Gynecologic Oncology 137 (2015) 508–515

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Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno

Feasibility of a lifestyle intervention for overweight/obese endometrial and breast cancer survivors using an interactive mobile application☆ Michele L. McCarroll a,c,⁎, Shannon Armbruster a, Rachael J. Pohle-Krauza a,b, Amy M. Lyzen a, Sarah Min c, David W. Nash c, G. Dante Roulette a,c, Stephen J. Andrews a,c, Vivian E. von Gruenigen a,c a b c

Summa Health System, Akron, OH, USA Youngstown State University, Youngstown, OH, USA Northeast Ohio Medical University (NEOMED), Rootstown, OH, USA

H I G H L I G H T S • The purpose of this study was to elicit weight-loss via mobile app lifestyle intervention. • The lifestyle intervention delivered via an app showed significant reductions in body weight. • Significant improvements were noted in the Weight Efficacy Life-Style Questionnaire.

a r t i c l e

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Article history: Received 14 July 2014 Received in revised form 19 December 2014 Accepted 20 December 2014 Available online 11 February 2015 Keywords: Endometrial cancer Lifestyle Weight loss

a b s t r a c t Objective. The study aimed to assess a one-month lifestyle intervention delivered via a web- and mobilebased weight-loss application (app) (LoseIt!) using a healthcare-provider interface. Methods. Early-stage overweight/obese (body mass index [BMI] ≥ 25 kg/m2) cancer survivors (CS) diagnosed in the past three years, and without recurrent disease were enrolled and received exercise and nutrition counseling using the LoseIt! app. Entry and exit quality of life (FACT-G) and Weight Efficacy Lifestyle Questionnaire (WEL) measuring self-efficacy were measured along with anthropometrics, daily food intake, and physical activity (PA) using the app. Results. Mean participant age was 58.4 ± 10.3 years (n = 50). Significant reductions (p b 0.0006) in anthropometrics were noted between pre- and post-intervention weight (105.0 ± 21.8 kg versus 98.6 ± 22.5 kg); BMI (34.9 ± 8.7 kg/m2 versus 33.9 ± 8.4 kg/m2); and waist circumference (108.1 ± 14.9 cm versus 103.7 ± 15.1 cm). A significant improvement in pre- and post-intervention total WEL score was noted (99.38 ± 41.8 versus 120.19 ± 47.1, p = 0.043). No significant differences were noted in FACT-G, macronutrient consumption, and PA patterns. Conclusion. These results indicate that a lifestyle intervention delivered via a web- and mobile-based weightloss app is a feasible option by which to elicit short-term reductions in weight. Though these results parallel the recent survivors of uterine cancer empowered by exercise and healthy diet (SUCCEED) trial, it is notable that they were achieved without encumbering significant cost and barrier-access issues (i.e. time, transportation, weather, parking, etc.). © 2014 Published by Elsevier Inc.

1. Introduction Overweight/obese endometrial (EC) and breast cancer (BC) survivors face numerous co-morbidities that are the leading cause of death

☆ Presentation at meeting: Oral Plenary Presentation Society of Gynecologic Oncology, Tampa, FL March 23, 2014. ⁎ Corresponding author at: Summa Center for Women's Health Research, Summa Health System, 525 East Market Street, Medical Building 2nd Floor, Akron, OH 44304, USA. E-mail address: [email protected] (M.L. McCarroll).

http://dx.doi.org/10.1016/j.ygyno.2014.12.025 0090-8258/© 2014 Published by Elsevier Inc.

that supersedes cancer diagnosis [1,2]. The majority of women in the United States of America (USA) are overweight or obese; therefore, not surprising that the majority of EC and BC survivors are overweight or obese which can interfere with a survivor's recovery and subsequent quality of life (QOL) [2–4]. Correspondingly, the majority of overweight/ obese cancer survivors are not meeting public health exercise and/or nutrition recommendations [2]. There is a critical need to determine what methods of weight-loss and risk factor reduction in this population are most effective. As a result, the strategic plan for the National Institutes of Health (NIH) Obesity Research calls for innovations to

