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Publicly available apps for cancer survivors: a scoping review

Objectives To review the nature and scope of apps targeting individuals living with and beyond cancer. Design Scoping review, searching the two largest app stores, Google Play and Apple’s App store. App descriptions were exported verbatim, and summarised descriptively, thematically and by content coding. Results We included 151 apps targeting individuals living with and beyond cancer. Most targeted all cancer types (n=89, 58.9%) or breast cancer (n=22, 14.6%) and originated in the USA (n=68, 45.0%). The country of origin was unclear for 31 (20.5%) apps. Most apps were developed by commercial companies/private individuals (n=64, 43%) or non-profit organisations (n=30, 19.9%) and marketed apps in terms of fighting metaphors, navigating a journey and becoming empowered to take control. App content could be summarised under five main categories: (1) imparting information about cancer; (2) planning and organising cancer care; (3) interacting with others (including others affected by cancer and healthcare professionals); (4) enacting management strategies and adjusting to life with or beyond cancer and (5) getting feedback about cancer management, for example, by sharing self-monitoring reports with professionals. We found some apps describing ‘cures’ for cancer or selling products, such as alkaline waters to cancer survivors. Conclusions Apps are currently available via on-line stores that cover a large spectrum of cancer survivorship activities. The effects of such apps on clinical consultations, patient work/burden and clinical outcomes merit further attention. Most apps are developed by commercial organisations, and promises of empowerment in the ‘fight’ against cancer are tempered by the potential for exaggerated claims and exploitation.

The number of individuals living with and beyond cancer (also known as cancer survivors) is increasing (1,2). In the United Kingdom, it is estimated that the number of cancer survivors will grow by approximately one million every decade, from 2.1 million in 2010 to 5.3 million in 2040 (2). Cancer is increasingly becoming a chronic disease. Cancer survivors can experience increased physical, psychological, and social issues after their diagnosis, (3) accompanied by a range of unmet needs (4). There is growing political and clinical interest in utilising digital technologies to deliver efficient, high quality care for cancer survivors (5) and to empower patients to perform self-management activities (6).
The market for apps, including health apps is growing rapidly (7,8) with an estimated 318,000 health apps available in 2018. It is estimated that over 200 health apps are added daily to app stores (9). Against this changing technological environment, attempts to summarise and evaluate healthcare apps in traditional systematic reviews are limited by the relatively small proportion of technologies which are reported in published literature (10,11).
An alternative strategy has been to identify and review apps that are available for download via on-line stores (12)(13)(14) .
In 2012, Bender et al searched online stores to characterise the purpose and content of apps focusing on any aspect of cancer (15). Of 295 cancer apps, most were limited in their scope, focusing primarily on providing information and raising awareness about cancer in general, and promoting/fundraising for charities (15). In 2014, Kassianos et al searched on-line stores for melanoma detection apps, identifying 39 apps. Most gave education or advice about melanoma, ultraviolet radiation exposure, and skin self-examination strategies (16).
Relatively little is known about apps targeting people living with and beyond cancer. Dahlke et al conducted a review to identify behaviour change techniques (17) (BCTs) embedded in cancer survivorship apps, searching app stores in November 2013 (18). Eighteen BCTs were present across 65 apps, including providing instruction, tailoring (for example, adjusting the information delivered based on user input), personalisation (for example, the user can select elements specific to them such as disease type), and prompting intention formation. What was less clear were the range of behaviours targeted, the aims and scope of the apps, how the BCTs were operationalised and organised, and where the technology itself might add value to survivorship care.
The aim of this review is to characterise apps targeting individuals living with and beyond cancer that are currently available for download via the two major app stores (Google Play and Apple's App Store), which have been estimated to contain over ninety percent of all apps (16). The review will provide a summary of the apps' advertised components, stated aims, and technological features. We aim to categorise and organise the apps such that clinicians, app developers, and policy makers can make sense of the current international app market for people living with and beyond cancer.

Methods
We performed a scoping review, (19) searching Apple's App Store and Google Play to identify apps targeting people living with and beyond cancer, and used content analysis (20) to characterise advertised content. Scoping reviews differ from traditional systematic reviews in that they map a topic in order to communicate the breadth and depth of the field, (21) and do not tend to involve formal quality assessment of the evidence (19). They describe the "extent, range, and nature" (19) of the available evidence, and set it in context in terms of current understanding. Scoping reviews require analytical interpretation of the subject area (22). They are particularly useful when synthesis involves non-research material, (22) and for emerging areas of research.
In this scoping review, we did not download and interact with the apps or test quality or functionality. In a previous review, Kassianos et al used app store summaries and were able to yield detailed descriptions of melanoma app content (16). Based on older reviews, (15,18) we expected to find a large number of apps, and in this rapidly changing field, the time required to interact with each app would lead to significant delays in communicating our findings. We wished to include paid apps, and had limited resources to buy individual apps for multiple authors. We also wished to include any apps affiliated with specific centres or clinical trials which would require log in credentials.

