Introduction
Cancer is the second leading cause of death in the worldwide.1 Breast cancer is one of the most common malignant diseases suffered by women throughout the world and ranks first in cancer incidence among women globally.2 Globally, 2.3 million new cases and 670,000 deaths from female breast cancer will occur in 2022.2,3 In Indonesia, breast cancer is also the most common cancer.4
Given the high incidence and mortality rates, supportive interventions efforts for breast cancer patients are essential.5 In this context, telehealth-based health services are essential to reduce mortality rates while improving patients’ quality of life. Based on a recent meta-analysis, telehealth-based interventions are effective in reducing psychological symptoms such as depression and stress that breast cancer survivors often experience.6 Telehealth also improves patient competency in health management, provides easier access to medical services, and helps patients implement rehabilitation programs and healthy lifestyles.7 Studies showed that telehealth can benefit various areas, including sleep quality, body image perception, and treatment adherence.6,7
Telehealth is an innovative approach to health care that integrates communication and information technology to provide remote health services and care to cancer patients.8 This approach allows patients to receive clinical support, health education, and symptom management without having to make an in-person visit to a health facility, thereby improving accessibility and continuity of care.7 Telehealth integrates technology with various healthcare services, including medical consultations, patient education, patient condition monitoring, and health management.9
Despite the numerous benefits offered by telehealth, its implementation continues to frequently face obstacles and challenges. The primary barriers include limited access to technology, digital literacy issues, inadequate infrastructure, and concerns about equity, particularly for vulnerable populations.10–12 In addition, lack of internet access and devices, especially in rural or low-income areas, is the most frequently reported significant barrier.13,14 Moreover, the patient’s age also significantly influences the implementation of interventions involving technology. Older adults and those with limited technological experience have difficulty with telehealth.15,16
Nurses play a key role in implementing telehealth for cancer patients.17 In telehealth, nurses are responsible for assessing patient needs, providing education on symptom management, and offering emotional and psychosocial support.18–20 They also play a crucial role in coordinating care between health professionals and ensuring continuity of services, particularly for patients residing in remote areas or those with limited access to healthcare facilities.21 Nurse-led interventions effectively reduce symptom severity and improve patient quality of life.17,19
Although several studies have been conducted to evaluate telehealth interventions in breast cancer care, significant differences remain in the approaches used, intervention content, duration of implementation, and outcome indicators measured. These inconsistencies make it difficult for health workers, researchers, and policymakers to determine which interventions are most effective and feasible for widespread implementation. To date, no systematic review has specifically summarised and analyzed the approach models, program content, and outcomes of telehealth for breast cancer patients. Therefore, an in-depth study is necessary to integrate the existing findings and provide a comprehensive understanding of the variations in telehealth interventions and their clinical impact. This review is critical to supporting the development of evidence-based practices, improving the quality of care, and ensuring the optimal use of telehealth in breast cancer management across various healthcare contexts.
Materials and Methods
Study Design
The study employed a systematic review methodology, guided by the Cochrane Handbook for Systematic Reviews of Interventions, which was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.22,23 This review has been registered in PROSPERO with the ID number CRD420251056554.
Eligibility Criteria
Three independent reviewers selected relevant articles in this review according to the PRISMA guidelines (see Figure 1). Research questions and eligibility criteria were developed based on the PICOT framework. The population (P) of interest consisted of adults with breast cancer. The intervention (I) studied was telehealth, encompassing telemedicine and telenursing. The comparator (C) was standard care or usual care, and the outcome (O) focused on health outcomes, including self-management, symptom management, quality of life, depression, anxiety, and other relevant measures. The study type (T) included in this review was restricted to randomized controlled trials (RCTs).
|
Figure 1 PRISMA Flowchart. Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Creative Commons.22
|
Studies were eligible for inclusion if they were full-text, published in English, and utilized an RCT design evaluating the effectiveness of telenursing in the care of adult patients with breast cancer. Publications were excluded if the full text was unavailable, the language was not English, or the study constituted secondary research such as reviews or meta-analyses. No restrictions were placed on the publication year to ensure a comprehensive examination of relevant studies.
Search Strategy
The articles were identified systematically through several primary databases: EBSCOhost, PubMed, Scopus, ScienceDirect, Taylor and Francis, and the search engine Google Scholar. The search keywords were: “Breast Cancer OR Breast Neoplasms OR Breast Tumors OR Breast Carcinoma AND telenursing or telehealth or e-nursing or digital nursing AND clinical outcomes or patient outcomes or client outcomes”.
The Boolean operators “AND” and “OR” were used to refine or broaden the search results, effectively capturing relevant literature across various databases.
In addition to database searching, hand searching was also conducted. Hand searching refers to the manual process of reviewing reference lists of relevant articles, journals, or conference proceedings to identify additional studies that may not have been retrieved through electronic databases. This approach was used to ensure a more comprehensive identification of eligible studies for inclusion in the review.
