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Net survival rates of cancer are increasing worldwide, placing a strain on health service provision. There is a drive to transfer the care of cancer survivors—individuals living with and beyond cancer—to the community and encourage them to play an active role in their own care. Telehealth, the use of technology in remote exchange of data and communication between patients and health care professionals (HCPs), is an important contributor to this evolving model of care. Telehealth interventions are “complex,” and understanding patient experiences of them is important in evaluating their impact. However, a wider view of patient experience is lacking as qualitative studies detailing cancer survivor engagement with telehealth are yet to be synthesized.
To systematically identify, appraise, and synthesize qualitative research evidence on the experiences of adult cancer survivors participating in telehealth interventions, to characterize the patient experience of telehealth interventions for this group.
Medline (PubMed), PsychINFO, Cumulative Index for Nursing and Allied Health Professionals (CINAHL), Embase, and Cochrane Central Register of Controlled Trials were searched on August 14, 2015, and March 8, 2016, for English-language papers published between 2006 and 2016. Inclusion criteria were as follows: adult cancer survivors aged 18 years and over, cancer diagnosis, experience of participating in a telehealth intervention (defined as remote communication or remote monitoring with an HCP delivered by telephone, Internet, or hand-held or mobile technology), and reporting qualitative data including verbatim quotes. An adapted Critical Appraisal Skill Programme (CASP) checklist for qualitative research was used to assess paper quality. The results section of each included article was coded line by line, and all papers underwent inductive analysis, involving comparison, reexamination, and grouping of codes to develop descriptive themes. Analytical themes were developed through an iterative process of reflection on, and interpretation of, the descriptive themes within and across studies.
Across the 22 included papers, 3 analytical themes emerged, each with 3 descriptive subthemes: (1) influence of telehealth on the disrupted lives of cancer survivors (convenience, independence, and burden); (2) personalized care across physical distance (time, space, and the human factor); and (3) remote reassurance—a safety net of health care professional connection (active connection, passive connection, and slipping through the net). Telehealth interventions represent a convenient approach, which can potentially minimize treatment burden and disruption to cancer survivors’ lives. Telehealth interventions can facilitate an experience of personalized care and reassurance for those living with and beyond cancer; however, it is important to consider individual factors when tailoring interventions to ensure engagement promotes benefit rather than burden.
Telehealth interventions can provide cancer survivors with independence and reassurance. Future telehealth interventions need to be developed iteratively in collaboration with a broad range of cancer survivors to maximize engagement and benefit.
The term “cancer survivor” is used to encompass all individuals living with cancer “from the time of diagnosis and for the balance of life” [
The effort to develop and implement technological innovations to support cancer survivorship is a global one, reflecting the drive to transfer the care of cancer survivors from hospital to community settings [
However, little is known about cancer survivors’ engagement with, and acceptance of, cancer telehealth interventions, and their lived experience of being remotely monitored—often the focus is on intervention outcomes. Of recent reviews, 3 sought to synthesize trial findings from studies reporting outcomes from interventions tested with cancer survivors in a supportive capacity [
Telehealth interventions are “complex,” comprising many components, and can be time consuming and expensive to develop and test. Medical Research Council guidance on developing and evaluating complex interventions highlights the importance of qualitative research for developing the theoretical understanding of complex interventions’ impact and processes of action [
The aim of this review therefore was to systematically identify, appraise, and synthesize qualitative research evidence on the experience of adult cancer survivors who have engaged with telehealth intervention(s) and provide a fine-grained understanding of users’ perspectives. The intent was to enhance characterization of the impact of telehealth interventions upon the experience of cancer survivorship and identify potential steps to improve engagement of cancer survivors with telehealth.
The reporting of this qualitative synthesis follows the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines [
A comprehensive search strategy was developed to identify all the studies relevant to our research question. The search strategy was developed for Medline (PubMed), then adapted and applied to PsychINFO, Cumulative Index for Nursing and Allied Health Professionals (CINAHL), Embase, and the Cochrane Central Register of Controlled Trials. These databases were chosen to encompass nursing, medicine, social sciences, and psychology. To retrieve other relevant publications, the reference lists of selected publications were hand searched and articles considered against the eligibility criteria. Nonresearch publications and “gray” literature were excluded. The search was conducted on August 14, 2015, and updated on March 8, 2016. Search results were uploaded and stored using Endnote version 7.4 (Clarivate Analytics). Duplications of studies were removed.
