Jan Franco

BACKGROUND Fatigue is burdensome in advanced cancer. Wearable-informed mobile health (mHealth) apps may support monitoring and self-management, but evidence on usability and engagement in this population is limited. OBJECTIVE To evaluate the feasibility, usability, engagement, and patient experience of a wearable-informed mHealth app for fatigue self-management, and the reception of its exploratory digital fatigue score. METHODS In this 4-week, single-arm pilot study, adults with stage III-IV cancer according to the Union for International Cancer Control used the app and an activity tracker. We assessed enrollment, retention, and dropout reasons for feasibility, week-4 usability with the System Usability Scale (SUS) and the German version of the mHealth App Usability Questionnaire (GER-MAUQ), engagement through weekly self-reported use and satisfaction ratings and app usage logs, patient experience through optional weekly free-text responses, and reception of the fatigue score through study-specific ratings. Fatigue, health-related quality of life, and distress were exploratory outcomes assessed at baseline and weekly. Analyses included descriptive statistics, linear mixed models, and correlations. RESULTS Of 38 enrolled participants, 29 completed baseline and 23 completed week 4 (postbaseline retention 79.3%). Dropout respondents (n=5) mainly cited disease burden, and weekly free-text responses mainly described illness-related barriers. Mean SUS was 68.9 (SD 17.8), in the upper marginal range, and GER-MAUQ usefulness (median 4.29) was rated lower than ease of use (median 5.80, P<.001). Weekly active users decreased from 23 in week 1 to 19 in week 4. The fatigue score was used by 20 of 23 participants (87.0%), but its helpfulness was rated low (median 2.0 on a 1-5 scale). CONCLUSIONS The app appeared feasible over 4 weeks in selected patients with advanced cancer, and dropout responses mainly cited illness burden rather than technical or privacy-related barriers. Usability was in the marginal to acceptable range, while usefulness was rated lower than ease of use. Engagement differed mainly in reach across features, and illness-related barriers and rigid daily planning limited use. The fatigue score attracted interest but needs clearer explanations, more actionable recommendations, and independent validation. Clinical outcomes were exploratory, and efficacy requires controlled evaluation.

Background: Digital health technologies may support communication, symptom management, continuity of care, and access to services in hospice and palliative care. National data on their adoption, on professionals’ attitudes, and on perceived barriers are scarce. We examined digital health adoption, attitudes towards digital health, perceived suitability, perceived barriers, and self-rated eHealth literacy among hospice and palliative care professionals in Germany. Methods: We conducted a national cross-sectional web-based survey among all members of the German Society for Palliative Medicine (DGP) between 15 August and 28 September 2024. The questionnaire covered current use of digital devices and services, perceived suitability and impact of digital health, perceived usefulness across care domains, perceived barriers, use of and willingness to use artificial intelligence (AI), and self-rated eHealth literacy using the German Revised eHealth Literacy Scale (GR-eHEALS). We analyzed data descriptively and with bivariate tests. We report the study according to the CHERRIES and CROSS checklists. Results: In total, 618 professionals completed the survey (completion rate 88%; 9.6% of all invited members). Established tools were used by most respondents (computers 99%, email 98%, electronic patient documentation 73%), whereas patient-facing and newer technologies were used less often (electronic health card 39%, mobile health apps 29%, video consultation 20%). In 2024, 69% reported no regular AI use; 12.7% selected the maximum score for willingness to use AI regularly at work. Respondents rated digital health as less suitable for hospice and palliative care than for general healthcare (M = 3.53 vs. 4.00 on a 1–5 scale; Cohen’s d = 0.59). Digital tools were rated as most useful for coordination with external professionals, advance care planning, and communication with relatives, and as least useful for nursing care, therapies, and pastoral care. The most frequently perceived barriers were inadequate technical infrastructure (75%) and perceived limited digital literacy among patients (67%) and relatives (62%). Self-rated eHealth literacy was high (GR-eHEALS M = 4.31 on a 1–5 scale). Conclusions: Hospice and palliative care professionals in Germany broadly use established digital tools, whereas patient-facing technologies are used less. Acceptance is context-specific: digital support is welcomed for coordination, advance care planning, and communication, and viewed more cautiously where personal presence is central to care. Implementation should prioritize technical infrastructure and context-sensitive design that preserves relational, person-centered care.

