European Journal of Oncology Nursing 52 (2021) 101960

Contents lists available at ScienceDirect

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Effect of mobile phone app-based training on the quality of life for women
with breast cancer☆
Derya Çınar a, *, Ayfer Karadakovan b, Atike Pınar Erdoğan c
a
İzmir Bakırçay University Health Sciences of Faculty, Nursing Department, Izmir, Turkey
b
Ege University Faculty of Nursing, Izmir, Turkey
c
Manisa Celal Bayar University, Faculty of Medicine, Department of Medical Oncology, Manisa, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: The study purpose was to determine the effects on quality of life (QoL) of a mobile phone app–based
Breast cancer training for supportive care of women with breast cancer who were using adjuvant endocrine hormonal therapy.
Breast cancer management Methods: The study is based on a randomized pre-post test design. Participants were randomly assigned to either
Endocrine hormone therapy
a control group that received routine care or an intervention group that received routine care plus access to the
Mobile applications
Quality of life
mobile phone app–based training support for 12 weeks. QoL and symptom distress were measured before
intervention (T0), and after 12 weeks (T1) of intervention. This study is the application of two modality com­
binations: the mobile app-based patient education (1) and web-based management application (2). The mobile
app-based training also provided basic information about breast cancer, symptom diary and lifestyle recom­
mendations (adequate and balanced nutrition, regular physical activity, deal with stress effectively).
Results: QoL of the treatment group after intervention increased and distress level was lower compared to the
control group; these results were statistically significant. The majority of the patients reported that the mobile
application was "informative and useful".
Conclusions: This demonstrated that the mobile app is an effective intervention for supportive care in women with
breast cancer. The mobile app–based training, which is an innovative intervention, is recommended as a sup­
portive care initiative for women with breast cancer.

1. Introduction
Breast cancer is the most commonly diagnosed cancer among women
globally (Bray et al., 2018; Globocan Observatory et al., 2019). World­
wide, there were approximately 2.1 million (2,088,849) newly diag­
nosed breast cancer cases in 2018, and about one in four cancer cases
among women were breast cancer (Bray et al., 2018). Of the women
with breast cancer, approximately two out of three were hormone
receptor-positive (ER + and/or PgR +) (American Cancer Society,
2020). EHT and the use of Tamoxifen or Aromatase Inhibitor (AI) hor­
monal agents for at least five years is recommended for women with
hormone receptor positive (ER + and/or PgR +) (American Cancer So­
ciety, 2020; Roberts et al., 2015; Chalela et al., 2018). EHT causes
problems such as hot flashes and/or night sweats, headaches, nausea,
pain, vaginal dryness, or discharge (American Cancer Society, 2020).
Although the effectiveness of EHT approach has been proven, these
common side effects, which are not life threatening, can negatively
affect the QoL (Chalela et al., 2018; Sert et al., 2013). EHT side effects
can affect the physical, emotional, and social well-being of patients (Sert
et al., 2013). Oncology nurses should undertake the tasks of developing
skills and providing emotional support by effectively communicating
with patients, and providing adequate knowledge and training to
improve the QoL of women with breast cancer (Miyashita, 2015).
Mobile health (mHealth) is a widely accessible method that provides
healthcare services through portable devices (Jongerius, 2019). In the
management of cancer patients, the development of new eHealth and
mHealth initiatives has been reported to be promising, especially in the
context of supportive care and follow-up (El Shafie et al., 2018; Cannon,
2018). It has been shown that using mHealth practices in health care
management of women with breast cancer has positive effects. In the
studies, it was shown that mobile health practices in breast cancer care
management were effective in weight management, improving quality

☆
This study was registered at the ClinicalTrials.gov (register number: NCT04315012, date of registration: 2020) (retrospectively registered).
* Corresponding author. İzmir Bakırçay University Health Sciences of Faculty, Nursing Department, Izmir, Turkey.
E-mail addresses: derya.cinar@bakircay.edu.tr (D. Çınar), akaradakovan@gmail.com (A. Karadakovan), dr_pinarcan@yahoo.com (A.P. Erdoğan).

