Using Mobile Health (mHealth) Interventions to Optimise Breast Cancer Care: A Scoping Review

1. Undergraduate Student, Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India. 2. Undergraduate Student, Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India. 3. Dean and Distinguished Professor, School of Public Health, The University of Memphis, Memphis, TN 38152, USA. 4. Vice Principal and Professor, Department of Biochemistry, Medical Education, Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India.

Abstract

Introduction: Mobile phones have become ubiquitous in recent years. This portable device can be efficiently utilised to promote health and deliver high-quality healthcare services via Mobile Health (mHealth) technology interventions. In view of the increasing global burden of breast cancer cases, mHealth interventions can be constructive in breast cancer prevention and management. Nevertheless, there is a paucity of evidence to support the utility of mHealth interventions in breast cancer care.

Aim: To analyse and synthesise evidence from published literature on the feasibility and effectiveness of mHealth interventions employed for breast cancer prevention, detection, management, and rehabilitation. Additionally, this study intends to draft a conceptual framework for mHealth intervention strategies in breast cancer management.

Materials and Methods: A comprehensive literature search was conducted at Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India, from June 2022 to December 2022. Google Scholar and PubMed databases were used to find published articles relevant to the study’s objectives. The reviewers selected articles based on the relevance of the article and eligibility criteria. Articles on mHealth interventions for the female population above 18 years of age with breast cancer were included.

Results: A total of 13 articles were selected based on the eligibility criteria. Regardless of the type of mHealth technology employed, target population, and purpose of intervention, all the studies strongly support the use of mHealth technology-based interventions over usual care to enhance breast cancer management.

Conclusion: The use of mHealth applications has increased exponentially in recent years. Since then, many studies have been conducted to validate their use. However, the usability of these applications is not well established. The involvement of not only patients but also healthcare professionals is crucial to develop well-equipped digital health applications. Personalised applications that provide security and safeguard user privacy are highly preferred by patients. A collaborative approach involving patients, healthcare professionals, and application developers will aid in the development of highly efficient mHealth applications.

Early detection, mHealth application, Prevention, Smartphones, Treatment

The Global Observatory for electronic health describes mobile health as the adoption of mobile technology and the use of other wireless gadgets to enhance medical and public health practices (1). The new generation smartphones, which are on par with computers, pave the way for the development and utilisation of health-based applications (2). These newer mHealth tools can be constructively exploited to promote health, facilitate health behaviour changes, aid in the diagnosis and management of diseases (3). A combination of mHealth interventions and conventional treatment has the potential to produce promising results in the long-term management of diseases (4). They assist in achieving the sustainable development goals (5) of good health and well-being, boost health self-governance, and help to keep track of treatment progression (6).

Cancer continues to pose multifarious challenges to patients, as well as healthcare professionals. The struggle is more evident in developing countries due to a deficit of resources, lack of patient awareness, disparities in access to healthcare, and non adherence to treatment plans (7). A greater number of cancer survivors describe an awful journey of recovery owing to a lack of supportive care for the detrimental long-term consequences of cancer. mHealth interventions are an excellent means to optimise cancer care and confront the unmet demands of cancer survivors through technology (8). The majority of cancer patients are in agreement with communicating information via an application to reinforce their screening and treatment modalities. Healthcare professionals also recognise the vital role that mHealth interventions can play in determining treatment outcomes (9). The contemporary mHealth tools undoubtedly help cancer patients in their battle against the deadly disease. This particularly holds true in regard to breast cancer management.

According to the World Health Organisation (WHO), breast cancer has retained the first position in the list of the most prevalent cancers across the globe since 2020, surpassing lung cancer (10),(11). Novel technologies like mHealth interventions provide a scope to facilitate effective patient-physician interaction, enhancing the knowledge and awareness of patients. This may help reduce the burden of active breast cancer cases globally. The post-diagnostic psychological effects of breast cancer, such as stress, anxiety, and depression, make it imperative for physicians to extend mental support to patients post-diagnosis and treatment. These technological advancements will pave the way to promote the psychological well-being and preparedness of patients towards diagnosis, treatment, and follow-up (12). The increased risk of recurrence and decreased survival rate among breast cancer patients is associated with obesity (13). mHealth may serve as a beneficial platform to encourage physical activity among this population, countering the adverse effects and fostering a healthy lifestyle (14),(15),(16).

Initial studies assessing the outcome of breast cancer applications have highlighted the lack of a primary evidence base to validate their use. Over the past 10 years, there has been a steady increase in the use of smartphone applications in breast cancer care. Given the ubiquity of smartphones and the increasing global burden of breast cancer, mobile phone applications have a positive impact on breast cancer care worldwide (17). The paucity of knowledge regarding the clinical effectiveness of these mHealth applications for breast cancer calls for more studies investigating the efficacy and reliability of mHealth tools. Even though mHealth interventions have played a positive role in improving physical activity among cancer patients, there is a dire need for mHealth interventions individually tailored for breast cancer patients. Hence, the present scoping review was conducted to explore the existing mHealth applications, their efficiency, accessibility, and acceptability among the target population. Additionally, identification of gaps in the successful implementation of these emerging technological interventions was performed.

