# Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions.

Valentyn Fournier, Christelle Duprez, Delphine Grynberg, Pascal Antoine, Kristopher Lamore

► To cite this version:

Valentyn Fournier, Christelle Duprez, Delphine Grynberg, Pascal Antoine, Kristopher Lamore. Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions.. Cancer Medicine, 2023, Cancer Medicine, 10.1002/cam4.6695. hal-04304177v2

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Submitted on 15 May 2024

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# Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions.

Valentyn Fournier, Christelle Duprez, Delphine Grynberg, Pascal Antoine, Kristopher Lamore

<figure><img src="image_1.png" /></figure>

## ► To cite this version:

Valentyn Fournier, Christelle Duprez, Delphine Grynberg, Pascal Antoine, Kristopher Lamore. Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions. Cancer Medicine, 2023, Cancer Medicine, 10.1002/cam4.6695. hal-04304177v2

HAL Id: hal-04304177

https://hal.univ-lille.fr/hal-04304177v2

Submitted on 15 May 2024

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
# Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions

Valentyn Fournier<fnref n="1" /> ID

Christelle Duprez<fnref n="1" /> ID

Delphine Grynberg<fnref n="1" />,<fnref n="2" /> ID

Pascal Antoine<fnref n="1" />

Kristopher Lamore<fnref n="1" />

## Correspondence

Valentyn Fournier, CNRS, UMR 9193—SCALab—Sciences Cognitives et Sciences Affectives, Université de Lille, Lille 59000, France.

Email: valentyn.fournier@univ-lille.fr

## Funding information

Institut National Du Cancer, Grant/Award Number: INCA/16136

## Abstract

**Background:** Digital health technologies have expanded tremendously in the last two decades, creating an emerging research and clinical field. They are regarded as cost-effective, and their use in healthcare is prioritized by many countries. However, the constant evolution of these technologies has led to an abundance of related literature. Thus, we conducted an umbrella review to identify and characterize digital supportive care interventions for patients with cancer and their relatives.

**Methods:** A preregistered umbrella review was conducted (PROSPERO registration number CRD42022333110). Five databases were searched (Embase, PsycINFO, PubMed, CINAHL, and the Cochrane Library). To be considered, studies had to be systematic reviews or meta-analyses, be performed on pediatric or adult patients with cancer or survivors or their relatives, report results on web-based or app-based supportive care interventions, and measure psychological, functional, or behavioral variables or quality of life related to cancer. The methodological quality of the studies was assessed using the AMSTAR-2 tool.

**Findings:** Twenty eligible studies were identified. Most of the included studies reported results from adult patients with cancer. Globally, digital interventions were shown to be effective for physical activity in patients with cancer but had mixed results regarding emotional outcomes and quality of life. Additionally, a lack of methodological quality was noted for most of the included reviews.

**Discussion:** Digital supportive care interventions could be an effective tool in cancer care for some outcomes. Recommendations have been formulated for further research in this field using adapted methodologies for the development of digital health interventions.

## KEYWORDS

digital intervention, patients, relatives, supportive care, umbrella review

<footnote n="1">¹Université de Lille, CNRS, UMR 9193—SCALab—Sciences Cognitives et Sciences Affectives, Lille, France</footnote>

<footnote n="2">²Institut Universitaire de France, Paris, France</footnote>
# Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions

Valentyn Fournier<fnref n="1" /> ID

Christelle Duprez<fnref n="1" /> ID

Delphine Grynberg<fnref n="1" />,<fnref n="2" /> ID

Pascal Antoine<fnref n="1" />

Kristopher Lamore<fnref n="1" />

## Correspondence

Valentyn Fournier, CNRS, UMR 9193—SCALab—Sciences Cognitives et Sciences Affectives, Université de Lille, Lille 59000, France.

Email: valentyn.fournier@univ-lille.fr

## Funding information

Institut National Du Cancer, Grant/Award Number: INCA/16136

## Abstract

**Background:** Digital health technologies have expanded tremendously in the last two decades, creating an emerging research and clinical field. They are regarded as cost-effective, and their use in healthcare is prioritized by many countries. However, the constant evolution of these technologies has led to an abundance of related literature. Thus, we conducted an umbrella review to identify and characterize digital supportive care interventions for patients with cancer and their relatives.

**Methods:** A preregistered umbrella review was conducted (PROSPERO registration number CRD42022333110). Five databases were searched (Embase, PsycINFO, PubMed, CINAHL, and the Cochrane Library). To be considered, studies had to be systematic reviews or meta-analyses, be performed on pediatric or adult patients with cancer or survivors or their relatives, report results on web-based or app-based supportive care interventions, and measure psychological, functional, or behavioral variables or quality of life related to cancer. The methodological quality of the studies was assessed using the AMSTAR-2 tool.

**Findings:** Twenty eligible studies were identified. Most of the included studies reported results from adult patients with cancer. Globally, digital interventions were shown to be effective for physical activity in patients with cancer but had mixed results regarding emotional outcomes and quality of life. Additionally, a lack of methodological quality was noted for most of the included reviews.

**Discussion:** Digital supportive care interventions could be an effective tool in cancer care for some outcomes. Recommendations have been formulated for further research in this field using adapted methodologies for the development of digital health interventions.

## KEYWORDS

digital intervention, patients, relatives, supportive care, umbrella review

<footnote n="1">¹Université de Lille, CNRS, UMR 9193—SCALab—Sciences Cognitives et Sciences Affectives, Lille, France</footnote>

<footnote n="2">²Institut Universitaire de France, Paris, France</footnote>
# 1 | INTRODUCTION

The global burden of cancer is growing and improvements in clinical care are urgently needed to face it.¹⁻³ The improvements in cancer care require more healthcare professionals to meet basic clinical demand in oncology units⁴ and in supportive care units that are already understaffed.⁵ There is a need for innovative, cost-effective approaches for optimal patient management, and psychosocial care that do not require workforce increases.⁶⁻⁸ In some cases, new effective psychosocial face-to-face interventions (e.g., group interventions, mindfulness) can be more expensive than institutions cannot afford.⁸ These costs can be related, for example, to the professional who takes more time with one patient to the detriment of others, additional training costs, or increased demand. In addition, given the high risk of psychopathological disorders in the relatives of patients with cancer, such new cost-effective interventions should also be available to them.⁹

In the last two decades, digital technologies have expanded tremendously. Technologies developed to support human health and well-being are more recent, and their effectiveness and impact on the healthcare system need to be evaluated constantly. Digital technologies comprise electronic health (eHealth), mobile health (mHealth), telemedicine, telemonitoring, and digital therapeutics. Digital health interventions can be used to promote healthy behaviors, support individuals with mental health conditions or long-term conditions such as cancer, and facilitate care pathway.¹⁰ Additionally, these interventions can facilitate care access for underserved groups and maintain patient-centered care within a system involving family members in care.¹¹ National and international guidelines outline the importance of implementing health-related digital technologies to support care.¹² However, despite the growing interest reflected in the numerous extant systematic reviews and meta-analyses of digital interventions in cancer care, the collected evidenced-based results need to be synthesized to confirm the relevance and efficacy of digital health interventions in providing psychosocial support to patients with cancer and their relatives.

Thus, we conducted an umbrella review aiming to identify the existing digital interventions developed to provide supportive care to patients with cancer and their relatives in the cancer care continuum. The secondary aim was to report how those interventions influence outcomes of interest.

# 2 | METHODS

This umbrella review was preregistered on PROSPERO (International prospective register of systematic reviews,

CRD42022333110). It adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines¹³ and follows the recommendations of Aromataris et al.¹⁴

## 2.1 | Search strategy

Five databases were searched on April 4, 2022 (and rerun on November 23, 2022): Embase, PsycINFO, PubMed, CINAHL, and the Cochrane Library. Gray literature (Google Scholar) and references included in studies were checked to ensure a comprehensive search. Searches were performed using a comprehensive list of keywords related to the type of article (systematic reviews and meta-analyses), digital interventions, and cancer (see Appendix 1).

## 2.2 | Study selection

Study selection was performed with the web application Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). All the steps were performed independently by two authors (VF and KL). After removal of duplicates, the titles and abstracts of the studies were screened. Then, a full text review of the remaining studies was performed. In case of disagreement, conflicts were resolved through discussion about the motivation for the choice until an agreement was reached. Finally, data extraction and summarization were performed. An interrater agreement rate was calculated for each stage of the process.

## 2.3 | Inclusion criteria

To be included, the systematic reviews or meta-analyses had to meet each of the following PICOS criteria.¹⁵,¹⁶ The population of interest comprised patients with cancer regardless of age and/or their relatives throughout the cancer continuum, from diagnosis to survivorship (Population). Interventions had to be either web-based or app-based digital health psychosocial, behavioral, or supportive care interventions. For this review, given the scarcity of other interventions (e.g., telemedicine, telemonitoring), the considered digital interventions included web-based interventions and app-based interventions (Intervention). Where applicable, the comparator had to be a usual care group or a group of participants exposed to another intervention (Comparator). The outcomes of interest included psychological variables (e.g., anxiety, depression), functional variables (e.g., pain, cognitive
# 1 | INTRODUCTION

The global burden of cancer is growing and improvements in clinical care are urgently needed to face it.¹⁻³ The improvements in cancer care require more healthcare professionals to meet basic clinical demand in oncology units⁴ and in supportive care units that are already understaffed.⁵ There is a need for innovative, cost-effective approaches for optimal patient management, and psychosocial care that do not require workforce increases.⁶⁻⁸ In some cases, new effective psychosocial face-to-face interventions (e.g., group interventions, mindfulness) can be more expensive than institutions cannot afford.⁸ These costs can be related, for example, to the professional who takes more time with one patient to the detriment of others, additional training costs, or increased demand. In addition, given the high risk of psychopathological disorders in the relatives of patients with cancer, such new cost-effective interventions should also be available to them.⁹

In the last two decades, digital technologies have expanded tremendously. Technologies developed to support human health and well-being are more recent, and their effectiveness and impact on the healthcare system need to be evaluated constantly. Digital technologies comprise electronic health (eHealth), mobile health (mHealth), telemedicine, telemonitoring, and digital therapeutics. Digital health interventions can be used to promote healthy behaviors, support individuals with mental health conditions or long-term conditions such as cancer, and facilitate care pathway.¹⁰ Additionally, these interventions can facilitate care access for underserved groups and maintain patient-centered care within a system involving family members in care.¹¹ National and international guidelines outline the importance of implementing health-related digital technologies to support care.¹² However, despite the growing interest reflected in the numerous extant systematic reviews and meta-analyses of digital interventions in cancer care, the collected evidenced-based results need to be synthesized to confirm the relevance and efficacy of digital health interventions in providing psychosocial support to patients with cancer and their relatives.

Thus, we conducted an umbrella review aiming to identify the existing digital interventions developed to provide supportive care to patients with cancer and their relatives in the cancer care continuum. The secondary aim was to report how those interventions influence outcomes of interest.

# 2 | METHODS

This umbrella review was preregistered on PROSPERO (International prospective register of systematic reviews,

CRD42022333110). It adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines¹³ and follows the recommendations of Aromataris et al.¹⁴

## 2.1 | Search strategy

Five databases were searched on April 4, 2022 (and rerun on November 23, 2022): Embase, PsycINFO, PubMed, CINAHL, and the Cochrane Library. Gray literature (Google Scholar) and references included in studies were checked to ensure a comprehensive search. Searches were performed using a comprehensive list of keywords related to the type of article (systematic reviews and meta-analyses), digital interventions, and cancer (see Appendix 1).

## 2.2 | Study selection

Study selection was performed with the web application Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). All the steps were performed independently by two authors (VF and KL). After removal of duplicates, the titles and abstracts of the studies were screened. Then, a full text review of the remaining studies was performed. In case of disagreement, conflicts were resolved through discussion about the motivation for the choice until an agreement was reached. Finally, data extraction and summarization were performed. An interrater agreement rate was calculated for each stage of the process.

## 2.3 | Inclusion criteria

To be included, the systematic reviews or meta-analyses had to meet each of the following PICOS criteria.¹⁵,¹⁶ The population of interest comprised patients with cancer regardless of age and/or their relatives throughout the cancer continuum, from diagnosis to survivorship (Population). Interventions had to be either web-based or app-based digital health psychosocial, behavioral, or supportive care interventions. For this review, given the scarcity of other interventions (e.g., telemedicine, telemonitoring), the considered digital interventions included web-based interventions and app-based interventions (Intervention). Where applicable, the comparator had to be a usual care group or a group of participants exposed to another intervention (Comparator). The outcomes of interest included psychological variables (e.g., anxiety, depression), functional variables (e.g., pain, cognitive
functioning), behavioral variables (e.g., physical activity), or the quality of life related to the cancer (Outcome). Only systematic reviews of quantitative studies and meta-analyses were included (Study type).

