---
title: "Feasibility trial of ASTENZ: an interactive web app to support patients with advanced cancer and r"
id: "bmj-open-17-supporting-patients-with-advanced-cancer-and-their-relatives-via-an-interactive"
canonical_url: "https://medichelpline.com/clinical-feed/bmj-open-17-supporting-patients-with-advanced-cancer-and-their-relatives-via-an-interactive"
content_type: "clinical_feed_article"
specialty: "Oncology"
source_name: "BMJ Open"
source_url: "http://bmjopen.bmj.com/cgi/content/short/16/7/e121654?rss=1"
published_at: "2026-07-17T10:56:52.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Feasibility trial of ASTENZ: an interactive web app to support patients with advanced cancer and r
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/bmj-open-17-supporting-patients-with-advanced-cancer-and-their-relatives-via-an-interactive
- **Specialty:** [Oncology](https://medichelpline.com/clinical-feed/oncology.md)
- **Primary Source:** BMJ Open
- **Source URL:** [Original Journal Publication](http://bmjopen.bmj.com/cgi/content/short/16/7/e121654?rss=1)
- **Published At:** 2026-07-17T10:56:52.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The study describes development and feasibility testing of **ASTENZ**, an interactive web-based application designed to support patients with **advanced cancer** and their relatives by addressing knowledge, communication, relationships and confidence. - The app was developed by a multidisciplinary team using prior qualitative research (interviews with patients, relatives and professionals) and a systematic review to define content and design choices. - ASTENZ is a progressive web application offering 10 chapters of multimedia content (documentary-style film, animated educational videos, in-depth videos), bookmark and question-prompt list functions, and an option to share needs with the research team for referral. - The feasibility study is a single-centre, randomised, controlled, two-arm pilot trial with mixed methods and a realist approach, recruiting patients (>18 years) with advanced cancer and relatives from hospital units at University Hospital Marburg, Germany. - Planned sample size is n=171 participants (114 patients, 57 relatives), randomised 2:1 to intervention (app access) or control (treatment as usual) with assessments at 4 and 8 weeks; control participants receive app access after the survey period. - Primary outcomes focus on **feasibility**, **usability** (System Usability Scale) and acceptability (MARS-G section E), plus technical performance and qualitative interviews; secondary outcomes include knowledge on end-of-life topics, confidence/readiness for end-of-life conversations, anxiety/depression, psychosocial distress, technical usage data and number of consultations. - The trial will collect quantitative and qualitative data to inform a future effectiveness trial; primary analyses will be descriptive and guided by a realist evaluation of what works, for whom and in which conditions. - Ethics approval was obtained from the Philipps University Marburg ethics committee (ref. 25–292 BO) and the trial is preregistered (DRKS00037577); written informed consent will be obtained and results will be disseminated in peer-reviewed journals and conferences. - Strengths include multidisciplinary development, patient-centred content addressing existential and end-of-life issues, and a mixed-methods realist design; limitations include that the current study tests a prototype's usability and feasibility rather than efficacy.
## Clinical Analysis & Structured Key Points
Skip to main content Intended for healthcare professionals Log In Basket Search for this keyword Advanced search Latest content Archive For authors About Browse by collection You are here Home Archive Volume 16, Issue 7 Email alerts Article Text Article info Citation Tools Share Rapid Responses Article metrics Alerts PDF Palliative care Protocol Supporting patients with advanced cancer and their relatives via an interactive online application: a study protocol for the development and feasibility testing of a complex intervention http://orcid.org/0009-0001-3586-519XAlina Senßfelder1, Matthias Havemann2,3, Pia von Blanckenburg1, Kurt Schmidt4, Martin Hirsch5, http://orcid.org/0000-0002-6262-0518Carola Seifart2 Correspondence to Alina Senßfelder; alina.senssfelder@uni-marburg.de Abstract Introduction Effective support for patients with advanced cancer and their relatives requires addressing individual needs, preferences and wishes, with communication as a central component. However, discussions about end-of-life issues are often perceived as difficult, and communication needs frequently remain unmet. While past interventions have primarily targeted healthcare professionals, evidence suggests that directly involving patients can have positive effects. eHealth solutions offer a promising approach to facilitate access to information, support communication and promote patient engagement. Building on this, we developed a web-based application (ASTENZ) and are now evaluating its feasibility, usability and acceptability in a pilot study. Methods and analysis A single-centre, randomised, controlled, two-arm trial with mixed-methods elements will be conducted to assess the feasibility of app usage and the study design. A realist approach will guide the study, with quantitative data complemented by qualitative interviews. Patients aged >18 years with advanced cancer and/or their relatives will be recruited from the interdisciplinary ambulatory chemotherapy unit, the palliative care unit and the dermatology cancer unit at the University Hospital of Marburg, Germany. Sample size calculations indicate a total of n=171 participants (114 patients, 57 relatives), randomly assigned in a 2:1 ratio to the intervention group (using the ASTENZ app) or control group (treatment as usual). Control group participants will receive app access after the survey period. Both groups will be assessed at 4 and 8 weeks. Primary outcomes: feasibility, usability and acceptability; secondary outcomes: knowledge on end-of-life topics, confidence, readiness for end-of-life conversations, functionality, anxiety and depression, psychosocial distress, technical data and number of consultations. Primary analyses will be descriptive. Trial status: recruitment is planned to start on 12 February 2026. Ethics and dissemination The study was approved by the Ethics Committee for Human Research at Philipps University Marburg (ref. 25–292 BO) and preregistered in the German Clinical Trials Register (DRKS00037577). All materials and procedures were reviewed and approved by the ethics committee, and written informed consent will be obtained prior to inclusion. Study results will be published in peer-reviewed journals, presented at conferences and used to inform the design of a future effectiveness trial, with potential options for wider app dissemination. Trial registration number DRKS00037577. https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/. https://doi.org/10.1136/bmjopen-2026-121654 Request Permissions If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways. Request permissions STRENGTHS AND LIMITATIONS OF THIS STUDY The ASTENZ app was developed by a multidisciplinary research team, building on relevant previous patient-centred research and designed as an easily accessible intervention to support patients with advanced cancer and their relatives/caregivers. The app places a particular emphasis on educational and informational content addressing existential concerns, end-of-life issues, dying and death as well as providing additional support for communication-related needs. Testing of the app prototype focuses on assessing usability, acceptability and the need for further refinement. Evaluation of the feasibility of the proposed study design will inform the planning of a future large-scale trial to assess the app’s efficacy. A mixed-methods design, guided by the principles of a realist approach, was employed to gain deeper insights into how and under which conditions the app may be beneficial. Introduction Background and rationale Palliative care for patients with advanced cancer aims to address individual needs, preferences and wishes.1 Evidence suggests that the diagnosis of advanced cancer can profoundly affect the whole person, giving rise to diverse challenges and threatening the integrity of personhood.2 Building on the work of Wakefield et al,3 a central question is how to support individuals facing a life-limiting illness. Support can be provided in various ways, including the sharing of information, knowledge and communication. This is particularly important, as patients may wish to be involved in care, treatment decisions and end-of-life decision-making, although both the desire for involvement and the preferred level vary considerably.4 5 Such involvement requires adequate communication among patients, their relatives and healthcare professionals, including discussions of challenging end-of-life issues. Communication about end-of-life issues has been associated with high rates of satisfaction with communication processes, improved congruence between patients, surrogates and clinicians, and increased advance care planning documentation as well as greater alignment of care with patient preferences.6 However, despite the high relevance,7 communication between these groups remains difficult for all parties involved and is, therefore, infrequent.8–10 Many existing interventions aimed at improving communication skills for end-of-life discussions focus on healthcare professionals (HCPs), with demonstrated improvements in outcomes such as empathy, confidence and self-efficacy among physicians treating patients with cancer.11 However, improvements in clinicians’ communication skills do not necessarily translate into better patient-level outcomes. For example, although an intervention improved oncologists’ ability to explore patients’ values, this did not result in more frequent or higher quality goals-of-care discussions with patients with advanced cancer.12 In contrast, evidence suggests that approaches targeting both patients and HCPs may be more effective, as reflected in an increase in goals-of-care discussions from 31% to 74%.13 These findings indicate that strengthening clinicians’ communication skills alone may be insufficient and highlight the importance of directly supporting patients’ ability to actively participate in end-of-life discussions. A prerequisite for meaningful participation is the availability of sufficient, high-quality information, including information that is reliable, timely, specific and tailored to patients’ individual needs.5 14 Such information enables patients to understand their situation, cope with their illness and actively participate in decisions about their treatment and care.4 5 Patients require adequate information about prognosis, treatment options, potential side effects and end-of-life issues,4 while relatives similarly report extensive information needs.15 16 In clinical practice, however, these needs often remain unmet, and crucial information is frequently lacking.17 While HCPs are regarded as the primary sources of information, individuals increasingly turn to electronic resources to meet their information needs.18 In recent years, eHealth approaches, broadly defined as the use of internet-based and related technologies