This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.
Breast cancer is one of the leading contributors to preventable illness and death among women. Although mobile phone apps provide unprecedented opportunity to engage women along the cancer continuum, little is known about the availability, content, and usability of breast cancer mobile phone apps.
This study analyzed the content and adherence to literate design standards of all breast cancer-related apps available on the App Store and Google Play, as well as the relationship between their content, user ratings, and price.
Following identification and downloading of all available breast cancer mobile phone apps in October 2015, 101 apps were confirmed as focusing on breast cancer. Based on prior research, we adapted and applied a content analysis scheme that was specific to breast cancer apps, including their main purpose, relevance to the cancer care continuum, and adherence to usability standards outlined by the Institute of Medicine (IOM).
The most common aim of apps was educational (73/101, 72.3%), followed by behavior change (24/101, 23.9%), fundraising (20/101, 19.8%), and advocacy (14/101, 13.9%). On the cancer continuum, primary prevention (strategies to prevent cancer cells from occurring) was mentioned in almost one-third of the apps (30/101, 29.7%). Less than half of the apps (46/101, 45.5%) presented information about mammography and/or breast clinical exam, and 53 apps (52.5%) discussed breast self-exam (which is no longer recommended). Symptoms of cancer prediagnosis, such as a lump, were discussed in almost half of the apps (48/101, 47.5%) and a similar number of apps included information about genetic risk for breast cancer (47/101, 46.5%). Information about breast cancer diagnosis was included in 42 apps (41.58%) and 43 (42.6%) apps discussed treatment options. Survivorship issues were addressed in 17 (16.8%) apps. Only one (1.0%) app discussed hospice. Adherence to usability recommendations was low. The median composite score was 3 (mean 2.60, SD 1.20) of the six recommended usability items. With eight plain language items, the median of the composite health literacy score was 5 (mean 5.06, SD 2.00). Most apps did not use easy-to-understand words (44/101, 43.6%) and few (24/101, 23.8%) defined key terms.
Current breast cancer apps provide important information about breast cancer, but the most common topic covered is breast self-examination, a non-evidence-based screening strategy. Apps that focus on evidence-based strategies on the cancer continuum are needed, with a notable pressing need for apps that would address survivorship and end of life. Finally, developers of breast cancer apps should adhere to IOM standards to meet the needs of diverse populations and reduce current disparities.
More than 1,677,000 women worldwide are diagnosed with breast cancer and more than 522,000 die of it annually [
Mobile health technology, or mHealth, holds great potential in reducing disparities in cancer-related health outcomes. With nine of 10 Americans owning at least one cell phone, and a majority (63%) of these devices providing access to mobile Internet service [
To reach individuals from low-resources communities who are disproportionally affected by preventable cancer burden, literate principles should be followed in the design of apps. The Institute of Medicine (IOM) published guidelines on mHealth-literate design strategies, including plain language and appropriate usability features [
In view of the importance of breast cancer as a public health concern, the goal of this study was to systematically analyze the availability and content of breast cancer apps available on the main platforms of Google Play and the App Store, and their main features, including content on the cancer care continuum, goals, adherence to the IOM literacy guidelines, price, and user ratings. The following sections review past research on these factors as they relate to breast cancer mHealth.
A growing body of evidence documents mHealth interventions’ effectiveness in engaging users in cancer preventive measures [
Apps are also utilized to enhance care delivery during cancer treatment. These apps work as information management tools where patients can check appointments, journal symptoms, and log medications [
Survivorship is another important area for mHealth cancer care interventions. In addition to cancer recurrence, breast cancer survivors are at a greater risk of comorbid conditions, such as obesity, osteoporosis, cardiovascular disease, and diabetes [
User skills are key to effective utilization of mHealth, particularly among underserved communities. Digital health literacy is related to one’s ability to seek, locate, comprehend, and assess health information from electronic sources [
The price of apps is an additional factor in apps’ dissemination and adoption of health promotion messages. Paid diabetes apps demonstrated better adherence to IOM standards compared to free apps [
Finally, although systematic reviews aim at addressing availability and analyzing the content and features of the analyzed apps use [
In view of the preceding research, the goal of this study is to evaluate the availability and content of existing breast cancer-related apps. In particular, we assessed apps’ content for intended purpose, consistency with the breast cancer care continuum, adherence to IOM plain language and usability standards, and the association between adherence to standards and apps’ prices and users’ reviews.
