Telehealth Chapter 3: Telemedicine and Cancer Care
This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020
Magalhaes, B et al (2020) [Systematic Review] The use of mobile applications for managing care processes during chemotherapy treatments: a systematic review
The aim of this study was to gather scientific evidence about the efficacy of the use of mobile apps during chemotherapy treatments. A systematic review of quantitative studies was performed. Based on the available research, mobile apps are likely to be a useful and acceptable tool to monitor interventions and complications. In addition, mobile apps can help in the self-management of treatment-related complications. Importantly, these apps need to bridge the academic context and clinical practice, by evaluating the impact of the use of mobile apps in patients. The concept of prescribing apps is being addressed to ensure that apps work and have fair privacy and data security policies that address safety requirements.
Abahussin, AA et al (2019) [Systematic Review] PROMs for pain in adult cancer patients: a systematic review of measurement properties
The objective of this study is to systematically review measurement properties of patient-reported outcome measures (PROMs) used for adult cancer patients to measure pain and, as a secondary goal, to investigate the evidence of validated mobile health (mHealth) applications used to measure pain. Abahussin et al conclude that better quality validation studies of PROMs for cancer pain are needed to explore the full range of measurement properties. Utilising mHealth applications to measure pain in cancer patients is an innovative approach worthy of further investigation.
Bártolo, A et al (2019) [Systematic Review] Effectiveness of psycho-educational interventions with telecommunication technologies on emotional distress and quality of life of adult cancer patients: a systematic review
The purpose of this study was to provide a comprehensive review of psycho-educational interventions using telecommunication technologies developed for adult cancer patients, assessing their effectiveness in reducing emotional distress and improving quality of life. Bártolo et al found the efficacy of interventions using distance approaches in the cancer setting is still not well-established. Further research should be conducted through well-designed studies with more interactive features that minimize the lack of face-to-face interaction. Programs using telecommunications technologies may reduce disparities in service delivery within this setting, minimizing geographic and socio-economic barriers to engagement in the interventions. With the current technological development, it is possible to perform more interactive interventions that stimulate therapist-patient interactions. However, available protocols in this field still employ basic resources: eg websites, email, and videos. Young adult cancer patients are exposed to additional requirements related to fertility and parenthood. New intervention approaches should consider their informational needs.
Hernandez Silva, E et al (2019) [Systematic Review] The effectiveness of mHealth for self-management in improving pain, psychological distress, fatigue, and sleep in cancer survivors: a systematic review
The authors aim to assess the effectiveness of mHealth applications for self-management in improving pain, psychological distress, fatigue, or sleep outcomes in adult cancer survivors. Experimental quantitative studies evaluating apps aiming to support self-management for adult cancer survivors and reporting pain, psychological distress, fatigue, or sleep outcomes were included. There is emerging evidence that mHealth interventions that support self-management can improve pain and fatigue outcomes in cancer survivors, and some promise for psychological distress and sleep outcomes. Further development and investigation of mHealth is needed, incorporating targeted, evidence-based models of care into app design. mHealth interventions can improve outcomes for cancer survivors and have significant potential to benefit this growing population due to their reach.
Jongerius, C et al (2019) [Systematic Review] Research-tested mobile apps for breast cancer care: systematic review
The main objective of this review was to provide an overview of the available research-tested interventions using mHealth apps and their impact on breast cancer care. The results indicate consistent and promising findings of interventions using mHealth apps that target care management in breast cancer. Among the categories of mHealth apps focusing on survivorship, mHealth-based interventions showed a positive effect by promoting weight loss, improving the quality of life, and decreasing stress. There is conflicting and less conclusive data on the effect of mHealth apps on psychological dimensions. The authors advocate further investigation to confirm and strengthen these findings. No consistent evidence for the impact of interventions using mHealth apps in breast cancer prevention and early detection was identified due to the limited number of studies identified by the search. Future research should continue to explore the impact of mHealth apps on breast cancer care to build on these initial recommendations.
Vergani, L et al (2019) [Systematic Review] Training cognitive functions using mobile apps in breast cancer patients: systematic review
This systematic review gives an overview of the state-of-the-art mobile apps aimed at training cognitive functions to better understand whether these apps could be useful tools to counteract cognitive impairment in breast cancer patients. The authors systematically searched all the full-text articles from both PubMed and Embase. Their results highlight the lack of empirical evidence on the efficacy of currently available apps to train cognitive function. Cognitive domains are not well defined across studies. It is noteworthy that no apps are specifically developed for cancer patients, and their applicability to breast cancer should not be taken for granted. Future studies should test the feasibility, usability, and effectiveness of available cognitive training apps in women with breast cancer. Due to the complexity and multidimensionality of cognitive difficulties in this cancer population, it may be useful to design, develop, and implement an ad hoc app targeting cognitive impairment in breast cancer patients.
Han, CJ et al (2018) [Systematic Review] Interventions using social media for cancer prevention and management: a systematic review
Han et al aim to systematically review intervention studies using social media for cancer care. A systematic search, using seven electronic databases was conducted to identify surveys and interventions using contemporary social media tools with a focus on cancer. Based on their findings, the authors conclude that social media tools have the potential to be effective in delivering interventions for cancer prevention and management. However, there was a dearth of studies with rigorous study methodologies to test social media effects on various cancer-related clinical outcomes. Social media use in cancer care will facilitate improved communication and support among patients, caregivers, and clinicians and, ultimately, improved patient care. Clinicians need to carefully harness social media to enhance patient care and clinical outcomes.
Moradian, S et al (2018) [Systematic Review] Effectiveness of Internet-based interventions in managing chemotherapy-related symptoms in patients with cancer: a systematic literature review
The aims of this review were to: 1. examine the effectiveness of Internet-based interventions on cancer chemotherapy-related physical symptoms [severity and/or distress] and health-related quality of life outcomes; and 2. identify the design elements and processes for implementing these interventions in oncology practices. Despite the evidence in support of using the Internet as a worthwhile tool for effective patient engagement and self-management of chemotherapy-related symptoms outside clinic visits, methodological limitations in the evidence base require further well-planned and quality research.
