Discussion
breast cancer, cancer, cognitive problems, sexual dysfunction, Cancer
BREAST CANCER, CANCER, DISEASE, BREAST CANCER DIAGNOSIS, CANCER
There is a critical need to improve breast cancer patient engagement, education, and self-efficacy to allow for informed treatment decision making, effective symptom management and improved quality of life [We found that inclusion of the Outcomes4Me app along with routine care for patients with any subtype or stage of breast cancer was feasible with 60% of patients engaging with the app at least 3 times over the 12-week study period. Engagement with the app was highly variable across the study population, with approximately 20% of participants engaging with the app 10 times of more, and close to one third of participants with minimal engagement. This seems consistent with preferences for use of a healthcare app in the general oncology population. The National Cancer Institute’s 2015 National Health Trends Survey found that 22% of respondents used a mobile health app, with greater usage associated with younger age, higher education, and higher income [Similarly, the app was considered “useable” with an average SUS score of 70, above the standard threshold for average usability of 68 suggested in the literature [The population enrolled in this study was intentionally heterogeneous to allow for a preliminary assessment of how patients in different phases of breast cancer treatment interacted with the app. Increased app use in newly diagnosed participants was expected since these patients may be most interested in gathering information about their disease as part of planning their course of treatment. In addition, while the unmet needs including symptom management and treatment information among breast cancer survivors are well documented, it is not surprising that only a subset of patients in the survivorship phase of care had substantial engagement with the app during the study period. As prior research has demonstrated, survivorship needs among patients with breast cancer vary and at any given period in time, up to 40% of patients may have minimal needs [One recognized challenge in the care of patients with breast cancer is the under-reporting of potentially sensitive topics including distress, cognitive problems, and sexual dysfunction in routine clinical care [Many patients demonstrated interest in clinical trials at baseline. The majority of patients found the clinical trial information in the app helpful, over a quarter identified specific trials they wished to explore, and one third reported that the app experience made them more likely to consider clinical trials in the future. Because the majority of patients were already on treatment at the time of study enrollment and we do not know what trials were available to the newly diagnosed patients on the study, we were not able to evaluate the long-term impact of the Outcomes4Me app on trial enrollment. However, the number of patients reporting greater interest in trials is encouraging, given the historically low rate of clinical trial participation in adult oncology patients [There are several limitations to our study. First, we actively approached eligible patients to participate in the study and then provided assistance to download the app. Therefore, the patient population may not reflect the real-world spectrum of patients who would otherwise seek out and use such a navigation app. This would tend to bias results away from frequent engagement with the app. We did not prescreen patients for unmet information or navigation needs, or for specific interest in using an app to support their care, which might have boosted the level of engagement with the app during the study period. In addition, the study population was generally highly educated, recruited from a specialized breast cancer clinic, and at baseline reported high satisfaction with their provider, which may reflect a population at lower baseline need of supplemental information or navigation assistance compared to the general population of patients with breast cancer. In addition, we purposefully recruited patients across the full continuum of a breast cancer diagnosis, which allowed us to explore utility among subgroups of patients, but limited the number of patients within each subcategory. This was a single-arm study and we did not evaluate actual changes in care as a result of the intervention. This will be explored in future research. Another limitation was that only 75% of participants completed the final survey. Although there were no obvious differences in patient characteristics between the subsets that did or did not complete the end of treatment survey, it is possible that there may have been differences in the usability scores. The study feasibility assessment period was restricted to 12 weeks which is another limitation of the study and may have been too short to assess the feasibility.In summary, we demonstrated that it is feasible to incorporate a patient navigation app into standard care for patients with breast cancer to provide information about treatment decisions, clinical trials, and symptom management. The app was generally deemed useful by patients as a means to learn more about their disease, identify and learn about clinical trials, and capture symptoms including some that may not be as well captured in clinic visits. Engagement with and perceived benefit from the app was highly variable, suggesting that this approach to education and navigation may be helpful for some, but not all patients with breast cancer, but usability and benefit was demonstrated across patients of all ages and education levels. In an unselected group of patients presenting for routine care, the Outcomes4Me app appeared particularly useful for patients with newly diagnosed cancer and for those on chemotherapy. With the ubiquity of mobile devices, this and other app-based approaches to patient education, symptom tracking and management and clinical trial matching hold promise to improve the care and outcomes for patients with breast cancer. Future research will explore how adaptation of the Outcomes4Me app to specific populations of patients with breast cancer can broaden its utility in all settings and evaluate its impact on care delivery.