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improve health outcomes in populations affected by obesity using theory based approaches such as Social Cognitive Theory (SCT) and Theory of Planned Behavior (TPB) [5–7]. Recent studies have demonstrated that increased obesity or body mass index (BMI) is associated with decreased survival [8,9]. The National Cancer Institute (NCI) emphasizes the need for interventions including weight, physical activity, nutrition counseling that contribute to survivorship, and methods to improve health outcomes and mortality for cancer survivors [10,11]. Improving body weight in EC and BC survivors may decrease morbidity and have the potential to improve overall survival since relative risk of death for obese EC women with a body mass index (BMI) 30–34 was 2.53, and BMI N40 was 6.25; the highest of all cancers [12,13]. Specifically, the risk of death from cardiovascular disease (CVD) related causes begin to exceed the risk from cancerrelated causes 3.5 years after EC diagnosis [14]. Thus, interventions that address dietary change and increased exercise together are necessary to elicit weight-loss and improve cardiovascular disease risk factors. Lifestyle interventions have been shown to improve wellness, self-efficacy, and QOL in cancer survivors [15–18]. Mobile health (mHealth) applications (aka. “apps”) using web- and/ or a mobile-based app are tools that have the potential to improve effective patient-provider communication, adherence to treatment and selfmanagement, especially in regards to weight-loss. In recent years, mobile phones have become a major conduit for communication and information. The uses of web- and mobile-based apps as a tool for health promotion and weight-loss have been successful in randomized trials [19,20]. The current study aimed to assess the feasibility of delivering a lifestyle intervention focusing on weight-loss using a multi-disciplinary team via popular mHealth app (LoseIt!) which offers both a website and mobile versions for users. The secondary objective was to assess characteristics of EC and BC survivors in regards to nutrient intake, physical activity (PA), self-efficacy, QOL, and correlation to patientprovider contact points. We hypothesized that EC and BC survivors would be willing to engage in a lifestyle program using mHealth technology and improve the principal co-morbidity of weight. 2. Methods 2.1. Study design and patient recruitment This study was a prospective intervention in 50 overweight/obese women with a history of Stage I or II (early) EC and/or BC. The comprehensive lifestyle program with emphasis on nutrition quality, physical activity, and improving eating self-efficacy was delivered using a “beta” healthcare provider version of LoseIt! (Boston, MA), a popular web- and mobile-based app for logging food intake and volitional exercise. The multi-disciplinary team delivering the comprehensive lifestyle program included a gynecologic oncologist (GO), resident physician (RP), research coordinator (RC), registered dietician nutritionist (RDN), and a certified clinical exercise specialist (CES) by the American College of Sports Medicine (ACSM) to elicit weight-loss in patients at a rate of 1.0–2 lb per week. Participants were monitored over the course of 4-weeks through the “beta” healthcare provider version of LoseIt!. This allowed for real-time interface to provide personalized feedback via notifications. Weight change was the primary outcome. Secondary outcomes included the number of motivational patient-provider feedback notifications to the participant in relation to weight-loss, self-efficacy towards weight-loss, minutes spent in physical activity, and nutritional content. Women included in the study were aged 18 to 75 years with histologically confirmed Stage I or II EC or BC within the previous three years and no evidence of recurrent disease. Participants needed access to a smartphone or Internet with unlimited data or Internet connection, body mass index (BMI) ≥ 25 kg/m2, medical clearance from the patient's oncologist, a performance status of 0–2, surgical treatment