Search strategy
Initial searches were conducted by two authors, DM and RA, who refined the search criteria.
The lead author then searched the two leading app stores, Apple's App store (we used an iPhone with iOS operating system), and Android's Google Play (we used a PC with Windows operating system) in September 2018 using the keywords "cancer", "cancer survivor", and "cancer survivorship".

Inclusion and exclusion criteria
We included: apps aimed at patients living with and beyond cancer; free and paid apps from any country; apps that included pre-diagnosis support and information (so long as they also specifically targeted individuals living with and beyond cancer); and apps covering more than one clinical condition, so long as cancer was a named condition.
We excluded: apps unavailable in English or without English descriptions; simple awareness raising or pre-diagnosis apps (apps raising awareness of symptoms that were potentially indicative of cancer or risk assessment tools, skin/mole checking apps for individuals without a diagnosis of skin cancer, simple factsheets about a certain cancer type, or glossaries); and recipe and diet apps that were not specifically targeting patients living with and beyond cancer.
Apple's App store operates a "continuous scroll" function, meaning that the store loads content continuously to return results. General search terms or keywords (e.g. "cancer") can result in "endless scrolling" or "infinite scrolling", where results are continuously returned without an apparent end point. Our initial scoping searches showed that apps became much less relevant after the first few hundred results, and we decided to limit our search of Apple's App store to the first 500 results for the term "cancer". The online stores are not set up to allow search results to be exported, and decisions about inclusion and exclusion were made by a single author (RA). The final apps selected for inclusion were reviewed by a second author (DM) to ensure that they met the eligibility criteria.

Data extraction and synthesis
A data extraction form was created in Microsoft Excel and two researchers (RA and DM) independently extracted data from all apps that met the inclusion criteria. Data were obtained from the stores' on-line app descriptions, principally the narrative text, but notes were also taken based upon screenshots of the apps within the store. These notes were added to summarise any visible content from the screenshots which was in image form but not directly mentioned in the app description. Verbatim text from the screenshots was imported where available. We searched for and visited developer websites when available in order to gather background information on the app, particularly with respect to the nature of the organisation involved in app development (e.g. non-profit organisation or charity, commercial, academic) and country of origin.
Data were extracted on: cancer type(s); name of owner and/or developer (sometimes the same); country of origin; operating system (Apple/Android/both); fee to download; type of owner (charity, commercial, academic institution, healthcare provider, combination); number of downloads (available on Google Play only); star rating and the presence/absence of a statement about clinical or scientific input into app development. Data on number of downloads, and star ratings were extracted by the lead author alone, as this was judged to be a changing parameter. Data were imported into SPSS version 24, and descriptive statistics were calculated.
The text description of the app given in the online store was copied verbatim and imported into Microsoft Word. We used content analysis (20) and thematic analysis (23) to organise, categorise, and synthesise qualitative data. App descriptions and accompanying notes were imported into NVivo version 11. Data familiarisation took place by reading and re-reading app descriptions. Initial codes were generated by the lead author in order to organise the data into meaningful groups and these were discussed with a second author (DP) (24) Codes were sorted into categories, based on how the codes were related and linked. Each app was then analysed independently by two reviewers (RA and DM) to categorise the advertised content.
The reviewers were alert to any content which did not fit the categories. We also analysed themes within the language used to describe the apps. Reviewers met after the data categorisation exercise and compared results, reaching consensus by discussion. We did not involve patients or the public in this scoping review, but rather plan to use the results to inform technology co-design projects which involve patients and the public.

Results
We screened 1265 apps and included 151 in our final synthesis (see flow chart, Figure 1).
The main reasons for exclusion were apps not specifically targeting cancer survivors, only targeting clinicians, or not relating to cancer. Four apps (Cancer Stage IV Cure Methodology, Driver, Inspire, and NIH Breast Cancer Information) became unavailable during our data analysis process between 8 th September 2018 and 24 th May 2019, and were excluded because we were unable to return to the on-line descriptions to check accuracy during dual data extraction.
A full list of included apps, data on star ratings, and the raw data used in our analyses are included as a supplementary data file. App names will be reported in Italics throughout our results.

App demographics
Characteristics of the apps are provided in Table 1. Of note, most of the apps covered all cancer types (n = 89, 58.9%) or were specific to breast cancer (n = 22, 14.6%). Over 90 percent were free to download. Apps were developed by a mix of private companies/individuals (n =64, 43%), charity/non-profit organisations (n = 30, 19.9%), healthcare organisations (n = 15, 9.9%) and academic institutions (n = 8, 5.3%). We found apps sharing the same developer and with similar content, but differing by cancer type: Eight apps were developed by "@point of care", and five apps developed by "Self-care catalysts", both commercial developers based in the USA. The nature of the developer could not be  Of the 104 apps available on Google Play, 45 apps (43.3%) had been downloaded less than 100 times. Five apps ( Cancer.net mobile, MD Anderson mobile, Cancer fighting food, Cancer Curing foods, and My Cancer Coach) had between 10,000 and 50,000 downloads.
One app, Belong Life, had over 50,000 downloads. Belong Life markets itself as an "information sharing platform", featuring an on-line social network of individuals with cancer, healthcare professionals who answer questions, access to personalised information, and a clinical trial matching service.

