J Canc Educ DOI 10.1007/s13187-014-0681-3

Smartphone Applications for the Clinical Oncologist in UK Practice Hamoun Rozati & Sonya Pratik Shah & Neha Shah

# Springer Science+Business Media New York 2014

Abstract A number of medical smartphone applications have been developed to assist clinical oncology specialists. Concerns have arisen that the information provided may not be under sufficient scrutiny. This study aims to analyse the current applications available for clinical oncologists in the UK. Applications aimed specifically at physician clinical oncologists were searched for on the major smartphone operating systems: Apple iOS; Google Android; Microsoft Windows OS; and Blackberry OS. All applications were installed and analysed. The applications were scrutinised to assess the following information: cost; whether the information included was referenced; when the information was last updated; and whether they made any reference to UK guidelines. A novel rating score based on these criteria was applied to each application. Fifty applications were identified: 24 for Apple’s iOS; 23 for Google’s Android; 2 for Blackberry OS; and 1 for Windows OS. The categories of applications available were: drug reference; journal reference; learning; clinical calculators; decision support; guidelines; and dictionaries. Journal reference and guideline applications scored highly on our rating system. Drug reference application costs were prohibitive. Learning tools were poorly referenced and not up-todate. Smartphones provide easy access to information. There are numerous applications devoted to oncology physicians, many of which are free and contain referenced, up-to-date H. Rozati (*) Barnet and Chase Farm Hospitals NHS Trust, Barnet Hospital, Wellhouse Lane, Barnet, Herts EN5 3DJ, UK e-mail: [email protected] S. P. Shah Croydon Health Services NHS Trust, Croydon University Hospital, Croydon CR7 7YE, UK N. Shah Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, London SE1 9RT, UK

data. The cost and quality of drug reference and learning applications have significant scope for improvement. A regulatory body is needed to ensure the presence of peer-reviewed, validated applications to ensure their reliability. Keywords Smartphones . Applications . Oncology . Clinical . Radiation

Introduction Smartphones incorporate numerous advanced computing capabilities, the scope of which is dependent on the mobile telephone itself and its operating platform. The most commonly used smartphones are the Apple iPhone and Samsung Galaxy, which run the iOS and Android operating systems, respectively. These operating systems have access to a range of medical applications (known as ‘medical apps’) which are designed to increase availability of medical textbooks, guidelines and calculators amongst others. Apple’s iOS runs a closed system, whereby each application must conform to a set of preapproved rules. This restricts the number available but aims to ensure stable and high-quality software [1]. Google’s Android is an open-sourced operating system without the restrictions placed on applications on iOS and therefore has a larger number of applications, but with the risk of these being lower-quality or unstable [2]. Blackberry’s iOS and Windows Phone OS are the two next leading operating systems for smartphones, although their popularity and number of applications are significantly less than that of Apple and Google [3]. The use of medical smartphone applications amongst medical students and junior doctors in the UK is well established. Brighton and Sussex Medical School became the first UK medical school to introduce the widespread use of mobile devices to its students in 2005, since when this practice has

