JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

Original Paper

A Mobile Game for Patients With Breast Cancer for Chemotherapy

Self-Management and Quality-of-Life Improvement: Randomized
Controlled Trial

Hee Jun Kim1, MD, PhD; Sun Mi Kim2, MD, PhD; Heechul Shin3, MD, PhD; Joung-Soon Jang1, MD, PhD; Young
In Kim2, MD; Doug Hyun Han2, MD, PhD
1
Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Republic Of Korea
2
Department of Psychiatry, College of Medicine, Chung-Ang University, Seoul, Republic Of Korea
3
Department of Surgery, College of Medicine, Chung-Ang University, Seoul, Republic Of Korea

Corresponding Author:
Doug Hyun Han, MD, PhD
Department of Psychiatry
College of Medicine
Chung-Ang University
224-1 Heukseok-dong
Dongjak-gu
Seoul,
Republic Of Korea
Phone: 82 2 6299 3132
Fax: 82 2 6299 2064
Email: hduk70@gmail.com

Abstract
Background: The application of game-based learning in clinical practice has shown potential advantages in previous studies.
However, there have been little efforts to use smartphone-based mobile games in the management of adult patients with cancer.
Objective: The objective of our study was to evaluate if patient education using a mobile game may increase drug compliance,
decrease physical side effects of chemotherapy, and improve psychological status in breast cancer patients.
Methods: A total of 76 patients with metastatic breast cancer who were planned to receive cytotoxic chemotherapy were enrolled
in this trial. Study participants were randomly assigned to a mobile game play group (game group, n=36) or a conventional
education group (control group, n=40) in a ratio of 1:1. The patients were unblinded and followed prospectively for 3 weeks.
Outcome measures included time spent for education, compliance to medication, physical side effects, and psychological side
effects including quality of life (QoL).
Results: Overall, 72 out of 76 patients completed the study after 3 weeks (95%). The subjects in the game group showed high
levels of satisfaction with the app. The time spent playing the mobile game in the game group was longer than that spent for
self-education in the control group (mean 22.2, SD 6.1 vs mean 5.5, SD 4.0 minutes a day; P<.001). The mobile game group
showed better drug adherence (Korean version of the Medication Adherence Rating Scale; mean 7.6, SD 0.7 vs mean 6.5, SD
0.5; P<.001). The use of the mobile game was associated with lower rates of chemotherapy-related side effects, such as nausea,
fatigue, numbness of hand or foot, and hair loss, than the control group. The game group exhibited better QoL during chemotherapy
(mean 74.9, SD 3.5 vs mean 72.2, SD 5.3; P=.01). However, there were no significant differences in terms of depression and
anxiety scales.
Conclusions: This study suggests the feasibility and potentiality of the use of smartphone mobile games for patients with breast
cancer receiving chemotherapy. Education using a mobile game led to better patient education, improved drug compliance,
decreased side effects, and better QoL compared with conventional education. Mobile games can be used as easy, fun, and
effective measures for patient education and have the potential to improve treatment outcomes.
Trial Registration: ClinicalTrials.gov NCT03205969; http://clinicaltrials.gov/ct2/show/NCT03205969 (Archived by WebCite
at http://www.webcitation.org/71jfSBOq9).

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 1

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

(J Med Internet Res 2018;20(10):e273) doi: 10.2196/jmir.9559

KEYWORDS
mobile phone; breast cancer; chemotherapy; side effects; quality of life

and Statistical Manual of Mental Disorders, Fourth Edition,

Introduction Text Revision Axis I Disorders [11]. The inclusion criteria were
Playing console and Web-based games is a popular free-time as follows: females diagnosed with metastatic breast cancer,
activity among children, adolescents, and adults [1]. Recent aged 18-65 years, use of at least third-line palliative
studies with health-related internet games have shown positive chemotherapy treatment comprising taxanes, anthracyclines,
effects, such as improving coping strategies for health problems, capecitabine, and platinum compounds, and ability to use a
strengthening treatment compliance, and increasing motivation smartphone for the mobile game. The exclusion criteria were
to overcome the difficult times during illness [2]. Potential as follows: current or history of uncontrolled medical diseases
benefits of using computer-based patient education programs except for breast cancer, psychiatric diseases, including major
include increased patient knowledge in perceived information depressive disorder and anxiety disorders, and history of
competence [3]. Game-based learning may be enjoyable, substance abuse, including alcohol, nicotine, and drugs. Major
interesting, and immersive and therefore, more effective than depressive disorder and anxiety disorder were diagnosed based
classical learning [4]. Patient education has shown to be on the Diagnostic and Statistical Manual of Mental Disorders,
effective in the management of patients with teenage cancer, Fourth Edition, Text Revision, the authoritative guide to the
diabetes, and asthma [2]. However, there have been limited diagnosis of mental disorders published by American Psychiatric
studies conducted in adults. Association [12].

