Improving adherence to endocrine hormonal therapy among breast cancer patients: Study protocol for a randomized controlled trial

A Machine Learning Model to Predict Patients' Adherence Behavior and a Decision Support System for Patients With Metastatic Breast Cancer: Protocol for a Randomized Controlled Trial

BACKGROUND

Adherence to oral anticancer treatments is critical in the disease trajectory of patients with breast cancer. Given the impact of nonadherence on clinical outcomes and the associated economic burden for the health care system, finding ways to increase treatment adherence is particularly relevant.

OBJECTIVE

The primary end point is to evaluate the effectiveness of a decision support system (DSS) and a machine learning web application in promoting adherence to oral anticancer treatments among patients with metastatic breast cancer. The secondary end point is to collect a set of new physical, psychological, social, behavioral, and quality of life predictive variables that could be used to refine the preliminary version of the machine learning model to predict patients' adherence behavior.

METHODS

This prospective, randomized controlled study is nested in a large-scale international project named "Enhancing therapy adherence among metastatic breast cancer patients" (Pfizer 65080791), aimed to develop a predictive model of nonadherence and associated DSS and guidelines to foster patients' engagement and therapy adherence. A web-based DSS named TREAT (treatment adherence support) was developed using a patient-driven approach, with 4 sections, that is, Section A: Metastatic Breast Cancer; Section B: Adherence to Cancer Therapies; Section C: Promoting Adherence; and Section D: My Adherence Diary. Moreover, a machine learning-based web application was developed to predict patients' risk factors of adherence to anticancer treatment, specifically pertaining to physical status and comorbid conditions, as well as short and long-term side effects. Overall, 100 patients consecutively admitted at the European Institute of Oncology (IEO) at the Division of Medical Senology will be enrolled; 50 patients with metastatic breast cancer will be exposed to the DSS and machine learning web application for 3 months (experimental group), and 50 patients will not be exposed to the intervention (control group). Each participant will fill a weekly medication diary and a set of standardized self-reports evaluating psychological and quality of life variables (Adherence Attitude Inventory, Beck Depression Inventory-II, Brief Pain Inventory, 13-item Sense of Coherence scale, Brief Italian version of Cancer Behavior Inventory, European Organization for Research and Treatment of Cancer Quality of Life 23-item Breast Cancer-specific Questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, 8-item Morisky Medication Adherence Scale, State-Trait Anxiety Inventory forms I and II, Big Five Inventory, and visual analogue scales evaluating risk perception). The 3 assessment time points are T0 (baseline), T1 (1 month), T2 (2 months), and T3 (3 months). This study was approved by the IEO ethics committee (R1786/22-IEO 1907).

RESULTS

The recruitment process started in May 2023 and is expected to conclude on December 2023.

CONCLUSIONS

The contribution of machine learning techniques through risk-predictive models integrated into DSS will enable medication adherence by patients with cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06161181; https://clinicaltrials.gov/study/NCT06161181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48852.

"Interventions to increase adherence to oral therapies in breast cancer patients: A systematic review based on the behavior change technique taxonomy"

OBJECTIVE

High rates of non-adherence to oral medications in breast cancer (BC) patients have been reported. Here we provide an up-to-date systematic review of the interventions aimed at increasing adherence to oral medication in BC patients, with a particular focus on the content of the interventions.

METHODS

PubMed, Scopus, Embase and Ovid databases and reference lists of relevant studies were searched through October 2022. Studies which (1) described an intervention aimed at increasing adherence to oral anticancer medication, (2) included (or planned to include) at least one sub-group of BC patients, (3) were written in English, and (4) with full-text available were included. The contents of the interventions were coded using the Behavior Change Technique Taxonomy. Quality assessment was conducted using Downs and Black scale.

RESULTS

Thirty-six studies met the inclusion criteria and involved a total sample of 28,528 BC patients. Interventions were mainly delivered with eHealth devices (n = 21) and most of them used mobile app. Other studies used in-person modalities (e.g., CBT, relaxation technique) or written materials (e.g., psycho-educational booklet). The behavior change techniques most frequently implemented were "problem solving," "social support," "information about health consequences," and "prompts/cues". Quality assessment revealed that the higher risk of bias refers to the selection process.