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been adopted by numerous other medical schools [4]. The Wales training deanery has provided trainee doctors with a smartphone device and medical software since October 2009 [5]. The goal of these programmes is to fulfil the General Medical Council requirement as outlined in its Good Medical Practice guidelines for doctors to be able to “use information effectively in a medical context”. This includes the requirement to “make effective use of computers and other information systems, including storing and retrieving information” [6]. Medical applications are now increasingly being targeted to more specialist and senior doctors. While the majority of smartphone applications available to physicians in the UK are made in accordance with US clinical guidelines [7], the widespread use of smartphones in clinical practice in Britain is well documented and their use is likely to only increase. An online survey from 2012 of junior doctors in UK practice showed that 74.8 % of doctors owned a smartphone, with which medical applications were used for 1–20 min every 24 h [8]. There are concerns over the quality of the applications available. One digital survey of trainee doctors in California found that, despite demand, there was felt to be an absence of high-quality applications available across the major platforms [9]. Concerns have arisen that the information provided via these smartphone applications may not be under the same scrutiny as traditional sources of information, such as textbooks and validated websites [10]. Many of the applications may not be applicable to UK practice if information is not in keeping with national guidelines [11]. There have also been concerns raised regarding the validity of using smartphone applications as diagnostic aids [12]. Clinical oncology is a rapidly evolving specialty in which it is often difficult to keep up to date with the latest advances, and oncology education may be underrepresented at both undergraduate and postgraduate training levels [13]. A number of medical applications have been developed to assist clinical oncology specialists to keep abreast of recent developments and to provide ease of access to current guidelines. There are particular concerns regarding oncology applications whether their use improves care and patient outcomes, regardless of whether they are aimed the general public [14] or specifically at oncology health professionals [15]. This review aims to analyse the current applications aimed at clinical oncologists and to assess whether they are appropriately referenced, regularly updated, and applicable to UK practice.

Methods Medical applications aimed specifically at clinical oncologists were searched for on the major smartphone operating systems: Apple iOS; Google Android; Microsoft Windows OS; and

Blackberry OS. The search terms used to find the medical applications for clinical oncologists were: oncology; clinical oncology; radiation oncology; chemotherapy; and radiotherapy. Additional medical applications were included in this review if, on installation, the search engine suggested an appropriate alternative application. Only English language applications and software specifically targeted at oncology physicians were included. Applications were excluded if they did not specifically target oncology physicians. The applications were searched for, installed and reviewed over the 5th and 6th April 2014. All applications were installed and analysed. The applications were scrutinised to assess the following information: the cost; whether the information included was referenced; when the information was last updated, determined by noting the date of the most recent update to the information provided; and whether they made any reference to UK guidelines. A novel rating system was devised to calculate a score for each application depending on how well they fulfilled certain criteria. One mark was awarded for each of the following criteria fulfilled: cost less than 5.00 GBP; contain referenced information; application updated within the last 12 months; the application references UK guidelines. We thus gave each application a total score out of 4 to give an indication of their value to clinical oncologists, particularly those based in the UK. The applications were analysed and reviewed by three junior trainees in clinical oncology based in the UK, with author HR ultimately responsible for the data collection and determining consensus regarding impressions of each application. A figure of 5.00 GBP as a prohibitive cost for a smartphone application was agreed upon by the authors before data collection began, as this was felt to be representative of the opinion of the trainee physician population.

Results Sixty-eight applications were downloaded and evaluated. Eighteen were excluded as they targeted auxiliary oncology staff rather than physicians in particular. Therefore, a total of 50 applications were identified which fulfilled our inclusion criteria. Of these, 24 were available for Apple’s iOS; 23 were available for Google’s Android; two were available for Blackberry OS; and one for Windows OS. The same applications available across different operating systems were reviewed separately. The applications were subdivided into the following categories as defined by the application developers: drug reference applications; journal reference applications; learning applications; clinical calculators; decision support applications; guidelines; dictionaries. A full table of all

J Canc Educ Table 1 Table of all the oncology applications available across the four operating systems Med app name

App category

Platform

Cost/GBP Information Date last Information Rating/4 referenced? updated references UK (as of April practice? 2014)

Harrisons Manual of Oncology for Blackberry Skyscape Oncology Suite Harrisons Manual of Oncology for iOS Lilly Oncology CT Resource for Blackberry Lilly Oncology CT Resource for Android MDLinx Oncology Articles for Android Journal Scan Oncology Lilly Oncology CT Resource for iOS ecancer MDLinx Oncology Articles for iOS Oncology Practice The Oncologist BioOncology HD Oncology Flashcards Plus

Drug reference Drug reference Drug reference Journal reference Journal reference Journal reference Journal reference Journal reference Journal reference Journal reference Journal reference Journal reference Journal reference Learning

