11] , by providing the first meta-analytic evidence that quantifies cultural background as a key moderator of treatment efficacy.Building upon the findings of recent reviews [15] , our study provides the first meta-analytic evidence that quantifies cultural background as a key moderator of treatment efficacy. We pooled effect size is in line with recent reviews which explored mindfulness in the cancers populations [34, 35] . However, the high heterogeneity ( I² = 73.83%) suggests that mindfulness interventions are not a homogeneous entity and should be interpreted with caution. The funnel plot imbalance as well as important outcome from Egger’s test ( P =0.03), indicates that publication bias might be occurred, which can be originated from scarcity of underpowered negative-result studies, and result in overestimation of the pooled effect size. The methodological heterogeneity can be a contributing factor to this asymmetry, and therefore bias are due considerations to interpreting the over all effect of mindfulness interventions. Several factors may explain this cultural disparity: ① The cultural affinity and philosophical compatibility of mindfulness interventions. Mindfulness, originating from Eastern meditation, aligns closely with core principles (e.g., insight, acceptance) found in Chinese philosophies such as Confucian “introspection” and Daoist “going with the flow.” This alignment may facilitate acceptance among Chinese patients and enhance its positive effects [36, 37] . ② Differences in social support resources. Mindfulness groups in China may provide limited yet secure avenues for emotional and social support, crucial for mitigating fear of recurrence [38] . In contrast, Western societies typically offer a broader range of psychosocial support resources, potentially diluting the supportive effect of mindfulness groups [36] . ③ Variations in expectations regarding psychological interventions and levels of stigma. The Chinese literature included in this study was predominantly published within the last year, reflecting a growing domestic focus on psycho-oncology. Patients’ heightened expectations for psychological interventions may amplify their perceived benefits to some extent [39] . Beyond cultural factors, the substantial heterogeneity observed ( I² = 73.83%) may also stem from variations in intervention implementation. Differences in instructor qualifications (e.g., clinical psychologists vs. trained peers), specific mindfulness practices emphasized (e.g., body scan vs. meditation), and group dynamics could significantly influence outcomes [33] . A deeper analysis of these implementation factors is crucial for understanding the “active ingredients” of MBIs. Notably, intervention protocols lasting more than 8 weeks did not demonstrate superior effects compared to those shorter than 8 weeks (between-group P = 0.99), challenging the linear “dose-response” relationship. There may be a law of diminishing returns, suggesting that beyond a certain duration, additional practice yields diminishing marginal benefits and increases participant burden, leading to negative emotions [40] . Conversely, the high heterogeneity within the short-duration subgroup ( I² = 85.62%) indicates that specific patient subgroups (e.g., those with high baseline fear levels) may benefit significantly from longer interventions, while those with low fear levels may benefit less. Identifying these differences and aligning them with appropriate intervention durations is an important direction for future research. Although all three assessment tools (CARS, FCRI, FoP-Q-SF) demonstrated significant effects of mindfulness interventions, the CARS subgroup exhibited extremely high heterogeneity ( I² = 82.75%), suggesting that fear of cancer recurrence may be a multidimensional construct. Different scales may emphasize different dimensions [15, 41-43] , and mindfulness interventions might primarily affect certain dimensions (e.g., metacognitive awareness of fearful thoughts) while having weaker effects on others (e.g., behavioral avoidance). Therefore, using different scales essentially measures slightly distinct psychological aspects, leading to inconsistent results. Future research should emphasize detailed reporting and analysis of the various dimensions of these scales [44] . Implications (Clinical and Research) For clinical translation, we propose a specific pathway for Chinese breast cancer patients: a 6-8 week group-based mindfulness program integrating culturally resonant elements (e.g., combining ‘mindful breathing’ with Daoist concepts of ‘going with the flow’), with FCR outcomes preferentially assessed using the FoP-Q-SF scale for its sensitivity. While acknowledging the value of mindfulness interventions, clinicians should avoid a “one-size-fits-all” approach and instead recommend personalized intervention plans that consider patients’ cultural backgrounds, personal preferences, and available resources (e.g., time and financial constraints) [35] . Future research should focus on identifying the “active ingredients” within intervention protocols [47] . Conducting individual participant data meta-analyses is recommended to explore the predictive role of individual patient characteristics on treatment responses [46] . Additionally, mechanism-based randomized controlled trials are encouraged to test efficacy while validating potential mediating pathways of mindfulness interventions, such as cognitive defusion and reduced rumination [15] . Furthermore, research reports should detail strategies implemented for cultural adaptation and advocate for multidimensional, multi-tool outcome measurement and reporting of fear of cancer recurrence [35, 41] . Limitations This study has several limitations. First, although we conducted subgroup analyses to identify potential moderating factors, the insufficient reporting of individual patient data in the original studies prevented us from performing more detailed meta-regression analyses on key variables such as cancer stage, treatment phase, or baseline fear level, which may represent important sources of residual heterogeneity. Second, as mentioned, funnel plot asymmetry and the results of Egger’s test suggest the presence of potential publication bias, which may impact the accuracy of the overall effect size estimate [45] . Third, the total number of studies included remains limited, particularly in the “other countries” subgroup, which may affect the stability of the effect estimate for that subgroup [46] .Finally, the included studies provided insufficient details on intervention fidelity (e.g., adherence to the protocol), which may have influenced the observed effects and limited our ability to assess the quality of implementation [33] . 5. Conclusion In conclusion, this meta-analysis confirms that MBIs are effective in reducing FCR in breast cancer patients, with efficacy significantly moderated by cultural background. The development of culturally-adapted mindfulness programs is crucial for maximizing therapeutic benefits. Declarations Author Contributions Conceptualization: Xinyu Wang Data curation: Xinyu Wang Formal analysis:Xinyu Wang Investigation: Xinyu Wang Methodology: Xian Ma Project administration: Xinyu Wang Resources: Man Yuan Software: Xinyu Wang Supervision: Man Yuan Validation: Xian Ma Visualization: Xinyu Wang Writing – original draft: Xinyu Wang Writing – review & editing: Xinyu Wang Disclosure Statement The authors report no conflicts of interest. Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request. References Kim J, Harper A, McCormack V, Sung H, Houssami N, Morgan E, Mutebi M, Garvey G, Soerjomataram I, Fidler-Benaoudia MM. Global patterns and trends in breast cancer incidence and mortality across 185 countries. Nat Med. 2025;31(4):1154–1162. doi: 10.1038/s41591-025-03502-3 . Epub 2025 Feb 24. PMID: 39994475. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024 May-Jun;74(3):229–263. doi: 10.3322/caac.21834. Epub 2024 Apr 4. PMID: 38572751. Feng RM, Zong YN, Cao SM, Xu RH. Current cancer situation in China: good or bad news from the 2018 Global Cancer Statistics? Cancer Commun (Lond). 2019;39(1):22. doi: 10.1186/s40880-019-0368-6 . PMID: 31030667; PMCID: PMC6487510. Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials. Lancet Oncol. 2018;19(1):27–39. doi: 10.1016/S1470-2045(17)30777-5. Epub 2017 Dec 11. PMID: 29242041; PMCID: PMC5757427. Lebel S, Ozakinci G, Humphris G, Mutsaers B, Thewes B, Prins J, Dinkel A, Butow P; University of Ottawa Fear of Cancer Recurrence Colloquium attendees. From normal response to clinical problem: definition and clinical features of fear of cancer recurrence. Support Care Cancer. 2016;24(8):3265–8. doi: 10.1007/s00520-016-3272-5 . Epub 2016 May 12. PMID: 27169703. Ng DWL, Kwong A, Suen D, Chan M, Or A, Ng SS, Foo CC, Fielding BFS, Lam WWT. Fear of cancer recurrence among Chinese cancer survivors: Prevalence and associations with metacognition and neuroticism. Psychooncology. 2019;28(6):1243–1251. doi: 10.1002/pon.5073 . Epub 2019 Apr 26. PMID: 30932279. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156. https://doi.org/10.1093/clipsy.bpg016 Zhai, X. Y., Li, Y., & Zhang, Y. (2024). Application Progress of Mindfulness Therapy in Patients with Malignant Tumors. Advances in Clinical Medicine, 14(5), 1296–1302. https://doi.org/10.12677/acm.2024.1451553 Lutz J, Herwig U, Opialla S, Hittmeyer A, Jäncke L, Rufer M, Grosse Holtforth M, Brühl AB. Mindfulness and emotion regulation–an fMRI study. Soc Cogn Affect Neurosci. 2014;9(6):776–85. doi: 10.1093/scan/nst043 . Epub 2013 Apr 5. PMID: 23563850; PMCID: PMC4040090. Fardell JE, Thewes B, Turner J, Gilchrist J, Sharpe L, Smith A', Girgis A, Butow P. Fear of cancer recurrence: a theoretical review and novel cognitive processing formulation. J Cancer Surviv. 2016;10(4):663–73. doi: 10.1007/s11764-015-0512-5 . Epub 2016 Jan 19. PMID: 26782171. Carlson LE. Mindfulness-based interventions for coping with cancer. Ann N Y Acad Sci. 2016;1373(1):5–12. doi: 10.1111/nyas.13029 . Epub 2016 Mar 9. PMID: 26963792. Cramer H, Lauche R, Paul A, Dobos G. Mindfulness-based stress reduction for breast cancer-a systematic review and meta-analysis. Curr Oncol. 2012;19(5):e343-52. doi: 10.3747/co.19.1016 . PMID: 23144582; PMCID: PMC3457885. Oberoi S, Yang J, Woodgate RL, Niraula S, Banerji S, Israels SJ, Altman G, Beattie S, Rabbani R, Askin N, Gupta A, Sung L, Abou-Setta AM, Zarychanski R. Association of Mindfulness-Based Interventions With Anxiety Severity in Adults With Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(8):e2012598. doi: 10.1001/jamanetworkopen.2020.12598 . PMID: 32766801; PMCID: PMC7414391. Piet J, Würtzen H, Zachariae R. The effect of mindfulness-based therapy on symptoms of anxiety and depression in adult cancer patients and survivors: a systematic review and meta-analysis. J Consult Clin Psychol. 