Study Selection and Quality Appraisal
Two authors (AN and FS) independently screened the studies according to the predefined eligibility criteria. During the initial selection phase, duplicates were identified and removed using Mendeley Reference Manager. Next, the articles’ titles, abstracts, and full texts were evaluated for their relevance to the research topic, with the inclusion and exclusion criteria applied. In the final stage, three authors (AN, APP, and FS) conducted a detailed review of each selected article using the Joanna Briggs Institute (JBI) critical appraisal checklist to evaluate the quality of the studies.24 Articles with a randomized controlled trial design were evaluated using 13 criteria for quality assessment. Each item provided four response options: Yes, No, Not Applicable, and Unclear. A score of 1 was assigned for each “Yes” response, while all others received a 0. Studies with a JBI score of less than 75% were excluded from the review. Any discrepancies in the assessment results were discussed among the authors, and decisions were jointly led by the primary author (YT). However, no disagreements occurred regarding the suitability of the selected studies for inclusion.
Data Extraction and Analysis
This review systematically gathered and organized relevant data from the selected studies using summary tables that captured key findings related to the research focus. Two independent reviewers (AN and FS) conducted the data extraction process, with verification conducted by two additional reviewers (YT, AA, and APP). The extraction tables included critical details such as study characteristics and intervention components. A thematic analysis was conducted using an exploratory, descriptive method. This analysis began by categorizing and presenting the extracted data in a tabular format, corresponding to each included study. The findings were then interpreted and elaborated upon based on the presented information. The research team undertook a comprehensive final review of all the studies conducted to enhance accuracy.
Results
Study Selection
The process of identifying and selecting studies through various databases and other methods for a systematic review. In the initial stage, 4,076 studies were identified from various databases, including PubMed, Scopus, ScienceDirect, EBSCOhost, Taylor & Francis, and Google Scholar. Furthermore, 2,170 studies were removed as duplicates, resulting in 1,906 studies remaining. Of these, 1,844 studies were excluded because they did not meet the inclusion criteria, leaving 62 studies for analysis. Then, at the eligibility assessment stage, 43 studies were further evaluated. Of these, 27 reports were excluded for various reasons, including participant heterogeneity, inappropriate study design, inappropriate interventions, and non-English publications. Meanwhile, another method employed was manual searching, which yielded 8 studies. All studies retrieved through this hand search were successfully accessed and evaluated without being excluded. Finally, 24 studies were included in the review (see Figure 1).
Quality Appraisal of Included Studies
Most studies analyzed demonstrated excellent methodological quality, with most scores meeting or nearly meeting the criteria set by the JBI. Many studies successfully met the criteria for randomization, concealed allocation, appropriate analysis, and homogeneity of treatment groups. However, some studies have shortcomings, particularly in terms of blinding participants or treatment providers, and unclear implementation of specific other criteria.
Most studies scored highly, with most meeting 10 of the 13 criteria. Six of the superior studies even met all JBI assessments.25–30 These studies can be considered examples of research with excellent methodological quality. However, specific weaknesses, such as ambiguity or uncertainty in some elements, indicate areas where further improvements could be made to increase the precision and reliability of the findings.
Characteristics of Studies
All studies included in this review used an RCT design and involved women with breast cancer as participants (see Table 1). The number of participants in each study varied significantly, with Ozkan et al from Turkey reporting the smallest sample size of 42 participants, while the largest sample size was found in a study conducted by del Valle et al in Spain, involving 454 women. This variation reflects differences in context, resources, and scope of intervention in each study.
 |
Table 1 Characteristic of Study
|
These studies were conducted geographically in various countries (see Figure 2). These countries include the United States, Denmark, Norway, Australia, the United Kingdom, Spain, the Netherlands, Turkey, Singapore, and Finland, indicating a global interest in the application of telenursing in breast cancer care. This diversity of locations provides a broad range of perspectives on the effectiveness and implementation of telenursing in various healthcare systems.
 |
Figure 2 A summary study by the country.
|
Characteristics of Participants
The mean age of participants generally ranged from 47 to 64 years, with the youngest recorded age being 40 and the oldest age reaching 79 years (see Table 1). This suggests that telenursing is being applied to the adult to elderly age group, which is the general population of breast cancer survivors. The cancer stages addressed in these studies mainly were early to intermediate stages, namely from stage 0 to III, although some studies also involved patients with stage IV cancer. Some studies specifically target specific groups, such as women undergoing adjuvant therapy, post-operative patients, or cancer survivors within a specific period after treatment.
Analysis of Telehealth Models Based on Delivery Methods
The delivery methods or approaches to delivering telehealth services are classified into three main themes: telephone call-based interventions, web or internet-based systems, and smartphone apps (see Table 2). These three approaches have different characteristics, intervention models, and effects in supporting breast cancer patients during the treatment and recovery. Each method provides flexibility in terms of accessibility, depth of intervention, and patient involvement in the program offered (see Figure 3).
 |
Table 2 Characteristics of Intervention, Model, Delivery Method, Content, and Summary of Results
|
 |
Figure 3 Overview of Telenursing Models and Delivery Methods.