Blackberry Android iOS Blackberry Android Android Android iOS iOS iOS iOS iOS iOS Windows

65.49 60.96 57.99 0.00 0.00 0.00 5.51 0.00 0.00 0.00 0.00 0.00 0.00 2.99

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No

Nov 10 Apr 13 Nov 10 Apr 14 Apr 14 Apr 14 Apr 14 Apr 14 Mar 14 Apr 14 Apr 14 Apr 14 Apr 14 Sep 13

No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No

1 2 1 4 4 4 3 4 4 4 4 4 4 2

Smartest Oncologist Oncology pocketcards Cancer and Oncology Radiation Oncology Oncology flashcards Oncology Flashcards Plus Radiation Oncology Review Oncology at a Glance Oncology Board Review-1000MCQs Cancer and Oncology Oncology pocketcards Oncology Review BMI/BSA Oncology Lung TNM Calc Radiation Oncologist Tool Miniatlas Oncology Handbook of Radiation Oncology RadOnc Decision Support

Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Clinical calculators Clinical calculators Clinical calculators Decision support Decision support Decision support

Android Android Android Android Android Android Android Android Android iOS iOS iOS Android Android iOS Android Android Android

0.00 3.23 1.86 50.59 0.94 2.47 12.35 24.98 12.35 1.99 2.99 0.69 0.00 0.00 0.00 1.80 44.64 0.00

No No No Yes No No No Yes No No No No No No No No Yes Yes

Sep 11 Aug 13 Dec 09 Mar 12 Sep 11 Sep 13 Jan 14 Apr 13 Jan 14 Mar 10 May 13 Dec 11 Feb 14 Mar 13 Nov 11 Jun 12 Dec 11 Dec 13

No No No No No No No Yes No No No No Yes Yes No No No No

1 2 1 1 1 2 1 3 1 1 2 1 1 2 1 1 1 2

Rad Onc Resource IASLC Staging Atlas in Thoracic Oncology Oxford Handbook of Clinical Oncology, Third Ed IASLC Staging Resource in Thoracic Oncology RadOnc Decision Support Radonculous Cancer staging inPractice Oncology The Oncologist NCCN Guidelines for Smartphone inPractice Oncology ESMO Cancer Guidelines Chemotherapy advisor ONCOassist

Decision support Decision support Decision support Decision support Decision support Decision support Decision support Guidelines Guidelines Guidelines Guidelines Guidelines Guidelines Guidelines

Android iOS iOS iOS iOS iOS iOS Android Android Android iOS iOS iOS iOS

0.00 0.00 34.99 2.99 2.99 0.00 2.99 0.00 0.00 0.00 0.00 0.00 0.00 15.49

Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes

Nov 13 Nov 11 Sep 10 Nov 11 Jan 14 Jun 12 Jan 12 Jul 13 Apr 14 Mar 14 Jul 13 Apr 14 Nov 13 Mar 14

No No Yes No No No No No No No No Yes No No

3 2 2 2 3 1 2 3 3 3 3 4 3 2

J Canc Educ Table 1 (continued) Med app name

App category

Platform

Cost/GBP Information Date last Information Rating/4 referenced? updated references UK (as of April practice? 2014)

NCCN Guidelines by Epocrates Oncology-Medical Dictionary Cancer Terms Pro Oncology Dictionary