to provide or support health services and health information,19 have gained increasing relevance, including in palliative care.20 Many interventions aim to improve communication and information exchange or support symptom management.21 Evidence suggests that eHealth interventions can enhance self-efficacy, facilitate communication with HCPs, empower relatives and are generally well accepted.21 22 In addition, a digital intervention incorporating cognitive behavioural therapy elements has been associated with improvements in patient-reported outcomes, including reduced fatigue and enhanced psychological well-being.23 Meta-analytic findings also indicate that web-based and mobile-based interventions targeting symptom management can help reduce the physical symptom burden in patients with advanced cancer.24 Despite the growing number of apps in palliative care, many of which focus on telecommunication, little is known about their validity and effectiveness.25 In Germany, only two apps are currently listed in the official directory of digital health applications, both have undergone scientific evaluation as a prerequisite for listing. However, these applications address highly specific issues, focusing on fatigue management and support during and after treatment for breast cancer, respectively. To our knowledge, no German-language app has been specifically developed for patients with advanced cancer receiving palliative care. This population has distinct and evolving information and communication needs, which may change over the course of illness.26 While international applications may be available in English, language barriers, differences in healthcare systems and variations in care pathways may limit their applicability for German-speaking patients. Particularly in this context, accessible approaches to addressing complex issues, including end-of-life topics, are highly relevant. Although developed and evaluated in a different cultural and healthcare context, the SUPPORT+mobile application for patients with advanced cancer in Hong Kong demonstrated promising effects, including increased end-of-life discussions, lower depression scores and greater knowledge about palliative care.26 These findings suggest that digital interventions may be a feasible and potentially effective approach to supporting patients with advanced cancer. To ensure that such an intervention would address the specific needs of German-speaking patients and their relatives, we first explored the experiences and needs of those affected in a preliminary study.2 Four domains were identified that may be subjected to disruptive effects of the disease while simultaneously representing key targets for intervention: knowledge, communication, relationships and confidence. We consider the involvement of relatives important, as they are often actively involved in the care and treatment of patients with advanced cancer17 and simultaneously experience substantial needs for information and support.16 Based on these insights, we developed an interactive web-based application addressing these domains to support the ‘unit of care’ (patients and their relatives/caregivers) in multiple ways, for example, by providing information and generating a personalised list of relevant topics. The feasibility of this app prototype will be evaluated in the present study. Objectives The trial objectives are: To assess the feasibility, usability and acceptability of the app among participants after 4 and 8 weeks using the System Usability Scale (SUS), section E of the Mobile App Rating Scale (MARS-G), technical data and qualitative interviews. To evaluate the app’s functionality and technical performance during routine clinical care in a hospital setting. To pilot the study design, including recruitment strategies, data collection procedures and study instruments, in preparation for a subsequent large-scale evaluation. The results will inform the design and conduct of a future study assessing the app’s efficacy. Development of the interactive online application ‘ASTENZ’ The development of the app was carried out by a multidisciplinary team comprising experts in oncology, palliative care, nursing, psychology, psychotherapy, public health, theology, medical ethics and artificial intelligence. Furthermore, it was based on two preliminary works: (1) a comprehensive qualitative study and (2) a systematic review of the existing literature. The ASTENZ application was developed using a progressive web application framework, allowing users to access and use it in a manner similar to a conventional mobile app. Participants in the feasibility study are granted access via a unique study ID, which serves as their login credential and does not require the creation of a separate user account. An overview of the development process is shown in figure 1. Download figure Open in new tab Download powerpoint Figure 1 Development of the ASTENZ app. Qualitative study In-depth interviews with advanced cancer patients (n=17, mean age=64.29 years), relatives (n=15, mean age=54.2 years) and care professionals (n=22, mean age=52.27 years) were conducted to enhance understanding of the lived experience of an advanced cancer diagnosis. The findings indicate that such a diagnosis can significantly disrupt the integrity of personhood and give rise to a range of challenges and needs related to illness, end-of-life care, dying and death.2 The results further revealed a broad variety of topics, which were classified into eight categories: disease and therapy, structures of care, advance planning, psychological condition, dying, existential issues and communication and relationships. Based on these findings, we developed a