BACKGROUND Smartwatches are increasingly used for decentralized data collection in clinical research, but the everyday-life settings that make these data attractive also introduce variability. Before a smartwatch-derived feature can support clinical monitoring, its reproducibility must be established: features with low test-retest reliability weaken associations with clinical outcomes and potentially generate non-actionable signals. Reliability is expected to vary by feature type, aggregation window, and data availability, but has not been systematically screened in a clinical cohort. OBJECTIVE This study aimed to evaluate the test-retest reliability of candidate smartwatch-derived features for longitudinal monitoring in adults with advanced cancer and in healthy controls, and to determine how reliability depends on the temporal aggregation window. METHODS In a prospective single-centre observational cohort study, we analysed 8 weeks of Garmin Vivosmart 5 sensor data from 60 adults with advanced cancer, and 20 healthy controls. Out of 80 participants, 77 contributed usable smartwatch data. We examined 35 daily features across seven domains: heart rate variability, heart rate, respiration, oxygen saturation, sleep, activity, and smartwatch-derived stress. Test-retest reliability was quantified as the intraclass correlation coefficient (ICC(2,1)) across adjacent non-overlapping 1-, 3-, and 7-day windows, with 95% CIs from subject-level bootstrap resampling (10,000 resamples). Between-group and therapy-centred contrasts used permutation testing with Benjamini-Hochberg false discovery rate correction. RESULTS Reliability improved with longer aggregation windows in both cohorts. Between 1-day and 7-day windows, median ICC(2,1) increased from 0.53 to 0.73 in controls and from 0.66 to 0.79 in patients. The number of features reaching good-to-excellent reliability, defined as ICC(2,1)≥0.75, increased from 5 of 35 to 15 of 34 in controls and from 12 of 35 to 26 of 35 in patients. Heart rate and heart rate variability features were the most reliable, with 4 of 11 reaching weekly ICC(2,1)≥0.90 in both cohorts. Activity, respiration, sleep and oxygen-saturation features were more sensitive to aggregation window and data availability, showing larger gains from daily to weekly aggregation (e.g., step count ICC increased from 0.30 to 0.73 in controls). Weekly reliability did not differ significantly between patients and controls (median ΔICC=0.036, no feature survived FDR correction, all q>0.05). No feature showed a significant change in reliability around therapy (median ΔICC=0.016, all q>0.05). CONCLUSIONS Weekly aggregation improved the reliability of many smartwatch-derived features, but reliability remained feature specific. Heart rate and heart rate-variability features were consistently reliable, whereas selected sleep and oxygen-saturation features displayed only moderate reliability across all aggregation windows. Reliability was comparable across cohorts and stable around therapy, indicating that feature-wise estimates are transferable across these clinical contexts. Feature-level reliability screening is a prerequisite before smartwatch-derived measures are used in clinical monitoring.

Background: Lung cancer is one of the most common cancers in Germany, with around 56,000 new cases diagnosed in 2020. Approximately 65% are diagnosed at advanced stages, where symptoms such as fatigue, pain, dyspnea, and weight loss are prevalent. These patients often suffer from cardiovascular and pulmonary comorbidities, which interact with treatment toxicity, outcome, and increase treatment costs. Although exercise therapy is proven to alleviate cancer-related symptoms and to improve quality of life, current lung cancer treatment guidelines fail to adequately prioritize its crucial role. Methods: The Better symptom contRol with Exercise in pAtients wiTH advanced non-small cell lung cancer (BREATH) study is a prospective, three-arm randomized controlled trial (RCT) designed to assess the impact of exercise therapy on patients with advanced NSCLC (stage IIIB-IV) who are receiving first- or second-line systemic therapy in the palliative setting. Patients ( n = 104) are randomized in a 2:1:1 ratio into a control group (receiving exercise recommendations) or one of two intervention arms: endurance training and breathing exercise or combined endurance and resistance training. The intervention groups will exercise twice a week for 12 weeks. The control group participants will be randomized again in a 1:1 ratio into one of the two intervention arms after completion of the control period. The study will assess outcomes at baseline, 12 weeks, and 24 weeks. The primary outcome is improvement of aerobic capacity (VO ₂ peak). Secondary outcomes include quality of life, fatigue, adherence to exercise, and adverse events. Patient representatives were involved in all stages of protocol development. Discussion: The BREATH study addresses a significant gap in the current management of advanced lung cancer treatment by evaluating the impact of different exercise treatment protocols to reduce symptoms and improve clinical outcome. The study design and exercise program aim to enhance adherence and optimize patient-related outcomes. The results of the BREATH study have the potential to influence future guidelines and improve the management of patients with advanced NSCLC. Trial registration: ClinicalTrials.gov NCT06374160. Registered on April 18, 2024.