2012;80(6):1007–20. doi: 10.1037/a0028329 . Epub 2012 May 7. PMID: 22563637. Lyu MM, Siah RC, Lam ASL, Cheng KKF. The effect of psychological interventions on fear of cancer recurrence in breast cancer survivors: A systematic review and meta-analysis. J Adv Nurs. 2022;78(10):3069–3082. doi: 10.1111/jan.15321 . Epub 2022 Jun 13. PMID: 35696315. Zhang, L. L., Chen, H., Luo, H., et al. Systematic Review of Fear of Cancer Recurrence Assessment Tools Based on the Consensus-Based Standards for the Selection of Health Measurement Instruments. Chinese General Practice, 2023, 26(17), pp. 2138–2146. DOI: 10.12114/j.issn.1007-9572.2022.0810 . Roemer, A., Cervin, M., Medvedeva, A. et al. Big Five of Mindfulness and Personality: Cross-Cultural Network Analysis. Mindfulness 15, 37–47 (2024). https://doi.org/10.1007/s12671-023-02293-3 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71 . PMID: 33782057; PMCID: PMC8005924. Sterne JA, et al. RoB 2: a revised tool for assessing risk of bias in randomized trials. BMJ. 2019. Borenstein M, et al. Introduction to Meta-Analysis. John Wiley & Sons; 2009. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (2024). Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34. doi: 10.1136/bmj.315.7109.629 . PMID: 9310563; PMCID: PMC2127453. Zhou, J. J. (2020). Study on the current status and intervention effect of fear of recurrence in patients with breast cancer during postoperative chemotherapy period [Master's thesis, Yangzhou University]. DOI: 10.27441/d.cnki.gyzdu.2020.001044 . Yang, G. D. (2024). Effect of online mindfulness-based stress reduction therapy on negative emotions in perioperative stage 0-II breast cancer patients [Master's thesis, Hebei Medical University]. DOI: 10.27111/d.cnki.ghyku.2024.000556 . Wang, J. M., Mei, H. Y., & Sun, Y. L. (2021). Effects of mindfulness relaxation training on fear of cancer recurrence, cancer-related fatigue and sleep quality in breast cancer patients. Chinese Journal of Clinical Oncology and Rehabilitation, 28(02), 228–233. DOI: 10.13455/j.cnki.cjcor.2021.02.26 . Huang, M. P., & Wei, P. Y. (2025). Impact of mindfulness-based stress reduction therapy on young breast cancer patients. Economic and Social Development Research, 2025(21), 0271–0273. Wang, X. M. (2021). Study on the intervention effect of mindfulness-based stress reduction therapy on fear of cancer recurrence in breast cancer patients [Master's thesis, Shihezi University]. DOI: 10.27332/d.cnki.gshzu.2021.000354 . Lengacher CA, Shelton MM, Reich RR, Barta MK, Johnson-Mallard V, Moscoso MS, Paterson C, Ramesar S, Budhrani P, Carranza I, Lucas J, Jacobsen PB, Goodman MJ, Kip KE. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37(2):185–95. doi: 10.1007/s10865-012-9473-6 . Epub 2012 Nov 27. PMID: 23184061; PMCID: PMC3627743. Chu X, Lou Y, Wang Z, Xu Q. Effect of mindfulness based cognitive therapy on the mental health and quality of life in patients with breast cancer. Indian J Pharm Sci. (2020) 82:48–52. doi: 10.36468/pharmaceutical-sciences.spl.143 Peng L, Yang Y, Chen M, Xu C, Chen Y, Liu R, Cao X, Li M. Effects of an online mindfulness-based intervention on Fear of Cancer Recurrence and quality of life among Chinese breast cancer survivors. Complement Ther Clin Pract. 2022;49:101686. doi: 10.1016/j.ctcp.2022.101686. Epub 2022 Nov 3. PMID: 36347151. Lengacher CA, Reich RR, Paterson CL, Ramesar S, Park JY, Alinat C, Johnson-Mallard V, Moscoso M, Budhrani-Shani P, Miladinovic B, Jacobsen PB, Cox CE, Goodman M, Kip KE. Examination of Broad Symptom Improvement Resulting From Mindfulness-Based Stress Reduction in Breast Cancer Survivors: A Randomized Controlled Trial. J Clin Oncol. 2016;34(24):2827–34. doi: 10.1200/JCO.2015.65.7874. Epub 2016 May 31. PMID: 27247219; PMCID: PMC5012660. Park S, Sato Y, Takita Y, Tamura N, Ninomiya A, Kosugi T, Sado M, Nakagawa A, Takahashi M, Hayashida T, Fujisawa D. Mindfulness-Based Cognitive Therapy for Psychological Distress, Fear of Cancer Recurrence, Fatigue, Spiritual Well-Being, and Quality of Life in Patients With Breast Cancer-A Randomized Controlled Trial. J Pain Symptom Manage. 2020;60(2):381–389. doi: 10.1016/j.jpainsymman.2020.02.017. Epub 2020 Feb 24. PMID: 32105790. Sutton A J, Abrams K R, Jones D R, et al. Methods for meta-analysis in medical research[M]. Chichester: Wiley, 2000. Chayadi E, Baes N, Kiropoulos L. The effects of mindfulness-based interventions on symptoms of depression, anxiety, and cancer-related fatigue in oncology patients: A systematic review and meta-analysis. PLoS One. 2022;17(7):e0269519. doi: 10.1371/journal.pone.0269519 . PMID: 35834503; PMCID: PMC9282451. Baydoun M, Moran C, McLennan A, Piedalue KL, Oberoi D, Carlson LE. Mindfulness-Based Interventions in Cancer Survivors: A Systematic Review of Participants' Adherence to Home Practice. Patient Prefer Adherence. 2021;15:1225–1242. doi: 10.2147/PPA.S267064. PMID: 34135575; PMCID: PMC8200136. Tao TJ, Hui CLM, Lam BST, Ho ECN, Hui PWM, Suen YN, Lin JJ, Tong ACY, Lee EHM, Chan SKW, Chang WC, Chen EYH. Mindfulness meditation for Chinese patients with psychosis: A systematic review and meta-analysis. Schizophr Res. 2021;237:103–114. doi: 10.1016/j.schres.2021.08.033. Epub 2021 Sep 9. PMID: 34509897. Kirmayer LJ. Mindfulness in cultural context. Transcult Psychiatry. 2015;52(4):447 – 69. doi: 10.1177/1363461515598949. Erratum in: Transcult Psychiatry. 2015;52(5):e1. Erratum in: Transcult Psychiatry. 2015;52(5):e1. doi: 10.1177/1363461515605012 . PMID: 26264787. Wang, H. H., Li, N., Li, Y., et al. The Impact of Social Support on Fear of Cancer Recurrence in Breast Cancer Survivors: The Mediating Effect of Psychological Resilience. Military Nursing, 2022, 39(10), pp. 17–20. DOI: 10.3969/j.issn.2097-1826.2022.10.005 . Tang, L. L., Pang, Y., Song, L. L., et al. Current Status of Clinical Practice Development in Psychosocial Oncology at Home and Abroad. Medicine & Philosophy, 2022, 43(15), pp. 39–43. DOI: 10.12014/j.issn.1002-0772.2022.15.10 . Britton WB. Can mindfulness be too much of a good thing? The value of a middle way. Curr Opin Psychol. 2019;28:159–165. doi: 10.1016/j.copsyc.2018.12.011 . Epub 2019 Jan 7. PMID: 30708288; PMCID: PMC6612475. Simard S, Savard J. Fear of Cancer Recurrence Inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009;17(3):241–51. doi: 10.1007/s00520-008-0444-y . Epub 2008 Apr 15. PMID: 18414902. Maheu C, Tock WL, Fisher P, Galica J, Singh M, Centeno I, Hébert M, Moran C, Pietruczuk P, Dinkel A, Zwaal C, Thewes B, Estapé T. Systematic Review of Fear of Cancer Recurrence Patient-Reported Outcome Measures: Evaluating Methodological Quality and Measurement Properties Using the COSMIN Checklist. Healthcare (Basel). 2025;13(17):2165. doi: 10.3390/healthcare13172165 . PMID: 40941516; PMCID: PMC12427728. Custers, J. A., et al. (2016). Fear of cancer recurrence in breast cancer survivors. Psycho-Oncology, 25(11), 1336–1343. Smith AB, Costa D, Galica J, Lebel S, Tauber N, van Helmondt SJ, Zachariae R. Spotlight on the Fear of Cancer Recurrence Inventory (FCRI). Psychol Res Behav Manag. 2020;13:1257–1268. doi: 10.2147/PRBM.S231577. PMID: 33376421; PMCID: PMC7762428. Yao, A. L. A simulation study on the impact of publication bias on Meta-analysis results [Dissertation]. Guangdong: Southern Medical University; 2015. DOI: 10.7666/d.Y2911410 . Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006;25(20):3443-57. doi: 10.1002/sim.2380 . PMID: 16345038. Kan JM, Dieng M, Butow PN, Mireskandari S, Tesson S, Menzies SW, Costa DSJ, Morton RL, Mann GJ, Cust AE, Kasparian NA. Identifying the 'Active Ingredients' of an Effective Psychological Intervention to Reduce Fear of Cancer Recurrence: A Process Evaluation. Front Psychol. 2021;12:661190. doi: 10.3389/fpsyg.2021.661190 . PMID: 34163405; PMCID: PMC8215538. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 16 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Submission checks completed at journal 24 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8587364","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":573656246,"identity":"c590a421-46f6-45a4-b425-0d6eae279882","order_by":0,"name":"Xinyu Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACNmbm4z8+VNTwsMk/PkCcFj52tgTJGWeOyfEzpCUQp0WOn8dAmrON2ViyIceAWIexJRgzsLElbjhw5uONNwx2croNBLUwH0gu4JFJ3HCwd7PlHIZkY7MDRNhyeIYE0JbDvNukeRgOJG4jrIXHsJnHgDlxwzGeZ0RrMWbmSQB6v4eHjVgtbGmMMw4AA1mCzdhyjgERfpHvP3yM4eM/YFRKMD+88abCTo6gFhQgwUNk1CBrIVXHKBgFo2AUjAgAAFr/O33L81tBAAAAAElFTkSuQmCC","orcid":"","institution":"Beijing Tian Tan Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xinyu","middleName":"","lastName":"Wang","suffix":""},{"id":573656247,"identity":"d0d345d0-3d82-407d-a26c-72990113697f","order_by":1,"name":"Man Yuan","email":"","orcid":"","institution":"Beijing Tian Tan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Man","middleName":"","lastName":"Yuan","suffix":""},{"id":573656248,"identity":"31049569-47db-4e7b-bf4f-ef585b71705e","order_by":2,"name":"Xian Ma","email":"","orcid":"","institution":"Beijing Tian Tan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xian","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2026-01-13 05:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8587364/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8587364/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100667502,"identity":"0ecc062f-a29e-4c9d-ac96-061f9f442772","added_by":"auto","created_at":"2026-01-20 09:47:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":266279,"visible":true,"origin":"","legend":"","description":"","filename":"MindfulnessBasedInterventionsforFearofRecurrenceinPatientswithBreastCancerAMetaAnalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/999e138c64d81d6ddf7a0ec1.docx"},{"id":100667311,"identity":"f68eead5-efa2-46a7-b44e-a51f412be2b8","added_by":"auto","created_at":"2026-01-20 09:46:27","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7007,"visible":true,"origin":"","legend":"","description":"","filename":"5aa55e43327a4d52ad894cd7e3924be4.json","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/d8ce0dc3926f603e8449f47a.json"},{"id":100667437,"identity":"a3bd16e7-00e4-44da-96a5-3f6186a3c1b5","added_by":"auto","created_at":"2026-01-20 09:46:50","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135788,"visible":true,"origin":"","legend":"","description":"","filename":"5aa55e43327a4d52ad894cd7e3924be41enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/bdbe858da9b25358d1acd142.xml"},{"id":100667111,"identity":"8993c4dc-7f62-45c5-b537-a78f3be7c6ca","added_by":"auto","created_at":"2026-01-20 