CONCLUSIONS

The use of reminders, monitoring patients' medication-taking behaviors and giving feedback were the most frequently implemented techniques in those interventions that resulted significant. If these preliminary observations were to be confirmed by future comparative studies, they should be taken into account when developing new interventions.

Adherence to Adjuvant Endocrine Therapy in Breast Cancer Patients

BACKGROUND

Adjuvant endocrine therapy (AET) reduces breast cancer recurrence and mortality of women with hormone-receptor-positive tumors, but poor adherence remains a significant problem. The aim of this study was to analyze AET side effects and their impact on adherence to treatment.

METHODS

A total of 373 breast cancer patients treated with AET filled out a specific questionnaire during their follow up visits at the Breast Unit of our Centre.

RESULTS

Side effects were reported by 81% of patients, 84% of those taking tamoxifen and 80% of those taking aromatase inhibitors (AIs). The most common side effect in the tamoxifen group was hot flashes (55.6%), while in the AI group it was arthralgia (60.6%). The addition of GnRH agonists to both tamoxifen and AI significantly worsened all menopausal symptoms. Overall, 12% of patients definitively discontinued AET due to side effects, 6.4% during the first 5 years and 24% during extended therapy. Patients who had previously received chemotherapy or radiotherapy reported a significantly lower discontinuation rate.

CONCLUSIONS

AET side effects represent a significant problem in breast cancer survivors leading to irregular assumption and discontinuation of therapy. Adherence to AET may be improved by trustful patient-physician communication and a good-quality care network.

Assessing the Functional Accessibility, Actionability, and Quality of Patient Education Materials from Canadian Cancer Agencies

Patient education materials (PEM)s were extracted from provincial cancer agencies to determine their organizational health literacy by evaluating the quality, actionability, and functional accessibility (e.g., readability and understandability) of their PEMs. PEMs from 10 provincial agencies were assessed for their grade reading level (GRL), using eight numerical and two graphical readability scales, and underwent a difficult word analysis. The agencies were assessed for PEM quality using two methods (JAMA benchmarks and DISCERN), while actionability and understandability were assessed using the Patient Education Materials Assessment Tool (PEMAT). Seven hundred and eighty-six PEMs were analyzed. The overall average GRL was 9.3 ± 2.1, which is above the recommended 7th GRL for health information. The difficult word analysis showed that 15.4% ± 5.1% of texts contained complex words, 35.8% ± 6.8% of texts contained long words, and 24.2% ± 6.6% of texts contained unfamiliar words. Additionally, there was high overlap between the most frequently identified difficult words in the PEMs and the most frequently misunderstood words by cancer patients identified in the literature. Regarding quality indicators, no agency displayed all four indicators according to the JAMA benchmarks and DISCERN scores ranged between 38 (poor) to 66 (excellent). PEMAT scores ranged between 68% to 88% for understandability and 57% to 88% for actionability. PEMs continue to be written at a level above the recommended GRL across all provinces, and there was overall high variability in the quality, understandability, and actionability of PEMs among provincial agencies. This represents an opportunity to optimize materials, thus ensuring understanding by a wider audience and improving health literacy among Canadian cancer patients.

A framework for design and usability testing of telerehabilitation system for adults with chronic diseases: A panoramic scoping review

Objective

This scoping review aimed to identify the design and usability testing of a telerehabilitation (TR) system, and its characteristics and functionalities that are best-suited for rehabilitating adults with chronic diseases.

Methods

Searches were conducted in PubMed, EBSCO, Web of Science, and Cochrane library for studies published between January 2017 and December 2022. We followed the Joanna Briggs Institute guidelines and the framework by Arksey and O'Malley. Screening was undertaken by two reviewers, and data extraction was undertaken by the first author. Then, the data were further reviewed and discussed thoroughly with the team members.