https://doi.org/10.1016/j.ejon.2021.101960
Received 19 November 2020; Received in revised form 26 March 2021; Accepted 1 April 2021
Available online 18 April 2021
1462-3889/© 2021 Elsevier Ltd. All rights reserved.
D. Çınar et al.
of life, improving patient well-being, better coping with symptoms, and
reducing stress levels (Jongerius, 2019; Cruz et al., 2019; Grašič Kuhar
et al., 2020). It also emphasizes that mHealth practices can play a crucial
role in breast cancer care (Jongerius, 2019).
Many studies were aimed at assessing mHealth apps and their impact
on the quality of life of women with breast cancer (Rosen et al., 2018;
Zhu et al., 2018 a,b; Buscemi et al. (2019); Wallwiener, 2017). Zhu et al.
(2018a,b) studied the effectiveness of a mobile application-based breast
cancer e-support program to support women with breast cancer who
received chemotherapy (Zhu et al., 2018 a,b). They found that the
mobile application intervention is more effective in increasing
self-efficacy and total QoL score, whilst reducing symptom burden
during chemotherapy (Zhu et al., 2018 b). Given the physical limitations
in accessing healthcare due to geographic distance, it has been reported
that individuals use mobile applications as an additional intervention
(Rosen et al., 2018). In a systematic review, in breast cancer care and
addressed prevention and survivorship mHealth practices have been
shown to impact weight control, improving QoL and reducing stress
levels (Jongerius, 2019). However, the effectiveness of mobile applica­
tion was not found significant when compared with routine care in terms
of social support, symptom severity, anxiety, and depression among
patients receiving breast cancer treatment (Zhu et al., 2018 b). In Foley
et al., it was determined that training materials about surgical treat­
ments including mobile information application had an alarming effect
on the anxiety levels of women with breast cancer in the preoperative
period (Foley, 2016).
To our knowledge, there is no standardized mobile app for the
management of patients receiving EHT, possible side effects, symptom
management, and QoL and requirements regarding follow up and sup­
portive care (Egbring vd., 2016; Zhu vd., 2018; Lozano-Lozano vd.,
2018; Jongerius C, Russo S, Mazzocco K, 2019). The purpose of this
study is to find the effect of mobile app-based training on the QoL in
women with breast cancer using EHT.
We hypothesized that the mobile app-based training given to cope
with the side effects of EHT, and managing the symptoms and the dis­
ease process, will effect the QOL of women with breast cancer.
1.1. Mobile phone app-based training
In this study, the mobile app was developed in 4 steps (Sturm et al.,
2017; Flora et al., 2013) (Fig. 1):
1. Preparation phase: To develop this application we conducted a
literature review. Studies using the mobile app in the management of
breast cancer care were examined (Egbring et al., 2016; Zhu et al.,
2017; Zhu et al., 2018a, 2018b; Lozano-Lozano et al., 2018; Jon­
gerius C, Russo S, Mazzocco K, 2019; Cruz et al., 2019; Grašič Kuhar
et al., 2020).
2. Design phase: The researcher conducted a literature review on the
subject, and in line with the guidelines for evidence-based care
standards, the care needs of breast cancer patients diagnosed with
Fig. 1. The mobile application development process (Sturm et al., 2017; Flora et al., 2013).
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European Journal of Oncology Nursing 52 (2021) 101960
EHT for cancer and treatment-related symptoms were determined
(American Cancer Society, 2017; NCCN Guidelines Version1. 2017).
Participants’ training contents on side effects and symptom man­
agement of EHT, coping strategies and mobile app design were
created in line with the literature and expert opinions. Expert opin­
ions were obtained from nursing faculty members (2), oncology
education nurse (1) and medical oncology specialist (1). Font type,
size, style and color selection were selected carefully for the legibility
and the visibility of the app on the screen. Especially, pink color was
selected as the font and heading color in the mobile app since it is the
symbol of breast cancer reflecting hope and happiness (Chittaro,
2006; Lee et al., 2006). Since only the researcher is authorized to
read the personal data registered in the Android platform applica­
tion, data security was provided. For the interaction of the mobile
app, patients were always able to access specialist nurse counseling
and all parts of the application, regardless of location and time.
Modules included in the mobile app content (Picture 1):
Training: This module constitutes information about breast cancer,
treatment methods, problems and suggestions in EHT (1) how to deal
with hot flashes/night sweats; 2) vaginal dryness, itching and bleeding
management; 3) fatigue management; 4) how to deal with mood
changes; 5) pain management; 6) sleep management; 7) how to deal
with sexual issues; 8) how to deal with upper limber lymphoedema),
regular physical activity, balanced and healthy diet, and information
about coping with stress. The application was enriched with visuals,
audio and video CDs so that the users could comprehend the information
more easily and the content be interesting. Besides as relaxation tech­
niques (relaxation exercises sound CD of 30 min which includes
breathing and muscle exercises) and guided imaginary (guided imagi­
nary video as the mind-body-based practice of 12 min which includes
natural views accompanied by relaxing, restful, slow music for the
oncology patients) were installed in the app for side effects of EHT to
cope effectively.
Symptom Diary: It is the section where the participants record the
symptoms, they experience such as pain, nausea, vomiting, insomnia,
anxiety, anorexia, symptom severity, and situations that increase and
improve the severity.
Questions: This is the section where the participants can ask questions
to the research specialist nurse and get counseling regarding problems.
Reminders: It is the section sent by the researcher as a daily text
message to the participants to regularly record their symptom diary, to
practice relaxation techniques to help them cope with the problems
experienced in EHT, and to manage symptoms. The application also had
a push notification function for new incoming reminder messages.