Material and Methods

A comprehensive literature search was conducted at Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India, from June 2022 to December 2022. The synthesis of evidence was performed based on an extensive search of scholarly articles from the databases Google Scholar and PubMed. Studies from 2009 were considered for the present review. Arksey H and O Malley L reported five-stage methodological framework was followed (18): 1) Identifying the research topic; 2) Identifying relevant research papers; 3) Selecting the studies; 4) Charting the data; 5) Collating, reporting, and summarising the findings. The PRISMA extension for scoping reviews was followed to structure the present review (19).

Source of Information

A comprehensive literature search was conducted in the databases Google Scholar and PubMed. Scholarly research articles that were consistent with the inclusion criteria were selected for the review.

Search Strategy

The following search terms relating to breast cancer were used: (“Breast cancer”, “Breast cancer awareness”, “early diagnosis”, “prevention”, “treatment”, “postsurgery”) and relating to smartphones (“mobile health”, “telemedicine”, “mHealth applications”, “smartphones”). The retrieved articles were further filtered based on inclusion and exclusion criteria.

Stage 3: Process of Selection

Eligibility criteria: Articles were screened and included for the present scoping review based on the following inclusion and exclusion criteria (Table/Fig 1),(Table/Fig 2).

Data Charting

The selected studies were thoroughly analysed, and the extracted data were sorted into variables: Title, name of the first author, year, country, main objective, study design, target population, control group, type of mHealth intervention, target of intervention, summary of intervention, duration, follow-up, features of mHealth technology, purpose of intervention, strength of mHealth technology, limitation of mHealth technology, measures of outcome, and major findings.

Results

Selection of Source of Evidence

A total of 1,238 articles were retrieved from the databases Google Scholar and PubMed. These articles underwent screening at three levels (title, abstract, and full-text stage) based on the inclusion and exclusion criteria. Duplicate records, studies that did not meet the inclusion criteria, scoping and systematic reviews, editorials, commentaries, and articles with unavailable full texts were excluded from the analysis. A total of 13 articles were selected for the present review (9),(14),(20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30).

Characteristics and results of sources of evidence: The table below presents an array of parameters that were assessed for the present review. All the extracted data are represented under the appropriate variables (Table/Fig 3),(Table/Fig 4),(Table/Fig 5) (9),(14),(20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30).

Characteristics of the Studies Included

The primary search provided 1,238 records, out of which 13 articles were selected for the review following several rounds of screening based on inclusion and exclusion criteria (9),(14),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30). The present investigation revealed that over the last decade, mHealth technology and its application in breast cancer have shown promising results for targeted patients. The majority of the papers were published in 2020 (9),(24),(25) and 2021 (14),(25),(26) (n=3 each) (Table/Fig 6). The scrutinised articles mainly focused on breast cancer patients, with very few articles discussing the impact of mHealth applications on breast cancer awareness among the general population [22,23]. The authors have included articles under the following types of study design: a) qualitative study (14) (n=1); b) Randomised Controlled Trial (RCT) (n=6) (9),(20),(21),(23),(29),(30); c) clinical trial (n=1) (26); d) mixed-method study (n=2) (22),(28); e) non randomised group control study (n=1) (24); f) pilot pre-post study (n=1) (25); g) quasi-experimental study (n=1) (27). (Table/Fig 7) depicts the number of articles included under different types of study design that have been analysed. 69.23% of the studies considered for the present review involved mobile applications (9),(14),(22),(23),(24),(25),(26),(27),(29), while 15.38% used conventional telephone calls as a medium to transfer information (20),(21). The other 7.69% of articles used short message service/text messages (28), and 7.69% used snapchat as the mHealth technology (Table/Fig 8) (30). Furthermore, among the included articles, it has been found that a greater number of studies were conducted in the USA (n=5) (Table/Fig 9) (22),(24),(25),(26),(29).

The majority of the studies 6 (46.15%) have been conducted with an objective to identify the factors that contribute to the acceptability of mHealth interventions among breast cancer patients (14),(21),(22),(24),(26),(27). (Table/Fig 10) portrays the target of intervention of the studies included in the present review. Various physical, sociodemographic, psychological, social, and organisational factors act as levers to improve the acceptance of mHealth interventions in breast cancer patients. The results of the studies suggest that digital health innovations are highly accepted by breast cancer patients, and mHealth serves as a reliable medium for imparting knowledge about breast cancer. A mixed-method study conducted to assess survivor preferences for mHealth applications suggested that preferences vary around themes of relevance, ease of use, and enhancing personal motivation (28). More personalised and intimate applications are preferred for health interventions by breast cancer patients (28). (Table/Fig 11) portrays the purpose of intervention of the included studies.