Results

A total of 31 results were identified, with the core criteria of developing and testing a telerehabilitation system, including a mobile app for cardiovascular diseases, cancer, diabetes, and chronic respiratory disorders. All developed systems resulted from multidisciplinary teams and employed mixed-methods research. We proposed the "input-process-output" framework that identified phases of both system design and usability testing. Through system design, we reported the use of user-centered design, iterative design, users' needs and characteristics, theory underpinning development, and the expert panel in 64%, 75%, 86%, 82%, and 71% of the studies, respectively. We recorded the application of moderated usability testing, unmoderated testing (1), and unmoderated testing (2) in 74%, 63%, and 15% of the studies, respectively. The identified design and testing activities produced a matured system, a high-fidelity prototype, and a released system in 81.5%, 15%, and 3.5%, respectively.

Conclusion

This review provides a framework for TR system design and testing for a wide range of chronic diseases that require prolonged management through remote monitoring using a mobile app. The identified "input-process-output" framework highlights the inputs, design, development, and improvement as components of the system design. It also identifies the "moderated-unmoderated" model for conducting usability testing. This review illustrates characteristics and functionalities of the TR systems and healthcare professional roles.

Endocrine therapy initiation and overall survival outcomes with omission of radiation therapy in older Medicare patients with early‐stage hormone‐receptor‐positive breast cancer

BACKGROUND

Guidelines allow for the omission of radiotherapy in older women with early-stage, hormone-receptor-positive breast cancer, given that the patients receive adequate endocrine therapy (ET). However, the initiation of ET and survival outcomes after forgoing radiation therapy among these patients have not been well-studied.

METHODS

We identified patients aged 70 to 90 years old newly diagnosed in 2010-2015 with early-stage, hormone receptor positive, and human epidermal growth factor receptor 2 (HER2) negative (HR+/Her2-) breast cancer who received lumpectomy and omitted radiation therapy using the SEER-Medicare database. We examined the initiation of ET and the utilization patterns of ET using a multivariable logistic regression. We further examined the overall survival outcomes using Kaplan-Meier estimation and Cox proportional hazard model with inverse probability weighting.

RESULTS

Of the 2618 patients, 808 (30.9%) received no ET. The multivariable logistic regression showed that more recent years had better ET initiation (2013-2015 vs. 2010-2012: OR = 1.39, 95% CI:[1.16, 1.66]), while older patients (81-90 vs. 70-80: OR = 0.45, 95% CI:[0.38, 0.54]) were less likely to receive ET. Both the Kaplan-Meier estimation (log-rank p-value<0.0001) and the Cox proportional hazard model with inverse probability weighting (HR = 0.76, 95% CI:[0.58, 0.99]) showed that receiving ET was associated with better overall survival.

CONCLUSION

This population-based study suggests that a sizable proportion of patients who omitted radiation did not receive endocrine therapy and receiving endocrine therapy was beneficial among these patients. Although ET initiation has improved in more recent years, certain patient groups were still especially susceptible to no endocrine therapy.

Prospective feasibility study of a mindfulness-based program for breast cancer patients in the southeastern US

BACKGROUND

Mindfulness interventions can improve psychological distress and quality of life (QoL) in cancer survivors. Few mindfulness programs for cancer recovery exist in Southeastern U.S. The primary objective of this study was to assess the feasibility of a modified mindfulness-based stress reduction (MBSR) program for breast cancer patients in Birmingham, Alabama. The secondary objective was to explore potential program effects on mindfulness skills and QoL.

METHODS

This study was a prospective, quasi-experimental feasibility study conducted over 10 months at a university hospital. Feasibility was achieved if 80% of eligible patients screened enrolled in the study and 70% of enrolled patients attended all 8 program sessions. Effectiveness was estimated by changes in mindfulness and QoL indicators measured with validated scales administered at 3 time points and assessed with a non-parametric Friedman test. Sessions included meditation, yoga, and an attention practice called body scan. There were 3 groups of 2-5 patients.