Search terms were split into 3 categories: cancer survivors (population), eHealth (intervention), and survivor experience (outcome). Each category included medical subject headings (MeSH) and keywords using trunctation (*) within title or abstract fields (see
Original articles in English published in the period of January 1, 2006, to March 8, 2016
Papers reporting on adults (over 18 years) who had received a diagnosis of cancer, regardless of gender, tumor type, or comorbidities
Papers reporting on participants who had experienced a telehealth intervention, which enabled remote communication or remote monitoring with health care professionals (HCPs) (the main component of the intervention was delivered by telephone, using the Internet, or using hand-held or mobile technology)
Papers reporting qualitative data—including verbatim quotes—on cancer survivors’ experience of using a telehealth intervention
Broader experience of eHealth—did not provide remote communication or monitoring with health care professionals (HCPs) (eg, chat rooms, social media, remote peer support)
Data collected during development of an intervention based on the user’s expectations rather than experience
Experience of carers only
Experience of users with conditions other than cancer
Gray literature or reviews
Qualitative data that did not include verbatim quotes
A 2-stage screening process was conducted. In stage one, 3 reviewers (first author and 2 members of the research team) screened all identified titles and abstracts that were potentially eligible for inclusion irrespective of research methodology. Full papers were then obtained and potentially eligible studies were assessed for inclusion independently by at least two of the 5 members of the review team (AC, AM, WK, FM, RM); at this stage papers that did not incorporate qualitative data were excluded. Uncertainties around paper inclusion were resolved by the final member of the review team (last author) if necessary.
All members of the research team independently extracted data for each paper using a data extraction form devised by the team; data from each paper were extracted twice by 2 separate members. All text from the papers labelled as “results” or “findings” was extracted electronically and entered into Nvivo 10, a qualitative data analysis computer software package (QSR International). Data extraction forms were compared across reviewers for each paper to ensure accuracy and comprehensiveness of data extraction.
The review team adapted the Critical Appraisal Skill Programme (CASP) checklist for qualitative research [
The findings of primary research studies were synthesized using methods proposed by Thomas and Harden [
Of the review team, 2 members (AC and GL) coded the results section of each included article line by line and developed descriptive themes through inductive analysis, involving comparison, reexamination, and grouping of codes. Descriptive themes were shared with and considered by all authors to ensure they were consistent and apposite. Descriptive themes were grouped and analytical themes were developed through an iterative process of reflection on, and interpretation of the descriptive themes within and across studies.
The search yielded 2909 records. Based on titles and abstracts, 168 records were selected for full text screening, resulting in a selection of 22 publications that met all eligibility criteria (
All the included studies were deemed to be of sufficient quality to contribute equally to the thematic synthesis. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart is presented in
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) study selection flowchart.
The 22 included studies used semistructured or in-depth interviews, or open-ended questions within surveys undertaken, with a total 445 patients (sample sizes listed in
Regarding the aims of the 22 studies, 9 explored the views of patients and health care professionals as to the use of telehealth [
Three analytical themes encompassing patients’ experience of telehealth interventions emerged, with 3 descriptive themes underpinning each of these:
This theme articulates how the remote nature of telehealth limited the disruption to peoples’ lives. Cancer survivors across many of the studies felt that their lives had been disrupted by the disease. Telehealth interventions enable the management of care remotely—away from the hospital environment—thereby minimizing this disruption. This analytical theme encompasses 3 descriptive themes: convenience, independence, and burden.