The abstracts and full text had to be written in English, French, or Spanish. Only studies published after 2000 were considered.

## 2.4 | Exclusion criteria

Items were excluded if (i) they did not exclusively consider patients with cancer or their relatives, (ii) they did not mainly relate to web-based or app-based digital interventions, (iii) the intervention was exclusively implemented via social media, or (iv) they reviewed case reports, observational studies, qualitative studies, or study protocols.

## 2.5 | Study quality assessment

The quality of the reviews or meta-analyses was assessed independently by VF and KL using the Assessing the Methodological quality of Systematic Reviews tool (AMSTAR-2).¹⁷ AMSTAR-2 consists of 16 items (14 for systematic reviews and meta-analyses and two additional only for meta-analyses).

## 2.6 | Data extraction and synthesis

Data were extracted independently by VF and KL (see Appendix 2). The two respective versions were compared and discussed in case of disagreement. Results regarding web-based and mobile-based interventions were distinguished because of potential differences due to the medium.

According to recommendations, a narrative synthesis of the data was performed distinguishing intervention type, aim of the intervention, and outcomes.¹⁴

## 2.7 | Role of the funding source

The funding source had no role in study design, data collection, data analysis, data interpretation, writing of the report, or in the decision to submit the paper for publication.

# 3 | RESULTS

Three thousand eight hundred and twenty articles after primary systematic search and were screened based on

their titles and abstracts (inter-rater agreement: 98.53%). As a result, 83 articles were chosen for full-text review (inter-rater agreement: 72.29%; see Appendix 3) and 18 fully met the inclusion criteria, reporting on a total of 255 original studies after the removal of duplicates (see Appendix 4). The rerun of the systematic search led to the identification of 394 supplementary articles leading to the identification of two articles after applying same screening process. Finally, 20 reviews were included in this umbrella review (see Figure 1).

## 3.1 | Studies characteristics

Eligible reviews were published between 2015 and 2022. Sixteen reported results from adult patients with cancer undergoing active treatment (diverse localizations¹⁸⁻²⁶ and breast cancer²⁷,²⁸), patients with an advanced stage of the disease,²⁹ or cancer survivors³⁰⁻³³; two reviews were related to pediatric cancers (diverse cancer localizations for patients under active treatment and survivors³⁴ or survivors only³⁵); and two dealt with the caregivers of patients with cancer (one with both adult cancer survivors and their partners³⁶ and one with caregivers only³⁷) (see Appendix 4).

The quality assessment (see Table 1) showed discrepancies between the reviews. Eleven reviews fulfilled at least half of the criteria,¹⁸,²²,²⁴,²⁵,²⁷⁻³⁰,³²,³⁴,³⁵ whereas nine did not.¹⁹⁻²¹,²³,²⁶,³¹,³³,³⁶,³⁷ (inter-rater agreement: 93.66%). Overall ratings of confidence were applied to the reviews.²⁰ Therefore, the rating of confidence was high for three reviews,²⁴,²⁷,³⁴ moderate for 2,²⁵,²⁸ low for 3,¹⁸,²²,³⁵ and critically low for 12.¹⁹⁻²¹,²³,²⁶,²⁹⁻³³,³⁶,³⁷

## 3.2 | Types of interventions

Of the 20 reviews, 12 reported results from both web-based and app-based interventions,¹⁸,²⁰,²²,²⁴,²⁷⁻³⁰,³²⁻³⁵ seven from web-based interventions only,¹⁹,²³,²⁵,²⁶,³¹,³⁶,³⁷ and one from app-based interventions only.²¹

Two reviews did not specify the duration of the interventions,²¹,³⁷ one did for only one of the interventions (six weeks²⁰), and one was not clear on this point (potentially 6–12 weeks³⁴). The remaining reviews reported interventions that were between 1 week and 52 weeks long.

## 3.3 | Summary of evidence and effectiveness of the interventions

The reported interventions were considered effective when at least half of them showed positive results for a
functioning), behavioral variables (e.g., physical activity), or the quality of life related to the cancer (Outcome). Only systematic reviews of quantitative studies and meta-analyses were included (Study type).

The abstracts and full text had to be written in English, French, or Spanish. Only studies published after 2000 were considered.

## 2.4 | Exclusion criteria

Items were excluded if (i) they did not exclusively consider patients with cancer or their relatives, (ii) they did not mainly relate to web-based or app-based digital interventions, (iii) the intervention was exclusively implemented via social media, or (iv) they reviewed case reports, observational studies, qualitative studies, or study protocols.

## 2.5 | Study quality assessment

The quality of the reviews or meta-analyses was assessed independently by VF and KL using the Assessing the Methodological quality of Systematic Reviews tool (AMSTAR-2).¹⁷ AMSTAR-2 consists of 16 items (14 for systematic reviews and meta-analyses and two additional only for meta-analyses).

## 2.6 | Data extraction and synthesis

Data were extracted independently by VF and KL (see Appendix 2). The two respective versions were compared and discussed in case of disagreement. Results regarding web-based and mobile-based interventions were distinguished because of potential differences due to the medium.

According to recommendations, a narrative synthesis of the data was performed distinguishing intervention type, aim of the intervention, and outcomes.¹⁴

## 2.7 | Role of the funding source

The funding source had no role in study design, data collection, data analysis, data interpretation, writing of the report, or in the decision to submit the paper for publication.

# 3 | RESULTS

Three thousand eight hundred and twenty articles after primary systematic search and were screened based on

their titles and abstracts (inter-rater agreement: 98.53%). As a result, 83 articles were chosen for full-text review (inter-rater agreement: 72.29%; see Appendix 3) and 18 fully met the inclusion criteria, reporting on a total of 255 original studies after the removal of duplicates (see Appendix 4). The rerun of the systematic search led to the identification of 394 supplementary articles leading to the identification of two articles after applying same screening process. Finally, 20 reviews were included in this umbrella review (see Figure 1).

## 3.1 | Studies characteristics

Eligible reviews were published between 2015 and 2022. Sixteen reported results from adult patients with cancer undergoing active treatment (diverse localizations¹⁸⁻²⁶ and breast cancer²⁷,²⁸), patients with an advanced stage of the disease,²⁹ or cancer survivors³⁰⁻³³; two reviews were related to pediatric cancers (diverse cancer localizations for patients under active treatment and survivors³⁴ or survivors only³⁵); and two dealt with the caregivers of patients with cancer (one with both adult cancer survivors and their partners³⁶ and one with caregivers only³⁷) (see Appendix 4).

The quality assessment (see Table 1) showed discrepancies between the reviews. Eleven reviews fulfilled at least half of the criteria,¹⁸,²²,²⁴,²⁵,²⁷⁻³⁰,³²,³⁴,³⁵ whereas nine did not.¹⁹⁻²¹,²³,²⁶,³¹,³³,³⁶,³⁷ (inter-rater agreement: 93.66%). Overall ratings of confidence were applied to the reviews.²⁰ Therefore, the rating of confidence was high for three reviews,²⁴,²⁷,³⁴ moderate for 2,²⁵,²⁸ low for 3,¹⁸,²²,³⁵ and critically low for 12.¹⁹⁻²¹,²³,²⁶,²⁹⁻³³,³⁶,³⁷

## 3.2 | Types of interventions

Of the 20 reviews, 12 reported results from both web-based and app-based interventions,¹⁸,²⁰,²²,²⁴,²⁷⁻³⁰,³²⁻³⁵ seven from web-based interventions only,¹⁹,²³,²⁵,²⁶,³¹,³⁶,³⁷ and one from app-based interventions only.²¹

Two reviews did not specify the duration of the interventions,²¹,³⁷ one did for only one of the interventions (six weeks²⁰), and one was not clear on this point (potentially 6–12 weeks³⁴). The remaining reviews reported interventions that were between 1 week and 52 weeks long.

## 3.3 | Summary of evidence and effectiveness of the interventions

The reported interventions were considered effective when at least half of them showed positive results for a
<figure><img src="image_2.png" /><figcaption>FIGURE 1 PRISMA flowchart.</figcaption></figure>

considered variable (for narrative synthesis) or when
meta-analysis showed significant results. The global ef-
fect of the interventions and the parts of primary studies
showing a positive effect are depicted in Tables 2, 3, and 4.
Neither statistical pooling of the results nor a meta-analy-
sis was performed because of the high heterogeneity of the
included reviews.

3.4 | Web-based interventions

3.4.1 | Interventions on emotions and emotional disorders

Interventions respectively targeting anxiety and depres-
sion showed no significant efficiency in either adult pa-
tients or pediatric patients (10 studies on anxiety and 14
on depression).<sup>29</sup> However, when the target was unspeci-
fied psychological distress, the interventions seemed to be
moderately efficient (nine studies).<sup>29</sup>

Some reviews reported results from interventions using cognitive behavioral therapy (CBT), involving various elements of this approach (e.g., cognitive reframing, coping skills training, cognitive restructuration). Web-based CBT interventions showed positive effects on emotional distress (12 studies),²⁶ fatigue (four studies),³⁰

emotional well-being (two studies),³³ insomnia (one study),³⁰ sleep quality (one study),²³ and social functioning (one study).³³ However, these interventions showed no significant results regarding Health-Related Quality of Life (HRQoL; 17 studies),¹⁸,²³,²⁶,³⁰,³³ depression (seven studies),¹⁸,²³,³⁰ anxiety (five studies),¹⁸,²³ or physical health (one study).³³ Other interventions targeting mindfulness to reduce stress in adult patients showed a positive effect on emotional distress (eight studies),²⁶ HRQoL (three studies), ³³ and fatigue (one study).³⁰ Interventions targeting coping skills showed mixed results, with a positive effect on emotional well-being (one study) but no significant effect on HRQoL (one study).²³

3.4.2 | Interventions on behaviors

Physical activity and nutrition-related behaviors were the main behavioral targets of web-based interventions. Physical activity interventions were shown to be efficient for enhancing physical activity (19 studies),²⁴,²⁸,³² HRQoL (two studies),³³ and emotional well-being (one study).³³ However, no significant effect was observed for fatigue (one study).³⁰

When nutrition and physical activity were considered to-
gether,²³ interventions were efficient for fatigue (three stud-
ies), HRQoL (three studies), and insomnia (one study) but
<figure><img src="image_3.png" /><figcaption>FIGURE 1 PRISMA flowchart.</figcaption></figure>

considered variable (for narrative synthesis) or when
meta-analysis showed significant results. The global ef-
fect of the interventions and the parts of primary studies
showing a positive effect are depicted in Tables 2, 3, and 4.
Neither statistical pooling of the results nor a meta-analy-
sis was performed because of the high heterogeneity of the
included reviews.

3.4 | Web-based interventions

3.4.1 | Interventions on emotions and emotional disorders

Interventions respectively targeting anxiety and depres-
sion showed no significant efficiency in either adult pa-
tients or pediatric patients (10 studies on anxiety and 14
on depression).<sup>29</sup> However, when the target was unspeci-
fied psychological distress, the interventions seemed to be
moderately efficient (nine studies).<sup>29</sup>

Some reviews reported results from interventions
using cognitive behavioral therapy (CBT), involving var-
ious elements of this approach (e.g., cognitive refram-
ing, coping skills training, cognitive restructuration).
Web-based CBT interventions showed positive effects on
emotional distress (12 studies),²⁶ fatigue (four studies),³⁰

emotional well-being (two studies),³³ insomnia (one study),³⁰ sleep quality (one study),²³ and social functioning (one study).³³ However, these interventions showed no significant results regarding Health-Related Quality of Life (HRQoL; 17 studies),¹⁸,²³,²⁶,³⁰,³³ depression (seven studies),¹⁸,²³,³⁰ anxiety (five studies),¹⁸,²³ or physical health (one study).³³ Other interventions targeting mindfulness to reduce stress in adult patients showed a positive effect on emotional distress (eight studies),²⁶ HRQoL (three studies), ³³ and fatigue (one study).³⁰ Interventions targeting coping skills showed mixed results, with a positive effect on emotional well-being (one study) but no significant effect on HRQoL (one study).²³

3.4.2 | Interventions on behaviors

Physical activity and nutrition-related behaviors were the main behavioral targets of web-based interventions. Physical activity interventions were shown to be efficient for enhancing physical activity (19 studies),²⁴,²⁸,³² HRQoL (two studies),³³ and emotional well-being (one study).³³ However, no significant effect was observed for fatigue (one study).³⁰

When nutrition and physical activity were considered to-
gether,²³ interventions were efficient for fatigue (three stud-
ies), HRQoL (three studies), and insomnia (one study) but
<table><caption>TABLE 1 Appraisal of the quality of studies (AMSTAR-2) (colors needed).</caption><thead><tr><th></th><th>Bunevíiene, 2021</th><th>Dorri, 2020</th><th>Ester, 2021</th><th>Goliţă, 2019</th><th>Haberlin, 2018</th><th>Hong, 2021</th><th>Huang, 2020</th><th>Kaltenbaugh, 2015</th><th>Kamalumpundi, 2022</th><th>Kang, 2018</th><th>Kim, 2019</th><th>Kiss, 2019</th><th>McAlpine, 2015</th><th>Qan'ir, 2019</th><th>Ramsey, 2020</th><th>Seiler, 2017</th><th>Singleton, 2022</th><th>Wan, 2022</th><th>Zhang, 2022</th><th>Zheng, 2020</th></tr></thead><tbody><tr><td>Item 1</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 2</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 3</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 4</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 5</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 6</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 7</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 8</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 9</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>RCTs</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 9</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>NRSI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 10</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 11</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>RCTs</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 11</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>NRSI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 12</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 13</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 14</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 15</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 16</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

Note: ●, criteria met; ●, criteria not met or unable to answer from the available information; *, includes only RCTs; **, no meta-analysis was conducted.

