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Patients undergoing radiotherapy for prostate cancer experience symptoms related to both the cancer itself and its treatment, and it is evident that patients with prostate cancer have unmet supportive care needs related to their disease. Over the past decade, there has been an increase in the amount of research within the field of mobile health and the use of apps as tools for managing illness. The main challenge is to develop a mobile technology to its full potential of being interactive in real time. The interactive app Interaktor, which aims to identify and manage symptoms in real time includes (1) a function for patients’ assessment of the occurrence, frequency, and distress of symptoms; (2) a connection to a monitoring Web interface; (3) a risk assessment model that sends alerts via text message to health care providers; (4) continuous access to evidence-based self-care advice and links to relevant websites for more information; and (5) graphs for the patients and health care providers to view the history of symptom reporting.
The aim of the study was to investigate user behavior, adherence to reporting, and the patients’ experiences of using Interaktor during radiotherapy for localized advanced prostate cancer.
The patients were instructed to report daily during the time of treatment and then for an additional 3 weeks. Logged data from patients’ use of the app were analyzed with descriptive statistics. Interview data about experiences of using the app were analyzed with content analysis.
A total of 66 patients participated in the study. Logged data showed that adherence to daily reporting of symptoms was high (87%). The patients used all the symptoms included in the app. Of the reports, 15.6% generated alerts to the health care providers. Overall, the patients found that it was easy and not particularly time-consuming to send a daily report, and many described it as becoming a routine. Reporting symptoms facilitated reflection on their symptoms and gave them a sense of security. Few technological problems were reported.
The use of Interaktor increased patients’ sense of security and their reflections on their own well-being and thereby served as a supportive tool for the self-management of symptoms during treatment of prostate cancer. Some further development of the app’s content might be beneficial for future use.
Prostate cancer is the most common form of cancer in men and occurs mainly in middle and older age [
More studies concerning the use of apps are warranted as it is still in its initial phase [
In collaboration with a Swedish company, Health Navigator, that specializes in health care management and new innovative care solutions, an interactive app (Interaktor), for smartphones and tablet computers has been developed. The theoretical underpinning in the developmental process was person-centered care [
This study involves a prostate cancer version for use during radiotherapy. The radiotherapy is predominantly given at outpatient clinics, which means that the patients largely manage their symptoms and concerns at home based on information and advice provided by the clinic. There is a clear knowledge gap on how to support patients with prostate cancer in an effective and timely manner during radiotherapy. Therefore, testing Interaktor during treatment in outpatient care was considered appropriate to identify its potential to be beneficial for easing symptom burden.
In previous feasibility studies, the version of Interaktor for prostate cancer and a version for older adults with homecare were observed to be acceptable and user-friendly [
The study was conducted at two university hospitals, one urban and one rural, where the intervention group that used Interaktor during radiotherapy was compared with a historical control group [
This version includes 14 identified [
Some of the reported symptoms generate an alert, defined by symptom frequency or distress level, to registered nurses at the respective clinics. The levels at which alerts are triggered are the same for all patients and are set according to a risk assessment model based on consultations with health care professionals caring for this group of patients. The conclusion was to differentiate symptoms into alerts that demand rather instant care (such as a prescription for a painkiller or a coaching conversation), or that represent an acute threat to the patients’ health and are a direct cause of seeking emergency care if left unattended for too long. The alerts were set regarding urinary urgency, difficulties in urinating, obstipation, blood in stool, pain, worry, depression, and hematuria. There are two kinds of alerts—yellow alerts that request a nurse to contact the patient during the same day, for example, reporting having pain sometimes, and red alerts requiring contact within 1 hour, for example, reporting urinating difficulties as often or almost always.
A total of 16 self-care advice regarding symptoms related to prostate cancer and radiotherapy are included in the app together with relevant links to evidence-based Web pages. An overview of the components in Interaktor is presented in
Illustration of the Interaktor app.