09:45:25","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78417,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/f4d623786d9cc0a1d2ea2461.png"},{"id":100667444,"identity":"9cd4b19c-8908-46ad-a3e9-431b736c7caf","added_by":"auto","created_at":"2026-01-20 09:46:56","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86105,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/f1eeebd7cd2f0ceda5ac6eab.png"},{"id":100667305,"identity":"b10bb311-8d82-4bce-9b4b-c65b0d96e0a3","added_by":"auto","created_at":"2026-01-20 09:46:22","extension":"emf","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78096,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.emf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/99185d419462e6a83cd0dd61.emf"},{"id":100667304,"identity":"b3b50294-67f0-4189-a1e8-a49161e627a1","added_by":"auto","created_at":"2026-01-20 09:46:22","extension":"emf","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72812,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.emf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/d14e89af266ffde7d484d190.emf"},{"id":100667568,"identity":"cd846c55-d528-4e5e-aba9-dad1e01083e0","added_by":"auto","created_at":"2026-01-20 09:48:05","extension":"emf","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96332,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.emf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/92aee2c33a1595af58446423.emf"},{"id":100667308,"identity":"8b4a40fa-4cf8-4f7d-b2fa-4b98093396cb","added_by":"auto","created_at":"2026-01-20 09:46:24","extension":"emf","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96268,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.emf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/4e30f58475728a66f080c1eb.emf"},{"id":100667422,"identity":"db23cebe-a3dd-43e5-a4b6-9b4bc154d938","added_by":"auto","created_at":"2026-01-20 09:46:41","extension":"emf","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":107068,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.emf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/626454818275b1f91a997eaf.emf"},{"id":100667104,"identity":"05b0c30b-cb62-4f76-b02f-9af0230cf61f","added_by":"auto","created_at":"2026-01-20 09:45:20","extension":"emf","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98724,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage8.emf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/a7b0936cd8c188c18f135b3a.emf"},{"id":100667428,"identity":"fcdee882-d088-43e2-a283-f638625975ef","added_by":"auto","created_at":"2026-01-20 09:46:45","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":31452,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/78914c8bdf6ae656a919dcc0.png"},{"id":100667266,"identity":"75b873d3-08fc-4bdb-a8df-81e69dc5853f","added_by":"auto","created_at":"2026-01-20 09:46:16","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32139,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/33d5097bb64fa4788f129d35.png"},{"id":100667156,"identity":"0e785acd-f323-48cf-989f-92a29916cab9","added_by":"auto","created_at":"2026-01-20 09:45:44","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":313658,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/869cde02af25a28478ec02e3.png"},{"id":100667482,"identity":"644744d4-e159-4ba4-8a92-f421dd917842","added_by":"auto","created_at":"2026-01-20 09:47:16","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":296857,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/dd1d9f9cdcbdfc2a0e669e3a.png"},{"id":100667164,"identity":"16e5faf6-0287-4001-95ba-3f404e083d2e","added_by":"auto","created_at":"2026-01-20 09:45:48","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":409785,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/5d58384998cd061098e60130.png"},{"id":100667157,"identity":"100b84a4-05d6-4db5-9120-345d34b6e85b","added_by":"auto","created_at":"2026-01-20 09:45:44","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":409863,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/c7b64b6dd0fe1fa55970c65e.png"},{"id":100667485,"identity":"866ed29f-5981-4720-8f6e-ebc7586479da","added_by":"auto","created_at":"2026-01-20 09:47:19","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":461549,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/6b7c7aef96cb9716f2a70643.png"},{"id":100667171,"identity":"49da8423-0176-4936-bed8-46af511d2395","added_by":"auto","created_at":"2026-01-20 09:45:53","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94732,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/4f97d5713c261efdfcc56d9d.png"},{"id":100667393,"identity":"b18122bb-7900-49de-9512-00849d7fef48","added_by":"auto","created_at":"2026-01-20 09:46:35","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":128399,"visible":true,"origin":"","legend":"","description":"","filename":"5aa55e43327a4d52ad894cd7e3924be41structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/7f3b57f5ccd45afb35e0cfb9.xml"},{"id":100667473,"identity":"d9024a90-a8db-4bb3-9fb1-77fb29091f94","added_by":"auto","created_at":"2026-01-20 09:47:08","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":145966,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/a23e8d07da1a625e9c220dd4.html"},{"id":100667419,"identity":"a2ee494a-4906-4943-b6fe-ba6fd3679268","added_by":"auto","created_at":"2026-01-20 09:46:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31452,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/fa49f8690a329345a8ff1649.png"},{"id":100667301,"identity":"dc16c78d-5896-4451-9889-8d806734b262","added_by":"auto","created_at":"2026-01-20 09:46:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32139,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of Bias Assessment Results for Included Studies\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/e0648679e149ed73317091dc.png"},{"id":100667539,"identity":"9b7b4e85-12f5-4754-9ae8-3cff1ab5e1c9","added_by":"auto","created_at":"2026-01-20 09:48:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":313658,"visible":true,"origin":"","legend":"\u003cp\u003eOverall Forest Plot Before Excluding Huang_2025\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/91ed5b539afeecc096264a50.png"},{"id":100667440,"identity":"959b655f-b6d9-4f71-99c2-eafa0a9b598c","added_by":"auto","created_at":"2026-01-20 09:46:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":296857,"visible":true,"origin":"","legend":"\u003cp\u003eOverall Forest Plot\u003c/p\u003e","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/67d1b6487b9799553ae0f9e4.png"},{"id":100667129,"identity":"fcfda643-bd05-430a-ad86-5a8fba99ca4c","added_by":"auto","created_at":"2026-01-20 09:45:36","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":409785,"visible":true,"origin":"","legend":"\u003cp\u003eForest Plot for Subgroup Analysis by Country\u003c/p\u003e","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/29224fc239e761c452b389b5.png"},{"id":100667430,"identity":"b05d41f6-3473-4b48-a4c6-7cf261e9684e","added_by":"auto","created_at":"2026-01-20 09:46:46","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":409863,"visible":true,"origin":"","legend":"\u003cp\u003eForest Plot for Subgroup Analysis by Intervention Duration\u003c/p\u003e","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/edda0dda15c69a85e8dcfe8c.png"},{"id":100667397,"identity":"d7c1fd0a-a0e3-4538-a872-11109be34f40","added_by":"auto","created_at":"2026-01-20 09:46:37","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":461549,"visible":true,"origin":"","legend":"\u003cp\u003eForest Plot for Subgroup Analysis by Questionnaire Type\u003c/p\u003e","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/a02e17524f749ae830f9fdd1.png"},{"id":100667391,"identity":"2d66f1e4-c134-4a46-a6c6-a92ecb6b00a4","added_by":"auto","created_at":"2026-01-20 09:46:34","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":28025,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel Plot\u003c/p\u003e","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/1725cf0acf9c399183390f2d.png"},{"id":100671254,"identity":"a0ea674c-441d-4916-9e98-0d3e214cae3a","added_by":"auto","created_at":"2026-01-20 10:30:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3693031,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8587364/v1/7cbb83ef-f0f8-448e-b971-16d2188652f1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mindfulness-Based Interventions for Fear of Recurrence in Patients with Breast Cancer: A Meta-Analysis","fulltext":[{"header":"1. Background","content":"\u003cp\u003eBreast cancer (BC) was the most common cancer throughout 169 countries or regions and regions in the whole world. It has become one of the most important malignant tumors that threatened the life and health of human beings, and has become the primary cause of death among women and seriously affected the overall quality of living of all women across the globe in recent years \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Data released in recent years show that the burden is gradually increasing \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The recurrence rate of breast cancer is high, and 30% to 40% of women still have a recurrence or metastasis even 15 to 20 years after operation \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. In recent years, fear of cancer recurrence(FCR) refers to anxiety, worry and/or uneasiness towards risk of cancer returning or worsening \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. FCR includes not only the simple fear but also the complex process of cognitive emotional and behavioral co-existence simultaneously, its neurobiology foundation is gradually revealed \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs an emerging psychological intervention, mindfulness interventions show significant promise in psycho-oncology. Rooted in Eastern contemplative traditions, mindfulness emphasizes present-moment awareness with an attentive and non-judgmental attitude \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Mindfulness-based interventions (MBIs), such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), enhance patients\u0026rsquo; awareness and acceptance of their mental and physical states through targeted practices like body scans, sitting meditation, and mindful yoga \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Neuroimaging studies further confirm that mindfulness practice can modulate brain network activity associated with emotion regulation and self-referential processing \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTheoretically, MBIs may benefit FCR in multiple ways. FCR is an anticipatory, chronic, catastrophized kind of rumination \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, and mindfulness training intervenes this kind of recurrent, negative thoughts by grounding attention in the here and now \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. It trains patients to see and frame recurrence-related thoughts as thoughts (mental event), not facts, and creates a decentered, non- evaluative relationship with the thoughts, i.e., the MBI induces a coping attitude \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Previous studies have shown MBIs are beneficial and efficacious in reducing anxiety, depression, fatigue, and improving sleep and quality of life in cancer patients generally\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite many randomized controlled trials conducted to explore mindfulnessbased interventions (MBIs) effects on fear of cancer recurrence (FCR) in breast cancer patients, the results are sometimes incompatible. These variations in research design factors, including difference in the format of the interventions (online versus offline), dose, culture and variability in FCR scales are considered the reasons of the incongruent findings \u003csup\u003e[15、16]\u003c/sup\u003e. Amongst these factors, culture, has a notable effect since it considerably influences patients\u0026rsquo; willingness to practice mindfulness and achieve the expected outcomes of the intervention \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. This mosaic of contradictory evidence does not help to apply it clinically. Although neuroimaging research shows that mindfulness can modulate the emotional regulation circuits\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, it is unknown yet how it can affect the underlying neurocognitive circuits for the phenomenon fear of cancer recurrence in different cultures. Therefore, it is necessary to perform a systematic review and a meta-analysis in order to integrate this existing controversial evidence, assess the general effectiveness of mindfulness interventions on fear of cancer recurrence of breast cancer patients and provide a possible explanation for its variability to establish a theoretical frame more homogeneous and reliable to support evidence-based practice.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Study Design and Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study presents the systematic review and meta-analysis of the impact of the mindfulness-based interventions on cancer recurrence concern among breast cancer patients. The research design was previously registered in PROSPERO (Registration number: CRD420251127306). We planned, conducted, and documented this study in accordance with the PRISMA guidelines as strictly as possible\u003csup\u003e[18]\u003c/sup\u003e. \u003c/p\u003e\n\u003cp\u003eThe protocol can be viewed at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251127306\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Literature Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe searched Chinese and English databases including PubMed, Web of Science, Scopus, Cochrane Library, China National Knowledge Infrastructure(CNKI), WanFang Data and VIP Journal (CQVIP). We searched each database until August 30, 2025, and used a subject headings and free-text keywords combination-based search strategy.\u003c/p\u003e\n\u003cp\u003eThe English search terms were: (\u0026ldquo;breast cancer\u0026rdquo; OR \u0026ldquo;breast neoplasm*\u0026rdquo; OR \u0026ldquo;breast tumor\u0026rdquo; OR \u0026ldquo;breast carcinoma\u0026rdquo; OR \u0026ldquo;breast cancer patients\u0026rdquo; OR \u0026ldquo;patients with breast cancer\u0026rdquo; OR \u0026ldquo;breast neoplasm patients\u0026rdquo;) AND (\u0026ldquo;mindfulness-based intervention\u0026rdquo; OR \u0026ldquo;mindfulness therapy\u0026rdquo; OR \u0026ldquo;mindfulness training\u0026rdquo; OR \u0026ldquo;mindfulness-based stress reduction\u0026rdquo; OR \u0026ldquo;mindfulness-based cognitive therapy\u0026rdquo; OR \u0026ldquo;mindfulness meditation\u0026rdquo;) AND (\u0026ldquo;fear of recurrence\u0026rdquo; OR \u0026ldquo;fear of cancer recurrence\u0026rdquo; OR \u0026ldquo;cancer recurrence fear\u0026rdquo; OR \u0026ldquo;fear of relapse\u0026rdquo; OR \u0026ldquo;recurrence fear\u0026rdquo; OR \u0026ldquo;fear of cancer relapse\u0026rdquo; OR \u0026ldquo;Fear of Cancer Recurrence Inventory\u0026rdquo;). \u003c/p\u003e\n\u003cp\u003eThe Chinese search terms were: (\u0026ldquo;乳腺癌\u0026rdquo; OR \u0026ldquo;乳癌\u0026rdquo; OR \u0026ldquo;乳腺恶性肿瘤\u0026rdquo; OR \u0026ldquo;乳腺癌患者\u0026rdquo; OR \u0026ldquo;乳腺肿瘤患者\u0026rdquo; OR \u0026ldquo;乳腺癌幸存者\u0026rdquo; OR \u0026ldquo;乳腺肿瘤幸存者\u0026rdquo;) AND (\u0026ldquo;正念疗法\u0026rdquo; OR \u0026ldquo;正念减压\u0026rdquo; OR \u0026ldquo;正念冥想\u0026rdquo; OR \u0026ldquo;正念训练\u0026rdquo; OR \u0026ldquo;正念认知疗法\u0026rdquo; OR \u0026ldquo;正念减压疗法\u0026rdquo; OR \u0026ldquo;正念基础干预\u0026rdquo; OR \u0026ldquo;正念行为疗法\u0026rdquo;) AND (\u0026ldquo;复发恐惧\u0026rdquo; OR \u0026ldquo;恐惧复发\u0026rdquo; OR \u0026ldquo;癌症复发恐惧\u0026rdquo; OR \u0026ldquo;对复发的恐惧\u0026rdquo; OR \u0026ldquo;肿瘤复发恐惧\u0026rdquo; OR \u0026ldquo;复发担忧\u0026rdquo; OR \u0026ldquo;害怕复发\u0026rdquo; OR \u0026ldquo;癌症复发焦虑\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eAdditionally, to minimize omissions, we manually searched the reference lists of relevant reviews to supplement potential literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Literature Inclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion and exclusion criteria were developed based on the PICOS principle:\u003c/p\u003e\n\u003cp\u003eParticipants (P): Pathologically confirmed breast cancer patients, regardless of age, cancer stage, or treatment phase.\u003c/p\u003e\n\u003cp\u003eIntervention (I): Structured interventions based on mindfulness, such as Mindfulness-Based Stress Reduction or Mindfulness-Based Cognitive Therapy.\u003c/p\u003e\n\u003cp\u003eComparison (C): Usual care, waitlist, health education, or other non-mindfulness psychological interventions.\u003c/p\u003e\n\u003cp\u003eOutcome (O): The primary outcome was fear of cancer recurrence, measured using validated scales.\u003c/p\u003e\n\u003cp\u003eStudy design (S): Randomized controlled trials.All included RCTs reported ethical approval from an institutional review board.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: ① Non-Chinese or English literature; ② Full text unavailable or incomplete data even after contacting authors; ③ Duplicate publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Literature Screening and Data Extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo investigators independently screened the literature, performed data extraction, and cross-checked the extracted information. Disputes were settled through discussion to consensus or by arbitration from a third investigator. The literatures were firstly de-duplicated by reference management software, preliminarily screened by reading title and abstract, and screened based on full texts reading finally.\u003c/p\u003e\n\u003cp\u003eData extraction included: ① Basic study information: first author, publication year, and country; ② Participant characteristics: sample size per group, patient age, and disease status; ③ Intervention details: specific intervention method, session duration, frequency, and total intervention dose; ④ Description of control measures; ⑤ Outcome data: mean, standard deviation, and sample size for each group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Risk of Bias Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Cochrane Risk of Bias tool (RoB 2.0) was used to appraise the methodologic quality of RCTs included\u003csup\u003e [19]\u003c/sup\u003e. The review considered domains included: randomisation process, selective exclusion of participants, missing outcome data, outcome assessment and reporting outcome. All the studies were rated by two independent reviewers using the risk of bias as \u0026ldquo;low risk\u0026rdquo;, \u0026ldquo;high risk\u0026rdquo; or \u0026ldquo;some concerns\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were conducted using Stata 18.0. The effect size, \u003cem\u003eHedges\u0026rsquo;s g\u003c/em\u003e with its 95% confidence interval (CI), was calculated to correct for potential bias in small sample studies\u003csup\u003e [20]\u003c/sup\u003e. Heterogeneity across studies was quantified using the \u003cem\u003eI\u0026sup2;\u003c/em\u003e statistic, with \u003cem\u003eI\u0026sup2;\u003c/em\u003e \u0026ge; 50% indicating substantial heterogeneity. Given the anticipated clinical and methodological diversity (e.g., variations in cultural backgrounds and intervention formats), a random-effects model was employed, utilizing the DerSimonian-Laird method to estimate between-study variance (\u003cem\u003e\u0026tau;\u0026sup2;\u003c/em\u003e)\u003csup\u003e [21]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTo investigate the sources of heterogeneity, we performed pre-defined subgroup analyses based on Region (China vs. other countries), Intervention format (in-person group vs. online), Intervention duration (\u0026lt;8 weeks vs. \u0026ge;8 weeks), and Assessment tool (CARS vs. FCRI vs. FoP-Q-SF). An exploratory analysis was also conducted to examine the distribution of intervention formats within the regional subgroups. Meta-regression was not performed due to the limited number of included studies (\u0026lt;10), in accordance with the recommendations of the Cochrane Handbook \u003csup\u003e[21]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe robustness of the pooled effect size was assessed through a sensitivity analysis using the leave-one-out method. Publication bias was evaluated by visual inspection of funnel plots and Egger\u0026rsquo;s test \u003csup\u003e[22]\u003c/sup\u003e. A p-value of \u0026lt; 0.05 was considered statistically significant for all tests\u003csup\u003e [21]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Literature Screening Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial search yielded 264 relevant records. Following a stepwise screening process, 10 randomized controlled trials were ultimately included in this systematic review and meta-analysis. The literature screening process and reasons for exclusion are detailed in the PRISMA flow diagram (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Basic Characteristics and Risk of Bias Assessment of Included Studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 10 included studies involved a total of 896 breast cancer patients (Figure \u0026nbsp; 2). Seven studies were conducted in China, and the remaining three were from the United States (2) and Japan (1). The interventions were primarily structured courses based on MBSR or MBCT; control conditions included usual care, health education, or waitlist. For the primary outcome (fear of cancer recurrence), studies used standardized scales such as CARS, FCRI, and FoP-Q-SF. According to the Cochrane Risk of Bias tool (RoB 2.0), all 10 studies were rated as \u0026quot;low risk\u0026quot; (Figure 3).