Guidelines Dictionaries Dictionaries Dictionaries

iOS Android iOS iOS

0.00 0.00 1.49 1.49

the oncology applications available across the four operating systems is shown in Table 1 showing which platform they are available for, cost, whether the information is referenced, the date the information was last referenced as of April 2014, whether the data references UK practice and our rating for each application out of four using our pre-determined criteria as outlined in the “Methods” section. Drug reference applications Three drug reference applications were available across the Blackberry (n=1), Android (n=1) and iOS (n=1) platforms. They had an average cost of 61.48 GBP (range, 57.99–65.49). All applications contained referenced data, with an average time since last update of 30.7 months (range, 12–36 months) and with none of the three applications referencing UK practice. The three applications achieved an average rating of 1.33 (range, 1–2). Journal reference applications Ten journal reference applications were available across the Blackberry (n=1), Android (n=3) and iOS (n=6) platforms. They had an average cost of 0.55 GBP (range, 0.00–5.51). There were nine applications available to download for free. All applications contained referenced data, with an average time since last update of 0.1 months (range, 0–1 months). All ten applications referenced UK practice. The ten applications achieved an average rating of 3.9 (range, 3–4). Learning applications Thirteen learning applications were available across the Windows (n=1), Android (n=9) and iOS (n=3) platforms. They had an average cost of 9.03 GBP (range, 0.00–50.59). There was one application available to download for free on the Android system. Two of the applications contained referenced data, with an average time since last update of 23.3 months (range, 3–51 months). One of the thirteen applications referenced UK practice. The thirteen applications achieved an average rating of 1.5 (range, 1–3).

Yes No No No

Dec 13 Feb 14 Feb 10 Jan 12

No No No No

3 2 1 1

Clinical calculator applications Three clinical oncology calculator applications were available across the Android (n=2) and iOS (n=1) platforms. All three applications were free to download. None of the applications contained referenced data, with an average time since last update of 13.7 months (range, 1–32 months). Two of the three applications referenced UK practice. The three applications achieved an average rating of 1.3 (range, 1–2). Decision support applications Ten decision support applications were available across the Android (n=4) and iOS (n=6) platforms. They had an average cost of 9.04 GBP (range, 0.00–44.64). There were four applications available to download for free across both iOS and Android platforms. Eight of the applications contained referenced data, with an average time since last update of 20.2 months (range, 2–41 months). One application referenced UK practice. The ten applications achieved an average rating of 1.9 (range, 1–3). Guidelines Eight guidelines applications were available across the Android (n=3) and iOS (n=5) platforms. They had an average cost of 1.94 GBP (range, 0.00–15.49). There were seven applications available to download for free across both iOS and Android platforms. All eight of the applications contained referenced data, with an average time since last update of 3.4 months (range, 0–9 months). One application referenced UK practice. The eight applications achieved an average rating of 3.0 (range, 2–4). Oncology dictionaries Three oncology dictionary applications were available across the Android (n=1) and iOS (n=2) platforms. They had an average cost of 0.99 GBP (range, 0.00–1.49). One application was available to download for free across on the Android platform. None of the applications contained referenced data,

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with an average time since last update of 26.0 months (range, 0–37 months). None of the applications referenced UK practice. The three applications achieved an average rating of 1.3 (range, 1–2).

Discussion The specialist oncology drug reference applications are unlikely to find much use in day-to-day clinical oncology practice. There are no free applications available, and an average of 30.7 months since the last update mean the applications are not providing the most up to date information such as can be found elsewhere. The drawbacks of these applications are reflected by our average mark of 1.33/4 for the three applications reviewed. Harrison’s Manual of Oncology and the Skyscape Oncology Suite both cost over 60.00 GBP and reference the American National Cancer Institute and American Society of Clinical Oncology guidelines with no reference to UK guidelines. The Skyscape Oncology Suite, for example, has information on thousands of drug brands and generics, a built in tool to assess for drug interactions, pill images and dosing calculators, much of which would be of use for the practice of oncology in any country. The formulary information and clinical resources are specific to American practice. There appears to be a market for a UK-based drug reference manual specific for oncology which the current applications do not fulfil. The free British National Formulary application for iOS and Android provides useful drug information on smartphones, and the American-based Monthly Prescribing Decision Support application is regularly updated and has an easy to use interface, though neither of these is specifically aimed at oncologists and so was not included in our review data. A number of applications which aim to collate recent oncology articles are available. These tend to be free to use, have the advantage of being able to filter articles according to the user’s preference and the applications tend to optimise the electronic articles to be easily read on smartphone screens. The MDLinx Oncology Articles for Android has all of these features, is free to download and indexes close to 150 journals. In each of the journal applications reviewed, the article abstracts are free to view, with the option to enter Athens or institutional logons to access full text articles. Some applications also provide easy access to free-to-view articles. The majority of applications provide a link to download a full PDF version of the article, which can then be transferred to a desktop PC or, if the smartphone has the capability, can be printed directly. The worth of these applications is reflected by our high average rating of 3.9/4. The interactive learning applications available provide a means for clinicians to revise for examinations or consolidate

