eHealth Platforms Facilitate Prostate Cancer Shared Care: A Systematic Review

Background: Prostate cancer survivorship care is essential for the early identification of cancer recurrence and progression and the monitoring of adverse effects. Prostate cancer survivorship programs have enabled care to be shared between specialists using digital healthcare platforms. We systematically reviewed the literature to examine if prostate cancer survivorship care had been successfully digitalised. Methods: English language articles were searched on PubMed, Embase, and Cochrane Libraries. The search terms included combinations of “eHealth”, “digital health”, “prostate cancer”, “shared care”, and related keywords (studies published between [1 January 1946 and 20 March 2023]). Results: Our search strategy yielded 1722 publications, of which 17 studies were included in our final review. Diverse eHealth interventions (web platforms, apps, patient portals) for digital prostate cancer shared care enabled communication, symptom management, and holistic assessment, with potential for reducing anxiety, enhancing outcomes, and increasing engagement. The studies (9 months to 5 years duration) involved participants across different care phases (16 to 3521 participants). We identified ten eHealth platforms, which provided successful symptom tracking, needs assessment, and communications. The platform-based interventions improved some aspects of communication, symptom management, and care delivery. The ongoing clinical need for a robust digital platform that caters to all domains of shared care was identified. Conclusions: eHealth will certainly play a central role in digital prostate cancer shared care, providing better health outcomes and care delivery. Future larger studies in this field should address the implementation barriers, including cost-effectiveness and primary care remuneration. It is also crucial to refine application useability and workflow, focusing on standardization and patient-centred approaches.


Introduction
Prostate cancer is the prevalent internal malignancy in men, with 1.4 million men globally and 460,000 men in Europe diagnosed in 2020 [1][2][3].Survival rates post-diagnosis have doubled (from 1993-2013), with 5-year survival ranging from 97.1% [1] in the USA to 83% in Europe [2,3].More than 3.3 million prostate cancer survivors exist in the USA alone.This is set to increase with earlier detection and more effective treatments, straining survivorship care demand [1].
Vigilant monitoring is crucial to detect disease recurrence, treatment side effects, and psychological distress.Key areas of prostate survivorship care include management of incontinence, erectile dysfunction, and mental health problems [4].Androgen deprivation therapy further increases risks of metabolic disease, heart issues, and mood disturbance [5].With increasing diagnosis and survival, the survivorship population continues to expand, further stressing outpatient services and emergency departments.This issue is amplified in remote areas by geographical barriers, thus necessitating innovation in delivery of shared care [6].
Shared survivorship care has been defined as the joint participation of primary and specialist clinicians in planned delivery of care informed by an enhanced information exchange [7,8].Prostate cancer shared care models involving urologists, nurses, and family doctors have demonstrated success [9].However, effective coordination requires significant time and financial investment [4,10].One American study used SEER-Medicare data (79,826 men categorized by costs, from 1992-2005, ages 66-99, ~14% of survivorship population) to quantify these factors [10].Whilst initial care incurred the highest cost (AUD 987 million), continuing care (AUD 533 million) was a significant expense (per patient yearly cost AUD 1464).Notably, after 8 years, continuing care costs surpassed initial care for survivors (AUD 10,248 vs. AUD 8799).Of this, office visits for follow-up care comprised 27.3% (the most significant cost was androgen deprivation therapy at 62.7%).This ongoing survivorship cost is a significant public health issue.eHealth technologies have been proffered as a solution to this; efficiently coordinating multidisciplinary, multi-institutional care reducing the need for outpatient review [6,11].We systematically reviewed the literature to explore eHealth's emerging role in digital prostate cancer shared care, interrogating the limitations of available technology and the implementation barriers they face.

