Mobile and Wireless Technologies for Gastrointestinal Cancer Treatment

Mobile and Wireless Technologies for Gastric Cancer Treatment

To date, one prospective study and one randomized controlled trial have investigated the use of mobile and wireless technologies in the treatment of gastric cancer.

Wu et al. evaluated the feasibility and clinical value of wearable devices linked to mobile platforms for recording physical activity in 43 patients with gastric cancer undergoing gastrectomy (11). The primary objective of the study was to validate the feasibility of the present system, defined as the proportion of patients using each element of the system (wearing the device and uploading step counts) for at least 70% of the 28-day study period. The secondary objective was to assess the clinical value of step counting by examining whether it was associated with early discharge. Forty-three patients were enrolled in the study. In the feasibility assessment, 100% of the patients submitted data in the first week, 93% in the second week, 91% in the third week, and 86% in the fourth week. The overall daily submission rate of this study was 95.5%. In the clinical value assessment, each 1000-step increase in walking on postoperative day 5 was associated with early discharge. They concluded that the use of mobile phone apps with wearable devices to record physical activity in patients with gastric cancer undergoing gastrectomy is feasible and useful.

Park et al. conducted a prospective single-arm pilot study (NCT04800991) (12). This pilot study developed and evaluated the feasibility and effectiveness of digital therapeutics for postoperative supportive care in 39 patients with gastric cancer who underwent minimally invasive surgery. The primary endpoint was to assess the feasibility of the mobile apps. The primary endpoint of this study was the score for each section of the HDT-202 UX questionnaire. This questionnaire was scored as 0 (strongly disagree), 1 (disagree), 2 (agree), and 3 (strongly agree) with regard to ease of learning, usability, and effectiveness. The secondary outcomes were compliance with the research app, changes in weight and achievement of calorie and protein targets at 10 weeks compared to baseline, frequency of post-gastrectomy symptoms, and changes in QoL questionnaire scores. In this study, the mobile application was an Android-based smartphone. The application automatically calculates and provides daily targets for calorie and protein intake according to the patient’s body mass index. Patients also recorded daily food intake, body weight, and symptoms in the application and completed questionnaires to assess the feasibility of the application. In the primary endpoint analysis, the mean questionnaire scores for ease of learning, ease of use, and effectiveness of the app were 2.32±0.41, 2.35±0.43, and 2.4±0.39 (range=0-3), respectively, at the 10-week follow-up. Of the 39 patients, four were classified as underweight [body mass index (BMI) <18.5], 12 as normal (BMI= 18.5-24.9), and 11 as overweight (BMI ≥25.0) according to their predischarge BMI. After 10 weeks of follow-up, underweight patients had higher compliance with app use (98% vs. 77% vs. 81%, p=0.0313) and higher rates of reaching calorie (102% vs. 75% vs. 61%, p=0.0111) and protein (106% vs. 79% vs. 64%, p=0.0429) targets than normal-weight and overweight patients. Two patients went from underweight to normal weight, one from normal weight to underweight, and two from overweight to normal weight. They concluded that the mobile app is feasible and useful for postoperative supportive care and that digital therapeutics may be an effective way to provide supportive care for post-gastrectomy patients.

Mobile and Wireless Technologies for Esophageal Cancer Treatment

There has been one randomized trial and one prospective trial for esophageal cancer patients.

Yang et al. prospectively evaluated the feasibility of a mobile health coaching application to prevent nutritional status and body composition changes in patients with esophageal cancer receiving neoadjuvant chemoradiation therapy (13). In this study, Noom (Noom Inc., New York City, NY, USA), a commercial mobile health application, was used primarily for obese individuals to manage their body weight. Noom tracked food intake, exercise, and weight changes during treatment. A total of 38 patients were enrolled in the study. The patients’ nutritional and inflammation-related laboratory parameters and body composition, including the skeletal muscle index, were measured before and after treatment. Changes in nutritional status and body composition were compared between the mobile device application and baseline groups. In the feasibility analysis, mobile application compliance was 72.2% after eight weeks of treatment. The activation of the mobile application was high in 69.4%, moderate in 8.3%, and low in 22.2%. The most activated records were for the diet part, whereas the most inactivated records were for the exercise part. In the power analysis, there were no significant differences in the changes in skeletal muscle index and the number of patients with excessive muscle loss. They concluded that an individualized care model with appropriate exercise and nutritional support may be needed to reduce muscle loss and malnutrition.

