Supportive eHealth technologies and its effects on physical functioning and quality of life for people with lung cancer:A systematic review

Background: Despite improvements in treatment and early diagnosis people with lung cancer are not living as long as people with other cancers. Therefore, good symptom management and improved quality of life is a priority in this patient group. The more common symptoms of lung cancer; breathlessness, fatigue and depression can be improved by improving patients’ physical functioning. However, current health care services have limited capacity to provide this support. One way to address this issue of health care resources is to empower patients to self-manage their condition using electronic health technologies. Objective: The purpose of this review was to locate and assess available research on technologies that support the person with lung cancer to improve or maintain their physical functioning and/or their quality of life. Methods: Six databases (PubMed, Web of Science, CINAHL, Medline, SPORTDiscus and PsychInfo) were searched from January 1990 to April 2023. Studies were suitable for inclusion if; study participants included people with lung cancer over the age of 18, participants were exposed to a physical activity, exercise or a training intervention that was delivered via an electronic or web-based application with or without a comparator. Furthermore, the study must have reported on the impact of the intervention on physical function and/or quality of life. Studies that focused on telemedicine without an online intervention were excluded. The GRADE system was used to assess the quality of included papers. Due to the heterogeneity of the studies a narrative synthesis was undertaken. Results: This review is reported in accordance with the PRISMA guidelines. Seven hundred and ninety-four papers were initially identified through our search; following screening eight papers were confirmed suitable for inclusion in the review. Two papers reported on different stages of the same study therefore only seven studies were included in our analysis. Studies were undertaken between 2010-2018 across multiple countries. Included studies aimed to develop a technology


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Introduction
Lung cancer is the most prevalent cancer globally with 2.21 million new cases being diagnosed in 2020; this is anticipated to increase to 3.8 million by 2050 (1).Lung cancer also accounts for the highest number of cancer related deaths across all cancer types (2).
In the UK, there are approximately 48,500 new lung cancer cases diagnosed per year(3).It's incidence strongly correlates with age, peaking among older individuals.In the UK from 2016-2018, over 44% of new cases annually were in those aged 75+.Rates rise sharply from around age 45-49, reaching a peak in females aged 75-79 and males aged 85-89, then decline in older age groups.
Females typically have lower incidence rates than males, particularly evident at age 90+, where the rate in females is half that of males (3).One-year survival rates have almost doubled since the 1970's due to early diagnosis and improved treatments.Survival at 5 and 10 years has not improved as much as other cancers (3).
For people living with lung cancer, it is imperative that supportive care needs, which are central to patient-centered care (4) are addressed promptly as their condition is associated with a high symptom burden and high levels of unmet need throughout the disease trajectory (5).Additionally, approximately two-thirds of people with lung cancer have at least one other pre-existing health condition, and up to half have two or more (6).Addressing the supportive care need will contribute to efficient use of healthcare resources and minimise hospital admissions.If not managed effectively this could negatively impact patient outcomes including physical functioning, psychological wellbeing, and HRQoL (4).Common symptoms of lung cancer include fatigue, breathlessness, depression -all of which can be improved by exercise interventions (9).More generally, other positive implications for people with cancer undertaking physical activity include improvements in HRQoL (10)(11)(12)18), lung function (10,12), sleep (10,14), immune function and markers (10,15), mood (10)(11), bone strength (10,16), muscle mass (10,17) and decreased cancer cell proliferation (10,15).However, less than one third of people with lung cancer meet recommended exercise guidelines to reduce time spent sedentary, increase strength, and balance building activities and to undertake 150 minutes aerobic activity per week (19).
Self-management practices, including those with an exercise component, can help patients to regain health and fitness, reduce side-effects from treatment and symptoms of the disease, relax the mind and body, enhance HRQoL and regain a sense of normality post-cancer (20).More recently, the National Institute for Clinical Excellence (NICE) has recognised exercise as a first-line treatment within healthcare and holistic disease management (21).In the absence of a robust national rehabilitation system there is pressure for self-management support to be integrated into routine cancer care (22).But, patient adherence to rehabilitation programs delivered at hospital outpatient centres can be low due to the required travel and associated socioeconomic factors (23), Furthermore studies have demonstrated that home-based rehabilitation improves patient adherence and HRQoL (24).
Web based interventions have grown in popularity over recent years.These interventions enable the user to independently navigate a recommended online program that is operated via a website with the aim to create a positive change to health and wellbeing (25).Government organisations are actively trying to translate 'in-person' activities to online (26).Following the COVID-19 lockdown this was subject to renewed prominence as the advantages of digital technology were highlighted.
Furthermore, earlier reviews have identified several mobile and electronic apps along the cancer continuum from cancer prevention to survivorship (27).The use of mobile health (mHealth) and electronic health (eHealth) technologies such as wearables, activity trackers, apps and web-based programs that can be accessed via smartphones and tablets, provide new methods for educating, monitoring, and supporting patients with chronic conditions/cancer.The World Health Organisation (WHO) recognises the potential of mHealth and eHealth interventions to support health care delivery (28).They can assist patients in self-managing their health behaviours and are considered feasible, acceptable, and effective approaches to providing supportive care (29,30).
There is a growing body of evidence to support technology interventions in health care and this is supported within the UK National Health Service (NHS) Long Term Plan (31).Yet, evidence-based mHealth and eHealth interventions to enhance exercise and physical activity for people with lung cancer remain uncommon.Furthermore, of the cancer related apps that are available, a limited number adopt a personalised approach to physical activity and exercise that accommodates patients' preferences.

