The term breast cancer refers to a malignant tumor that develops from cells in the breast. Its stage is usually expressed on a scale of 0 through IV with stage 0 describing noninvasive cancers that remain within their original location and stage IV describing invasive cancers that spread outside the breast to other parts of the body [1]. According to the World Health Organization, the estimated number of newly diagnosed breast cancer cases worldwide was 2,088,849 in 2018 [2], which was the highest among women’s cancers. Over 10,000 women are diagnosed with breast cancer every year in Taiwan. Most women are between the ages of 40 and 65 years at the time of diagnosis and usually have breast cancer that is between stages 0 and II [3]. Treatments for breast cancer include surgery, chemotherapy, immunotherapy, radiation therapy, hormonal therapy, and targeted therapy; these are often accompanied by side effects such as pain, fever, diarrhea, lymphedema, dry skin, fatigue, and insomnia [4]. Research indicates that there is compelling evidence of an increased risk of anxiety, depression, suicide, and neurocognitive and sexual dysfunctions among breast cancer survivors when compared with women with no prior incidence of cancer [5-7]. However, when breast cancer is treated appropriately, the 5-year survival rate approaches 88% [8]. Therefore, breast cancer is now treated as a chronic disease and self-management of symptoms is necessary for women to live well with breast cancer. Self-management is “the ability of the individual, in conjunction with family, community, and health care professionals, to manage symptoms, treatments, lifestyle changes, and psychosocial, cultural, and spiritual consequences of health conditions” [9]. Evidence suggests that self-management interventions improve the quality of life of women with breast cancer by enabling self-care [10], mindfulness-based stress reduction [11], and improved management of medical, emotional, and role-based tasks [12].

Today, mobile phones are popular and convenient, with an open architecture that allows third parties to develop mobile health (mHealth) apps. mHealth apps are highly relevant to the future of disease and health management [13]. Research indicates that using mHealth apps to support patients with breast cancer has many advantages including enhanced knowledge, increased physical activity, eliciting short-term reductions in weight, decreased anxiety, improved self-confidence, emotional well-being, and improved quality of life [14-17]. According to one study, there were 599 breast cancer–related apps in the iOS and Android markets in the United States in February 2016. Breast cancer–related apps most commonly addressed disease and treatment information (29.22%), addressed disease management (19.03%), and increased awareness (15.03%) [18].

To our knowledge, there are no breast cancer self-management support apps targeting Taiwanese women, and this creates several barriers in the use of existing apps. First, most apps do not provide educational content in traditional Chinese language. The noneffective use of language decreases app acceptance [19]. Second, when software is used to support instant translation, the accuracy and validity of the translation is unknown [20]. Third, the content of most existing apps lacks academic sources and references [18], leading to a lack of trust among Taiwanese women [21]. In addition to these barriers, several cross-cultural comparison studies have indicated that there are important differences in the depressive symptoms and quality of life between eastern and western breast cancer survivors [22-24]. Therefore, the contents of disease self-management support apps should consider cultural differences related to medical resources, food intake, personal beliefs, and support systems of their end users. To address this gap, our research team consisting of health care professionals (IC, MF, and PY), technology experts (SS and PC), and professionals at the Taiwan Breast Cancer Foundation (TBCF; KJ, HC, and IJ) partnered with Taiwanese women with breast cancer to investigate their information needs and to develop an app to meet their needs.

In this study, our team used the design thinking approach. Design thinking is a user-centered problem-solving methodology that starts with assessing people's needs and then seeks innovative solutions to address the range of issues identified. The 5-step design thinking model comprises empathy, define (the problem), ideate, prototype, and test steps and was proposed by the Hasso-Plattner Institute of Design at Stanford (d.school) [25,26]. The concepts underpinning each step and the methodologies we used are summarized in Table 1. The study was approved by the Institutional Review Board (IRB) at National Yang-Ming University (IRB no: YM106005E).