Lee et al. conducted a randomized controlled trial to evaluate the efficacy of an electronic patient reported outcome (PRO) symptom monitoring system in patients with breast, lung, head and neck, esophageal, or gynecological cancer who received chemotherapy or chemoradiation therapy (NCT04568278) (14). A total of 222 patients were enrolled in this study. Of the 222 patients, 40 had head and neck or esophageal cancer. Two hundred and twenty-two patients were randomly assigned to the intervention (n=147) and control (n=75) groups. Patients in the intervention group received a symptom monitoring application for eight weeks. When patients reported symptoms, the application provided graphical summaries to help them understand their health status. At the same time, the reported data were automatically transferred to a web dashboard, which could be accessed directly by clinicians in the office. Patients in the control group received daily clinical care. The primary endpoint was improvement in symptom management, while the secondary endpoints were the QoL and unplanned outpatient clinic visits. In the primary endpoint analysis, symptom management at week eight was significantly better in the intervention group than in the control group (mean score; 8.5 vs. 8.0; p=0.01). Conversely, in the secondary endpoint analysis, the QoL and unplanned outpatient clinic visits were similar between the two groups. They concluded that a mobile-based symptom monitoring system was useful for patients receiving cancer therapy. They also suggested that digital-based tools can empower patients to play a more active role in their treatment.

Mobile and Wireless Technologies for Colorectal Cancer Treatment

Two randomized control studies and three prospective studies have evaluated mobile and wireless technologies in colorectal cancer treatment.

Miller et al. conducted a randomized control trial to evaluate the effectiveness of a digital intervention on colorectal cancer screening (NCT02088333) (15). A total of 450 patients were enrolled and divided into intervention (n=223) and control (n=227) groups. Patients in the intervention group used an iPad application that displays a colorectal cancer screening decision aid, allows them to order their own screening tests, and sends automated electronic follow-up messages to support them. Patients in the control group received the usual care. The primary outcome was the completion of a colorectal cancer screening test within 24 weeks of enrollment. The screening test completion rates were 30% in the intervention group and 15% in the control group. The detection rate of colorectal neoplasia was 7.2% in the intervention group and 2.6% in the control group. They concluded that a digital health intervention that allows patients to undergo “self-order” tests can increase colorectal cancer screening.

Cheong et al. conducted a prospective study to evaluate the efficacy and feasibility of a smartphone application-based personalized exercise intervention in patients with colorectal cancer receiving chemotherapy (16). A total of 102 patients with colorectal cancer were enrolled in this study. Patients used a mobile application and wearable device that included a rehabilitation exercise program [including warm-up (4.5 min), stretching (5.5 min), aerobic exercise, resistance exercise (4 min), and pelvic floor exercise (6 min)], and information about the patient’s disease and treatment for 12 weeks. The grip strength test, 30-s chair-stand test, 2-min walk test, amount of physical activity, QoL, and nutritional status were assessed and measured at baseline, mid-intervention (6 weeks), and at the end of the intervention (12 weeks). In the feasibility analysis, 75 of 102 patients completed 12 weeks of the intervention. In the efficacy analysis, lower extremity muscle strength and cardiorespiratory endurance improved significantly at six and 12 weeks compared with baseline and from six to 12 weeks. In addition, in the QoL assessment, fatigue and nausea/vomiting improved significantly. However, nutritional status and self-reported physical activity did not change. The researchers concluded that a personalized rehabilitation exercise program is effective in improving exercise capacity and treatment-related symptoms during chemotherapy for colorectal cancer. den Bakker et al. evaluated the feasibility and effectiveness of an electronic health care (eHealth) intervention for colorectal cancer patients in a randomized controlled trial (Netherlands Trial Registry NTR5686) (17). A total of 151 patients with colorectal cancer who had undergone surgery were enrolled and divided into an intervention group (n=73) and a control group (n=78). Patients in the control group received the usual care and had access to a placebo website. Patients in the intervention group had access to an eHealth program that included a website, mobile phone app, activity tracker, and the ability to ask questions of health professionals in their own hospital via an eConsult. The quantitative evaluation used Linnan and Steckler’s framework to assess the delivered dose, received dose, adherence, and participant attitudes, while the qualitative evaluation used the Unified Theory of Acceptance and Use of Technology framework. Quantitative data were obtained from participant questionnaires, a logistical database, a weblog, and participant medical records. In the quantitative evaluation, the overall implementation scores for websites, mobile apps, eHealth consultations, and activity trackers were 64%, 63%, 44%, and 67%, respectively, while in the qualitative evaluation, the eHealth program was supportive and provided guidance on the recovery process after colorectal surgery. However, patients with complications or who received adjuvant chemotherapy needed a more tailored program. The authors concluded that the eHealth perioperative care program was supportive and useful for the recovery process after colorectal surgery.