Abbreviations: RCTs, randomized controlled trials; NRSI, non-randomized studies of interventions
<table><caption>TABLE 1 Appraisal of the quality of studies (AMSTAR-2) (colors needed).</caption><thead><tr><th></th><th>Bunevíiene, 2021</th><th>Dorri, 2020</th><th>Ester, 2021</th><th>Goliţă, 2019</th><th>Haberlin, 2018</th><th>Hong, 2021</th><th>Huang, 2020</th><th>Kaltenbaugh, 2015</th><th>Kamalumpundi, 2022</th><th>Kang, 2018</th><th>Kim, 2019</th><th>Kiss, 2019</th><th>McAlpine, 2015</th><th>Qan'ir, 2019</th><th>Ramsey, 2020</th><th>Seiler, 2017</th><th>Singleton, 2022</th><th>Wan, 2022</th><th>Zhang, 2022</th><th>Zheng, 2020</th></tr></thead><tbody><tr><td>Item 1</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 2</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 3</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 4</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 5</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 6</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 7</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 8</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 9</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>RCTs</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 9</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>NRSI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 10</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 11</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>RCTs</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 11</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>NRSI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 12</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 13</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 14</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 15</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Item 16</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

Note: ●, criteria met; ●, criteria not met or unable to answer from the available information; *, includes only RCTs; **, no meta-analysis was conducted.

Abbreviations: RCTs, randomized controlled trials; NRSI, non-randomized studies of interventions
<table><caption>TABLE 2 Summary of evidence for web-based interventions.</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="12">Emotions and emotional disorders</td><td>Anxiety</td><td>Kamalumpundi, 2022<br/>Ramsey, 2020</td><td>Anxiety</td><td>13</td></tr><tr><td>Depression</td><td>Kamalumpundi, 2022<br/>Ramsey, 2020</td><td>Depression</td><td>12</td></tr><tr><td>Post-traumatic stress</td><td>Ramsey, 2020</td><td>Post-traumatic stress</td><td>9</td></tr><tr><td>Psychological distress</td><td>Kamalumpundi, 2022</td><td>Psychological distress</td><td>9</td></tr><tr><td rowspan="10">Cognitive behavioral therapy</td><td>McAlpine, 2015<br/>Qan'ir, 2019</td><td>Anxiety</td><td>5</td></tr><tr><td>McAlpine, 2015<br/>Qan'ir, 2019<br/>Seiler, 2017</td><td>Depression</td><td>7</td></tr><tr><td>Goliţă, 2019</td><td>Emotional distress</td><td>12</td></tr><tr><td>Buneviciene, 2021</td><td>Emotional well-being</td><td>2</td></tr><tr><td>Seiler, 2017</td><td>Fatigue</td><td>4</td></tr><tr><td>Qan'ir, 2019<br/>Seiler, 2017</td><td>HRQoL</td><td>17</td></tr><tr><td>Buneviciene, 2021<br/>Goliţă, 2019<br/>McAlpine, 2015</td><td>Insomnia</td><td>1</td></tr><tr><td>Seiler, 2017</td><td>Physical health</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>Sleep quality</td><td>1</td></tr><tr><td>McAlpine, 2015</td><td>Social functioning</td><td>1</td></tr><tr><td rowspan="10">Mindfulness/stress</td><td>Seiler, 2017</td><td>Fatigue</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>HRQoL</td><td>3</td></tr><tr><td>Goliţă, 2019</td><td>Emotional distress</td><td>8</td></tr><tr><td>McAlpine, 2015</td><td>Emotional well-being</td><td>1</td></tr><tr><td>McAlpine, 2015</td><td>HRQoL</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>HRQoL</td><td>1</td></tr><tr><td>Goliţă, 2019</td><td>Emotional distress</td><td>8</td></tr><tr><td>Goliţă, 2019</td><td>HRQoL</td><td>2</td></tr><tr><td>Binge drinking</td><td>Ramsey, 2020</td><td>Binge drinking</td><td>1</td></tr><tr><td>Smoking cessation</td><td>Ramsey, 2020</td><td>Smoking cessation</td><td>2</td></tr><tr><td rowspan="10">Nutrition and physical activity</td><td>Kiss, 2019</td><td>Anxiety</td><td>1</td></tr><tr><td>Kiss, 2019</td><td>Diet</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>Fatigue</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>HRQoL subdimensions</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>Insomnia</td><td>1</td></tr><tr><td>Kiss, 2019</td><td>Mental health</td><td>1</td></tr><tr><td>Kiss, 2019</td><td>Physical activity</td><td>5</td></tr><tr><td>Kiss, 2019</td><td>Pain</td><td>2</td></tr><tr><td>Buneviciene, 2021</td><td>Emotional well-being</td><td>1</td></tr><tr><td>Seiler, 2017</td><td>Fatigue</td><td>1</td></tr><tr><td rowspan="5">Physical activity</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>2</td></tr><tr><td>Dorri, 2019</td><td>Physical activity</td><td>57</td></tr><tr><td>Ester, 2021</td><td></td><td></td></tr><tr><td>Haberlin, 2018</td><td></td><td></td></tr><tr><td>Ramsey, 2020</td><td></td><td></td></tr><tr><td>Weight management</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>1</td></tr></tbody></table>
<table><caption>TABLE 2 Summary of evidence for web-based interventions.</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="12">Emotions and emotional disorders</td><td>Anxiety</td><td>Kamalumpundi, 2022<br/>Ramsey, 2020</td><td>Anxiety</td><td>13</td></tr><tr><td>Depression</td><td>Kamalumpundi, 2022<br/>Ramsey, 2020</td><td>Depression</td><td>12</td></tr><tr><td>Post-traumatic stress</td><td>Ramsey, 2020</td><td>Post-traumatic stress</td><td>9</td></tr><tr><td>Psychological distress</td><td>Kamalumpundi, 2022</td><td>Psychological distress</td><td>9</td></tr><tr><td rowspan="10">Cognitive behavioral therapy</td><td>McAlpine, 2015<br/>Qan'ir, 2019</td><td>Anxiety</td><td>5</td></tr><tr><td>McAlpine, 2015<br/>Qan'ir, 2019<br/>Seiler, 2017</td><td>Depression</td><td>7</td></tr><tr><td>Goliţă, 2019</td><td>Emotional distress</td><td>12</td></tr><tr><td>Buneviciene, 2021</td><td>Emotional well-being</td><td>2</td></tr><tr><td>Seiler, 2017</td><td>Fatigue</td><td>4</td></tr><tr><td>Qan'ir, 2019<br/>Seiler, 2017</td><td>HRQoL</td><td>17</td></tr><tr><td>Buneviciene, 2021<br/>Goliţă, 2019<br/>McAlpine, 2015</td><td>Insomnia</td><td>1</td></tr><tr><td>Seiler, 2017</td><td>Physical health</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>Sleep quality</td><td>1</td></tr><tr><td>McAlpine, 2015</td><td>Social functioning</td><td>1</td></tr><tr><td rowspan="10">Mindfulness/stress</td><td>Seiler, 2017</td><td>Fatigue</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>HRQoL</td><td>3</td></tr><tr><td>Goliţă, 2019</td><td>Emotional distress</td><td>8</td></tr><tr><td>McAlpine, 2015</td><td>Emotional well-being</td><td>1</td></tr><tr><td>McAlpine, 2015</td><td>HRQoL</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>HRQoL</td><td>1</td></tr><tr><td>Goliţă, 2019</td><td>Emotional distress</td><td>8</td></tr><tr><td>Goliţă, 2019</td><td>HRQoL</td><td>2</td></tr><tr><td>Binge drinking</td><td>Ramsey, 2020</td><td>Binge drinking</td><td>1</td></tr><tr><td>Smoking cessation</td><td>Ramsey, 2020</td><td>Smoking cessation</td><td>2</td></tr><tr><td rowspan="10">Nutrition and physical activity</td><td>Kiss, 2019</td><td>Anxiety</td><td>1</td></tr><tr><td>Kiss, 2019</td><td>Diet</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>Fatigue</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>HRQoL subdimensions</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>Insomnia</td><td>1</td></tr><tr><td>Kiss, 2019</td><td>Mental health</td><td>1</td></tr><tr><td>Kiss, 2019</td><td>Physical activity</td><td>5</td></tr><tr><td>Kiss, 2019</td><td>Pain</td><td>2</td></tr><tr><td>Buneviciene, 2021</td><td>Emotional well-being</td><td>1</td></tr><tr><td>Seiler, 2017</td><td>Fatigue</td><td>1</td></tr><tr><td rowspan="5">Physical activity</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>2</td></tr><tr><td>Dorri, 2019</td><td>Physical activity</td><td>57</td></tr><tr><td>Ester, 2021</td><td></td><td></td></tr><tr><td>Haberlin, 2018</td><td></td><td></td></tr><tr><td>Ramsey, 2020</td><td></td><td></td></tr><tr><td>Weight management</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>1</td></tr></tbody></table>
<table><caption>TABLE 2 (Continued)</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="12">Information and self-management</td><td rowspan="2">Cancer knowledge</td><td>Ramsey, 2020</td><td>Cancer knowledge</td><td>1</td></tr><tr><td>McAlpine, 2015<br/>Qan'ir, 2019</td><td>Anxiety</td><td>2</td></tr><tr><td rowspan="5">Information/psychoeducation</td><td>McAlpine, 2015<br/>Qan'ir, 2019</td><td>Depression</td><td>2</td></tr><tr><td>McAlpine, 2015</td><td>Fatigue</td><td>1</td></tr><tr><td>McAlpine, 2015<br/>Buneviciene, 2021<br/>Qan'ir, 2019</td><td>HRQoL</td><td>5</td></tr><tr><td>McAlpine, 2015<br/>Qan'ir, 2019</td><td>Physical activity</td><td>1</td></tr><tr><td>McAlpine, 2015<br/>Qan'ir, 2019</td><td>HRQoL</td><td>3</td></tr><tr><td rowspan="7">Self-management</td><td>Seiler, 2017</td><td>Fatigue</td><td>2</td></tr><tr><td>Seiler, 2017</td><td>Fatigue self-efficacy</td><td>1</td></tr><tr><td>Seiler, 2017</td><td>Insomnia</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Binge drinking</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Fitness outcomes</td><td>2</td></tr><tr><td>Hong, 2021</td><td>Working memory</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Physical activity</td><td>3</td></tr><tr><td rowspan="10">Cognitive function</td><td rowspan="10">Cognitive function</td><td>Kim, 2019</td><td>Anxiety</td><td>3</td></tr><tr><td>Kim, 2019<br/>Seiler, 2017</td><td>Cognitive function (several outcomes)</td><td>4</td></tr><tr><td>Kim, 2019</td><td>Depression</td><td>3</td></tr><tr><td>Kim, 2019<br/>Seiler, 2017</td><td>Fatigue</td><td>3</td></tr><tr><td>Kim, 2019<br/>Seiler, 2017</td><td>Global health status</td><td>1</td></tr><tr><td>Kim, 2019</td><td>HRQoL</td><td>2</td></tr><tr><td>Kim, 2019</td><td>Stress</td><td>2</td></tr><tr><td>Kang, 2018</td><td>Dyadic functioning</td><td>1</td></tr><tr><td>Kang, 2018</td><td>Partner sexual function</td><td>2</td></tr><tr><td>Kang, 2018</td><td>Patient sexual function</td><td>3</td></tr><tr><td>Kang, 2018</td><td>Psychological distress</td><td>1</td></tr><tr><td>Kang, 2018</td><td>HRQoL</td><td>1</td></tr><tr><td rowspan="6">Sexual function</td><td rowspan="6">Sexuality</td><td>Zhang, 2022</td><td>Depression</td><td>6</td></tr><tr><td>Zhang, 2022</td><td>HRQoL</td><td>5</td></tr><tr><td>Zhang, 2022</td><td>Self-efficacy</td><td>3</td></tr><tr><td>Zhang, 2022</td><td>Symptom distress</td><td>3</td></tr><tr><td>Kaltenbaugh, 2015</td><td>Physical activity</td><td>1</td></tr><tr><td>Kaltenbaugh, 2015</td><td>Psychological variables</td><td>5</td></tr><tr><td rowspan="7">Multitargeted or nonspecific interventions</td><td rowspan="7">Web-based (outcome not clear)</td><td>Kaltenbaugh, 2015</td><td>Social support</td><td>1</td></tr><tr><td>Wan, 2022</td><td>Self-efficacy</td><td>7</td></tr><tr><td>Wan, 2022</td><td>Anxiety</td><td>3</td></tr><tr><td>Wan, 2022</td><td>Depression</td><td>8</td></tr><tr><td>Wan, 2022</td><td>HRQoL</td><td>3</td></tr><tr><td>Wan, 2022</td><td>Psychological distress</td><td>5</td></tr><tr><td>Web-based multi-component intervention</td><td>Kaltenbaugh, 2015</td><td>Physical activity</td><td>1</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 2 (Continued)</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="12">Information and self-management</td><td rowspan="2">Cancer knowledge</td><td>Ramsey, 2020</td><td>Cancer knowledge</td><td>1</td></tr><tr><td>McAlpine, 2015<br>Qan'ir, 2019</td><td>Anxiety</td><td>2</td></tr><tr><td rowspan="5">Information/psychoeducation</td><td>McAlpine, 2015<br>Qan'ir, 2019</td><td>Depression</td><td>2</td></tr><tr><td>McAlpine, 2015</td><td>Fatigue</td><td>1</td></tr><tr><td>McAlpine, 2015<br>Buneviciene, 2021<br>Qan'ir, 2019</td><td>HRQoL</td><td>5</td></tr><tr><td>McAlpine, 2015<br>Qan'ir, 2019</td><td>Physical activity</td><td>1</td></tr><tr><td>McAlpine, 2015<br>Qan'ir, 2019</td><td>HRQoL</td><td>3</td></tr><tr><td rowspan="7">Self-management</td><td>Seiler, 2017</td><td>Fatigue</td><td>2</td></tr><tr><td>Seiler, 2017</td><td>Fatigue self-efficacy</td><td>1</td></tr><tr><td>Seiler, 2017</td><td>Insomnia</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Binge drinking</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Fitness outcomes</td><td>2</td></tr><tr><td>Hong, 2021</td><td>Working memory</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Physical activity</td><td>3</td></tr><tr><td rowspan="10">Cognitive function</td><td rowspan="10">Cognitive function</td><td>Kim, 2019</td><td>Anxiety</td><td>3</td></tr><tr><td>Kim, 2019<br>Seiler, 2017</td><td>Cognitive function (several outcomes)</td><td>4</td></tr><tr><td>Kim, 2019</td><td>Depression</td><td>3</td></tr><tr><td>Kim, 2019<br>Seiler, 2017</td><td>Fatigue</td><td>3</td></tr><tr><td>Kim, 2019<br>Seiler, 2017</td><td>Global health status</td><td>1</td></tr><tr><td>Kim, 2019</td><td>HRQoL</td><td>2</td></tr><tr><td>Kim, 2019</td><td>Stress</td><td>2</td></tr><tr><td>Kang, 2018</td><td>Dyadic functioning</td><td>1</td></tr><tr><td>Kang, 2018</td><td>Partner sexual function</td><td>2</td></tr><tr><td>Kang, 2018</td><td>Patient sexual function</td><td>3</td></tr><tr><td>Kang, 2018</td><td>Psychological distress</td><td>1</td></tr><tr><td>Kang, 2018</td><td>HRQoL</td><td>1</td></tr><tr><td rowspan="6">Sexual function</td><td rowspan="6">Sexuality</td><td>Zhang, 2022</td><td>Depression</td><td>6</td></tr><tr><td>Zhang, 2022</td><td>HRQoL</td><td>5</td></tr><tr><td>Zhang, 2022</td><td>Self-efficacy</td><td>3</td></tr><tr><td>Zhang, 2022</td><td>Symptom distress</td><td>3</td></tr><tr><td>Kaltenbaugh, 2015</td><td>Physical activity</td><td>1</td></tr><tr><td>Kaltenbaugh, 2015</td><td>Psychological variables</td><td>5</td></tr><tr><td rowspan="7">Multitargeted or nonspecific interventions</td><td rowspan="7">Web-based (outcome not clear)</td><td>Kaltenbaugh, 2015</td><td>Social support</td><td>1</td></tr><tr><td>Wan, 2022</td><td>Self-efficacy</td><td>7</td></tr><tr><td>Wan, 2022</td><td>Anxiety</td><td>3</td></tr><tr><td>Wan, 2022</td><td>Depression</td><td>8</td></tr><tr><td>Wan, 2022</td><td>HRQoL</td><td>3</td></tr><tr><td>Wan, 2022</td><td>Psychological distress</td><td>5</td></tr><tr><td>Web-based multi-component intervention</td><td>Kaltenbaugh, 2015</td><td></td><td></td></tr></tbody></table>