Chemotherapy is the main treatment for breast cancer, which The Chung-Ang University Hospital Institutional Review Board
has proven to reduce the rate of recurrence and mortality in approved the research protocol for this study (Number
breast cancer patients [5]. Chemotherapy is accompanied by C20141447). Informed consent was obtained from all patients
significant side effects. Consequently, many cancer survivors during hospitalization for chemotherapy after explaining the
experience physical and psychological symptoms that hamper design, protocol, and consequences of the study
their quality of life (QoL) and disrupt their daily living activities, (NCT03205969).
family relationships, and work schedules [6]. Diarrhea, nausea, Description of the Mobile Game
vomiting, hair loss, and mucositis are among the most common
A mobile game, ILOVEBREAST (CLGAMES, Seoul, Korea),
side effects [7]. These side effects may cause poor drug
was developed with an intention to improve self-management
compliance, prohibiting successful anticancer treatment. Poor
and to reduce the side effects of chemotherapy drugs. The
education is one of the main determinants of poor adherence to
ILOVEBREAST program used in this study was a 3-week
chemotherapy [8]. Therefore, proper education and sufficient
program using typical multiplayer, social network, and
communication are important to increase adherence, which may
platform-based features. The game’s key pedagogical features
eventually contribute to improved clinical outcomes [9,10].
were as follows: education for preventing side effects of
An easily accessible, immersive, and interactive Web-based anticancer drugs, support for the prevention of side effects of
game (ILOVEBREAST) was developed for adult patients with anticancer drugs including numbness, hair loss, and loss of
metastatic breast cancer. Although previous efforts using games appetite, encouragement of mood and activity, including
were mostly focused on children, adolescents, or young adults, exercise, pet walking, cooking, and social game playing, which
ILOVEBREAST is specifically designed for adult users. This may facilitate participation in such activities in real life, and
study was a proof-of-concept randomized controlled trial aimed self-assessment using a personal avatar, as seen in Figure 1.
at evaluating the benefits of smartphone-based mobile game
At the start of game play, an avatar is generated based on the
use in breast cancer patients receiving cytotoxic chemotherapy.
patient’s medical information including the status of blood
We hypothesized that mobile gaming would lead to increased
components, general medical condition, and chemotherapeutic
drug compliance, decreased physical side effects of
drugs. Avatars are to visit their home, pharmacy, hospital, and
chemotherapy, and improved psychological status among
gymnasium; make purchases from shops; and operate a farm
patients.
to harvest ingredients for food. They can receive prescribed
medications, cook food appropriate for their health, and exercise.
Methods Depending on the patient’s medication dosage, avatars can
Patients pursue a quest to minimize the side effects. The quest consists
of taking the medication at the right time, cooking a meal for
Patients with pathologically proven, clinical stage IV breast oneself, exercising, going outside for a walk, and chatting with
cancer were enrolled in this study at Chung-Ang University a friend. An alarm alerts the avatar to take medications timely.
Hospital, Korea, from September 2013 to September 2014. Each time the avatar accomplishes a quest, “heart coins” are
Patients who had metastatic breast cancer and agreed to rewarded. The greater the number of the coins the patient
participate in an education-controlled trial of mobile game receives, the greater the improvement in the avatar’s health
management were screened with the research and the patient status. The avatar can then use these coins to purchase items
edition version of Structured Clinical Interview for Diagnostic
http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 2
(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

such as hats, gloves, and food ingredients. Patients are asked to visit their doctor weekly to assess their health status.
Figure 1. Representative screenshots of the ILOVEBREAST game. Source and copyright: Industry Academic Cooperation Foundation, Chung-Ang
University Hospital.