model describing the experience following diagnosis by identifying factors that contribute to both disintegration and restoration of personhood across four domains: communication, knowledge, relationships and confidence. Both the development of the intervention, including the app addressing these domains (see figure 2), and the design of the feasibility study were guided by this conceptual model. Download figure Open in new tab Download powerpoint Figure 2 Pathways to restoring personhood via the ASTENZ app. Systematic review of literature Additionally, we conducted a systematic review of existing research on the communication needs of palliative cancer patients and their relatives to expand and complement the findings from our qualitative study. The results provided important insights into preferred communication partners, timing, topics and approaches to end-of-life communication. As these needs were found to be highly individual, the findings underscore the importance of personalised and tailored approaches. In particular, results related to relevant communication topics informed the content development of the app.27 Creation and description of the app prototype The development of the content was carried out by the interdisciplinary research team based on the points outlined above. The team held regular meetings to discuss progress and advance the development process. The app consists of an introductory section to familiarise users with the app, followed by a total of 10 chapters covering key topics, each complemented by subtopics and more in-depth information. An overview of the topics is provided in table 1. The content is presented in different media formats, with each chapter consisting of: a film sequence in which two advanced cancer patients are accompanied during their illness. Subtopics presented as educational animated videos. In-depth information provided as educational videos. VIEW INLINE VIEW POPUP Table 1 Overview of the app content To enhance usability, especially for patients who may experience disease-related impairments that are common in palliative stages, we decided to reduce the amount of text wherever possible. A documentary-style film was developed based on findings from the preliminary qualitative study and the identified information needs of the target population. The script was drafted by an expert and informed by the study results. Both script development and film production followed an iterative process involving regular review and discussion within the multidisciplinary research team (MHa, PvB, KS, MHi, CS, AS) to ensure the accuracy, relevance and comprehensive coverage of all key topics identified in the needs assessment. The final film accompanies two patients over the course of their illness: a 35-year-old married woman with advanced breast cancer and liver metastases, mother of two young children (aged 5 and 7); and a 67-year-old single man with advanced lung cancer and newly developed liver metastases, whose three adult children live at a distance. For both patients, no curative treatment options remain. The portrayal of their experiences is intended to facilitate identification and provide opportunities for observational learning by illustrating how patients navigate common challenges associated with advanced cancer and palliative care. Throughout the film, patients are shown navigating various aspects of care, including visiting a palliative care unit, attending a psycho-oncology consultation and discussing advance directives. The design of the app has been developed in co-operation with a user experience designer and gone through several iterations including patient and user feedback and testing. Particular attention was paid to readability and accessibility, including adequate colour contrast and font sizes suitable for the target population. A calm colour palette was chosen to ensure visual comfort while maintaining readability. Features of the app Users can select app content according to their interests; no fixed order is required. Two key features are included. First, users can create bookmarks with brief personal notes related to specific subtopics or in-depth information. These bookmarks are stored and can be viewed as a list of personally relevant topics, following the concept of question prompt lists. The list may also be emailed to users to support, for example, preparation for upcoming medical consultations. Second, if additional support is required, the list of personally relevant topics (or selected individual topics) can be shared with the research team. A study nurse will then assess the user’s needs and facilitate referral to appropriate services, for example, by arranging consultation appointments. Screenshots illustrating the app are provided in online supplemental materials. Supplemental material [bmjopen-2026-121654supp001.pdf] Methods and analysis Trial design The study is planned as a single-centre randomised, controlled, two-arm pilot trial with mixed methods elements to assess the feasibility of the study design and app usage. A realist approach will provide insights into what is feasible and acceptable, for whom, and under which circumstances,28 29 informing potential adjustments to hypotheses for a subsequent evaluation of the app. In addition to collecting quantitative data, qualitative interviews with users should be conducted. Participants will be randomly assigned to the intervention or the control group (treatment as usual (TAU)). Trial setting and recruitment Patients with advanced cancer and their relatives will be recruited at a German university hospital in Marburg, particularly from the interdisci
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