|
Theme I: Phone Call-Based Intervention
Telephone call-based interventions are common in various studies to provide health education, psychosocial counseling, and monitor patient progress.19,25,27,30,31,33,40–45 In this context, several studies have shown positive results. For example, Jacobs et al, through the STRIDE intervention using a combination of telephone calls and virtual sessions, showed a reduction in psychological symptoms and an increase in patients’ self-management abilities.31 Likewise, other studies using behavioral intervention and psychoeducation models were conducted using an educational approach, counseling, videoconferencing, and structured exercises via telephone to help patients adapt psychosocially to the stages of cancer treatment they are undergoing.25,30,31,33,40,42,45
Freeman et al showed that an imagination-based intervention conducted via telephone calls could reduce fatigue and sleep disturbances and improve overall quality of life.25 Meanwhile, the Exercise program for Health27,41 and LEAN40 demonstrated that telephone counseling sessions effectively promoted physical activity and weight management. Telephone-based approaches are also utilized in nutrition education,19 emotional expression, and Randal follow-ups, as carried out by Kimman et al43 and Beaver et al.44
Another approach employed is structured psychological skills training with telepsychiatric follow-up, which is also utilized in a more comprehensive psychological context.45 Ozkan et al combined anger management training with weekly telephone follow-up and noted significant decreases in depression and increases in self-esteem.45 A telephone-based psychoeducational intervention conducted by Ashing et al also noted a reduction in depressive symptoms, suggesting that this approach may be particularly beneficial in the context of community-based psychological support.
Theme II: Web or Internet-Based Intervention
This theme encompasses telehealth interventions delivered through online platforms, including websites, eHealth portals, and integrated symptom reporting and self-management systems. Some programs also incorporate interactive elements such as educational videos, communication forums, and support from online health professionals.28,29,32,34–37,39,46,47
Several studies utilize cognitive behavior and psychoeducation models packaged in web-based or internet forms.29,32,35,47 Lally et al32 developed Caring Guidance, a web-based self-paced psychoeducation platform that successfully reduced distress and depressive symptoms in patients. In a similar approach, Wagner et al35 used a combination of text-based and video-based cognitive behavioral therapy, combined with tele-coaching, to reduce levels of Fear of Cancer Recurrence. This demonstrates the potential of a web-based approach complemented by human interaction to increase program retention and effectiveness.
The WebChoice program is a comprehensive approach that provides health information, symptom monitoring tools, and a communication space between patients.37 Their findings showed that the WebChoice user group experienced significant reductions in anxiety and distress levels.37 Meanwhile, BREATH,29 which is a CBT intervention with weekly psychologically themed modules with Email reminders, is effective in reducing short-term distress, especially in survivors with low levels of initial distress. The program includes information scripts, practice assignments, self-assessments with automated feedback, and educational videos to support independent cognitive and behavioral change.29
However, not all web-based programs have demonstrated a substantial clinical impact. For example, the MyHealth program, which aims to improve work capacity through remote symptom monitoring by nurses, did not demonstrate significant results about its primary objective.34 Although designed based on empowering knowledge theory, the pathway program did not note significant differences in patient quality of life or anxiety.46 Several other studies have also highlighted the benefits of web-based programs in supporting healthy lifestyles and physical rehabilitation. Santa-Maria et al and Galiano-Castillo et al demonstrated that combining online educational content with direct support (via telephone or messaging system) led to significant improvements in health biomarkers, decreased pain, and increased muscle strength.28,36 Even in more specialized approaches, such as online cognitive training, there is evidence of increased working memory capacity and verbal learning in participants.47
Theme III: Smartphone App-Based Intervention
Smartphone applications are one approach to telehealth. Interventions in this theme generally involve apps that can be downloaded and accessed via smartphone, with features that include education, monitoring, and social and emotional support.26,38 Im et al’s study developed TICAA, an application based on Bandura’s Self-Efficacy theory that provides interactive information, online educational sessions, and connectivity with communities through social media.26 Although the reduction in symptoms in the intervention group was not statistically significant, there was a marked improvement in the participants’ quality of life compared to the control group. Then, Pang et al showed a more focused approach through the iCareBreast application, which is designed to support patients in the perioperative phase.38 This app provides care guidance, education about medical procedures, and emotional support. Although it did not significantly impact increasing self-efficacy, participants who used this application showed higher satisfaction with their treatment process.
Analysis of Content in Telehealth
The three intervention methods, telephone-based, web/internet, and smartphone applications, offer content designed to holistically support patients through various educational and supportive approaches. In the telephone method, content includes educational videos and medical information,30,31,33,40–42 emotional support such as relaxation techniques and anger management,27,45 lifestyle and behavioral changes that include exercise programs and behavioral therapy,19,25,27,31,40,45 and strengthening independent abilities through goal setting and self-monitoring,19,27,41,44 plus clinical monitoring with evaluation of side effects and follow-up by health workers.40,41,43
The web-based method integrates education and empowerment with weekly modules that combine CBT theory and specific information,29,32,36,37,46,47 self-management strategies such as symptom monitoring and reporting,32,34,35,37 clinical monitoring and support in the form of documentation, follow-up, personal support,34,37,39 and other categories are physical and cognitive training,28,47 plus individually tailored physical and cognitive exercises. While the smartphone app focuses on online perioperative education sessions,26,38 psychosocial support sessions through peer interaction and social media,26,38 coaching and self-management sessions are provided digitally, and provide easy access and social involvement in the recovery process. This content is designed to meet patients’ educational, emotional, behavioral, and clinical needs with a complementary approach.