learning away from the confines of textbooks or desktop PCs. These applications use a combination of question-andanswers and picture quizzes. Their interactive nature provides a useful addition to traditional methods of learning and have proved popular, as evidenced by the number of downloads these applications have attained. They do, however, have some disadvantages. The majority of these applications are not free to download. Besides the Radiation Oncology learning tool, they are not referenced, and so it is difficult to validate the information given. An average time since last update of 23.3 months means that the applications are unlikely to contain recent changes to best practice. This is primarily the cause for the reduced average rating of 1.5/4 for these applications. The Radiation Oncology application is certainly an impressively comprehensive learning tool which includes questions on staging, mnemonics, radiotherapy planning and concise reviews of major studies. However, a cost of 50.59 GBP is likely to prove inhibitive, and there is no reference to UK practice guidelines, being aimed at oncology residents in the USA as it references American Society of Clinical Oncology guidelines. Less costly applications, such as Oncology Review on iOS and the Oncology flashcards on Android, have less than 100 questions each, often have a clunky interface and the answers to questions provided are often disputed on the feedback left for the applications on the Google and Apple websites. The pitch of the questions also tends to be more towards medical students and junior doctors rather than oncologists. The usefulness of these cheaper applications is limited for the oncology specialist. While there is a large number of general medical calculators available, there are relatively few available specifically aimed at oncologists. The Radiation Oncologist Tool available on iOS has a number of radiotherapy calculators based on the American textbook Basic Clinical Radiobiology by Michael Joiner and Albert van der Kogel which are of use for clinical oncologists. The BMI/BSA Oncology application for Android is a body surface area calculator with drug dose adjustment for chemotherapy agents, while the Lung TNM Calc improves classification of lung cancers compared to the TNM staging criteria. Clinical calculators are amongst the most popular applications, with the most popular general medical calculator application Calculate by QxMD being downloaded 500,000 times [16]. Although not specifically aimed at oncologists and hence not included in our review list, it contains many calculators useful to everyday oncology practice and so is likely to prove popular. The small amount of research into the accuracy of smartphone calculator applications shows that they provide accurate and reliable results and supports their use [17]. Our low average rating of 1.3/4 for the oncology calculators reviewed is skewed by the fact that the applications are not

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referenced or regularly updated; however, the nature of these applications is such that these facts are not likely to deter from their usefulness in clinical practice. There are a number of applications available as tools to support clinical decision making, four of which are available to download for free. Likely the most useful for clinical oncologists practicing in the UK is Oxford Handbook of Clinical Oncology, Third Ed, for iOS. It is not simply a miniaturised version of the paper handbook; rather, the book content has been adapted to work seamlessly with a smartphone, providing ease of navigation throughout the text. As the application is based on a widely used handbook, the information contained within is likely to prove useful to oncology physicians. However, at a cost of 34.99 GBP, it is amongst the most expensive oncology applications available and is currently only available on Apple’s iOS. The remaining decision support applications are based in the United States and reference American National Cancer Institute and American Society of Clinical Oncology guidelines but still contain useful information regarding basic sciences, epidemiology and aetiology. Of note, the Rad Onc Resource on iOS and Android provides links to online evidence-based clinical resources and also provides several clinical calculators for tissue tolerance for radiotherapy and biologic equivalence of different dose/fractionation schemes. Access to clinical guidelines is of particular interest to clinical oncologists, as this is a rapidly evolving area and one in which it is often difficult to keep up-to-date with changes. In light of this, there have been a number of applications designed to update the user on various available oncology guidelines. These are regularly updated and invariably free to download. Of particular interest is the ESMO Cancer Guidelines on iOS. Each set of ESMO guidelines provide information on the incidence of the malignancy, diagnostic criteria, staging of disease and risk assessment, treatment plans and follow-up, and the applications is regularly updated and available for free. This is reflected by our rating of 4/4 based on our predetermined criteria. It is, however, only available on Apple’s iOS. A popular alterative application is the inPractice Oncology application available on both iOS and Android. It advertises itself as providing ‘expert-authored’ best practice guidelines and provides a streamlined, easy to use application free of charge. The average rating of 3.0/4 shows that the majority of these applications are likely to be of use to clinical oncologists regardless of their country of practice. The National Institute for Clinical Excellence (NICE) have their own application available. Though not specifically targeted to oncologists, it does provide easy access to all available NICE guidelines and is also free to use [18]. The small number of available oncology dictionaries attempt to set themselves apart from traditional dictionaries by advertising themselves as revision tools and by having added