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"722\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy (Author, Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Phase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size (I/C)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age (I/C) years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration (weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFCR Scale Used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eZhou et al., 2020\u003cstrong\u003e\u003csup\u003e[23]\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePostoperative chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e52/52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e-/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eFoP-Q-SF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eYang et al., 2024\u003csup\u003e[24]\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePerioperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e35/35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e44.85/45.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eOnline MBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eFCRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eWang et al., 2021\u003csup\u003e[25]\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e41/43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e49.15/51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eCARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eHuang et al., 2025\u003csup\u003e[26]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e40/40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e29.29/29.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eFoP-Q-SF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eWang et al., 2021\u003csup\u003e[27]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003eDuring treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e30/30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e50.83/51.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eOnline MBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eFCRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eLengacher et al., 2012\u003csup\u003e[28]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e40/42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e57.5/57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eCARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eChu et al., 2020\u003csup\u003e[29]\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePost-surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e42/42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e54.6/54.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eCARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003ePeng et al., 2022\u003csup\u003e[30]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e28/29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e-/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eOnline MBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eFCRI-SF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eLengacher et al., 2016\u003csup\u003e[31]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e167/155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e56.5/57.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eCARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003ePark et al., 2020\u003csup\u003e[32]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eJapan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003eNon-metastatic breast cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e38/36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e53.21/54.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMBCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003eCARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: I/C: Intervention group/Control group; FCR: Fear of cancer recurrence; MBSR: Mindfulness-Based Stress Reduction; MBCT: Mindfulness-Based Cognitive Therapy; CARS: Concerns About Recurrence Scale; FCRI: Fear of Cancer Recurrence Inventory; FoP-Q-SF: Fear of Progression Questionnaire-Short Form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Sensitivity Analysis and Study Exclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA preliminary meta-analysis revealed\u0026nbsp;high heterogeneity among studies (\u003cem\u003eI\u0026sup2;\u003c/em\u003e \u0026gt; 90%, Figure 4). Leave-one-out analysis revealed that the study by Huang (2025) had the most significant impact on overall heterogeneity. After excluding this study, heterogeneity decreased significantly from \u0026gt;90% to 73.83%, and the direction and statistical significance of the pooled effect size did not change, indicating relatively robust overall results. Considering that the effect size reported by Huang (2025) was substantially larger than in other studies (\u003cem\u003eHedges\u0026rsquo;s g\u003c/em\u003e = -3.56), its extreme effect size may be attributable to unique intervention protocols, assessment tools, or population characteristics. To prevent this study from unduly influencing the overall estimate, we decided to exclude it from subsequent analyses. Therefore, all following analyses are based on the remaining 9 studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Meta-Analysis Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4.1 Overall Effect\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe meta-analysis results based on the random-effects model (Figure 5) showed that compared to the control group, mindfulness interventions significantly reduced fear of cancer recurrence levels in breast cancer patients, with a pooled effect size of \u003cem\u003eHedges\u0026rsquo;s g\u003c/em\u003e = -0.56 (95% CI: -0.83 to -0.29, P \u0026lt; 0.001). Substantial heterogeneity was observed among studies (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 73.83%, \u003cem\u003e\u0026tau;\u0026sup2;\u003c/em\u003e = 0.12, P \u0026lt; 0.01), indicating a need to further investigate sources of heterogeneity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4.2 Subgroup Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo explore sources of heterogeneity, we conducted subgroup analyses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results showed that region was an important factor influencing the effect size (between-group difference P = 0.03)\u0026nbsp;(Figure 6).In the Chinese population, mindfulness interventions had a moderate and significant effect on reducing fear of cancer recurrence (Hedges\u0026apos;s g = -0.71, 95% CI: -0.90 to -0.44, p \u0026lt; 0.001), with moderate heterogeneity within this subgroup (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 52.30%, p = 0.06). In populations from other countries, the intervention effect was small and did not reach statistical significance (Hedges\u0026apos;s g = -0.26, 95% CI: -0.56 to 0.04, \u003cem\u003ep\u003c/em\u003e = 0.08), with moderate heterogeneity within the subgroup (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 52.03%).\u003c/p\u003e\n\u003cp\u003eSubgroup analysis based on intervention duration (\u0026lt;8 weeks vs. \u0026ge;8 weeks) (Figure 7) showed that both short (\u0026lt;8 weeks: \u003cem\u003eHedges\u0026rsquo;s g\u003c/em\u003e = -0.57, 95% CI: -1.09 to -0.06, \u003cem\u003eP\u003c/em\u003e = 0.03) and long (\u0026ge;8 weeks: \u003cem\u003eHedges\u0026rsquo;s g\u003c/em\u003e = -0.57, 95% CI: -0.83 to -0.31, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) interventions had significant effects, with no significant difference between the groups (between-group difference \u003cem\u003eP\u003c/em\u003e = 0.99). Notably, the \u0026lt;8 weeks subgroup had high heterogeneity (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 85.62%), while the \u0026ge;8 weeks subgroup had lower heterogeneity (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 39.82%).\u003c/p\u003e\n\u003cp\u003eSubgroup analysis based on different assessment tools (Figure 8) showed that studies using the CARS scale (Hedges\u0026apos;s g = -0.56, 95% CI: -0.97 to -0.15, \u003cem\u003ep\u003c/em\u003e = 0.01), FCRI scale (Hedges\u0026apos;s g = -0.54, 95% CI: -1.00 to -0.08, \u003cem\u003ep\u003c/em\u003e = 0.02), and FoP-Q-SF scale (Hedges\u0026apos;s g = -0.68, 95% CI: -1.07 to -0.29, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) all reported significant mindfulness intervention outcomes. There was no significant difference in effect sizes between the different assessment tool subgroups (between-group difference \u003cem\u003ep\u003c/em\u003e = 0.88). However, high heterogeneity existed within the subgroup using the CARS scale (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 82.75%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4.\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Sensitivity Analysis of Follow-up Data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the included studies, three reported follow-up data at 12 weeks\u003csup\u003e\u0026nbsp;[26, 28, 31]\u003c/sup\u003e. A qualitative synthesis of these studies suggested that the beneficial effects of MBIs on FCR were maintained at short-term follow-up. However, due to variations in reporting formats, a quantitative meta-analysis of follow-up effects was not feasible. This highlights a need for standardized long-term outcome reporting in future trials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Publication Bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter excluding the study by Huang et al. (2025), publication bias was assessed for the remaining 9 studies. Visual inspection of the funnel plot showed asymmetry (Figure 9), suggesting possible publication bias\u003csup\u003e\u0026nbsp;[33]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis meta-analysis demonstrates that mindfulness interventions significantly reduce the fear of cancer recurrence among breast cancer patients (\u003cem\u003eHedges\u0026rsquo;s g\u003c/em\u003e = -0.56). Our findings build on foundational work in psycho-oncology, such as the definition of FCR\u003csup\u003e\u0026nbsp;[5]\u003c/sup\u003e and the established role of mindfulness in cancer care \u003csup\u003e[11]\u003c/sup\u003e, by providing the first meta-analytic evidence that quantifies cultural background as a key moderator of treatment efficacy.Building upon the findings of recent reviews \u003csup\u003e[15]\u003c/sup\u003e, our study provides the first meta-analytic evidence that quantifies cultural background as a key moderator of treatment efficacy.