Themes within on-line descriptions of the apps
Verbatim app descriptions and text from screenshots ran to over 30,000 words. Three prominent themes were: Fighting for Life, Navigating a Journey, and Being Empowered to Take Control. Examples of app descriptions fitting these themes, with quotations, are included in Table 2. Fighting metaphors were observed within a range of apps and were sometimes contained within the app title (e.g. Attack Cancer using Hypnosis & Guided Imagery/Meditation, Cancer Defeated, and Cancer Fighting Foods). In fighting metaphors, cancer was depicted as an enemy invader and surviving cancer as a battle. Metaphors about fighting and battles were prominent in apps promoting healthy eating or specific "cancerfighting" foods or diets.
Cancer was often compared to a journey and apps marketed themselves as tools to help navigate that journey. Apps that incorporated social networking often emphasised that the cancer journey did not have to be navigated alone. Social networking was suggested as a source of knowledge and emotional support. Many apps promoted peer comparison, and emphasised that others around the world were facing very similar problems, with some apps referring to "others like you". There was a sense within language used that cancer was associated with loss of control, and that downloading and interacting with an app was a  "Whip cancer provides people with the power to instantly and accurately picture the cancer cells they want to expel from their bodies… Whip Cancer is a powerful tool to help you become relaxed and thus feel empowered while battling your cancer." Navigating a journey Breast Cancer healthline: "You're not on this journey alone. Are you facing a diagnosis? Already in treatment? Remission? We'll connect you with people just like you, at the same stage in the journey".
"The BigC-Connect platform has been designed to help survivors of cancer on their journey to survival. Being empowered to take control "Hearing that you have been diagnosed with breast cancer can turn your world upside down. The OWise breast cancer app can help you regain control during the chaotic times of illness and treatments" Blood Cancer Storylines is filled with great tools to help you take control of your health.

Content analysis
The apps offered content that could be summarised under five main categories: (1) Imparting Feedback about Cancer Management. The specific app features that support each of these activities are summarised in Table 3 and discussed below.  Clinical trials matching 1 (0.7%) Access to an on-line cancer community or social network (Four offered a matching service) 25 (16.6%) List of local (geographically limited) sources of peer support 11 (7.3%) Message a linked healthcare professional 4 (2.7%)

Interacting with others
Ask a professional within an online community 3 (2.0%) Track and record specific symptoms or physiological parameters 29 (19.2%) Provides symptom management tips and advice 5 (3.3%) Set alarms as reminders to take medication 14 (9.3%) Track fitness or diet (four apps offered integration with wearable fitness trackers)

Enacting management strategies and adjusting
Offers spiritual support e.g. bible verses, prayers 2 (1.4%) Generates graphical summaries of self-monitoring data for personal reflection and sharing with others (particularly clinicians) 21 (13.9%) Generates or supports creation of question prompt lists (intended to be used during medical encounters) 13  fact-sheets/written information, news feeds and updates, questions and answers, and videos.
Some apps (e.g. Breast Cancer Ally) provided personalised information based on userreported characteristics, including treatments received or disease subtype. One app, Personalized Sarcoma Care, offered prognostic information to users with high-grade soft tissue sarcoma of the limb who were going to be treated with surgery and radiotherapy. The app offered a disclaimer that it was not a medical device, not meant to be used to inform clinical decisions, and not tested for clinical usefulness. Users were instructed to discuss prognostic results with their physician.

Planning and Organising Cancer Care
Twenty-five apps (16.6%) allowed users to enter and store records relating to their cancer care, such as results or diaries of treatments they had received. Apps also allowed users to keep a calendar of appointments (n=12, 8 Guidelines and regulatory procedures for health apps have been introduced in the UK (29,30) and the USA (31), but these mainly apply to apps classed as medical devices (used to diagnose, support diagnosis or clinical decision making, or make calculations to determine diagnosis or treatment), which are considered to carry the highest risks. Apps that provide education, monitor health or well-being, and store or transmit data without change are not subject to the same regulatory procedures.(30) These types of apps can be developed quickly by anyone who wishes to (32), without specific regulatory requirements.
There is increasing recognition that lack of public trust is a major barrier to the successful utilisation of data and technology to improve patient outcomes. (33) In a recent review, Wyatt discussed problems with health apps, including privacy issues, poor quality content, and variable accuracy, for example, in diagnosing melanoma (34). In our review, the majority of apps were free, and it was beyond the scope of this review to determine how apps attracted revenue. Potential sources include advertising, in-app purchases, and data "harvesting". There is increasing evidence that sharing of user data is routine in medical apps (35)  There seems to be a widely held assumption in symptom management apps that providing patients with simple graphical summaries of their self-reported symptom data will afford insights that could improve symptom management. Conversely, there is a danger that apps could increase the work and burden of cancer survivorship activities without resultant benefits to the user. We noted close parallels between categories of app content (Table 3), and models of treatment burden in other chronic conditions. (29)(30)(31).