Chen, YY et al (2018) [Meta-Analysis] Effect of telehealth intervention on breast cancer patients’ quality of life and psychological outcomes: A meta-analysis
Telehealth intervention has been proposed as an innovative intervention approach to breast cancer patients, but there are still conflicting results in the literature about its effect. PubMed, EMBASE, CENTRAL and China National Knowledge Infrastructure were searched from inception to October 2016 for randomized controlled trials which assessed the effect of telehealth intervention versus usual care in breast cancer patients. Telehealth intervention is superior to usual care in breast cancer patients for improved quality of life, higher self-efficacy and less depression, distress, and perceived stress. However, these results should be recognized cautiously due to between-study heterogeneity, indicating that further well-designed RCTs are warranted.
Cox, A et al (2017) [Systematic Review] Cancer survivors’ experience with telehealth: a systematic review and thematic synthesis
The objective of this study was to systematically identify, appraise, and synthesize qualitative research evidence on the experiences of adult cancer survivors participating in telehealth interventions, to characterize the patient experience of telehealth interventions for this group. Across the included papers, three analytical themes emerged, each with three descriptive subthemes: 1. influence of telehealth on the disrupted lives of cancer survivors [convenience, independence, and burden]; 2. personalized care across physical distance [time, space, and the human factor]; and 3. remote reassurance-a safety net of health care professional connection [active connection, passive connection, and slipping through the net]. Telehealth interventions represent a convenient approach, which can potentially minimize treatment burden and disruption to cancer survivors’ lives. Telehealth interventions can facilitate an experience of personalized care and reassurance for those living with and beyond cancer; however, it is important to consider individual factors when tailoring interventions to ensure engagement promotes benefit rather than burden. Telehealth interventions can provide cancer survivors with independence and reassurance. Future telehealth interventions need to be developed iteratively in collaboration with a broad range of cancer survivors to maximize engagement and benefit.
Roberts, AL et al (2017) [Systematic Review and Meta-Analysis] Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis
Digital behaviour change interventions (DBCIs) have the potential to reach large numbers of cancer survivors. Roberts et al conducted a systematic review and meta-analyses of relevant studies identified by a search of Medline, EMBASE, PubMed and CINAHL. Studies which assessed a DBCI with measures of physical activity (PA), diet and/or sedentary behaviour were included. DBCIs may improve PA and BMI among cancer survivors, and there is mixed evidence for diet. The number of included studies is small, and risk of bias and heterogeneity was high. Future research should address these limitations with large, high-quality RCTs, with objective measures of PA and sedentary time. Digital technologies offer a promising approach to encourage health behaviour change among cancer survivors.
Randomised Controlled Trials
Greer, JA et al (2020) [Randomised Controlled Trial] Randomized trial of a smartphone mobile app to improve symptoms and adherence to oral therapy for cancer
The authors conducted a randomized trial to test the use of a smartphone mobile app to improve symptoms and adherence to oral cancer therapy. From February 18, 2015, through December 31, 2016, 181 patients with diverse cancers who were prescribed oral therapy were randomized to receive either the smartphone mobile app or standard care. The mobile app included a medication plan with reminders, a symptom-reporting module, and patient education. Primary outcomes were adherence (per electronic pill caps), symptom burden (per MD Anderson Symptom Inventory), and quality of life (per the Functional Assessment of Cancer Therapy-General). Participants also completed self-report measures of medication adherence, anxiety and depression symptoms, social support, quality of care, and healthcare utilization. Although the mobile app may not improve outcomes for all patients prescribed oral cancer therapy, the intervention may be beneficial for those with certain risk factors, such as difficulties with adherence or anxiety.
Handa, S et al (2020) [Randomised Controlled Trial] Effectiveness of a smartphone application as a support tool for patients undergoing breast cancer chemotherapy: a randomized controlled trial
The effectiveness of a smartphone application as a support tool for patients undergoing breast cancer chemotherapy was tested in a randomized clinical trial, with 102 patients assigned to an app-using or a control group. Hospital-related anxiety, health literacy, and side effects were recorded. Sharing patients’ reports through a smartphone app might optimize chemotherapy and deliver suitable support. Of the 102 patients, 95 completed the present study. No significant improvement was seen in anxiety, depression, or health literacy at the end of treatment between the BPSS and no-BPSS app groups. Overall, 1868 side effects were reported. When the patients’ records were compared with the medical staff records, the analysis revealed that the medical staff had underestimated some grade 3 symptoms. The BPSS app is a feasible tool for patients with breast cancer and might be useful as a support tool for information sharing between patients and medical staff in an effort to optimize chemotherapy and deliver suitable patient care and support.
Zhou, K et al (2020) [Randomised Controlled Trial] Benefits of a WeChat-based multimodal nursing program on early rehabilitation in postoperative women with breast cancer: A clinical randomized controlled trial
This study aimed to evaluate the benefits of a WeChat-based multimodal nursing program on early rehabilitation in postoperative women with breast cancer. The researchers recruited patients with breast cancer and randomly allocated them to the intervention and control groups. The former was subjected to the WeChat-based multimodal nursing program plus routine nursing care for 6 months, whereas the latter received only routine nursing care. They found a significant improvement in the health-related quality of life of postoperative women with breast cancer who used the WeChat-based multimodal nursing program during early rehabilitation. This demonstrated that the program is an effective intervention for postoperative rehabilitation in such patients. Findings of the study will provide evidence for eHealth services in clinical and transitional nursing care.
Ariza-Garcia, A et al (2019) [Randomised Controlled Trial] A web-based exercise system (e-CuidateChemo) to counter the side effects of chemotherapy in patients with breast cancer: randomized controlled trial
This study aimed to evaluate the effectiveness of a web-based exercise program e-CuidateChemo to mitigate the side effects of chemotherapy on the physical being, anthropometric aspects, and body composition. A total of 68 patients diagnosed with breast cancer, who were undergoing chemotherapy, were enrolled. The patients were categorized into two groups: e-CuidateChemo (n=34) and controls (n=34). The e-CuidateChemo group participated in an adapted 8-week tailored exercise program through a web-based system. A blinded, trained researcher assessed functional capacity, strength, anthropometric parameters, and body composition. The intervention effects were tested using analysis of covariance and Cohen d tests. This paper showed that a web-based exercise program was effective in reversing the detriment in functional capacity and strength due to chemotherapy.