We conducted this research in 2 phases using the 5-step design thinking methodology (Table 1). In phase one, we designed three concurrent 3-hour focus groups in the multifunction room of the TBCF, which included steps 1 through 3. We then entered the second phase of prototyping (step 4) followed by developing and testing (step 5). The research group conducted a data analysis by triangulating the qualitative interview data with our literature review and team discussion to iteratively develop the prototype. The original participants were invited to use the developed prototype, and it was validated further through in-depth interviews.

We used purposive sampling to enroll Taiwanese women with breast cancer in our study. As suggested by others, we planned to include 5 to 8 members in each focus group [27-29]. Therefore, we planned to recruit 15 to 24 women with breast cancer for 3 concurrent focus groups. The recruitment was posted on TBCF’s social networking sites (eg, Facebook and Line) and interested participants contacted us through online registration. A total of 20 women with breast cancer were registered but 5 dropped out because of illness or work obligations that coincided with our study date. The demographic data of the remaining 15 participants are shown in Table 2. Their average age was 55 years, and most women received routine outpatient care for follow-up or long-term hormone therapy. In the beginning of the focus group discussion, study investigators introduced the study, secured informed consent, and encouraged participants to share their ideas with us. In total, 2 female authors (IC and MF) moderated and 3 nurse graduate students joined each subgroup as a facilitator. In addition, 1 nurse graduate student and 2 TBCF staff observed, took photos, and recorded notes. Audio and visual recorders were used to collect data during the focus group discussion.

All participants in phase one were invited to participate in individual interviews. A total of 13 focus group subjects agreed to be interviewed individually. Two subjects did not enroll because of a transportation problem (ID: A5) and one felt that her disease was not severe enough to share her experience (ID: B4). The in-person interviews were held for 1.5 to 2 hours by a study investigator (MF) at a place near the subjects’ house or office, or at a café. An audio recorder was used to collect the interview data. All subjects were given US $30 after participating in the research.

The concepts and study activities that were completed over 2 phases using the 5-step design thinking methodology are described below.

After the thematic analysis, 8 major themes and 30 codes were identified. The framework is shown in Figure 5. The definitions of each theme and their codes are described below.

According to our 5-step design thinking approach and thematic analysis, a total of 8 themes that included treatment, physical activity, emotions, diet, health records, social resources, experience sharing, and expert consulting were retrieved. In each theme, there were multiple codes that consisted of the information needs of the end users of the app. Previous research has indicated that the information needs of women with breast cancer included knowledge of the disease, the impact of breast cancer on the body, cancer metastasis or relapse, understanding and preparing for treatment, preventing and facing side effects and risk, survival prediction, survival rate, consultations, follow-up schedule, diet suggestion and restrictions, body image changes, self-management, and mental support [35-38]. Four of our main themes and the codes (eg, treatment, diet, emotional support, and health records) matched findings from prior research. In this study, our subjects did not mention the information needs of survival prediction and survival rate. It may have been that our subjects were mostly current breast cancer victims and were focused on healthy lifestyles to prevent cancer recurrence [39].

Previous research has also indicated that physical activity including exercise and physical therapy was helpful in lymphedema prevention, postoperative pain relief, and body weight control to prevent cancer relapse [39,40]. Our subjects expressed a positive attitude toward participation in group physical activities. However, in some cases, low immune tolerance and meeting schedules limited participation. Therefore, including some e-learning exercise courses on the app to enhance flexibility should be considered.

With regard to the theme of diet, our subjects’ perceptions were consistent with findings from previous studies that suggested that women with breast cancer were concerned about healthy eating, food, and nutrition-related side effects of chemotherapy [41-43]. The incorporation of culturally appropriate Taiwanese recipes for women with breast cancer and related nutritional information in the simulation app was positively received by most subjects. However, subjects also felt that it would be difficult to cook by themselves during treatment. Thus, offering some convenient and reliable food ordering and delivery functions on the app was also considered helpful. Diet and physical activity recommendations could help those who had completed treatment control their body weight. Participants requested more advanced and useful body weight control functions within the app such as food calorie or energy burning calculators.

