Effects of an interactive mHealth innovation for early detection of patient-reported symptom distress with focus on participatory care: protocol for a study based on prospective, randomised, controlled trials in patients with prostate and breast cancer

Telemedicine and Cancer Clinical Research: Opportunities for Transformation

ABSTRACT

Telemedicine represents an established mode of patient care delivery that has and will continue to transform cancer clinical research. Through telemedicine, opportunities exist to improve patient care, enhance access to novel therapies, streamline data collection and monitoring, support communication, and increase trial efficiency. Potential challenges include disparities in technology access and literacy, physical examination performance, biospecimen collection, privacy and security concerns, coverage of services by insurance, and regulatory considerations. Coupled with artificial intelligence, telemedicine may offer ways to reach geographically dispersed candidates for narrowly focused cancer clinical trials, such as those targeting rare genomic subsets. Collaboration among clinical trial staff, clinicians, regulators, professional societies, patients, and their advocates is critical to optimize the benefits of telemedicine for clinical cancer research.

Patients' Individualized Care Perceptions and Health Literacy Using an Interactive App During Breast and Prostate Cancer Treatment: Two Parallel Randomized Controlled Trials

The use of symptom management mobile apps can reduce patients' symptom burden during cancer treatment, but the evidence is lacking about their effect on care. Moreover, if patients' health literacy can be improved, it needs to be more rigorously tested. This study aimed to evaluate patients' perceptions of individualized care and health literacy using an interactive app in two randomized trials. Patients undergoing neoadjuvant chemotherapy for breast cancer (N = 149) and radiotherapy for prostate cancer (N = 150) were consecutively included and randomized into one intervention or control group. Outcome measures were Individualized Care Scale, Swedish Functional Health Literacy Scale, and Swedish Communicative and Critical Health Literacy Scale. In the breast cancer trial, no group differences were observed regarding individualized care or health literacy. Most patients had sufficient health literacy levels. In the prostate cancer trial, intervention group patients rated higher perceived individualized care regarding decision control at follow-up than the control group. Less than half had sufficient health literacy levels and intervention group patients significantly improved their ability to seek, understand, and communicate health information. Education level explained significant variance in health literacy in both trials. Using an interactive app can positively affect individualization in care and health literacy skills among patients treated for prostate cancer, although further research is warranted.

Electronic patient-reported outcome (ePRO) application for patients with prostate cancer

INTRODUCTION

Cancer patients experience different complications and outcomes during or after medical treatments. Electronic reporting of the outcomes by patients is a solution that facilitates communication with physicians and improve patient health status. The aim of this study was to develop a smartphone-based application for electronic reporting of outcomes by patients with prostate cancer.

METHODS

The present research was conducted in 2021 in two phases. In the first phase, initially, users' requirements were identified based on reviewing the related literature, existing applications, and guidelines. Then, a questionnaire was designed and the specialists' opinions about the users' requirements were investigated. The specialties included urologists, hemato-oncologists, uro-oncologists, and radiotherapists (n = 15). In the second phase, the application was designed, and patients with prostate cancer (n = 21) and specialists (n = 10) evaluated it using the post-study system usability questionnaire (PSSUQ). Data were analyzed using descriptive statistics.

RESULTS

The findings of the first phase of the research showed that out of 108 data elements and functions proposed for the application, 91 items were found essential by the specialists. Data elements were categorized into the patient data, general complications of prostate cancer and side effects of drug therapy, surgery, chemotherapy, cryotherapy, radiation therapy, and hormone therapy. Necessary functions for the application included presenting a patient care summary, communication between the patient and the specialist, free text explanation for complications and sides effects, generating reports, reminder and alert, completing quality of life questionnaire, and calculating the score for the questionnaire. In the second phase of the research, the application was developed and evaluated. The mean value for user satisfaction was (5.95 ± 0.55) out of 7.

CONCLUSION

The developed application can help to accelerate communication with the specialists. It can improve quality of care, reduce unnecessary treatment visits and side effects, and improve timely data collection for a variety of research purposes. However, further research on the cost-effectiveness and usefulness of the collected data is recommended.

Mobile health (mHealth) interventions in prostate cancer survivorship: a scoping review

PURPOSE

This scoping review explores the application of mHealth technology in prostate cancer (CaP) management along the survivorship continuum.

METHODS

The scoping review was conducted using the five-step framework developed by Arksey and O'Malley. Using predefined criteria, we screened citations from Embase, EBSCOHost, Cochrane Library, PubMed, ProQuest, SCOPUS, and Web of Science for primary studies published before December 2021. We selected studies that explored the application of mHealth technology in CaP management and survivorship. Evidence from 14 eligible studies was summarized using narrative synthesis.