Kelleher, SA et al (2019) [Randomised Controlled Trial] A behavioral cancer pain intervention: A randomized noninferiority trial comparing in-person with videoconference delivery
This study compared videoconference-delivered mobile health pain coping skills training (mPCST) to in-person pain coping skills training (PCST-traditional). This was a randomized, non-inferiority trial with cancer patients. Participants were randomly assigned to four, 45-minute sessions of mPCST or PCST-traditional. Session content focused on evidence-based cognitive and behavioural pain management skills. Assessments were completed at baseline, post-treatment, and 3-month post-treatment and included measures of primary intervention outcomes [ie pain severity and pain interference] and secondary intervention outcomes [ie physical symptoms, psychological distress, physical well-being, and self-efficacy]. The authors conclude that mPCST is highly accessible and noninferior to PCST-traditional.
Kubo, A et al (2019) [Randomised Controlled Trial] A randomized controlled trial of mHealth mindfulness intervention for cancer patients and informal cancer caregivers: a feasibility study within an integrated health care delivery system
The purpose of this research was to assess feasibility and preliminary efficacy of a mobile/online-based (mHealth) mindfulness intervention for cancer patients and their caregivers to reduce distress and improve quality of life (QoL). Two-arm randomized controlled trial within Kaiser Permanente Northern California targeting cancer patients who received chemotherapy and their informal caregivers. The intervention group received a commercially available mindfulness program for 8 weeks. The wait-list control group received usual care. Kubo et al assessed feasibility using retention and adherence rates and obtained participant-reported data on distress, QoL, sleep, mindfulness, and posttraumatic growth before and immediately after the intervention. The authors conclude that results from fully powered efficacy trials would inform the potential for clinicians to use this scalable intervention to help improve QoL of those affected by cancer and their caregivers.
Van Blarigan, EL et al (2019) [Randomised Controlled Trial] Self-monitoring and reminder text messages to increase physical activity in colorectal cancer survivors (Smart Pace): a pilot randomized controlled trial
Van Blarigan et al conducted a 2-arm non-blinded pilot randomised controlled trial. Participants were randomised 1:1 to receive the intervention with print educational materials or print educational materials alone. They explored the impact of the intervention versus usual care on physical activity using ActiGraph GT3X+ accelerometers pre-/post-intervention. They screened 406 individuals and randomised 42 to intervention (n = 21) or control (n = 21) groups. During the 12-week study, the intervention arm wore their Fitbits a median of 74 days [88% of days in study period, interquartile range: 23-83 days] and responded to a median of 34 out of 46 text messages that asked for a reply [interquartile range: 13-38 text messages]. Among the 16 intervention participants who completed the feedback survey, the majority (88%) reported that the intervention motivated them to exercise and that they were satisfied with their experience. No statistically significant difference in change in moderate-to-vigorous physical activity was found from baseline to 12 weeks between arms. A 12-week physical activity intervention with a Fitbit and text messages was feasible and acceptable among colorectal cancer patients after curative treatment. Larger studies are needed to determine whether the intervention increases physical activity.
Wall, LR et al (2019) [Randomised Controlled Trial] Economic analysis of a three-arm RCT exploring the delivery of intensive, prophylactic swallowing therapy to patients with head and neck cancer during (chemo) radiotherapy
Research advocates for the use of intensive, prophylactic swallowing therapy to help reduce the severity of dysphagia in patients receiving (chemo) radiotherapy (CRT) for head/neck cancer (HNC). Unfortunately, the intensity of this therapy, coupled with growing patient numbers and limited clinical resources, provides challenges to many international cancer facilities. Telepractice has been proposed as a potential method to provide patients with greater support in home-practice, whilst minimising burden to the health service. This study investigated the clinical and patient-attributable costs of delivering an intensive, prophylactic swallowing therapy protocol via a new telepractice application SwallowIT as compared to clinician-directed FTF therapy and independent patient self-directed therapy. SwallowIT provided a cost-efficient model of care when compared to the clinician-directed model. The SwallowIT model also proved more cost-effective than the patient-directed model, yielding clinically significantly superior QoL at the end of (C)RT, for comparable costs. Overall, when compared to the alternate methods of service-delivery, SwallowIT provided a financially viable and cost-effective method for the delivery of intensive, prophylactic swallowing therapy to patients with HNC during (C)RT.
Yang, J et al (2019) [Randomised Controlled Trial] Development and testing of a mobile app for pain management among cancer patients discharged from hospital treatment: randomized controlled trial
The aim was to design, construct, and test the Pain Guard app in patients managing cancer pain, evaluate the total remission rate of pain and the improvement in quality of life (QoL) to improve pain management for cancer pain patients, and assess patient acceptance of the app. This randomised controlled double-arm study involved 58 patients with cancer pain symptoms. Participants were randomly assigned to a group receiving care through the Pain Guard app or to a control group who received only traditional pharmaceutical care. The system’s usability, feasibility, app compliance, and satisfaction were also assessed. The primary outcome was remission rate of pain, and secondary outcomes were medication adherence, improvements in QoL, frequency of breakthrough cancer pain (BTcP), incidence of adverse reactions, and satisfaction of patients. Pain Guard was effective for the management of pain in discharged patients with cancer pain, and its operability was effective and easily accepted by patients.