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greater than 6-months prior to start of the study, and an endorsed desire to lose weight. Exclusion criteria included: non-English speaking, inability to read the consent form, lack of smartphone or Internet connection, inability to use the LoseIt! app, patients with severe depression, physical or cognitive deficits, pregnancy, plan to become pregnant, breastfeeding, surgical treatment less than 6-months prior to start of the study, and women who participated in a structured weight-loss program in the last 6-months. The cancer registry was used to identify eligible BC patients based upon time of diagnosis and stage of disease. Endometrial cancer patients were identified through the use of ICD-9 codes and eligibility was determined through subsequent chart review. All eligible women were contacted via telephone or in-person in the oncology office, screened using inclusion and exclusion criteria, and provided a baseline research appointment, if interested in participating (Fig. 1). 2.2. Intervention protocol Participants individually met with a member of the research team (RP, RC, or CES) for two-visits, one at baseline and another at exit, four-weeks later. The baseline visit lasted between 30 and 60 min, time depending on patient familiarity with web- or mobile-based apps and time to answer questions. Each woman received log-on information and instructions on how to use LoseIt!. Each participant passed a LoseIt! competency test, which encompassed logging exercise as well as looking up and logging foods from different venues including supermarket items, restaurant items, and home cooked meals. Participants were then instructed to use LoseIt! in order to log daily food choices, daily exercise type and duration, and daily body weight in the morning over the course of the next four, consecutive weeks. The nutritional component of our intervention focused on limiting the daily intake of carbohydrates to less than 70 g per day and increasing fiber intake to 30 g per day, and an approach that has been demonstrated as effective in other weight-loss programs [21]. Nutrition goals were conveyed to participants during the baseline visit. Here, participants were shown nutrition labels to aid their understanding of monitoring carbohydrate and fiber intake. No other restrictions in fat or calories were made. Participants were able to monitor their carbohydrate intake through the LoseIt! app. Women were encouraged to meet standard physical activity guidelines as indicated by the ACSM which emphasizes moderateintensity cardiorespiratory exercise training for ≥ 150 min per week, vigorous exercise ≥40 min per week, and resistance exercises for each of the major muscle groups [22]. Weight-loss goals were established at the baseline visit and included the loss of approximately 1–2 lb/week. The real-time feedback component provided by the multi-disciplinary team was based on the SCT whereas messaging focused on the patient to improve weight-loss self-efficacy by using verbal or typed persuasion, vicarious learning experiences, mastery, and social support [6,23,24]. Participants received motivational patient-provider feedback notifications in response to their individual input in the LoseIt! app for the four weeks study period. A patient-provider feedback notification is defined as a phone call, email message, and/or a push notification which was manually generated based on user input. Push notifications were automatically provided by LoseIt! technology to serve as motivation reminders to log meals at specified times throughout the day and reward compliance. User input regarding declining adherence to entering weight, dietary information, and exercise habits triggered the more frequent delivery of automatic push notifications. Patients were encouraged to log nutrition and exercise in real-time or at least once a day. The daily exercise and nutrition logs were monitored by the multi-disciplinary team (GO, RP, RC, RD, and CES). Participants were also provided a Bluetooth scale (Withings©, Boston, MA) to assist in weight tracking during the intervention period; however, the final analyses were completed from the validated scale in the clinical office (499KL Health O Meter ® Professional Digital Column Scale, Neosho, MO).

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Fig. 1. Study design.

2.3. Measures Patient demographic and clinical data were obtained at baseline. Patient-related outcome measures (PROS) were collected at baseline. Participant's height and weight were measured at baseline and exit in their street clothes, without shoes to the nearest 0.1 kg for weight and nearest 1/8th inch for height (499KL Health O Meter ® Professional Digital Column Scale, Neosho, MO). Waist circumference was obtained to the nearest centimeter (cm) and taken as the average of a series of three measurements, using a spring-loaded tape measure (Gulick Tape Measure, Perform Better). Patient-reported outcomes QOL and self-efficacy were measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and the Weight Efficacy Life-Style Questionnaire (WEL), respectively.

