JMIR Publications

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  Viewpoints on Innovations in Cancer...

  Nov 24, 2020

  Virtual Cancer Care During the COVID-19 Pandemic and Beyond: A Call for Evaluation

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  Authors List:

  • Oren Hannun Levine  
  • Michael McGillion  
  • Mark Levine  

  Abstract:

  The interplay of virtual care and cancer care in the context of the COVID-19 pandemic is unique and unprecedented. Patients with cancer are at increased risk of SARS-CoV-2 infection and have worse outcomes than patients with COVID-19 who do not have cancer. Virtual care has been introduced quickly and extemporaneously in cancer treatment centers worldwide to maintain COVID-19–free zones. The outbreak of COVID-19 in a cancer center could have devastating consequences. The virtual care intervention that was first used in our cancer center, as well as many others, was a landline telephone in an office or clinic that connected a clinician with a patient. There is a lack of virtual care evaluation from the perspectives of patients and oncology health care providers. A number of factors for assessing oncology care delivered through a virtual care intervention have been described, including patient rapport, frailty, delicate conversations, team-based care, resident education, patient safety, technical effectiveness, privacy, operational effectiveness, and resource utilization. These factors are organized according to the National Quality Forum framework for the assessment of telehealth in oncology. This includes the following 4 domains of assessing outcomes: experience, access to care, effectiveness, and financial impact or cost. In terms of virtual care and oncology, the pandemic has opened the door to change. The lessons learned during the initial period of the pandemic have given rise to opportunities for the evolution of long-term virtual care. The opportunity to evaluate and improve virtual care should be seized upon.

  • JMIR Cancer 2020;6(2):e24222

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  Viewpoints on Innovations in Cancer...

  Nov 24, 2020

  Telehealth and Palliative Care for Patients With Cancer: Implications of the COVID-19 Pandemic

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  • Udhayvir Singh Grewal  
  • Stephanie Terauchi  
  • Muhammad Shaalan Beg  

  Abstract:

  It has been reported that the incidence of SARS-CoV-2 infection is higher in patients with cancer than in the general population and that patients with cancer are at an increased risk of developing severe life-threatening complications from COVID-19. Increased transmission and poor outcomes noted in emerging data on patients with cancer and COVID-19 call for aggressive isolation and minimization of nosocomial exposure. Palliative care and oncology providers are posed with unique challenges due to the ongoing COVID-19 pandemic. Telepalliative care is the use of telehealth services for remotely delivering palliative care to patients through videoconferencing, telephonic communication, or remote symptom monitoring. It offers great promise in addressing the palliative and supportive care needs of patients with advanced cancer during the ongoing pandemic. We discuss the case of a 75-year-old woman who was initiated on second-line chemotherapy, to highlight how innovations in technology and telehealth-based interventions can be used to address patients’ palliative and supportive care needs in the ongoing epidemic.

  • JMIR Cancer 2020;6(2):e20288

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  Nutrition, Physical Activity, Healthy...

  Nov 10, 2020

  Web-Based Lifestyle Interventions for Prostate Cancer Survivors: Qualitative Study

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  Authors List:

  • Elizabeth Y Wang  
  • Rebecca E Graff  
  • June M Chan  
  • Crystal S Langlais  
  • Jeanette M Broering  
  • Justin W Ramsdill  
  • Elizabeth R Kessler  
  • Kerri M Winters-Stone  
  • Erin L Van Blarigan  
  • Stacey A Kenfield  

  Abstract:

  Background: Exercise and a healthy diet can improve the quality of life and prognosis of prostate cancer survivors, but there have been limited studies on the feasibility of web-based lifestyle interventions in this population. Objective: This study aims to develop a data-driven grounded theory of web-based engagement by prostate cancer survivors based on their experience in the Community of Wellness, a 12-week randomized clinical trial designed to support healthy diet and exercise habits. Methods: TrueNTH’s Community of Wellness was a four-arm pilot study of men with prostate cancer (N=202) who received progressive levels of behavioral support (level 1: website; level 2: website with individualized diet and exercise recommendations; level 3: website with individualized diet and exercise recommendations, Fitbit, and text messages; and level 4: website with individualized diet and exercise recommendations, Fitbit and text messages, and separate phone calls with an exercise trainer and a registered dietitian). The primary aim of the study is to determine the feasibility and estimate the effects on behaviors (results reported in a separate paper). Following the 12-week intervention, we invited participants to participate in 4 focus groups, one for each intervention level. In this report, we used grounded theory analyses including open, axial, and selective coding to generate codes and themes from the focus group transcripts. Categories were refined across levels using embodied categorization and constant comparative methods. Results: In total, 20 men with prostate cancer participated in the focus groups: 5, 4, 5, and 6 men in levels 1, 2, 3, and 4, respectively. Participants converged on 5 common factors influencing engagement with the intervention: environment (home environment, competing priorities, and other lifestyle programs), motivation (accountability and discordance experienced within the health care system), preparedness (technology literacy, health literacy, trust, and readiness to change), program design (communication, materials, and customization), and program support (education, ally, and community). Each of these factors influenced the survivors’ long-term impressions and habits. We proposed a grounded theory associating these constructs to describe the components contributing to the intuitiveness of a web-based lifestyle intervention. Conclusions: These analyses suggest that web-based lifestyle interventions are more intuitive when we optimize participants’ technology and health literacy; tailor interface design, content, and feedback; and leverage key motivators (ie, health care providers, family members, web-based coach) and environmental factors (ie, familiarity with other lifestyle programs). Together, these grounded theory–based efforts may improve engagement with web-based interventions designed to support prostate cancer survivorship.

  • JMIR Cancer 2020;6(2):e19362

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  Innovations and Technology for Cancer...

  Oct 29, 2020

  The Impact of COVID-19 on Cancer Screening: Challenges and Opportunities

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  Authors List:

  • Ramon S Cancino  
  • Zhaohui Su  
  • Ruben Mesa  
  • Gail E Tomlinson  
  • Jing Wang  

  Abstract:

  Cancer is a leading cause of death in the United States and across the globe. Cancer screening is an effective preventive measure that can reduce cancer incidence and mortality. While cancer screening is integral to cancer control and prevention, due to the COVID-19 outbreak many screenings have either been canceled or postponed, leaving a vast number of patients without access to recommended health care services. This disruption to cancer screening services may have a significant impact on patients, health care practitioners, and health systems. In this paper, we aim to offer a comprehensive view of the impact of COVID-19 on cancer screening. We present the challenges COVID-19 has exerted on patients, health care practitioners, and health systems as well as potential opportunities that could help address these challenges.

  • JMIR Cancer 2020;6(2):e21697

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  Mobile Apps for Cancer Care and...

  Sep 15, 2020

  Assessment of Data Usage of Cancer e-Interventions (ADUCI) Framework for Health App Use of Cancer Patients and Their Caregivers: Framework Development Study

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  Authors List:

  • Natalie Heynsbergh  
  • Seung Chul (Eric) O  
  • Patricia M Livingston  

  Abstract:

  Background: Multimedia interventions can provide a cost-effective solution to public health needs; however, user engagement is low. Multimedia use within specific populations such as those affected by cancer differs from that of the general population. To our knowledge, there are no frameworks on how to accurately assess usage within this population to ensure that interventions are appropriate for the end users. Therefore, a framework was developed to improve the accuracy of determining data usage. Formative work included creating a data usage framework during target audience testing for smartphone app development and analysis in a pilot study. Objective: The purpose of this study was to develop a framework for assessing smartphone app usage among people living with cancer and their caregivers. Methods: The frequency and duration of use were compared based on manual data extraction from two previous studies and the newly developed Assessment of Data Usage of Cancer e-Interventions (ADUCI) Framework. Results: Manual extraction demonstrated that 279 logins occurred compared with 241 when the ADUCI Framework was applied. The frequency of use in each section of the app also decreased when the ADUCI Framework was used. The total duration of use was 91,256 seconds (25.3 hours) compared with 53,074 seconds (14.7 hours) when using the ADUCI Framework. The ADUCI Framework identified 38 logins with no navigation, and there were 15 discrepancies in the data where time on a specific page of the app exceeded the login time. Practice recommendations to improve user engagement and capturing usage data include tracking data use in external websites, having a login function on apps, creating a five-star page rating functionality, using the ADUCI Framework to thoroughly clean usage data, and validating the Framework between expected and observed use. Conclusions: Applying the ADUCI Framework may eliminate errors and allow for more accurate analysis of usage data in e-research projects. The Framework can also improve the process of capturing usage data by providing a guide for usage data analysis to facilitate evidence-based assessment of user engagement with apps.