All of the patients were provided with a smartphone belonging to the project with the app Interaktor installed and were requested to report their symptoms daily (or more often if they wished) during office hours on weekdays throughout the radiotherapy period and for 3 weeks after. The patients were given thorough instructions by the researchers on how to use the app and a written checklist including a phone number for technical support. The patients were given an individual log-in and personal identification number (PIN) to get access to the app. They were also informed that in case of an alert, a nurse would call them during office hours on their home phone number until they could be reached. Any acute problem occurring at other time points had to be handled according to the standard procedure of the oncological clinic, that is, a certain phone number at the clinic to call for advice. A notification was sent out as a reminder to the patients to make a report in the app if they had not reported by 3 PM. The patient’s self-report was sent directly via the secure server and was accessible from a Web interface for the nurses at the hospitals and the researchers at the university. The average time required for reporting was estimated to be 5 minutes [
Data were collected from two sources, which are (1) logged data from database, and (2) telephone and face-to-face interview.
First, logged data extracted from the database, which included (1) the total number of reports, (2) the number of reports per symptom, (3) the severity and distress levels of symptoms, (4) the alerts generated, (5) patients’ responses to the open-ended question, and (6) actions on alerts. The readings of self-care advice and historical graphs were not logged.
Second, data obtained from telephone and face-to-face interviews conducted by 3 members of the research team shortly after the end of using the app. The interviews followed a semistructured guide with the initial question “What was it like to report in the mobile phone?” (
The semistructured interview guide.
Question | Follow-up question | |
1. | What was it like to report in the mobile phone? | Difficulties and benefits or opportunities? |
2. | How did you experience the technology? | |
3. | How did you perceive the questions? | Relevant or something missing? |
4. | What was it like to report daily? | |
5. | Was it relevant to report from the beginning of treatment to 3 weeks after the end of treatment? | |
6. | Have you been contacted by a nurse after an alert? | If so, your experience? |
7. | Can you describe what use you have had of the self-care advice? | |
8. | Can you describe how you used the Internet links? | |
9. | Can you describe how you used the historical graph? | |
10. | Is there anything else you want to add? |
Logged data were analyzed using descriptive statistics. The statistical procedures were performed in Microsoft Office Excel 2010 (Microsoft Corporation, Redmond, WA, USA) and IBM SPSS (version 23.0 for Windows, Chicago, IL, USA). The logged symptom data were organized by frequency (1=very seldom, 2=sometimes, 3=often, or 4=almost always) and by how distressing the symptom was (1=not at all, 2=a little, 3=rather much, or 4=very much).
The analysis of the notes taken during the semistructured interviews was conducted using summative content analysis [
Ethical approval for the study was obtained from the Regional Ethical Review Board of Uppsala University (dnr 2011/256). All participants gave their oral and written consent to participate. This study was designed to meet the ethical principles for research described by the International Council of Nurses by ensuring anonymity, integrity, and confidentiality for the participants [
There were 107 eligible patients in the intervention group, but 34 patients declined or could not be reached and 7 did not fulfill the inclusion criteria leaving 66 ( 61.7%) patients that participated in the study. The patients’ mean age was 69 years, and further clinical and demographic data are presented in
A total of 53 patients participated in the interviews (face-to-face, n=9) regarding the experience of using Interaktor. There were 13 patients that did not answer repeated telephone calls from the researcher after they finished reporting through the app.
A total of 3 patients filled out the report once, when instructed about the app, but did not file any further reports during the study period. The logged data from the remaining 63 patients showed that adherence to reporting symptoms daily was on average 87% (median 92%, range 16%-100%). The patients had in total sent in 3536 reports during the study period, and the patients reported 10,025 specific symptoms in total. All of the symptoms included in the app were used by the patients (
Of the 10,025 reported symptoms, 1566 (15.60%) generated alerts to the nurse at the oncology clinic (
Clinical and sociodemographic characteristics of the study participants.
Clinical and sociodemographic characteristics | Descriptive analyses (N=66) | |
Mean (SD) | 69 (5.8) | |
Median (range) | 70 (53-82) | |
Married or living with partner | 57 (86) | |
Living alone | 9 (14) | |
Junior compulsory | 9 (14) | |
Senior high school | 23 (36) | |
Postgraduate or university | 32 (50) | |
Working, retired | 59 (89) | |
Sick leave | 7 (11) | |
1 | 16 (24) | |
2 | 29 (44) | |
3 | 17 (26) | |
Missing | 4 (6) | |
Adjuvant hormonal therapy | 50 (76) | |
EBRTa | 20 (30) | |
Brachytherapy combined with EBRT | 46 (70) |
aEBRT: external beam radiotherapy.