We found that some subjects kept their own health records (eg, recoding body weight and temperature). The simulation app offered many structured health record options but based on the subjects’ feedback, it was difficult for us to assess whether Taiwanese women with breast cancer wanted to keep these records on their own in the future. According to a previous study based on a survey of oncology patients on app-assisted cancer care, the introduction of mobile apps needs to follow different strategies depending on the patients’ attitudes and apps could support clinic visits, document adverse effects, and provide reminders of treatment dates or medication schedules [44].

In summary, 8 main themes were identified by the research team. The information needs based on these main themes and their codes were used to form the framework for a breast cancer self-management support mHealth app. Most themes were consistent with previous studies but some new themes specific to Chinese culture were also uncovered. We believe that the design thinking approach is a strong method for identifying the information needs for Taiwanese women with breast cancer for the development of mHealth technology.

From the analysis, two minor findings emerged. The first was that the app should be used under the supervision of a professional. Taking physical activity for example, we provided three levels of rehabilitation actions to help women with breast cancer recover from surgery and to prevent lymphedema. However, they did not understand when to do these actions. Such patients would like to consult a professional rather than use an app. They also wanted the nutritionist to review their daily food records and prescribe the correct diet based on their assessment. We concluded that professional support while using the app would make end users more confident in the benefits of using the mHealth app.

The second minor finding was related to the management of the app. Expert consulting was seen as important for supporting women with breast cancer; however, such services will require a significant time commitment from professionals. Our subjects were concerned about the workload of these professionals and recommended that we offer frequently asked questions instead. Moreover, women with breast cancer wanted to share their experiences on online forums and also recommended using an app manager to ensure the credibility of information. These two minor findings can facilitate end user trust in the app.

The 5-step design thinking approach allowed users to brainstorm, design mockups, test, and provide feedback before the actual breast cancer–related self-management support app was developed. Through this approach, the app developer can identify new app requirements and compare end user requirements with those addressed in existing apps. In the ideate step, our participants sketched several balloons with different function labels as the main menu of the app (Figure 3) on the smartphone prototype. In eastern culture, people use a circle to represent the notion that everything is copasetic. Women with breast cancer may use the notion to pray for a smooth process during their cancer treatment. The design thinking approach and use of the illustration activity helped discover the user’s interface preferences and increased the programmer’s sensitivity to their needs.

In this study, the women with breast cancer had some information needs related to traditional Chinese medicine (TCM). The role of TCM was viewed as supportive medicine in the treatment of breast cancer. TCM is commonly used in eastern countries (eg, in Chinese culture, people often use Chinese herbs such as Angelica sinensis, Fructus lycii, pilosulae, tuceahoe, and shitake to enhance immunity) [45,46]. We were unable to find references or existing breast cancer–related self-management support apps that provide evidence of the effects of TCM treatment. Consistent with previous Chinese studies [45,46], most of our subjects wanted to know how TCM could help them during treatment. However, most women with breast cancer in Taiwan are undergoing treatment in hospitals (eg, the western medicine approach) and most of them are told by their physicians that TCM may interfere with western medicine treatment (eg, cause drug-drug interactions). To prevent confusion, a few subjects rejected the idea of including TCM information in the app. For such information needs, our team plans to consult with professional TCM physicians in the future. Our study did show that the design thinking approach is adequate to develop a user-centered and culturally sensitive support app for patients with cancer in a different social context.

One limitation of this study was that the sample size was inadequate in offering perspectives from women across all stages of breast cancer (eg, initial diagnosis through stage IV). Our study was conducted in an urban area with more medical resources than are typically available in the more rural areas of the country, and this may result in a geographical bias. Our testing was done using a simulation app rather than the real app, which may result in different feedback.

Our team used the design thinking process to retrieve information needs related to the use of an mHealth app by women with breast cancer in Taiwan. The needs were retrieved using one focus group with three subgroups that included brainstorming, discussion, and validation. The interactive simulation app coupled with individual interviews helped us identify content and begin prototyping before designing the real app. A total of 8 themes with multiple codes consisting of common and culturally specific information needs provided the framework for the self-management support mHealth app that we developed for Taiwanese women with breast cancer.