2. Is the game difficult to play?

Study Procedure 3. Is the game fun?
This study was a 3-week prospective trial. All study participants 4. Is the game helpful for taking your medication?
received a combination of 4 chemotherapy drugs (taxanes, 5. Does the game provide you with information about breast
anthracyclines, capecitabine, and cisplatin). Patients were cancer and treatment?
randomly assigned to education using mobile game play (game 6. Does the game decrease your unease with chemotherapy?
group) or conventional education (control group) utilizing an 7. Do you plan to play ILOVEBREAST during your next
interactive Web randomization system. chemotherapy session?
8. Would you recommend ILOVEBREAST to other patients
For patients in the game group, the study mobile game
(ILOVEBREAST) was installed on the participants’ with breast cancer?
smartphones. They were recommended to play the game for The questions were assessed using a self-reported scale of 10
>30 minutes a day, 3 times per week. They were interviewed levels with 10 indicating “very bad” to 100 indicating “very
every week via cell phone until the end of the study. The patients good.”
in the game group were checked with the record of access to
the ILOVEBREAST game. The patients in the control group Trial outcomes were measured in the following 4 domains: time
received routine care. A brochure elaborating the coping spent for education, compliance to medication, physical side
strategies for the side effects of chemotherapy drugs was effects, and psychological side effects including QoL. Education
provided to the control group only. The 26-page education time was measured as either the time spent for game playing or
material consisted of 2 parts. Part 1 provided the overall self-education using the brochure with preventive measures.
guidelines relating to life patterns, definition and purpose of The manufacturer (CLGAMES, Seoul, Korea) provided the
chemotherapy, and broad side effects of chemotherapy. Part 2 time the users spent playing the mobile game. Medication
contained individualized educational material comprising each compliance was assessed with the Korean version of the
patient’s purpose for chemotherapy, the name of the anticancer Medication Adherence Rating Scale (K-MARS), which has a
drugs, chemotherapy schedule, individualized management of Cronbach reliability alpha of .71 [13].
side effects and symptoms, and guidance for daily life and Physical and psychological side effects were assessed at baseline
mental attitude. The subjects in the control group were and the end of the 3-week follow-up period using questionnaires
recommended to read the material for >30 minutes a day, 3 [7]. The questionnaires for the presence and severity of side
times per week. The patients in the game group were requested effects (ie, nausea, fatigue, decreased appetite, numbness on
to rate the level of satisfaction using the following 8 questions: hand or foot, stomatitis, diarrhea or constipation, hair loss, and
1. What percentage of game content do you use while playing skin rash) were measured using a 5-point Likert scale.
the game? Questionnaires for psychological assessment included the Beck

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 3

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

Depression Inventory (BDI) with a Cronbach reliability alpha

of .83 [14], the Spielberger State-Trait Anxiety Scale with alpha
Results
of .84 [15], and the World Health Organization Quality of Demographic Characteristics
Life-BREF Scale with alpha of .87 [16]. BDI is one of the most
widely used self-reported scales to assess the severity of A flow diagram of the study is shown in Figure 2. A total of 83
depressive mood and consists of 21 multiple-choice [14] patients with metastatic breast cancer agreed to participate in
questions. The Spielberger State-Trait Anxiety Scale has 20 the study. Among them, 2 were excluded because of severe
items each to measure trait anxiety and state anxiety [17]. State depressive and anxiety symptoms, 4 for having difficulties in
anxiety means a temporary response to perceived threats, using the mobile game, and 1 for withdrawal of consent for an
whereas trait anxiety refers to a consistent personality trait to unspecified reason. Among the 76 female patients who were
experience anxiety. For this study, only state anxiety was finally enrolled, 36 and 40 were randomly assigned to the mobile
measured because we intended to measure short-term response game and control groups, respectively. After 3 weeks of the
related to chemotherapy [15]. The World Health Organization study duration, 34 and 38 patients in each group completed the
Quality of Life-BREF Scale is an abbreviated generic Quality study (94.7%).
of Life Scale developed through the World Health Organization The baseline characteristics of the study subjects are summarized
and consists of 26 items in the following 4 domains: physical in Table 1. The mean age was 50.9 (SD 7.0) years, and all the
health, psychosocial health, social relationships, and patients were female. All the participants had an Eastern
environment [16]. Cooperative Oncology Group performance status between 0
Statistics and 2. There were no significant differences in demographics
status and socioeconomic status, pathologic classification, and
Because this study was a proof-of-concept trial, the sample size hormonal status between the 2 groups.
calculation was done on a practical basis. In the center where
this study was undertaken, an average of 200 patients receives Overall Satisfaction
cytotoxic chemotherapy in a month. We assumed approximately The patients in the game group were requested to assess their
30 patients a month would meet the inclusion and exclusion level of satisfaction with ILOVEBREAST, as seen in Figure 3.
criteria of this study and planned to recruit 90 patients for 3 Patients in the game group played 41% of the game contents
months. Patient enrollment was slower than expected, and we (quests, level ups, and rewards), and more than half responded
decided to stop enrollment 1 year after the initiation of the study. that it was difficult to use (20/36, 56%). However, 67% (24/36)
Continuous variables were presented as mean (SD), and and 61% (22/36) of the patients responded that the game was
categorical variables were presented as counts and percentages. fun and helpful in taking their medications, respectively.
Continuous variables were compared with independent t tests Approximately ¾ of patients (27/36) responded positively in
or Mann-Whitney U-tests as appropriate. The Chi-square test terms of acquisition of information (74.4%), usefulness in
or Fisher’s exact test was used for dichotomous variables. For overcoming chemotherapy side effects (73.9%), and willingness
all statistical analyses, the significance level alpha was set at.05, to play again (72.2%). Furthermore, approximately 81% reported
and all analyses were performed using SPSS 18.0 (Chicago, IL, they would recommend the game to other patients with breast
USA). cancer.