\u003c/p\u003e\n\u003cp\u003eWe pooled effect size is in line with recent reviews which explored mindfulness in the cancers populations \u003csup\u003e[34, 35]\u003c/sup\u003e. However, the high heterogeneity (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 73.83%) suggests that mindfulness interventions are not a homogeneous entity and should be interpreted with caution. The funnel plot imbalance as well as important outcome from Egger\u0026rsquo;s test (\u003cem\u003eP\u003c/em\u003e=0.03), indicates that publication bias might be occurred, which can be originated from scarcity of underpowered negative-result studies, and result in overestimation of the pooled effect size. The methodological heterogeneity can be a contributing factor to this asymmetry, and therefore bias are due considerations to interpreting the over all effect of mindfulness interventions.\u003c/p\u003e\n\u003cp\u003eSeveral factors may explain this cultural disparity: ① The cultural affinity and philosophical compatibility of mindfulness interventions. Mindfulness, originating from Eastern meditation, aligns closely with core principles (e.g., insight, acceptance) found in Chinese philosophies such as Confucian \u0026ldquo;introspection\u0026rdquo; and Daoist \u0026ldquo;going with the flow.\u0026rdquo; This alignment may facilitate acceptance among Chinese patients and enhance its positive effects\u003csup\u003e\u0026nbsp;[36, 37]\u003c/sup\u003e. ② Differences in social support resources. Mindfulness groups in China may provide limited yet secure avenues for emotional and social support, crucial for mitigating fear of recurrence \u003csup\u003e[38]\u003c/sup\u003e. In contrast, Western societies typically offer a broader range of psychosocial support resources, potentially diluting the supportive effect of mindfulness groups \u003csup\u003e[36]\u003c/sup\u003e. ③ Variations in expectations regarding psychological interventions and levels of stigma. The Chinese literature included in this study was predominantly published within the last year, reflecting a growing domestic focus on psycho-oncology. Patients\u0026rsquo; heightened expectations for psychological interventions may amplify their perceived benefits to some extent \u003csup\u003e[39]\u003c/sup\u003e. Beyond cultural factors, the substantial heterogeneity observed (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 73.83%) may also stem from variations in intervention implementation. Differences in instructor qualifications (e.g., clinical psychologists vs. trained peers), specific mindfulness practices emphasized (e.g., body scan vs. meditation), and group dynamics could significantly influence outcomes\u003csup\u003e\u0026nbsp;[33]\u003c/sup\u003e. A deeper analysis of these implementation factors is crucial for understanding the \u0026ldquo;active ingredients\u0026rdquo; of MBIs.\u003c/p\u003e\n\u003cp\u003eNotably, intervention protocols lasting more than 8 weeks did not demonstrate superior effects compared to those shorter than 8 weeks (between-group \u003cem\u003eP\u003c/em\u003e = 0.99), challenging the linear \u0026ldquo;dose-response\u0026rdquo; relationship. There may be a law of diminishing returns, suggesting that beyond a certain duration, additional practice yields diminishing marginal benefits and increases participant burden, leading to negative emotions \u003csup\u003e[40]\u003c/sup\u003e. Conversely, the high heterogeneity within the short-duration subgroup (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 85.62%) indicates that specific patient subgroups (e.g., those with high baseline fear levels) may benefit significantly from longer interventions, while those with low fear levels may benefit less. Identifying these differences and aligning them with appropriate intervention durations is an important direction for future research.\u003c/p\u003e\n\u003cp\u003eAlthough all three assessment tools (CARS, FCRI, FoP-Q-SF) demonstrated significant effects of mindfulness interventions, the CARS subgroup exhibited extremely high heterogeneity (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 82.75%), suggesting that fear of cancer recurrence may be a multidimensional construct. Different scales may emphasize different dimensions \u003csup\u003e[15, 41-43]\u003c/sup\u003e, and mindfulness interventions might primarily affect certain dimensions (e.g., metacognitive awareness of fearful thoughts) while having weaker effects on others (e.g., behavioral avoidance). Therefore, using different scales essentially measures slightly distinct psychological aspects, leading to inconsistent results. Future research should emphasize detailed reporting and analysis of the various dimensions of these scales \u003csup\u003e[44]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eImplications (Clinical and Research)\u003c/p\u003e\n\u003cp\u003eFor clinical translation, we propose a specific pathway for Chinese breast cancer patients: a 6-8 week group-based mindfulness program integrating culturally resonant elements (e.g., combining \u0026lsquo;mindful breathing\u0026rsquo; with Daoist concepts of \u0026lsquo;going with the flow\u0026rsquo;), with FCR outcomes preferentially assessed using the FoP-Q-SF scale for its sensitivity. While acknowledging the value of mindfulness interventions, clinicians should avoid a \u0026ldquo;one-size-fits-all\u0026rdquo; approach and instead recommend personalized intervention plans that consider patients\u0026rsquo; cultural backgrounds, personal preferences, and available resources (e.g., time and financial constraints) \u003csup\u003e[35]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eFuture research should focus on identifying the \u0026ldquo;active ingredients\u0026rdquo; within intervention protocols \u003csup\u003e[47]\u003c/sup\u003e. Conducting individual participant data meta-analyses is recommended to explore the predictive role of individual patient characteristics on treatment responses \u003csup\u003e[46]\u003c/sup\u003e. Additionally, mechanism-based randomized controlled trials are encouraged to test efficacy while validating potential mediating pathways of mindfulness interventions, such as cognitive defusion and reduced rumination \u003csup\u003e[15]\u003c/sup\u003e. Furthermore, research reports should detail strategies implemented for cultural adaptation and advocate for multidimensional, multi-tool outcome measurement and reporting of fear of cancer recurrence \u003csup\u003e[35, 41]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eLimitations\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, although we conducted subgroup analyses to identify potential moderating factors, the insufficient reporting of individual patient data in the original studies prevented us from performing more detailed meta-regression analyses on key variables such as cancer stage, treatment phase, or baseline fear level, which may represent important sources of residual heterogeneity. Second, as mentioned, funnel plot asymmetry and the results of Egger\u0026rsquo;s test suggest the presence of potential publication bias, which may impact the accuracy of the overall effect size estimate \u003csup\u003e[45]\u003c/sup\u003e. Third, the total number of studies included remains limited, particularly in the \u0026ldquo;other countries\u0026rdquo; subgroup, which may affect the stability of the effect estimate for that subgroup \u003csup\u003e[46]\u003c/sup\u003e.Finally, the included studies provided insufficient details on intervention fidelity (e.g., adherence to the protocol), which may have influenced the observed effects and limited our ability to assess the quality of implementation \u003csup\u003e[33]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn conclusion, this meta-analysis confirms that MBIs are effective in reducing FCR in breast cancer patients, with efficacy significantly moderated by cultural background. The development of culturally-adapted mindfulness programs is crucial for maximizing therapeutic benefits.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eData curation: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eFormal analysis:Xinyu Wang\u003c/p\u003e\n\u003cp\u003eInvestigation: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eMethodology: Xian Ma\u003c/p\u003e\n\u003cp\u003eProject administration: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eResources: Man Yuan\u003c/p\u003e\n\u003cp\u003eSoftware: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eSupervision: Man Yuan\u003c/p\u003e\n\u003cp\u003eValidation: Xian Ma\u003c/p\u003e\n\u003cp\u003eVisualization: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Xinyu Wang\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Xinyu Wang\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKim J, Harper A, McCormack V, Sung H, Houssami N, Morgan E, Mutebi M, Garvey G, Soerjomataram I, Fidler-Benaoudia MM. Global patterns and trends in breast cancer incidence and mortality across 185 countries. Nat Med. 2025;31(4):1154\u0026ndash;1162. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41591-025-03502-3\u003c/span\u003e\u003cspan address=\"10.1038/s41591-025-03502-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2025 Feb 24. PMID: 39994475.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024 May-Jun;74(3):229\u0026ndash;263. doi: 10.3322/caac.21834. Epub 2024 Apr 4. PMID: 38572751.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng RM, Zong YN, Cao SM, Xu RH. Current cancer situation in China: good or bad news from the 2018 Global Cancer Statistics? Cancer Commun (Lond). 2019;39(1):22. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40880-019-0368-6\u003c/span\u003e\u003cspan address=\"10.1186/s40880-019-0368-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 31030667; PMCID: PMC6487510.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEarly Breast Cancer Trialists' Collaborative Group (EBCTCG). Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials. Lancet Oncol. 2018;19(1):27\u0026ndash;39. doi: 10.1016/S1470-2045(17)30777-5. Epub 2017 Dec 11. PMID: 29242041; PMCID: PMC5757427.