RESULTS

The sample totaled 12 patients. Forty-four percent (12/27) of eligible patients enrolled in the study, and two out of 12 enrolled patients completed 8 program sessions, resulting in 16.7% (2/12) retention. However, more than half (66.7%) of participants completed at least 7 sessions. Between baseline and 8-week follow-up, patients demonstrated statistically significant improvements in distress, general wellbeing, and fatigue-related QoL.

CONCLUSIONS

Feasibility objectives were not achieved. However, a majority of participants (66.7%) completed 7 of 8 program sessions. Program effects were promising for distress, fatigue, and wellbeing. Results warrant further research on MBSR-like programs for breast cancer patients in Alabama.

Adherence to Hormonal Therapy in Breast Cancer Patients in Saudi Arabia: A Single-Center Study

Breast cancer is one of the most common types of cancer in women. Approximately three-quarters of all breast cancer patients have estrogen and/or progesterone receptor positivity. As a result, the majority of patients receive hormonal treatment for between five and 10 years. Long-term use of hormonal therapy reduces the recurrence rate and the risk of death. In Saudi patients, adherence to hormonal therapy is not adequately assessed. The primary objective of this study is to determine the clinical outcomes associated with hormonal therapy adherence in breast cancer patients.

This is a retrospective cohort study of patients who received adjuvant hormonal therapy for hormone-receptor-positive breast cancer. Patients were included if they had received at least two prescription refills following their breast cancer diagnosis. The primary outcome measure was mortality and disease progression in relation to hormonal therapy adherence. Progression of disease is defined as local recurrence or radiographic evidence of metastatic disease. The secondary outcome measure was the study population's adherence to hormonal therapy. The proportion of days covered during hormonal therapy was used to assess adherence (PDC). PDC was calculated as the number of days in the prescription period divided by the total number of days in the prescription period. Patients are considered adherent if their PDC value is greater than 0.8. The mortality and disease progression curves were generated using the Kaplan-Meier method. The proportion of patients adhering to hormonal therapy was determined using descriptive analysis. The IRB granted approval. A total of 121 patients were included in the study from the 380 patients screened. Tamoxifen, letrozole, and anastrozole were administered to 58%, 27%, and 14% of patients, respectively. The median age was 53 years. Women who were postmenopausal constituted 52.3% of the study population. The majority of patients were in Stages II and I (56.2% and 16.53%, respectively). The majority of the tumors were Grade II (58.68 %). Adherence was not associated with disease progression (HR, 0.66; 95% CI, 0.25-1.72) or mortality (HR, 1.391; 95 percent CI, 0.33-5.82). Disease progression and mortality were not found to be significantly associated with hormonal therapy adherence in this study. A larger study is required to confirm the findings of our study.

Endocrine adherence in male versus female breast cancer: a seer-medicare review

PURPOSE

Breast cancer in men (BC-M) is almost exclusively hormone receptor positive. We conducted a large review of the SEER-Medicare linked database to compare endocrine therapy adherence, discontinuation, and survival outcomes of male versus female patients with breast cancer.

METHODS

Study data were obtained through the SEER-Medicare linked database. The study included patients age ≥ 65 years-old diagnosed with breast cancer between 2007 and 2015. The primary endpoints were rates of adherence and discontinuation of endocrine therapy (ET). Adherence was defined as a gap of less than 90 days in-between consecutive Medicare prescriptions. Discontinuation was defined as a gap of greater than 12 months in-between Medicare prescriptions. Secondary endpoint was the association of use of ET with overall survival (OS).

RESULTS

Of the 363 male patients on ET, 214 patients (59.0%) were adherent to the therapy, and 149 patients (41.0%) were nonadherent. Of the 20,722 females on ET, 10,752 (51.9%) were adherent to the therapy, and 9970 (48.1%) were nonadherent. 39 male patients (10.7%) discontinued therapy, while 324 (89.3%) did not discontinue therapy. 1849 female patients (8.9%) discontinued therapy, while 18,873 (91.1%) patients did not. Men were significantly more adherent than women (p = 0.008), but there was no significant difference in discontinuation among men and women (p = 0.228). Survival was significantly improved in both men (HR 0.77, 95% CI 0.60-0.99, p = 0.039) and women (HR 0.84, 95% CI 0.81-0.87, p < 0.001) on ET.