Results suggest there is benefit of telehealth in terms of convenience for cancer survivors, which allowed them to either return to normal activities or limit the interruption to daily routines. Ten studies reflected on this convenience in different ways. In telehealth interventions where telephone contact was used to replace face-to-face care, patients did not have to travel into the hospital, thereby saving time and money, and reducing the stress and burden of travel [
Studies reviewed suggested that telehealth can alter the way in which survivors relate to HCPs. Remote consultations and monitoring mean survivors have a sense of physical independence, which puts an emphasis on self-care. Eight studies reported that participants felt telehealth had educated them about ways they could improve or manage their symptoms, or raised their awareness of potential issues to look out for with regards to their disease [
If a telehealth intervention is difficult to engage with or time consuming, then it becomes a disruption in itself. Of the Web-based interventions, 2 were seen as an extra burden for survivors [
This theme illustrates how telehealth can enable close and personalized relationships between cancer survivors and service providers even though the technology is remote and functions through physical distance. This perception of personalized care is underpinned by 3 descriptive themes: perception of personal space, which is created by survivors engaging with health care in their chosen environment, expanded sense of time that the remote environment engenders, and the effect remote connection has on the sense of human contact.
In telehealth interventions, cancer survivors experience a different form of contact with their providers, engaging with their care physically from their place of choice. Of the included studies, 4 reported that remote communication gave them a sense of space to focus on their concerns and needs as they were in a familiar and relaxing environment [
A prevalent theme reported across a number of studies (n=5) was that by being away from the clinical environment, survivors felt they had time to express their concerns and did not feel as rushed as they would have in a hospital setting [
Of the included studies, 9 reported that for some cancer survivors, telehealth was perceived as impersonal and lacking physical human contact [
The computer was highlighted as a particularly impersonal medium [
A common theme across the studies was that survivors felt they had immediate access to professional advice and that this acted as a safety net in that possible issues with their treatment, symptoms, or recovery would not be missed [
Eight studies reported that telehealth interventions helped to reassure survivors by providing access to support and care through an active connection to HCPs [
Eight studies identified how survivors felt monitored or watched over by health professionals in telehealth interventions [
It is noteworthy that the reassurance provided by telehealth interventions was enhanced by the sense that telehealth provided consistency and continuity of contact. A trusting relationship, which extended “beyond the hospital boundaries” [
The reassurance provided by the frequency and constancy of contact with HCPs in telehealth interventions was jeopardized in some studies [
Themes identified in each study: influence of telehealth on the disrupted lives of cancer survivors.
Paper | Convenience |
Independence |
Burden |
Beaver, Williamson, and Chalmers, 2010 [ |
✓a | ||
Chambers et al, 2015 [ |
|||
Chan et al, 2013 [ |
✓ | ✓ | ✓ |
Cornwall, Moore, and Plant, 2008 [ |
✓ | ✓ | |
Cox et al, 2008 [ |
✓ | ||
Cox and Faithfull, 2015 [ |
✓ | ||
Fergus et al, 2014 [ |
✓ | ✓ | |
Hogberg et al, 2013 [ |
✓ | ||
Hogberg et al, 2015 [ |
✓ | ||
Kearney et al, 2006 [ |
✓ | ||
Kilbourn et al, 2013 [ |
|||
Lai et al, 2015 [ |
✓ | ||
Livingston et al, 2006 [ |
|||
Maguire et al, 2015 [ |
✓ | ||
McCann et al, 2009 [ |
✓ | ✓ | |
Ream et al, 2015 [ |
✓ | ||
Snyder et al, 2013 [ |
✓ | ||
Stacey et al, 2016 [ |
✓ | ||
Williamson, Chalmers, and Beaver, 2015 [ |
✓ | ||
Zheng et al, 2013 [ |
✓ | ||
a✓ indicates the theme was present within the paper.
Themes identified in each study: personalized care delivered from a distance.