The study did not involve recruitment of human population; therefore, ethics committee approval was not required. Following previous content analyses of mHealth apps [
App Exclusion Chart.
At the time of the study, only one prior study explored content of apps and adherence to IOM standards in diabetes-related apps [
Variable categories, names, definitions, and intercoder reliabilities.
Category and name | Definition | Intercoder reliability, Krippendorf αa | ||||
Information/education | Content to inform/educate | 1.0 | ||||
Behavior change/maintenance | Content to motivate, encourage behavior change | 1.0 | ||||
Fundraising | Raising money, donations | 0.88 | ||||
Advocacy | Other than fundraising | 0.86 | ||||
Primary prevention | Health promotion activities, diet, and exercise | 1.0 | ||||
Risk | Genetic risk (eg, BRCA discussed) | 0.89 | ||||
Screening | Genetic screening discussed | 1.0 | ||||
Mammography | Mammography discussed | 0.90 | ||||
Clinical breast exam discussed | 1.0 | |||||
Breast self-exam | Breast self-exam discussed | 1.0 | ||||
Symptoms prediagnosis | Cancer symptoms prediagnosis discussed/explained | 0.90 | ||||
Stage | Cancer stages discussed | 0.89 | ||||
Tumor type | Types of tumors discussed | 0.90 | ||||
Prognosis | Prognosis discussed, including survival | 1.0 | ||||
Treatment options | Breast cancer treatment discussed | 1.0 | ||||
Side effects/symptoms | Treatment side effects discussed | 1.0 | ||||
Medication care management | Information on medication types/brands | 1.0 | ||||
Chemotherapy prevention medication | 1.0 | |||||
Survivorship | Life after cancer discussed | N/A | ||||
End of life | End-of-life/hospice information | N/A | ||||
Breast cancer continuum care | Breast cancer continuum care and or behaviors discussed | 0.89 | ||||
Research/Science | ||||||
Biological process | Information on biological process of breast cancer | 1.0 | ||||
Trial recruitment | Clinical trial recruitment | N/A | ||||
Research referenced | App cites medical research studies | 0.74 | ||||
Common, everyday words | Common plain language used | 1.0 | ||||
Personal pronouns | Personal pronouns such as “you” used | 0.90 | ||||
Defined terms | Terms explained/defined | 1.0 | ||||
Active voice | Use of active voice | 1.0 | ||||
Action words | Direct action language used | 1.0 | ||||
Present tense | Present tense used | 1.0 | ||||
Short sentences | Sentences 15-20 words max | 1.0 | ||||
Limited paragraph size | Short paragraphs, use of bullets/lists | 1.0 | ||||
Images for learning | Use images that facilitate learning | 1.0 | ||||
Bold colors/background | Use bold colors with contrast; avoid dark backgrounds | 0.71 | ||||
Home/menu page | Enables easy access to home/menu page | 0.71 | ||||
Back button | Back button identified as arrow or labeled | 0.85 | ||||
Simple search | Utilizes simple search tool | 0.71 | ||||
Browsing | Easy browsing/navigating through app | 0.75 | ||||
Connected with device email option/in-app email options | 0.71 | |||||
Calendar | Connected with device calendar | 0.53 | ||||
Reminders/notifications | Offered device notifications | 0.78 | ||||
Maps/GPS | Offered maps/GPS options | 0.87 | ||||
Included print options | 0.65 | |||||
Save options | Save content as .doc, PDF, image files | N/A | ||||
Personal information | Contact information input | 1.0 | ||||
Personal statistics | Input of height, weight, etc | 1.0 | ||||
Expert interaction | Interactions with medical professionals | 1.0 | ||||
Peer support | Interaction with other app users | N/A | ||||
Connect with event | Link user with event source | 1.0 | ||||
Audio/video features | Use of sound bite/video content | 1.0 | ||||
New media | Use of social media and/or text | 0.90 |
a N/A: Krippendorff alpha could not be calculated due to lack of variance.