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLebel S, Ozakinci G, Humphris G, Mutsaers B, Thewes B, Prins J, Dinkel A, Butow P; University of Ottawa Fear of Cancer Recurrence Colloquium attendees. From normal response to clinical problem: definition and clinical features of fear of cancer recurrence. Support Care Cancer. 2016;24(8):3265\u0026ndash;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00520-016-3272-5\u003c/span\u003e\u003cspan address=\"10.1007/s00520-016-3272-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 May 12. PMID: 27169703.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg DWL, Kwong A, Suen D, Chan M, Or A, Ng SS, Foo CC, Fielding BFS, Lam WWT. Fear of cancer recurrence among Chinese cancer survivors: Prevalence and associations with metacognition and neuroticism. Psychooncology. 2019;28(6):1243\u0026ndash;1251. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/pon.5073\u003c/span\u003e\u003cspan address=\"10.1002/pon.5073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Apr 26. PMID: 30932279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144\u0026ndash;156. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/clipsy.bpg016\u003c/span\u003e\u003cspan address=\"10.1093/clipsy.bpg016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhai, X. Y., Li, Y., \u0026amp; Zhang, Y. (2024). Application Progress of Mindfulness Therapy in Patients with Malignant Tumors. Advances in Clinical Medicine, 14(5), 1296\u0026ndash;1302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12677/acm.2024.1451553\u003c/span\u003e\u003cspan address=\"10.12677/acm.2024.1451553\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLutz J, Herwig U, Opialla S, Hittmeyer A, J\u0026auml;ncke L, Rufer M, Grosse Holtforth M, Br\u0026uuml;hl AB. Mindfulness and emotion regulation\u0026ndash;an fMRI study. Soc Cogn Affect Neurosci. 2014;9(6):776\u0026ndash;85. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/scan/nst043\u003c/span\u003e\u003cspan address=\"10.1093/scan/nst043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2013 Apr 5. PMID: 23563850; PMCID: PMC4040090.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFardell JE, Thewes B, Turner J, Gilchrist J, Sharpe L, Smith A', Girgis A, Butow P. Fear of cancer recurrence: a theoretical review and novel cognitive processing formulation. J Cancer Surviv. 2016;10(4):663\u0026ndash;73. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11764-015-0512-5\u003c/span\u003e\u003cspan address=\"10.1007/s11764-015-0512-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Jan 19. PMID: 26782171.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlson LE. Mindfulness-based interventions for coping with cancer. Ann N Y Acad Sci. 2016;1373(1):5\u0026ndash;12. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/nyas.13029\u003c/span\u003e\u003cspan address=\"10.1111/nyas.13029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Mar 9. PMID: 26963792.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCramer H, Lauche R, Paul A, Dobos G. Mindfulness-based stress reduction for breast cancer-a systematic review and meta-analysis. Curr Oncol. 2012;19(5):e343-52. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3747/co.19.1016\u003c/span\u003e\u003cspan address=\"10.3747/co.19.1016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 23144582; PMCID: PMC3457885.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOberoi S, Yang J, Woodgate RL, Niraula S, Banerji S, Israels SJ, Altman G, Beattie S, Rabbani R, Askin N, Gupta A, Sung L, Abou-Setta AM, Zarychanski R. Association of Mindfulness-Based Interventions With Anxiety Severity in Adults With Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(8):e2012598. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2020.12598\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2020.12598\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 32766801; PMCID: PMC7414391.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiet J, W\u0026uuml;rtzen H, Zachariae R. The effect of mindfulness-based therapy on symptoms of anxiety and depression in adult cancer patients and survivors: a systematic review and meta-analysis. J Consult Clin Psychol. 2012;80(6):1007\u0026ndash;20. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/a0028329\u003c/span\u003e\u003cspan address=\"10.1037/a0028329\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 May 7. PMID: 22563637.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyu MM, Siah RC, Lam ASL, Cheng KKF. The effect of psychological interventions on fear of cancer recurrence in breast cancer survivors: A systematic review and meta-analysis. J Adv Nurs. 2022;78(10):3069\u0026ndash;3082. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jan.15321\u003c/span\u003e\u003cspan address=\"10.1111/jan.15321\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Jun 13. PMID: 35696315.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, L. L., Chen, H., Luo, H., et al. Systematic Review of Fear of Cancer Recurrence Assessment Tools Based on the Consensus-Based Standards for the Selection of Health Measurement Instruments. Chinese General Practice, 2023, 26(17), pp. 2138\u0026ndash;2146. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12114/j.issn.1007-9572.2022.0810\u003c/span\u003e\u003cspan address=\"10.12114/j.issn.1007-9572.2022.0810\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoemer, A., Cervin, M., Medvedeva, A. et al. Big Five of Mindfulness and Personality: Cross-Cultural Network Analysis. Mindfulness 15, 37\u0026ndash;47 (2024). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12671-023-02293-3\u003c/span\u003e\u003cspan address=\"10.1007/s12671-023-02293-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hr\u0026oacute;bjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.n71\u003c/span\u003e\u003cspan address=\"10.1136/bmj.n71\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 33782057; PMCID: PMC8005924.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSterne JA, et al. RoB 2: a revised tool for assessing risk of bias in randomized trials. BMJ. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorenstein M, et al. Introduction to Meta-Analysis. John Wiley \u0026amp; Sons; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629\u0026ndash;34. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.315.7109.629\u003c/span\u003e\u003cspan address=\"10.1136/bmj.315.7109.629\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 9310563; PMCID: PMC2127453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou, J. J. (2020). Study on the current status and intervention effect of fear of recurrence in patients with breast cancer during postoperative chemotherapy period [Master's thesis, Yangzhou University]. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.27441/d.cnki.gyzdu.2020.001044\u003c/span\u003e\u003cspan address=\"10.27441/d.cnki.gyzdu.2020.001044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang, G. D. (2024). Effect of online mindfulness-based stress reduction therapy on negative emotions in perioperative stage 0-II breast cancer patients [Master's thesis, Hebei Medical University]. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.27111/d.cnki.ghyku.2024.000556\u003c/span\u003e\u003cspan address=\"10.27111/d.cnki.ghyku.2024.000556\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, J. M., Mei, H. Y., \u0026amp; Sun, Y. L. (2021). Effects of mindfulness relaxation training on fear of cancer recurrence, cancer-related fatigue and sleep quality in breast cancer patients. Chinese Journal of Clinical Oncology and Rehabilitation, 28(02), 228\u0026ndash;233. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.13455/j.cnki.cjcor.2021.02.26\u003c/span\u003e\u003cspan address=\"10.13455/j.cnki.cjcor.2021.02.26\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang, M. P., \u0026amp; Wei, P. Y. (2025). Impact of mindfulness-based stress reduction therapy on young breast cancer patients. Economic and Social Development Research, 2025(21), 0271\u0026ndash;0273.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, X. M. (2021). Study on the intervention effect of mindfulness-based stress reduction therapy on fear of cancer recurrence in breast cancer patients [Master's thesis, Shihezi University]. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.27332/d.cnki.gshzu.2021.000354\u003c/span\u003e\u003cspan address=\"10.27332/d.cnki.gshzu.2021.000354\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLengacher CA, Shelton MM, Reich RR, Barta MK, Johnson-Mallard V, Moscoso MS, Paterson C, Ramesar S, Budhrani P, Carranza I, Lucas J, Jacobsen PB, Goodman MJ, Kip KE. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37(2):185\u0026ndash;95. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10865-012-9473-6\u003c/span\u003e\u003cspan address=\"10.1007/s10865-012-9473-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 Nov 27. PMID: 23184061; PMCID: PMC3627743.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu X, Lou Y, Wang Z, Xu Q. Effect of mindfulness based cognitive therapy on the mental health and quality of life in patients with breast cancer. Indian J Pharm Sci. (2020) 82:48\u0026ndash;52. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.36468/pharmaceutical-sciences.spl.143\u003c/span\u003e\u003cspan address=\"10.36468/pharmaceutical-sciences.spl.143\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng L, Yang Y, Chen M, Xu C, Chen Y, Liu R, Cao X, Li M. Effects of an online mindfulness-based intervention on Fear of Cancer Recurrence and quality of life among Chinese breast cancer survivors. Complement Ther Clin Pract. 2022;49:101686. doi: 10.1016/j.ctcp.2022.101686. Epub 2022 Nov 3. PMID: 36347151.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLengacher CA, Reich RR, Paterson CL, Ramesar S, Park JY, Alinat C, Johnson-Mallard V, Moscoso M, Budhrani-Shani P, Miladinovic B, Jacobsen PB, Cox CE, Goodman M, Kip KE. Examination of Broad Symptom Improvement Resulting From Mindfulness-Based Stress Reduction in Breast Cancer Survivors: A Randomized Controlled Trial. J Clin Oncol. 2016;34(24):2827\u0026ndash;34. doi: 10.1200/JCO.2015.65.7874. Epub 2016 May 31. PMID: 27247219; PMCID: PMC5012660.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark S, Sato Y, Takita Y, Tamura N, Ninomiya A, Kosugi T, Sado M, Nakagawa A, Takahashi M, Hayashida T, Fujisawa D. Mindfulness-Based Cognitive Therapy for Psychological Distress, Fear of Cancer Recurrence, Fatigue, Spiritual Well-Being, and Quality of Life in Patients With Breast Cancer-A Randomized Controlled Trial. J Pain Symptom Manage. 2020;60(2):381\u0026ndash;389. doi: 10.1016/j.jpainsymman.2020.02.017. Epub 2020 Feb 24. PMID: 32105790.