Strengths and limitations
The app market is changing rapidly -more apps are being added to app stores every day, and it is also possible for developers to delete apps from on-line stores. within the apps. We did not register a review protocol, which is a relatively new requirement in updated PRISMA guidelines for scoping reviews, which were published after we started this review (40).
App stores are commercial entities and are not searchable in the same way as databases of published medical literature. We fully expect that other relevant apps exist which have not been identified by our searches. Furthermore, it is not possible to save or export searches.
Apps are displayed in an order that is determined by on-line stores, and, to the best of our knowledge, the exact sort algorithms utilised by stores are not in the public domain. This makes searches difficult to accurately reproduce, and also made it difficult to involve two authors in all stages of the app selection process. Nevertheless, where possible, we have adopted principles of systematic reviewing. We are confident that we have identified apps in a systematic and unbiased way, and have characterised a large spectrum of currently available apps.

Conclusions
Apps exist that cover a large spectrum of cancer survivorship activities: key components are information provision, storing personal summaries, and self-monitoring. Contributions: RA conceptualized this review, designed the review, undertook searches, assessed the apps for inclusion/exclusion, undertook data extraction, and wrote the paper.
DM undertook scoping searches, helped refine the search criteria, checked the final apps fulfilled inclusion/exclusion criteria, and performed independent dual data extraction and content coding. He contributed to drafts of the paper, and revising the article critically.

Figure 1: Identification and screening process for apps included in this review
.  *Apple's app store was searched up to and not including the 500 th app on the on-line store: after several hundred apps, the apps became less relevant to our review ** There were three apps which we were unable to find again after the initial searches: two (faith.org; and ovarian cancer treatments (things to do) seemed to be removed from the store, and there was an administrative error during recording the name of the third app, which led to a missing field in our exclusion file   *The nature of the owner and country of origin was open to a degree of interpretation/judgement by the authors, and therefore we involved two authors in extracting this data independently. Linked websites were visited. There were high levels of agreement and we reached consensus by discussion. We have applied the term "charity" to cover non-profit organisations.
$Google Play will publish a "star" rating when there is one or more reviews of the app. Many of the apps available via Apple's app store reported that there were not enough reviews to present a star rating. Ratings were accurate to November 2018. Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.

Rationale 3
Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.
3 Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.
X, reported in limitations, discussion Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

5
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

Search 8
Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

5
Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

5
Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators. 6

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made.

6
Critical appraisal of individual 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe Not done

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

18
Limitations 20 Discuss the limitations of the scoping review process. 20

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.
Click here to enter text. JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. * Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites. † A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote). ‡ The frameworks by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4,5) refer to the process of data extraction in a scoping review as data charting. § The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).  (7). There is growing political and clinical interest in utilising digital technologies to deliver efficient, high quality care for cancer survivors (8) and to empower patients to perform self-management activities (9).
The market for apps, including health apps is growing rapidly (10,11) with an estimated 318,000 health apps available in 2017 (12). It is estimated that over 200 health apps are added daily to app stores (13). Against this changing technological environment, attempts to summarise and evaluate healthcare apps in traditional systematic reviews are limited by the relatively small proportion of technologies which are reported in published literature (14,15).
An alternative strategy has been to identify and review apps that are available for download via on-line stores (16)(17)(18) . The aim of this review is to characterise apps targeting individuals living with and beyond cancer that are currently available for download via the two major app stores (Google Play and Apple's App Store), which have been estimated to contain over ninety percent of all apps (20). The review will provide a summary of the apps' advertised components, stated aims, and technological features. We aim to categorise and organise the apps such that clinicians, app developers, and policy makers can make sense of the current international app market for people living with and beyond cancer.

Methods
We performed a scoping review,(23) searching Apple's App Store and Google Play to identify apps targeting people living with and beyond cancer, and used content analysis (24) to characterise advertised content. Scoping reviews differ from traditional systematic reviews in that they map a topic in order to communicate the breadth and depth of the field,(25) and do not tend to involve formal quality assessment of the evidence (23). They describe the "extent, range, and nature" (23) of the available evidence, and set it in context in terms of current understanding. Scoping reviews require analytical interpretation of the subject area (26). They are particularly useful when synthesis involves non-research material, (26) and for emerging areas of research.
In this scoping review, we did not download and interact with the apps or test quality or functionality. In a previous review, Kassianos et al used app store summaries and were able to yield detailed descriptions of melanoma app content (20). Based on older reviews, (19,22) we expected to find a large number of apps, and in this rapidly changing field, the time required to interact with each app would lead to significant delays in communicating our findings. We wished to include paid apps, and had limited resources to buy individual apps for multiple authors. We also wished to include any apps affiliated with specific centres or clinical trials which would require log in credentials.