Basic information was captured from the App Store and Google Play, such as the provider or seller, price (if any), age rating, app category, and numbers for both ratings and reviews for each coded app and its price.
For perceived purpose of the app content, coders noted one or more of the following four categories: (1) information/education (eg, reference/glossary of breast cancer terms), (2) behavior change/maintenance (eg, becoming more physically active, participating in screening), (3) fundraising, and (4) advocacy (eg, awareness-raising campaigns).
To examine the apps’ foci on the cancer care continuum, one or more of the following variables were coded: (1) primary prevention; (2) evidence-based cancer screening (mammography, clinical breast exam); (3) diagnosis, including information about cancer staging, type of tumor, and information about prognosis, such as survival rate; (4) disease management/therapeutics, including information about treatment, side effects of treatments, and treatment medications and chemo prevention to prevent recurrence; (5) survivorship; and (6) end-of-life care. In addition, the following prediagnosis categories were coded: (1) genetic risk (eg, family history of cancer) and (2) breast self-exam and symptoms of breast cancer prediagnosis. Finally, the coding scheme included research and scientific-related content, which was comprised of information on the biological process of cancer, references to research, and discussions of clinical trials.
To assess the apps’ adherence to the IOM mHealth literacy guidelines [
Usability was measured as a composite of (1) avoidance of dark backgrounds, (2) easy access to home page (eg, home/menu button), (3) clearly labeled back button, (4) in-app simple search, (5) enabled browsing, and (6) use of images that facilitate learning (eg, diagrams of breast anatomy). Each of these six variables was coded (0=not present; 1=present) and summed to create a composite usability score [
Variables on graphics and technology use were also recorded and were composed of integration with other device apps (email, calendar, maps, reminders, GPS) and save/print options. Interactivity variables included user-tailored/interactive content (eg, input contact information, measures such as weight and height, expert interactions, online peer support, connect user with event), use of audio and video features, and use of new media or texting (eg, Facebook, Twitter).
We used SPSS version 23 (IBM Corp, Armonk, NY, USA) to calculate descriptive statistics;
Our goal in this study was to better understand availability and content of breast cancer-related apps available to the public, with a focus on their purpose, cancer continuum-related content, adherence to IOM literate design standards, price, and user ratings.
The final sample of apps that met our selection criteria and was used in the final analysis (N=101) included 44 apps (43.7%) that were available on Google Play only, 28 (27.7%) apps that were available exclusively on the App Store, and 19 (18.8%) that were available on both platforms (see
Characteristics of breast cancer-related apps on the App Store and Google Play (N=101).
App characteristics | n (%) | ||
Android | 44 (43.6) | ||
Apple | 38 (37.6) | ||
Android & Apple | 19 (18.8) | ||
Free apps | 85 (84.1) | ||
Paid apps | 16 (14.8) | ||
Information/education | 73 (72.3) | ||
Behavior change/maintenance | 24 (23.8) | ||
Fundraising | 20 (19.8) | ||
Advocacy | 14 (13.9) | ||
Prebiological onset | 30 (29.7) | ||
Genetic risk/screening | |||
Risk | 47 (46.5) | ||
Screening | 29 (28.7) | ||
Mammography | 45 (44.6) | ||
Clinical exam | 38 (37.6) | ||
Breast self-exam | 53 (52.5) | ||
Symptoms prediagnosis | 48 (47.5) | ||
Stage | 30 (29.7) | ||
Tumor type | 35 (34.7) | ||
Prognosis | 19 (18.8) | ||
Treatment | 38 (37.6) | ||
Side effects | 19 (18.8) | ||
Care management | 31 (30.7) | ||
Chemotherapy prevention | 14 (13.9) | ||
Survivorship | 17 (16.8) | ||
End of life | 1 (1.0) | ||
Biological information | 40 (39.6) | ||
Trial recruitment | 5 (5.0) | ||
Research referenced | 24 (23.8) | ||
Common everyday words | 44 (43.6) | ||
Personal pronouns | 60 (59.4) | ||
Defined terms | 24 (23.8) | ||
Active voice | 78 (77.2) | ||
Action words | 75 (74.3) | ||
Present tense | 84 (83.2) | ||
Short sentences | 78 (77.2) | ||
Limit paragraph size | 68 (67.3) | ||
Images that facilitate learning | 44 (43.6) | ||
Bold colors, no dark backgrounds | 89 (88.1) | ||
Home/Menu pages | 51 (50.5) | ||
Back button | 37 (36.6) | ||
Simple search | 9 (8.9) | ||
Browsing | 33 (32.7) | ||
32 (31.7) | |||
Calendar | 11 (10.9) | ||
Reminders | 17 (16.8) | ||
Maps/GPS | 4 (4.0) | ||
3 (3.0) | |||
Save | 8 (7.9) | ||
Personal information | 15 (14.9) | ||
Personal statistics | 19 (18.8) | ||
Expert interaction | 2 (2.0) | ||
Peer support | 8 (7.9) | ||
Connect to an event | 15 (14.9) | ||
Incorporate Audio and Visual | 31 (30.7) | ||
Integrate social media or text messages | 42 (41.6) |
App characteristic percentages on App Store and Google Play: content/goal, primary prevention genetic risk/screening, screening/early detection, and diagnosis (N=101).
