Among women, breast cancer is ranked first in inci-dence and mortality in most countries of the world. The incidence rates of the disease in developed and developing countries are 55.9 and 29.7 cases per 100,000 respect-ively. However, mortality rates in developing countries is 17% higher compared to developed countries (1, 2). The new cases of breast cancer have been on the rise,  with an estimated 2.3 million cases worldwide in 2020 (3). 
Based on recent reports, roughly 20 new cases per 100,000 women are identified in Iran every year (4). According to statistics of the National Cancer Institute of Iran, 57.6% of breast cancers are seen in women under the age of 50, which is a decade lower than the global peak age of incidence (5). Breast cancer has significant effects on the lives of sufferers and creates challenges to personal life, daily activities, job, communication, and family roles and also hurts the quality of life and mental health of patients (6). Breast cancer patients need a variety of skills and abilities to deal with the physical, mental, and psycho-logical consequences of illness, such as positive thinking, emotional expression, disease acceptance, religious rites, yoga, sports, and social and family support (6-8).
The studies show that the self-management program for chronic diseases has a positive effect on the improvement of self-efficacy and quality of life, and health outcomes especially in cancer patients (7, 8). Self-management is one of the emerging operational strategies in the field of chronic disease management, which leads to enhance-ment of patients’ skills and confidence through managing their diseases, including the symptoms handling, treat-ment adherence, and lifestyle improvement (8, 9). Self-management is a concept that refers to the ability of active participation and responsibility of the patient in conscious clinical decisions and cooperation with healthcare providers (10, 11). Given the importance of self-manage-ment and remote monitoring of breast cancer patients, the use of smartphone apps can be useful and helpful in the health domain (12, 13).
Because of the popularity and ubiquity of smartphones and also potential capacities and the low cost of this technology, the use of health apps in different countries has increased (14, 15). Today, smartphone apps are used as a support tool for breast cancer patients in various fields such as controlling the side effects of treatment, adherence to medication, reduction of patients’ stress and depress-ion, self-monitoring of physical activity, handling of nutrition, communication of patient-clinician, improving quality of life, promoting emotional well-being and shar-ing accurate and up-to-date information (14-16).
Understanding patient’s learning needs, expectations, and preferences is the first step in designing more effective apps (17,18). Nowadays, the patient-centered design is an app development method that can help to enhance patient adoption and utility of the app (19). Then patients’ involvement in determining the educational contents and technical features of smartphone apps is critical in the development of smartphone apps as a self-management tool (17-22).
Many studies have been conducted worldwide on the needs assessment of women with breast cancer with different and specific results based on cultural and envir-onmental characteristics (15, 21, 23, 24). In Iran, SheikhTaheri et al, conducted a survey to identify the educational needs of breast cancer patients for designing a self-care app (19). They investigated breast cancer patients undergoing only chemotherapy (not all treat-ments methods) with a small sample of patients.
Due to the increasing prevalence of breast cancer among Iranian women and the vital need to empower these patients for self-management, development of smartphone apps seems very important. The design of apps based on patients' needs and preferences will make this app more acceptable (15, 23-26). According to this background, the aim of this study was to identify the educational contents and technical features necessary for a self-management app from the perspective of breast cancer patients in Iran.

 

Of the 120 questionnaires distributed among the breast cancer patients, we received responses
from 103 participants with total response rate of 85.83%. The highest percentage of participants ranged between 40-50 years (40.78%).The majority of patients were married (74.23%), high school graduates (46.60%), unemployed (64.08%) and urban residents (72.89%). 31.06% of patients had family history of breast cancer. In terms of treatment modality, 82.52%  had mastectomy and also all of them underwent chemotherapy. 88.35% of patients owned smartphones and 85.43% were interested in using breast cancer applications (Table 1).

Table 1. Demographic and clinical characteristics of the Participants

According to the patients' opinion, in the category of information acquisition, the highest and lowest levels of scale were related to common side effects of treatment (4.68) and breast anatomy (3.48) respectively; in lifestyle management, the highest rate was related to physical activity (4.55) and the lowest rate was related to pregnancy (3.28). Impact of spirituality (4.15), in psych-ological management; management of chemotherapy side effects (4.75) , in symptom management ;and adaptation to physical changes (4.36), in Compatibility with changes were the highest average scores (Table 2)..

 
Table2. Mean of items related to educational contents of breast cancer smartphone app (range 1-5)

The most important technical features  of smartphone app include: ease of use of the app (4.83), simple and well-ordered visual interface (4.75), security and privacy of patient information (4.63), reminders about drug, diet, exercise, appointment (4.55),and ability to communicate with the health team (4.42) respectively (Table 3).

Table3. Technical features of breast cancer smartphone app (range 1-5)

As shown in Figure 1, from the standpoint of the breast cancer patients, the most important contentfea-tures of smartphone app in 5 main categories include information acquisition (4.73), lifestyle management (4.65), symptom management (4.43), psychological management (4.01), and compatibility with changes (3.98) respectively.