Graetz, I et al (2018) [Randomised Controlled Trial] Use of a web-based app to improve breast cancer symptom management and adherence for aromatase inhibitors: a randomized controlled feasibility trial
Graetz et al conducted a pilot randomized controlled trial to test the use of a web-based application (app) designed with and without weekly reminders for patients to report real-time symptoms and AI use outside of clinic visits with built-in alerts to patients’ oncology providers. Their goal was to improve symptom burden and medication adherence. Forty-four women with early-stage breast cancer and a new AI prescription were randomized to either an App+Reminder [weekly reminders to use app] or an App [no reminders] group. Pre- and post-assessment data were collected from all participants. Weekly reminders to use a web-based app to report AI adherence and treatment-related symptoms demonstrated feasibility and improved short-term AI adherence, which may reduce symptom burden for women with breast cancer and a new AI prescription. If short-term gains in adherence persist, this low-cost intervention could improve survival outcomes for women with breast cancer. A larger, long-term study should examine if AI adherence and symptom burden improvements persist for a 5-year treatment period.
Kim, HJ et al (2018) [Randomised Controlled Trial] A mobile game for patients with breast cancer for chemotherapy self-management and quality-of-life improvement: randomized controlled trial
The objective of this study was to evaluate if patient education using a mobile game may increase drug compliance, decrease physical side effects of chemotherapy, and improve psychological status in breast cancer patients. A total of 76 patients with metastatic breast cancer who were planned to receive cytotoxic chemotherapy were enrolled in this trial. Study participants were randomly assigned to a mobile game play group or a conventional education group. The patients were unblinded and followed prospectively for three weeks. Outcome measures included time spent for education, compliance to medication, physical side effects, and psychological side effects including quality of life (QoL). Results from the study suggest the feasibility and potentiality of the use of smartphone mobile games for patients with breast cancer receiving chemotherapy. Education using a mobile game led to better patient education, improved drug compliance, decreased side effects, and better QoL compared with conventional education. Mobile games can be used as easy, fun, and effective measures for patient education and have the potential to improve treatment outcomes.
Ormel, HL et al (2018) [Randomised Controlled Trial] Self-monitoring physical activity with a smartphone application in cancer patients: a randomized feasibility study (SMART-trial)
This study aimed to examine whether using RunKeeper to increase self-reported PA is feasible in cancer patients and to evaluate patients’ opinion about using RunKeeper in a 12-week programme. Self-monitoring PA with RunKeeper was safe and feasible in cancer patients. Adult patients (n = 32), diagnosed with cancer, were randomised between usual care (n = 16) or a 12-week intervention with instructions to self-monitor PA with RunKeeper (n = 16). Changes in PA were determined with the Physical Activity Scale for the Elderly (PASE) at baseline (T0), 6 weeks (T1), and 12 weeks (T2). Usability and patients’ experiences were tested at T2 with the System Usability Scale (SUS) and a semi-structured interview. The RunKeeper use resulted in an increase in PA after 6 weeks. Ormel et al conclude that RunKeeper usability was rated good and can be used to study PA in cancer patients.
Petzel, SV et al (2018) [Randomised Controlled Trial] Effects of web-based instruction and patient preferences on patient-reported outcomes and learning for women with advanced ovarian cancer: A randomized controlled trial
A randomised controlled trial was conducted of a web-based intervention to improve advanced care planning in women with ovarian cancer. A secondary analysis of 35 randomized women focused on changes in distress and knowledge about ovarian cancer through distress monitoring and information tailored to patients’ cognitive coping style. Pre-/postresults indicated the Intervention group demonstrated lower distress (p = 0.06); blunting was associated with lower depression (p = 0.04); knowledge in both groups was unchanged. Women in the Intervention vs. Control group reported their family was less likely to be upset by cancer information (p = 0.0004). This intervention reduced distress while incorporating patient preferences.
Bray, VJ et al (2017) [Randomised Controlled Trial] Evaluation of a web-based cognitive rehabilitation program in cancer survivors reporting cognitive symptoms after chemotherapy
Bray et al evaluated a cognitive rehabilitation program (Insight) and compared it with standard care in cancer survivors self-reporting cognitive symptoms. They recruited adult cancer survivors with a primary malignancy excluding central nervous system malignancies who had completed three or more cycles of adjuvant chemotherapy in the previous 6 to 60 months and reported persistent cognitive symptoms. All participants received a 30-minute telephone consultation and were then randomly assigned to the 15-week, home-based intervention or to standard care. The intervention, Insight, led to improvements in cognitive symptoms compared with standard care. To the authors’ knowledge, this is the first large randomized controlled trial showing an improvement in self-reported cognitive function in cancer survivors, indicating that this intervention is a feasible treatment.
Mooney, KH et al (2017) [Randomised Controlled Trial] Automated home monitoring and management of patient-reported symptoms during chemotherapy: results of the symptom care at home RCT
In a randomised controlled trial, the efficacy of an automated symptom management system was tested to determine if it reduced chemotherapy-related symptoms. Prospectively, 358 patients beginning chemotherapy were randomized to the Symptom Care at Home (SCH) intervention (n = 180) or enhanced usual care (UC) (n = 178). Participants called the automated monitoring system daily reporting severity of 11 symptoms. SCH participants received automated self-management coaching and nurse practitioner (NP) telephone follow-up for poorly controlled symptoms. NPs used a guideline-based decision support system. Primary endpoints were symptom severity across all symptoms, and the number of severe, moderate, mild, and no symptom days. A secondary endpoint was individual symptom severity. All individual symptoms, except diarrhoea, were significantly lower for SCH participants (P < 0.05). Symptom Care at Home dramatically improved symptom outcomes. These results demonstrate that symptoms can be improved through automated home monitoring and follow-up to intensify care for poorly controlled symptoms.
Zhu, J et al (2017) [Randomised Controlled Trial] A mobile application of breast cancer e-support program versus routine care in the treatment of Chinese women with breast cancer undergoing chemotherapy: study protocol for a randomized controlled trial
Breast Cancer e-Support is a mobile application program that provides patients with individually tailored information and a support group of peers and health care professionals. Breast Cancer e-Support aims to promote women’s self-efficacy, social support and symptom management, thus improving their quality of life and psychological well-being. This is the first study of its kind in China to evaluate the use of a mobile application intervention with a rigorous research design and theoretical framework. This study will contribute to evidence regarding the effectiveness of a theory-based mobile application to support women with breast cancer undergoing chemotherapy. The results should provide a better understanding of the role of self-efficacy and social support in reducing symptom distress and of the credibility of using a theoretical framework to develop Internet-based interventions. The results will provide evidence to support the implementation of an innovative and easily accessible intervention that enhances health outcomes.