App characteristic percentages on App Store and Google Play: management/therapeutics, postcare/end of life, breast cancer care, and research/science (N=101).
App characteristic percentages on App Store and Google Play: plain language and usability (N=101).
App characteristic percentages on App Store and Google Play: technology, interactivity, and approach/theoretical underpinning (N=101).
The analysis included the classification of the apps’ goals by four main categories, according to the messages they advanced: (1) aimed at providing information and education about breast cancer, (2) targeted behavior change related to breast cancer, (3) included messages about fundraising, and (4) aimed at breast cancer advocacy. Most of the apps contained information/education messages (73/101, 72.3%), approximately one-quarter (24/101, 23.9%) targeted behavior change, one-fifth (20/101, 19.8%) aimed at fundraising, and a one-sixth of the apps (14/101, 13.9%) were related to advocacy. More than half of the apps focused on only one of these categories (56/101, 55.4%), 26 (25.7%) on two categories, five (5%) included three categories, and two apps included all categories. Most apps that targeted behavior change also included informational/educational goals (18/101, 75%).
Almost one-third of the apps (30/101, 29.7%) presented information about primary prevention of breast cancer, such as information about diet and exercise.
Less than half of the apps in our sample (46/101, 45.5%) presented information about evidence-based methods of breast cancer screening (mammography and breast clinical exam). Of this subsample, 37 apps (80.4%) included information about both mammography and clinical breast exam. Eight apps contained information about breast mammography alone (17.39%), and only one contained information about clinical breast exams (2.17%).
In all, 53 apps (52.5%) discussed breast self-exam. Additional prediagnosis variables included symptoms of cancer prediagnosis, such as a lump (48/101, 47.5%) and genetic risk for breast cancer (47/101, 46.5%).
Information about breast cancer diagnosis was included in 42 apps (41.6%). Of these apps, 15 (36%) provided information about stages of breast cancer, prognosis, and types of breast cancer tumor together; 10 apps (24%) discussed stages of breast cancer and types of breast cancer tumors together; and two (5%) provided information about stages of cancer as well as prognosis. In addition, 11 (27%) provided information about types of breast cancer tumors only, three (7%) communicated information about stages of breast cancer only, and two (5%) addressed prognosis only.
Of the 101 apps, 43 (42.6%) discussed various treatment options for breast cancer patients. Of these, 18 (17.8%) provided concurrent information on (1) different treatment options, (2) possible side effects of treatment, and (3) care management of breast cancer; eight (8%) discussed treatment options and side effects; and one (2%) provided information on different treatment options and care management of breast cancer together. Eleven (26%) apps provided information about different treatment options only, and five (12%) discussed care management only.
Seventeen of 101 apps (16.8%) discussed issues related to survivorship, such as care coordination after completion of therapeutic treatment for cancer, financial burden of cancer, late and long-term effects of breast cancer diagnosis and treatment, or health promotion after a breast cancer diagnosis. Only one of 101 apps (1.0%) discussed end-of-life hospice.
