The World Health Organization defines mobile health (mHealth) as a “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices” [1]. In the last decade, the health sector has seen a substantial rise in the number of mHealth apps, many of which are designed to assist users in weight reduction and diabetes management. In 2016, there were 79,000 apps available in the Health & Fitness category in the Google and Apple stores [2]. However, the implementation of mHealth in oncology is lagging, and there are comparatively few available apps. There is a need for the development of more mHealth apps in oncology settings considering the increasing disease burden and potential clinical benefit. According to Cancer Research UK, there were 17 million incident cases of cancer and 9.6 million deaths globally in 2018. This is estimated to increase substantially to 27.5 million incident cases by 2040 [3].

How are apps helping researchers?

According to Deloitte Insights’ article, “Smart health communities and the future of health”, in recent years healthcare delivery is moving back to the community from traditional care organizations such as hospitals. There are now several prevention initiatives, including mHealth, that are working with the community (users) to increase healthcare access, inform behavioral change, and facilitate data collection [4]. mHealth apps from pharmaceutical companies are providing personalized healthcare by giving patients the ability to track and monitor their disease [1]. mHealth initiatives along with app-accompanied randomized controlled trials (RCTs), called smart RCTs, and app-based studies are expected to drive future medical research [2].

Conducting traditional research has always been challenging for numerous reasons, including biased samples not representative of the population as a whole, skewed responses/self-reported data, and a lack of standardization of methods. mHealth apps can counter these design flaws by tracking activity and other health-related data more accurately and efficiently [5]. They also have the flexibility to experiment and determine how to effectively engage with users to help them achieve their goals [4]. With the use of apps, users can quickly opt-in to research studies relating to their health conditions, saving time and money for researchers. There are also no geographical limitations, and apps can capture significantly more data to help understand a disease better. This also means patient data can be sent directly to researchers more easily and frequently than if patients were required to travel to give samples or perform tests [6].

How are apps helping cancer patients?

Cancer patients often experience a long, and frequently stressful, personal care journey. Cancer mHealth apps can help promote better patient-doctor communication and encourage shared decision-making during treatment. After treatment, apps can ease follow-up care and help patients deal with side effects or make behavioral changes to improve their quality of life [7].

There are several apps on the market and in development aimed at providing cancer patients with more personalized care by tracking symptoms, patient journeys, treatment side effects and successes. Select examples include:

• Share the Journey is an interactive research study that aims to understand why some breast cancer survivors recover more quickly than others, and why their symptoms vary. This app tracks five common consequences of breast cancer treatment: fatigue, cognitive function, sleep disturbances, mood changes, and exercise performance. The plan is to use the resulting data for further research that may lead to interventions/strategize personalized treatments [8].
• TapCloud aims to simplify complex care plans of cancer patients into daily steps, customize care plans for any disease condition, track patient health and compliance in real time, and identify which patients need help and patient management. For instance, after surgery, the TapCloud platform adjusts to include advice for how best to recover. In this app, patients see a word cloud filled with phrases like “OK”, “stuffy”, “bloated”, and “good”. They are then invited to tap on the words that apply to them, with personalized treatment follow-up [9].
• My Cancer Circle is an online tool created by Boehringer Ingelheim in collaboration with CancerCare to help caregivers create their own community of support. The app allows caregivers to coordinate activities such as bringing meals or transporting patients to their appointments. My Cancer Circle also provides a private space where users can offer words of support and encouragement [10].

Research on user behavior and usefulness of apps

A US-based consumer survey published in 2018 reported findings on attitudes and behaviors across a patient journey; that is, searching for healthcare, accessing new care, and sharing personal health information. The report observed that about one-third of users were interested in using apps for identifying symptoms, advice on nutrition, exercise, sleep, and stress management, and directing them to a physician or nurse. It was interesting to note that users who considered themselves to be in excellent or very good health and those in poor health were more likely to use these apps when compared with those in moderate health. In all, 60% of surveyed users said that they were willing to share personal health data with their doctor to improve their health, with chronically ill users more likely to share tracked information. Overall, the use of tools for measuring fitness and other health improvement goals increased from 17% in 2013 to 42% in 2018 [11].

A patient survey analyzed cancer patients’ acceptance regarding app use and investigated the functions of cancer care health apps that are most required, and the main reasons to refuse app-assisted cancer care. Of all patients, almost half (48.5%) were willing to send data to their treating clinic from their app, and among them about two-thirds believed that additional and regularly sent data are helpful. Moreover, the vast majority (86.8%) wanted to be contacted when user-entered data showed irregularities. The main reasons for those who indicated they would refuse app use (43%) were: lack of skills, concerns about the use of data, lack of capable devices, and personal contact with the treating physician. The survey also reported that there was a significant relationship between patient demographic and app use, favoring males and patients aged 18–39 years. Also, it was interesting to note that those using cancer health apps were also using other mHealth apps such as running apps or tracking apps for blood sugar, heart rate, or weight reduction. The study concluded that mobile apps need to follow different strategies based on varying patient attitudes towards data anonymization, data protection, and feedback from a physician based on patient input [12].

In terms of the usefulness of mHealth in cancer prevention and care, apps have provided effective methods to conduct clinical trials by improving recruitment of patients, in addition to examples demonstrating improved quality of life and even better survival rates. The Metastatic Breast Cancer Project, for example, was able to recruit more than 2,000 patients in every US state in a span of seven months by using social media and a website, which otherwise would not have been possible. This project was aimed at examining factors that trigger breast cancer metastasis at a genomic level using patient tissue [13]. Another example is the Moovcare app that is used to detect cancer relapse or complications in Stage III/IV lung cancer patients during follow-up assigned through a web or app interface. A research study presented at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting reported that Moovcare improved patients’ quality of life considerably. One of the most important findings of this report was that after one year of follow-up, 75% of app users were still alive, compared to 49% of non-users [14].