Basch, E et al (2016) [Randomised Controlled Trial] Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial
There is growing interest to enhance symptom monitoring during routine cancer care using patient-reported outcomes, but evidence of impact on clinical outcomes is limited. The authors randomly assigned patients receiving routine outpatient chemotherapy for advanced solid tumours to report 12 common symptoms via tablet computers or to receive usual care consisting of symptom monitoring at the discretion of clinicians. Those with home computers received weekly e-mail prompts to report between visits. Treating physicians received symptom printouts at visits, and nurses received e-mail alerts when participants reported severe or worsening symptoms. The primary outcome was change in health-related quality of life at 6 months compared with baseline, measured by the EuroQol EQ-5D Index. Secondary endpoints included emergency room visits, hospitalizations, and survival. Benefits were greater for participants lacking prior computer experience. Most patients receiving intervention (63%) reported severe symptoms during the study. Nurses frequently initiated clinical actions in response to e-mail alerts. Clinical benefits were associated with symptom self-reporting during cancer care.
Egbring, M et al (2016) [Randomised Controlled Trial] A mobile app to stabilize daily functional activity of breast cancer patients in collaboration with the physician: a randomized controlled clinical trial
The aim of the study was to evaluate the effects of a mobile app on patient-reported daily functional activity in a supervised and unsupervised setting. The researchers conducted a randomized controlled study of 139 breast cancer patients undergoing chemotherapy. Participants were randomly assigned to a control group, an unsupervised group that used a mobile app to record data, or a supervised group that used the app and reviewed data with a physician. The mobile app was associated with stabilized daily functional activity when used under collaborative review. App-using participants could more frequently report adverse events, and those under supervision made fewer and more precise entries than unsupervised participants. Our findings suggest that patient well-being and awareness of chemotherapy adverse effects can be improved by using a mobile app in collaboration with the treating physician.
Foley, NM et al (2016) [Randomised Controlled Trial] PATI: Patient accessed tailored information: A pilot study to evaluate the effect on preoperative breast cancer patients of information delivered via a mobile application
The aim of this project was to evaluate the effects of a mobile information application on anxiety levels of patients undergoing surgery for breast cancer. An application was developed for use with Apple iPad containing information on basic breast cancer biology, different treatments used and surgical techniques. Anxiety and depression in breast cancer patients is both multifactorial and significant, with anxiety levels directly correlating with reduced quality of life. Intuitively, information should improve anxiety levels; however, Foley et al have demonstrated that surgical patients with less information reported significantly lower anxiety. They advise the thorough testing and auditing of information initiatives before deployment.
Kim, KK et al (2016) [Randomised Controlled Trial] A personal health network for chemotherapy care coordination: evaluation of usability among patients
This study evaluates the usability of the “personal health network” (PHN), a novel solution leveraging social networking and mobile technologies, among individuals undergoing chemotherapy and receiving care coordination. Early results from interviews of 12 participants in a randomized pragmatic trial suggest that they feel more connected to the healthcare team using the PHN, find value in access to the patient education library, and are better equipped to organise the many activities that occur during chemotherapy. Improvements are needed in navigation, connectivity, and integration with electronic health records. Findings contribute to improvements in the PHN, and inform a roadmap for potentially greater impact in technology-enabled cancer care coordination.
Schwenk, M et al (2016) [Randomised Controlled Trial] Interactive sensor-based balance training in older cancer patients with chemotherapy-induced peripheral neuropathy: A randomized controlled trial
This pilot study investigated the effect of an interactive motor adaptation balance training program based on wearable sensors for improving balance in older cancer patients with CIPN. Twenty-two patients (age: 70.3 +/- 8.7 years) with objectively confirmed CIPN were randomised to either an intervention or a control group. The intervention group received interactive game-based balance training including repetitive weight shifting and virtual obstacle crossing tasks. Wearable sensors provided real-time visual/auditory feedback from the lower limb trajectory and allowed the perception of motor errors during each motor action. The control group received no exercise intervention and continued their normal activity. This proof-of-concept study demonstrates that older cancer patients with CIPN can significantly improve their postural balance with specifically tailored, sensor-based exercise training. The training approach has potential as a therapy for improving CIPN-related postural control deficits. However, future studies comparing the proposed technology-based training with traditional balance training are required to evaluate the benefit of the interactive joint movement feedback.
Siekkinen, M et al (2015) [Randomised Controlled Trial] Psychosocial outcomes of e-feedback of radiotherapy for breast cancer patients: a randomized controlled trial
This study aims to test the effectiveness on psychosocial outcomes of electronic feedback knowledge of radiotherapy intervention [e-Re-Know] for breast cancer patients. A randomised controlled trial in one university hospital in Finland was carried out. Breast cancer patients (n = 126) in the radiotherapy (RT) department were randomly assigned into two groups: intervention (the e-Re-Know and standard education) and control group (standard education). The e-Re-Know intervention consisted of e-feedback after response to the knowledge test delivered by e-mail. Instruments were completed before commencing first RT (M1), after concluding last RT (M2) and 3 months after last RT (M3). The main outcomes were anxiety and QOL. Compared with the control group, the patients in the intervention group reported a marginally significant improvement in anxiety and significant improvement in QOL over time. The e-Re-Know seems to have positive effects on psychosocial outcomes for breast cancer patients. They might gain additional value from the e-Re-Know over a longer time period. Further research needs to focus more on development of e-feedback in patient education.
Spoelstra, SL et al (2015) [Randomised Controlled Trial] A randomized controlled trial of the feasibility and preliminary efficacy of a texting intervention on medication adherence in adults prescribed oral anti-cancer agents: study protocol
The aim of this study was to report a study protocol that examines feasibility, preliminary efficacy and satisfaction of a text message intervention on the outcome of medication adherence in adult patients prescribed oral anti-cancer agents. Research indicates patients miss nearly one-third of the prescribed oral anti-cancer agent dosages. Text message interventions have been shown to improve medication adherence in chronic conditions other than cancer. Standardised text message intervention protocol and detailed study procedures have been developed in this study to improve medication adherence.