features such as animations. The Oncology-Medical Dictionary application on Android is an ‘animated’ dictionary which displays graphical representations of topics as diverse as types of cancers and cancer staging systems to cell functions, enzymes and growth factors. The application also includes some tuition videos and is available for free. The two oncology dictionaries on Apple’s iOS are paid-for downloads but do not include the added features found on the Oncology-Medical Dictionary application. They do all include the feature to be used without an active internet connection and, at a maximum cost of 1.49 GBP, are still relatively inexpensive. The low average rating of 1.3/4 is likely due to the fact that dictionaries are not often referenced or updated regularly.

Review limitations A limitation of this review results from a lack of high-quality studies such as multi-centred or controlled trials assessing the benefit of smartphones in oncology. As the use of smartphones in clinical medicine and oncology in particular increase, this may be addressed in future reviews. A further limitation is the fact that smartphones and software is a rapidly progressing area of technology with new phones and applications created on a regular basis, and so this review may not include all applications available at the time of print. The rating system we incorporated is also flawed in that it likely unfairly penalises dictionaries and calculators due to the fact that these resources often do not provide citations, make no reference to a particular country’s guidelines and are not updated as often as other medical applications. These resources are often useful to clinicians despite these drawbacks, and we attempted to address this issue in the discussion of this review.

Conclusion The increased use of smartphones has led to the potential for their use as portable information hubs, providing ease of access to ever increasing volumes of clinical topics. This review has shown the large number of smartphone applications available devoted to oncology physicians, many of which are free to download and contain referenced, up-todate data. While oncology applications related to searching online journals and viewing local guidelines scored highly in our review, there appears to be significant scope to develop more appealing drug reference and oncology learning applications. Concerns arise, however, due to the lack of regulation of applications available. Studies have found that applications in

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specialist areas are often not validated or not in date, therefore not suitable for purpose [19–21]. There is a lack of information available as to who has made each application and therefore who is accountable. The need to properly assess the validity of these applications is beginning to be addressed [22]. Application developers can help meet the needs of oncologists by ensuring applications are updated regularly, are properly referenced, that the information is clearly applicable to local guidelines and that the cost is not excessive. Our consensus was that a cost of more than 5.00 GBP for a smartphone application is likely to prove prohibitive. Studies analysing a number of medical applications in isolation have shown their use to be beneficial in practice [23, 24]. The challenge for the physician is to be able to discern from the large number of applications available which are informative, validated, evidence-based and therefore most useful. With these concerns, and the growing threat of plagiarism from unregulated applications [25], a regulating body to ensure the presence of a number of peer-reviewed applications available for smartphones would be required to ensure their reliability.

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Smartphone Applications for the Clinical Oncologist in UK Practice.

A number of medical smartphone applications have been developed to assist clinical oncology specialists. Concerns have arisen that the information pro...
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