(Continues)
<table><caption>TABLE 2 (Continued)</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="6">Category of intervention</td><td rowspan="6">Target of the intervention</td><td>Wan, 2022</td><td>Cancer-specific psychological distress</td><td>4</td></tr><tr><td>Huang, 2020</td><td>Anxiety</td><td>2</td></tr><tr><td>Huang, 2020</td><td>Depression</td><td>2</td></tr><tr><td>Huang, 2020</td><td>Fatigue</td><td>13</td></tr><tr><td>Huang, 2020</td><td>HRQoL</td><td>2</td></tr><tr><td>Huang, 2020</td><td>Sleep quality</td><td>2</td></tr></tbody></table>

Note: ●, global efficacy; ●, not significant; ●, deleterious.

Abbreviations: HRQoL, health-related quality of life.

<table><caption>TABLE 3 Summary of evidence for app-based interventions (colors needed).</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="5">Emotions and emotional disorders</td><td>Anxiety</td><td>Kamalumpundi, 2022</td><td>Anxiety</td><td>3</td></tr><tr><td>Depression</td><td>Kamalumpundi, 2022</td><td>Depression</td><td>3</td></tr><tr><td>Cognitive behavioral therapy</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>3</td></tr><tr><td>Mindfulness/stress</td><td>Buneviciene, 2021</td><td>QoL</td><td>2</td></tr><tr><td>Social support</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>2</td></tr><tr><td rowspan="4">Behaviors</td><td rowspan="3">Physical activity</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>5</td></tr><tr><td>Buneviciene, 2021</td><td>Social functioning</td><td>1</td></tr><tr><td>Dorri, 2019</td><td>Physical activity</td><td>26</td></tr><tr><td rowspan="2">Nutrition and physical activity</td><td>Kiss, 2019</td><td>Physical activity</td><td>3</td></tr><tr><td>Kiss, 2019</td><td>HRQoL</td><td>1</td></tr><tr><td>Information and self-management</td><td>Information/psychoeducation</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>1</td></tr><tr><td rowspan="7">Symptoms</td><td rowspan="7">Digital self-management interventions</td><td>Hong, 2021</td><td>Physical activity</td><td>2</td></tr><tr><td>Hong, 2021</td><td>HRQoL</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Social functioning</td><td>1</td></tr><tr><td>Ramsey, 2020</td><td>Pain</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>Anxiety</td><td>5</td></tr><tr><td>Zheng, 2020</td><td>Fatigue</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>Pain/pain catastrophizing</td><td>9</td></tr><tr><td rowspan="5">Nonspecific interventions</td><td rowspan="5">Mobile app</td><td>Zheng, 2020</td><td>Pain self-efficacy</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>HRQoL</td><td>5</td></tr><tr><td>Zheng, 2020</td><td>Symptom reporting</td><td>2</td></tr><tr><td>Zhang, 2022</td><td>HRQoL</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>Pain</td><td>3</td></tr></tbody></table>

Note: ●, global efficacy; ●, not significant; ●, deleterious.

Abbreviations: HRQoL, health-related quality of life.

not for physical activity amount (five studies), diet (three studies), pain (two studies), or anxiety (one study). A study showed no effect of the intervention on the experimental

group but an improvement of mental health in the wait-listed control group. Interventions targeting weight management had no effect on HRQoL (one study).³³
<table><caption>TABLE 2 (Continued)</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="6">Category of intervention</td><td rowspan="6">Target of the intervention</td><td>Wan, 2022</td><td>Cancer-specific psychological distress</td><td>4</td></tr><tr><td>Huang, 2020</td><td>Anxiety</td><td>2</td></tr><tr><td>Huang, 2020</td><td>Depression</td><td>2</td></tr><tr><td>Huang, 2020</td><td>Fatigue</td><td>13</td></tr><tr><td>Huang, 2020</td><td>HRQoL</td><td>2</td></tr><tr><td>Huang, 2020</td><td>Sleep quality</td><td>2</td></tr></tbody></table>

Note: ●, global efficacy; ●, not significant; ●, deleterious.

Abbreviations: HRQoL, health-related quality of life.

<table><caption>TABLE 3 Summary of evidence for app-based interventions (colors needed).</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td rowspan="5">Emotions and emotional disorders</td><td>Anxiety</td><td>Kamalumpundi, 2022</td><td>Anxiety</td><td>3</td></tr><tr><td>Depression</td><td>Kamalumpundi, 2022</td><td>Depression</td><td>3</td></tr><tr><td>Cognitive behavioral therapy</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>3</td></tr><tr><td>Mindfulness/stress</td><td>Buneviciene, 2021</td><td>QoL</td><td>2</td></tr><tr><td>Social support</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>2</td></tr><tr><td rowspan="4">Behaviors</td><td rowspan="2">Physical activity</td><td>Buneviciene, 2021</td><td>HRQoL</td><td>5</td></tr><tr><td>Buneviciene, 2021</td><td>Social functioning</td><td>1</td></tr><tr><td rowspan="2">Nutrition and physical activity</td><td>Dorri, 2019</td><td>Physical activity</td><td>26</td></tr><tr><td>Kiss, 2019</td><td>Physical activity</td><td>3</td></tr><tr><td rowspan="2">Information and self-management</td><td rowspan="2">Information/psychoeducation</td><td>Kiss, 2019</td><td>HRQoL</td><td>1</td></tr><tr><td>Buneviciene, 2021</td><td>HRQoL</td><td>1</td></tr><tr><td rowspan="8">Symptoms</td><td rowspan="8">Digital self-management interventions</td><td>Hong, 2021</td><td>Physical activity</td><td>2</td></tr><tr><td>Hong, 2021</td><td>HRQoL</td><td>1</td></tr><tr><td>Hong, 2021</td><td>Social functioning</td><td>1</td></tr><tr><td rowspan="7">Pain</td><td>Ramsey, 2020</td><td>Pain</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>Anxiety</td><td>5</td></tr><tr><td>Zheng, 2020</td><td>Fatigue</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>Pain/pain catastrophizing</td><td>9</td></tr><tr><td>Zheng, 2020</td><td>Pain self-efficacy</td><td>1</td></tr><tr><td>Zheng, 2020</td><td>HRQoL</td><td>5</td></tr><tr><td>Zheng, 2020</td><td>Symptom reporting</td><td>2</td></tr><tr><td rowspan="2">Nonspecific interventions</td><td>Mobile app</td><td>Zhang, 2022</td><td>HRQoL</td><td>1</td></tr><tr><td>Mobile app with instant messaging module</td><td>Zheng, 2020</td><td>Pain</td><td>3</td></tr></tbody></table>

Note: ●, global efficacy; ●, not significant; ●, deleterious.

Abbreviations: HRQoL, health-related quality of life.

not for physical activity amount (five studies), diet (three studies), pain (two studies), or anxiety (one study). A study showed no effect of the intervention on the experimental

group but an improvement of mental health in the wait-listed control group. Interventions targeting weight management had no effect on HRQoL (one study).³³
<table><caption>TABLE 4 Summary of evidence for both web-based and app-based interventions (colors needed).</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td>Behaviors</td><td>Physical activity</td><td>Haberlin, 2018</td><td>Physical activity</td><td>4</td></tr><tr><td rowspan="6">Multitargeted or nonspecific interventions</td><td rowspan="5">Multi-component intervention</td><td>Singleton, 2022</td><td>HRQoL</td><td>11</td></tr><tr><td>Singleton, 2022</td><td>Anxiety</td><td>6</td></tr><tr><td>Singleton, 2022</td><td>Depression</td><td>6</td></tr><tr><td>Singleton, 2022</td><td>Psychological distress</td><td>3</td></tr><tr><td>Singleton, 2022</td><td>Self-efficacy</td><td>7</td></tr><tr><td>Singleton, 2022</td><td>Fatigue</td><td>5</td></tr></tbody></table>

Note: ●, global efficacy; ●●, not significant.

Abbreviations: HRQoL, health-related quality of life.