Aim
This study aims to establish what mHealth and eHealth technologies have been developed to support people with lung cancer to improve or maintain physical functioning and/or impact their HRQoL.

Objectives
The primary objective of the review was to establish if any mHealth or eHealth technologies identified impacted on the physical functioning and HRQoL of the person with lung cancer.
The secondary objectives were to: assess the demand on clinician's time, the acceptability of the intervention to patients, carers and/or health care professionals, user satisfaction with the technology, identify security features (clinical safety, data protection, technical security), and to identify the cost impact of the mHealth or eHealth app/intervention.

Design
This review was prospectively registered with the International Prospective Register for Systematic Reviews (PROSPERO; CRD42023414094) and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to improve the quality of the review and to ensure transparency at all stages.

Types of Studies
We included all primary research studies, without study design or publication status limitations or language or geographical area restrictions.Case studies were also included.Reference lists of systematic reviews were cross checked to identify any potential studies to include.We limited the search to studies published after 1990, as internet interventions did not exist prior to this date (32).

Population
We included studies that were undertaken with adults (>18 years), diagnosed with a lung cancerregardless of the stage of their disease, treatment allocation, sex, or where they were cared for.

Intervention:
Study participants in the included studies must have been exposed to a physical activity, exercise or training intervention that was delivered via an electronic or web-based application with or without a comparator.

Outcome Measures
Studies were included if they reported on the impact of the digital intervention on physical function or HRQoL or both HRQoL and physical functioning using any validated measure.We included studies that measured impact at one or multiple timepoints.

Exclusion Criteria
We excluded the following:  Cancer studies where the total number of participants with lung cancer accounted for less than fifty percent of the study population. Studies that focused on tele healthcare only and did not include an electronic or web based online intervention.For example, studies that evaluated remote sessions with a clinician via video link were excluded. Apps used to track activity that could be linked to a wearable device but did not provide any other support.

Search Strategy
A search of six databases: PubMed, Web of science, CINAHL, Medline, SPORTDiscus and PsychInfo was carried out on 17th April 2023, via EBSCO, using a list of key terms focusing on three distinct categories; the intervention characteristics (e.g., online, internet, app/application, remote, digital), physical functioning (e.g., activity, exercise, training, movement, athletics) and the population of interest (e.g.lung cancer patient/survivor, cancer).These were amalgamated using Boolean operators to formulate a comprehensive search string.The full list of search terms is listed in Table 1.Other sources such as references of included records were searched.

Selection of Studies
After removing duplicates, 581 papers were retrieved by the search and were screened by two reviewers (SK/PW/CH/ZD).Title and Abstract screening were undertaken, and 544 papers were excluded in this process, leaving 37 papers remaining.A further seven were excluded as they were conference abstracts.A full text screening of the remaining 30 papers was then conducted, and 22 papers were excluded, leaving eight papers remaining for final inclusion.Any discrepancies identified by reviewers during the screening process were resolved by discussion with a third member of the review team.The screening process is outlined in Figure 1.

