Outcomes of a randomised controlled trial assessing a smartphone application to reduce unmet needs among people diagnosed with CancEr (ACE)
Using smartphone technology to deliver practical solutions for people affected by cancer at previously unimaginable scale.
Smartphone technology represents an opportunity to deliver practical solutions at a scale that was previously unimaginable. It offers new possibilities for health promotion and treatment management that can reach patients regardless of where they live, including appointment monitoring, [1,2] improved access to cancer information and support services  and lead to improved participation in health care over time.[4,5]
This study, led by the Institute’s Professor Trish Livingston, aimed to determine whether a smartphone app reduced the unmet needs among people newly diagnosed with cancer.
Unmet needs refer to the gap between a person’s experience of services and the actual services required or desired.  Despite consistent evidence and widespread acknowledgment of the psychological impact of a cancer diagnosis, unmet needs that may contribute to an individual’s distress are poorly recognised and undertreated.  A systematic review found that up to 93% of newly diagnosed patients reported unmet needs across a range of domains comprising psychological, informational, and physical.  An earlier review  identified that the most common unmet needs were those associated with activities of daily living, economic needs, physical needs, supportive care needs, and sexuality. This situation has not changed in nearly a decade. 
With the rapid development of information science and technology, digital health has become an important tool for health care. As a result, many people seek health-related information on the Internet. [11, 12] However, concerns over the quality of information  and level of e-health literacy  highlight the need to provide people affected by cancer with quality and flexible access to information from reputable sources.
There has been increasing interest in mobile phones as a platform for interventions for people with cancer.  A recent systematic review highlighted mobile interventions for people with cancer only met treatment or symptom-related information needs and did not meet patients’ full range of cancer-related information needs, from information on psychological support to how to manage finances during cancer, and the long-term effects of treatment.  The smartphone app intervention attempted to fill this gap by providing information, support services, clinical trials information, and allied health resources to people newly diagnosed with cancer.
The researchers conducted a single blind, multisite randomised controlled trial to determine the impact of an app-based, four-month intervention that was co-designed with cancer patients. Patients in the intervention group received access to the newly designed app, and those included in the control group received usual care.
The app included cancer information, with links to reputable sources such as cancer support services, clinical trials and allied health services. It also included health service navigation and appointment scheduling features, a notebook for writing down questions prior to appointments and emergency contact numbers. To measure impacts on distress, the app included a distress thermometer, which participants completed at baseline and then monthly until the conclusion of the intervention. Participants also completed surveys to measure unmet needs, cancer distress, health education impact, health literacy and satisfaction with the app. App usage data was downloaded to track frequency and patterns of use over time.
Despite consumer involvement in the design of this smartphone technology, the app did not reduce unmet needs. This may have been due to the study being underpowered. The results did indicate an encouraging reduction in distress.
The practical difficulties in undertaking smartphone technology research are highlighted by this study. The practicality of apps may not match the reality in that people may use such apps initially but tend not to continue to use them consistently for longer periods. Providing additional information such as survivorship features or sharing the app with carers may facilitate ongoing use. Undertaking technology-based research in hospital settings can be problematic with Internet black spots, firewalls and technology incompatibility, posing substantial impediments to the conduct of studies. 
To contribute to a meaningful understanding and improved implementation of smartphone technology to support people affected by cancer, practical considerations, such as recruitment issues and access to, and confidence with, apps, need to be considered.
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