Research Question and Search Strategy
The primary research question guiding this systematic review is as follows: How does eHealth contribute to prostate cancer shared care?
A systematic and comprehensive search was conducted across electronic databases, including PubMed, Embase, and Cochrane Library.Study eligibility was assessed using the 'Patient, Intervention, Comparison, Outcome' (PICO) basis.We included the studies that targeted patients with prostate cancer and/or prostate cancer survivors.The main interventions included the application of a digital healthcare platform and the assessment of the outcome of their implementation.Comparison to the paper-based system of shared care was considered but not always implemented.Various forms of desirable outcome were assessed, including cost-effectiveness/minimization, improvement of care, and/or health.
The search terms included combinations of "eHealth", "digital health", "prostate cancer", "shared care", and related keywords.The search was limited to studies published between [1 January 1946 and 20 March 2023] (Figure 1).Additionally, references from relevant articles, grey literature including abstracts, conference procedures, and online tools were hand-searched to identify any additional studies.All selected studies were screened by two separate authors (DH and JM), and disagreements were independently adjudicated (GI).
This systematic review protocol and description of the search strategy were registered and published in the PROSPERO database on 18 July 2024.The project registration ID is CRD42024566664.
To identify all steps in the selection process and analysis, the authors adapted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Supplementary Materials) which is designed to explain the process of gathering and selection of the appropriate information.
(Supplementary Materials) which is designed to explain the process of gathering and selection of the appropriate information.

Inclusion Criteria
Full-text English original articles focusing on eHealth 'shared care' interventions in prostate cancer shared care were eligible.Full text studies which described care model or trial-based evaluations were included.Papers that were not presented in full texts (e.g., abstracts) and non-research studies (e.g., reviews) were excluded, although some of them were screened to identify potential links to the full text originals (Figure 1).Duplicate

Inclusion Criteria
Full-text English original articles focusing on eHealth 'shared care' interventions in prostate cancer shared care were eligible.Full text studies which described care model or trial-based evaluations were included.Papers that were not presented in full texts (e.g., abstracts) and non-research studies (e.g., reviews) were excluded, although some of them were screened to identify potential links to the full text originals (Figure 1).Duplicate manuscripts were excluded using Covidence application tool (https://www.covidence.org/; accessed on 5 September 2023).

Shared Care Application Definition
This review focused on shared care applications, which were defined as including evidence-based Patient-Reported Outcome Measures (PROMs) (at more than two discrete timepoints including: patient satisfaction, quality of life, and clinical outcomes), communication tools (either instant message, email notification, or asynchronous text based), as well as clinician-led intervention rather than solely application-led self-care symptom control.These studies were chosen as they best addressed the key domains of shared care.

Risk of Bias Assessment (Quality Evaluation)
The selected articles were evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool to estimate the quality of the published data.The sources of information, design of the study, and the description of the sample (number of participants and centres) were assessed for each full-text article.

Results
The studies examined included various eHealth interventions, such as web-based platforms, smartphone applications, and multi-platform patient portals.Key findings indicated that these interventions facilitated varying amounts of communication, symptom management, and holistic needs assessment.

Study Selection and Characteristics
Seventeen studies were selected for inclusion in the systematic review, focusing on eHealth interventions in digital prostate cancer shared care (Table 1).These studies were chosen based on keyword-based search strategy and predefined inclusion criteria.

Participant Characteristics
The studies included diverse populations of prostate cancer patients, encompassing various phases of survivorship cancer care, including radiotherapy, chemotherapy, and post-surgical care.Sample sizes varied across studies, ranging from 16 to 3521 participants, reflecting the heterogeneity of the patient populations under investigation (Table 1).

Intervention Characteristics
A variety of eHealth interventions have been used to improve communication, symptom management, and overall care delivery across these platforms.The heterogeneity of the selected studies was noted and discussed as part of the qualitative assessment.

Holistic Needs Assessment (HNA) Tools
CHAT-P, a web-based shared care platform, was built around the principals of HNA [12,21].This includes patient-reported outcome measures, information provision, and support for the financial and legal aspects of care.The rationale of HNA tools was to create a more holistic understanding of patients' physical, psychological, and social needs, enabling personalized care planning.The published pilot study was limited to qualitative interview data about perceived benefits around time saving and holistic care.However, at this stage, there has been no proven quantified benefit from this platform.

Symptom Tracking and Management
Various interventions focused on symptom tracking and management throughout the prostate cancer care journey.Smartphone applications, such as Interaktor, enabled patients to perform daily symptom scoring and receive real-time alerts based on the occurrence, frequency, and distress of symptoms [14,15,[22][23][24][25]. Interaktor then provided evidence-based self-care advice and facilitated targeted communication between patients and healthcare providers.By empowering patients to monitor and manage their symptoms, these interventions aimed to improve symptom control and overall well-being.

Patient-Reported Outcome Measures (PROMs)
All platforms integrated patient-reported outcome measures (PROMs) into their eHealth interventions.Web-based patient portals, such as PROMIS CAT T (EPIC, My-Chart), were used to collect patient-reported data on symptoms, quality of life, and care needs [19].PROMs facilitated the identification of prevalent symptoms and allowed for a more patient-centred approach to care.The integration of PROMs into existing electronic health record systems enabled efficient data collection and facilitated clinical review when specific symptoms or care needs were identified.