Data Extraction
Data was independently extracted from included papers by the lead author (SK) using a data extraction template developed for the purpose of this review.The extracted data was reviewed by the co-authors (CH, ZD, PW) and discrepancies were resolved.In case of missing study data, we attempted to contact the corresponding authors to obtain the required information.Three authors were contacted (33)(34)(35), but none replied.These papers were not excluded as they still met the inclusion criteria and reported on some of our objectives.
We extracted the following data:  Study characteristics; author, year of publication, title, country of study, year of study, study objective, overall study design, recruitment method, sample size, participant age range, gender, study duration  Intervention characteristics: technology name, setting, intervention details, exercise details (type, frequency, intensity, and duration)  Outcome measures of interest (impact on physical function, impact on HRQoL and user acceptability)  Other outcomes of interest: impact on clinician time, user acceptability/satisfaction, safety features, cost impact

Risk of Bias
Two reviewers (SK and ZD) independently assessed the risk of bias of each included study and confirmed agreement.The Joanna Briggs Institute (JBI) checklists (36) were used to assess randomised controlled trials, quasi experimental studies, qualitative research and cohort studies.

Quality Appraisal
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was adopted to assess the quality of the evidence used to support the synthesised findings (37,38).

Data Synthesis and Analysis
Due to the methodological heterogeneity of the included studies, we were unable to undertake a meta-analysis.Instead, the Synthesis without meta-analysis reporting items (SWiM) checklist was employed to aid transparency in the reporting process (39).This enabled us to report on the key features of included studies, group the studies and explain our findings.A narrative synthesis (40) was also undertaken according to the study objectives stated earlier.This allowed us to provide a comprehensive summary of the impact and effectiveness of the interventions identified in our included studies.

Results
Eight papers were identified as suitable for inclusion.But two papers (33,41), reported on different stages of the same study, hence only seven studies were included in the review.The screening process is outlined in the PRISMA diagram shown in Figure 1.
Participants were identified from secondary care settings.The number of participants in studies ranged from 5 [45] to 100 [44], study participants mean ages ranged from 55.1 [44] to 64.6 [33,41] years.Overall, there were more female participants(n=195) than male participants (n=145) across four studies [33,[42][43][44]; one study did not report the gender breakdown of their participants (34).The intervention duration ranged from 6-12 weeks; one study (34) did not report the intervention duration but it was clear that the intervention was delivered pre and post operatively with a study duration of no more than 18 months.Characteristics of included studies are detailed in Table 2.

Quality Appraisal
The risk of bias for all studies was low, and quality appraisal scores were moderate as illustrated in Table 2.

Intervention characteristics
The review identified seven technologies that had been studied in people with lung cancer; four mobile apps (34,35,43,44) and three web-based apps (33,41,42,45).Of the web-based apps two studies used a gaming console to deliver part of the exercise prescription (33,41,45).
The frequency, intensity, time, and type (FITT) formula ( 46) was used to extract key components about the exercise prescription of each study.Only four of the seven studies reported the full details of the exercise prescription according to the FITT formula (33,34,41,44,25).
The studies that did not provide a detailed exercise prescription provided more general information and recommendations regarding physical activity (35,42); alternatively, the interactive app would support the participant to edit the frequency, intensity, and duration of the exercise (43).Where the technology included an interactive patient portal it was noted that the physical activity support program that was incorporated in the portal was only used by one-third of participants (42).
The intervention details are summarised in Table 3. Used a computerised system that provided advice depending on nutritional status, possible contraindications for physical activity, treatment phase, tumour type (breast or lung cancer), whether the patient is participating in a supervised exercise program, and if yes, whether additional information on physical activity is desired.

Physical Functioning
All included studies demonstrated some improvement in physical functioning, but the methods of assessment varied between studies.The most common assessment was walking time/distance.Both ( 43) and ( 45) demonstrated improvement in the 6MWT/D while ( 35) noted an improvement in the 2min walking distance.An increase in walking duration and step count was also observed by ( 33)and ( 34) showed an increase in the shuttle walk test.
No improvement in muscle strength was noted by ( 45) while ( 35) demonstrated an improvement in lower extremity strength but not in upper extremity muscle strength.
Only one study showed an improvement in balance and cancer related fatigue (33,41) and another showed an improvement in dyspnoea grade (43).
One study identified no significant improvement in physical activity but an improvement in vigorous activity over time (42).Lastly, one study highlighted that although exercise capacity improved in stable patients, this was not the case in patients with progressive disease (44).