A qualitative study conducted focus group discussions and individual interviews to understand the perceptions and needs of breast cancer patients (15). This key finding aids in the development of applications and bridges the gap between consumers and developers. Randomised control trials have shown that the use of mHealth applications had a positive impact on promoting the quality of life of women diagnosed with breast cancer. Additionally, the characteristics of breast cancer-associated applications have been studied. A total of 599 applications were reviewed. Many applications were free, and the most common application type was disease and treatment information applications. Only one-fourth of all applications had a disclaimer about usage, and less than one-fifth mentioned references or source material. Lozano-Lozano M et al., concluded that although these applications are highly beneficial, areas like data privacy and data handling need more expertise to widen accessibility and usage among breast cancer patients (27).

Discussion

The mHealth applications play a crucial role in providing health education and promoting healthy lifestyles. A scoping review focused on mHealth applications for breast cancer revealed that they contribute to awareness, prevention, early diagnosis, and psychological support during medical procedures (28). However, most of these interventions are prevalent in developed countries (31). Given the global burden of breast cancer, understanding the utility of related mobile applications is essential (32). Many of these applications focus on raising awareness and educating users about breast cancer (33). The popularity of mHealth applications is growing due to their cost-effectiveness and widespread mobile technology use, especially among women (34).

Breast cancer patients undergo various stages of care, and mHealth applications are addressing issues like upper limb dysfunction, fatigue, and sleep disturbances (35). Interventions like the “physical activity and your nutrition for cancer” app provide constructive plans for risk reduction (35). A study on applications like the Breast Cancer Survivorship Management System (BCSMS) app in Taiwan shows that they improve patients’ quality of life (9). Image-based behavioural interventions using telemedicine have also demonstrated enhanced quality of life for survivors (36),(37).

mHealth technologies effectively spread awareness and knowledge about breast cancer, impacting disease incidence. Applications like the Mammogram app have been shown to improve knowledge and attitudes about breast cancer screening (29). Even social networking applications like “Snapchat” have been used to educate Saudi Arabian women about breast cancer (30). Early detection is crucial, and applications are aiding in promoting screenings. A dedicated app for healthcare workers includes data collection, motivational videos, and mammogram appointments for patients (38). Decision-making aids like the Mammopad on iPad mini positively influence women’s decisions for mammogram screenings (39).

Psychological distress is common among breast cancer patients, and mHealth interventions are addressing this issue. They have shown promise in reducing emotional distress, although further research is needed (40),(41). Applications also improve medication adherence, as seen with the ILOVEBREAST app (42). For survivors, mHealth tools and virtual wellness programmes are extending supportive care, leading to positive outcomes (43).

While mHealth interventions are beneficial, barriers exist. Sociocultural issues, including gender inequalities and privacy concerns, hinder their adoption (40). Ethical and legal considerations, as well as a lack of transparency, complicate data collection via these applications (32). Guidelines are needed to create user-friendly and patient-centered applications (32). The mHealth technologies, including text messages and applications, offer support throughout breast cancer treatment and recovery (44),(45).

The “PIONEER” Framework

From the review of existing literature, it is evident that a meticulously framed conceptual framework for the development, implementation, and governance of mHealth interventions is the need of the hour. In this regard, the authors have conceptualised the ‘PIONEER’ framework to aid the development of mHealth technologies and their virtuous implementation in breast cancer care.

Problem identification: It is of paramount importance to perform diligent investigation and ascertain the problem in conventional care, along with its root cause. This can be done by analysing and reviewing existing research findings. Additionally, obtaining a reliable source of information can be achieved by interaction with multiple stakeholders and patients.

To effectively address the problem, it is necessary to delineate the severity of the issue, its outcomes, and its impact on the population. This should be done with evidence, highlighting the manifestations of the problem, the population affected, the intensity of the issue, contributors to the problem, and the characteristics of the problem. Furthermore, it is important to identify under what circumstances the problem is likely to flare up.

Innovate mHealth tool: Developing innovative, feasible, and effective mHealth tools that can address the gaps in conventional cancer care is crucial. Studies have established the superiority of mHealth tools over usual care in producing better treatment outcomes. However, there are numerous obstacles to the virtuous delivery of healthcare through mHealth tools, with the digital divide being a predominant hurdle. It is imperative to construct innovative mHealth tools with the objective of overcoming these existing barriers.

Optimise the mHealth tool for breast cancer: An mHealth tool dedicated to breast cancer should have unique features that comply with the disease course and meet the unique requirements of patients. A multidisciplinary approach is essential to optimise the mHealth tool for breast cancer. Individual, social, cultural, and economic factors need to be considered when optimising the mHealth tool for breast cancer.