Wang, P et al (2015) [Randomised Controlled Trial] Effect of remote Internet follow-up on postradiotherapy compliance among patients with esophageal cancer: a randomized controlled study
The aim of this study was to explore the effects of using remote Internet follow-up on post-radiotherapy compliance with medical advice provided to patients with oesophageal cancer. A total of 128 patients with oesophageal squamous cell cancer treated with radiotherapy were randomly assigned to either an observation group or a control group. The control group received routine outpatient follow-up, whereas the observation group received additional remote Internet follow-up for six months after discharge from the hospital. The treatment effects and compliance were investigated using a questionnaire. At three months and six months after discharge, patients in the observation group had sought significantly more consultations and undergone more periodic re-examinations than patients in the control group. Furthermore, both the disease-free survival rate and the symptom reduction rate were significantly higher in the observation group compared with the control group. Wang et al conclude that remote Internet follow-up is an easy and fast method for improving post-radiotherapy compliance with medical instructions and promoting normalisation among patients with oesophageal cancer.
Coats, V et al (2020) [Pilot Study] Feasibility of an eight-week telerehabilitation intervention for patients with unresectable thoracic neoplasia receiving chemotherapy: A pilot study
The aim of this study was to investigate the feasibility, adherence and satisfaction of a home-based telerehabilitation program [TELERP] with real-time physiological parameters acquisition in patients with unresectable thoracic neoplasia receiving chemotherapy and to explore its effects on patients’ functional capacity. Five patients receiving chemotherapy followed an 8-week TELERP using real-time monitoring combined with interactive exercises. The TELERP included supervised and unsupervised exercise sessions. The feasibility of the TELERP, adverse outcomes and adherence were analysed. Six-minute walking test (6MWT) and timed stair test (TST) were done to assess functional capacity. These results support the feasibility of a TELERP and suggest that such intervention may contribute to maintain or improve functional capacity for patients with thoracic neoplasia receiving chemotherapy.
Potdar, R et al (2020) [Cross-Sectional Study] Access to Internet, smartphone usage, and acceptability of mobile health technology among cancer patients
The use of mobile health (mHealth) technologies to augment patient care enables providers to communicate remotely with patients enhancing the quality of care and patient engagement. Few studies evaluated predictive factors of its acceptance and subsequent implementation, especially in medically underserved populations. A cross-sectional study of 151 cancer patients was conducted at an academic medical centre in the USA. A trained interviewer performed structured interviews regarding the barriers and facilitators of patients’ current and desired use of mHealth technology for healthcare services. The study suggests that factors such as age, educational achievement, and access to Internet are significant predictors of acceptability of a mHealth application among cancer patients. Healthcare organisations should consider these factors when launching patient engagement platforms.
Osborn, J et al (2020) [Review] Do mHealth applications improve clinical outcomes of patients with cancer? A critical appraisal of the peer-reviewed literature
The impact of usage of cancer-related mobile health (mHealth) applications on patient-related outcomes requires investigation. A critical appraisal of the literature was performed for the following question: In patients with cancer have mHealth applications been compared with usual care to examine impact on commonly used clinical outcomes? Smartphone applications or Internet portals collected data on symptoms or patient activity. Several studies showed statistically significant differences in patient-reported outcomes when symptom monitoring using mobile health application was compared to usual care. Change in mobility was the only outcome that was related directly to toxicity. Only limited data on mortality, cancer-related morbidity including complications of care, health-economic outcomes or long-term outcomes were reported. Studies on mHealth applications might improve aspects of symptom control in patients with cancer, but there is currently little evidence for impact on other outcomes. This requires future research in interventional studies.
Shalowitz, DI et al (2020) [Review] Telemedicine and gynecologic cancer care
Patients with gynaecologic cancers experience better outcomes when treated by specialists and institutions with experience in their diseases. Unfortunately, high-volume centres tend to be located in densely populated regions, leaving many women with geographic barriers to care. Remote management through telemedicine offers the possibility of decreasing these disparities by extending the reach of specialty expertise and minimizing travel burdens. Telemedicine can assist in diagnosis, treatment planning, preoperative and postoperative follow-up, administration of chemotherapy, provision of palliative care, and surveillance. Telemedical infrastructure requires careful consideration of the needs of relevant stakeholders including patients, caregivers, referring clinicians, specialists, and health system administrators.
Al-Shamsi, HO et al (2020) [Review. Article in Press] A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID-19) pandemic: an international collaborative group
In this review, the potential challenges associated with managing cancer patients during the COVID-19 infection pandemic will be addressed, with suggestions of some practical approaches. The main management strategies for treating cancer patients during the COVID-19 epidemic include clear communication and education about hand hygiene, infection control measures, high-risk exposure, and the signs and symptoms of COVID-19. Consideration of risk and benefit for active intervention in the cancer population must be individualized. Postponing elective surgery or adjuvant chemotherapy for cancer patients with low risk of progression should be considered on a case-by-case basis. Minimising outpatient visits can help to mitigate exposure and possible further transmission. Telemedicine may be used to support patients to minimize number of visits and risk of exposure.
Dorfman, CS et al (2019) [Clinical Trial] Development and pilot testing of an mHealth behavioral cancer pain protocol for medically underserved communities
The purpose of this study was to refine and test a mobile-health behavioural cancer pain coping skills training protocol for women with breast cancer and pain from medically underserved areas. Three focus groups (Phase 1) were used to refine the initial protocol. A single-arm pilot trial (Phase 2) was conducted to assess feasibility, acceptability, and changes in outcomes. The intervention was delivered at a community-based clinic via videoconferencing technology. Participants were women with breast cancer and pain in medically underserved areas. Major themes from focus groups were used to refine the intervention. The refined intervention demonstrated feasibility and acceptability. Participants reported significant improvement in pain severity, pain interference, and self-efficacy for pain management. The intervention is feasible, acceptable, and likely to lead to improvement in pain-related outcomes for breast cancer patients in medically underserved areas. Implications for Psychosocial Oncology Practice Breast cancer patients being treated in medically underserved areas have a dearth of exposure to behavioural interventions that may improve their ability to manage pain. Dorfman et al conclude that evidence from this single-arm pilot trial suggests their mobile-health behavioural cancer pain coping skills training protocol is acceptable and feasible in this vulnerable population. Appropriately adapted mobile-health technologies may provide an avenue to reach underserved patients and implement behavioural interventions to improve pain management.