A systematic review that analyzed mHealth apps specific to breast cancer also revealed broad positive benefits. It was shown that breast cancer patients who participated in mHealth-based interventions had greater effects of weight loss, improved quality of life, and less stress. However, the study noted that there is a need for stricter regulation, and apps need to be extensively research-tested for their utility, effectiveness, and safety before making them available to the public [15]. A separate study that assessed the quality of mHealth apps observed huge heterogeneity in assessment criteria for the apps in different studies, either due to the various assessment approaches used by researchers or different definitions for each criterion. Therefore, it seems necessary to reach a consensus among experts on definitions and assessment criteria. Addressing these points will lead to the improvement of existing mHealth tools and the development of more comprehensive apps [16].

The future of mHealth apps

The US-based consumer survey data emphasized the need for app developers and organizations working with the data to build trust to encourage users to share their personal information. This report pointed out that one way to do this is to let users own their health records. Data often reside in multiple places across different providers, which makes valuable pieces of information and a complete picture of one’s health unavailable to doctors, researchers, and the users themselves. This makes it difficult for healthcare systems to target care when most needed. Organizations are working towards this goal, including Apple, which released the Health feature on its smartphones that collates and centralizes the medical history and data of its users. On similar lines, the mHealth start-up Ciitizen is providing cancer patients access to their own records, such as lab results, images, and genetic information, that can be shared digitally [11]. Such efforts to improve the accessibility of health data will be essential for the clinical potential of mHealth to be realized, both in the treatment of cancer and general healthcare.

References

[1] International Pharmaceutical Federation (FIP) (2019) mHealth — Use of mobile health tools in pharmacy practice. The Hague, International Pharmaceutical Federation.

[2] Cancer Therapy Advisor (2017) Mobile Apps: The Future of Cancer Care? Available from: https://www.cancertherapyadvisor.com/home/cancer-topics/general-oncology/mobile-apps-the-future-of-cancer-care/ [Accessed August 2019].

[3] Cancer Research UK (2018)Worldwide cancer statistics. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/worldwide-cancer [Accessed August 2019].

[4] Dhar, A., Friedman, D. A., Chang, C., & Majerol, M. (2019). Smart health communities and the future of health: Five core components industry and government stakeholders can consider in the shift to health and well-being. Available from: https://www2.deloitte.com/us/en/insights/industry/health-care/smart-health-communities.html [Accessed August 2019].

[5] Wallace, C. (2017). Smartphones Open a New World for Medical Researchers. Available from: https://www.wsj.com/articles/smartphones-open-a-new-world-for-medical-researchers-1498442821?mod=article_inline [Accessed August 2019].

[6] Charara, S. (2017). Apple ResearchKit: Everything you need to know about the medical research platform. Available from: https://www.wareable.com/features/what-is-apple-researchkit-iphone-watch-everything-you-need-to-know-931 [Accessed August 2019].

[7] Hall, L. K., Kunz, B. F., Davis, E. V., Dawson, R. I., & Powers, R. S. (2015). The cancer experience map: an approach to including the patient voice in supportive care solutions. Journal of Medical Internet Research, 17(5), e132.

[8] Sage Bionetworks (2015) Sage Bionetworks Launches “Share the Journey,” A Mobile App-Based Research Study for the Breast Cancer Community. Available from: https://sagebionetworks.org/in-the-news/sage-bionetworks-launches-share-the-journey-a-mobile-app-based-research-study-for-the-breast-cancer-community/ [Accessed August 2019].

[9] TapCloud (2019) Available from: https://www.tapcloud.com/ [Accessed August 2019].

[10] My Cancer Circle (2019) Available from: https://mycancercircle.lotsahelpinghands.com/caregiving/home/ [Accessed August 2019].

[11] Betts, D., & Korenda, L. (2018). Inside the patient journey: Three key touch points for consumer engagement strategies: Findings from the Deloitte 2018 Health Care Consumer Survey. Available from: https://www2.deloitte.com/us/en/insights/industry/health-care/patient-engagement-health-care-consumer-survey.html [Accessed August 2019].

[12] Kessel, K. A., Vogel, M. M., Kessel, C., Bier, H., Biedermann, T., Friess, H., ... & Keller, U. (2017). Mobile health in oncology: a patient survey about app-assisted cancer care. JMIR mHealth and uHealth, 5(6), e81.

[13] O’Leary, D. P., Zaheer, A., Redmond, H. P., & Corrigan, M. A. (2016). Integration of advances in social media and mHealth technology are pivotal to successful cancer prevention and control. mHealth, 2.

[14] Denis, F., Basch, E., Septans, A. L., Bennouna, J., Urban, T., Dueck, A. C., & Letellier, C. (2019). Two-year survival comparing web-based symptom monitoring vs routine surveillance following treatment for lung cancer. Jama, 321(3), 306-307.

[15] Jongerius, C., Russo, S., Mazzocco, K., & Pravettoni, G. (2019). Research-Tested Mobile Apps for Breast Cancer Care: Systematic Review. JMIR mHealth and uHealth, 7(2), e10930.

[16] Nouri, R., Niakan Kalhori, S., Ghazisaeedi, M., Marchand, G., & Yasini, M. (2018). Criteria for assessing the quality of mHealth apps: a systematic review. Journal of the American Medical Informatics Association, 25(8), 1089-1098.