Figure 2. CONSORT study flow diagram.

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 4

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

Table 1. Demographic data.

Characteristics Game group (n=36) Control group (n=40) P value
Age (years), median 49.8 52.1 .24
Years of education, mean (SD) 13.5 (2.0) 13.2 (1.9) .51

Economic statusa, n (%) .94

Highest tertile 2 (6) 2 (5)

Middle tertile 32 (89) 35 (88)
Lowest tertile 2 (6) 3 (8)
Current smoker, n (%) 5 (14) 4 (10) .43
Social drinking, n (%) 17 (47) 19 (48) .49
History of mobile gaming, n (%) 20 (56) 22 (55.0) .50
Performance status, n (%) .94

ECOGb 0-1 35 (97) 39 (98)

ECOG 2 1 (3) 1 (2.5)
ECOG 3-4 0 (0) 0 (0.0)
Pathologic characteristics, n (%) .99
Invasive ductal carcinoma 35 (97) 38 (95)
Others 1 (3) 2 (5)
Stage, n (%) .79
Initial stage IV 8 (22) 10 (25)
Relapsed stage IV 26 (72) 30 (75)
Hormone receptor status, n (%) .77
Positive 25 (69) 29 (73)
Negative 11 (31) 11 (28)
Human epidermal growth factor receptor 2, n (%) .07
Positive 13 (36) 7 (18)
Negative 23 (64) 33 (83)
Triple negative phenotype, n (%) .84
Nontriple negative 30 (83) 34 (85)
Triple negative 6 (17) 6 (15)

a
Economic status was classified into the following tertiles: highest, > US $100,000; middle, $30000-$100,000; and lowest, <$30000.
b
ECOG: Eastern Cooperative Oncology Group.

including nausea (P=.02), fatigue (P=.002), and hair loss (P=.01)

Study Endpoints was shown to be lower in the game group.
The time spent on game playing in the mobile game group was
higher than that spent for self-education in the control group After the study period of 3 weeks, the game group showed a
(22.2, SD 6.1 vs 5.5, SD 4.0 minutes; P<.001; Table 2). The higher QoL than in the control group, as seen in Table 3 and
game group also showed improved compliance to medications Figure 4. The decrease in the QoL score was also significantly
compared with the control group (K-MARS score, 7.6, SD 0.7 lower in the game group than in the control group (P=.01).
vs 6.5, SD 0.5; P<.001). The patients in the study group reported Regarding the subitems of QoL, the use of the mobile game
lower rates of physically adverse events, such as nausea (P=.02), was associated with lower decreases in physical health and
fatigue (P=.02), and numbness in the hand or foot (P=.02). environment but a higher decrease in psychological health than
Clinically significant adverse events, defined by grade ≥3 of the usual care. There were no significant differences in the BDI
Common Terminology Criteria for Adverse Events 3.0, score or state anxiety scale between the 2 groups.

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 5

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

Figure 3. Levels of satisfaction in ILOVEBREAST.

Table 2. Comparison of physically adverse events between study groups.