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutton A J, Abrams K R, Jones D R, et al. Methods for meta-analysis in medical research[M]. Chichester: Wiley, 2000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChayadi E, Baes N, Kiropoulos L. The effects of mindfulness-based interventions on symptoms of depression, anxiety, and cancer-related fatigue in oncology patients: A systematic review and meta-analysis. PLoS One. 2022;17(7):e0269519. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0269519\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0269519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35834503; PMCID: PMC9282451.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaydoun M, Moran C, McLennan A, Piedalue KL, Oberoi D, Carlson LE. Mindfulness-Based Interventions in Cancer Survivors: A Systematic Review of Participants' Adherence to Home Practice. Patient Prefer Adherence. 2021;15:1225\u0026ndash;1242. doi: 10.2147/PPA.S267064. PMID: 34135575; PMCID: PMC8200136.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTao TJ, Hui CLM, Lam BST, Ho ECN, Hui PWM, Suen YN, Lin JJ, Tong ACY, Lee EHM, Chan SKW, Chang WC, Chen EYH. Mindfulness meditation for Chinese patients with psychosis: A systematic review and meta-analysis. Schizophr Res. 2021;237:103\u0026ndash;114. doi: 10.1016/j.schres.2021.08.033. Epub 2021 Sep 9. PMID: 34509897.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirmayer LJ. Mindfulness in cultural context. Transcult Psychiatry. 2015;52(4):447\u0026thinsp;\u0026ndash;\u0026thinsp;69. doi: 10.1177/1363461515598949. Erratum in: Transcult Psychiatry. 2015;52(5):e1. Erratum in: Transcult Psychiatry. 2015;52(5):e1. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1363461515605012\u003c/span\u003e\u003cspan address=\"10.1177/1363461515605012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 26264787.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, H. H., Li, N., Li, Y., et al. The Impact of Social Support on Fear of Cancer Recurrence in Breast Cancer Survivors: The Mediating Effect of Psychological Resilience. Military Nursing, 2022, 39(10), pp. 17\u0026ndash;20. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3969/j.issn.2097-1826.2022.10.005\u003c/span\u003e\u003cspan address=\"10.3969/j.issn.2097-1826.2022.10.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang, L. L., Pang, Y., Song, L. L., et al. Current Status of Clinical Practice Development in Psychosocial Oncology at Home and Abroad. Medicine \u0026amp; Philosophy, 2022, 43(15), pp. 39\u0026ndash;43. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12014/j.issn.1002-0772.2022.15.10\u003c/span\u003e\u003cspan address=\"10.12014/j.issn.1002-0772.2022.15.10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritton WB. Can mindfulness be too much of a good thing? The value of a middle way. Curr Opin Psychol. 2019;28:159\u0026ndash;165. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.copsyc.2018.12.011\u003c/span\u003e\u003cspan address=\"10.1016/j.copsyc.2018.12.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Jan 7. PMID: 30708288; PMCID: PMC6612475.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimard S, Savard J. Fear of Cancer Recurrence Inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009;17(3):241\u0026ndash;51. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00520-008-0444-y\u003c/span\u003e\u003cspan address=\"10.1007/s00520-008-0444-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2008 Apr 15. PMID: 18414902.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaheu C, Tock WL, Fisher P, Galica J, Singh M, Centeno I, H\u0026eacute;bert M, Moran C, Pietruczuk P, Dinkel A, Zwaal C, Thewes B, Estap\u0026eacute; T. Systematic Review of Fear of Cancer Recurrence Patient-Reported Outcome Measures: Evaluating Methodological Quality and Measurement Properties Using the COSMIN Checklist. Healthcare (Basel). 2025;13(17):2165. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/healthcare13172165\u003c/span\u003e\u003cspan address=\"10.3390/healthcare13172165\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 40941516; PMCID: PMC12427728.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCusters, J. A., et al. (2016). Fear of cancer recurrence in breast cancer survivors. Psycho-Oncology, 25(11), 1336\u0026ndash;1343.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith AB, Costa D, Galica J, Lebel S, Tauber N, van Helmondt SJ, Zachariae R. Spotlight on the Fear of Cancer Recurrence Inventory (FCRI). Psychol Res Behav Manag. 2020;13:1257\u0026ndash;1268. doi: 10.2147/PRBM.S231577. PMID: 33376421; PMCID: PMC7762428.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYao, A. L. A simulation study on the impact of publication bias on Meta-analysis results [Dissertation]. Guangdong: Southern Medical University; 2015. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7666/d.Y2911410\u003c/span\u003e\u003cspan address=\"10.7666/d.Y2911410\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006;25(20):3443-57. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/sim.2380\u003c/span\u003e\u003cspan address=\"10.1002/sim.2380\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 16345038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKan JM, Dieng M, Butow PN, Mireskandari S, Tesson S, Menzies SW, Costa DSJ, Morton RL, Mann GJ, Cust AE, Kasparian NA. Identifying the 'Active Ingredients' of an Effective Psychological Intervention to Reduce Fear of Cancer Recurrence: A Process Evaluation. Front Psychol. 2021;12:661190. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2021.661190\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2021.661190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34163405; PMCID: PMC8215538.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Breast cancer, Fear of recurrence, Mindfulness, Meta-analysis, Randomized controlled trial, Cultural differences, Cultural adaptation","lastPublishedDoi":"10.21203/rs.3.rs-8587364/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8587364/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eFear of cancer recurrence (FCR) is a prevalent psychological distress among breast cancer survivors. Although mindfulness-based interventions (MBIs) are increasingly used in cancer care, their efficacy remains inconclusive, and the influence of cultural background on outcomes is unclear. This heterogeneity hinders the development of personalized clinical strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eWe aimed to systematically evaluate the overall efficacy of MBIs in terms of FCR in people with breast cancer through meta-analysis, and to examine the moderate effects of factors, such as geographic area, length of intervention, and measurement instruments. This study intends to yield evidence supporting the creation of individualized intervention in clinical settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe searched relevant databases in Chinese and English, including PubMed, Web of Science, Scopus, Cochrane Library, the China National Knowledge Infrastructure (CNKI), WanFang Data, and VIP Journal (CQVIP) for articles that published from inception through Aug 30 2025, which compared MBIs with control groups to determine the effects of MBIs on FCR of breast cancer patients. We used the Cochrane Risk of Bias tool (RoB 2.0) to assess the methodological qualities. The combined analysis was based on a random-effects model using \u003cem\u003eHedges’s\u003c/em\u003e g to yield the effect size. Subgroup analysis was used to explore sources of heterogeneity. We used funnel plot and Egger’s test to analyze for publication bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe initial search yielded 264 records. Following a stepwise screening process, 10 RCTs were included. Sensitivity analysis identified one outlier study. After its exclusion, the analysis was based on the remaining 9 studies (involving 896 patients). The results showed that MBIs significantly reduced FCR levels in breast cancer patients, with a pooled effect size of \u003cem\u003eHedges’s g\u003c/em\u003e = -0.56 (95% CI: -0.83 to -0.29, \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.001). However, substantial heterogeneity was observed among studies (\u003cem\u003eI²\u003c/em\u003e= 73.83%). Subgroup analysis indicated: 1) Region significantly moderated the efficacy, with MBIs showing a pronounced effect in Chinese patients (g = -0.71, 95% CI: -0.90 to -0.44, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), while the effect was not statistically significant in patients from other countries (g = -0.26, 95% CI: -0.56 to 0.04, \u003cem\u003eP\u003c/em\u003e = 0.08); 2) Intervention duration (\u0026lt;8 weeks vs. ≥8 weeks) had no significant effect on efficacy (\u003cem\u003eP\u003c/em\u003e = 0.99); 3) Different assessment tools (CARS, FCRI, FoP-Q-SF) all confirmed the effectiveness of MBIs (all \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), with no difference in efficacy between tools (\u003cem\u003eP\u003c/em\u003e= 0.88). Egger’s test (\u003cem\u003eP\u003c/em\u003e = 0.03) suggested potential publication bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eMindfulness-based interventions can effectively reduce fear of cancer recurrence in breast cancer patients, and their efficacy is moderated by cultural background, with more pronounced effects observed in Chinese populations. For clinical practice, we strongly recommend developing culturally adapted mindfulness programs, especially for Chinese patients, to maximize therapeutic benefits. Future research requires larger sample sizes and higher-quality studies to verify long-term efficacy and explore core mechanisms of action.\u003c/p\u003e","manuscriptTitle":"Mindfulness-Based Interventions for Fear of Recurrence in Patients with Breast Cancer: A Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 08:41:03","doi":"10.21203/rs.3.rs-8587364/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-17T02:59:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T02:57:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-24T05:11:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-01-13T04:49:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"503e9f2f-6e85-4e60-bd31-57d322c3ce4c","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T03:08:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 08:41:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8587364","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8587364","identity":"rs-8587364","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}