Opinions: It is the section where the participants convey their opin­
ions about mobile-based application training after the intervention.
3. Software phase: The mobile-app-based training is an Android mo­
bile application. The content prepared by the researchers was placed
in the application formally. Software application development and
D. Çınar et al.
technical maintenance were carried out by a Technopark office in
Turkey. A pilot study was carried out with five patients to test and
improve the mobile app. After analysis of the feedback received the
application design was completed.
4. Publishing phase: The mobile app, which was sent to the patients as
a short message (SMS), was installed by directly downloading the file
with an extension “.apk” to their smartphones. The participants can
sign into the app with their given username and password.
2. Methods
2.1. Design
The study was conducted in a state hospital in Turkey, between
January 2018 to July 2018. A single-blinded, single-centered, and ran­
domized design was used. This study was registered at the ClinicalTrials.
gov (register number: NCT04315012). Participants were randomly
assigned to either a control group that receives routine care or a treat­
ment group that receives routine care plus access to the mobile
app–based training support for 12 weeks (Fig. 2). Assessments were
conducted at two time points: baseline (before to intervention, T0) and
12 weeks (after the intervention, T1).
2.2. Participants
The population was composed of women with breast cancer using
adjuvant EHT consulting the Medical Oncology Clinic. Participants with
the following traits met the inclusion criteria to the study, aged 18–65,
who are diagnosed with primary breast cancer, non-metastatic, who are
hormone receptor-positive (ER + and/or PgR +) and treated with EHT at
least for three months, and finally who have a smartphone.
Power analysis was conducted and it was determined that 64 patients
were required in the study; treatment group (n = 31) and control group
(n = 33). While calculating the power analysis of the study, it was taken
into account that approximately 40% of breast cancer cases in the da­
tabases of national cancer registry units received adjuvant EHT (kanser.
gov.tr). The calculation for the sample size of the research made over the
difference of two groups within the limits of 95% confidence interval, it
was calculated as a minimum of 56 persons (28 cases + 28 controls) for 1
to 1 case-control ratio. However, to prevent data loss in the study, the
data collection phase was terminated by interviewing with the
Fig. 2. Diagram of the study.
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European Journal of Oncology Nursing 52 (2021) 101960
accessible amount of patients.
2.3. Intervention
This study used two modality combinations: the mobile app-based
patient education (1) and web-based management application (2). The
specialist nurse can access two modalities; however, participants can
only access the mobile-based app modality.
(1) Mobile app-based patient education: The treatment group received
face-to-face training on the use of the mobile app (T0) before the
intervention. Modules were introduced to the participants and
the mobile-app was downloaded to their smartphones. A user
name and password were provided by the researcher for the pa­
tients to log into the mobile app. The patients could access the
educational contents and relaxation exercises and guided imag­
ery applications on the mobile app whenever they wished. They
recorded the symptoms they experienced from the symptom
diary module. They sent questions to the specialist nurse about
their diseases and treatment-related problems through the ques­
tions module, and they could see the answers. They followed the
reminders sent daily by the specialist nurse through the re­
minders module. They were able to instantly receive notifications
of new incoming reminder messages through the application.
Patients could access supportive care with effective nurse inter­
action, regardless of place and time. The treatment group
received supportive care for 12 weeks including symptom man­
agement, and specialist nurse counseling.
(2) Web-based management application: This modality was for
researcher specialist nurses, which offers information, advice,
and consultation to patients. This modality is where user infor­
mation and logins are monitored, consulting activities are
managed (question, answer, reminder) by the specialist nurse.
Questions and reports regarding symptoms sent by the partici­
pants were answered through the web-based application. The
researcher specialist nurse read all the questions every day and
provided appropriate advice within 24 h as needed. Once a day,
reminder messages were sent to the participants about personal
care, supportive care, and symptom management in the "Re­
minders" section. The participants in the treatment group can
only read the consultancies and the messages through the mobile
app. Distress was evaluated as it affects coping effectively (Riba
et al., 2019). Patients were reminded to do guided imagination
and relaxation exercises regularly regarding symptoms due to the
side effects of EHT to cope effectively. The researchers collabo­
rated with a multidisciplinary team (medical oncologist, radia­
tion oncologist, psychologist, oncology training nurse,
radiotherapy training nurse, physiotherapist, dietician) to get
advice and support regarding supportive care.
2.4. Control group
Data collection forms with control group patients were recorded at
the first assessments (T0) and second assessments after the end of the
12th week (T1) of the study. During this period, patients received
routine care. After the research was completed, the mobile application
training content was given to the control group patients as a training
booklet.
2.5. Data collection and research instruments
Data from the treatment and control groups were collected simul­
taneously by the researcher. Two assessments were conducted to both
groups: Include the first assessment prior to randomization (T0) and the
second assessment is in the 12th week after the intervention (T1). Each
data collection process varied from 20 to 50 min. In addition, the
D. Çınar et al. European Journal of Oncology Nursing 52 (2021) 101960