Patient Education and Support
Many programs (PERC, CHAT P) include patient education and support for prostate cancer patients and their partners [26].These programs offer modules on teamwork, managing treatment side effects, and promoting healthy behaviours.Additionally, they provide social support through online forums, meetings with health educators, and resource centres.By empowering patients and their partners with knowledge and support, these interventions aim to enhance patient self-management and satisfaction.
The studies showcase diverse ways to improve digital prostate cancer care, including holistic assessments, symptom tracking, and communication tools.These aim to enhance patient engagement, symptom control, and care quality.eHealth interventions with different designs and functions highlighted the role for multifaceted approaches for improving shared care.

Control Groups and Outcome Measures
Comprehensive meta-analysis on these studies was not plausible given variations in control groups and outcome measures (often limited or none).Comparator groups ranged widely from none to standard care to historical controls, causing further inconsistency.Most studies lacked clinical endpoints, relying instead on patient-reported outcomes or qualitative surveys, limiting assessment of health impacts (Table 1).Diverse study designs and small sample sizes further complicate comparisons.The heterogenicity of the various eHealth interventions and study durations introduced further difficulty making meaning extraction of data

Discussion
While many of these studies have part of a comprehensive shared care platform, their contributions to shared care are limited by their inability to address all realms.Effective implementation of eHealth in digital prostate cancer shared care is complex involving multisite, multidisciplinary integration.To successfully achieve this ambition, eHealth platforms need to facilitate all aspects of shared care.The central finding from this review is that current platforms fail to achieve comprehensive shared care facilitation.We dissect comparative enablers and barriers, strategies of platform development, implementation strategies, and platform strengths and weaknesses.We then formulate this to highlight gaps in contemporary practice.

Contrasting Enabling Strategies and Barriers
Previous studies reviewed present diverse eHealth interventions in aspects of digital prostate cancer shared care.They include the use of web-based platforms for holistic needs assessment [21], web-based asynchronous tools for communication between primary care providers and cancer specialists [13], integration of existing electronic health records for symptom screening and support [19], and the development of smartphone applications for symptom management [14].

Retrofitting Existing Systems vs. Creation of Novel Applications
Two studies chose to leverage existing EMRs to facilitate their digital shared care platform [19,20].Both studies used EPIC TM infrastructure to create new patient webbased patient portals (PROMIS CAT T) and patient applications (eSym).Whilst this overcomes intra-hospital integration barriers, it likely leads to less flexibility with primary care integration using various EMRs.In contrast to this, many other groups choose to custom-design novel web-portals and applications.

Implementation Barriers
The implementation of eHealth in digital prostate cancer shared care faces common barriers to any new eHealth platform.These include difficulties in integrating hospital and general practice IT systems [16], challenges in linking patients and healthcare teams through web-based portals [27], and varying levels of patient engagement with the applications [15].
However, implementation barriers are multifaceted, involving issues such as profitability, remuneration, accessibility, culture, and usability.Such socio-technical challenges and varying levels of technological readiness impact the implementation success of eHealth interventions [29,30].
Nanton et al. highlighted the difficulty of integrating web-based tools in prostate cancer care despite their potential benefits [12].Petrovic's trial found that eOncoNote reduced patient anxiety but did not improve care continuity, pointing to the need to evaluate both clinical and psychological outcomes [13].
Garcia et al. showed that integrating patient-reported outcomes into EHRs improved clinical reviews but increased patient anxiety, emphasizing the importance of psychological considerations [19].Sundberg's study on the Interaktor app demonstrated reduced symptoms during prostate cancer radiotherapy but required strong patient adherence and system integration [14].Lastly, Clarke's work on a shared digital platform revealed IT integration issues between hospitals and general practices, highlighting the need to address technical and systemic barriers for successful eHealth implementation [16].
Such implementation issues highlight the need for the planned effective coordination and interoperability of proposed eHealth interventions into existing healthcare digital architecture and clinical workflows.It is likely that effective implementation requires perceptible time savings, ease of use, and remuneration models for initial user implementation.