  • JMIR Cancer 2020;6(2):e18230

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  Patient Education for Cancer

  Aug 21, 2020

  Beliefs and Information Seeking in Patients With Cancer in Southwest China: Survey Study

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  Authors List:

  • Juan Xie  
  • Shi Xie  
  • Ying Cheng  
  • Zhe He  

  Abstract:

  Background: Although previous studies have reported the cancer information-seeking behaviors among patients in high-income countries, the cancer information-seeking practices of patients living in low- and middle-income areas are less known. Objective: This study investigated the beliefs and information-seeking patterns of cancer patients in southwest China. Methods: A questionnaire was designed, and data were collected in two hospitals (N=285) in southwest China. Statistical analyses included bivariate analyses and regressions. Results: Patients’ attitudes towards cancer fatalism were significantly influenced by marital status (P<.001), education (P<.001), and household income (P<.001). Moreover, endorsing fatalistic belief was positively associated with age (r=0.35, P<.001). The regression model showed that younger patients (odds ratio [OR] 0.96, 95% CI 0.93-0.99) and those with higher education (OR 1.75, 95% CI 1.09-2.81) were more likely to seek information. Additionally, patients who were less confident in getting information were more likely to find information (OR 1.70, 95% CI 1.15-2.52), while fatalism belief was not significant in the regression (OR 0.65, 95% CI 0.22-1.95). Conclusions: This study explored the information-seeking patterns of cancer patients in southwest China. It was found that many Chinese people endorsed cancer fatalism. These pessimistic beliefs about the potential to prevent and to cure cancer correlate with rather than cause cancer-related information seeking. However, self-efficacy about the confidence in finding needed cancer information was a significant predictor of information-seeking.

  • JMIR Cancer 2020;6(2):e16138

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  Cancer Epidemiology, Cancer...

  Aug 17, 2020

  Incorporating Breast Cancer Recurrence Events Into Population-Based Cancer Registries Using Medical Claims: Cohort Study

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  Authors List:

  • Teresa A'mar  
  • J David Beatty  
  • Catherine Fedorenko  
  • Daniel Markowitz  
  • Thomas Corey  
  • Jane Lange  
  • Stephen M Schwartz  
  • Bin Huang  
  • Jessica Chubak  
  • Ruth Etzioni  

  Abstract:

  Background: There is a need for automated approaches to incorporate information on cancer recurrence events into population-based cancer registries. Objective: The aim of this study is to determine the accuracy of a novel data mining algorithm to extract information from linked registry and medical claims data on the occurrence and timing of second breast cancer events (SBCE). Methods: We used supervised data from 3092 stage I and II breast cancer cases (with 394 recurrences), diagnosed between 1993 and 2006 inclusive, of patients at Kaiser Permanente Washington and cases in the Puget Sound Cancer Surveillance System. Our goal was to classify each month after primary treatment as pre- versus post-SBCE. The prediction feature set for a given month consisted of registry variables on disease and patient characteristics related to the primary breast cancer event, as well as features based on monthly counts of diagnosis and procedure codes for the current, prior, and future months. A month was classified as post-SBCE if the predicted probability exceeded a probability threshold (PT); the predicted time of the SBCE was taken to be the month of maximum increase in the predicted probability between adjacent months. Results: The Kaplan-Meier net probability of SBCE was 0.25 at 14 years. The month-level receiver operating characteristic curve on test data (20% of the data set) had an area under the curve of 0.986. The person-level predictions (at a monthly PT of 0.5) had a sensitivity of 0.89, a specificity of 0.98, a positive predictive value of 0.85, and a negative predictive value of 0.98. The corresponding median difference between the observed and predicted months of recurrence was 0 and the mean difference was 0.04 months. Conclusions: Data mining of medical claims holds promise for the streamlining of cancer registry operations to feasibly collect information about second breast cancer events.