CONCLUSION

Identification of contributing factors impacting adherence and discontinuation is needed to allow physicians to address barriers to long term use of ET.

Effect of mobile phone app-based training on the quality of life for women with breast cancer

PURPOSE

The study purpose was to determine the effects on quality of life (QoL) of a mobile phone app-based training for supportive care of women with breast cancer who were using adjuvant endocrine hormonal therapy.

METHODS

The study is based on a randomized pre-post test design. Participants were randomly assigned to either a control group that received routine care or an intervention group that received routine care plus access to the mobile phone app-based training support for 12 weeks. QoL and symptom distress were measured before intervention (T0), and after 12 weeks (T1) of intervention. This study is the application of two modality combinations: the mobile app-based patient education (1) and web-based management application (2). The mobile app-based training also provided basic information about breast cancer, symptom diary and lifestyle recommendations (adequate and balanced nutrition, regular physical activity, deal with stress effectively).

RESULTS

QoL of the treatment group after intervention increased and distress level was lower compared to the control group; these results were statistically significant. The majority of the patients reported that the mobile application was "informative and useful".

CONCLUSIONS

This demonstrated that the mobile app is an effective intervention for supportive care in women with breast cancer. The mobile app-based training, which is an innovative intervention, is recommended as a supportive care initiative for women with breast cancer.

Prescription Patterns, Initiation, and 5-Year Adherence to Adjuvant Hormonal Therapy Among Commercially Insured Patients With Breast Cancer

BACKGROUND

Tamoxifen and aromatase inhibitors (AIs) are used as adjuvant hormonal therapy (AHT) for early-stage hormone receptor-positive (HR+) breast cancer. Treatment for 5 years reduces cancer mortality by 30%. Despite this benefit, adherence to AHT has been suboptimal. Here, we evaluated AHT initiation and patient adherence in women with private health insurance.

MATERIALS AND METHODS

Female patients with breast cancer ≥ 18 years of age who underwent mastectomy or lumpectomy between 1999 and 2015 were identified in the IBM MarketScan Research Database. AHT initiation and adherence rates were estimated for all AHT users regardless of HR+ status. Initiation rates were standardized using HR+ breast cancer incidence rates in the Surveillance, Epidemiology, and End Results (SEER) program. Adherence was defined as medication possession ratio ≥ 80%. Risk ratios, odds ratios, and their 95% CIs were calculated for factors associated with patients' initiation and adherence.

RESULTS

Among 80,224 patients, the raw initiation rate was 71.8% and the standardized rate was 87.5%. We found 61.2% patients initiated treatment with AIs and 38.8% with tamoxifen. Patients' 1-year adherence rate was 84.4% and the 5-year rate was 65.2%. Prescription by mail-in order, using a single AHT regimen, 50 to 69 years of age, monthly out-of-pocket drug payment ≤ $11, in US dollars, no depression, no comorbidity, living in the Northeast, treatment in recent years, and receipt of a combination of chemotherapy, radiation, and surgery were associated with better adherence.

CONCLUSION

Five-year AHT adherence rates are low among female patients with breast cancer with private health insurance. Effective approaches to improve AHT adherence are needed.

Quality of life outcomes from a randomized controlled trial of patient navigation in Latina breast cancer survivors

INTRODUCTION

Breast cancer survivorship is a life-long process involving challenges to health-care communities and individuals, especially Latinas. Patient Navigation has shown some success in meeting these challenges. The purpose of this study was to compare the effects of an enhanced Patient Navigation program (Intervention; PN+) vs Control (PN) over time on general cancer and breast cancer-specific quality of life (QoL) in Latina breast cancer survivors (BCS).