Occurrences, frequency, and distress of the symptoms as reported in the app by patients with prostate cancer (N=63) during their radiotherapy.
Symptoms (number of patients reporting at least once) | Occurrence | Frequency | Distress (N=14) | ||
n (%) | Mean (SD) | Range | Mean (SD) | Range | |
Urinary urgency (n=60) | 1875 (18.70) | 2.18 (0.676) | 1-4 | 2.07 (0.437) | 1-3 |
Fatigue (n=58) | 1838 (18.33) | 2.22 (0.589) | 1-4 | 2.06 (0.577) | 1-4 |
Hot flushes (n=43) | 1621 (16.17) | 1.99 (0.483) | 1-4 | 1.89 (0.429) | 1-4 |
Difficulties in urinating (n=47) | 1053 (10.50) | 2.28 (0.692) | 1-4 | 2.22 (0.734) | 1-4 |
Pain (n=46) | 685 (6.83) | 2.30 (0.714) | 1-4 | 2.38 (0.559) | 1-4 |
Insomnia (n=43) | 651 (6.49) | N/Aa | N/A | 2.20 (0.592) | 1-4 |
Diarrhea (n=48) | 598 (5.97) | 2.08 (0.525) | 1-4 | 2.10 (0.536) | 1-4 |
Urinary leakage (n=27) | 358 (3.58) | 1.94 (0.568) | 1-3 | 2.14 (0.602) | 1-4 |
Stool leakage (n=29) | 273 (2.72) | 1.59 (0.527) | 1-3 | 2.01 (0.756) | 1-4 |
Obstipation (n=30) | 255 (2.54) | N/A | N/A | 2.20 (0.689) | 1-4 |
Depression (n=28) | 253 (2.52) | 2.29 (0.885) | 1-4 | 2.39 (0.780) | 1-4 |
Worry (n=23) | 248 (2.48) | 1.95 (0.724) | 1-4 | 2.20 (0.610) | 1-4 |
Hematuria (n=33) | 175 (1.75) | 2.23 (0.833) | 1-4 | 1.79 (0.497) | 1-3 |
Blood in stool (n=22) | 142 (1.42) | N/A | N/A | 1.93 (0.608) | 1-4 |
aN/A: not applicable.
Distribution of the alerts as reported in the app by patients with prostate cancer (N=63) during their radiotherapy presented on symptom and alert levels.
Symptoms (number of patients reporting) | Yellow alerts, N=1049, n (%) | Red alerts, N=517, n (%) |
Urinary urgency (n=52) | 359 (34.22) | 127 (24.6) |
Pain (n=63) | 287 (27.36) | 212 (41.0) |
Difficulties urinating (n=44) | 274 (26.12) | 72 (13.9) |
Depressed (n=13) | 75 (7.15) | 38 (7.4) |
Worry (n=16) | 29 (2.77) | 36 (6.9) |
Hematuria (n=21) | 25 (2.38) | 32 (6.2) |
Obstipation | 0 (0.00) | 0 (0.0) |
Blood in stool | 0 (0.00) | 0 (0.0) |
A total of 47 (75%) patients sent 433 free-text comments through the open question. These mainly consisted of the message “You don´t need to call, my symptom is the same as yesterday.” Other free-text messages were such as “I have back pain but cannot see how this could be related to the treatment” or reporting another symptom not included in the app, for example, “I feel dizzy.” The free-text was also used for other communications with the nurses such as wishing the nurse a good weekend or describing upcoming plans for the patient’s weekend.
The analysis of the interviews resulted in the following six categories: reporting and content, self-care advice, historical graphs, alerts, technology, and safety and novelty. Overall, the patients reported that it was easy to use the app, even those few who were not accustomed to smartphones. It was not particularly time-consuming to send reports daily, and the patients described reporting as becoming a routine. Reporting symptoms was described as making the patients reflect over their own well-being.
According to the patients (n=44), the possibility to report daily facilitated reflection on their symptoms and illness:
When I answered the questions, I thought a lot about how I was feeling...It gave me perspective on my illness...I was feeling pretty good after all...