Picture 1. Mobile phone app-based training panel screen shot.

4
D. Çınar et al.
treatment group was asked to report their opinions about mobile
application training after the intervention. Participants conveyed their
opinions about the application through the "Opinions " section of the
mobile application. Questionnaires were completed with the researcher
by using the following measurement instruments:
Participants Information Form: The form was prepared by the
researcher by analyzing the relevant studies (El Shafie et al., 2018;
Badger et al., 2013; Ryhänen et al., 2013; Suh and Lee, 2017; Schneider
et al., 2014; Traeger et al., 2015) .related to the QoL of women with
breast cancer. There are 20 questions related to sociodemographic
characteristics such as age, marital status, education status, number of
children and medical history and clinical features related to the
treatment.
FACT-ES Quality of Life Scale (FACT-ES QLS): The scale is
designed to measure the side effects and the potential benefits of the
treatment for women with breast cancer using EHT. Validity and reli­
ability of the scale were verified by Fallowfield et al. and translated into
different languages other than English (Fallowfield et al., 1999). The
scale includes five sub-dimensions and a total of 46 items measuring the
well-being of patients within the course of the last 7 days. There are sub
dimensions for each of the following: physical well-being (7 items, 0–28
points), social/family well-being (7 items, 0–28 points), emotional
well-being (6 items, 0–24 points), functional well-being (7 items, 0–28
points) and endocrine symptoms (19 items, 0–76 points). Endocrine
symptoms’ subdimension contains symptoms related to the side effects
of EHT. Total Cronbach alpha value was found as 0.92. Scale sub­
dimensions’ Cronbach alpha values range from 0.65 to 0.91 (Fallowfield
et al., 1999). Turkish translations and necessary permissions were
received from the administrator of the web site. The range of total points
of the scale is 0–184. It shows that QOL increases as total points of the
scale increase.
NCCN Distress Thermometer: Distress was measured because it was
directly related to the sub-dimensions of QoL (Riba et al., 2019; Badger
et al., 2013). This is a measurement instrument improved in 1998 by
Roth et al., to determine the distress level of cancer patients (Roth et al.,
1998). Distress level is graded in between 0 and 10 on a ‘thermometer’.
Patients may specify the severity of the distress level they experienced
related to their problems, with these numbers, within the course of the
last 7 days. No distress is specified with “0” points, a severe amount of
distress is specified with “10” points. 5 and more points of NCCN scale
shows that there is distress and follow up and assessment of the in­
dividuals should be made.
2.6. Ethical considerations
Ethical Committee Permit (The Ethics Committee of the University of
Balıkesir, 2017/143) and institution permits were received for this
study. participants’ consent was taken by informing them about the
purpose of the research.
2.7. Data analysis
Data were assessed in IBM SPSS Version 25. Descriptive statistics
related to the factors were presented with numbers (n), percentage (%)
and continuous variables with mean ± standard deviation, median
(minimum– maximum) values. For the calculation of categorical vari­
ables, chi-square analysis, ANOVA test for repeated measurements,
parametric and non-parametric tests were used. Student t-test and Mann
Whitney U tests were used for the comparison of the two independent
groups. The level of significance was established at p ≤ 0.05.
3. Results
3.1. Demographic and clinical characteristics of study participants
The average age of the patients involved in the research is 45.7 ± 9.0
5
European Journal of Oncology Nursing 52 (2021) 101960
(min:30- max:65), X̃ [IQR]: 44,5 [12.0], mean disease duration is 30.1
± 22.6 (min:5-max:120), X̃ [IQR]: 24.0 [23.75] months and mean EHT
duration is18.1 ± 17.3 (min:3-max:84), X̃ [IQR]: 12.0[20.0] months.
46.8% of them are primary school graduates, breast conserving surgery
(BCS) was experienced by 62.5% of participants and it was determined
that 76.6% of the patients had taken chemotherapy (CT), radiotherapy
(RT), surgical therapy (ST), and EHT. No significant difference was
found between groups according to age, education status, marital status,
disease duration, breast cancer stage, medicine group administered in
EHT (Tamoxifen and aromatase inhibitors), and menopause cause
related to the patients in treatment and control groups (p > 0.05)
(Table 1).
3.2. Treatment and control group’ pre-test (T0) and post-test (T1) data
When total FACT-ES QLS points of the participants and point means
of sub-dimensions were compared; no significant difference was found
in between groups at T0 (p > 0,05) (Table 2).
A significant difference (p < 0,05) was determined statistically in the
treatment group after the intervention (T1) (Table 3) in FACT-ES QLS
total points; physical, emotional well-being and endocrine symptom
sub-dimensions mean points of the participants, compared to the period
before intervention (T0). Also, there was no significant difference found
in the treatment group in T1 compared to T0 for functional and social/
family well-being sub-dimension average points (p > 0,05).
When it comes to comparing the control group pre- and post-tests, a
significant difference (p < 0,05) was determined statistically (Table 3) in
FACT-ES QLS total points, functional and emotional well-being and
endocrine symptom sub-dimensions mean points. There were no sig­
nificant differences found in the control group T1 compared to T0 in
physical and social/family well-being sub-dimension average points (p
> 0,05).
A significant difference (p < 0,05) was determined statistically after
the intervention (T1) (Table 4) in FACT-ES QLS total points; physical,
emotional, functional well-being and endocrine symptom sub-
dimensions mean points of the participants in the treatment group,
compared to the control group (T0). There were no significant differ­
ences found in T1 compared with T0 in social/family well-being sub-
dimension average points (p = 0,336).
FACT-ES QLS total average points of both groups at T0 and T1 were
compared (T0:t = − 1,76, p = 0,083; T1:t = 2,987, p = 0,004). The
repeated measurement analysis (ANOVA) of the mean score, significant
variance was found (F = 35,883 p < 0,001). Interaction of time and
groups were determined as statistically significant (p < 0,05). As FACT-
ES QLS mean score increased in the treatment group, it decreased in the
control group.
FACT-ES QLS mean score of patients significantly increased (p <
0,05) in the treatment group, after mobile app-based training (T1) was
provided, in all age groups, at secondary education, bachelor’s degree
and master degree levels, at all stages of breast cancer (I-II-III), for whom
surgical therapy (mastectomy and MKC) was received, EHT was used
(Tamoxifen and AI), and menopause as a result of chemotherapy/sur­
gical therapy, who does not have any chronic disease.
NCCN Distress Thermometer mean score of half of the participants
(50%) involved in the study was determined as ≥4 before intervention
(T0). In the correlation analysis; as distress points increase, it was
determined that QOL points decreased (r = − ,527, p = 0,002) (Table 5).
A statistically significant difference was found between the distress
scores of the treatment group before (T0) and after the intervention (T1)
(p = 0.004). In the treatment group, the mean post-intervention (T1)
distress mean scores before the intervention (T0) were found to be
significantly lower than the control group (p = 0.027). In the control
group, no statistically significant difference was found between the pre-
intervention (T0) and post-intervention (T1) mean scores (p = 0.082).
When NCCN Distress Thermometer mean scores were compared;
D. Çınar et al. European Journal of Oncology Nursing 52 (2021) 101960