The Outcomes of Telehealth in Managing Breast Cancer Patients
The telephone-based, web, internet, and smartphone application interventions examined in this study significantly improved patient health and well-being (see Figure 4). In general, interventions using telehealth in breast cancer patients can improve psychological outcomes, such as quality of life,25,26,28,31,41,42 anxiety,29,31,37,41,42,44 depression,30,32,37,45 psychological well-being,31 self-esteem,45 anger and fear,35 and coping strategies.31 Telehealth can also improve fatigue,25,41 cognitive dysfunction,25,41 sleep quality,25 adherence,45 pain symptoms, and muscle strength,28 and weight loss strategy.36,40 Meanwhile, several studies also reported insignificant outcomes. Several studies also reported that the use of telehealth was not significant in terms of anxiety,43,46 HRQOL,43 QoL,46 emotional functioning,43 self-efficacy,37,38 physical adjustment,31 workability,34 total appointments and healthcare usage,39 and patient empowerment.29
 |
Figure 4 Overview of Telenursing Content Based on Delivery Methods.
|
Discussion
This study provides a comprehensive review of the use of telehealth in breast cancer care, highlighting various intervention models, delivery methods, program content, and clinical outcomes. Each model is tailored to meet the specific needs of patients and the context of healthcare services in each country. As an innovation in health services, telehealth offers excellent opportunities to improve the quality of care for breast cancer patients, especially in the era of increasingly developed digital health.7 However, its effectiveness and implementation are significantly influenced by the intervention model used and the context in which it is used.
The findings of this review identified substantial variability in intervention designs, patient demographic characteristics, and outcome measures across the included studies. Each study employed distinct telehealth models, ranging from telephone-based interventions to web-based platforms and smartphone applications, with diverse program contents that included health education, psychosocial support, physical or cognitive training, and others. Furthermore, the participant populations demonstrated a wide age range (40–79 years) and varied cancer stages, from early to advanced. These differences significantly influenced the outcomes of each intervention, as factors such as age, digital literacy, and individual patient needs play a critical role in determining the effectiveness of the chosen approach. Similarly, the wide range of measured outcomes, including quality of life, anxiety, depression, fatigue, and self-efficacy, yielded heterogeneous findings across studies.
To enhance the generalizability of the results, the interventions were classified into three themes. In this review, telehealth interventions are organized based on their delivery method: telephone call-based, web/internet-based, and smartphone app-based models. Additionally, both the intervention content and measured outcomes were categorized according to these three modalities (see Figures 3 and 4). This classification was undertaken to facilitate more structured analysis and to enable systematic comparisons of outcomes and effectiveness across the different telehealth delivery models.
The telephone call-based intervention model is the most common and well-established method used in breast cancer care.31,33,40,41 This model enables direct interaction between patients and healthcare workers, particularly nurses, thereby providing an opportunity for personalized education and intensive psychosocial support.48,49 Studies that adopted this model, such as the STRIDE intervention,31 and anger management training program with telephone follow-up,45 showed significant results in reducing distress, depression, anger, increasing self-esteem and self-management abilities of patients.25,28,40,41,45 Telephone calls are increasingly used in cancer care for follow-up, symptom management, and psychological support.50–52 Telephone calls offer significant advantages in accessibility and convenience, but also present limitations regarding communication quality and patient engagement.50,51
Another model used is web-based internet. This model offers more flexible interventions and can be accessed at any time by patients and healthcare workers.53 These website-based online platforms typically provide educational modules, cognitive training, and self-monitoring, which patients can follow at their own pace and in their own time.28,29,32,37,39 Programs like Caring Guidance32 and WebChoice37 showed that this approach is effective in reducing psychological symptoms such as depression and anxiety, as well as improving patients’ self-management skills. The primary advantages of this model are its high scalability and ability to reach a large number of patients without directly burdening healthcare workers.54,55 However, the downside is the lack of direct interaction, which can reduce patient engagement and motivation.56,57 Several studies reported that not all web programs showed clinically significant results, which is likely related to a lack of personalization and ongoing support from health professionals.34,46
The smartphone application model is the latest innovation in telehealth, combining the ease of digital access with interactive and social features.26,38 Apps like TICAA and iCareBreast provide education, monitoring, and social support through social media and digital coaching.26,38 This model can potentially increase patient engagement, especially among the digitally literate generation.58 These interventions take advantage of smartphones’ ubiquity and ability to deliver personalized, timely, and engaging content. However, the findings of this review found that smartphone applications in the context of breast cancer are still limited, and the results tend not to be statistically significant in reducing psychological symptoms or increasing self-efficacy consistently. This indicates that while technology offers convenience, the success of an intervention also depends on the right content, an attractive design, and seamless integration within the application.