RESULTS

Fourteen studies published between 2015 and 2021 were included. Ten mHealth apps were identified with only one still in use. Most apps were explored for their supportive care roles during radiotherapy (n = 9) and androgen deprivation therapy (ADT) (n = 1) treatment, mainly to assess outcomes (n = 1) and manage patient-reported symptoms (n = 5). One study deployed mHealth to facilitate recovery after surgery. Very few studies (n = 3) applied mHealth for lifestyle management (i.e., physical activity). Barriers to app usage included connectivity issues, end-user familiarity with the app, login hurdles, and time constraints. Facilitators of app usage included apps being downloaded for participants, devices provided for participants, and the ability to connect with providers through the platform.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

The improving survival rates from CaP suggest that men are now living longer with unfavorable treatment side effects such as reduced sexual functioning, pain, and fatigue. Hence, mHealth represents new hope in men's illness trajectory. However, current application in patients' care pathways remains poor, particularly in the active phase of CaP management. Efforts must be accelerated to explore individual and healthcare-level drivers of mHealth use. The feasibility and descriptive nature of current studies point to a lack of attention to actual implementation and scale-up issues in research considering mHealth application in CaP, hence accounting partly for the gap in research/practice.

Medication safety education in nursing research: Text network analysis and topic modeling

OBJECTIVES

This study aimed to identify the knowledge structure of medication safety nursing education literature by developing schematic diagrams of the relationship between keywords from a macro perspective. This study also identifies the research topics and trends over time.

DESIGN

This quantitative content study used text network analysis to explore keywords and research topics using topic modeling within the medication safety nursing education literature.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were used to search for the medication safety nursing education literature published until December 2021.

METHODS

Keywords from 2085 articles were examined using text network analysis and topic modeling with NetMiner 4.4.3.

RESULTS

The keywords with the most frequency and the highest networking degree in centrality were "patient," "medication," "program," "nurse," and "care." The emerging keywords assessed by time periods were identified; the first phase ("heart failure," "insulin," "chemotherapy," and "infusion"), the second phase ("medication errors," "staff," and "information"), the third phase ("program," "management," and "data"). The results of topic modeling were as follows: safe medication administration, safe medication reconciliation process, medication education for patients, medication errors in nursing practice, and multidisciplinary teamwork for medication safety.

CONCLUSION

These findings will help nursing researchers and educators to understand the trends and insights for medication safety education and educate future nurses to provide safer nursing care.

Performance and usability evaluation of a mobile health data capture application in clinical cancer trials follow-up

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A mobile health data capture application can improve quality of data collection in clinical cancer trials.

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The use of a mobile health data capture application optimizes the efficiency and effectivity of a trial participant’s visit to a clinic.

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A mobile health data capture application relieves participants from instant recall on possible health changes during visits.

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The use of a mobile health data capture application helps a healthcare provider in preparing a participant’s visit.

Mobile health data capture applications (mHDA’s) may improve communication between healthcare providers and patients. However, there is limited literature about the use of mHDA’s facilitating clinical trials. In this study, the effectiveness of an application, supporting follow-up visits of cancer trial participants was investigated. Twenty participants were provided with an e-questionnaire via the mHDA. Participants rated the usability of the application as high performing (mean Systems Usability Scale 87 points). The research team rated the mHDA as highly applicable and efficient in preparing visits. Anamnesis, physical examination and agreement on further policy were performed within an average of 31 min.

Patients’ Experiences of Care With or Without the Support of an Interactive App During Neoadjuvant Chemotherapy for Breast Cancer: Interview Study

Background

Neoadjuvant chemotherapy (NACT) is often recommended for patients with breast cancer with more aggressive tumor characteristics. As with all chemotherapies, they can cause substantially disturbing symptoms. Most patients receive their treatment as outpatients, which means that they must take responsibility for self-care and management of symptoms at home for a long period. Patients with breast cancer undergoing chemotherapy may not receive sufficient support for management of treatment-related symptoms. For patients undergoing NACT, it has been concluded that information and supportive needs are not always met. In our previous study, the use of mobile health to support patients with breast cancer undergoing NACT reduced symptoms during treatment with the support of an interactive app. Therefore, it is important to investigate how patients experience their care and explore any specific contribution that the app may have brought in care.

Objective

This study aims to explore patients’ experiences of care with or without the support of an interactive app during NACT for breast cancer.

Methods

This qualitative study was part of a larger randomized controlled trial and included 40 individual face-to-face interviews conducted with patients in both intervention and control groups after the end of NACT. The interviews were audio recorded, and the data were analyzed inductively using thematic analysis.