Needs Assessment among the Target Population

Needs assessment is one of the critical investigative tools that help in determining the expected outcomes of mHealth technology-based interventions. Although there are a number of mHealth applications available, there is a paucity of personalised and individually tailored mHealth tools. Studies have evidently presented the existence of irrelevant information in mHealth applications (46). This calls for extensive needs assessment among the population to develop a user-centered mHealth tool.

Engage Multiple Stakeholders and Patients in Development Process

A multifaceted approach that actively engages individuals from diverse fields and backgrounds - including healthcare professionals, researchers, app developers, Information Technology (IT) professionals, and, most importantly, end users such as patients representing heterogeneous cultures and societies - is the prime requisite for the establishment of an mHealth tool.

Educate the Population on the Working and Use of mHealth Application

The mere development of a highly efficacious application cannot guarantee its successful utilisation. It is indispensable for healthcare professionals and developers to educate and train the users to effectively utilise the mHealth service provided. Training sessions should be conducted, and adequate information on the usage of personal data collected, data privacy, and security should be provided to the users.

Review the mHealth Tool

Reviews create space for improvement and refinement. It is important to periodically review the mHealth tool and update it in line with technological advancements. Analysing the feedback and reviews provided by users is crucial, and the mHealth tool should be upgraded accordingly.

Knowledge Gaps

Although numerous studies have been conducted to investigate the influence of mHealth applications on breast cancer care, there are potential gaps in existing knowledge. While ample scientific data exists to support the use of mHealth technology to enhance physical activity and improve mental health, individual patient factors that prevent its acceptability have yet to be investigated. There is a lack of studies to prove that mHealth interventions can play a significant role in spreading awareness about breast cancer. Most of the studies have been performed to analyse the results of mHealth interventions in breast cancer patients (14),(20),(21),(24),(25),(26),(27),(28),(29),(30).

Directions for Future Research

Studying mHealth interventions in the vulnerable population is the need of the hour. This will help generate awareness among the targeted population, leading to the prevention and early diagnosis of the disease. To gain further knowledge about patients’ preferences for mHealth applications, a qualitative study should be conducted. The efficacy of mHealth applications can be enhanced by analysing individual factors that influence the acceptability of such applications. Factors such as accessibility to mobile phones, network coverage, and economic status contribute to the acceptance or rejection of eHealth technology. These attributes should be thoroughly examined for the successful implementation of mHealth interventions in breast cancer care.

Limitation(s)

There are certain potential limitations in this review. Only two databases were involved in the electronic search. Moreover, published articles in languages other than English were excluded. Furthermore, studies with a male study population were not assessed due to the rarity of this disease in them.

Conclusion

The breast cancer-specific mHealth application improved the overall health of the patients, particularly in terms of enhancing physical activity and managing psychological stress. In general, mHealth interventions effectively improved the quality of breast cancer care. Despite the fact that numerous studies have been conducted investigating the impact of mHealth on breast cancer care, the clinical effectiveness of mHealth applications is yet to be clearly defined. A collaborative approach involving patients and healthcare professionals in the process of development and testing can significantly enhance the quality of the application.

Acknowledgement

The authors acknowledge Panimalar Medical College Hospital and Research Institute, Chennai, and Foundation of Healthcare Technologies Society, New Delhi, for introducing the “Foundations in Research Methodologies” course in the I Bachelor of Medicine and Bachelor of Surgery (MBBS) curriculum. This course provided the knowledge and skills necessary for conducting and publishing the present study.

Authors contribution: Conceptualisation: K.M.S.; Methodology: S.P., J.N.B., A.J., and K.M.S.; Software: K.M.S.; Validation: S.P., J.N.B., A.J., and K.M.S.; Formal analysis: S.P., J.N.B., A.J., and K.M.S.; Investigation: S.P., J.N.B., and K.M.S.; Resources: K.M.S.; Data curation: A.J. and K.M.S.; Writing-original draft preparation: S.P., J.N.B., and K.M.S.; Writing-review and editing: S.P., J.N.B., A.J., and K.M.S.; Visualisation: S.P., J.N.B., and K.M.S.; Supervision: K.M.S.; Project administration: K.M.S.; Funding acquisition: K.M.S.

DOI and Others

DOI: 10.7860/JCDR/2024/65710.18858

Date of Submission: May 30, 2023
Date of Peer Review: Aug 07, 2023
Date of Acceptance: Oct 05, 2023
Date of Publishing: Jan 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 02, 2023
• Manual Googling: Aug 18, 2023
• iThenticate Software: Oct 03, 2023 (11%)

ETYMOLOGY: Author Origin

EMENDATIONS: 7