Search strategy
Initial searches were conducted by two authors, DM and RA, who refined the search criteria.
The lead author then searched the two leading app stores, Apple's App store (we used an iPhone with iOS operating system), and Android's Google Play (we used a PC with Windows operating system) in September 2018 using the keywords "cancer", "cancer survivor", and "cancer survivorship". We included: apps aimed at patients living with and beyond cancer; free and paid apps from any country; apps that included pre-diagnosis support and information (so long as they also specifically targeted individuals living with and beyond cancer); and apps covering more than one clinical condition, so long as cancer was a named condition.
We excluded: apps unavailable in English or without English descriptions; simple awareness raising or pre-diagnosis apps (apps raising awareness of symptoms that were potentially indicative of cancer or risk assessment tools, skin/mole checking apps for individuals without a diagnosis of skin cancer, simple factsheets about a certain cancer type, or glossaries); and recipe and diet apps that were not specifically targeting patients living with and beyond cancer.
Apple's App store operates a "continuous scroll" function, meaning that the store loads content continuously to return results. General search terms or keywords (e.g. "cancer") can result in "endless scrolling" or "infinite scrolling", where results are continuously returned without an apparent end point. Our initial scoping searches showed that apps became much less relevant after the first few hundred results, and we decided to limit our search of Apple's App store to the first 500 results for the term "cancer". The online stores are not set up to allow search results to be exported, and decisions about inclusion and exclusion were made by a single author (RA). Eligibility was determined from the descriptions of the apps within the app stores. Descriptions of the final apps selected for inclusion were reviewed by a second author (DM) to ensure that apps met the eligibility criteria.

Data extraction and synthesis
A data extraction form was created in Microsoft Excel and two researchers (RA and DM) independently extracted data from all apps that met the inclusion criteria. Data were obtained The text description of the app given in the online store was copied verbatim and imported into Microsoft Word. We used content analysis (24) and thematic analysis (27) to organise, categorise, and synthesise qualitative data. App descriptions and accompanying notes were imported into NVivo version 11. Data familiarisation took place by reading and re-reading app descriptions. Initial codes were generated by the lead author in order to organise the data into meaningful groups and these were discussed with a second author (DP) (28) Codes were sorted into categories, based on how the codes were related and linked. Each app was then analysed independently by two reviewers (RA and DM) to categorise the advertised content.
The reviewers were alert to any content which did not fit the categories. We also analysed

Patient and Public Involvement
We did not involve patients or the public in this scoping review, but rather plan to use the results to inform technology co-design projects which involve patients and the public.

Results
We screened 1265 apps and included 151 in our final synthesis (see flow chart, Figure 1). A full list of included apps, data on star ratings, and the raw data used in our analyses are included as a supplementary data file. App names will be reported in Italics throughout our results.

App demographics
Characteristics of the apps are provided in healthcare organisations (n = 15, 9.9%) and academic institutions (n = 8, 5.3%). We found apps sharing the same developer and with similar content, but differing by cancer type: Eight apps were developed by "@point of care", and five apps developed by "Self-care catalysts",   fighting and battles were prominent in apps promoting healthy eating or specific "cancerfighting" foods or diets.
Cancer was often compared to a journey and apps marketed themselves as tools to help navigate that journey. Apps that incorporated social networking often emphasised that the cancer journey did not have to be navigated alone. Social networking was suggested as a source of knowledge and emotional support. Many apps promoted peer comparison, and emphasised that others around the world were facing very similar problems, with some apps referring to "others like you". There was a sense within language used that cancer was associated with loss of control, and that downloading and interacting with an app was a  "Whip cancer provides people with the power to instantly and accurately picture the cancer cells they want to expel from their bodies… Whip Cancer is a powerful tool to help you become relaxed and thus feel empowered while battling your cancer." Navigating a journey Breast Cancer healthline: "You're not on this journey alone. Are you facing a diagnosis? Already in treatment? Remission? We'll connect you with people just like you, at the same stage in the journey".
"The BigC-Connect platform has been designed to help survivors of cancer on their journey to survival." Being empowered to take control "Hearing that you have been diagnosed with breast cancer can turn your world upside down. The OWise breast cancer app can help you regain control during the chaotic times of illness and treatments" "Blood Cancer Storylines is filled with great tools to help you take control of your health."