The FACT-G (version 4.0) is a valid and reliable 27-item questionnaire evaluating physical well-being, social/family well-being, emotional well-being, and functional well-being [25]. The FACT-G provides a generic core of questions that are often combined with cancer sitespecific questionnaires [26]. Previous studies have set bench-marks for the FACT-G scores in the general and cancer populations; thus, relevant for our population in this study [27,28]. Self efficacy was measured with the WEL, a validated metric assessing five situational factors: negative emotions, availability, social pressure, physical discomfort, and positive activities [29]. Here, the participant is asked to rate their ability to resist eating (0 = not confident and 9 = very confident) in context of five situational scenarios, one relating to each domain, with a higher score indicative of greater self-control over nutritional decisions. The domain of negative emotions relating to self-efficacy included anxiety, depression,

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failure, and anger. WEL was administered at the baseline and four-week follow up/exit visit.

Table 1 Demographics. Variable

2.4. Feasibility outcomes Outcomes for the study included compliance with daily logging of nutrition and exercise information, recruitment age of the population using the technology, adherence to measurement completion from baseline to exit, and program evaluation. Non-compliance was addressed for women who failed to log for more than three-days in a row by telephoning them to address any logging concerns. Participants were asked to log nutrition and exercise during the four-weeks. Logging for N75% of days during study duration was necessary for continued inclusion. Individuals were removed from the final analysis if they stopped logging or did not log greater than three-weeks. Adherence was measured by attendance at baseline and exit sessions. 2.5. Statistical analysis Demographics and clinical outcomes were assessed. Statistical analyses were performed using SPSS 22.0 software to conduct a paired samples Student's t-test for changes between baseline and exit along with repeated measures analysis of variance (ANOVA) with Geisser– Greenhouse's correction for time points (TP) throughout the intervention and Bonferroni post-hoc analysis. Statistical testing was two-sided with p b 0.05 considered statistically significant. Pearson's productmoment correlations were used to evaluate the association between weight-loss and the number of healthcare provider contact points. 3. Results Baseline variables are presented in Table 1. Mean participant age was 58.4 ± 10.3 years. Forty-four of the fifty participants were white (88.0%), while six were African American (12%). Twenty-six (52%) and 19 (38%) participants had a diagnosis of endometrial and breast cancers, respectively, while five (10%) had history of both cancers. Education level was dispersed with 14 high school graduates (28%), 12 who attended college (24%), 12 with an associate or bachelor's degree (24%), 10 with a master's degree (20%), and two with a doctoral degree (4%). Fifty cancer survivors were enrolled and attended the baseline intervention visit. All patients received instruction on using the Loseit! app for logging exercise and nutrition information. Exit visits and participant adherence rate was 70% with a dropout rate of 30%, leaving n = 35 participants completing the logging and the follow-up visit requirements. There were no significant differences (age, race/ethnicity, and cancer type) at baseline in those participants that did not complete the study. Fig. 2 includes the primary anthropometric changes demonstrating significant reductions between pre- and post-intervention weight (97.3 ± 22.5 kg versus 95.0 ± 22.1 kg; p = 0.000), BMI (36.4 ± 8.1 kg/m2 versus 35.6 ± 8.0 kg/m2; p = 0.0000), and WC (106.6 ± 16.8 cm versus 103.4 ± 17.4 cm; p = 0.0006). In Table 2, secondary outcomes of WEL and FACT-G scores showed differing results. The mean WEL score significantly improved (p = 0.0432) from baseline 99.38 (± 41.8) to exit 120.19 (± 471). Quality of life scores via the FACT-G showed no significant changes (p = 0.152) from baseline 50.47 (±13.3) to exit 44.35 (±19.9). 3.1. Nutrient quality Nutrition data was calculated using the dietary logs from the LoseIt! healthcare provider interface. Weekly consumption of each macronutrient (carbohydrate, fat, protein, and fiber) along with calories were collected at baseline and averaged each week for four-weeks consisting of four recorded TP. Table 3 displays the mean (SD) consumption for