Ohri, N et al (2019) [Clinical Trial] Daily step counts: a new prognostic factor in locally advanced non-small cell lung cancer?
Ohri et al explore the prognostic value of baseline step count data captured using wearable devices for patients treated with definitive chemoradiation therapy for locally advanced non-small cell lung cancer (NSCLC). Patients with locally advanced NSCLC wore a commercial fitness tracker during a course of definitive, concurrent chemoradiation therapy as part of a clinical trial. Baseline activity level measured using wearable devices may help identify patients with NSCLC who are fit for concurrent chemoradiation therapy and can predict clinical outcomes in this setting.
Terstriep, SA et al (2019) [Conference Abstract] Use of remote symptom monitoring with breast cancer survivors using patient reported outcome measures through Epic Mychart
This pilot study of breast cancer survivors assessed utilisation and satisfaction of proactive PRO symptom and adherence monitoring through an EHR patient portal (EPIC MyChart). Eighty breast cancer survivors who had completed surgery, chemotherapy, and/or radiation and received a survivorship care plan were randomised 1:1 either to usual care or PRO monitoring. The PRO group received questions from the NIH PROMIS toolkit through EPIC MyChart monthly between visits for 6 months. The triage nurse received an EPIC Inbasket alert if the survivor reported moderate to severe symptoms, had not taken their medication or reported they wanted to speak to a nurse. Participants in the control group were assessed for sadness, anxiety and satisfaction with provider communication at their usual follow visits. Remote electronic monitoring of symptoms and adherence through the EHR bet was feasible with high completion rates, improved satisfaction, and did not increase anxiety in breast cancer survivors. Follow up work is assessing PRO monitoring to improve efficiency of following cancer survivors, and implementation of survivorship care plans.
Bae, WK et al (2018) [Clinical Trial] Feasibility and accessibility of electronic patient-reported outcome measures using a smartphone during routine chemotherapy: a pilot study
Bae et al evaluated the feasibility and accessibility of electronic patient-reported outcomes (PRO) measures using a smartphone (PRO-SMART) for cancer patients receiving routine chemotherapy. The proposed PRO-SMART application obtains daily personal health record (PHR) data from cancer patients via a smartphone. An analysis report of cumulative PHR data is provided to the clinician in a format suitable for upload to electronic medical records. Cancer outpatients who had received at least two cycles of chemotherapy, and who were scheduled for two more cycles were enrolled. This study suggests that the proposed PRO-SMART is feasible and accessible for assessment of symptomatic adverse events in cancer patients receiving chemotherapy for a prospective randomised trial.
Cheong, IY et al (2018) [Clinical Trial] Efficacy of mobile health care application and wearable device in improvement of physical performance in colorectal cancer patients undergoing chemotherapy
The aim of this study was to evaluate the efficacy and feasibility of comprehensive mobile health care using a tailored rehabilitation program for colorectal cancer patients undergoing active chemotherapy. A total of 102 colorectal cancer patients undergoing chemotherapy underwent 12 weeks of smartphone aftercare through provision of a mobile application and wearable device that included a rehabilitation exercise program and information on their disease and treatment. The grip strength test, 30-second chair stand test, 2-minute walk test, amount of physical activity, quality of life and nutritional status were assessed and measured at baseline, at mid-intervention, and at completion of the intervention. The rehabilitation exercise intensity was adjusted by the test results at every assessment and through real-time communication between the patients and clinicians. A tailored rehabilitation exercise programme provided through a comprehensive mobile health care application was effective in improving patients’ physical capacity and treatment-related symptoms even during active chemotherapy.
Hardcastle, SJ et al (2018) [Clinical Trial] Acceptability and utility of, and preference for wearable activity trackers amongst non-metropolitan cancer survivors
The study purpose was to investigate the acceptability and utility of, and preference for, wearable activity trackers (WATs) amongst cancer survivors living in regional and remote areas of Western Australia. Twenty participants were recruited to test two to three trackers from five available models: Fitbit Alta, Garmin Vivofit 2, Garmin Vivosmart, Polar loop 2 and Polar A300. Participants wore each device for two weeks, followed by a one-week washout period between devices. Interviews were conducted with participants to explore user perceptions and experiences. Interview transcripts were analysed using thematic analysis. Four main themes emerged: 1. consciousness raising; 2. prompts and feedback; 3. accuracy and registry of activities; and, 4. WAT preferences and features. WATs were acceptable and useful to cancer survivors. WATs increased self-awareness of physical activity, provided real time feedback in relation to step goals, and reinforced progress and efforts towards goals. The aesthetics of the WATs were deemed crucial in determining preference and likelihood of use. Future interventions may do well to have two different WATs available for participants to choose from, according to activity preferences, aesthetic preferences, and display size.
Devine, KA et al (2018) [Narrative Review] Digital health interventions for adolescent and young adult cancer survivors
This narrative review describes the evidence regarding digital health interventions targeting adolescent and young adult (AYA) cancer survivors. Devine et al reviewed the published literature for studies involving Internet, mHealth, social media, telehealth, and other digital interventions for AYA survivors. They highlight selected studies to illustrate the state of the research in this unique patient population. Interventions have used various digital modalities to improve health behaviours, enhance emotional well-being, track and intervene on cancer-related symptoms, and improve survivorship care delivery. The majority of studies have demonstrated feasibility and acceptability of digital health interventions for AYA survivors, but few efficacy studies have been conducted. Digital health interventions are promising to address unmet psychosocial and health information needs of AYA survivors. Researchers should use rigorous development and evaluation methods to demonstrate the efficacy of these approaches to improve health outcomes for AYA survivors.