Waller et al. evaluated the effectiveness of a tri-modal prehabilitation program using smartwatches in patients undergoing major abdominal cancer surgery (18). A total of 22 patients were included in the study. Of the 22 patients, 15 had colorectal adenocarcinoma. The 22 patients were randomized into the intervention group (n=11) and the control group (n=11). The patients in the intervention group received home-based exercise, nutrition, and dietary advice using a wrist-worn smartwatch connected to a smartphone application. The primary endpoint was preoperative physical activity, including the 6-minute walk test (6MWT) distance, and the secondary endpoints were changes in body weight and the Hospital Anxiety and Depression Scale (HADS). In the efficacy analysis, the daily minutes of moderate and vigorous physical activity were greater in the intervention group than in the control group (daily minutes of moderate physical activity: 25.1 min vs. 13.1 min, p=0.063) (vigorous physical activity: 36.1 min vs. 17.5 min). In addition, the intervention group had significantly greater improvements in 6MWT distance compared to the control group (+85.6 m vs. +13.23 m, p=0.014). However, the HADS scores were similar between the two groups. They concluded that prehabilitation in colorectal cancer care can be delivered using smartwatches and mobile applications and showed that these technologies can improve the functional capacity before surgery.

Eustache et al. conducted a prospective study to evaluate the efficacy of a mobile phone application to reduce emergency department (ED) visits after colorectal surgery (19). A total of 114 patients were enrolled and compared with a retrospective cohort of 608 patients undergoing colorectal surgery. The mobile phone application included patient education material, daily post-discharge assessment questionnaires, and a patient-provider chat. The primary outcome was preventable 30-day emergency visits. The preventability of ED visits was classified according to the New York University ED grading algorithm on a scale of 1 to 4: 1) non-emergent, 2) emergent but treatable in an outpatient setting, 3) emergent/ED care required but preventable if timely outpatient care was available, and 4) emergent/ED care required and not preventable. Grades 1-3 were considered potentially preventable. The secondary outcomes were length of stay, complications, total emergency department visits, readmission, and application usability. In the primary analysis, there were significantly fewer preventable ED visits in the intervention group than in the control group. The total number of avoidable ED visits was four in the intervention group and 23 in the cohort group (p=0.043). The length of hospital stay was also significantly shorter in the intervention group than in the cohort group (3.2 days vs. 4.6 days, p=0.011). However, complication rates (22% vs. 27%, p=0.175), total number of emergency visits (15 vs. 41, p=0.594), and readmission rates (7% vs. 6%, p=0.348) were similar between the intervention and cohort groups. They concluded that the use of a mobile phone application can improve post-discharge monitoring and patient-provider communication and reduce avoidable emergency visits.

Mobile and Wireless Technologies for Pancreatic Cancer Treatment

Only one prospective study has evaluated the use of mobile and wireless technologies in the treatment of pancreatic cancer.

Gustavell et al. evaluated the clinical impact of the Interaktor app on the health-related QoL and self-care activities in patients who had undergone pancreaticoduodenectomy for cancer (20). The application consists of 12 symptom questions and 22 self-care advice areas. The primary component of the Interaktor application was the assessment of self-reported symptoms, a monitoring web interface, risk assessment of models for alerts, access to evidence-based self-care advice, and graphs for patients to view the history of their symptom reporting. A total of 26 patients were enrolled in this study. The health-related QoL and self-care were assessed preoperatively, six weeks postoperatively and six months postoperatively and compared with their historical control group (n=33). In the efficacy analysis, the Interaktor application group had a significantly higher emotional function and less nausea/vomiting, pain, loss of appetite, constipation, and worry about low weight than the control group at six weeks after surgery. In addition, the Interaktor application group had significantly less liver pain and less worry about low weight than the control group at six months after surgery. During the first 4 weeks, patients reported symptoms on a median of 95% of the intended days and a median of 83% for the rest of the period. The authors concluded that the use of a patient-reported outcome management app reduces symptom burden six weeks after pancreaticoduodenectomy for cancer.