Despite the large number of telehealth studies on breast cancer patients, the selection of models using smartphone applications has not been widely carried out. Smartphone applications are a telehealth model that is increasingly relevant in the era of digital health, especially for young patients and adults who are more adaptable to digital technology than older age groups. Recent epidemiological studies indicate that although breast cancer is generally more common in women aged 50 years and over, there is a significant increase in incidence in young women aged 20–40 years.59,60 This phenomenon adds to the urgency of developing telehealth models that can effectively reach and engage patients in this age group.
A comparison between the three models indicates that the direct interaction maintained in the telephone-based model still provides a more tangible psychosocial impact than the web-based or application-based models, which tend to be self-guided. However, web-based and app-based models offer greater flexibility and reach, allowing for more systematic personalization and monitoring at a more efficient cost.28,30,41,44,47 Therefore, the success of telehealth in breast cancer care is greatly influenced by the ability to combine each model’s advantages, such as interactive telephone sessions with online educational modules or easily accessible mobile applications.
Although several studies have been conducted to evaluate telehealth interventions in breast cancer care, significant differences still exist in the approaches used. This review analyzes 24 RCT studies, revealing variations in delivery models, intervention content, implementation duration, and outcome indicators measured. Unlike previous reviews that focused more on the effectiveness and barriers of telehealth,7 this review also incorporates two new RCT studies that have the potential to enhance the generalizability of the findings.
The context of telehealth implementation is also an important factor in determining the success of the intervention. The role of nurses as the primary liaison in telehealth is crucial, especially in providing education, managing symptoms, and offering ongoing psychosocial support.21 The involvement of trained and adaptive health workers in digital technologies increases the effectiveness of interventions and the sustainability of telehealth use.61 In addition, environmental factors such as internet access, patient digital literacy, and the readiness of health facilities to support technology also greatly influence the results.61 Therefore, to ensure that telehealth implementation is effective and provides maximum benefits for breast cancer patients, an integrated approach involves intensive training for health workers, increasing patient digital literacy, and investing in adequate technological infrastructure.
Implications for Practice
The effectiveness of telehealth is not free from several challenges and limitations. One of the main issues that emerged was the variation in approach, content, duration, and outcome indicators used in various studies. This heterogeneity makes it difficult for researchers and practitioners to determine the most effective and widely adopted intervention model. In addition, several studies have shown that telehealth has not been able to significantly impact several aspects, such as anxiety, emotional functioning, self-efficacy, and physical adjustment, so a combination with face-to-face interventions is still needed for more optimal results.31,37,43,46
An inclusive and patient-centered approach should be adopted, providing services that are easily accessible and tailored to individual needs. Using user-friendly technology and integrating telehealth into daily clinical workflows will also increase the adoption and success of interventions. Thus, telehealth functions not only as a temporary solution but also as an integral part of a healthcare system that is responsive and adaptive to the changing times and the needs of breast cancer patients.
Strengths and Limitations
This study has several key strengths that make its results valid and relevant to telehealth practice in breast cancer care. First, the methodology employed was a systematic review with a strict PRISMA approach, and only studies with RCT designs, considered the standard of evidence in clinical research, were included. Additionally, the study’s broad geographic coverage across multiple countries provides a global perspective and enhances the generalizability of the findings.
This review also examines various telehealth models, ranging from telephone calls to web platforms and smartphone applications, providing a comprehensive overview of the various intervention methods used in real-world practice. However, this study also faces limitations that need to be taken into consideration. Considerable variation in intervention approaches, program duration, content, and outcome indicators measured across studies creates high heterogeneity. This makes direct comparisons challenging and hinders the determination of the most universally effective telehealth model.
In this review, almost all of the studies included had a mean age of participants ranging from 47 to 64 years. This limits the generalizability of the findings, as the review does not cover younger breast cancer patients or those in the advanced stages of the disease. Therefore, the results may not fully represent the experiences and challenges encountered by younger subgroups or patients with advanced-stage breast cancer. Further research is necessary that includes patients with a broader age range and covers different stages of breast cancer, in order to provide a more comprehensive understanding of the impact of the disease on these groups.
Conclusions
Telehealth holds significant promise in enhancing the quality of life and clinical outcomes for breast cancer patients by offering a range of intervention models. In this review, 24 randomized controlled trials (RCTs) were analyzed, revealing three primary telehealth intervention models: telephone-based, web or internet-based, and smartphone application-based interventions. Each model has distinct advantages and challenges, and its impact on patient care outcomes varies accordingly. Telehealth offers patients convenient access to care, psychosocial support, education, and self-monitoring, all of which are essential during both the treatment and recovery phases.
The findings suggest that interventions combining face-to-face interaction, such as telephone calls, with online educational content or mobile applications are likely to be the most effective moving forward. These hybrid approaches combine the flexibility and scalability of digital tools with the personal engagement provided by healthcare professionals, ensuring more holistic patient care. The role of nurses as primary facilitators in telehealth interventions is crucial in maintaining continuity of care and providing personalized support, particularly for patients in remote areas or those with limited access to in-person care.