Education time and medication compliance Game group (n=34) Control group (n=38) P value
Time spent for game playing or self-education (minutes/day), mean (SD) 22.2 (6.1) 5.5 (4.0) <.001
Korean Medication Adherence Rating Scale, mean (SD) 7.6 (0.7) 6.5 (0.5) <.001
Any physical adverse events, n (%)
Nausea 29 (85) 23 (61) .02
Fatigue 16 (47) 29 (76) .02
Decreased appetite 16 (47) 11 (29) .18
Numbness of hand/foot 0 (0) 22 (58) .02
Stomatitis 0 (0) 4 (11) .15
Gastrointestinal (diarrhea or constipation) 7 (21) 9 (24) .97
Hair loss 0 (0) 10 (26) .27

Skin rash 0 (0) 0 (0) N/Aa

Physical adverse events grade ≥3 of Common Terminology Criteria for Adverse Events, n (%)
Nausea 5 (15) 0 (0) .02
Fatigue 1 (3) 12 (32) .002
Decreased appetite 3 (9) 6 (16) .59
Numbness of hand and foot 0 (0) 3 (8) .28
Stomatitis 0 (0) 3 (8) .28
Gastrointestinal (diarrhea or constipation) 1 (3) 5 (13) .25
Hair loss 0 (0) 8 (21) .01
Skin rash 0 (0) 0 (0) N/A

a
N/A: not applicable.

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 6

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

Table 3. Comparison of psychological side effects between study groups.

Psychological side effects Baseline At 3 weeks Differences
Game, Control, P value Game, Control, P value Game, Control, P value
mean (SD) mean (SD) mean (SD) mean (SD) mean (SD) mean (SD)
Quality of life 77.5 (3.4) 76.8 (4.5) .48 74.9 (3.5) 72.2 (5.3) .01 −2.6 (1.5) −4.6 (4.4) .01
Overall quality 2.3 (0.7) 2.3 (0.6) .74 2.5 (0.7) 2.5 (0.6) .85 −0.3 (0.3) 0.4 (0.2) .65
Overall health 1.9 (0.5) 1.7 (0.6) .14 2.1(0.7) 2.3 (0.6) .47 0.3 (0.6) 0.6 (0.9) .08
Physical health 19.1 (2.2) 18.7 (1.8) .37 20.4 (2.2) 21.1 (1.7) .16 1.3 (1.0) 2.4 (1.9) .003
Psychological health 18.1 (1.4) 17.6 (43.1) .31 18.7 (1.4) 19.3 (4.3) .43 −2.1 (0.7) 1.7 (2.9) .02
Social relationships 9.3 (1.3) 9.6 (1.6) .37 9.4 (1.2) 9.9 (1.9) .22 0.1 (0.3) 0.2 (2.1) .67
Environment 23.8 (1.7) 22.9 (3.5) .16 24.3 (1.9) 24.3 (3.3) .90 0.4 (1.1) 1.4 (2.5) .03
Beck’s depression index 13.1 (3.5) 12.4 (5.6) .51 15.7 (3.7) 14.9 (5.2) .50 2.6 (1.1) 2.6 (1.7) .99
State anxiety 37.4 (3.8) 37.9 (3.3) .43 40.6 (3.6) 42.0 (3.8) .11 3.4 (0.9) 4.1 (3.4) .21

Figure 4. Psychological adverse events: (A) quality of life, (B) Beck’s depression index, and (C) state anxiety. *: P<.05.

higher in the game group than in the control group. The quests
Discussion for taking medication and reminder alarms in the game may
Principal Findings have contributed to improving patients’ knowledge of the
disease, medication, and adverse events. Previous studies have
The mobile game ILOVEBREAST was developed to help shown that knowledge about the disease course and adverse
patients with advanced breast cancer learn more about the drug events is closely linked to patient drug adherence [18].
disease course, properties of medications, and expected adverse Since the release of the “Re-Mission” titles, which showed good
drug reactions. Adults users were generally satisfied with the adherence to treatments and easy access to knowledge, from
game app. The mobile game-based intervention improved patient HopeLab in California, the use of computer games in health
compliance, decreased the prevalence of physical side effects, education and physical education has been considered to have
and maintained the patients’ QoL compared with the positive effects [19]. Some video games have also been used
conventional care. The use of the game had no impact on as vehicles to transmit health education regarding fire and street
psychological side effects including mood and anxiety. safety, and self-management of diabetes and asthma [20,21].
Improved Drug Compliance Although most health education games have focused on children,
adolescents, and young adults [22-25], this study implies that
The patients in the study group used approximately 40% of the
adults can also utilize and benefit from game-based learning if
game contents, and the overall satisfaction was acceptable.
the contents are specifically designed for them.
Notably, a high proportion of the patients expressed a
willingness to play the game again at their next chemotherapy
session and to recommend the game to other patients. In
addition, education time and drug adherence were significantly
http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 7
(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