Paper | Space |
Time |
The human factor |
Beaver, Williamson, and Chalmers, 2010 [ |
✓a | ✓ | ✓ |
Chambers et al, 2015 [ |
|||
Chan et al, 2013 [ |
|||
Cornwall, Moore, and Plant, 2008 [ |
✓ | ✓ | |
Cox et al, 2008 [ |
✓ | ||
Cox and Faithfull, 2015 [ |
✓ | ||
Fergus et al, 2014 [ |
✓ | ||
Head et al, 2011 [ |
|||
Hogberg et al, 2013 [ |
✓ | ✓ | ✓ |
Hogberg et al, 2015 [ |
✓ | ✓ | |
Kearney et al, 2006 [ |
|||
Kilbourn et al, 2013 [ |
✓ | ||
Lai et al, 2015 [ |
|||
Livingston et al, 2006 [ |
✓ | ||
Maguire et al, 2015 [ |
|||
McCall et al, 2008 [ |
✓ | ||
McCann et al, 2009 [ |
✓ | ||
Ream et al, 2015 [ |
✓ | ||
Snyder et al, 2013 [ |
✓ | ||
Stacey et al, 2016 [ |
|||
Williamson, Chalmers, and Beaver, 2015 [ |
✓ | ✓ | ✓ |
Zheng et al, 2013 [ |
a✓: indicates the theme was present within the paper.
Themes identified in each study: remote reassurance-a safety net of health care professionals (HCPs) Connection.
Paper | Active connection |
Passive connection |
Slipping through the net |
Beaver, Williamson and Chalmers, 2010 [ |
✓a | ✓ | |
Chambers et al, 2015 [ |
✓ | ✓ | |
Cornwall, Moore, and Plant, 2008 [ |
✓ | ✓ | |
Cox et al, 2008 [ |
✓ | ||
Cox and Faithfull, 2015 [ |
✓ | ✓ | |
Fergus et al, 2014 [ |
✓ | ||
Head et al, 2011 [ |
|||
Hogberg et al, 2013 [ |
✓ | ||
Hogberg et al, 2015 [ |
✓ | ✓ | ✓ |
Kearney et al, 2006 [ |
✓ | ✓ | |
Kilbourn et al, 2013 [ |
|||
Lai et al, 2015 [ |
✓ | ||
Livingston et al, 2006 [ |
|||
Maguire et al, 2015 [ |
✓ | ||
McCall et al, 2008 [ |
✓ | ||
McCann et al, 2009 [ |
✓ | ✓ | |
Ream et al, 2015 [ |
|||
Snyder et al, 2013 [ |
|||
Stacey et al, 2016 [ |
✓ | ✓ | |
Williamson, Chalmers, and Beaver, 2015 [ |
✓ | ||
Zheng et al, 2013 [ |
✓ |
a✓ indicates the theme was present within the paper.
Quotations from participants from primary studies to illustrate each theme.
Analytic themes | Descriptive themes | Quotations from participants in primary study |
Influence of telehealth on the disrupted lives of cancer survivors | Convenience: |
“Because I’m still working, I’m self-employed and I travel all over the country... and it’s difficult sometimes to be at a hospital at a certain time. So that was good.” [ |
“It was very easy, it was very simple to do and eh, it didn’t really encroach on lifestyle or anything like that at all, just had to remember to do it (laughs), set the ‘pinger’ on the cooker.” [ |
||
“I haven’t got a car so I’d have to take two buses you see to go to the hospital. When I get to the hospital I have about an hour and a half wait in the waiting room. And I go see the doctor, 2 min and I'm out again.” [ |
||
Independence: |
“It is educational in the sense that I have an overall view about the side effect of chemotherapy.” [ |
|
“I learned what I could do to make myself feel better” [ |
||
“I’m one of those people that likes statistics and numbers and things...and you could see on Tuesday I must have been quite bad...the graph’s right up and then it’s back down to normal today...” [ |
||
Burden: |
“We have very limited free time available and found it difficult to finish the lessons within a week.” [ |
|
“It really was just one more thing to do. I didn’t feel that good a lot of the time so I really didn’t feel like doing one more thing. But I did it because I had to.” [ |
||
Personalized care delivered from a distance | Space: |
“It is much more relaxed to know that you don’t have the alien thing of the hospital. You can have it in your home (telephone follow-up). You have it at work. You can have it on your mobile if you want sat in the car.” [ |
Time: |
“I felt that time was never an issue, that whatever I wanted to talk about, it was relevant. The time was given and it was discussed and that was good.” [ |
|
“It has also been very nice with a written response. You can read it several times.” [ |
||
“Quite happy. I did feel that I perhaps gleaned more information, I didn’t feel rushed or anything. And I’m sure that I sort of gleaned more information from my colorectal nurse than I would have perhaps done in a clinic situation.” [ |
||
Human factor: |
“If I should share my innermost thoughts, I’d probably like to have some kind of relation with the person I’m writing to. Otherwise, I need to know exactly what I’m asking for.” [ |