Results

No major differences in experience of care were observed between the groups. A total of 4 overarching themes emerged. In the first theme, The health care context, patients described care as assessible, although sometimes there was a lack of time and continuity with nurses. In the second theme, Being a recipient of care, it emerged that the patients experienced a warm and positive atmosphere at the clinics. In the third theme, Taking an active role as a patient, patients described being active in searching for information and various ways of participation in their own care. In the fourth theme, The value of the app, patients who had used the app experienced it as a complementary source of information, creating a sense of security. Using the app provided patients with the support of being contacted by a nurse if needed, enabled self-care, and facilitated the planning of daily activities.

Conclusions

Overall, patients’ experiences of care were similar and mostly positive. However, for patients using the app, it provided additional support for information and self-care and enhanced participation in their own care. The easy access to a nurse gave patients a sense of security. The findings suggest integrating an interactive app as a complement to standard care to support patients with breast cancer during treatment.

International Registered Report Identifier (IRRID)

RR2-DOI: 10.1186/s12885-017-3450-y

Artificial intelligence empowered Digital Health Technologies in Cancer Survivorship Care: a scoping review

Objective

The objectives of this systematic review are to describe features and specific application scenarios for current cancer survivorship care services of Artificial intelligence (AI)-driven digital health technologies (DHTs) and to explore the acceptance and briefly evaluate its feasibility in the application process.

Methods

Search for literatures published from 2010 to 2022 on sites MEDLINE, IEEE-Xplor, PubMed, Embase, Cochrane Central Register of Controlled Trials and Scopus systematically. The types of literatures include original research, descriptive study, randomized controlled trial, pilot study, and feasible or acceptable study. The literatures above described current status and effectiveness of digital medical technologies based on AI and used in cancer survivorship care services. Additionally, we use QuADS quality assessment tool to evaluate the quality of literatures included in this review.

Results

43 studies that met the inclusion criteria were analyzed and qualitatively synthesized. The current status and results related to the application of AI-driven DHTs in cancer survivorship care were reviewed. Most of these studies were designed specifically for breast cancer survivors’ care and focused on the areas of recurrence or secondary cancer prediction, clinical decision support, cancer survivability prediction, population or treatment stratified, anti-cancer treatment-induced adverse reaction prediction, and so on. Applying AI-based DHTs to cancer survivors actually has shown some positive outcomes, including increased motivation of patient-reported outcomes (PROs), reduce fatigue and pain levels, improved quality of life, and physical function. However, current research mostly explored the technology development and formation (testing) phases, with limited-scale population, and single-center trial. Therefore, it is not suitable to draw conclusions that the effectiveness of AI-based DHTs in supportive cancer care, as most of applications are still in the early stage of development and feasibility testing.

Conclusions

While digital therapies are promising in the care of cancer patients, more high-quality studies are still needed in the future to demonstrate the effectiveness of digital therapies in cancer care. Studies should explore how to develop uniform standards for measuring patient-related outcomes, ensure the scientific validity of research methods, and emphasize patient and health practitioner involvement in the development and use of technology.

Nurses' Experiences Using an Interactive System to Assess and Manage Treatment-Related Symptoms of Patients With Pancreatic Cancer: Interview Study

BACKGROUND

Treatment for pancreatic cancer entails symptom distress and a high burden of self-care. Patient-reported outcomes, collected with the support of mobile health (mHealth), have shown positive effects on symptom management, patient satisfaction, and quality of life for patients with cancer. For mHealth tools to become an integral part of clinical routine, experiences from health care professionals are needed.

OBJECTIVE

The aim of this paper is to describe nurses' experiences of integrating an interactive system (Interaktor) for symptom assessment and management into daily practice, when caring for patients following pancreaticoduodenectomy and during chemotherapy treatment due to pancreatic cancer.

METHODS

Patients reported symptoms via the Interaktor app daily for 6 months. In the event of alarming symptoms, an alert was triggered to the patient's nurse who then called the patient to offer advice and support. All nurses (n=8) who assessed patients were interviewed either individually or in a group. Transcribed interviews were analyzed using qualitative thematic analysis.

RESULTS

mHealth can facilitate person-centered care by offering nurses a way to gain knowledge about patients and to build relationships. Further, obstacles to implementation could be seen due to a lack of structural prerequisites and uncertainty about multiple ways to interact with patients.

CONCLUSIONS

The Interaktor system can provide person-centered care. However, to implement mHealth tools as a clinical routine, focus needs to be placed on creating the necessary organizational conditions.

ATIENT REPORTED OUTCOMES IN THE DAILY PRACTICE IN CLINICAL ONCOLOGY: A SYSTEMATIC REVIEW

The use of patient-reported outcomes brings direct benefits to the daily practice in Clinical Oncology, providing information that allows the monitoring of patients between consultations, with an increase in the bond with the medical team and the patient's satisfaction with their treatment. This review seeks to identify electronic systems for collecting patient data, highlighting the possible benefits that motivated the use of these systems and identifying the population, instruments, way of handling alerts and possible limitations and barriers to implementation in clinical practice. Thus, 25 articles were selected and reviewed, following a previously established systematic literature review protocol. This review is useful for gathering information for the development of new patient-focused applications in Oncology.