In all, 40 of 101 apps (39.6%) provided biological information about breast cancer, such as the mechanism of tumor development in the breast. Only 24 apps (23.8%) cited scientific research or evidence-based guidelines to support their information. Five apps (5.0%) discussed clinical trials.
The median of the composite health literacy score was 5 (mean 5.06, SD 2.00), and only 13 (13%) apps had a composite plain language score of 8 of 8. A majority of the apps used present tense (84/101, 83.2%), active voice (78/101, 77.2%), short sentences (78/101, 77.2%), action words (75/101, 74.3%), short paragraph size (68/101, 67.3%), and personal pronouns such as “you” (60/101, 59.4%). However, fewer than half of the apps primarily used common and easy-to-understand words (44/101, 43.6%) and only 24 (23.8%) defined terms.
The median composite usability composite score was 3 (mean 2.60, SD 1.20). None of the apps contained all six usability items recommended by the IOM. Five apps (5.0%) had a composite usability score of 5 of 6. The most common usability feature was the use of bold colors without dark backgrounds (89/101, 88.1%). In all, 51 (50.5%) apps provided easy access to home/menu pages, 44 (43.6%) used images that facilitated learning, 37 (36.6%) had a back button, 33 (32.7%) were easy to browse, and nine (8.9%) had a simple search option available.
The most common technological feature was the ability to share content via email through the app (32/101, 31.7%). In addition, eight (7.9%) apps had the option to save documents. Four apps (4.0%) connected users to maps or GPS and three (3.0%) provided users the option to print directly from the apps.
Most apps (93/101, 92.1%) did not allow the user to customize information (ie, input weight, height, and other personal measures); only eight (7.9%) offered peer support and two (2.0%) provided an “ask the expert” option.
There was no statistically significant difference in the composite plain language scores of apps that focused on information/education content (mean 5.10, SD 1.89) and apps that did not (mean 4.96, SD 2.41;
Adherence of apps to literate principles (N=101).
Content | Composite plain language score | Composite usability score | |||||
Mean (SD) | Mean (SD) | ||||||
–0.26 (40.34) | .13 | –0.26 (99) | .77 | ||||
No information/ education content | 4.96 (2.41) | 2.32 (1.25) | |||||
With information/education content | 5.10 (1.89) | 2.71 (1.12) | |||||
–2.80 (99) | .006 | –0.30 (99) | .77 | ||||
No behavior change content | 4.75 (2.00) | 2.58 (1.21) | |||||
With behavior change content | 6.04 (1.85) | 2.67 (1.05) | |||||
–3.47 (99) | .001 | 0.23 (99) | .82 | ||||
No fundraising content | 4.73 (1.97) | 2.62 (1.11) | |||||
With fundraising content | 6.40 (1.73) | 2.55 (1.39) | |||||
–2.19 (99) | .031 | 0.11 (99) | .91 | ||||
No advocacy content | 4.89 (2.07) | 2.61 (1.20) | |||||
With advocacy content | 6.14 (1.41) | 2.57 (0.94) | |||||
0.80 (99) | .43 | –2.73 (99) | .007 | ||||
Free | 5.13 (2.09) | 2.47 (1.17) | |||||
Paid | 4.69 (1.70) | 3.31 (0.87) |
Apps aimed at behavior change scored higher on use of plain language (mean 6.04, SD 1.85) than apps that did not aim at behavior change (mean 0.75, SD 2.00) and the relationship was statistically significant (
The
Apps that included advocacy for breast cancer causes scored higher for plain language (mean 6.14, SD 1.41) compared to those that did not advocate for breast cancer causes (mean 4.89, SD 2.07) and the relationship was statistically significant (
Of the 73 apps that had information/education content, 58 (79%) were free and 15 (21%) were paid. Most of the 24 apps that targeted behavior change were free (21/24, 88%), and three (13%) were paid. All 20 (100%) of the apps that aimed at fundraising were free. Of the 14 apps that that included breast cancer advocacy, 12 (86%) were free, and two (14%) were paid (see
Free apps (mean 5.13, SD 2.09) did not differ significantly from paid apps in use of plain language (mean 4.69, SD 1.70;
Pearson correlations and
Average ratings were significantly higher for apps that used action words (mean 4.26, SD 1.07) than for apps that did not (mean 3.42, SD 1.52;
There was no significant correlation between an app’s user rating and its composite usability score (
This study examined the availability of breast cancer-related apps, their purpose, cancer continuum-related content, adherence to literate principles design, price, and user ratings. At the time of data collection, 101 apps focusing on breast cancer were available to the public. The majority of these apps were available on Android. The proportion of Apple-only apps in the sample represented their respective share of the cellular market of 28% at the time of data collection [
Although apps often have multiple purposes, the majority are designed to provide information and education. Consistent with past studies [