  • JMIR Cancer 2020;6(2):e18143

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  Doctor-Patient Communication on...

  Aug 10, 2020

  Differences in Electronic Personal Health Information Tool Use Between Rural and Urban Cancer Patients in the United States: Secondary Data Analysis

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  Authors List:

  • Alexandra Greenberg-Worisek  
  • Liaa Ferede  
  • Joyce Balls-Berry  
  • Ian Marigi  
  • Emily Valentin Mendez  
  • Numra Bajwa  
  • Melody Ouk  
  • Minerva Orellana  
  • Felicity Enders  

  Abstract:

  Background: Studies have previously shown that rural cancer patients are diagnosed at later stages of disease. This delay is felt throughout treatment and follow-up, reflected in the fact that rural patients often have poorer clinical outcomes compared with their urban counterparts. Objective: Few studies have explored whether there is a difference in cancer patients’ current use of health information technology tools by residential location. Methods: Data from 7 cycles of the Health Information National Trends Survey (HINTS, 2003-2017) were merged and analyzed to examine whether differences exist in managing electronic personal health information (ePHI) and emailing health care providers among rural and urban cancer patients. Geographic location was categorized using Rural-Urban Continuum Codes (RUCCs). Bivariate analyses and multivariable logistic regression were used to determine whether associations existed between rural/urban residency and use of health information technology among cancer patients. Results: Of the 3031 cancer patients/survivors who responded across the 7 cycles of HINTS, 797 (26.9%) resided in rural areas. No difference was found between rural and urban cancer patients in having managed ePHI in the past 12 months (OR 0.78, 95% CI 0.43-1.40). Rural cancer patients were significantly less likely to email health care providers than their urban counterparts (OR 0.52, 95% CI 0.32-0.84). Conclusions: The digital divide between rural and urban cancer residents does not extend to general ePHI management; however, electronic communication with providers is significantly lower among rural cancer patients than urban cancer patients. Further research is needed to determine whether such disparities extend to other health information technology tools that might benefit rural cancer patients as well as other chronic conditions.

  • JMIR Cancer 2020;6(2):e17352

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  Cancer Survivorship

  May 26, 2020

  Assessing Breast Cancer Survivors’ Perceptions of Using Voice-Activated Technology to Address Insomnia: Feasibility Study Featuring Focus Groups and...

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  Authors List:

  • Hannah Arem  
  • Remle Scott  
  • Daniel Greenberg  
  • Rebecca Kaltman  
  • Daniel Lieberman  
  • Daniel Lewin  

  Abstract:

  Background: Breast cancer survivors (BCSs) are a growing population with a higher prevalence of insomnia than women of the same age without a history of cancer. Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be effective in this population, but it is not widely available to those who need it. Objective: This study aimed to better understand BCSs’ experiences with insomnia and to explore the feasibility and acceptability of delivering CBT-I using a virtual assistant (Amazon Alexa). Methods: We first conducted a formative phase with 2 focus groups and 3 in-depth interviews to understand BCSs’ perceptions of insomnia as well as their interest in and comfort with using a virtual assistant to learn about CBT-I. We then developed a prototype incorporating participant preferences and CBT-I components and demonstrated it in group and individual settings to BCSs to evaluate acceptability, interest, perceived feasibility, educational potential, and usability of the prototype. We also collected open-ended feedback on the content and used frequencies to describe the quantitative data. Results: We recruited 11 BCSs with insomnia in the formative phase and 14 BCSs in the prototype demonstration. In formative work, anxiety, fear, and hot flashes were identified as causes of insomnia. After prototype demonstration, nearly 79% (11/14) of participants reported an interest in and perceived feasibility of using the virtual assistant to record sleep patterns. Approximately two-thirds of the participants thought lifestyle modification (9/14, 64%) and sleep restriction (9/14, 64%) would be feasible and were interested in this feature of the program (10/14, 71% and 9/14, 64%, respectively). Relaxation exercises were rated as interesting and feasible using the virtual assistant by 71% (10/14) of the participants. Usability was rated as better than average, and all women reported that they would recommend the program to friends and family. Conclusions: This virtual assistant prototype delivering CBT-I components by using a smart speaker was rated as feasible and acceptable, suggesting that this prototype should be fully developed and tested for efficacy in the BCS population. If efficacy is shown in this population, the prototype should also be adapted for other high-risk populations.

  • JMIR Cancer 2020;6(1):e15859

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  Basic Cancer Research

  May 19, 2020

  Expression of Genes Related to Lipid Handling and the Obesity Paradox in Melanoma: Database Analysis

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  Authors List:

  • Claudia Giampietri  
  • Luana Tomaipitinca  
  • Francesca Scatozza  
  • Antonio Facchiano  

  Abstract:

  Background: Publicly available genomic and transcriptomic data in searchable databases allow researchers to investigate specific medical issues in thousands of patients. Many studies have highlighted the role lipids play in cancer initiation and progression and reported nutritional interventions aimed at improving prognosis and survival. Therefore, there is an increasing interest in the role that fat intake may play in cancer. It is known that there is a relationship between BMI and survival in patients with cancer, and that there is an association between a high-fat diet and increased cancer risk. In some cancers, such as colorectal cancer, obesity and high fat intake are known to increase the risk of cancer initiation and progression. On the contrary, in patients undergoing treatment for melanoma, a higher BMI unexpectedly acts as a protective factor rather than a risk factor; this phenomenon is known as the obesity paradox. Objective: We aimed to identify the molecular mechanism underlying the obesity paradox, with the expectation that this could indicate new effective strategies to reduce risk factors and improve protective approaches. Methods: In order to determine the genes potentially involved in this process, we investigated the expression values of lipid-related genes in patients with melanoma or colorectal cancer. We used available data from 2990 patients from 3 public databases (IST [In Silico Transcriptomics] Online, GEO [Gene Expression Omnibus], and Oncomine) in an analysis that involved 3 consecutive validation steps. Of this group, data from 1410 individuals were analyzed in the IST Online database (208 patients with melanoma and 147 healthy controls, as well as 991 patients with colorectal cancer and 64 healthy controls). In addition, 45 melanoma, 18 nevi, and 7 healthy skin biopsies were analyzed in another database, GEO, to validate the IST Online data. Finally, using the Oncomine database, 318 patients with melanoma (312 controls) and 435 patients with colorectal cancer (445 controls) were analyzed. Results: In the first and second database investigated (IST Online and GEO, respectively), patients with melanoma consistently showed significantly (P<.001) lower expression levels of 4 genes compared to healthy controls: CD36, MARCO, FABP4, and FABP7. This strong reduction was not observed in patients with colorectal cancer. An additional analysis was carried out on a DNA-TCGA data set from the Oncomine database, further validating CD36 and FABP4. Conclusions: The observed lower expression of genes such as CD36 and FABP4 in melanoma may reduce the cellular internalization of fat and therefore make patients with melanoma less sensitive to a high dietary fat intake, explaining in part the obesity paradox observed in patients with melanoma.

  • JMIR Cancer 2020;6(1):e16974

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  Nutrition, Physical Activity, Healthy...

