Evaluation of two mobile health apps for patients with breast cancer using the Mobile Application Rating Scale

Introduction

Epidemiology

According to estimates of cancer incidence and mortality, breast cancer is the most frequently diagnosed cancer in 135 countries and the leading cause of cancer related mortality in over 100 (1). Globally, over 2 million cases of breast cancer are diagnosed each year, accounting for almost 1 in 4 cases of cancer in women. In the UK and the US, it is estimated that between 1 in 7 and 1 in 8 women will develop breast cancer in their lifetime (2,3).

UK breast cancer policy

Earlier detection through screening has helped improve breast cancer mortality. The UK breast cancer screening programme was the first of its kind and began in 1988. Through the programme, women aged 50–70 can receive mammograms every 3 years (4).

In the last decade UK government and leading cancer charity policy has aimed to build on the success of the screening programme. Key policy themes include better education on symptoms and signs, improving lifestyles to reduce incidence, earlier diagnosis through screening, improving access to treatment, and enhancing patient experience and quality of life (5-8).

More recently, the NHS long term plan has advocated for more personalised therapeutic options and follow-up pathways for women diagnosed with breast cancer (9).

Information needs

National policy has to take a broad approach to cancer-related interventions that may not account for the needs of specific patient sub-groups. Efforts have been made to investigate the information needs of women with breast cancer (Table 1). The majority of studies are cross-sectional (10-18) with several literature reviews and meta-syntheses (19,20). The research is varied, investigating the information needs of women during and post treatment (10-12,15,21). Some studies have focussed on younger women with breast cancer (13,16), whilst others have focussed on long term survivors (19) and those managing advanced (17) and metastatic breast cancer (14).

Populations investigated were diverse including women from Lebanon (10), Ireland (11), Japan (12,16), America (13,14), Canada (22), Malaysia (21), Spain (15), United Kingdom (23), Australia (17) and Iranian immigrants (18). Unfortunately, most studies used relatively small sample sizes ranging from 19 participants (22) to 207 (12) making the accuracy of the insights difficult to interpret.

Furthermore, validated questionnaires like the breast cancer version of the Toronto Informational Needs Questionnaire (TINQ-BC) were not commonly employed as part of the research methodology (11,21) with many using bespoke questionnaires instead (15,16,18).

Common findings from the studies reviewed included variation in information needs based on age (10,16,19), a general preference to receive information directly from the healthcare provider (10,12,17,20), and a desire for high-quality information related to recovery and prognosis (11,14,15,20,21).

Methods

Personas

A common tool for both the design and evaluation of digital health technology (DHT), and a key component of user-centred design, is the use of personas. Personas are an empirically derived user archetype (24) that can be used to communicate the key concerns, motivations and interests of a user group. These archetypes are developed through quantitative and qualitative user experience research and serve as a useful communication tool to help developers understand the needs of target users (25,26).

Personas have been used extensively in the development of DHTs. Example patient groups include diabetics (27), older adults with heart failure (24), patients with coronary heart disease (28), multiple sclerosis (29), renal disease (30), children with cancer (31), women with gynaecological cancer (32), and older people generally (33).

It is beyond the scope of this study to undertake the qualitative and quantitative research to define persona archetypes for breast cancer patients. A review of the literature has identified several studies which have undertaken this process for specific DHT interventions. One used a qualitative approach and focus group methodology to collect user needs and preferences for the content and features of a mobile app for arm and shoulder exercises after breast cancer treatment (34). Another similar qualitative research study using semi-structured interviews with breast cancer survivors explored user experiences and needs regarding rehabilitation and technology (35).

Based on these studies and the information needs for breast cancer patients described previously, it is possible to derive two broad archetypes for the purpose of finding appropriate DHTs to evaluate (Figure 1). These are patients who are currently undergoing treatment for breast cancer and those who have ‘completed’ treatment. The information requirements of these two groups are different. Those currently receiving treatment express a greater need for information related to treatment plans and side-effects (21), whilst those under long term follow up require help with social and physical rehabilitation (12,15), and information related to prognosis (14).

