Integrative review of remote patient monitoring in gynecologic and urologic surgical oncology

Patients with cancer facing complex and invasive urologic and gynecologic cancer surgery often experience symptoms and rapid declines in functional capacity postoperatively. Remote patient monitoring that leverages patient‐generated health data is a potential approach to assess and promote postoperative recovery. This integrative review aims to provide an overview of the current literature and research on remote patient monitoring in gynecologic and urologic surgical oncology.


| INTRODUCTION
Technology has rapidly advanced within the last decade prompting cancer centers and oncology practices to integrate these advancements into cancer care. Fueled by the ongoing COVID-19 pandemic, telehealth has become a common option in surgical oncology, and electronic medical records provide the ability to rapidly communicate and share medical information. As technology is increasingly integrated into cancer care, research to study remote monitoring of patientgenerated health data (PGHD) in surgical oncology has increased. The United States Office of the National Coordinator for Health Information Technology (ONC) defines PGHD as any health-related data created, recorded, or gathered by or from patients (or family members or other caregivers) to help address a health concern. 1 PGHDs are inclusive of a wide range of data, including health and treatment history, biometric data captured through wearable sensors, patientreported symptoms, and lifestyle choices. 1 They can provide information on how patients are doing between oncology care visits, guide shared decision-making, and potentially enhance the quality of cancer care delivery. 1,2 Importantly, PGHDs can make surgical oncology care more patient-centered.
As surgical approaches become more minimally invasive, patients with cancer are spending fewer days in the hospital after surgery, and postoperative recovery is spent largely at home and in the community. To support postoperative recovery and minimize undesired utilization of healthcare resources such as readmissions, remote patient monitoring approaches that leverage the sharing and use of PGHD can be used to track and monitor postoperative recovery and for clinical care decision-making purposes. 3,4 The information collected can potentially result in the early identification of problems, prompting timely interventions before conditions worsen.
Although remote monitoring shows promise in improving outcomes and making cancer care more patient-centered, evidence on its efficacy and effectiveness in surgical oncology is lacking. A previous review paper from this group focused on PGHD integration and use of artificial intelligence/machine learning in surgical oncology. 5 The purpose of this integrative review paper is to provide an overview of the literature and research on remote monitoring in gynecologic and urologic surgical oncology. Specifically, the review aims to describe the following: (1) types of remote monitoring approaches; (2) types of PGHDs measured; and (3) outcomes associated with remote monitoring.

| MATERIALS AND METHODS
Whittemore and Knafl's integrative review approach was used to guide this paper. For this approach, integrative review is defined as a specific review method that "summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular phenomenon or healthcare problem." 6 Integrative reviews can be used to identify knowledge gaps and inform research and clinical practice. [6][7][8] The integrative review method was selected because the evidence in remote patient monitoring in surgical oncology is still relatively nascent. Thus, an approach that focuses on a more comprehensive strategy that allows for the inclusion of diverse study design and methodologies (e.g., pilot feasibility and randomized trials) was warranted. This review was guided by the following five stages to enhance rigor: problem identification, literature search, data evaluation, data analysis, and presentation. however, these outcomes are not adequately tested nor routinely integrated into gynecologic and urologic surgical oncology. The question remains whether remote patient monitoring is equally as beneficial or more beneficial for patients and families as standard surgical care. It is possible that remote patient monitoring could provide more proactive, real-time quality surgical care earlier in the treatment course. However, there is a lack of evidence and consensus on best approaches and most relevant PGHDs to capture.

| Problem identification
Understanding the characteristics and outcomes of published research can inform surgical research and clinical practice.

| Literature search and data evaluation
Multiple methods were used to identify the maximum number of relevant articles. The literature search was completed using three separate bibliographic databases: PubMed, CINAHL, and PsychInfo.
Each database was used to search for published articles between 2011 and 2022. Searches were completed separately for gynecologic and urologic malignancies in each of the bibliographic databases. Search keywords included "Mobile Applications," "Mobile Health," "Wearable Devices," "mHealth", "eHealth", "fitness tracker, "physical activity," and "Digital Health." Terms included for the urological search: "prostate cancer," "bladder cancer," "urothelial cancer," "Kidney cancer," "cystectomy," "Prostatectomy," and "nephrectomy." For the gynecological search the terms included: "hysterectomy," "salpingo-oopherectomy," "gynecological cancer surgery," "endometrial cancer," "ovarian cancer," "cervical cancer," and "vulvar cancer." Data evaluation, as proposed by Whittemore and Knafl, focuses on the appraisal of the selected literature's relevance to the topic of interest. [6][7][8] Initially, articles were selected for full-text reviews by screening of titles and abstracts. Inclusion for full-text review was based on the following criteria: (1) studies that focused on gynecologic or urologic cancers exclusively; (2) multiple cancer type studies where at least 25% of the study population were diagnosed with gynecologic or urologic malignancies; (3) studies conducted in the preoperative, perioperative, and/or postoperative settings; (4) studies that used a remote patient monitoring component as part of surgical oncology care; and (5) English language articles. Editorials, case studies, dissertations, and conference presentations were excluded. Systematic reviews and other narrative reviews identified through the search were accessed for their reference lists to maximize the number of relevant articles. All titles and abstracts were reviewed by three investigators (F. P., T. C., V. S.) for inclusion, and discordant reviews were discussed until consensus was reached.