Table 1
Distribution and comparison of participants in treatment and control groups in accordance with their descriptive and clinical characteristics.
Variables Treatment Group n = 31 Control Group n = 33 Test Statistics

X ± SS X̃ [IQR] X ± SS X̃ [IQR] X ± SS X̃ [IQR] U p-value

Age (Years) 45,7 ± 9,0 44,5 [12.0] 45,9 ± 8,3 46,0 [12.0] 45,5 ± 9,8 44,0 [14.0] 468,00 0,559
Disease Duration (Months) 30,1 ± 22,6 24.0 [23.75] 30,5 ± 25,6 24.0 [30.0] 29,7 ± 19,8 24.0[19.0] 486,50 0,736
EHT Implementation Duration (Months) 18,1 ± 17,3 12.0[20.0] 16,12 ± 17,1 12.0[20.0] 20,0 ± 17,5 14.0[23.5] 438,50 0,323
Education Status n (%) n (%) X2 p-value
Primary Education 10 (32,3) 20 (60,6) 5526 0,063
Secondary Education 12 (38,7) 6 (18,2)
Bachelor’s Degree 9 (29,0) 5 (15,2)
Master Degree 0 2 (6,1)
Total 31 (100) 33 (100)
Marital Status
Married 29 (93,5) 29 (87,9) 0,605 0673
Single 2 (6,5) 4 (12,1)
Total 31 (100) 33 (100)
Breast Cancer Stage
Stage I 9 (29,0) 12 (36,4) 0,419 0811
Stage II 12 (38,7) 12 (36,4)
Stage III 10 (32,3) 9 (27,2)
Total 31 (100) 33 (100)
Breast Surgery Type
Mastectomy (total) 12 (38,7) 12 (36,4) 0,038 0846
Breast Conserving Surgery 19 (61,3) 21 (63,6)
Total 31 (100) 33 (100)
EHT Drugs
Tamoxifen 17 (54,8) 19 (57,6) 0,049 0825
Aromatase inhibitors 14 (45,2) 14 (42,4)
Total 31 (100) 33 (100)

̃ : Median , IQR : Interquertile Range, X2: chi-square test statistics, U: Mann Whitney U Test
X : Mean, SS : Standard Deviation Min : Minimum, Max : Maximum, X
Statistics, p < 0,05 Significance Level.

Table 2
Comparison of FACT-ES QLS total and average sub-dimension points related to pre-test (T0) data of treatment and control group.
FACT-ES QOL Treatment group (n = 31) Control Group (n = 33) Test Statistics

X ± SS X̃ [IQR] X ± SS X̃ [IQR] t* p**

Total Points 122.03 ± 24.85 126.0 [40.0] 132.64 ± 23.34 130.0 [30.5] − 1.76 0.083
Physical Well Being 21.0 ± 5.32 23.0 [7.0] 22.15 ± 4.8 23.0 [6.0] − 0.911 0.366
Social/Family Well Being 17.97 ± 6.48 19.0 [8.0] 20.15 ± 6.01 21.0 [9.5] − 1.399 0.167
Emotional Well Being 12.97 ± 4.48 13.0 [4.0] 14.88 ± 5.27 14.0 [8.5] − 1.558 0.124
Functional Well Being 19.84 ± 3.96 20.0 [5.0] 20.36 ± 5.21 20.0 [8.0] − 0.452 0.653
Endocrine Symptoms 50.26 ± 10.53 51.0 [18.0] 55.09 ± 9.55 55.0 [11.0] − 1.926 0.059

t*: Dependent sample test statistics, p**: p < 0.05 Significance level,X : Mean, SS : Standard ​ Deviation, X
̃ : Median , ​ IQR : Interquertile ​ Range.