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Participant Demographics (n = 50)

Age (Years) Average (SD) Median Min–max Ethnicity — n (%) Non-Hispanic Hispanic Race — n (%) White Black American Indian/Alaskan Asian Cancer history — n (%) Breast Endometrial Both endometrial and breast Marital status — n (%) Single Married Widowed Divorced Education level — n (%) Junior high High school Some college Associate/bachelor Masters Doctoral Individual income level — n (%) b$40 k $41–60 k N $60 k Employment status — n (%) Full-time Part-time Retired Unemployed Unable to work

58.4 (10.3) 60 39–75 50 (100%) 0 (0%) 44 (88%) 6 (12%) 0 (0%) 0 (0.0%) 26 (52%) 19 (38%) 5 (10%) 5 (10%) 30 (60%) 7 (14%) 8 (16%) 0 (0%) 14 (28%) 12 (24%) 12 (24%) 10 (20%) 2 (4%) 16 (32%) 12 (24%) 22 (44%) 19 (38%) 14 (28%) 15 (30%) 0 (0%) 2 (4%)

macronutrients at each TP. There were no significant differences between the TP in each of the macronutrient categories: carbohydrates p = 0.726; fat p = 0.184; protein p = 0.226; fiber p = 0.281; and calories p = 0.263. However, noted changes in caloric intake were observed from the second TP to the other remaining TPs while carbohydrate, fat, protein, and fiber intake remained relatively steady. There were caloric changes following the restricted carbohydrate approach whereas patients usually reported to be less hungry due to the changes in protein, fiber, and fat intake. 3.2. Physical activity Physical activity data was calculated using the PA logs from the LoseIt! healthcare provider interface. Fig. 3 demonstrates PA minutes and calories participants engaged in at baseline and during the intervention period. Baseline revealed 77.5185 (± 156.6) kcals expended and 22.7 (± 44.0) minutes which indicated that no one was meeting the recommendations for physical activity at the commencement of the study. A significant increase (p = 0.001) in PA was noted from baseline to TP1 in caloric expenditure 1971.8 kcals (± 1105.4) and time 182.3 min (±196.6). No other significant differences (p = 1.00) were noted between TP in calories expended: TP2: 973.0 kcals (± 953.7); TP3: 826.2 kcals (±958.6); and TP4: 632.0 kcals (±909.8) and in time spent doing PA: TP2: 200.2 min (±216.1); TP3: 181.2 min (±244.0); and TP4: 127.0 min (±185.3). However, TP1 and TP2 to TP4 showed a trend towards a significance (p = 0.09) as PA levels were lower than

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Fig. 2. Physical activity (PA) patterns during intervention.

the other TP. The first and second TP were noted to have the highest level of minutes and caloric expenditure followed by TP three which all met the ACSM guidelines for quantity of PA at 150-minutes per week. The last TP of the intervention, PA minutes 127.0 min (±185.3) no longer met the ACSM guidelines for PA quantity recommendations.

3.3. Patient-provider interaction On average, each participant received 15.7 (±13.4) feedback and/or push notifications regarding their progress in logging. A moderate positive correlation between total WEL scores 120.19 (± 47.1) and the amount of healthcare provider feedback and push notifications (r = 0.349, p = 0.382) were noted. While not significant, the result supports the literature whereby the more patient “interactions” from a healthcare provider, the more successful the patient is in weight-loss. No other notable correlations were found.