Physical Side Effects and Quality of Life with obesity who played educational games for about 10
The ILOVEBREAST game presents an avatar that can prevent weeks-2 years improved their psychosocial functions, including
side effects of numbness and hair loss by purchasing gloves or depression, self-efficacy, and self-esteem [30]. One possible
hats. The users are rewarded for continuous medication use, explanation is the short study duration (ie, 3 weeks) of this
and they can chat with other players who have the same disease research. The age of the participants may be another factor.
and difficulties. The player can buy food ingredients and learn Unlike children and adolescents, older patients may have a lower
how to cook and prepare healthy diets. We assume that such propensity to have interest in playing a game.
activities resulted in decreased prevalence and severity of the Study Limitations
physical side effects in the game group. Twitter, as a
The major limitation of this study is the small sample size and
complementary method, was shown to be effective in increasing
the short study period. Future studies are needed to confirm
knowledge about overall disease course, survivorship, cancer
which patients most benefit from the strategy using mobile
types and biology, and treatment options in patients with breast
games and whether the benefits may lead to an improvement
cancer in a previous study [26]. The Web-based game properties
in hard endpoints such as mortality or recurrence. Next, adverse
of immersivity, attention-maintaining properties of stories,
events related to chemotherapy were assessed subjectively.
engaging properties of interactivity, and behavior-change
Objective assessments such as scales, blood tests, or laboratory
technology may improve health-related behaviors and habits in
tests may better describe the adverse effects of chemotherapy.
patients with breast cancer [27]. Several video games have been
Also, this study reflects the difficulty when using games for
created to distract people from acute or chronic pain. The
adult patients. Although the patients generally expressed
“Re-Mission” from HopeLab in California is the most
satisfaction, the users experienced only a limited amount of the
representative mobile game that has these positive effects [19].
contents, and more than half had difficulty using the app. We
The mobile game group in this study showed a higher QoL in believe this fact provides an important lesson for future
various domains, including total health, physical health, developers.
psychological health, and environmental areas. Pompeu et al
reported improved QoL in 7 patients with Parkinson disease by
Conclusion
a game named Kinect Adventures! (Xbox 360, Microsoft Game A mobile game, ILOVEBREAST, was helpful in educating
Studios, United States) [28]. Reichlin et al also reported an adult patients with breast cancer receiving cytotoxic
improvement in the QoL in 13 patients with localized prostate chemotherapy. The game was associated with improved drug
cancer after playing an interactive game, Time After Time compliance, decreased prevalence rates of physical side effects,
(AMIGO, Gigamic, Piatnik, Playroom Entertainment, Germany) and better QoL. Patient education with smartphone mobile
[29]. games can be used as an easy, fun, and effective measure to
promote treatment adherence, which may potentially lead to
However, we observed no improvement in the psychological improved survival.
effects in this study. Chen et al reported that pediatric patients

Acknowledgments
This research study was supported by a grant of Nexon 2014 and a grant from the Korea Creative Content Agency, Ministry of
Culture, Sports and Tourism (2013040436).

Conflicts of Interest
None declared.

Multimedia Appendix 1
CONSORT-EHEALTH checklist ( V1.6.1).
[PDF File (Adobe PDF File), 90KB-Multimedia Appendix 1]

References
1. Mumtaz S. Children's enjoyment and perception of computer use in the home and the school. Computers & Education 2001
May 4;36(4):347-362 [FREE Full text] [doi: 10.1016/S0360-1315(01)00023-9]
2. Primack BA, Carroll MV, McNamara M, Klem ML, King B, Rich M, et al. Role of video games in improving health-related
outcomes: a systematic review. Am J Prev Med 2012 Jun;42(6):630-638 [FREE Full text] [doi: 10.1016/j.amepre.2012.02.023]
[Medline: 22608382]
3. Ryhänen AM, Siekkinen M, Rankinen S, Korvenranta H, Leino-Kilpi H. The effects of Internet or interactive computer-based
patient education in the field of breast cancer: a systematic literature review. Patient Educ Couns 2010 Apr;79(1):5-13.
[doi: 10.1016/j.pec.2009.08.005] [Medline: 19744817]
4. Oblinger D. The Next Generation of Educational Engagement. JIME 2004 May 21;2004(1):10 [FREE Full text] [doi:
10.5334/2004-8-oblinger]