Table 3
Comparison of FACT-ES QLS total and average sub-dimension points related to pre-test (T0) and post- test (T1) data of treatment group and control group.
FACT-ES QLS Test Time Treatment Group (n = 31) Control Group (n = 33)

X± SS Test statistics X± SS Test statistics

t P t p

Total Points T0 122.03 ± 24.85 − 5.128 <0.001 132.64 ± 23.34 3.245 0.003
T1 137.58 ± 16.94 123.7 ± 20
Physical Well Being T0 21.0 ± 5.32 − 4.604 <0.001 22.15 ± 4.8 1.131 0.267
T1 24.1 ± 3.51 21.39 ± 5.5
Social/Family Well Being T0 17.97 ± 6.48 − 0.236 0.815 20.15 ± 6.01 0.500 0.620
T1 18.06 ± 6.24 19.61 ± 6.47
Emotional Well Being T0 12.97 ± 4.48 − 2.582 0.015 14.88 ± 5.27 2.883 0.007
T1 15.29 ± 4.22 13.03 ± 4.13
Functional Well Being T0 19.84 ± 3.96 − 1.012 0.319 20.36 ± 5.21 2.671 0.012
T1 20.68 ± 4.39 18.36 ± 4.72
Endocrine Symptoms T0 50.26 ± 10.53 − 6.485 <0.001 55.09 ± 9.55 3.084 0.004
T1 59.45 ± 7.61 51.3 ± 8.86

t*: Dependent sample test statistics, p**: p < 0.05 Significance level, X : Average.SS : Standard ​ Deviation, T0 : Time ​ 0, ​ T1 : Time ​ 1.

there were no statistically significant differences between both groups at (ANOVA) of the mean score, the variance was found significant (F =
T0 (p > 0,05). There was a statistically significant difference between 11,214 p = 0,001). Interaction of time and groups were determined as
both groups at T1 (p < 0,05). The repeated measurement analysis statistically significant (p < 0.05). While distress mean score decreased

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D. Çınar et al. European Journal of Oncology Nursing 52 (2021) 101960

Table 4
Comparison of FACT-ES QLS total and average sub-dimension points related to post-test (T1) data of treatment and control group.
FACT-ES QOL Treatment Group (n = 31) Control Group (n = 33) Test Statistics

X ± SS X̃ [IQR] X ± SS X̃ [IQR] t* p**

Total Points 137,58 ± 16,94 139.0[27.0] 123,70 ± 20 127.0[29.0] 2987 0,004

Physical Well Being 24,1 ± 3,51 25.0[3.0] 21,39 ± 5,5 23.0[7.0] 2327 0,023
Social/Family Well Being 18,06 ± 6,24 19.0[9.0] 19,61 ± 6,47 20.0[10.0] − 0,969 0336
Emotional Well Being 15,29 ± 4,22 15.0[7.0] 13,03 ± 4,13 13.0[7.0] 2166 0,034
Functional Well Being 20,68 ± 4,39 21.0[7.0] 18,36 ± 4,72 18.0[7.0] 2028 0,047
Endocrine Symptoms 59,45 ± 7,61 62.0[12.0] 51,30 ± 8,86 53.0[9.0] 3936 <0,001

t*: Dependent sample test statistics, p**: p < 0.05 Significance level, X : Average.SS : Standard ​ Deviation, X
̃ : Median , ​ IQR : Interquertile ​ Range.

Table 5
Comparison of NCCN distress thermometer average scores related to post-test (T1) data of treatment and control group.
Variables Test Time Treatment Group (n = 31) Control Group (n = 33) Test Statistics

X ± SS X̃ [IQR] X ± SS X̃ [IQR] t* p**

Distress Thermometer Scores T0 4,90 ± 2,79 4.0[5.0] 4,21 ± 2,72 5.0[4.0] 1003 0,320
T1 3,65 ± 2,46 4.0[3.0] 5,06 ± 2,54 5.0[3.5] − 2265 0,027

t*: Dependent sample test statistics, p**: p < 0.05 Significance level, X : Average.SS : Standard ​ Deviation, X
̃ : Median , ​ IQR : Interquertile ​ Range, ​ T0 : Time ​ 0,
​ T1 : Time ​ 1.