### 3.4.3 | Interventions on information and self-management

Interventions targeting knowledge had a positive impact on fatigue (13 studies), depression (two studies), HRQoL (two studies), and sleep quality (two studies) but not on anxiety (two studies).¹⁹ When interventions aimed for psychoeducation, only an improvement in fatigue symptoms was observed (one study),²³ whereas no effect was observed for anxiety (two studies), depression (two studies),¹⁸,²³ HRQoL (five studies),¹⁸,²³,³³ or physical activity (one study).²³

One review reported the effectiveness of self-management interventions in adult patients with cancer.²¹ These interventions had a positive effect on fatigue self-efficacy (one study) and insomnia (one study). However, they had no significant effect on fatigue (two studies) or physical activity (two studies).

### 3.4.4 | Interventions on cognitive function

Cognitive function-specific interventions were shown to be efficient regarding cognitive functions (four studies), fatigue (three studies),³⁰,³¹ and global health status (one study).³⁰ They had no significant effect on emotional outcomes, such as anxiety (three studies), depression (three studies), or stress (two studies), or HRQoL (two studies).³¹

### 3.4.5 | Interventions on sexual function

Only one review synthesized the results from studies on sexual function using a dyadic approach.³⁶ Online interventions were efficient regarding both patients' and partners' sexual function (three and two studies, respectively), unspecified psychological distress (one study), and HRQoL (one study) but not dyadic functioning (one study).

### 3.4.6 | Multitargeted or nonspecific interventions

Some reviews did not specify the target of the reviewed intervention, forcing a global interpretation of their results. In this context, multitargeted web-based interventions were shown to be efficient in adult patients regarding emotional disorders, including depression (14 studies),²⁰,²⁵ general and cancer-specific psychological distress (five and four studies, respectively), anxiety (three studies),²⁵ and symptom distress (three studies),²⁰ self-efficacy (10 studies), and HRQoL (eight studies).²⁰,²⁵ A review on caregivers³⁷ showed efficiency regarding psychological variables (five studies), no significance regarding physical burden (one study), and a deleterious effect of interventions for perceived social support (one study).

### 3.4.7 | Interventions in pediatric patients or childhood cancer survivors

In pediatric patients and childhood cancer survivors, a review suggested that web-based interventions were efficient for physical activity (eight studies) improving depression (two studies) but not anxiety (three studies).³⁴ Interventions targeted at binge drinking and smoking cessation were shown to have a positive effect on the former but no significant effect on the latter (one and two studies, respectively).³⁴ When they targeted knowledge about cancer, interventions had no significant effect in pediatric patients and childhood cancer survivors (one study).³⁴ One study reviewed the effectiveness of self-management interventions in pediatric patients and childhood cancer
<table><caption>TABLE 4 Summary of evidence for both web-based and app-based interventions (colors needed).</caption><thead><tr><th>Category of intervention</th><th>Target of the intervention</th><th>Articles (first author)</th><th>Outcome of interest</th><th>Number of studies</th></tr></thead><tbody><tr><td>Behaviors</td><td>Physical activity</td><td>Haberlin, 2018</td><td>Physical activity</td><td>4</td></tr><tr><td rowspan="6">Multitargeted or nonspecific interventions</td><td rowspan="5">Multi-component intervention</td><td>Singleton, 2022</td><td>HRQoL</td><td>11</td></tr><tr><td>Singleton, 2022</td><td>Anxiety</td><td>6</td></tr><tr><td>Singleton, 2022</td><td>Depression</td><td>6</td></tr><tr><td>Singleton, 2022</td><td>Psychological distress</td><td>3</td></tr><tr><td>Singleton, 2022</td><td>Self-efficacy</td><td>7</td></tr><tr><td>Singleton, 2022</td><td>Fatigue</td><td>5</td></tr></tbody></table>

Note: ●, global efficacy; ●●, not significant.

Abbreviations: HRQoL, health-related quality of life.

### 3.4.3 | Interventions on information and self-management

Interventions targeting knowledge had a positive impact on fatigue (13 studies), depression (two studies), HRQoL (two studies), and sleep quality (two studies) but not on anxiety (two studies).¹⁹ When interventions aimed for psychoeducation, only an improvement in fatigue symptoms was observed (one study),²³ whereas no effect was observed for anxiety (two studies), depression (two studies),¹⁸,²³ HRQoL (five studies),¹⁸,²³,³³ or physical activity (one study).²³

One review reported the effectiveness of self-management interventions in adult patients with cancer.²¹ These interventions had a positive effect on fatigue self-efficacy (one study) and insomnia (one study). However, they had no significant effect on fatigue (two studies) or physical activity (two studies).

### 3.4.4 | Interventions on cognitive function

Cognitive function-specific interventions were shown to be efficient regarding cognitive functions (four studies), fatigue (three studies),³⁰,³¹ and global health status (one study).³⁰ They had no significant effect on emotional outcomes, such as anxiety (three studies), depression (three studies), or stress (two studies), or HRQoL (two studies).³¹

### 3.4.5 | Interventions on sexual function

Only one review synthesized the results from studies on sexual function using a dyadic approach.³⁶ Online interventions were efficient regarding both patients' and partners' sexual function (three and two studies, respectively), unspecified psychological distress (one study), and HRQoL (one study) but not dyadic functioning (one study).

### 3.4.6 | Multitargeted or nonspecific interventions

Some reviews did not specify the target of the reviewed intervention, forcing a global interpretation of their results. In this context, multitargeted web-based interventions were shown to be efficient in adult patients regarding emotional disorders, including depression (14 studies),²⁰,²⁵ general and cancer-specific psychological distress (five and four studies, respectively), anxiety (three studies),²⁵ and symptom distress (three studies),²⁰ self-efficacy (10 studies), and HRQoL (eight studies).²⁰,²⁵ A review on caregivers³⁷ showed efficiency regarding psychological variables (five studies), no significance regarding physical burden (one study), and a deleterious effect of interventions for perceived social support (one study).

### 3.4.7 | Interventions in pediatric patients or childhood cancer survivors

In pediatric patients and childhood cancer survivors, a review suggested that web-based interventions were efficient for physical activity (eight studies) improving depression (two studies) but not anxiety (three studies).³⁴ Interventions targeted at binge drinking and smoking cessation were shown to have a positive effect on the former but no significant effect on the latter (one and two studies, respectively).³⁴ When they targeted knowledge about cancer, interventions had no significant effect in pediatric patients and childhood cancer survivors (one study).³⁴ One study reviewed the effectiveness of self-management interventions in pediatric patients and childhood cancer
survivors.³⁵ These interventions had a positive effect on binge drinking (one study) and working memory (one study) (14). However, they had no significant effect on physical activity (one study).³⁵

## 3.5 | App-based interventions

### 3.5.1 | Interventions on emotions and emotional disorders

Interventions targeting anxiety and depression were effective for both (three studies each).²⁹ App-based CBT interventions did not have a significant effect on HRQoL (three studies), whereas mindfulness interventions did (two studies).³³

Studies targeting perceived social support to cope with illness showed no significant results regarding HRQoL (two studies).³³

### 3.5.2 | Interventions on behaviors

Physical activity-targeting app-based interventions were efficient in enhancing physical activity (26 studies)²⁸ and HRQoL (five studies).³³ A single study showed a detrimental effect of these interventions on social functioning.³³ Interventions targeting both nutrition and physical activity showed no significant effect on physical activity amount (three studies) or HRQoL (one study).²²

### 3.5.3 | Interventions on information and self-management

App-based psychoeducational interventions did not have any significant effect on HRQoL in adult patients with cancer (one study).³³

### 3.5.4 | Interventions on pain symptoms

Interventions targeting pain as a symptom were efficient against pain catastrophizing (nine studies), anxiety (five studies), and fatigue (one study) and for enhancing HRQoL (five studies).²¹ These interventions had deleterious effects on pain self-efficacy according to one study.²¹ When compared, mobile-based interventions using an instant messaging module in adult patients (three studies) seemed more efficient against pain symptoms than interventions without such a module in pediatric patients (one study).²¹,³⁴ More generic symptom-reporting applications had a positive effect on HRQoL (one study).¹⁸

### 3.5.5 | Interventions in pediatric patients or childhood cancer survivors

Digital self-management interventions in childhood cancer survivors had positive effects on social functioning (one study) but no significant effect on physical activity (two studies) or HRQoL (one study).³⁵

## 3.6 | Unspecified interventions

An included review did not allow for distinguishing web-based from app-based interventions.²⁷ These interventions were shown to have a positive effect on HRQoL (11 studies), self-efficacy (seven studies), fatigue (five studies), and unspecified psychological distress (three studies) but not anxiety (six studies) or depression (six studies).

Another review did not allow for distinguishing the format of physical activity-targeting interventions and showed no significant results regarding physical activity (four studies).³²

# 4 | DISCUSSION

This umbrella review highlighted that most studies referred to adult patients with cancer or survivors, with only two on pediatric patients or survivors and two on caregivers of patients. Digital interventions were shown to be effective for physical activity but produced mixed results regarding emotional outcomes (depending on their nature, i.e., anxiodepressive symptoms or unspecified psychological distress). However, the quality assessment of the included reviews demonstrated that most of them suffered from a lack a methodological quality.¹⁷

The two main categories of outcomes were emotional (mainly anxiety, depression, and emotional distress) and behavioral (mostly physical activity). Digital interventions showed mixed results for emotional variables. Even if some studies tended to show a positive effect of these interventions on anxiety (app-based interventions²¹,²⁹) and depression (web-based¹⁹,²⁰,²⁵,³⁰,³⁴ and app-based²⁹) interventions), the general tendency was to not observe statistically significant effects.¹⁸,¹⁹,²³,²⁷,²⁹,³¹,³⁴ However, regarding psychological distress, studies showed positive effects for both web-based and app-based interventions.²⁵⁻²⁷,²⁹,³⁶ The discrepancy in the results between anxiety and depression on one hand and unspecified psychological distress on the other may be surprising given the conceptual proximity of those two categories of variables. This could be explained by the fact that emotional distress and emotional well-being are a blurry concept in digital health research, which may contain anxio-depressive symptoms.³⁸ This confusion
survivors.³⁵ These interventions had a positive effect on binge drinking (one study) and working memory (one study) (14). However, they had no significant effect on physical activity (one study).³⁵

## 3.5 | App-based interventions

### 3.5.1 | Interventions on emotions and emotional disorders

Interventions targeting anxiety and depression were effective for both (three studies each).²⁹ App-based CBT interventions did not have a significant effect on HRQoL (three studies), whereas mindfulness interventions did (two studies).³³

Studies targeting perceived social support to cope with illness showed no significant results regarding HRQoL (two studies).³³

### 3.5.2 | Interventions on behaviors

Physical activity-targeting app-based interventions were efficient in enhancing physical activity (26 studies)²⁸ and HRQoL (five studies).³³ A single study showed a detrimental effect of these interventions on social functioning.³³ Interventions targeting both nutrition and physical activity showed no significant effect on physical activity amount (three studies) or HRQoL (one study).²²

### 3.5.3 | Interventions on information and self-management

App-based psychoeducational interventions did not have any significant effect on HRQoL in adult patients with cancer (one study).³³

### 3.5.4 | Interventions on pain symptoms

Interventions targeting pain as a symptom were efficient against pain catastrophizing (nine studies), anxiety (five studies), and fatigue (one study) and for enhancing HRQoL (five studies).²¹ These interventions had deleterious effects on pain self-efficacy according to one study.²¹ When compared, mobile-based interventions using an instant messaging module in adult patients (three studies) seemed more efficient against pain symptoms than interventions without such a module in pediatric patients (one study).²¹,³⁴ More generic symptom-reporting applications had a positive effect on HRQoL (one study).¹⁸

### 3.5.5 | Interventions in pediatric patients or childhood cancer survivors

Digital self-management interventions in childhood cancer survivors had positive effects on social functioning (one study) but no significant effect on physical activity (two studies) or HRQoL (one study).³⁵

## 3.6 | Unspecified interventions

An included review did not allow for distinguishing web-based from app-based interventions.²⁷ These interventions were shown to have a positive effect on HRQoL (11 studies), self-efficacy (seven studies), fatigue (five studies), and unspecified psychological distress (three studies) but not anxiety (six studies) or depression (six studies).

