Abstract

BACKGROUND

Remote patient monitoring (RPM) through electronic patient-reported outcomes (ePROs) has been shown to improve symptom management, treatment adherence, and quality of care in oncology. Despite these benefits, implementation in routine practice remains challenging due to organisational constraints, digital literacy gaps among patients and providers, and variability in institutional adoption of RPM. Vulnerable patients are among those who most benefit from such pathways but may have difficulty accessing these tools. Digital illiteracy, defined as difficulty using digital tools, is associated with age, education, and social vulnerability. Healthcare providers play a key role in initiating RPM but may hold implicit biases that influence patients' access. This study aimed to evaluate healthcare providers' perceptions and patient-reported digital literacy influence on access to RPM and patient engagement, potentially contributing to disparities in symptom monitoring in routine oncology care.

METHODS

We conducted a multi-component observational study across oncology centres in France and Belgium. First, a cross-sectional survey was distributed to healthcare providers to assess their confidence in digital tools and the factors influencing their RPM prescriptions. Two composite scores were developed: a Practitioner Representation Score and a Patient Capability Projection Score. Second, a prospective (September 2023 to December 2024) single-centre survey captured consultation-level decisions around RPM proposals. Third, we analysed patient-reported outcomes, through a retrospective observational cohort (June 2022 to March 2025), to evaluate adherence and symptom burden according to self-declared digital literacy.

FINDINGS

Healthcare providers (n = 103) reported high personal confidence with digital health (49.5/65), but their perception of patient digital capacity was significantly influenced by age, socioeconomic status, and geriatric vulnerability (31.0/40). In clinical practice, RPM was influenced by perceived social isolation and patient's understanding of the digital tool (3.9/5), language barriers, and smartphone ownership (3.2/5). Among patients (n = 4762), those with unfavourable digital literacy (n = 1308) had higher baseline symptom burden but demonstrated comparable adhesion (81.3% vs 85.6%; p < 0.0001) and similar symptom improvement after alerts compared to their digitally literate peers (96.4%; p = 0.99).

INTERPRETATION

Healthcare providers bias and perceived digital barriers may restrict equitable access to RPM. However, patients with low digital literacy, who often experience more severe symptoms, can engage effectively when included and may benefit most. Efforts to mitigate bias, adapt tools, and support onboarding and engagement are essential to ensure digital equity in cancer care.

FUNDING

Breast Cancer Research and Resilience Care. Maria Alice Franzoi reports funding from IHU PRISM (Agence Nationale de la Recherche) [grant number ANR-18-IBHU-0002]; Agence Nationale de la Recherche under the Investissements Program integrated into France 2030 [WeShare grant number ANR-21-ESRE-0017] a Conquer Cancer-Breast Cancer Research Foundation Career Development Award for Diversity and Inclusion, supported by Breast Cancer Research Foundation (no grant number).

MeSH

Bias, Monitoring, Ambulatory, Breast Neoplasms, Perception, Health Personnel, Literacy