4. Discussion The majority of EC and BC survivors are overweight/obese and not meeting recommendations for a healthy lifestyle. Treatment for early stage disease only marks the beginning of a journey for these overweight/obese cancer survivors due to the co-morbidities associated with their obesity. New technology and weight-loss interventions have a rich history of success. Previous studies involving technology-based interventions have shown that individually customized messages are

Table 2 Self-efficacy and quality of life measures. Study group Variable

Pre (n = 50)

Post (n = 35)

Mean difference, 95% CI

p-Value

WEL total score Mean (SD) 99.38 (±41.8) 120.19 (±47.1) 19.42 (0.6389, 38.21) 0.0432a FACT-G total score Mean (SD) 50.47 (±13.3) 44.35 (±19.9) −5.968 (−14.25, 2.316) 0.152 Weight Efficacy Lifestyle Questionnaire: WEL. Functional Assessment of Cancer Therapy-General: FACT-G. Confidence Interval: CI. Paired sample t-tests were performed on only those patients that followed-up. a = The mean difference is significant at the .05 level.

more effective than non-customized messages in improving selfefficacy and dietary behaviors [30,31]. As established in this study, mobile health apps can facilitate significant short-term weight-loss, decreased waist circumference, and increased self-efficacy in EC and BC survivors. Our study focused on limiting carbohydrate intake, an approach that is supported by the literature as a means to reduce obesity, risk factors for heart disease, and diabetes [32,33]. Novel interventions such as this study are essential to improve the health of these survivors, especially EC patients that have a history of not seeing their cancer diagnosis as a “sentinel event” for making lifestyle changes [32]. Even with the challenges of EC and BC survivors making lifestyle changes, several randomized controlled trials regarding lifestyle interventions have been successful [33,34]. von Gruenigen et al. (2011) examined the effects of a six-month face-to-face multi-disciplinary lifestyle intervention whereby the group lost significantly (~ 5% from baseline) more weight than the control group. A reduction in body weight of 5% has been shown to decrease medical co-morbidities [35–37]. The present study had an average weight-loss of 6% of initial body weight using a similar multi-disciplinary approach. Social Cognitive Theory was the foundation on how the multidisciplinary team interacted with study participants during the intervention to emphasize eating self-efficacy (SE). The counselor notes in the healthcare provider version of LoseIt! were the central communication points for all GO, RP, RC, RD, and CES providers. Messages were sent to specific providers within each discipline if the patient demonstrated or requested more focus in this arena (e.g. nutrition quality — RD; exercise tips — CES; concerns about fatigue — GO, RP; and technical issues related to logging — RC). The emphasis on personalized feedback received through the app as well as the patient's knowledge that healthcare professionals were watching their nutrition and exercise choices in real-time potentially impacted the participant's SE. Selfefficacy has been shown to be a predictor of behavior change in obese women, particularly weight loss [38]. Rejeski et al. showed the role of SE in weight reduction and the QOL [39]. McCarroll et al. (2013) revealed that an increase of the total WEL score by 4.49 points resulted in a loss of 1 unit of BMI using a face-to-face intervention (p b0.0001) [23]. Self-efficacy is not only important for initial weight-loss but has been shown to be an important factor in long-term weight management [40,41]. Although our study only lasted for four-weeks, interventions focused on weight-loss, SE, and PA will lead to success with continued weight-loss and weight maintenance. This concept is echoed by Basen-Engquist et al. as they investigated 100 EC survivors and

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Table 3 Nutrition quality parameters of food intake. Baseline Variable/statistic Carbohydrates (g) Mean (SD) Fats (g) Mean (SD) Protein (g) Mean (SD) Fiber (g) Mean (SD) Calories (kcals) Mean (SD)

120.629 (±69.3)

Time point

Time point

Time point

Time point

1

2

3

4

p-Valuea

132.6 (±118.7)

124.4 (±102.6)

123.9 (±120.0)

124.0 (±120.3)

0.726

44.1 (±23.4)

63.8 (±69.6)

60.6 (±61.2)

60.2 (±71.3)

58.2 (±60.0)

0.184

55.2 (±26.6)

74.4 (±97.5)

75.4 (±63.8)

69.6 (±73.5)

65.4 (±62.3)

0.226

11.0 (±6.3)

14.9 (±16.0)

12.8 (±12.0)

12.1 (±12.8)

13.3 (±13.6)

0.281

1022.6 (±494.4)

2134.3 (±4373.9)