METHODS

We conducted a 2-year, two-arm randomized controlled trial of the "Staying Healthy" program among Latina BCS. The design compared PN+ vs PN over time. We recruited 60 patients into each study arm and randomized them by sequential numerical assignment. PN+ participants received culturally tailored educational materials and active, personalized Patient Navigation services, including phone calls, transportation, and care coordination. PN participants were navigated only upon request. Primary outcomes included general cancer (Functional Assessments of Cancer Therapy [FACTS]-G) and breast cancer-specific (FACT-B) QoL.

RESULTS

PN+ participants had significantly improved QoL measures compared to PN at 6-month follow-up on all subscales (P-values .007-.04) except physical well-being (PWB; P = .11). Intervention effect size coefficient (standard error) for FACT-G overall was 7.9 (3.1); P = .01. For FACT-B, it was 10.9 (3.9); P = .006. Again, all subscales showed significant effects [range 1.7-3.1 (0.8-1.2); P-values .006-.04], except for PWB [1.5 (1.0); P = .16] and social/family well-being (SWB) [2.1 (1.1); P = .06]. There were no differences between groups at baseline.

DISCUSSION

Multiple cultural, psychosocial, and socioeconomic variables contributing to these intervention effects will be addressed in future studies. As the national BCS population continues to increase, more Patient Navigation-focused partnerships among patients, health-care professionals, research groups, and community organizations are needed to improve BCS experiences. The Staying Healthy program has the potential to serve as a national survivorship care model for improving Latina BCS QoL.

Facilitating the development of cross-platform mHealth applications for chronic supportive care and a case study

Mobile health (mHealth) apps have received increasing attention, due to their abilities to support patients who suffer from various conditions. mHealth apps may be especially helpful for patients with chronic diseases, by providing pertinent information, tracking symptoms, and inspiring adherence to medication regimens. To achieve these objectives, researchers need to prototype mHealth apps with dedicated software architectures. In this paper, a cloud-based mHealth application development concept is presented for chronic patient supportive care apps. The concept integrates existing software platforms and services for simplified app development that can be reused for other target applications. This developmental method also facilitates app portability, through the use of common components found across multiple mobile platforms, and scalability, through the loose coupling of services. The results are demonstrated by the development of native Android and cross-platform web apps, in a case study that presents an mHealth solution for endocrine hormone therapy (EHT). A performance analysis methodology, an app usability evaluation, based on focus group responses, and alpha and pre-beta testing results are provided.

Photodynamic therapy mediated by aluminium-phthalocyanine nanoemulsion eliminates primary tumors and pulmonary metastases in a murine 4T1 breast adenocarcinoma model

Photodynamic therapy (PDT) is effective in the treatment of different types of cancer, such as basal cell carcinoma and other superficial cancers. However, improvements in photosensitizer delivery are still needed, and the use of PDT against more deeply located tumors has been the subject of many studies. Thus, the goal of this study was to evaluate the efficacy of a nanoemulsion containing aluminium-phthalocyanine (AlPc-NE) as a mediator of photodynamic therapy (PDT-AlPc-NE) against grafted 4T1 breast adenocarcinoma tumors in mice (BALB/c). Short after the appearance of the tumor, the animals were divided into groups (n = 5) as follows: untreated; only AlPc-NE and treated with PDT-AlPc-NE. The tumor volume was measured with a digital calliper at specific times. The presence of metastasis in the lungs was evaluated by microtomography and histopathological analyses. The results show that the application of PDT-AlPc-NE eradicated the transplanted tumors in all the treated animals, while the animals from control groups presented a robust increase in the tumor volume. Still more significantly, microtomography showed the animals submitted the PDT-AlPc-NE to be free of detectable metastasis in the lungs. The histological analysis of the lungs further confirmed the results verified by the microtomography. Therefore, this study suggests that PDT-AlPc-NE is effective in the elimination of experimentally grafted breast tumors in mice and also in preventing the formation of metastasis in the lungs.