Within Hospitals or within Primary Care
Raising awareness and training staff on system use and patient introduction are crucial for implementation [19].Avoiding burdensome workflows is also vital for staff uptake within larger care organisations.
Effective primary care consultation to inform uptake of new technologies is essential [31].Without an effective model for uptake addressing key primary care concerns, rollout is limited as learning new systems is often seen as burdensome, costly, and time inefficient [32].Robust primary care uptake of new shared care technology requires streamlined workflow (particularly intelligent synthesis of relevant information), improved communication, perceived patient benefit, and proper remuneration [31,32].

Common Weaknesses of eHealth Applications
Existing eHealth applications share certain weaknesses.These include implementation barriers, design flaws, lack of customization, and integration into existing electronic records.Existing publications on the use of digital tools in prostate cancer shared care show limited generalizability of findings due to small sample sizes and their pilot-type nature [15,18].Additionally, some studies report the need for further refinement and customization of eHealth interventions to address individual patient needs and preferences [15].Their clinical validation is further limited by a lack of clinical outcome measurements.Improved study designs with defined control groups and/or achievement-addressing scales are warranted.Future studies should target and mitigate for these common weaknesses early in their design phase.

Gaps and Limitations in Contemporary Practice
While existing eHealth platforms and their surrounding research have shown promise, there are significant gaps and limitations in eHealth prostate cancer shared care.These can be divided into application and study design factors.

Application Factors
The eHealth platforms examined lacked comprehensive inclusion of all domains of shared care.They face significant common challenges related to integration with existing hospital and primary care EMRs.Future attempts to create shared care platforms need to ensure that an effective implementation strategy is in place prior to application rollout.Additionally, some studies lack an emphasis on patient-centred care and shared decision-making in the development and implementation of eHealth interventions.By involving patients in the design process, we can create interventions that better address their individual needs.

Study Design Factors
Firstly, methodology variation used in the reviewed studies, including differences in study design, sample size, and duration, limits meaningful comparisons and definitive conclusions.To address this, large-scale randomized controlled trials and longer-term studies with defined clinical endpoints are required to establish the effectiveness (including oncological outcomes) and sustainability of eHealth interventions.Another important concern is the lack of standardized approaches and guidelines for developing and imple-menting eHealth platforms in digital prostate cancer shared care.The absence of consistent outcome measures and assessment tools makes it challenging to evaluate different interventions properly.
Furthermore, there is limited research on the cost-effectiveness and economic impact of eHealth applications in digital prostate cancer shared care.Future studies should consider the economic implications, feasibility, and long-term sustainability of implementing eHealth interventions in routine clinical practice.
The reviewed studies demonstrate that eHealth interventions, such as web-based platforms and smartphone applications, have the potential to enhance prostate cancer shared care by improving patient engagement, symptom management, and communication with healthcare providers.These tools empower patients to actively participate in their care, which is particularly valuable in managing chronic conditions like prostate cancer.However, the variability in study designs, populations, and outcome measures complicates the interpretation of results.The reliance on patient-reported outcomes and the lack of standardised endpoints make it difficult to assess the clinical effectiveness of these interventions.Despite these challenges, the studies highlight the promise of eHealth solutions in supporting personalized care.Future research should focus on standardising outcome measures and assessing the long-term impact of these digital tools to better understand their role in improving prostate cancer care.

Conclusions
This systematic review provides a comprehensive assessment of the role of eHealth in digital prostate cancer shared care.We identified ten eHealth platforms, which provided successful symptom tracking, needs assessment, and communications.Platform-based interventions improved some aspects of communication, symptom management, and care delivery.However, the ongoing clinical need for a robust digital platform that caters to all domains of shared care was identified.
The implementation of eHealth in digital prostate cancer shared care holds great potential for enhancing patient outcomes and improving the delivery of care.However, it requires careful consideration of strategies, addressing barriers, and refining eHealth applications to meet all patient's share care needs.Future research should focus on standardization, larger-scale studies, long-term evaluation, cost-effectiveness, and patient-centred approaches to further advance the field of eHealth in digital prostate cancer shared care.As implementation has been hindered by difficulties engaging primary care, effective remuneration strategies to enable uptake will be essential in future digital prostate cancer shared care.Moreover, existing attempts at digital shared care have lacked interoperability with existing EMRs, which further hampers their practicability.Future studies would benefit from a focus on effect interoperability and implementation.

Table 1 .
Summary of shared care applications in prostate cancer and their key characteristics.

Table 2 .
Functionality of different eHealth technologies for prostate cancer shared care.