Content analysis
The apps offered content that could be summarised under five main categories: (1) Imparting Feedback about Cancer Management. The specific app features that support each of these activities are summarised in Table 3 and discussed below.  Guidelines and regulatory procedures for health apps have been introduced in the UK (33,34) and the USA (35), but these mainly apply to apps classed as medical devices (used to diagnose, support diagnosis or clinical decision making, or make calculations to determine diagnosis or treatment), which are considered to carry the highest risks. Apps that provide education, monitor health or well-being, and store or transmit data without change are not subject to the same regulatory procedures.(34) These types of apps can be developed quickly by anyone who wishes to (36), without specific regulatory requirements.
There is increasing recognition that lack of public trust is a major barrier to the successful utilisation of data and technology to improve patient outcomes.(37) In a recent review, Wyatt discussed problems with health apps, including privacy issues, poor quality content, and variable accuracy, for example, in diagnosing melanoma (38). In our review, most apps were free, and it was beyond the scope of this review to determine how apps attracted revenue.
Potential sources include advertising, in-app purchases, and data "harvesting". There is increasing evidence that sharing of user data is routine in medical apps (39) and that data harvesting for targeted advertising is an important source of revenue for many app developers. (38) Questions remain about the clinical role of cancer apps, how they affect formal medical care and influence clinical outcomes. Some of the apps we reviewed helped users to generate lists There seems to be a widely held assumption in symptom management apps that providing patients with simple graphical summaries of their self-reported symptom data will afford insights that could improve symptom management. Conversely, there is a danger that apps could increase the work and burden of cancer survivorship activities without resultant benefits to the user. We noted close parallels between categories of app content (Table 3), and models of treatment burden in other chronic conditions. (29)(30)(31).
The app market is a potentially challenging environment for patients and clinicians to navigate in terms of judging app quality, effectiveness, clinical utility, and data privacy. It may be that app stores themselves should be asked to take more responsibility for the content of the apps they offer. Several high-profile scandals, for example, Cambridge Analytica allegedly using Facebook data to influence election results, (44) and suicides potentially linked to social media use (45), have led to increased public scrutiny surrounding the social While app stores continue to offer low quality and potentially exploitative apps, we propose a rudimentary check-list (Text box one), the "Four D's", which might be used by patients before downloading a health app. The checklist was derived pragmatically, based on our experiences of conducting this review, and on the existing literature/guidelines discussed above (33,35,38,39).

Text Box one: Four D's to discuss with patients if they are considering using a health app
Does something useful -does it solve a problem you are having?
Design -are there screenshots that summarise the content and give you an impression of how you would use the app?
Developer -do you recognise a credible organisation/source behind the app, and do links to the developer website work?
Data -does the app ask you for personal information that you would prefer not to be shared with others or provide safeguards to keep your information private?
Intuitively, we considered a fifth "D" -Downloads, in which the number of downloads and positive/detailed consumer reviews might serve as an indicator of quality and trustworthiness.
Apps by reputable organisations tended to be highly downloaded, but we also found highly times. We also considered that some app reviews could be false or purposefully misleading.
The association between number of downloads and objective measures of quality deserve further attention.

Strengths and limitations
The app market is changing rapidly -more apps are being added to app stores every day, and it is also possible for developers to delete apps from on-line stores. We have presented a snapshot of what was available between September 2018 and May 2019. The main limitation of this review is that we did not download and interact with individual apps. To have done so would have added considerable time to the review process (which was time-sensitive, given the changing nature of the market), and would have also involved buying several apps that looked to have limited content (e.g. "Don't die 2" retailed at £299.99). Our content analysis is based on what was stated in online descriptions, and may underestimate content contained within the apps. We did not register a review protocol, which is a relatively new requirement in updated PRISMA guidelines for scoping reviews, which were published after we started this review (47).
App stores are commercial entities and are not searchable in the same way as databases of published medical literature. We fully expect that other relevant apps exist which have not been identified by our searches. Furthermore, it is not possible to save or export searches.
Apps are displayed in an order that is determined by on-line stores, and, to the best of our knowledge, the exact sort algorithms utilised by stores are not in the public domain. This makes searches difficult to accurately reproduce, and made it difficult to involve two authors in all stages of the app selection process. Nevertheless, where possible, we have adopted

Conclusions
Apps exist that cover a large spectrum of cancer survivorship activities: key components are Contributions: RA conceptualized this review, designed the review, undertook searches, assessed the apps for inclusion/exclusion, undertook data extraction, and wrote the paper.
DM undertook scoping searches, helped refine the search criteria, checked the final apps fulfilled inclusion/exclusion criteria, and performed independent dual data extraction and content coding. He contributed to drafts of the paper, and revising the article critically. PM contributed to drafts of the paper and revising the article critically.

Data sharing statement
All data relevant to the study are included in the article or uploaded as supplementary information. .

Figure 1: Identification and screening process for apps included in this review
*Apple's app store was searched up to and not including the 500 th app on the on-line store: after several hundred apps, the apps became less relevant to our review ** There were three apps which we were unable to find again after the initial searches: two (faith.org; and ovarian cancer treatments (things to do) seemed to be removed from the store, and there was an administrative error during recording the name of the third app, which led to a missing field in our exclusion file  *The nature of the owner and country of origin was open to a degree of interpretation/judgement by the authors, and therefore we involved two authors in extracting this data independently. Linked websites were visited. There were high levels of agreement and we reached consensus by discussion. We have applied the term "charity" to cover non-profit organisations.
$Google Play will publish a "star" rating when there is one or more reviews of the app. Many of the apps available via Apple's app store reported that there were not enough reviews to present a star rating. Ratings were accurate to November 2018. Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.

Rationale 3
Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.
3 Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.
X, reported in limitations, discussion Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

5
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

Search 8
Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

5
Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

5
Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators. 6

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

23
Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.

Supplementary data
Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12). Not done

Results of individual sources of evidence 17
For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.