| Data analysis and presentation
Articles that met the inclusion criteria during the initial title and abstract screening were read by two reviewers (F. P., V. S.). A predetermined data document was used to complete data abstraction from the articles. The following study characteristics were extracted: first author's name, publication year, study aims, remote monitoring technology, outcomes, sample size, age, study design, and study findings. The final data abstraction was reviewed by the two reviewers, and discordant views were discussed and reconciled.

| Study characteristics-urologic malignancies
Key study characteristics for eligible articles in urologic malignancies are presented in Table 1. For the seven studies focused on urologic malignancies, three were small feasibility pilot studies, 9,11,13 and two were larger randomized trials. 10,12 One article 14 presented findings from a large prospective cohort study. The mean/median age of participants represented in the seven studies ranged between 61 and 69 years.
Overall, mobile application was the most common type of digital technology used for remote patient monitoring in the studies, followed by activity trackers (pedometers, accelerometers). Study outcomes were largely feasibility focused, and included uptake, adherence rates, response rates, and completion rates. Validated questionnaires were used to remotely capture patient-reported symptoms and health-related quality of life. In two studies 11,13 the mobile applications also included patient educational information; the mobile application from one study 13 included vital signs in addition to electronic symptom monitoring, activity tracking, and educational information.
Overall, most studies found that remote patient monitoring was feasible and acceptable to patients. Belarmino et al. 11 assessed the feasibility of an iPhone-based mobile application that to monitor recovery following robot-assisted radical prostatectomy. The app included a standardized quality of life and pain measures, step count tracking via the HealthKit app, and a library of perioperative Eligible studies also compared mobile application-based approaches with traditional paper and pencil approaches to capturing patient-reported outcomes. Faria et al. compared the impact of a mobile application-based symptom monitoring system on postop monitoring response rates, compared to conventional print questionnaires. 10 Response rates were six times higher for the app-based program when compared to print questionnaires. 10 In a randomized trial, Lee et al. tested the effectiveness of smartphone-based versus pedometer-based monitoring systems to promote a home-based exercise program for patients with prostate cancer treated with surgery or androgen-deprivation therapies. 12 Results found no significant group differences for uptake, adherence, or completion of the exercise program, and physical function for both groups improved. 12 Finally, Smith et al. aimed to compare self-reported versus accelerometer-measured physical activity in a cohort of men following radical prostatectomy. 14 Results found that objectively measured moderate-to-vigorous physical activity were critically low for up to 12 months after radical prostatectomy. There was discordance between self-reported and objectively measured physical activity, where self-reported measures greatly overestimated moderate to vigorous activity and were more reflective of light intensity activity. 14

| Study characteristics-gynecologic malignancies
Key study characteristics for the five eligible articles in gynecologic malignancies are presented in Table 2. Three out of the five articles were feasibility/pilot studies, 15,17,19 and two were prospective/ cohort studies. 16 were used, as well as validated quality of life questionnaires. 15,18,19 In all four studies that assessed web-based tracking or mobile applications, symptom alerts were triggered through email to the surgical team, which then triggered nursing contact to further assess and manage the symptoms. 15,[17][18][19] In addition to electronic symptom monitoring, one study also included discharge instructions as part of their web-based application. 17 Zivanovic et al. 15 20 The key reason is the burden to oncology nurses in addition to usual responsibilities on managing alerts. 20 Collectively, these findings underscore the need for more work to study the system-related aspects of integrating remote monitoring models into standard care. These include the overall cancer care system's capacity and readiness to integrate digital health approaches, and down to surgical team composition, workflow, communication, and trust. 22 Administrative level support with readjusting work responsibilities and optimizing workflow is also critically important. From a systems-level perspective, future studies should also take into account the rapidly evolving trends in postoperative care. As surgical oncology moves toward outpatient, minimally-invasive procedures, remote monitoring systems could serve as a tool to safely discharge patients home for short-stay procedures and support effective patient transitions from hospital to home.

| Limitations
This integrative review has several limitations that warrant further discussion. While the rigorous screening and data extraction

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.