Health related quality of life
Almost all studies included in our review report the impact of the digital health intervention on HRQoL (34,35,(42)(43)(44)(45).
The most common tool used to assess HRQoL was the EORTC QLQ-C30.Improvement in symptom scales were observed by (34,44), improvement in functional scales were observed by (35,44) and one study did not observe any significant changes (45).
Ji et al. used the EQ-VAS score to demonstrate a significant improvement between visit one and visit three but the EQ-5D did not differ between the same time points (43).The SF-36 was employed in one study (42) and no significant changes in the scores were noted.

Demand on clinician's time
The technologies varied with regard to the level of clinician involvement required to execute and maintain the patient on the technology.The authors attempted to assess the impact on clinicians' time for the various studies.This is outlined in Table 4.Only one study (42) explicitly reported the impact of adopting the intervention on health care professional time -60 minutes.

Acceptability and user satisfaction
All included studies reported either user satisfaction (43)(44)(45) or both acceptability and user satisfaction (33)(34)(35)42), as summarised in Table 4. Studies demonstrated high levels of acceptability and user satisfaction.

Safety features
Studies reported primarily on clinical safety features of the technology, for example access to a phone while exercising to contact study nurse [33,41], heart rate monitoring [33,34,41 43), monitoring of oxygen saturation levels [34]as noted in Table 4. Two studies also reported on the technology's security features to ensure limited authorised access to the app [43] or data base [42].

Cost Effectiveness
None of the studies evaluated the cost effectiveness of the digital health intervention in terms of clinical outcomes within a health economic context.Only one single centre, cohort study reported on the cost of implementing the technology (34).They estimated this to be £16-£34 per patient.Discussion eHealth eHealth, which encompasses information and communication technology, facilitates remote care delivery and health information transmission, promoting patient involvement, improving care quality, and enhancing accessibility, particularly in remote areas.Despite benefits like convenience and reduced travel, concerns exist, such as privacy issues, fears of diminished human interaction and access to technology and internet infrastructure (52).eHealth holds promise in supporting patient-centered care and empowers patients by enhancing their involvement in their healthcare (53).

Principal Results
To our knowledge, this is the first review that has looked specifically at digital technologies developed for people with lung cancer and their impact on physical functioning and/or HRQoL.Despite searching across a wide range of data bases we only identified seven studies for inclusion in our review.
The findings of this review suggest that digital health interventions with an exercise component are acceptable to people with lung cancer, as they help them play a more active role in their health care and can positively impact their physical functioning and HRQoL Various tools were employed in the studies to assess HRQoL.The EQ-5D, a questionnaire conventionally employed for economic cost analysis was used in one study to assess HRQoL and despite an observed increase in the EQ-VAS the EQ-5D did not improve [45]., The evidence to support the use of digital exercise interventions remains sparse as we draw on the findings of only a few studies that aimed primarily to develop and assess the feasibility of the intervention.
Nevertheless, the quality of the studies was high thereby strengthening the credibility of the review findings.Further research to observe the effects of the interventions over a longer period is required, as well as research that explores the potential cost savings associated with using a remote health management mobile application, including reduction in clinician time or number of consultations, improved disease management, the costs of implementing the technologies into routine care, as well as the safety and security risks of the technologies.