Another review did not allow for distinguishing the format of physical activity-targeting interventions and showed no significant results regarding physical activity (four studies).³²

# 4 | DISCUSSION

This umbrella review highlighted that most studies referred to adult patients with cancer or survivors, with only two on pediatric patients or survivors and two on caregivers of patients. Digital interventions were shown to be effective for physical activity but produced mixed results regarding emotional outcomes (depending on their nature, i.e., anxiodepressive symptoms or unspecified psychological distress). However, the quality assessment of the included reviews demonstrated that most of them suffered from a lack a methodological quality.¹⁷

The two main categories of outcomes were emotional (mainly anxiety, depression, and emotional distress) and behavioral (mostly physical activity). Digital interventions showed mixed results for emotional variables. Even if some studies tended to show a positive effect of these interventions on anxiety (app-based interventions²¹,²⁹) and depression (web-based¹⁹,²⁰,²⁵,³⁰,³⁴ and app-based²⁹) interventions), the general tendency was to not observe statistically significant effects.¹⁸,¹⁹,²³,²⁷,²⁹,³¹,³⁴ However, regarding psychological distress, studies showed positive effects for both web-based and app-based interventions.²⁵⁻²⁷,²⁹,³⁶ The discrepancy in the results between anxiety and depression on one hand and unspecified psychological distress on the other may be surprising given the conceptual proximity of those two categories of variables. This could be explained by the fact that emotional distress and emotional well-being are a blurry concept in digital health research, which may contain anxio-depressive symptoms.³⁸ This confusion
could lead to inconsistencies in the way these concepts are measured, leading to discrepancies in the results.

Regarding physical activity, the observed results were positive whether interventions were web-based or app-based.<sup>22-24,28,30,32,34,35</sup> Physical activity was the most frequently measured outcome in the studies. One original study reported by two reviews described positive effects on binge drinking.<sup>34,35</sup> However, other behavioral outcomes (i.e., diet, smoking cessation) seemed not to be significantly modified by digital interventions.<sup>22,34</sup>

On a functional level, the results of the interventions revealed globally good outcomes for some variables (e.g., fatigue,<sup>19,22,23,30,31</sup> sleep<sup>19,22,23,30</sup>) but nonsignificant effects for others (e.g., pain<sup>21,22,34</sup>). When HRQoL was considered alone, app-based interventions<sup>18,21,22,27,33,34</sup> were shown to be more effective than web-based ones.<sup>18,20,23,25,26,30,31,33,36</sup> However, it seems important to consider the variability in the conceptualization and measurement of HRQoL. Similarly, another element that could explain the variability in effectiveness regarding this variable is the targeted outcome of the interventions. For example, pain-targeted interventions or more generally functional interventions tended to be more effective regarding HRQoL than others. In this sense, it could be relevant to consider some variables more as mediators of the efficacy of the intervention than as final outcomes.

**4.1 | Perspectives and recommendations**

Some studies suggested nonsignificant effects on some outcomes (e.g., anxiety, depression). This result could be due to the declared target of the intervention that may differ from the outcome considered (e.g., an intervention developed to enhance daily physical activity but for which emotional variables are evaluated as a primary outcome). In this context, it might be crucial to correctly target the outcomes evaluated as they might affect the interpretation of the real efficacy of the intervention. To do so, it appears essential to clearly identify the pathways by which the interventions could determine the outcomes of interest.<sup>39</sup> This requires modeling of the supposed action mechanism of the interventions and thus, a solid theoretical background in their conception.<sup>40</sup>

Constating the mitigated efficacy of the interventions, it is possible to wonder if the measurements are being limited. Indeed, although some considered baseline levels of outcomes, others did not. Thus, the absence of a significant effect could be due to the fact that some patients don't show a pathological state at the beginning of the intervention and, therefore, don't benefit from the intervention. For these reasons, some nonsignificant results should be interpreted cautiously, and further research

should be conducted that matches the target of the interventions and the identified outcomes, and measures the baseline levels of outcomes of interest to avoid a floor effect. Implementing a baseline measure could also help develop adaptive interventions that would target outcomes for which a pathological level is observed at the beginning of the intervention. In the same vein, interventions could also continuously monitor the outcomes to adapt during their use. To do so, a strong call for the development and systematic use of standardized and sensitive measurement tools should be made (e.g., by implementing ecological momentary assessments).<sup>41</sup>

Adherence to digital interventions constitutes a common but complex problem that should be considered because of its potential influence on effectiveness.<sup>42,43</sup> A recent scoping review found that individual characteristics can influence adherence to digital interventions and thus, their effectiveness.<sup>44</sup> Beyond studying the effects of an intervention using patient-reported outcomes (PROs) as patient-centered evaluation tools,<sup>45</sup> it appears that measuring user adherence and perceived obstacles to use (e.g., numerical literacy, preference for computers or smartphones) as well as their acceptability,<sup>43</sup> is pertinent to improve the development of interventions. However, identifying these factors at the end of the development process could be more costly. Thus, it seems wise to investigate these parameters at the beginning of the development phase. Building interventions with patients based on their needs and characteristics seems necessary, as their experiential knowledge is important for intervention design.<sup>46-48</sup> Moreover, involving patients from the early stages of development could help to address some concerns regarding the preservation or exacerbation of social inequalities in access to devices, bringing an in-context point-of-view. Indeed, it has been observed that some patients could find it difficult to adopt the interventions because they lack access to the digital technology or because of socioeconomic deprivation.<sup>49</sup> This represents a problem, given that a chain reaction could lead to significant socioeconomic inequalities.<sup>50</sup> For those reasons, potential socioeconomic inequalities in implementing and adopting of digital interventions should be a crucial interest for the development of future interventions, as well as their cost-effectiveness. To date, these aspects have rarely been investigated and reported in publications.

A large proportion of the included reviews selected studies that used an RCT design to investigate the effects of interventions. Although this design is widely used in studies of pharmacological interventions and considered the gold standard,<sup>51</sup> it has been criticized in the context of non-pharmacological interventions such as digital interventions.<sup>43</sup> RCTs are adopted only when the studied intervention fulfills certain requirements (i.e., stability
could lead to inconsistencies in the way these concepts are measured, leading to discrepancies in the results.

Regarding physical activity, the observed results were positive whether interventions were web-based or app-based.<sup>22-24,28,30,32,34,35</sup> Physical activity was the most frequently measured outcome in the studies. One original study reported by two reviews described positive effects on binge drinking.<sup>34,35</sup> However, other behavioral outcomes (i.e., diet, smoking cessation) seemed not to be significantly modified by digital interventions.<sup>22,34</sup>

On a functional level, the results of the interventions revealed globally good outcomes for some variables (e.g., fatigue,<sup>19,22,23,30,31</sup> sleep<sup>19,22,23,30</sup>) but nonsignificant effects for others (e.g., pain<sup>21,22,34</sup>). When HRQoL was considered alone, app-based interventions<sup>18,21,22,27,33,34</sup> were shown to be more effective than web-based ones.<sup>18,20,23,25,26,30,31,33,36</sup> However, it seems important to consider the variability in the conceptualization and measurement of HRQoL. Similarly, another element that could explain the variability in effectiveness regarding this variable is the targeted outcome of the interventions. For example, pain-targeted interventions or more generally functional interventions tended to be more effective regarding HRQoL than others. In this sense, it could be relevant to consider some variables more as mediators of the efficacy of the intervention than as final outcomes.

**4.1 | Perspectives and recommendations**

Some studies suggested nonsignificant effects on some outcomes (e.g., anxiety, depression). This result could be due to the declared target of the intervention that may differ from the outcome considered (e.g., an intervention developed to enhance daily physical activity but for which emotional variables are evaluated as a primary outcome). In this context, it might be crucial to correctly target the outcomes evaluated as they might affect the interpretation of the real efficacy of the intervention. To do so, it appears essential to clearly identify the pathways by which the interventions could determine the outcomes of interest.<sup>39</sup> This requires modeling of the supposed action mechanism of the interventions and thus, a solid theoretical background in their conception.<sup>40</sup>

Constating the mitigated efficacy of the interventions, it is possible to wonder if the measurements are being limited. Indeed, although some considered baseline levels of outcomes, others did not. Thus, the absence of a significant effect could be due to the fact that some patients don't show a pathological state at the beginning of the intervention and, therefore, don't benefit from the intervention. For these reasons, some nonsignificant results should be interpreted cautiously, and further research

should be conducted that matches the target of the interventions and the identified outcomes, and measures the baseline levels of outcomes of interest to avoid a floor effect. Implementing a baseline measure could also help develop adaptive interventions that would target outcomes for which a pathological level is observed at the beginning of the intervention. In the same vein, interventions could also continuously monitor the outcomes to adapt during their use. To do so, a strong call for the development and systematic use of standardized and sensitive measurement tools should be made (e.g., by implementing ecological momentary assessments).<sup>41</sup>

Adherence to digital interventions constitutes a common but complex problem that should be considered because of its potential influence on effectiveness.<sup>42,43</sup> A recent scoping review found that individual characteristics can influence adherence to digital interventions and thus, their effectiveness.<sup>44</sup> Beyond studying the effects of an intervention using patient-reported outcomes (PROs) as patient-centered evaluation tools,<sup>45</sup> it appears that measuring user adherence and perceived obstacles to use (e.g., numerical literacy, preference for computers or smartphones) as well as their acceptability,<sup>43</sup> is pertinent to improve the development of interventions. However, identifying these factors at the end of the development process could be more costly. Thus, it seems wise to investigate these parameters at the beginning of the development phase. Building interventions with patients based on their needs and characteristics seems necessary, as their experiential knowledge is important for intervention design.<sup>46-48</sup> Moreover, involving patients from the early stages of development could help to address some concerns regarding the preservation or exacerbation of social inequalities in access to devices, bringing an in-context point-of-view. Indeed, it has been observed that some patients could find it difficult to adopt the interventions because they lack access to the digital technology or because of socioeconomic deprivation.<sup>49</sup> This represents a problem, given that a chain reaction could lead to significant socioeconomic inequalities.<sup>50</sup> For those reasons, potential socioeconomic inequalities in implementing and adopting of digital interventions should be a crucial interest for the development of future interventions, as well as their cost-effectiveness. To date, these aspects have rarely been investigated and reported in publications.

A large proportion of the included reviews selected studies that used an RCT design to investigate the effects of interventions. Although this design is widely used in studies of pharmacological interventions and considered the gold standard,<sup>51</sup> it has been criticized in the context of non-pharmacological interventions such as digital interventions.<sup>43</sup> RCTs are adopted only when the studied intervention fulfills certain requirements (i.e., stability
in providing the intervention, fidelity of the intervention, and likelihood of clinical significance of the benefits of the intervention).⁵² Given the characteristics of digital interventions, which can be rather complex, a model shift in the studies evaluating their effects could be useful. In this regard, Skivington et al. suggested specifying the perspective from which the intervention is evaluated (i.e., efficacy, effectiveness, theory-based, systems). This classification calls into question the setting (i.e., ideal, experimental, real-world) of the intervention, since RCTs are designed for ideal or experimental settings but digital interventions are characterized by the variability of their settings. Beyond the methodological considerations in the conception of studies, some authors claim that a move from RCTs to other, more individualized research paradigms would bring changes in data analysis, causing a shift from sample analysis to individual analysis (e.g., N-of-1 studies).⁵³ For these reasons, a shift in research methods might enable more consistency in evaluation and greater reliability in the results of the studies.⁵¹

The included reviews were characterized by their lack of methodological quality, measured using AMSTAR-2.¹⁷ One of the most significant factors contributing to quality impairment was the lack of descriptions of the included interventions, which prevents global interpretation regarding the elements that have the greatest effect on a specific outcome. Thus, adopting strict transparency in studies and their reporting is strongly recommended. This could be achieved in several ways. For example, more open practices in research could integrate systematic pre-registration, registered reports, data sharing plans, the dissemination of reproducible analysis code or detailed intervention contents, preprints, or data sharing.⁵⁴,⁵⁵ Among other open science principles, the preregistration of interventional studies could help build greater trust in interventional research, reducing the potential for a lack of transparency, selective reports in the results, or false-positives.⁵⁵,⁵⁶ Methodological quality evaluation tools also could be improved by implementing items on

transparency in the description of interventions and their results.⁵⁶ Other factors that could benefit from greater transparency include the level of adherence and the attrition rate and their determinants. Despite being common in interventional studies, few studies report these items.⁵⁷ Applying open science principles to interventional research is not only crucial for better reproducibility but would also enable better implementation of the interventions in the real world, allowing them to benefit more people and increasing their benefit-cost ratio.⁵⁸

The recommendations formulated are summarized in **Box 1**. Detailed recommendations to report psychosocial trials exist, such as the CONSORT statement,⁵⁹ GUIDED⁶⁰ or TIDieR⁶¹ checklists. However, these recommendations do not seem to be known or used by some in the scientific committee and can also be updated to include new elements, as discussed above.