|
“But there was things I thought – noo, that’s how I feel and that’s what I’ve got but they’re no asking that, so I could’nae put it doon, do you know what I mean.” [ |
||
remote reassurance-a safety net of health care professionals (HCPs) Connection | Active connection: |
“The sessions helped me because there was somebody on the end of the line when you’re having a down day. And I mean if you’re having a down day you can ring them. You know it’s not like you’re alone in the world.” [ |
“I used to make myself little cards that I carry round with me, one in my handbag, one at home here and one in my filing cabinet at work, so if I ever felt I needed to ring her up I’ve got ... ready access.” [ |
||
“It’s really good to just have the opportunity lying there, I do not have to use it, but just knowing that there is a possibility is a security. That I can ask has been an incredible relief.” [ |
||
Passive connection: |
“It was quite positive. It was quite reassuring; you did feel that you were being monitored. You didn’t think if you put in those symptoms that you would slip through the...you know that if you had really worrying symptoms you would have slipped through the system. Somebody would have picked it up.” [ |
|
“Well as far as I am concerned yes, because it was very helpful because I had this bad cough and 1 or 2 alerts came up and the nursing staff at the other end were immediately onto it the fact that we were in contact with the hospital very much quicker than we would be if we’d waited and maybe even phoned.” [ |
||
“I found it helpful and interesting. It made me feel that my existence had some purpose...I think it is something which ought to be continued. It does make people feel they are being looked after...and somebody is keeping an eye on them.” [ |
||
“I felt safe and reassured because the hospital staff followed up with me like a kite in their hand, so that I would not fly away.” [ |
||
Slipping through the net: “Missed the connection” | “I have trouble on the phone, I have dreadful trouble with the mobile. Just mainly because of the complications with the hearing.” [ |
|
“I got an answer that...made me...made me realize I had not put it (the issue) in the right way, and then I realized that I cannot sort this out, via this communication...with such long intervals.” [ |
||
“I did miss the camaraderie that you get from other patients. And, of course, what tends to happen when you go on hospital visits is that you tend to be there at the same time as the other people who had their ops (operations) with you.” [ |
The analytical constructs that have emerged through this qualitative synthesis demonstrate the complex experience of telehealth use in cancer survivorship. Telehealth can be experienced positively in terms of supporting a less disrupted life through providing convenience and independence to live life as a survivor rather than a patient. However, in order to embrace a more independent role, a trusted relationship with an HCP is crucial. This highlights an interplay for cancer survivors between appreciating the opportunity for home-based care and the reliance upon instant access to clinical support. Such interplay also exists between the convenience of such care and the increased responsibility, and potential burden, placed upon the survivor.
This paper is the first to metasynthesize the reported experiences of cancer survivors who have participated in telehealth interventions. From the analysis, 3 key analytic themes and 9 descriptive subthemes emerged, showing that telehealth interventions in the area of cancer care represent a convenient approach, which can reduce treatment burden and disruption to cancer survivors’ lives. Our findings suggest that while telehealth interventions can facilitate an experience of personalized care for those living with and beyond cancer, interventions need to take personal factors into account so as to maximize benefit and minimize burden. The relationship between these themes is presented in a model (
A model of cancer survivor engagement with telehealth—factors inhibiting and facilitating positive user experience.