7-17
Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives. 7-17

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

18
Limitations 20 Discuss the limitations of the scoping review process. 20

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.
Click here to enter text. JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. * Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites. † A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote). ‡ The frameworks by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4,5) refer to the process of data extraction in a scoping review as data charting. § The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 (7). There is growing political and clinical interest in utilising digital technologies to deliver efficient, high quality care for cancer survivors (8) and to empower patients to perform self-management activities (9).
The market for apps, including health apps is growing rapidly (10,11) with an estimated 318,000 health apps available in 2017 (12). It is estimated that over 200 health apps are added daily to app stores (13). Against this changing technological environment, attempts to summarise and evaluate healthcare apps in traditional systematic reviews are limited by the relatively small proportion of technologies which are reported in published literature (14,15).

Methods
We performed a scoping review,(23) searching Apple's App Store and Google Play to identify apps targeting people living with and beyond cancer, and used content analysis (24) to characterise advertised content. Scoping reviews differ from traditional systematic reviews in that they map a topic in order to communicate the breadth and depth of the field,(25) and do not tend to involve formal quality assessment of the evidence (23). They describe the "extent, range, and nature" (23) of the available evidence, and set it in context in terms of current understanding. Scoping reviews require analytical interpretation of the subject area (26). They are particularly useful when synthesis involves non-research material, (26) and for emerging areas of research.
In this scoping review, we did not download and interact with the apps or test quality or functionality. In a previous review, Kassianos et al used app store summaries and were able to yield detailed descriptions of melanoma app content (20). Based on older reviews, (19,22) we expected to find a large number of apps, and in this rapidly changing field, the time required to interact with each app would lead to significant delays in communicating our findings. We wished to include paid apps, and had limited resources to buy individual apps for multiple authors. We also wished to include any apps affiliated with specific centres or clinical trials which would require log in credentials.

Search strategy
Initial searches were conducted by two authors, DM and RA, who refined the search criteria.
The lead author then searched the two leading app stores, Apple's App store (we used an iPhone with iOS operating system), and Android's Google Play (we used a PC with Windows operating system) in September 2018 using the keywords "cancer", "cancer survivor", and "cancer survivorship". We included: apps aimed at patients living with and beyond cancer; free and paid apps from any country; apps that included pre-diagnosis support and information (so long as they also specifically targeted individuals living with and beyond cancer); and apps covering more than one clinical condition, so long as cancer was a named condition.
We excluded: apps unavailable in English or without English descriptions; simple awareness raising or pre-diagnosis apps (apps raising awareness of symptoms that were potentially indicative of cancer or risk assessment tools, skin/mole checking apps for individuals without a diagnosis of skin cancer, simple factsheets about a certain cancer type, or glossaries); and recipe and diet apps that were not specifically targeting patients living with and beyond cancer.
Apple's App store operates a "continuous scroll" function, meaning that the store loads content continuously to return results. General search terms or keywords (e.g. "cancer") can result in "endless scrolling" or "infinite scrolling", where results are continuously returned without an apparent end point. Our initial scoping searches showed that apps became much less relevant after the first few hundred results, and we decided to limit our search of Apple's App store to the first 500 results for the term "cancer". The online stores are not set up to allow search results to be exported, and decisions about inclusion and exclusion were made by a single author (RA). Eligibility was determined from the descriptions of the apps within the app stores. Descriptions of the final apps selected for inclusion were reviewed by a second author (DM) to ensure that apps met the eligibility criteria.

Data extraction and synthesis
A data extraction form was created in Microsoft Excel and two researchers (RA and DM) independently extracted data from all apps that met the inclusion criteria. Data were obtained The text description of the app given in the online store was copied verbatim and imported into Microsoft Word. We used content analysis (24) and thematic analysis (27) to organise, categorise, and synthesise qualitative data. App descriptions and accompanying notes were imported into NVivo version 11. Data familiarisation took place by reading and re-reading app descriptions. Initial codes were generated by the lead author in order to organise the data into meaningful groups and these were discussed with a second author (DP) (28) Codes were sorted into categories, based on how the codes were related and linked. Each app was then analysed independently by two reviewers (RA and DM) to categorise the advertised content.
The reviewers were alert to any content which did not fit the categories. We also analysed

Patient and Public Involvement
We did not involve patients or the public in this scoping review, but rather plan to use the results to inform technology co-design projects which involve patients and the public.

Results
We screened 1265 apps and included 151 in our final synthesis (see flow chart, Figure 1). A full list of included apps, data on star ratings, and the raw data used in our analyses are included as a supplementary data file. App names will be reported in Italics throughout our results.