Electronic Patient-Reported Outcome-Based Interventions for Palliative Cancer Care: A Systematic and Mapping Review

PURPOSE

Capitalizing on the promise of patient-reported outcomes (PROs), electronic implementations of PROs (ePROs) are expected to play an important role in the development of novel digital health interventions targeting palliative cancer care. We performed a systematic and mapping review of the scientific literature on the current ePRO-based approaches used for palliative cancer care.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, the conducted review answered the research questions: "What are the current ePRO-based approaches for palliative cancer care; what is their contribution/value in the domain of palliative cancer care; and what are the potential gaps, challenges, and opportunities for further research?" After a screening step, the corpus of included articles indexed in PubMed or the Web of Science underwent full text review, which mapped the articles across 15 predefined axes.

RESULTS

The corpus of 24 mapped studies includes 9 study protocols, 7 technical tools/solutions, 7 pilot/feasibility/acceptability studies, and 1 evaluation study. The review of the corpus revealed (1) an archetype of ePRO-enabled interventions for palliative cancer care, which most commonly use ePROs as study end point assessment instruments rather than integral intervention components; (2) the fact that the literature has not fully embraced the modern definitions that expand the scope of palliative care; (3) the striking shortage of promising ubiquitous computing devices (eg, smart activity trackers); and (4) emerging evidence about the benefits of narrowing down the target cancer population, especially when combined with modern patient-centered intervention design methodologies.

CONCLUSION

Although research on exploiting ePROs for the development of digital palliative cancer care interventions is considerably active and demonstrates several successful cases, there is considerable room for improvement along the directions of the aforementioned findings.

The Effect of the Mobile Application-Based Symptom Monitoring Process on the Symptom Control and Quality of Life in Breast Cancer Patients

OBJECTIVE

Patients with breast cancer receiving chemotherapy experience many symptoms. This study set out to determine the effect of the mobile application-based symptom monitoring process on symptom control and quality of life in breast cancer patients.

DATA SOURCES

The research sample consisted of 57 patients who applied to an outpatient chemotherapy unit of a university hospital. The patients in the intervention group reported symptoms starting from the first day when they received chemotherapy with Msemptom and until the 15th day after chemotherapy. After evaluation of the daily symptom reports of the patients, the patients were instructed via text message to report symptoms as moderate, severe, or very severe symptoms. After the application, the median of the Memorial Symptom Assessment Scale (MSAS)-physical subscale score of the patients in the control group was found to be statistically significantly higher than in the intervention group (P = .028). It was also found that after application, the medians of the European Organization for Research and Treatment of Cancer-Quality of Life (EORTC-QLQC30), symptom scale and nausea-vomiting score (P = .012), QLQ-BR23 Module sexual function (P = .024), and sexual pleasure subscale score (P = .026) were statistically significantly higher than patients in the intervention group.

CONCLUSION

The process of symptom monitoring with mobile applications is especially effective in controlling physical symptoms.

IMPLICATIONS FOR NURSING PRACTICE

It is recommended to expand mobile application-based symptom monitoring process in breast cancer patients and to support the patients in using this application-based process.

Digital health for optimal supportive care in oncology: benefits, limits, and future perspectives

BACKGROUND

Digital health provides solutions that capture patient-reported outcomes (PROs) and allows symptom monitoring and patient management. Digital therapeutics is the provision to patients of evidence-based therapeutic interventions through software applications aimed at prevention, monitoring, management, and treatment of symptoms and diseases or for treatment optimization. The digital health solutions collecting PROs address many unmet needs, including access to care and reassurance, increase in adherence and treatment efficacy, and decrease in hospitalizations. With current developments in oncology including increased availability of oral drugs and reduced availability of healthcare professionals, these solutions offer an innovative approach to optimize healthcare resource utilization.

DESIGN

This scoping review clarifies the role and impact of the digital health solutions in oncology supportive care, with a view of the current segmentation according to their technical features (connection to sensors, PRO collection, remote monitoring, self-management in real time…), and identifies evidence from clinical studies published about their benefits and limitations and drivers and barriers to adoption. A qualitative summary is presented.

RESULTS

Sixty-six studies were identified and included in the qualitative synthesis. Studies supported the use of 38 digital health solutions collecting ePROs and allowing remote monitoring, with benefits to patients regarding symptom reporting and management, reduction in symptom distress, decrease in unplanned hospitalizations and related costs and improved quality of life and survival. Among those 38 solutions 21 provided patient self-management with impactful symptom support, improvement of QoL, usefulness and reassurance. Principal challenges are in developing and implementing digital solutions to suit most patients, while ensuring patient compliance and adaptability for use in different healthcare systems and living environments.