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 8

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

5. Chia SK, Speers CH, D'yachkova Y, Kang A, Malfair-Taylor S, Barnett J, et al. The impact of new chemotherapeutic and
hormone agents on survival in a population-based cohort of women with metastatic breast cancer. Cancer 2007 Sep
01;110(5):973-979 [FREE Full text] [doi: 10.1002/cncr.22867] [Medline: 17647245]
6. Von Ah D, Habermann B, Carpenter JS, Schneider BL. Impact of perceived cognitive impairment in breast cancer survivors.
Eur J Oncol Nurs 2013 Apr;17(2):236-241. [doi: 10.1016/j.ejon.2012.06.002] [Medline: 22901546]
7. Hahn T, Wall D, Camitta B, Davies S, Dillon H, Gaynon P, et al. The role of cytotoxic therapy with hematopoietic stem
cell transplantation in the therapy of acute lymphoblastic leukemia in children: an evidence-based review. Biol Blood
Marrow Transplant 2005 Nov;11(11):823-861 [FREE Full text] [doi: 10.1016/j.bbmt.2005.08.035] [Medline: 16275588]
8. Sedjo RL, Devine S. Predictors of non-adherence to aromatase inhibitors among commercially insured women with breast
cancer. Breast Cancer Res Treat 2011 Jan;125(1):191-200. [doi: 10.1007/s10549-010-0952-6] [Medline: 20495864]
9. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005 Aug 4;353(5):487-497. [doi: 10.1056/NEJMra050100]
[Medline: 16079372]
10. Bhatia S, Landier W, Hageman L, Kim H, Chen Y, Crews KR, et al. 6MP adherence in a multiracial cohort of children
with acute lymphoblastic leukemia: a Children's Oncology Group study. Blood 2014 Oct 09;124(15):2345-2353 [FREE
Full text] [doi: 10.1182/blood-2014-01-552166] [Medline: 24829202]
11. First M, Spitzer R, Gibbon M, Williams J. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician
Version, Administration Booklet. Arlington: American Psychiatric Publishing, Incorporated; 1997.
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR). Arlington: American Psychiatric Publishing, Incorporated; 2000.
13. Jhin-Goo C, Daeyoung R, Chan-Hyung K. The Reliability and Validity of the Korean Version of Medication Adherence
Rating Scale. Korean J Psychopharmacol. Korean J Psychopharmacol 2015;26(2):43-49.
14. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961
Jun;4:561-571. [Medline: 13688369]
15. Charles S, Richard G, Robert L, Vagg PR, Gerard J. Manual for the State-Trait Anxiety Inventory. Arlington: Consulting
Psychologists Press, Inc; 1983.
16. Min SK, Kim KI, Lee CI, Jung YC, Suh SY, Kim DK. Development of the Korean versions of WHO Quality of Life scale
and WHOQOL-BREF. Qual Life Res 2002 Sep;11(6):593-600. [Medline: 12206580]
17. Spielberger C, Gorsuch R, Lushene R, Vagg P, Jacobs G. Manual for the State-Trait Anxiety Inventory. Arlington: Consulting
Psychologists Press, Inc; 1983.
18. Zhao S, Zhao H, Wang L, Du S, Qin Y. Education is critical for medication adherence in patients with coronary heart
disease. Acta Cardiol 2015 Apr;70(2):197-204. [doi: 10.2143/AC.70.2.3073511] [Medline: 26148380]
19. Kato PM, Cole SW, Bradlyn AS, Pollock BH. A video game improves behavioral outcomes in adolescents and young
adults with cancer: a randomized trial. Pediatrics 2008 Aug;122(2):e305-e317 [FREE Full text] [doi: 10.1542/peds.2007-3134]
[Medline: 18676516]
20. Brown SJ, Lieberman DA, Germeny BA, Fan YC, Wilson DM, Pasta DJ. Educational video game for juvenile diabetes:
results of a controlled trial. Med Inform (Lond) 1997;22(1):77-89. [Medline: 9183781]
21. Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and
Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ
Couns 2000 Feb;39(2-3):269-280. [Medline: 11040726]
22. Capel S, Whitehead M. The use of information and communication technology in physical education. In: Learning to Teach
Physical Education in the Secondary School: A Companion to School Experience. Abingdon-on-Thames: Taylor & Francis,
Inc; 2010.
23. Casazza K, Ciccazzo M. Improving the dietary patterns of adolescents using a computer-based approach. J Sch Health 2006
Feb;76(2):43-46. [doi: 10.1111/j.1746-1561.2006.00067.x] [Medline: 16466465]
24. Coles CD, Strickland DC, Padgett L, Bellmoff L. Games that "work": using computer games to teach alcohol-affected
children about fire and street safety. Res Dev Disabil 2007;28(5):518-530. [doi: 10.1016/j.ridd.2006.07.001] [Medline:
16965894]
25. Neuhauser L, Kreps GL. Rethinking Communication in the E-health Era. J Health Psychol 2003 Jan;8(1):7-23. [doi:
10.1177/1359105303008001426] [Medline: 22113897]
26. Attai DJ, Cowher MS, Al-Hamadani M, Schoger JM, Staley AC, Landercasper J. Twitter Social Media is an Effective Tool
for Breast Cancer Patient Education and Support: Patient-Reported Outcomes by Survey. J Med Internet Res 2015;17(7):e188
[FREE Full text] [doi: 10.2196/jmir.4721] [Medline: 26228234]
27. Baranowski T, Buday R, Thompson DI, Baranowski J. Playing for real: video games and stories for health-related behavior
change. Am J Prev Med 2008 Jan;34(1):74-82 [FREE Full text] [doi: 10.1016/j.amepre.2007.09.027] [Medline: 18083454]
28. Pompeu JE, Arduini LA, Botelho AR, Fonseca MBF, Pompeu SMAA, Torriani-Pasin C, et al. Feasibility, safety and
outcomes of playing Kinect Adventures!™ for people with Parkinson's disease: a pilot study. Physiotherapy 2014
Jun;100(2):162-168. [doi: 10.1016/j.physio.2013.10.003] [Medline: 24703891]