Ongoing Trials of Mobile and Wireless Technologies for Gastrointestinal Cancer Treatment

Two randomized studies on GC have been proposed. Kim et al. proposed a randomized controlled trial to evaluate the usefulness of a personalized digital exercise and nutrition-based rehabilitation program using a smartphone application for gastric cancer patients who have undergone gastrectomy (21). The primary endpoint was the change in body weight at 12 months between the intervention and control groups, and secondary endpoints were the QoL, physical activity, nutritional status, physical fitness, and pain intensity over time. A total of 324 patients with gastric cancer who underwent gastrectomy were to be recruited and randomized into intervention and control groups. The intervention group would receive a personalized digital rehabilitation program that included expert advice, exercise management, diet management, self-symptom tracking, physical activity management, comorbidity, and weight management. The control group was to undergo conventional education-based rehabilitation. This study has potential as a cornerstone for future digital therapeutics and telerehabilitation using hardware and software, focusing on personalized medicine.

Kim et al. additionally proposed a randomized trial to evaluate and compare the effects of human health coaching via a mobile application and conventional face-to-face counselling in patients with gastric cancer who have undergone gastrectomy (NCT04394585) (22). The primary endpoint was the dietary restriction score, and secondary endpoints were the QoL and dietary scores. Outcomes were to be measured for up to one year after surgery. A total of 180 patients would be recruited and randomized into a mobile application group and face-to-face group. The mobile app group would receive nutritional advice and counselling from an assigned dietitian via the Noom app for three months post-operatively, while the control group would receive face-to-face advice from a dietitian during their follow-up hospital visits at one and three months post-operatively. This study was expected to provide evidence of the effectiveness of human health coaching via a mobile app on dietary adjustment in patients who have undergone gastrectomy for gastric cancer.

Kim et al. further proposed a phase III trial to evaluate the efficacy of digital lifestyle interventions after colorectal cancer surgery using mobile applications (KCT0005447) (23). The primary endpoint was the health-related QoL using the EuroQol 5-dimension, while secondary endpoints were the health-related QoL calculated from multiple other surveys, including the health-related QoL and metabolic parameters. These endpoints were to be assessed at six, 12, and 18 months after enrollment. A total of 320 patients with colorectal cancer were to be recruited and randomized into four groups (group A, active safety; group B, basic walking; group C, cancer-specific; group D, control). Group A would be assigned to the Noom application, a paid global mobile application (Noom, Inc.); Group B to WalkOn (Swallaby Co., Seoul, Republic of Korea), a free application that can record a user’s step count and walking intensity; and Group C to a Second Doctor (Medi Plus Solution C., Seoul, Republic of Korea). Users were to select their specific condition (e.g., colorectal cancer) and upload basic information along with information regarding the treatment received. One-on-one consultations with human coaches, including nutritionists, are available through this application, and patients can automatically track their daily steps, calories consumed, heartbeat, and sleep patterns using a smart band. The results of this study provide evidence that easily accessible mobile apps can influence patients’ lifestyles. Studies such as these will explore new opportunities for mobile and wireless technologies for patients with gastrointestinal malignancies.

Future trials should focus on two issues. The first is the cost-benefit of mobile and wireless technologies for health. Although previous studies have shown the clinical benefits of mobile and wireless technologies, cost-benefit analyses are lacking. The initial costs of developing mobile and wireless technologies for health are significant; however, once developed, the subsequent costs are relatively low. Thus, it is necessary to analyze whether or not the introduction of mobile and wireless technologies for health would reduce the cost of healthcare to society. The second issue is the clinical relationship between mobile and wireless technologies for health, and long-term oncological outcomes. Previous studies have demonstrated that mobile health and wireless technologies affect the short-term oncological outcomes. It is necessary to consider whether or not short-term oncological improvements using mobile and wireless technologies for health contribute to long-term oncological outcomes.