App demographics
Characteristics of the apps are provided in healthcare organisations (n = 15, 9.9%) and academic institutions (n = 8, 5.3%). We found apps sharing the same developer and with similar content, but differing by cancer type: Eight apps were developed by "@point of care", and five apps developed by "Self-care catalysts",  fighting and battles were prominent in apps promoting healthy eating or specific "cancerfighting" foods or diets.
Cancer was often compared to a journey and apps marketed themselves as tools to help navigate that journey. Apps that incorporated social networking often emphasised that the cancer journey did not have to be navigated alone. Social networking was suggested as a source of knowledge and emotional support. Many apps promoted peer comparison, and emphasised that others around the world were facing very similar problems, with some apps referring to "others like you". There was a sense within language used that cancer was associated with loss of control, and that downloading and interacting with an app was a  "Whip cancer provides people with the power to instantly and accurately picture the cancer cells they want to expel from their bodies… Whip Cancer is a powerful tool to help you become relaxed and thus feel empowered while battling your cancer." Navigating a journey Breast Cancer healthline: "You're not on this journey alone. Are you facing a diagnosis? Already in treatment? Remission? We'll connect you with people just like you, at the same stage in the journey".
"The BigC-Connect platform has been designed to help survivors of cancer on their journey to survival." Being empowered to take control "Hearing that you have been diagnosed with breast cancer can turn your world upside down. The OWise breast cancer app can help you regain control during the chaotic times of illness and treatments" "Blood Cancer Storylines is filled with great tools to help you take control of your health."
There is increasing recognition that lack of public trust is a major barrier to the successful utilisation of data and technology to improve patient outcomes. (37) In a recent review, Wyatt discussed problems with health apps, including privacy issues, poor quality content, and variable accuracy, for example, in diagnosing melanoma (38). In our review, most apps were free, and it was beyond the scope of this review to determine how apps attracted revenue.
Potential sources include advertising, in-app purchases, and data "harvesting". There is increasing evidence that sharing of user data is routine in medical apps (39) and that data harvesting for targeted advertising is an important source of revenue for many app developers. (38) Questions remain about the clinical role of cancer apps, how they affect formal medical care and influence clinical outcomes. Some of the apps we reviewed helped users to generate lists  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  There seems to be a widely held assumption in symptom management apps that providing patients with simple graphical summaries of their self-reported symptom data will afford insights that could improve symptom management. Conversely, there is a danger that apps could increase the work and burden of cancer survivorship activities without resultant benefits to the user. We noted close parallels between categories of app content (Table 3), and models of treatment burden in other chronic conditions. (29)(30)(31).
The app market is a potentially challenging environment for patients and clinicians to navigate in terms of judging app quality, effectiveness, clinical utility, and data privacy. It may be that app stores themselves should be asked to take more responsibility for the content of the apps they offer. Several high-profile scandals, for example, Cambridge Analytica allegedly using Facebook data to influence election results, (44) and suicides potentially linked to social media use (45), have led to increased public scrutiny surrounding the social  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Design -are there screenshots that summarise the content and give you an impression of how you would use the app?
Developer -do you recognise a credible organisation/source behind the app, and do links to the developer website work?
Data -does the app ask you for personal information that you would prefer not to be shared with others or provide a transparent description of how data will be used and shared?
Intuitively, we considered a fifth "D" -Downloads, in which the number of downloads and positive/detailed consumer reviews might serve as an indicator of quality and trustworthiness.
The association between number of downloads and objective measures of quality deserve further attention.

Strengths and limitations
The app market is changing rapidly -more apps are being added to app stores every day, and it is also possible for developers to delete apps from on-line stores. We have presented a snapshot of what was available between September 2018 and May 2019. The main limitation of this review is that we did not download and interact with individual apps. To have done so would have added considerable time to the review process (which was time-sensitive, given the changing nature of the market), and would have also involved buying several apps that looked to have limited content (e.g. "Don't die 2" retailed at £299.99). Our content analysis is based on what was stated in online descriptions, and may underestimate content contained within the apps. We did not register a review protocol, which is a relatively new requirement in updated PRISMA guidelines for scoping reviews, which were published after we started this review (47).
App stores are commercial entities and are not searchable in the same way as databases of published medical literature. We fully expect that other relevant apps exist which have not been identified by our searches. Furthermore, it is not possible to save or export searches.
Apps are displayed in an order that is determined by on-line stores, and, to the best of our knowledge, the exact sort algorithms utilised by stores are not in the public domain. This makes searches difficult to accurately reproduce, and made it difficult to involve two authors in all stages of the app selection process. Nevertheless, where possible, we have adopted  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Contributions: RA conceptualized this review, designed the review, undertook searches, assessed the apps for inclusion/exclusion, undertook data extraction, and wrote the paper.
PM contributed to drafts of the paper and revising the article critically.

Data sharing statement
All data relevant to the study are included in the article or uploaded as supplementary information.
$Google Play will publish a "star" rating when there is one or more reviews of the app. Many of the apps available via Apple's app store reported that there were not enough reviews to present a star rating. Ratings were accurate to November 2018. Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.

Rationale 3
Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.
3 Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.
X, reported in limitations, discussion Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

5
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

Search 8
Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

5
Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

5
Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators. 6

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made.

6
Critical appraisal of individual 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe Not done

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

18
Limitations 20 Discuss the limitations of the scoping review process. 20

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.
Click here to enter text. JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. * Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites. † A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote). ‡ The frameworks by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4,5) refer to the process of data extraction in a scoping review as data charting. § The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60