CONCLUSIONS

There is growing evidence that digital health collecting ePROs provide benefits to patients related to clinical and health economic endpoints. These digital solutions can be integrated into routine supportive care in oncology practice to provide improved patient-centered care.

Use of Text Messaging (SMS) for the Management of Side Effects in Cancer Patients Undergoing Chemotherapy Treatment: a Randomized Controlled Trial

Cancer patients are often not sufficiently oriented to manage side effects at home. Sending text messages with self-care guidelines aimed managing side effects is the main objective of this randomized controlled trial. Patients who started outpatient chemotherapy treatment between March and December 2017 at a hospital in southern Brazil were invited to participate in this study and were allocated to the intervention or control group (ratio 1: 1). Each patient in the intervention group received a daily SMS (short message service) with some guidance on management or prevention of side effects. All text messages were sent to the intervention group patients in an automated and tailored way by our app called cHEmotHErApp. Side effects experienced by patients were verified using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30). Results showed intervention group patients experienced fewer side effects compared to the control group in cycle 1 (p < 0.05), in general. In addition, intervention group experienced less nausea in relation to the control group, in the cycle 1 and cycle 2 (p < 0.05). This study indicate text messaging may be a tool for supporting side effect management in patients receiving chemotherapy. This study was enrolled in ClinicalTrials.gov with the identification number NCT03087422. This research was performed in accordance with the Declaration of Helsinki.

Remote Oncology Care: Review of Current Technology and Future Directions

Cancer patients frequently develop tumor and treatment-related complications, leading to diminished quality of life, shortened survival, and overutilization of emergency department and hospital services. Outpatient oncology treatment has potential to leave cancer patients unmonitored for long periods while at risk of clinical deterioration which has been exaggerated during the COVID19 pandemic. Visits to cancer clinics and hospitals risk exposing immunocompromised patients to infectious complications. Remote patient reported outcomes monitoring systems have been developed for use in cancer treatment, showing benefits in economic and survival outcomes. While advanced devices such as pulmonary artery pressure monitors and implantable loop recorders have proven benefits in cardiovascular care, similar options do not exist for oncology. Here we review the current literature around remote patient monitoring in cancer care and propose the use of reliable devices for capturing and reporting patient symptoms and physiology.

Engagement in an Interactive App for Symptom Self-Management during Treatment in Patients With Breast or Prostate Cancer: Mixed Methods Study

Background

Using mobile technology for symptom management and self-care can improve patient-clinician communication and clinical outcomes in patients with cancer. The interactive app Interaktor has been shown to reduce symptom burden during cancer treatment. It includes symptom assessment, an alert system for contact with health care professionals, access to self-care advice, and visualization of symptom history. It is essential to understand how digital interventions operate; one approach is to examine engagement by assessing usage and exploring user experiences. Actual usage in relation to the intended use—adherence—is an essential factor of engagement.

Objective

This study aimed to describe engagement with the Interaktor app among patients with breast or prostate cancer during treatment.

Methods

Patients from the intervention groups of two separate randomized controlled trials were included: patients with breast cancer receiving neoadjuvant chemotherapy (n=74) and patients with locally advanced prostate cancer receiving treatment with radiotherapy (n=75). The patients reported their symptoms daily. Sociodemographic and clinical data were obtained from baseline questionnaires and medical records. Logged data usage was retrieved from the server and analyzed descriptively and with multiple regression analysis. Telephone interviews were conducted with patients about their perceptions of using the app and analyzed using content analysis.

Results

The median adherence percentage to daily symptom reporting was 83%. Most patients used the self-care advice and free text message component. Among the patients treated for breast cancer, higher age predicted a lower total number of free text messages sent (P=.04). Among the patients treated for prostate cancer, higher age (P=.01) and higher education level (P=.04), predicted an increase in total views on self-care advice, while higher comorbidity (P=.004) predicted a decrease in total views on self-care advice. Being married or living with a partner predicted a higher adherence to daily symptom reporting (P=.02). Daily symptom reporting created feelings of having continuous contact with health care professionals, being acknowledged, and safe. Being contacted by a nurse after a symptom alert was considered convenient and highly valued. Treatment and time-related aspects influenced engagement. Daily symptom reporting was perceived as particularly meaningful at the beginning of treatment. Requests were made for advice on diet and psychological symptoms, as well as for more comprehensive and detailed information as the patient progressed through treatment.