Mobilizing Breast Cancer Prevention Research Through Smartphone Apps: A Systematic Review of the Literature

Background: Breast cancer rates have been increasing worldwide, particularly among young women, suggesting important interactions between genes and health behaviors. At the same time, mobile technology, including smartphones applications (apps), has emerged as a new tool for delivering healthcare and health-related services. As of 2018, there were nearly 600 publicly available breast cancer apps designed to provide disease and treatment information, to manage disease, and to raise overall awareness. However, the extent to which apps are incorporated into breast cancer prevention research is unknown. Therefore, the objective of this review was to determine how mobile applications are being used for breast cancer prevention among women across the cancer control continuum. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched PubMed and Web of Science Core Collection databases using the keywords breast cancer, smartphone, mobile application, and phone app. Full-length journal articles available in English that addressed the research question were included. We categorized articles by prevention type (primary, secondary, and tertiary) and phase of research (protocol, development, feasibility, pilot, measurement, and effectiveness), and identified common themes and gaps. Results: Our search yielded 82 studies (69 unique) that used apps in breast cancer prevention research across 20 countries. Approximately half of the named apps were publicly available. The majority (73%) of studies targeted tertiary prevention; 15% targeted secondary and 13% targeted primary prevention. Apps were used across all phases of research with the predominant phase being feasibility in tertiary prevention (34%), effectiveness in secondary prevention (63%), and development (30%) and effectiveness (30%) in primary prevention. Common uses included assessing outcomes relevant to clinical care coordination, quality of life, increasing self-efficacy and screening behaviors, and tracking and managing health behaviors. Conclusions: We identified the following gaps: few effectiveness studies in tertiary prevention, minimal use of apps for breast cancer etiology or early detection, and few interventions in those at average risk of breast cancer. These findings suggest that while mobile apps can inform breast cancer prevention across the continuum, more work is needed to incorporate apps into primary prevention.

[E-health and "Cancer outside the hospital walls", Big Data and artificial intelligence]

To heal otherwise in oncology has become an imperative of Public Health and an economic imperative in France. Patients can therefore receive live most of their care outside of hospital with more ambulatory care. This ambulatory shift will benefit from the digital revolution and the development of digital health or e-health. Cancer research will also benefit with Big Data and artificial intelligence, which gather and analyze a huge amount of data. In this synthesis, we describe the different e-health tools and their potential impacts in oncology, at the levels of education and information of patients and caregivers, prevention, screening and diagnosis, treatment, follow-up, and research. A few randomized studies have already demonstrated clinical benefits. Large Big Data projects such as ConSoRe and Health Data Hub have been launched in France. We also discuss the issues and limitations of "cancer outside the hospital walls and e-health" from the point of view of patients, health care professionals, health facilities and government. This new organization will have to provide remote support "outside the walls" with care and follow-up of quality, continuous and prolonged in total safety and equity. Ongoing and future randomized clinical trials will need to definitively demonstrate areas of interest, advantages and drawbacks not only for patients, but also for caregivers, health facilities and governments.

Outpatient Cancer Care Delivery in the Context of E-Oncology: A French Perspective on "Cancer outside the Hospital Walls"

In oncology, the treatment of patients outside of hospitals has become imperative due to an increasing number of patients who are older and live longer, along with issues such as medical desertification, oncologist hyperspecialization, and difficulties in financing mounting health expenditures. Treatments have become less "invasive", with greater precision and efficiency. Patients can therefore receive most of their care outside of hospitals. The development of e-health can address these new imperatives. In this letter, we describe the different e-health tools and their potential clinical impacts in oncology, as already reported at every level of care, including education, prevention, diagnosis, treatment, and monitoring. A few randomized studies have yet demonstrated the clinical benefit. We also comment on issues and limits of "cancer outside the hospital walls" from the point of view of patients, health care professionals, health facilities, and public authorities. Care providers in hospitals and communities will have to adapt to these changes within well-coordinated networks in order to better meet patient expectations regarding increasing education and personalizing management. Ultimately, controlled studies should aim to definitively demonstrate areas of interest, benefits, and incentives, for not only patients, but also caregivers (formal and informal) and health care providers, health care facilities, and the nation.