Figure 1 Two personas describing the needs of different types of breast cancer patient. Persona 1 focuses on someone who has completed treatment whereas persona 2 focuses on a patient currently undergoing treatment.

Evaluation frameworks

Over 45 different mobile health app evaluation frameworks exist, created by a combination of academic institutions (36-39), non-profit organisations (40-42) and for-profit companies (43). Some frameworks focus on a specific type of health app such as mental health (39,42,44), while others have more general use-cases. Criteria vary between frameworks, but common themes include data safety and privacy, app effectiveness, user experience, data integration, clinical relevance and credibility.

Several studies have attempted to review the myriad of different evaluation frameworks through systematic review. The results are not particularly reassuring, suggesting that many frameworks cannot be used unaltered and need to improve their assessments of possible user harm and the impact of software updates (45). There is also evidence to suggest that ratings provided by certain frameworks can be inconsistent and contradictory when assessing popular behavioural health apps (46).

For the purpose of this study, the Mobile Application Rating Scale (MARS) was used for app assessment. MARS is a popular framework and has been used in the evaluation of a variety of health apps including those for diabetes (47), gestational diabetes (48), renal disease (49), genitourinary tumours (50) and food allergies (51). Since its creation in 2015 it has been translated into other languages including Spanish (52) and German (53), and has been adapted for use by end-users of health apps (54). Evaluation of the MARS framework has shown good interrater reliability and internal consistency (38).

Results

App selection

The selection of two appropriate apps for assessment attempted to follow a discovery process in line with each of the personas described in figure 1. Persona 1 had previously used the NHS Apps Library to find other health apps related to mental health. Following the same approach, searching for ‘breast cancer’ on the NHS app library returns the breast cancer app ‘Becca’ as the first result.

The description of ‘Becca’ (“Breast Cancer Now’s Becca app provides specialist support to help you live with, through and beyond breast cancer”), is aligned with Persona 1’s key characteristic of having completed their breast cancer treatment and requiring support in the post-treatment phase.

Persona 2 has a high level of technological literacy and is familiar with using mobile apps to track exercise and other aspects of her daily routine. Assuming persona 2 might take a more direct route to finding an appropriate resource for her needs, using the search query ‘breast cancer tracker’ within the Apple app store returns ‘OWise’ as the first result.

The description of ‘OWise’ (“…OWise gives you personalised, safe, reliable and credible information as well as practical support and guidance, in one easy-to-view place”) also aligns well with the requirements of Persona 2, particularly as she is currently undergoing treatment for breast cancer.

Evaluation results

Table 2 shows the number of user reviews and overall rating of both apps from the Apple app store and the Google Play Store, while Table 3 shows the MARS results for both apps. Scores are provided against each section of the framework: engagement, functionality, aesthetics and information. Completed MARS assessments for both apps are included in Table S1. Scoring was carried out by the author.

Both apps have received consistently positive user reviews across the major app stores suggesting they meet user requirements and expectations to some degree. Although positive, the number of reviews for each app is limited, particularly for OWise. This is despite both apps being available for download for several years (3 years for Becca, 5 years for OWise) in the United Kingdom.

Neither app has a paid version with all functionality Available online the outset. OWise has a particular focus on physical health using predominantly monitoring and tracking functionality. Conversely, Becca is more multi-faceted in its focus aiming to provide information and education on different topics relevant for women with breast cancer.

Both apps scored similarly overall. Within the sub-domains of functionality and aesthetics, each app was able to demonstrate excellent performance, gestural design, navigation and ease of use, perhaps reflecting the fact that both products had been developed by professional agencies with a track-record in app design.

The apps differed in their engagement and information scores. For engagement, OWise’s suite of features around tracking appointments, symptoms and treatment regimens made for a highly personalised and interactive experience. As a simple curator of high-quality breast cancer resources, Becca has less features to drive in-app engagement and is designed to direct users out of the app to relevant resources. Becca did have excellent accessibility features, allowing users to adjust screen size and zoom to suit their needs.