However, the effectiveness and success of telehealth interventions are heavily influenced by the context in which they are implemented. Key factors such as technological readiness, infrastructure, and patient digital literacy must be addressed for telehealth to reach its full potential. This highlights the need for a comprehensive and patient-centered approach in the development of telehealth solutions, which includes ongoing training for healthcare workers and the enhancement of technological infrastructure. Future research should focus on the development and evaluation of integrated telehealth-in-person models that address technological readiness, patient-centered design, and sustainability in real-world clinical settings. Additionally, there is a need to examine the long-term impacts and cost-effectiveness of such models across diverse populations, including underserved and digitally vulnerable groups.
Disclosure
The authors report no conflicts of interest in this work.
References
1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–263. doi:10.3322/caac.21834
2. World Health Organization. Breast cancer [Internet]; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/breast-cancer.
3. Kim J, Harper A, McCormack V, et al. Global patterns and trends in breast cancer incidence and mortality across 185 countries. Nat Med. 2025;31:1154–1162. doi:10.1038/s41591-025-03502-3
4. Kementrian Kesehatan Republik Indonesia. Rencana kanker nasional 2024–2034; 2024.
5. Barrios CH. Global challenges in breast cancer detection and treatment. Breast. 2022;62:S3–6. doi:10.1016/j.breast.2022.02.003
6. Ajmera P, Miraj M, Kalra S, et al. Impact of telehealth interventions on physiological and psychological outcomes in breast cancer survivors: a meta-analysis of randomised controlled trials. Front Oncol. 2023;12(January):1–19. doi:10.3389/fonc.2022.1017343
7. Kruse CS, Pacheco GJ, Vargas B, Lozano N, Castro S, Gattu M. Leveraging telehealth for the management of breast cancer: a systematic review. Healthc. 2022;10(10):2015. doi:10.3390/healthcare10102015
8. Lopez AM. Telehealth in cancer care: inequities, barriers, and opportunities. Cancer J. 2024;30(1):2–7. doi:10.1097/PPO.0000000000000694
9. Mechanic OJ, Persaud Y, Kimball AB. Telehealth system [Internet]. StatPearls [Internet]; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459384/.
10. Smith A, Smith A, Dadich A, et al. Optimising implementation of telehealth in oncology: a systematic review examining barriers and enablers using the RE-AIM planning and evaluation framework. Crit Rev Oncol Hematol. 2022;180:103869. doi:10.1016/j.critrevonc.2022.103869
11. Kirby A, Griffin D, Heavin C, Drummond F, McGrath C, Kiely F. Telehealth adoption in palliative care: a systematic review of patient barriers and facilitators. BMC Palliat Care. 2025;24. doi:10.1186/s12904-025-01698-2
12. Shaffer K, Turner K, Siwik C, et al. Digital health and telehealth in cancer care: a scoping review of reviews. Lancet Digit Heal. 2023;5.
13. Annunziata C, Dahut W, Willman C, Winn R, Knudsen K. Reflections on the state of telehealth and cancer care research and future directions. J Natl Cancer Inst Monogr. 2024;64:100–103. doi:10.1093/jncimonographs/lgae008
14. Abdelaleem M. Telehealth and digital technology: challenges and opportunities in cancer care. Int J Membr Sci Technol. 2023;10:1963–1968. doi:10.15379/ijmst.v10i4.2336
15. Spelten E, Hardman R, Pike K, Yuen E, Wilson C. Best practice in the implementation of telehealth-based supportive cancer care: using research evidence and discipline-based guidance. Patient Educ Couns. 2021;104:2682–2699. doi:10.1016/j.pec.2021.04.006
16. Das DK. Opportunities & challenges of telehealth implementation & remote care. Oncol Times [Internet]; 2022. Available from: https://consensus.app/papers/opportunities-challenges-of-telehealth-implementation-das/d377f6c4b8165ec1a5a1f10eabe565e4/.
17. Suh SR, Lee MK. Effects of nurse-led telephone-based supportive interventions for patients with cancer: a meta-analysis. Oncol Nurs Forum. 2017;44(4):E168–84. doi:10.1188/17.ONF.E168-E184
18. Kwok C, Degen C, Moradi N, Stacey D. Nurse-led telehealth interventions for symptom management in patients with cancer receiving systemic or radiation therapy: a systematic review and meta-analysis. Support Care Cancer off J Multinatl Assoc Support Care Cancer. 2022;30(9):7119–7132.
19. Del Valle MO, Martín-Payo R, Cuesta-Briand B, Lana A. Impact of two nurse-led interventions targeting diet among breast cancer survivors: results from a randomized controlled trial. Eur J Cancer Care. 2018;27(4):1–10.
20. Dwedar LM, Mahmoud FZ, Eldin AIE, Hamid AA. Effect of tele-nursing counseling on empowering the quality of life among women with breast cancer undergoing chemotherapy Lawahez. Egypt J Heal Care. 2022;13(2).
21. Knox J. Chapter 62 – The crucial role of nurses in telehealth. In: Kuriansky J, Kakkattil PBTRH, editors. Resilient Health. Academic Press; 2024:771–778.
22. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:1–11.