Conclusions

Patient engagement in the interactive app Interaktor was high. The app promoted patient participation in their care through continuous and convenient contact with health care professionals. The predictive ability of demographic variables differed between patient groups, but higher age and a higher educational level predicted usage of specific app functions for both patient groups. Patients’ experience of relevance and interactivity influenced their engagement positively.

Reduced symptom burden with the support of an interactive app during neoadjuvant chemotherapy for breast cancer - A randomized controlled trial

Objectives

Neoadjuvant chemotherapy causes distressing symptoms, which have to be managed by patients at home. Assessing and acting upon relevant patient-reported symptoms regularly with the support of mHealth such as apps, has shown to decrease symptom burden and improve health-related quality of life (HRQoL). There is a lack of apps for patients with breast cancer which are tested in rigorous trials and only a few include interactive components for immediate clinical management. The aim of this study was to evaluate whether the use of the interactive app Interaktor improves patients’ levels of symptom burden and HRQoL during neoadjuvant chemotherapy for breast cancer.

Materials and methods

This randomized controlled trial included patients in an intervention group (n = 74) and a control group (n = 75), recruited at two university hospitals in Stockholm, Sweden. The intervention group used Interaktor for symptom reporting, self-care advice and support from health-care professionals during treatment, and the control group received standard care alone. Self-reported symptoms and HRQoL were assessed at two time points to determine differences between the groups.

Results

The intervention group rated statistically significant less symptom prevalence in nausea, vomiting, feeling sad, appetite loss and constipation. Overall symptom distress and physical symptom distress were rated statistically significant lower in the intervention group. Further, emotional functioning was rated statistically significant higher in the intervention group.

Conclusions

By using the Interaktor app in clinical practice, patients get individual support when managing treatment-related symptoms during neoadjuvant chemotherapy for breast cancer, leading to decreased symptom burden and improved emotional functioning.

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Using the app Interaktor reduced symptom burden in patients with breast cancer.

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The use of Interaktor enhanced emotional functioning during treatment.

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Interaktor provided individual support during neoadjuvant chemotherapy.

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Use of Interaktor allowed breast cancer patients for daily reflection over symptoms.

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.

The Potential of Self-Management mHealth for Pediatric Cystic Fibrosis: Mixed-Methods Study for Health Care and App Assessment

Background

Remote care services and patient empowerment have boosted mobile health (mHealth). A study of user needs related to mHealth for pediatric cystic fibrosis (PCF) identified the set of preferred features mobile apps should support; however, the potential use of PCF apps and their suitability to fit into PCF clinical management remains unexplored.

Objective

We examine whether PCF holds potential for the implementation of mHealth care.

Methods

The study is based on a literature review and qualitative analysis of content and was conducted in two parts: (1) we reviewed scientific and gray literature to explore how European countries manage PCF and conducted a qualitative study of 6 PCF units and (2) we performed a systematic review of apps available in the myhealthapps.net repository searching for cystic fibrosis (CF) management and nutrition apps, which we analyzed for characteristics, business models, number of downloads, and usability.

Results

European CF routine care guidelines are acknowledged in most European countries, and treatments are fully covered in almost all countries. The majority of teams in CF units are interdisciplinary. With respect to the systematic review of apps, we reviewed 12 apps for CF management and 9 for general nutrition management in the myhealthapps.net directory. All analyzed apps provided functionalities for recording aspects related to the disease and nutrition such as medication, meals, measurements, reminders, and educational material. None of the apps reviewed in this study supported pancreatic enzyme replacement therapy. CF apps proved to be less appealing and usable than nutrition apps (2.66 [SD 1.15] vs 4.01 [SD 0.90]; P<.001, z-value: –2.6). User needs detected in previous research are partially matched by current apps for CF management.

Conclusions

The health care context for PCF is a unique opportunity for the adoption of mHealth. Well-established clinical guidelines, heterogeneous clinical teams, and coverage by national health care systems provide a suitable scenario for the use of mHealth solutions. However, available apps for CF self-management do not cover essential aspects such as nutrition and education. To increase the adoption of mHealth for CF self-management, new apps should include these features.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2016-014931

Enhanced Patient Activation in Cancer Care Transitions: Protocol for a Randomized Controlled Trial of a Tailored Electronic Health Intervention for Men With Prostate Cancer

Background

Prostate cancer has increased in incidence worldwide and is the leading cause of cancer death in 24 countries. The most common treatment is radical prostatectomy. However, surgery is associated with postoperative complications such as urinary incontinence and sexual dysfunction, causing decreased quality of life. If survivors are encouraged to be more active in self-care management, the symptom burden may decrease and quality of life may improve. An electronic health (eHealth) intervention based on motivational behavioral theory has been developed for this purpose.