The first analytic theme pertains to the concept of the cancer survivors’ disrupted life. Biographical disruption is a well-known consequence of chronic illness [
However, some cancer survivors experience telehealth as time-consuming [
The second analytical theme represents the concept of personalized care from a distance. Enabling care within the home can offer benefits such as a familiar and relaxing environment within which to interact with an HCP, and the sense that the focus of care can shift toward the patient’s preferences and needs [
This synthesis shows cancer survivors can experience telehealth interventions as lacking the “personal touch,” even when they are augmenting [
This heterogeneity in the study findings pertaining to personalized care could be down to a number of factors, such as the method of delivering the intervention. For example, 4 of the 10 studies where patients reported a sense of impersonality in telehealth did not provide the opportunity to cancer survivors to meet their telehealth professional face-to-face prior to intervention delivery [
Further to the second analytic theme of “personalized care,” some survivors felt that telehealth interventions using structured symptom or patient-reported outcome questionnaires or providing self-care information were not sufficiently tailored to their circumstances [
The final analytical theme identified was that of a “safety net” that cancer survivors felt was provided by either an active or passive connection to HCPs. Instances of active connection enabled the survivor to initiate the contact to receive support or advice, while passive connections such as responses to symptom or patient-reported outcome questionnaires, or routine telephone follow-up, were initiated by the HCP. This lead to survivors feeling reassured that they were being monitored, that medical assistance would be swift where it was deemed necessary, and that they could actively raise concerns. However, such connections may induce over-reliance on HCPs, potentially affecting cancer survivors’ autonomy and control. The risk for such dependency has been highlighted in recent reviews on telehealth in COPD [
This synthesis indicates that telehealth interventions can provide cancer survivors with the necessary support they need to feel safe to manage their condition within their chosen environment. The findings can also be considered in terms of the person-based approach put forward by Yardley et al [
Only studies conducted since 2006 were included in this synthesis to capture the exponential increase in telehealth interventions over the past 10 years [
The studies reviewed covered different disease stages, demonstrating that telehealth can support patients at any point in their cancer journey. It is noteworthy that overall the patients did not comment on the timing of the intervention, nor on its duration. Many of the survivors engaging in telehealth only do so for a relatively short period of time, with just 2 studies [
Arguably, other important factors might impact on cancer survivors’ experience of telehealth such as treatment stage, or the health care professional groups who are points of contact for the intervention. The conclusions drawn by this metasynthesis are limited by the research conducted to date which did not enable these factors to be addressed. Future research on telehealth interventions should explore the experience of cancer survivors at different stages of survivorship, and the impact of the HCPs monitoring these interventions on the experience of cancer survivors.
For 6 studies [
This thematic synthesis supports the value of telehealth as a convenient and reassuring approach to delivering cancer care, which can minimize treatment burden and subsequent disruption to cancer survivors’ lives. As to how this synthesis could inform the development of future telehealth interventions, we would suggest that telehealth developers should balance the use of standardized patient outcomes measures with the introduction of more specifically tailored measures to minimize any sense of impersonal care. Furthermore, telehealth interventions need to be developed to balance benefit of remote monitoring and communication against burden, and consider survivor needs—perhaps through their involvement in the early stages of intervention design. The themes identified in the study are echoed in the existing literature on telehealth both in cancer and other long-term conditions. The model developed as part of this review therefore has the potential to not only facilitate understanding of the patient experience of telehealth in other conditions, but to guide the design of telehealth interventions in these areas to avoid factors that inhibit positive user experience, thereby improving telehealth engagement.
Search strategy for Medline.
Summary of characteristics of qualitative components of publications included in the review.
age not specified
advanced symptom management system
cancer not specified
Cumulative Index for Nursing and Allied Health Professionals
duration not specified
Enhancing Transparency in Reporting the Synthesis of Qualitative Research
frequency not specified
gender not specified
health care professional
newly diagnosed
This synthesis was funded by the Cancer Care Research Group in the School of Health Sciences, University of Surrey. AC and FM designed the search strings. AC conducted the search. AC, AM, WG, FM, RM, and ER screened the papers for inclusion. AC, GL, AM, WG, FM, RM, and ER extracted data and appraised the quality of the papers. AC and GL coded the results section of each included paper and developed descriptive themes through an inductive analysis. AC, GL, AM, WG, FM, RM, and ER reflected on and interpreted the descriptive themes to develop analytical themes. All authors (AC, GL, AM, WG, FM, RM, ER, and MP) contributed to the writing and refinement of the paper. The authors thank Emmanouela Konstantara, and Eirini Oikonomou for their valuable input in the initial stage of the screening process.
None declared.