in the treatment group after the intervention (T1), it increased in the
control group (Table 5).
After the intervention (T1), the treatment group’s opinions were
sought related to availability, learning, and legibility of the mobile app.
All participants in the treatment group expressed their opinions about
the mobile app (n = 31). Most participants responding via the mobile-
based application 87,1% (n = 27) mentioned that the app was “an
informative and beneficial training” and 12,9% (n = 4) of them
mentioned that “it was such training to be provided at the beginning of
EHT.
Cooperation was made with the multidisciplinary team (medical
oncologist, radiation oncologist, psychologist, oncology training nurse,
radiotherapy training nurse, physiotherapist, dietician) related to the
training and consultancy provided by the researcher. Within the course
of the consultancy period; some patients were directed to the relevant
specialist in the following departments: Smoking Cessation Clinic (n =
2), Life with Celiac Association (n = 1), Nutrition and Diet Specialist (n
= 3), Surgery Clinic (n = 3) and (for the breast prosthesis) Recon­
structive Surgery Clinic (n = 2).
4. Discussion
Innovative, standardized, efficient, cost effective, supportive cancer
care methods should be administered to improve the QoL of patients.
Mobile health apps are appealing to the patients because of their cost-
effectiveness, flexible and high quality services for the benefit of the
patients, presenting an opportunity for remote monitoring and training
of patients, reachable at any place at any time (Güler, 2015). Our study
is the first made in Turkey which analyzes the effect of a mobile-app
based training to improve the QoL of women with breast cancer using
EHT.
It was determined after the intervention (T-1) that FACT-ES QLS total
points, physical well-being, emotional, functional well-being and
endocrine symptom mean scores were increased significantly for the
treatment group to whom mobile-app based training was provided,
compared to the control group. Besides, social/family well-being mean
scores were not statistically significant. The reason for this finding can
be the common family support for almost all the participants, even when
experiencing a change in the participants’ physical, emotional, or
functional status. This can be predicted considering the strong kinship
culture in Turkey, where family members support women with breast
cancer.
Our findings state that, while the QoL improved for the treatment
group, there was a decline in the control group. This improvement in the
quality of life of the treatment group may have different reasons. Par­
ticipants in the treatment group stated that the app was very beneficial
in the sense that it was important to learn about the side effects of EHT
and share their problems. The participants reported that the support of a
specialist nurse was easy to reach any moment. Also, the participants
added that they were pleased with receiving counseling and support by
the nurse. Participants’ ability to find solutions to their problems with
the mobile application without having to access any health institution or
having an appointment can also be effective in improving the QoL. Due
to inefficiencies in hospitals such as patient density, staff insufficiency
and time constraints, cancer patients may not be able to meet their
physical and psychosocial needs. In this context, our study was thought
to improve the quality of life of the participants by providing unlimited
support for women with breast cancer using EHT with educational and
supportive approaches in the mobile application.
Studies have reported that mobile app-based intervention is more
effective and advantageous than normal care on self-efficacy, quality of
life and symptom burden of breast cancer women (Jongerius, 2019; Zhu
et al., 2018a,b). In light of these findings, a decrease in the quality of life
of the control group in our study may have been experienced. Although
the side effects associated with EHT do not threaten the lives of women
with breast cancer, they may adversely affect their quality of life. The
possibility that the symptom burden that develops due to EHT side ef­
fects may increase as time passes may cause a decrease in the quality of
life of the control group in our study. Independent of the mobile appli­
cation, this interaction between time and the group can be considered as
the main reason for the difference between the pre-test (T0) and
post-test (T1) quality of life scores of the control group. After the study
was completed, information was given to the control group in individual
and group training and on the subject they wanted to consult within the
scope of breast cancer care management to ensure equality about the
patients’ information.
Sajjad et al. mentioned that training provided to women with breast
cancer by the nurses improved the QoL of patients (Sajjad, 2016). It was
determined in a meta-analysis study conducted by Suh & Lee that
telephone-based training provided by nurses improved QoL (Suh and
Lee, 2017). Similar results were also found in our study. It was deter­
mined that psychological interventions by Badger et al. (2013), provided
with telephone training and individual consultancy to the breast cancer
patients for whom a recent diagnosis was made, significantly decreased