Objective

This study aimed to compare the effectiveness of standard care in combination with a tailored eHealth and mobile health self-management support system, electronic Patient Activation in Treatment at Home (ePATH), with standard care of adverse effects of prostate cancer treatment (urinary incontinence and sexual functioning) in men undergoing radical prostatectomy. The secondary aim was to test the effect on patient activation, motivation, overall well-being, and health literacy over time in and between groups.

Methods

A pragmatic multicenter, block-randomized controlled trial with 2 study arms, standard care (control) and eHealth-assisted standard care (intervention), for patients undergoing radical prostatectomy. For 80% power, a sample of 242 men will need to be recruited.

Results

Recruitment started in January 2018 and is expected to be completed by August 2019. Data collection will be completed in August 2020. The first cross-sectional results from this trial are anticipated to be published in January 2020.

Conclusions

With the increasing number of prostate cancer survivors, attention should be paid to rehabilitation, psychosocial care, and support for endurance of self-care to reduce suffering from adverse treatment effects, poor quality of life, and depression because of postoperative complications. This project may increase knowledge of how patients can be supported to feel involved in their care and returning to as normal a life as possible. The anticipated effects of ePATH could improve health outcomes for individuals and facilitate follow-up for health care professionals.

Trial Registration

International Standard Randomised Controlled Trial Number: 18055968; http://www.isrctn.com/ISRCTN18055968 (Archived by WebCite at http://www.isrctn.com/ISRCTN18055968).

International Registered Report Identifier (IRRID)

DERR1-10.2196/11625

Electronic Systems for Patients to Report and Manage Side Effects of Cancer Treatment: Systematic Review

BACKGROUND

There has been a dramatic increase in the development of electronic systems to support cancer patients to report and manage side effects of treatment from home. Systems vary in the features they offer to patients, which may affect how patients engage with them and how they improve patient-centered outcomes.

OBJECTIVE

This review aimed to (1) describe the features and functions of existing electronic symptom reporting systems (eg, symptom monitoring, tailored self-management advice), and (2) explore which features may be associated with patient engagement and patient-centered outcomes.

METHODS

The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and followed guidelines from the Centre for Reviews and Dissemination (University of York, United Kingdom). Primary searches were undertaken of MEDLINE, Embase, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, and the Health Technology Assessment databases. Secondary searches were undertaken by screening reference lists and citations. Two researchers applied broad inclusion criteria to identify and select relevant records. Data were extracted and summarized using Microsoft Excel. In order to meet the aims, the study selection, data extraction, and data synthesis comprised two stages: (1) identifying and characterizing available systems and (2) summarizing data on patient engagement and patient-centered outcomes.

RESULTS

We identified 77 publications relating to 41 distinct systems. In Stage 1, all publications were included (N=77). The features identified that supported clinicians and care were facility for health professionals to remotely access and monitor patient-reported data (24/41, 58%) and function to send alerts to health professionals for severe symptoms (17/41, 41%). Features that supported patients were facility for patients to monitor/review their symptom reports over time (eg, graphs) (19/41, 46%), general patient information about cancer treatment and side effects (17/41, 41%), tailored automated patient advice on symptom management (12/41, 29%), feature for patients to communicate with the health care team (6/41, 15%), and a forum for patients to communicate with one another (4/41, 10%). In Stage 2, only publications that included some data on patient engagement or patient-centered outcomes were included (N=29). A lack of consistency between studies in how engagement was defined, measured, or reported, and a wide range of methods chosen to evaluate systems meant that it was not possible to compare across studies or make conclusions on relationships with system features.

CONCLUSIONS

Electronic systems have the potential to help patients manage side effects of cancer treatment, with some evidence to suggest a positive effect on patient-centered outcomes. However, comparison across studies is difficult due to the wide range of assessment tools used. There is a need to develop guidelines for assessing and reporting engagement with systems, and a set of core outcomes for evaluation. We hope that this review will contribute to the field by introducing a taxonomy for characterizing system features.

TRIAL REGISTRATION

PROSPERO CRD42016035915; www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016035915.

A Library of Analytic Indicators to Evaluate Effective Engagement with Consumer mHealth Apps for Chronic Conditions: Scoping Review

Background

There is mixed evidence to support current ambitions for mobile health (mHealth) apps to improve chronic health and well-being. One proposed explanation for this variable effect is that users do not engage with apps as intended. The application of analytics, defined as the use of data to generate new insights, is an emerging approach to study and interpret engagement with mHealth interventions.

Objective

This study aimed to consolidate how analytic indicators of engagement have previously been applied across clinical and technological contexts, to inform how they might be optimally applied in future evaluations.

Methods

We conducted a scoping review to catalog the range of analytic indicators being used in evaluations of consumer mHealth apps for chronic conditions. We categorized studies according to app structure and application of engagement data and calculated descriptive data for each category. Chi-square and Fisher exact tests of independence were applied to calculate differences between coded variables.