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 9

(page number not for citation purposes)
XSL• FO
RenderX
 JOURNAL OF MEDICAL INTERNET RESEARCH Kim et al

29. Reichlin L, Mani N, McArthur K, Harris AM, Rajan N, Dacso CC. Assessing the acceptability and usability of an interactive
serious game in aiding treatment decisions for patients with localized prostate cancer. J Med Internet Res 2011 Jan 12;13(1):e4
[FREE Full text] [doi: 10.2196/jmir.1519] [Medline: 21239374]
30. Chen J, Wilkosz ME. Efficacy of technology-based interventions for obesity prevention in adolescents: a systematic review.
Adolesc Health Med Ther 2014;5:159-170 [FREE Full text] [doi: 10.2147/AHMT.S39969] [Medline: 25177158]

Abbreviations
BDI: Beck Depression Inventory
K-MARS: Korean version of the Medication Adherence Rating Scale
QoL: quality of life

Edited by G Eysenbach; submitted 04.12.17; peer-reviewed by L Lam, JL Chen, M Shiyko; comments to author 18.03.18; revised
version received 23.06.18; accepted 10.07.18; published 29.10.18
Please cite as:
Kim HJ, Kim SM, Shin H, Jang JS, Kim YI, Han DH
A Mobile Game for Patients With Breast Cancer for Chemotherapy Self-Management and Quality-of-Life Improvement: Randomized
Controlled Trial
J Med Internet Res 2018;20(10):e273
URL: http://www.jmir.org/2018/10/e273/
doi: 10.2196/jmir.9559
PMID: 30578205

©Hee Jun Kim, Sun Mi Kim, Heechul Shin, Joung-Soon Jang, Young In Kim, Doug Hyun Han. Originally published in the
Journal of Medical Internet Research (http://www.jmir.org), 29.10.2018. This is an open-access article distributed under the terms
of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet
Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/,
as well as this copyright and license information must be included.

http://www.jmir.org/2018/10/e273/ J Med Internet Res 2018 | vol. 20 | iss. 10 | e273 | p. 10

(page number not for citation purposes)
XSL• FO
RenderX