23. Riley RD, Moons KGM, Snell KIE, et al. A guide to systematic review and meta-analysis of prognostic factor studies. BMJ. 2019;364. doi:10.1136/bmj.k4597
24. Joanna Briggs Institute (JBI). JBI’s critical appraisal tools [Internet]. Joanna Briggs Institute; 2022 [cited January 1, 2023]. Available from: https://jbi.global/critical-appraisal-tools.
25. Freeman LW, White R, Ratcliff CG, et al. A randomized trial comparing live and telemedicine delivery of an imagery-based behavioral intervention for breast cancer survivors: reducing symptoms and barriers to care. Psychooncology. 2015;24(8):910–918. doi:10.1002/pon.3656
26. Im EO, Chee W, Paul S, et al. A randomized controlled trial testing a virtual program for Asian American women breast cancer survivors. Nat Commun. 2023;14(1):1–9. doi:10.1038/s41467-023-42132-6
27. Hayes S, Rye S, Battistutta D, et al. Design and implementation of the exercise for health trial – A pragmatic exercise intervention for women with breast cancer. Contemp Clin Trials. 2011;32(4):577–585. doi:10.1016/j.cct.2011.03.015
28. Galiano-Castillo N, Cantarero-Villanueva I, Fernández-Lao C, et al. Telehealth system: a randomized controlled trial evaluating the impact of an internet-based exercise intervention on quality of life, pain, muscle strength, and fatigue in breast cancer survivors. Cancer. 2016;122(20):3166–3174. doi:10.1002/cncr.30172
29. Van Den Berg SW, Gielissen MFM, Custers JAE, Van Der Graaf WTA, Ottevanger PB, Prins JB. BREATH: web-based self-management for psychological adjustment after primary breast cancer-results of a multicenter randomized controlled trial. J Clin Oncol. 2015;33(25):2763–2771. doi:10.1200/JCO.2013.54.9386
30. Ashing K, Rosales M. A telephonic-based trial to reduce depressive symptoms among Latina breast cancer survivors. Psychooncology. 2014;23(5):507–515. doi:10.1002/pon.3441
31. Jacobs JM, Post K, Massad K, et al. A telehealth intervention for symptom management, distress, and adherence to adjuvant endocrine therapy: a randomized controlled trial. Cancer. 2022;128(19):3541–3551. doi:10.1002/cncr.34409
32. Lally RM, Kupzyk KA, Bellavia G, et al. CaringGuidanceTM after breast cancer diagnosis eHealth psychoeducational intervention to reduce early post-diagnosis distress. Support Care Cancer. 2020;28(5):2163–2174. doi:10.1007/s00520-019-05028-0
33. Sherman DW, Haber J, Hoskins CN, et al. The effects of psychoeducation and telephone counseling on the adjustment of women with early-stage breast cancer. Appl Nurs Res. 2012;25(1):3–16. doi:10.1016/j.apnr.2009.10.003
34. Horsbøl TA, Saltbæk L, Urhammer C, et al. Work ability following breast cancer – the MyHealth randomized controlled trial. Acta Oncol. 2025;64:34–39. doi:10.2340/1651-226X.2025.42221
35. Wagner LI, Tooze JA, Hall DL, et al. Targeted eHealth intervention to reduce breast cancer survivors’ fear of recurrence: results from the FoRtitude randomized trial. J Natl Cancer Inst. 2021;113(11):1495–1505. doi:10.1093/jnci/djab100
36. Santa-Maria CA, Coighlin JW, Sharma D, et al. The effects of a remote-based weight loss program on adipocytokines, metabolic markers, and telomere length in breast cancer survivors: the POWER-remote trial. Clin Cancer Res. 2020;176(1):3024–3034. doi:10.1158/1078-0432.CCR-19-2935
37. Børøsund E, Cvancarova M, Moore SM, Ekstedt M, Ruland CM. Comparing effects in regular practice of e-communication and web-based self-management support among breast cancer patients: preliminary results from a randomized controlled trial. J Med Internet Res. 2014;16(12):e295. doi:10.2196/jmir.3348
38. Pang Y, He H, Ng RP, et al. Effectiveness of an innovative mobile-based perioperative care program for women undergoing breast Cancer surgery (iCareBreast): randomized controlled trial. J Med Internet Res. 2025;27:1–18. doi:10.2196/71684
39. Wheelock AE, Bock MA, Martin EL, et al. SIS.NET: a randomized controlled trial evaluating a web-based system for symptom management after treatment of breast cancer. Cancer. 2015;121(6):893–899. doi:10.1002/cncr.29088
40. Harrigan M, Cartmel B, Loftfield E, et al. Randomized trial comparing telephone versus in-person weight loss counseling on body composition and circulating biomarkers in women treated for breast cancer: the lifestyle, exercise, and nutrition (LEAN) study. J Clin Oncol. 2016;34(7):669–676. doi:10.1200/JCO.2015.61.6375
41. Eakin EG, Lawler SP, Winkler EAH, Hayes SC. A randomized trial of a telephone-delivered exercise intervention for non-urban dwelling women newly diagnosed with breast cancer: exercise for health. Ann Behav Med. 2012;43(2):229–238. doi:10.1007/s12160-011-9324-7
42. Sandgren AK, McCaul KD. Long-term telephone therapy outcomes for breast cancer patients. Psycho-Oncology J Psychol Soc Behav Dimens Cancer. 2007;16(9):S25–S25.