Cannon, C (2018) [Review] Telehealth, mobile applications, and wearable devices are expanding cancer care beyond walls
The objective is to review telehealth solutions, mobile applications, and wearable devices that are currently impacting patients, caregivers, and providers who work in the oncology setting. A literature search was conducted using the terms (Telehealth, Mobile Health, mHealth, Wearable Devices) + (Oncology, Cancer Care). Cannon concludes there are many current applications of telehealth and mobile health in the oncology setting. Nurses who care for patients with cancer should be aware of the pervasiveness and impact of telehealth and mobile health to this unique population.
Fallahzadeh, R et al (2018) [Review] Digital health for geriatric oncology
In this review, the authors describe state-of-the-art digital health solutions for geriatric oncology and explore the potential application of emerging remote health-monitoring technologies in the context of cancer care. They also discuss the benefits and motivations behind adopting technology for symptom monitoring of older adults with cancer. They provide an overview of common symptoms and of the digital solutions-designed remote symptom assessment. They describe state-of-the-art systems for this purpose and highlight the limitations and challenges for the full-scale adoption of such solutions in geriatric oncology. They conclude that perhaps the clearest path to future large-scale use of remote digital health technologies in cancer research is designing and conducting collaborative studies involving computer scientists, oncologists, and patient advocates.
Gabrys, L et al (2017) [Clinical Trial] Real-time visual activity feedback for physical activity improvement in breast and colon cancer patients
The study aims to evaluate the effects and feasibility of a biofeedback device for physical activity (PA) improvement in breast and colon cancer patients. Daily PA of 19 cancer patients was measured by accelerometry (ActiGraph, GT1 M). Additionally, patients wore a motion sensor with real-time visual activity feedback (ActiSmile). Counts per minutes (cpm) and moderate to vigorous physical activity (MVPA) were calculated and patients’ activity data were compared to PA of 20 age-matched healthy controls. Baseline PA of patients was lower compared to controls. Following visual real-time feedback cancer patients increased cpm by 21% (p = .002) and MVPA by 9% (p = .007) compared to baseline measurement. PA levels in cancer patients obtained with visual feedback became almost equal compared to age-matched healthy controls: cpm (301; IQR 170 vs. 299; IQR 111), MVPA (36; IQR 23 vs. 41; IQR 25 min/day). Activity biofeedback seems to be feasible to induce changes in patients’ PA behaviour.
Ream, M et al (2017) [Conference Abstract] Patient engagement with a smartphone mobile app for adherence to oral chemotherapy
Ream et al developed a smartphone mobile app consisting of medication reminders, symptom reporting, clinician communication, and educational resources for improving adherence and symptom management. They sought to identify potential correlates of app usage. From December 2014 to August 2016, 181 patients with diverse malignancies prescribed oral chemotherapy enrolled in the randomised trial. Medication adherence was monitored using electronic pill caps (MEMScaps). Fostering patient engagement with the app may also serve to buffer difficulties in patient-clinician communication about care.
Maguire, R et al (2017) [Protocol] The eSMART study protocol: a randomised controlled trial to evaluate electronic symptom management using the advanced symptom management system (ASyMS) remote technology for patients with cancer
While some evidence exists that real-time remote symptom monitoring devices can decrease morbidity and prevent unplanned admissions in oncology patients, overall, these studies have significant methodological weaknesses. The electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology (eSMART) study is designed to specifically address these weaknesses with an appropriately powered, repeated-measures, parallel-group stratified randomised controlled trial of oncology patients. A total of 1,108 patients scheduled to commence first-line chemotherapy (CTX) for breast, colorectal or haematological cancer will be recruited from multiple sites across five European countries. Patients will be randomised (1:1) to the ASyMS intervention [intervention group] or to standard care currently available at each site [control group]. Patients in the control and intervention groups will complete a demographic and clinical questionnaire, as well as a set of valid and reliable electronic patient-reported outcome measures at enrolment, after each of their CTX cycles up to a maximum of six cycles, and at 3, 6, 9 and 12 months after completion of their sixth cycle of CTX. Outcomes that will be assessed include symptom burden [primary outcome], quality of life, supportive care needs, anxiety, self-care self-efficacy, work limitations and cost effectiveness and, from a health professional perspective, changes in clinical practice.
Shen, J et al (2017) [Review] Telehealth in older adults with cancer in the United States: the emerging use of wearable sensors
As the aging and cancer populations in the world continue to increase, the need for complements to traditional geriatric assessments and the logical incorporation of fast and reliable telehealth tools have become interlinked. In the United States, studies examining the use of telehealth for chronic disease management have shown promising results in small groups. The implementation of health technology on a broader scale requires older adults to both accept and adapt such innovation into routine medical care. Though the commercial and recreational use of new technology has increased in older individuals, the transition into creating a smart and connected home that can interface with both patients and healthcare professionals is in its early phases. Current limitations include an inherent digital divide, as well as concerns regarding privacy, data volume, rapid change, cost and reimbursement. The emergence of low-cost, high-fidelity wearable sensors with a spectrum of clinical utility may be the key to increased use and adaptation by older adults. An opportunity to utilise wearable sensors for objective and real-time assessment of older patients with cancer for baseline functional status and treatment toxicity may be on the horizon.
Burhenn, PS et al (2015) [Review] Using tools and technology to promote education and adherence to oral agents for cancer
The researchers reviewed electronic devices, as well as traditional methods such as calendars and pillboxes, that can assist patients in remembering to take the medication they are administering at home. A literature search was compiled and websites were searched for patient education tools, reminder tools, and smartphone applications. The project was part of the Oncology Nursing Society Putting Evidence into Practice effort on oral adherence. Burhenn et al conclude that education alone is insufficient to promote adherence to oral medication regimens. Multicomponent interventions have demonstrated improved adherence, and tools and technology directed at improving adherence to oral agents can be used. The researchers found multiple reminder aids to assist patients in adhering to an oral regimen. They are highlighted in this article.
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