1323.6 (±1062.5)

1275.9 (±1264.3)

1281.1 (±1130.6)

0.263

Grams = g. Standard Deviation = SD. Kilocalories = kcals. Time points = week in the intervention. Repeated measures analysis of variance (ANOVA) with Geisser–Greenhouse's correction. a = The mean difference is significant at the .05 level.

revealed their morning SE significantly (p b0.001) determined that day's exercise minutes [24]. The QOL outcomes were consistent with those found in the survivors of uterine cancer empowered by exercise and healthy diet (SUCCEED) randomized control trial; whereas, QOL did not change with weightloss outcomes [18,23]. However, several other studies conducting lifestyle interventions in female cancer survivors have reported QOL improvements after a group lifestyle intervention with associated weight-loss [42,43]. More research is needed to identify whether QOL is an indicator for weight-loss in female cancer survivors after a lifestyle intervention. Macronutrient intake was the focus of the dietary component of the intervention versus caloric restriction. The analysis revealed lower carbohydrate intake levels compared to the recommended daily values that recommends 30% of an individual's daily nutrition come from grains [44]. Weight-loss using simply energy restriction has not solved the obesity epidemic [29]. Furthermore, adopting a nutrition plan with variations in dietary macronutrient composition and functional foods are demonstrating success in weight-loss [45]. However, more in-

depth randomized clinical trials with longitudinal outcomes are needed to identify whether various eating plans using a mobile platform are more cost effective with improved PROS than face-to-face interventions. Since being in a weight-loss or exercise program for at least 6-months was an exclusion criterion for the study, most women reported to be sedentary. Physical activity levels peaked in the first week exceeding the recommended guidelines for PA; however, by the end of the fourth week, PA levels were below recommended guidelines for PA. The decline in PA could be the result of the Hawthorne effect in regards to being part of the study and the study nearing the end of completion [46]. Also, Forbes et al. found that the majority of cancer survivors do not meet PA guidelines and indicated that the Theory of Planned Behavior (TPB), accounted for 55% of variance in PA intentions for breast cancer survivors [47]. Also, a recent study by Speed-Andrews et al. indicated that the strongest correlate to PA was planning PA [48]. Thus, in future studies, emphasis on the TPB should be underscored to maintain PA levels throughout the entire intervention. As this was a feasibility study, there are several limitations to the study. Limitations include: short-term intervention period, small

Fig. 3. Physical activity (PA) patterns during intervention.

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sample size, a high standard of compliance for logging (N75%), differences in likability of using technology, ability of using technology, and lack of diversity in the sample size. We also acknowledge that this intervention approach will not be suitable for all cancer survivors and that lack of interest in weight-loss and understanding of current technology may deter some patients. One criticism prior to implementation of the study was that this generation of female EC and BC survivors would not use a mobile app or technology for a lifestyle intervention. Our study refutes this claim as many participants were able to use the technology with ease even for those women needing additional instruction for using the technology. Additionally, the patient has access to the multi-disciplinary team via LoseIt! which can be accessed at any point in time as well as from any device capable of access to the Internet or downloading apps. Lastly, compared to face-to-face methods, it is potentially be more convenient for both participants and providers as the app can be accessed at any point in time. Future studies involving mobile applications to deliver lifestyle interventions should be compared to “face-to-face” interventions for EC and BC survivors for cost comparisons, staff time/effort, and continued improvement of weight-loss. Also, incorporating a lifestyle intervention is a vital component of the Survivorship Care Plan (SCPs) released by the Society for Gynecologic Oncology (SGO) to ensure a cohesive approach to obesity treatment for cancer survivors [49–52]. More robust studies are merited to determine the sustainability of this intervention on weight-loss, health, QOL, SE, and ultimately to decrease co-morbidities to improve long-term survivorship of women with obesity-driven cancers. Conflict of interest statement None of the authors have any conflict of interest to disclose regarding the manuscript.

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