Results in context
In recent years there has been a growth in the number of digital health technologies, including mobile and electronic health, and wearable devices that are becoming an integral part of modern healthcare (47).The promotion of patient self-management practices facilitated by digital technology has gained attention as it can improve patient engagement and health care delivery (48) This has become particularly relevant and has exacerbated following the pressures placed on the health service during the COVID-19 pandemic (25).It is anticipated that strategies to encourage patients to self-manage their health behaviors will continue to be integrated into care pathways in the future (49).
In the context of lung cancer, that approximately two-thirds of people with lung cancer have at least one other pre-existing health condition, and up to half have two or more (27), making this group more complex to treat as they require a more tailored approach to rehab (50).We noted that the technologies identified in our review either produced an exercise prescription relevant to the individual participant's capability or gave the patient guidance on exercises they might be able to undertake.As the participants exercise tolerance improved the prescription was updated, affording a bespoke approach to rehabilitation that might be more relevant to people with lung cancer (51).
This review highlights the benefits of a digital health intervention that includes an exercise component, and demonstrated improvements in cancer related fatigue and balance (33,41), walking duration or distance or step count (33)(34)(35)41,45), general activity levels, dyspnoea (43), and muscle strength for people living with lung cancer (35).Nevertheless, there are still areas for development.For example, one of the studies (35) found that while there was an increase in lower extremity muscle strength, no change in upper extremity muscle strength was noted and in another study (44) for participants with progressive disease no improvement was observed in exercise capacity or dyspnoea scale.Furthermore, none of the studies included here provided a bespoke exercise prescription and demonstrated a positive impact on exercise endurance and muscle endurance and symptoms of dyspnoea.This reinforces the need to produce an exercise prescription that is relevant to the participants' disease status and individual exercise goals.More consideration is required to develop technologies with intelligent algorithms or artificial intelligence that can support the person with lung cancer to input data on their current condition and capability before a safe, bespoke, exercise prescription is recommended.This needs to be factored into app development and further research.
Improving HRQoL is a priority goal in supporting people with lung cancer (50).All studies that assessed the impact of HRQoLreported a positive impact.The direction of association between HRQoL and improved physical functioning was consistent across most studies that reported on both outcomes (34,35,(43)(44)(45).Improvements were primarily noted in the global health state, symptoms and functionals scales, but it is unclear if these improvements are a direct result of the exercise intervention, or improved disease management, and control.
This review highlighted the high levels of acceptability and participant satisfaction with the digital intervention.Having a home-based exercise intervention or online intervention, like the technologies in this review is advantageous as participants were able to continue to exercise during chemotherapy treatment when they're usually advised to limit their contacts with other people to reduce the risk of infections.Furthermore, studies that used a game console as part of their exercise program incentivised their participants to use the technology, work out more often and increase the intensity of the exercise (33,41,45).Other useful features of the technologies that have been highlighted include the use of a virtual environment for exercising (33,41), using dance to work out (45), dietary advice (35) and the value of incentivising participants (33,41,45).Hence, it is important that future app developers consider what incentives can be built into the intervention to improve adherence, reduce the clinician work load, and empower the patient to be more independent with their disease management.
It is anticipated that health apps like the ones identified in this review will enable improved disease management, reduce hospital admissions, and save the NHS money (34).Despite that, there is inadequate cost analysis to date to demonstrate cost impact on health care services, the health care workforce and people living with lung cancer.Our review identified only one cohort study undertaken in a single research active center that reported the cost of the intervention to the health care provider and the estimated time impact on health care professionals.

Limitations
We reported on available evidence within the published reported papers.We faced challenges in gathering details regarding missing study data.Despite our attempts to reach out to the corresponding authors to obtain the necessary information, we did not receive any response from them.Furthermore, it is unclear if any development information not included in the reports of the studies was excluded [33][34][35].
Studies included in our review were primarily quasi experimental and non randomised [33,35,42,44,45].Only one randomised controlled trial [43] and one cohort study [34] were included.Included studies focused on technology development and assessing feasibility most frequently for patients undergoing surgery [33][34][35]42,43).Additionally, the small cell sub type of lung cancer has poorer outcomes than non-small cell sub-types, with a primary focus on treatment being to improve HRQoL; this population was not well represented in our included studies.Furthermore, various tools were used to assess physical functioning and HRQoL making it difficult to draw comparisons across the studies due to their heterogeneity.

Conclusions
There appears to be a consistent relationship between digital technologies employed by people with lung cancer and a positive impact on physical functioning and HRQoL.The technologies reported in the review demonstrated high levels of acceptability or user satisfaction and have the potential to support people with lung cancer to manage their health more independently.However, most of the studies identified here report on the development and feasibility of the technology.Further multi center, large scale research studies using a randomised controlled trial design over an extended period are required to fully assess the true benefit of adopting electronic health technologies in standard care services for health care providers and people with lung cancer and should include a cost effectiveness outcome measure.

Figure 1 .
Figure 1.PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Diagram

Table 1 .
Groups of keywords used in the search strategy.
software app or cell phone apps or cellular phone apps or mobile technologies or mobile devices or smartphones or technology-enabled care services or interactive apps or telemedicine or virtual medicine or interactive consultative services or Web based tool or activity tracker or fitness tracker or physical fitness tracker or technology enabled care services

Table 4 .
Study outcome measures