The content and the design of the questions were described as relevant by the majority of the patients (n=48); however, some (n=10) said that it was sometimes difficult to nuance the answer alternatives:
Relevant questions, but might be a little blunt; hard to know what is meaningful to report, hard to put the level of how to respond to such as “not at all” or “a little” distress in the beginning.
Some patients (n=16) wanted the possibility to say more about the symptoms, and 3 said that the app lacked symptoms such as gas in the stomach and dizziness.
The reporting sometimes became a routine for the patients (n=20) commenting that:
I did it every morning after listening to the news on the radio.
Some patients (n=7) said that they appreciated the reminder that came at 3 PM, if they had not submitted a report earlier that day.
The self-care advice was read by the majority of patients (n=43). Many of them (n=25) reported that the advice had been important to them, particularly concerning knowledge (n=18) and support to alleviate symptom burden (n=7). A few patients (n=5) said that they had already received the information from the nurses about self-care advice or side effects, or they had decided that they did not need or want to use that feature of the app.
A total of 21 patients reported that they followed their symptoms over time in the graphs, and they described how this function gave them and their families confirmation of their well-being:
I looked at the lines and it gave me in some strange way a confirmation of how I was feeling
I used the graphs to show my family and friends that I actually felt good during the treatment.
Some patients (n=13) stated that they did not follow their own graphs, mainly because they had forgotten they had the option to do so (n=7).
To be contacted by the nurses in connection with an alert was described as positive (n=19) through the direct dialogue with the nurses:
It felt good to be called by the nurse... it was a confirmation that it worked...I felt like a VIP and my problem was easily solved by just talking to the nurse.
There were also patients who expressed a wish to decide for themselves when to call the nurse (n=10). A total of 4 patients did not want to be contacted because of alerts, and they described how they had learned to adjust their responses to avoid a call from the nurse:
It took me about a week to fine tune the level at which to report symptoms. At the start the nurses called me pretty often, but then I learned how to report the symptoms so as to avoid being contacted unnecessarily.
The majority of the patients (n=37) had not experienced any technological problem commenting that:
There was no problem at all with the phone...not at al...it was so easy to use that anyone can learn to use it...even for me as a non-technical person...
The technological problems that were reported by the patients were primarily connected to the beginning of the reporting period (n=20). Technological problems such as sending the report and having problems moving on to the next question in the app were solved by the patients themselves by restarting the smartphone. Other technical issues described by the patients were related to the server (n=2), insufficient connection to the network (n=3), and the need to log-in with the PIN each time they reported (n=2).
Several patients stated that the app gave a sense of security (n=21) in the form of being seen, monitored, and prioritized by the health care providers:
It felt like it was easy to get in touch with a nurse who was online all the time, it has felt really good.
Some patients (n=8) described the novelty of the app for future patients and how it could be of support to both patients and staff:
It almost feels like having health care staff in one’s home. I think there may be some kind of...perhaps less burden on the health care.
A few patients (n=3) brought up a sense of lack of safety mainly related to an alert that did not result in contact from the nurse, which made them question the technology:
I was disappointed when no one called...it seems questionable whether the system can be trusted.
This study shows high adherence to the daily reporting of symptoms through an interactive smartphone app (Interaktor) among a group of patients with prostate cancer during the entire period of radiotherapy and 3 weeks afterwards. In Borosund et al’s [
It was hypothesized that Interaktor should enhance patients’ participation in their own health care and that taking an active role will lead to better well-being and health. The theoretical underpinning (based on person-centered care [
The study has some methodological limitations. The patients who entered the study may have been more interested in using mHealth than nonparticipants, which might have impacted the findings. However, the participation rate, that is, 62%, is comparable with interventional clinical studies and is considered acceptable [
Patients with locally advanced prostate cancer adhere to, appreciate, and face few obstacles using an app for reporting and managing symptoms on a daily basis during radiotherapy. The Interaktor seems to consider patients’ different needs because it has several components that the patients can choose depending on their own needs. The patients felt secure when being monitored, and using the Interaktor increased their own reflections about their own well-being. The Interaktor seems to enable self-management and serves as a facilitator to attain person-centered care, although some adjustment and further development of the content will be beneficial for future use.
external beam radiation therapy
mobile health
not applicable
patient-reported outcome measures
personal identification number
This study was funded by the Swedish Research Council for Health, Working Life and Welfare and Karolinska Institutet.
None declared.