43. Kimman ML, Dirksen CD, Voogd AC, et al. Nurse-led telephone follow-up and an educational group programme after breast cancer treatment: results of a 2 x 2 randomised controlled trial. Eur J Cancer. 2011;47(7):1027–1036. doi:10.1016/j.ejca.2010.12.003
44. Beaver K, Tysver-Robinson D, Campbell M, et al. Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial. BMJ. 2009;338(7690):337–340. doi:10.1136/bmj.a3147
45. Ozkan B, Mentes S, Ozturk A, Soyuer S. Effects of follow-up by phone interview and anger management training provided to patients with breast cancer undergoing radiotherapy on levels of self-esteem, anger and depression. Uluslararasi Hematol Derg. 2014;24(4):260–269.
46. Ryhänen AM, Rankinen S, Siekkinen M, Saarinen M, Korvenranta H, Leino-Kilpi H. The impact of an empowering Internet-based breast cancer patient pathway program on breast cancer patients’ clinical outcomes: a randomised controlled trial. J Clin Nurs. 2013;22(7–8):1016–1025. doi:10.1111/jocn.12007
47. Damholdt MF, Mehlsen M, O’Toole MS, Andreasen RK, Pedersen AD, Zachariae R. Web-based cognitive training for breast cancer survivors with cognitive complaints—a randomized controlled trial. Psychooncology. 2016;25(11):1293–1300. doi:10.1002/pon.4058
48. Shaw J, Young J, Butow P, Chambers S, O’Brien L, Solomon M. Delivery of telephone-based supportive care to people with cancer: an analysis of cancer helpline operator and cancer nurse communication. Patient Educ Couns. 2013;93(3):444–450. doi:10.1016/j.pec.2013.07.003
49. Javadi P, Nejat N, Golaghaie F, Sharifi M. The effects of nurse-led telephone-based support on supportive care needs among women with breast cancer: a randomized clinical trial. Nurs Midwifery Stud. 2019;8(1):7–13. doi:10.4103/nms.nms_94_17
50. Piazza M, Drury A. An integrative review of adult cancer patients’ experiences of nursing telephone and virtual triage systems for symptom management. Eur J Oncol Nurs. 2023;67:102428. doi:10.1016/j.ejon.2023.102428
51. Liptrott S, Bee P, Lovell K. Acceptability of telephone support as perceived by patients with cancer: a systematic review. Eur J Cancer Care. 2018;27. doi:10.1111/ecc.12643
52. Cusack M, Taylor C. A literature review of the potential of telephone follow-up in colorectal cancer. J Clin Nurs. 2010;19(17–18):2394–2405. doi:10.1111/j.1365-2702.2010.03253.x
53. Mendes-Santos C, Weiderpass E, Santana R, Andersson G. A guided internet-delivered individually-tailored ACT-influenced cognitive behavioural intervention to improve psychosocial outcomes in breast cancer survivors (iNNOVBC): study protocol. Internet Interv. 2019;17:100236. doi:10.1016/j.invent.2019.01.004
54. Wallin E, Mattsson S, Olsson E. The preference for Internet-based psychological interventions by individuals without past or current use of mental health treatment delivered online: a survey study with mixed-methods analysis. JMIR Ment Heal. 2016;3.
55. Lorca-Cabrera J, Ferré-Grau C, Martí-Arques R, Raigal-Aran L, Falcó-Pegueroles A, Albacar-Riobóo N. Effectiveness of health web-based and mobile app-based interventions designed to improve informal caregiver’s well-being and quality of life: a systematic review. Int J Med Inform. 2019;134:104003. doi:10.1016/j.ijmedinf.2019.104003
56. Xie L, Itzkovitz A, Roy-Fleming A, Da Costa D, Brazeau A. Understanding self-guided web-based educational interventions for patients with chronic health conditions: systematic review of intervention features and adherence. J Med Internet Res. 2020;22:e18355. doi:10.2196/18355
57. Murray E. Web-based interventions for behavior change and self-management: potential, pitfalls, and progress. Med. 2012;20(1).
58. Domin A, Spruijt-Metz D, Theisen D, Ouzzahra Y, Vögele C. Smartphone-based interventions for physical activity promotion: scoping review of the evidence over the last 10 years. JMIR mHealth uHealth. 2021;9(7):e24308. doi:10.2196/24308
59. Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin. 2024;74(1):12–49. doi:10.3322/caac.21820
60. Xu S, Murtagh S, Han Y, Wan F, Toriola AT. Breast cancer incidence among US women aged 20 to 49 years by race, stage, and hormone receptor status. JAMA Network Open. 2024;7(1):e2353331. doi:10.1001/jamanetworkopen.2023.53331
61. Borges Do Nascimento IJ, Abdulazeem H, Vasanthan LT, et al. Barriers and facilitators to utilizing digital health technologies by healthcare professionals. NPJ Digit Med. 2023;6(1):161. doi:10.1038/s41746-023-00899-4