OWise scored marginally higher for the information section by virtue of having some, albeit limited, study literature to support its use in supporting women with breast cancer (55). A randomised clinical trial is underway, but results are yet to be reported. No supporting literature was found for Becca, however it was commissioned by a leading breast cancer charity and both apps have successfully gained access to the NHS Apps Library.

Discussion

Prior research investigating the effectiveness of breast cancer apps has consistently commented on the lack of a foundational evidence base to support their use. Several cross-sectional studies (56,57) and systematic analyses (58-60) have called for more evidence of clinical effectiveness and safety to support breast cancer app use. Of the two apps assessed here, only one (OWise) has made limited progress in this area, suggesting this is an ongoing issue in the realm of mobile health apps.

Becca does have the backing of a major UK breast cancer charity and aims to link users to high-quality information related to various aspects of breast cancer. However, research to evidence how these resources meet the information needs of women who have completed breast cancer treatment would be beneficial.

From a policy perspective, where personalisation in cancer care is being increasingly promoted (9), both apps aim to provide personalised experiences for their users. OWise has sophisticated symptom and treatment-tracking functionality whereas Becca can ‘learn’ what sort of breast cancer content any given user is most interested in for more personalised recommendations.

Accessibility is an important component of any DHT. Despite an excellent array of symptom and tracking functionality, OWise neglected to include simple accessibility features such as text enlargement and zoom capability which negatively impacted the engagement score. These features were present in Becca and should be viewed as a baseline requirement to ensure DHTs demonstrate a high level of inclusivity for a wide variety of users. Despite appropriate accessibility measures, Becca scored poorly for entertainment and interactivity. The app might benefit from added functionality, involving gamification or mood/symptom tracking in order to drive engagement and maximise the benefit of its information resources.

Data privacy is an important domain through which to assess DHTs and is one of the more notable omissions of the MARS framework. Data related features have been explored by Orcha, which has carried out assessments of both the apps described here. Orcha rated the data privacy of Becca and OWise at 45.6% and 51.4% respectively, identifying some gaps in data encryption and a risk of identification through the data collected (61,62).

Both apps seemed well suited to the specific user needs of the personas described in Figure 1. Unlike other health apps which aim to deploy one or more behaviour change techniques to impact a specific health behaviour, neither of the tools reviewed here had particular behavioural targets. However, they do address one of the key information needs of breast cancer patients—the provision of information by healthcare professionals. Becca provides an alternative source of high-quality information where this might be lacking from direct interactions with the patient’s healthcare team, while OWise allows for the capture of key trends and data in order to facilitate better quality discussions with care providers. Becca also has a rich array of resources related to recovery and post-treatment care which was identified as a key information need in the existing literature.

Although both apps were consistently and positively reviewed in the respective app stores, the overall number of reviews were limited. The reasons for this could be multifactorial. From the developer’s perspective, they could perhaps do more to encourage users to submit reviews and feedback. From the user’s perspective, providing feedback for a breast cancer app might be of low priority during a particularly stressful and uncertain period in their life. The use of app store reviews as a measure of meeting informational needs should be supported by other datapoints. This might include user focus groups or posts made on online breast cancer patient forums that reference the apps.

Conclusions

Becca and OWise are two breast cancer apps that score well on the MARS framework and address the needs of breast cancer patients after and during their treatment respectively. Both apps suffer from a lack of evidence to support their clinical effectiveness but aim to fill an informational needs gap that has been identified in the literature. As with many DHTs, particular attention should be paid to the handling of user data, to ensure it is compliant with national and international regulation and utilises suitable levels of encryption. More emphasis should also be placed on simple accessibility features to help ensure health apps are inclusive for different user groups. This study is based on the assessment of a single assessor. Future research should employ the use of multiple evaluators to validate the scores provided through the MARS framework and to allow more accurate comparison with the existing literature around breast cancer apps.

Acknowledgments

Funding: This work was supported by UK Research and Innovation (UKRI).

Footnote

Data Sharing Statement: Available at http://dx.doi.org/10.21037/mhealth-20-161

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/mhealth-20-161). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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