 
Figure 1. Educational contents of smartphone app, in 5 main categories (range 1-5)

Discussion

The aim of this study was to identify the educational contents and technical features required by an app for the self-management of women with breast cancer. The findings of this study indicated that the considerable educational contents included physical activity, side effects of treatment, dietary modifications, side effects of management, and stress management. In a similar study in 2020, a mobile health app for breast cancer self-management support in Taiwan via a design thinking approach was developed. The information needs of patients extracted a sum of 8 significant topics including treatment, physical action, diet, emotional help, health records, social resources, experience sha-ring, and master meeting (15). A study matching with the present study showed that breast cancer patients were less satisfied with the information received and the most unmet information needs of patients were about treatment options and their accompanying risks and side effects, as well as psychosocial support, depressive symptoms, and physical functioning (33).
Based on the findings of this study, breast cancer patients are willing to learn about educational contents, information acquisition (4.73), treatment types and their side effects, lifestyle management (4.65) including physical activity and dietary modifications, and symptom management (4.43) including chemo-therapy side effects management and pain and stress management. The study by Sheikh Taheri et al, (2018) indicated that the most important needs of breast cancer patients on the internet include treatment (4.62), daily activity (4.51), disease (4.42), disease acceptance and self-image (4.37), the effect of disease on private life (4.21), and sexual health (4.2) (19).
The results of other studies about the information needs of women with breast cancer indicated that the most important needs of patients include treatment options, side effects, diet, exercises, emotions, lifestyle changes, communication with health care providers and social support (33- 35). A comparison of the results of these researches with the results of the current study show that the information needs of breast cancer patients are consistent with the content features of the smart mobile application. The results of the study of Al Ayubi et al, in 2019 demonstrated that the most important usability factors of social m-health applic-ation for physical activity include ease of learning (4.72), ease of use (4.69), pleasant interface (4.35), organization of information (4.38), and ease of navigation (4.38) (36).
The results of another study conducted by SheikhTaheri et al, showed that the most important educational contents for designing a self-care app include various side effects of chemotherapy and the techniques of self-care to manage these side effects, self-care recommendations on nutrition, physical activity, hopeful messages, spiritual health and stress management (19).
Our research focuses on the educational needs of all breast cancer patients with a variety of treatment methods (surgery, radiation therapy, chemotherapy, etc.) and the results showed that in addition to lifestyle management and side effect of treatment emphasis should be placed on information acquisition, symptom management, psychological management and compa-tibility with changes.
Based on the present study, the most important technical features were ease of use of the app (4.83), simple and well-ordered visual interface (4.75), security and privacy of patient information (4.63), rem-inders about drug, diet, exercise, appointment (4.55), and the ability to communicate with the health team (4.42). The study by Park et al, in 2018 indicated that desired functions and features of mobile phone medication adherence from users’ viewpoints include optimization of information input, improvement of reminders, user-friendliness, upgrading app perfor-mance, backup of data and interoperability (37). Using smartphone features such as reminders makes people participate in related activities (26, 38-40).
The majority of breast cancer survivors believe that health apps designed can be effective for a healthy lifestyle (20). To the best of our knowledge, smart-phone apps can be very useful tools to empower breast cancer patients and help them with self-management. In many studies, the importance of need assessment and survivors’ preferences of breast cancer patients before designing and presenting an app has been noted (15,18, 19, 21, 25). In the same way, our study adder-ssed the needs assessment and survivors’ preferences of breast cancer patients to identify the requirements of patients to design a self-management app, the results of which can be considered by health apps developers.

 

Conclusion

Findings of  the current study indicated that the control of treatment side effects, physical activity, dietary modifications, pain and stress management are  the most desired contentfeatures prioritized by breast cancer patients. To ensure the use and acceptance of app, developers should design apps that possess technical requirements such as  ease of use, simple visual interface, data privacy and security, fit remin-ders and user customization. Therefore, it seems nece-ssary to involve breast cancer patients in designing smartphone applications. Eventually, for more effect-tive smartphone apps, educational contents and techn-ical features of apps should be designed based on the patients’ needs and preferences.  

 

Acknowledgements

This paper is derived from MSc thesis of Health Information Technology (No. 9872), supported by the Research Council of Urmia University of Medical Sciences, Urmia, Iran. The authors would like to thank all the professors and staff of Omid and Imam Khomeini hospitals in Urmia and Urmia University of Medical Sciences who assisted us in this study.

 

Study limitation

The existence of coronavirus conditions for breast cancer patients made it very difficult and time-consuming to collect questionnaires, which was solved by allocating more time to the questionnaire collection process.

 

Conflicts of Interest

The authors declare no conflict of interest.