The findings also indicate that provision of information in support of treatment-related decision making emerges as an area of need. Less than half of the apps that provided information on treatment included information about possible side effects and of treatment options. This deficiency might be explained by the reluctance of developers to include medical information due to paucity of clinical expertise involvement in development of mHealth [
The analysis of the content of the apps on the cancer continuum reveals that, in contrast to primary breast cancer prevention, screening, and treatment, only a few apps focused on survivorship and only one included information about hospice care. No apps covered other aspects of end-of-life decisions and care. It is possible that information and support on end-of-life decisions and care are available on apps that are not breast cancer-specific (and consequently in apps that were not included in this sample), past research on cancer-related apps did not document such focus [
The analysis further underscores that greater adherence to literate design strategies continues to be a pressing need in breast cancer app development. Adherence to most usability design standards was low. It is possible that this low adherence relates to lack of experience or training of developers working on this relatively new platform. For instance, the literacy design principle that was most closely adhered to included use of colors, which is consistent with design of websites. In contrast, features that are arguably more significant in-app design, such as an easy browse and use of images, were not frequently included in the apps.
Similarly, the findings underscore the importance of greater attention to using plain language principles in the design of breast cancer apps. Notably, of the plain language characteristics, text level was still too high in the vast majority of apps, which demonstrates that mHealth developers, like developers of print information [
Consistent with past studies that examined diabetes-related apps [
This study contributes to research on the use of mHealth to advance breast cancer-related education and behavior change in a few ways. First, this is the first study to focus solely on breast cancer apps. In view of the unique information, education, treatment, and support needs before and following breast cancer diagnosis [
As in any research project, the methodologies utilized in this study hold inherent limitations. Specifically, systematic content analyses are helpful in providing an overview on the content available to users and its adherence to scholarly and professional standards, but are limited in their ability to shed light on users’ experiences. Moreover, previous researchers noted that content analysis of mHealth cannot link user information to app use [
Despite exciting potential for consumer engagement along the cancer continuum, availability of evidence-based breast cancer information and integration of literate design strategies to mHealth users is limited. This current state reveals that mHealth has not met its potential in engaging consumers with evidence-based information and design necessary to reduce preventable breast cancer burden and its associated disparities in health outcomes. Specifically, breast cancer-specific apps represent a limited spectrum on the cancer continuum. Therefore, this study is important in supporting the need for better-designed breast cancer apps that would adhere to evidence-based as well as to plain language and usability standards, with an extreme need for apps that focus on information necessary for medical decision making, most notably side effects, survivorship, and end of life.
As a systematic review, the goal of this study was to provide an overview of availability of breast cancer apps and their adherence to evidence-based content and design principles. Such systematic analyses are time consuming and cannot be performed by users. Further, the characteristics of such users at this point are unknown and are likely very diverse, including cancer-free individuals, cancer patients, and cancer survivors, because different apps target women at different stages on the cancer continuum. Future studies should apply additional, user-centered research methods, including surveys and community-based studies to learn about users’ experiences using apps along the breast cancer continuum.
Institute of Medicine
Research reported in this publication was supported by grant # IRG-14-187-19 from the American Cancer Society. This research was also supported in part by the following: Washington University Center for Diabetes Translation Research, supported under the National Institute of Diabetes and Digestive and Kidney Disorders, P30DK092950 and National Cancer Institutes of the National Institutes of Health under award number R25CA171994. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
None declared.