Results

A total of 41 studies met our inclusion criteria. The average mHealth evaluation included for review was a two-group pretest-posttest randomized controlled trial of a hybrid-structured app for mental health self-management, had 103 participants, lasted 5 months, did not provide access to health care provider services, measured 3 analytic indicators of engagement, segmented users based on engagement data, applied engagement data for descriptive analyses, and did not report on attrition. Across the reviewed studies, engagement was measured using the following 7 analytic indicators: the number of measures recorded (76%, 31/41), the frequency of interactions logged (73%, 30/41), the number of features accessed (49%, 20/41), the number of log-ins or sessions logged (46%, 19/41), the number of modules or lessons started or completed (29%, 12/41), time spent engaging with the app (27%, 11/41), and the number or content of pages accessed (17%, 7/41). Engagement with unstructured apps was mostly measured by the number of features accessed (8/10, P=.04), and engagement with hybrid apps was mostly measured by the number of measures recorded (21/24, P=.03). A total of 24 studies presented, described, or summarized the data generated from applying analytic indicators to measure engagement. The remaining 17 studies used or planned to use these data to infer a relationship between engagement patterns and intended outcomes.

Conclusions

Although researchers measured on average 3 indicators in a single study, the majority reported findings descriptively and did not further investigate how engagement with an app contributed to its impact on health and well-being. Researchers are gaining nuanced insights into engagement but are not yet characterizing effective engagement for improved outcomes. Raising the standard of mHealth app efficacy through measuring analytic indicators of engagement may enable greater confidence in the causal impact of apps on improved chronic health and well-being.

Lower urinary tract symptoms in patients with prostate cancer under and after intensity-modulated radiation therapy

OBJECTIVE

The aim of the present study was to collect data on the characteristics, degree, and natural course of urinary complications, as well as self-care for such complications, in patients during and after prostate intensity-modulated radiation therapy (IMRT).

METHODS

Quality of life data were collected retrospectively for all eligible patients who underwent IMRT. In all eligible patients, urinary symptoms were evaluated using questionnaires and face-to-face interview. Participants were asked to respond to a self-administered questionnaire concerning the core lower urinary tract symptom score during the course of IMRT and up to 12 months after the completion of IMRT.

RESULTS

In all, 29 eligible patients were included in the study. The frequency of urinary symptoms increased over of the course of IMRT, decreased at ≥3 months after completion of IMRT, and disappeared 6 months after IMRT. Responses to the questionnaire revealed a variety of approaches to self-care and adaptations by patients to manage urinary symptoms.

CONCLUSIONS

During and after IMRT for localized prostate cancer, patients often developed more frequent urination and urgency than at the start of IMRT, and recovered 3-6 months after the completion of IMRT. Based on the present study, clinicians and nurses could help convey this information to patients and thus offer better support.

The timeliness of patients reporting the side effects of chemotherapy

PURPOSE

To explore the actions cancer patients reported they would take in response to a range of common side effects of chemotherapy and whether these were considered appropriate based on current guidelines and evidence; and to explore the sociodemographic and cancer-related variables associated with patients selecting the appropriate action (immediate medical attention or reporting) for two potentially life-threatening side effects: fever, and unusual bleeding and bruising.

METHODS

Four hundred thirty-six medical oncology and haematology patients receiving chemotherapy completed two surveys to provide demographic, disease and treatment characteristics, and details on how they would respond if they experienced a range of specified side effects of chemotherapy (for example, nausea and vomiting, fatigue, and skin rash or nail changes). The proportion of patients reporting the appropriate action for each side effect was calculated. Multiple logistic regressions examined the patient demographic and cancer characteristics associated with selecting the appropriate action (seeking immediate medical attention) for two potentially life-threatening side effects of chemotherapy: high fever of 38 °C or more, and unusual bleeding or bruising.

RESULTS

Two thirds of patients indicated that they would seek immediate medical attention for high fever (67%), but only 41% would seek immediate attention for bleeding or bruising. Cancer type and time since diagnosis were significantly associated with patients indicating that they would seek immediate medical attention for high fever; while time since diagnosis was the only variable significantly associated with patients reporting that they would seek immediate medical attention for unusual bleeding or bruising. For chronic side effects, like skin rash or nail changes, and tingling or numbness, which usually do not require urgent reporting, only between 12 and 16% would report them immediately. A significant proportion of patients reported that they would "do nothing" about fatigue or tiredness (24%). By comparison, less than 10% patients reported that they would do nothing for the other side effects investigated.

CONCLUSIONS

Tools need to be created so that patients better understand the side effects after being treated with chemotherapy and what action they should take.