## 4.2 | Limitations

The limitations of this umbrella review include the fact that concepts are generally poorly defined. Indeed, given that they encompass several types of interventions, digital interventions remain a relatively blurry concept in the literature.⁶²,⁶³ Two issues stem from this poor definition. First, there may be confusion in the characterization of the interventions and interpretation of the results. Thus, it appears crucial to bring more rigor in description and definition of digital interventions in the context of the considerable digitalization of the healthcare.⁶⁴ Regarding this definition, it appears that conclusions could be refined if some intervention components were clearly defined in reviews (e.g., CBT). Second, because of the heterogeneity in the methodologies, outcomes of interest, and methods of efficiency evaluation, it was impossible to conduct a quantitative synthesis. For this reason, it is impossible to systematically characterize the heterogeneity in the reviews as well as a potential publication bias. Third, most of the

### BOX 1 Recommendations for future interventional study designs

* Refer to a concrete theoretical anchoring to identify the mechanisms of action of the intervention

* Consider patients in the development of interventions, their perceived obstacles to utilization and potential inequality in implementation of the intervention

* Implement a solid measurement protocol: from baseline, all along the pathway, with standardized and sensitive tools

* Get out of the systematic use of randomized controlled trials model and look for alternative adapted evaluation models

* Bring strict transparency in the development with pre-registration or registered reports and data sharing plans

* Systematically report and discuss attrition rates, level of adherence and satisfaction of patients

* Assess the cost of the intervention for everyone (i.e., institutions, clinicians, and end-users)
in providing the intervention, fidelity of the intervention, and likelihood of clinical significance of the benefits of the intervention).⁵² Given the characteristics of digital interventions, which can be rather complex, a model shift in the studies evaluating their effects could be useful. In this regard, Skivington et al. suggested specifying the perspective from which the intervention is evaluated (i.e., efficacy, effectiveness, theory-based, systems). This classification calls into question the setting (i.e., ideal, experimental, real-world) of the intervention, since RCTs are designed for ideal or experimental settings but digital interventions are characterized by the variability of their settings. Beyond the methodological considerations in the conception of studies, some authors claim that a move from RCTs to other, more individualized research paradigms would bring changes in data analysis, causing a shift from sample analysis to individual analysis (e.g., N-of-1 studies).⁵³ For these reasons, a shift in research methods might enable more consistency in evaluation and greater reliability in the results of the studies.⁵¹

The included reviews were characterized by their lack of methodological quality, measured using AMSTAR-2.¹⁷ One of the most significant factors contributing to quality impairment was the lack of descriptions of the included interventions, which prevents global interpretation regarding the elements that have the greatest effect on a specific outcome. Thus, adopting strict transparency in studies and their reporting is strongly recommended. This could be achieved in several ways. For example, more open practices in research could integrate systematic pre-registration, registered reports, data sharing plans, the dissemination of reproducible analysis code or detailed intervention contents, preprints, or data sharing.⁵⁴,⁵⁵ Among other open science principles, the preregistration of interventional studies could help build greater trust in interventional research, reducing the potential for a lack of transparency, selective reports in the results, or false-positives.⁵⁵,⁵⁶ Methodological quality evaluation tools also could be improved by implementing items on

transparency in the description of interventions and their results.⁵⁶ Other factors that could benefit from greater transparency include the level of adherence and the attrition rate and their determinants. Despite being common in interventional studies, few studies report these items.⁵⁷ Applying open science principles to interventional research is not only crucial for better reproducibility but would also enable better implementation of the interventions in the real world, allowing them to benefit more people and increasing their benefit-cost ratio.⁵⁸

The recommendations formulated are summarized in Box 1. Detailed recommendations to report psychosocial trials exist, such as the CONSORT statement,⁵⁹ GUIDED⁶⁰ or TIDieR⁶¹ checklists. However, these recommendations do not seem to be known or used by some in the scientific committee and can also be updated to include new elements, as discussed above.

## 4.2 | Limitations

The limitations of this umbrella review include the fact that concepts are generally poorly defined. Indeed, given that they encompass several types of interventions, digital interventions remain a relatively blurry concept in the literature.⁶²,⁶³ Two issues stem from this poor definition. First, there may be confusion in the characterization of the interventions and interpretation of the results. Thus, it appears crucial to bring more rigor in description and definition of digital interventions in the context of the considerable digitalization of the healthcare.⁶⁴ Regarding this definition, it appears that conclusions could be refined if some intervention components were clearly defined in reviews (e.g., CBT). Second, because of the heterogeneity in the methodologies, outcomes of interest, and methods of efficiency evaluation, it was impossible to conduct a quantitative synthesis. For this reason, it is impossible to systematically characterize the heterogeneity in the reviews as well as a potential publication bias. Third, most of the

### BOX 1 Recommendations for future interventional study designs

* Refer to a concrete theoretical anchoring to identify the mechanisms of action of the intervention

* Consider patients in the development of interventions, their perceived obstacles to utilization and potential inequality in implementation of the intervention

* Implement a solid measurement protocol: from baseline, all along the pathway, with standardized and sensitive tools

* Get out of the systematic use of randomized controlled trials model and look for alternative adapted evaluation models

* Bring strict transparency in the development with pre-registration or registered reports and data sharing plans

* Systematically report and discuss attrition rates, level of adherence and satisfaction of patients

* Assess the cost of the intervention for everyone (i.e., institutions, clinicians, and end-users)
included reviews considered adult patients with cancer. Thus, although the objective of this umbrella review was to systematically synthesize the effectiveness of digital interventions in cancer care regarding both patients and their relatives, it remains impossible to draw solid conclusions for pediatric patients and caregivers. Finally, the recommendations for conducting umbrella reviews may lack flexibility in the case of interventional studies. It could be more informative to perform a rescreening of the primary studies to assess some of their aspects (e.g., contents of the interventions).

5 | CONCLUSION

As medical care and therapeutics have allowed patients to live longer, it has become increasingly important to develop cost-effective supportive care interventions for patients and their relatives. This umbrella review synthesized the results from 20 systematic reviews and meta-analyses to establish the effectiveness of digital interventions in cancer. The evidence shows that interventions are numerous and globally efficient. However, great heterogeneity in the interventions is observed, and several reviews do not fulfill the methodological requirements of reporting results from interventional studies, leading to doubts about their conclusions. Further research is needed to develop interventions that are methodologically founded, allowing for scrupulous testing to determine what type of intervention is efficient and on what outcome. Additionally, clearer recommendations in intervention research and related publications are needed, as the existing ones are not comprehensive enough.

AUTHOR CONTRIBUTIONS

**Valentyn Fournier:** Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (equal); validation (equal); visualization (equal); writing – original draft (equal); writing – review and editing (equal). **Christelle Duprez:** Conceptualization (equal); methodology (equal); validation (equal); visualization (equal); writing – review and editing (equal). **Delphine Grynberg:** Conceptualization (equal); methodology (equal); validation (equal); visualization (equal); writing – review and editing (equal). **Pascal Antoine:** Conceptualization (equal); methodology (equal); validation (equal); visualization (equal); writing – review and editing (equal). **Kristopher Lamore:** Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal);

project administration (equal); resources (equal); software (equal); supervision (equal); validation (equal); visualization (equal); writing – original draft (equal); writing – review and editing (equal).

ACKNOWLEDGMENTS

The SCALab laboratory is part of the ONCOLille Institute. This work was funded by the French National Cancer Institute (Institut National du Cancer, grant INCA/16136) in collaboration with the Université de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret that support the research chair opsyrii "innovations in psycho-oncology and intervention research." The authors thank the University of Lille for funding the English proofreading.

FUNDING INFORMATION

This work was funded by the French National Cancer Institute (Institut National du Cancer, grant INCA/16136) in collaboration with the Université de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret that support the research chair opsyrii "innovations in psycho-oncology and intervention research."

CONFLICT OF INTEREST STATEMENT

None.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

ORCID

Valentyn Fournier https://orcid.org/0000-0002-1289-8968
Christelle Duprez https://orcid.org/0000-0002-4254-2559
Delphine Grynberg https://orcid.org/0000-0002-4588-4116

REFERENCES

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. *CA Cancer J Clin.* 2018;68(6):394-424. doi:10.3322/caac.21492

2. International Agency for Research on Cancer (IARC). Estimated number of new cases in 2020, World, both sexes, all ages (excl. NMSC). 2023 https://gco.iarc.fr/today/online-analysis-table?v=2020&mode=cancer&modePopulation=contingents&population=900&populations=900&key=asr&sex=0&cancer=39&type=0&statistic=5&prevalence=0&population_group=0&ages_group%5B%5D=0&ages_group%5B%5D=17&group_cancer=1&include_nmsc=0&include_nmsc_other=1. http://gco.iarc.fr/today/home
included reviews considered adult patients with cancer. Thus, although the objective of this umbrella review was to systematically synthesize the effectiveness of digital interventions in cancer care regarding both patients and their relatives, it remains impossible to draw solid conclusions for pediatric patients and caregivers. Finally, the recommendations for conducting umbrella reviews may lack flexibility in the case of interventional studies. It could be more informative to perform a rescreening of the primary studies to assess some of their aspects (e.g., contents of the interventions).

5 | CONCLUSION

As medical care and therapeutics have allowed patients to live longer, it has become increasingly important to develop cost-effective supportive care interventions for patients and their relatives. This umbrella review synthesized the results from 20 systematic reviews and meta-analyses to establish the effectiveness of digital interventions in cancer. The evidence shows that interventions are numerous and globally efficient. However, great heterogeneity in the interventions is observed, and several reviews do not fulfill the methodological requirements of reporting results from interventional studies, leading to doubts about their conclusions. Further research is needed to develop interventions that are methodologically founded, allowing for scrupulous testing to determine what type of intervention is efficient and on what outcome. Additionally, clearer recommendations in intervention research and related publications are needed, as the existing ones are not comprehensive enough.

AUTHOR CONTRIBUTIONS

**Valentyn Fournier:** Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (equal); validation (equal); visualization (equal); writing – original draft (equal); writing – review and editing (equal). **Christelle Duprez:** Conceptualization (equal); methodology (equal); validation (equal); visualization (equal); writing – review and editing (equal). **Delphine Grynberg:** Conceptualization (equal); methodology (equal); validation (equal); visualization (equal); writing – review and editing (equal). **Pascal Antoine:** Conceptualization (equal); methodology (equal); validation (equal); visualization (equal); writing – review and editing (equal). **Kristopher Lamore:** Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal);

project administration (equal); resources (equal); software (equal); supervision (equal); validation (equal); visualization (equal); writing – original draft (equal); writing – review and editing (equal).

ACKNOWLEDGMENTS

The SCALab laboratory is part of the ONCOLille Institute. This work was funded by the French National Cancer Institute (Institut National du Cancer, grant INCA/16136) in collaboration with the Université de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret that support the research chair opsyrii "innovations in psycho-oncology and intervention research." The authors thank the University of Lille for funding the English proofreading.

FUNDING INFORMATION

This work was funded by the French National Cancer Institute (Institut National du Cancer, grant INCA/16136) in collaboration with the Université de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret that support the research chair opsyrii "innovations in psycho-oncology and intervention research."

CONFLICT OF INTEREST STATEMENT

None.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

ORCID

Valentyn Fournier https://orcid.org/0000-0002-1289-8968
Christelle Duprez https://orcid.org/0000-0002-4254-2559
Delphine Grynberg https://orcid.org/0000-0002-4588-4116

REFERENCES

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2. International Agency for Research on Cancer (IARC). Estimated number of new cases in 2020, World, both sexes, all ages (excl. NMSC). 2023 https://gco.iarc.fr/today/online-analysis-table?v=2020&mode=cancer&modePopulation=contingents&population=900&populations=900&key=asr&sex=0&cancer=39&type=0&statistic=5&prevalence=0&population_group=0&ages_group%5B%5D=0&ages_group%5B%5D=17&group_cancer=1&include_nmsc=0&include_nmsc_other=1. http://gco.iarc.fr/today/home
3. Cao Y, Lu J, Lu J. Paternal smoking before conception and during pregnancy is associated with an increased risk of childhood acute lymphoblastic leukemia: a systematic review and meta-analysis of 17 case-control studies. *J Pediatr Hematol Oncol.* 2020;42(1):32-40. doi:10.1097/MPH.0000000000001657

4. Levit L, Smith AP, Benz EJ, Ferrell B. Ensuring quality cancer care through the oncology workforce. *J Oncol Pract.* 2010;6(1):7-11. doi:10.1200/JOP.091067

5. The Royal College of Radiologists. New RCR workforce report shows oncologist shortages continue to impact patients. 2023 https://www.rcr.ac.uk/posts/new-rcr-workforce-report-shows-oncologist-shortages-continue-impact-patients

6. Cook R. Economic and clinical impact of multiple myeloma to managed care. *J Manag Care Pharm.* 2008;14(7 Supp A):19-25. doi:10.18553/jmcp.2008.14.S7-A.19

7. Carlson LE, Bultz BD. Efficacy and medical cost offset of psychosocial interventions in cancer care: making the case for economic analyses. *Psychooncology*. 2004;13(12):837-849. doi:10.1002/pon.832

8. Jansen F, van Zwieten V, Coupé VMH, Leemans CR, Verdonck-de Leeuw IM. A review on cost-effectiveness and cost-utility of psychosocial care in cancer patients. *Asia-Pac J Oncol Nurs.* 2016;3(2):125-136. doi:10.4103/2347-5625.182930