7
D. Çınar et al.
depression and physical symptoms of participants and increased social
and spiritual well-being (Badger et al., 2013). Ryhänen et al. studied, in
a randomized controlled study where QoL, anxiety and coping with side
effects related to the treatment were assessed for the internet-based
patient training program in to strengthen women with breast cancer
(Ryhänen et al., 2013). And they found that internet-based patient
training program did not decrease the anxiety level of women with
breast cancer or side effects of the treatment and that it did not improve
QoL sub-dimensions. Our study differs from Ryhänen et al. (2013), in the
sense that mobile-app based training provided to the treatment group to
whom EHT adjuvant was used, has improved the QoL (Ryhänen et al.,
2013).
It was determined in the literature that sociodemographic and clinic
characteristics such as age, education level, social support, financial
status, working status, disease stage are factors affecting QoL (Suh and
Lee, 2017; Haddou Rahou et al., 2016). Our study also found that
FACT-ES QLS mean score of patients who are provided with mobile-app
based training significantly affected sociodemographic and clinic
characteristics.
Distress results from physical, cognitive, behavioral, emotional, so­
cial, and spiritual factors and it is directly related to the sub-dimensions
of QoL (Riba et al., 2019; Badger et al., 2013). While a decrease was
noted for the distress level of the treatment group taking mobile-app
based training, there was an increase in the control group. As a result,
QoL was decreased for the participants whose distress level was
increased.
It was thought that this improvement resulted from the distress
management approaches in the mobile application. Distress levels of the
participants were determined to ameliorate the distress level manage­
ment of the treatment group. Information and suggestions on distress
management were included in the sections titled "dealing with stress",
"mood changes" and "healthy lifestyle" in the mobile-app content. Be­
sides, relaxation exercises including breathing and muscle exercises, CD
and guided imagery video were included in the "Trainings" section of the
mobile application. Reminder messages were sent periodically to the
participants through the mobile application to implement these
methods. In addition, the participants were encouraged to ask questions
related to their distress levels and receive consultancy from the "Ques­
tions" page of the mobile application. Participants stated in the “Opin­
ions” section of the mobile application that they are very satisfied with
the distress management approach and that it has a relaxing, supportive
and positive effect. The study findings show that these approaches are
effective in reducing the level of distress.
Visser et al., (2018), differ from our study, a tablet-based online app
was observed to have no significant effect on distress (Visser et al.,
2018). Rosen et al. (2018), mobile app-based mindfulness training
improved QoL and decreased distress for women with breast cancer
(Rosen et al., 2018). In a study conducted by Zhu et al. (2018a), women
with breast cancer were less distressed as given professional support
available with mobile app-based increased (Zhu et al., 2018a). Similar
results were also found in our study.
In a multi-centered prospective research to study the supportive care
provided with a mobile app to the cancer patients, it was noted that most
of the participants were strongly interested in using the mobile app (El
Shafie et al., 2018). In our study, most of the treatment group (87,1%)
expressed that mobile-app based training was beneficial. Common ex­
pressions were used because the participants received more than one
verbal statement. Overall, the participants were comfortable with using
the mobile app. The participants in the treatment group highly
acknowledged the intervention and its purpose. They found the
mobile-app helpful, as they also benefited from EHT-related information
from the speacialist nurse. They stated that their problems were resolved
on time by the nurse and/or a multidisciplinary team. Near all patients
stated that mobile-app based training was supportive.
In this study, since it is first and a new mobile application in Turkey,
we used some supportive approaches have which been adopted to
8
European Journal of Oncology Nursing 52 (2021) 101960
promote using the mobile applications. In addition to the mobile
application, regular phone calls, individual patient education, coun­
seling service, a specialist nurse that can be reached at any time, and
multidisciplinary team support were provided. It is estimated that these
support functions may also have affected the high satisfaction levels of
the participants regarding the mobile application.
In Zhu et al. (2018a) too, participants emphasized that the mobile
app facilitates receiving information, increases the level of trust and
supports emotional well-being. Also, participants suggested imple­
menting message reminders in Zhu et al. study (Zhu et al., 2018a). Our
study differs from Zhu et al. in terms of sending the participants message
reminders through the mobile app. These messages included advice
about personal care and supportive care.
Our findings of using the mobile app that targets care management in
breast cancer are promising. Among the mHealth apps focusing on
survivorship, the intervention based on mobile app showed an
improvement in the QoL, and decrease in distress. We support further
research to strengthen these findings.
5. Limitations
The limitations of the study are as the following; first the study took
place in a single center with participants who owned a smartphone.
Second, we could not measure how much time a participant spends on
using the mobile app and which specific features of the mobile app they
use. As third; since it is a first and new application for the participants,
phone calls were made to determine the problems related to the mobile
app and to evaluate the symptoms they reported via the mobile appli­
cation. The effect of these phone calls in mobile application design could
not be evaluated separately. Finally; one question was asked to the
treatment group regarding their views on the mobile app, but more
evaluation questions should have been be asked. The study was not
designed as a mobile application feasibility study. As far as we know,
since there is no standard mobile application to improve the quality of
life of women with breast cancer using EHT in the literature, the mobile
application was configured by researchers. Future studies should
continue to improve and test the mobile-based apps’ impact regarding
the adverse effects of the EHT of breast cancer.
8. Conclusion and relevance to clinical practice
As a result of the study, women with breast cancer to whom EHT was
used, along wıth and a mobile-app-based training and individual con­
sultancy were provided in line with their physical, social, psychosocial,
and spiritual needs, QoL increased, at the same time their distress level
decreased. Mobile application use in health institutions is recom­
mended, as these applications, can easily be used by the patients and the
nurses. It is considered that supportive care provided for oncology pa­
tients with mobile-app based training increases the satisfaction level of
the patients and that it strengthens trust and communication between
the patient and the nurse.
Funding
The mobile application software used in this study was financed by
Balıkesir Tuberculosis and Cancer Fight Association. No financial sup­
port has used for the design of the study, implementation of the study,
editorial assistance, analysis of the data or resulting publication.
CRediT authorship contribution statement
Derya Çınar: Conceptualization, design, Methodology, results,
Formal analysis, Writing – original draft. Ayfer Karadakovan:
Conceptualization, design, Methodology, results. Atike Pınar Erdoğan:
Conceptualization, design, Methodology.
D. Çınar et al.
Declaration of competing interest
The authors declare no conflicts of interest.
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