  Apr 28, 2020

  Perceptions of eHealth-Enabled Physical Activity Interventions Among Cancer Survivors: Mixed Methods Study

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  Authors List:

  • Ciaran Haberlin  
  • Dearbhaile M O' Donnell  
  • Jonathan Moran  
  • Julie Broderick  

  Abstract:

  Background: Achieving adequate levels of physical activity (PA) is especially important for cancer survivors to mitigate the side effects of cancer and its treatment as well as for other health benefits. Electronic health (eHealth)-based PA interventions may offer feasible alternatives to traditionally delivered programs and optimize physical recovery after a cancer diagnosis, but perspectives of cancer survivors on this new delivery medium have not been extensively explored. Objective: The overall aim was to explore participants’ perspectives of eHealth-enabled PA interventions to inform the design of a future intervention among cancer survivors. Methods: The study took place in a designated cancer center in Dublin, Ireland. A preceding questionnaire-based study was conducted primarily to establish interest in participating in subsequent eHealth-based studies. A follow-on focus group study was conducted to explore the concept of eHealth-based PA interventions for cancer survivors. The data were analyzed using thematic analysis. Results: The questionnaire-based study (N=102) indicated that participants had a high level of interest in participating in follow-on eHealth-based studies. The focus group study (n=23) indicated that, despite some trepidation, overall positivity was expressed by participants toward the concept of eHealth-based PA interventions. Four themes were generated: (1) Health impact, including PA as a barrier and as a motivating factor, (2) Education needs, which emphasized the need for integrated information about PA and to increase technical literacy, (3) Goal setting, which should be integrated within the technical specification as a motivating factor, and (4) Support needs, as well as the importance of personalized human interaction, in tandem with technology. Conclusions: Qualitative research at the pretrial phase adds value to the design of a complex intervention and is especially useful in an area such as eHealth. The findings highlighted an interest in participating in eHealth-focused research as well as barriers, training needs, and key design features that can be applied to optimize the design of future eHealth-based PA interventions in cancer.

  • JMIR Cancer 2020;6(1):e16469

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  Clinical Cancer Research

  Apr 20, 2020

  Facilitators and Barriers to Recruiting Ambulatory Oncology Practices Into a Large Multisite Study: Mixed Methods Study

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  Authors List:

  • Milisa Manojlovich  
  • Louise Bedard  
  • Jennifer J Griggs  
  • Michaella McBratnie  
  • Kari Mendelsohn-Victor  
  • Christopher R Friese  

  Abstract:

  Background: Practice-based research is essential to generate the data necessary to understand outcomes in ambulatory oncology care. Although there is an increased interest in studying ambulatory oncology care, given the rising patient volumes and complexity in those settings, little guidance is available on how best to recruit ambulatory oncology practices for research. Objective: This paper aimed to describe the facilitators and barriers to recruiting ambulatory oncology practices into a large multisite study. Methods: Using a mixed methods design, we sought to recruit 52 ambulatory oncology practices that have participated in a state-wide quality improvement collaborative for the quantitative phase. We used 4 domains of the Consolidated Framework for Implementation Research (CFIR) to describe facilitators and barriers to recruitment. Results: We successfully recruited 28 of the 52 collaborative-affiliated practices, collecting survey data from 2223 patients and 297 clinicians. Intervention attributes included multimodal outreach and training activities to assure high fidelity to the data collection protocol. The implementation process was enhanced through interactive training and practice-assigned champions responsible for data collection. External context attributes that facilitated practice recruitment included partnership with a quality improvement collaborative and the inclusion of a staff member from the collaborative in our team. Key opinion leaders within each practice who could identify challenges to participation and propose flexible solutions represented internal context attributes. We also reported lessons learned during the recruitment process, which included navigating diverse approaches to human subjects protection policies and understanding that recruitment could be a negotiated process that took longer than anticipated, among others. Conclusions: Our experience provides other researchers with challenges to anticipate and possible solutions for common issues. Using the CFIR as a guide, we identified numerous recruitment barriers and facilitators and devised strategies to enhance recruitment efforts. In conclusion, researchers and clinicians can partner effectively to design and implement research protocols that ultimately benefit patients who are increasingly seeking care in ambulatory practices.

  • JMIR Cancer 2020;6(1):e14476

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