9. Hu K, Liu Q, László KD, et al. Risk of psychiatric disorders among spouses of patients with cancer in Denmark and Sweden. *JAMA Netw Open*. 2023;6(1):e2249560. doi:10.1001/jamanetworkopen.2022.49560

10. Stark AL, Geukes C, Dockweiler C. Digital health promotion and prevention in settings: scoping review. *J Med Internet Res.* 2022;24(1):e21063. doi:10.2196/21063

11. Morris BB, Rossi B, Fuemmeler B. The role of digital health technology in rural cancer care delivery: a systematic review. *J Rural Health.* 2022;38(3):493-511. doi:10.1111/jrh.12619

12. Gentili A, Failla G, Melnyk A, et al. The cost-effectiveness of digital health interventions: a systematic review of the literature. *Front Public Health.* 2022;10:787135. doi:10.3389/fpubh.2022.787135

13. Rethlefsen ML, Kirtley S, Waffenschmidt S, et al. PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews. *Syst Rev.* 2021;10(1):39. doi:10.1186/s13643-020-01542-z

14. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. *Int J Evid Based Healthc.* 2015;13(3):132-140. doi:10.1097/XEB.0000000000000055

15. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. *BMC Health Serv Res.* 2014;14(1):579. doi:10.1186/s12913-014-0579-0

16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. *PLoS Med.* 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097

17. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. *BMJ.* 2017;358:j4008. doi:10.1136/bmj.j4008

18. Qan'ir Y, Song L. Systematic review of technology-based interventions to improve anxiety, depression, and health-related quality of life among patients with prostate cancer. *Psychooncology*. 2019;28(8):1601-1613. doi:10.1002/pon.5158

19. Huang J, Han Y, Wei J, et al. The effectiveness of the internet-based self-management program for cancer-related fatigue patients: a systematic review and meta-analysis. *Clin Rehabil.* 2020;34(3):287-298. doi:10.1177/0269215519889394

20. Zhang X, Ma L, Feng L. Web-based self-management intervention for patients with cancer: a meta-analysis and systematic review. *J Nurs Scholarsh.* 2022;54(5):598-606. doi:10.1111/jnu.12774

21. Zheng C, Chen X, Weng L, et al. Benefits of Mobile apps for cancer pain management: systematic review. *JMIR Mhealth Uhealth.* 2020;8(1):e17055. doi:10.2196/17055

22. Kiss N, Isenring E, Gough K, et al. Early and intensive dietary counseling in lung cancer patients receiving (chemo)radiotherapy—a pilot randomized controlled. *Trial.* 2016;68(6):958-967. doi:10.1080/01635581.2016.1188972

23. McAlpine H, Joubert L, Martin-Sanchez F, Merolli M, Drummond KJ. A systematic review of types and efficacy of online interventions for cancer patients. *Patient Educ Couns.* 2015;98(3):283-295. doi:10.1016/j.pec.2014.11.002

24. Ester M, Eisele M, Wurz A, McDonough MH, McNeely M, Culos-Reed SN. Current evidence and directions for future research in eHealth physical activity interventions for adults affected by cancer: systematic review. *JMIR Cancer.* 2021;7(3):e28852. doi:10.2196/28852

25. Wan SW, Chng YJD, Lim SH, Chong CS, Pikkarainen M, He HG. A systematic review and meta-analysis on the effectiveness of web-based psychosocial interventions among patients with colorectal cancer. *J Adv Nurs.* 2022;78(7):1883-1896. doi:10.1111/jan.15258

26. Goliță S, Băban A. A systematic review of the effects of internet-based psychological interventions on emotional distress and quality of life in adult cancer patients. *J Evid-Based Psychother.* 2019;19:47-78. doi:10.24193/jebp.2019.2.13

27. Singleton AC, Raeside R, Hyun KK, et al. Electronic health interventions for patients with breast cancer: systematic review and meta-analyses. *J Clin Oncol.* 2022;40(20):2257-2270. doi:10.1200/JCO.21.01171

28. Dorri S, Asadi F, Olfatbakhsh A, Kazemi A. A systematic review of electronic health (eHealth) interventions to improve physical activity in patients with breast cancer. *Breast Cancer Tokyo Jpn.* 2020;27(1):25-46. doi:10.1007/s12282-019-00982-3

29. Kamalumpundi V, Saeidzadeh S, Chi NC, Nair R, Gilbertson-White S. The efficacy of web or mobile-based interventions to alleviate emotional symptoms in people with advanced cancer: a systematic review and meta-analysis. *Support Care Cancer.* 2022;30(4):3029-3042. doi:10.1007/s00520-021-06496-z

30. Seiler A, Klaas V, Tröster G, Fagundes CP. eHealth and mHealth interventions in the treatment of fatigued cancer survivors: a systematic review and meta-analysis. *Psychooncology.* 2017;26(9):1239-1253. doi:10.1002/pon.4489

31. Kim Y, Kang SJ. Computerized programs for cancer survivors with cognitive problems: a systematic review. *J Cancer Surviv Res Pract.* 2019;13(6):911-920. doi:10.1007/s11764-019-00807-4

32. Haberlin C, O'Dwyer T, Mockler D, Moran J, O'Donnell DM, Broderick J. The use of eHealth to promote physical activity
3. Cao Y, Lu J, Lu J. Paternal smoking before conception and during pregnancy is associated with an increased risk of childhood acute lymphoblastic leukemia: a systematic review and meta-analysis of 17 case-control studies. *J Pediatr Hematol Oncol.* 2020;42(1):32-40. doi:10.1097/MPH.0000000000001657

4. Levit L, Smith AP, Benz EJ, Ferrell B. Ensuring quality cancer care through the oncology workforce. *J Oncol Pract.* 2010;6(1):7-11. doi:10.1200/JOP.091067

5. The Royal College of Radiologists. New RCR workforce report shows oncologist shortages continue to impact patients. 2023 https://www.rcr.ac.uk/posts/new-rcr-workforce-report-shows-oncologist-shortages-continue-impact-patients

6. Cook R. Economic and clinical impact of multiple myeloma to managed care. *J Manag Care Pharm.* 2008;14(7 Supp A):19-25. doi:10.18553/jmcp.2008.14.S7-A.19

7. Carlson LE, Bultz BD. Efficacy and medical cost offset of psychosocial interventions in cancer care: making the case for economic analyses. *Psychooncology*. 2004;13(12):837-849. doi:10.1002/pon.832

8. Jansen F, van Zwieten V, Coupé VMH, Leemans CR, Verdonck-de Leeuw IM. A review on cost-effectiveness and cost-utility of psychosocial care in cancer patients. *Asia-Pac J Oncol Nurs.* 2016;3(2):125-136. doi:10.4103/2347-5625.182930

9. Hu K, Liu Q, László KD, et al. Risk of psychiatric disorders among spouses of patients with cancer in Denmark and Sweden. *JAMA Netw Open*. 2023;6(1):e2249560. doi:10.1001/jamanetworkopen.2022.49560

10. Stark AL, Geukes C, Dockweiler C. Digital health promotion and prevention in settings: scoping review. *J Med Internet Res.* 2022;24(1):e21063. doi:10.2196/21063

11. Morris BB, Rossi B, Fuemmeler B. The role of digital health technology in rural cancer care delivery: a systematic review. *J Rural Health.* 2022;38(3):493-511. doi:10.1111/jrh.12619

12. Gentili A, Failla G, Melnyk A, et al. The cost-effectiveness of digital health interventions: a systematic review of the literature. *Front Public Health.* 2022;10:787135. doi:10.3389/fpubh.2022.787135

13. Rethlefsen ML, Kirtley S, Waffenschmidt S, et al. PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews. *Syst Rev.* 2021;10(1):39. doi:10.1186/s13643-020-01542-z

14. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. *Int J Evid Based Healthc.* 2015;13(3):132-140. doi:10.1097/XEB.0000000000000055

15. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. *BMC Health Serv Res.* 2014;14(1):579. doi:10.1186/s12913-014-0579-0

16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. *PLoS Med.* 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097

17. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. *BMJ.* 2017;358:j4008. doi:10.1136/bmj.j4008

18. Qan'ir Y, Song L. Systematic review of technology-based interventions to improve anxiety, depression, and health-related quality of life among patients with prostate cancer. *Psychooncology*. 2019;28(8):1601-1613. doi:10.1002/pon.5158

19. Huang J, Han Y, Wei J, et al. The effectiveness of the internet-based self-management program for cancer-related fatigue patients: a systematic review and meta-analysis. *Clin Rehabil.* 2020;34(3):287-298. doi:10.1177/0269215519889394

20. Zhang X, Ma L, Feng L. Web-based self-management intervention for patients with cancer: a meta-analysis and systematic review. *J Nurs Scholarsh.* 2022;54(5):598-606. doi:10.1111/jnu.12774

21. Zheng C, Chen X, Weng L, et al. Benefits of Mobile apps for cancer pain management: systematic review. *JMIR Mhealth Uhealth.* 2020;8(1):e17055. doi:10.2196/17055

22. Kiss N, Isenring E, Gough K, et al. Early and intensive dietary counseling in lung cancer patients receiving (chemo)radiotherapy—a pilot randomized controlled. *Trial.* 2016;68(6):958-967. doi:10.1080/01635581.2016.1188972

23. McAlpine H, Joubert L, Martin-Sanchez F, Merolli M, Drummond KJ. A systematic review of types and efficacy of online interventions for cancer patients. *Patient Educ Couns.* 2015;98(3):283-295. doi:10.1016/j.pec.2014.11.002

24. Ester M, Eisele M, Wurz A, McDonough MH, McNeely M, Culos-Reed SN. Current evidence and directions for future research in eHealth physical activity interventions for adults affected by cancer: systematic review. *JMIR Cancer.* 2021;7(3):e28852. doi:10.2196/28852

25. Wan SW, Chng YJD, Lim SH, Chong CS, Pikkarainen M, He HG. A systematic review and meta-analysis on the effectiveness of web-based psychosocial interventions among patients with colorectal cancer. *J Adv Nurs.* 2022;78(7):1883-1896. doi:10.1111/jan.15258

26. Goliță S, Băban A. A systematic review of the effects of internet-based psychological interventions on emotional distress and quality of life in adult cancer patients. *J Evid-Based Psychother.* 2019;19:47-78. doi:10.24193/jebp.2019.2.13

27. Singleton AC, Raeside R, Hyun KK, et al. Electronic health interventions for patients with breast cancer: systematic review and meta-analyses. *J Clin Oncol.* 2022;40(20):2257-2270. doi:10.1200/JCO.21.01171

28. Dorri S, Asadi F, Olfatbakhsh A, Kazemi A. A systematic review of electronic health (eHealth) interventions to improve physical activity in patients with breast cancer. *Breast Cancer Tokyo Jpn.* 2020;27(1):25-46. doi:10.1007/s12282-019-00982-3

29. Kamalumpundi V, Saeidzadeh S, Chi NC, Nair R, Gilbertson-White S. The efficacy of web or mobile-based interventions to alleviate emotional symptoms in people with advanced cancer: a systematic review and meta-analysis. *Support Care Cancer.* 2022;30(4):3029-3042. doi:10.1007/s00520-021-06496-z

30. Seiler A, Klaas V, Tröster G, Fagundes CP. eHealth and mHealth interventions in the treatment of fatigued cancer survivors: a systematic review and meta-analysis. *Psychooncology.* 2017;26(9):1239-1253. doi:10.1002/pon.4489

31. Kim Y, Kang SJ. Computerized programs for cancer survivors with cognitive problems: a systematic review. *J Cancer Surviv Res Pract.* 2019;13(6):911-920. doi:10.1007/s11764-019-00807-4

32. Haberlin C, O'Dwyer T, Mockler D, Moran J, O'Donnell DM, Broderick J. The use of eHealth to promote physical activity
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## SUPPORTING INFORMATION

Additional supporting information can be found online in the Supporting Information section at the end of this article.

**How to cite this article:** Fournier V, Duprez C, Grynberg D, Antoine P, Lamore K. Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions. *Cancer Med*. 2023;00:1-16. doi:10.1002/cam4.6695
63. van Gemert-Pijnen JEWC, Nijland N, van Limburg M, et al. A holistic framework to improve the uptake and impact of eHealth technologies. *J Med Internet Res.* 2011;13(4):e111. doi:10.2196/jmir.1672

64. Meskó B, Drobni Z, Bényei É, Gergely B, Győrffy Z. Digital health is a cultural transformation of traditional healthcare. *mHealth*. 2017;3:38. doi:10.21037/mhealth.2017.08.07

## SUPPORTING INFORMATION

Additional supporting information can be found online in the Supporting Information section at the end of this article.

**How to cite this article:** Fournier V, Duprez C, Grynberg D, Antoine P, Lamore K. Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions. *Cancer Med*. 2023;00:1-16. doi:10.1002/cam4.6695