-->PONE-D-25-09322-->-->Feasibility of the Xemio App for Breast Cancer Survivors in a Clinical Setting: Adherence, Acceptance, and Side Effect Monitoring (CTCAE vs. QoL)-->-->PLOS ONE

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Academic Editor

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“IG.

This research work was carried out as part of the EU-funded Research and Innovation Action, Artificial intelligence Supporting CAncer Patients across Europe (ASCAPE) (Project ID: 875351), [H2020-SC1-DTH-2019] SC1-DTH-01-2019, Big data and Artificial Intelligence for monitoring health status and quality of life after the cancer treatment.

The improvement of the Xemio-Research platform was supported by a La Caixa Foundation Grant (LCF/PR/AR19/51450002).”

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“IG.

This research work was carried out as part of the EU-funded Research and Innovation Action, Artificial intelligence Supporting CAncer Patients across Europe (ASCAPE) (Project ID: 875351), [H2020-SC1-DTH-2019] SC1-DTH-01-2019, Big data and Artificial Intelligence for monitoring health status and quality of life after the cancer treatment.

The improvement of the Xemio-Research platform was supported by a La Caixa Foundation Grant (LCF/PR/AR19/51450002).”

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Additional Editor Comments:

Dear authors,

Please review  the comments provided by the reviewers and revise the manuscript accordingly.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #2: Yes

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-->3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: No

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-->4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The manuscript effectively presents a well-structured and insightful evaluation of a digital health tool in breast cancer survivorship. The manuscript is generally well-prepared and suitable for publication in its current form. However, a few minor revisions could enhance the clarity and impact of the findings.

Reviewer #2: The article is a prospective feasibility study evaluating the Xemio-Research mobile health application for breast cancer survivors, with a focus on adherence, usability, and patient-reported outcomes. The authors have conducted a one-year longitudinal study within the ASCAPE project, reporting descriptive analysis of user engagement, usability scores, and symptom tracking.

The manuscript in overall is technically sound and presents a well-structured descriptive statistics study to evaluate the app’s usability, adherence, and patient-reported outcomes. However, several revisions are recommended: (a) more explicitly acknowledge the limitations of the small, convenience-based sample size and the absence of formal inferential analyses; (b) clarify that the findings are exploratory and feasibility-focused rather than confirmatory; (c) improve the Data Availability Statement to comply with the journal’s policy; and (d) address minor language, formatting, and readability issues.

The statistical analysis is appropriate for a feasibility study, with the focus on descriptive statistics (means, standard deviations, and frequencies). The analysis aligns with the study’s stated objectives. The use of validated instruments including the System Usability Scale (lines 213–216) strengthens the study approach. However, the analysis could be enhanced in several aspects. First, no inferential testing was conducted, such as in areas where simple comparisons (e.g., CTCAE vs. QoL reporting, lines 252–296) could be analysed with chi-square, correlation analyses, or Cohen’s kappa. Confidence intervals are not reported, which limits interpretation of uncertainty. In addition, handling of missing data is not discussed, despite clear reduction of participants over time (lines 178–184, 196–208). I recommend that the authors emphasize that this is an exploratory, feasibility-focused study but not a hypothesis testing. Adding basic inferential or agreement analyses will be helpful to strengthen the validity of the findings.

Apart from that, following the PLOS Data Policy, the current Data Availability Statement does not meet the required standard. The manuscript indicates that data cannot be shared publicly due to privacy regulations, and that access may be granted upon reasonable request to the author. While the sensitivity of patient data is acknowledged, PLOS requires that authors either deposit de-identified data in a public repository (setting up a controlled access if necessary) or provide a clear explanation of restrictions accompanied with a formal mechanism for data access (for example through an institutional or ethics committee). In this sense, author discretion via “reasonable request” is insufficient. I recommend that the authors revise the Data Availability Statement to ensure compliance with the journal policy.

While the discussion provides a summary of the main findings, I find the interpretation somewhat superficial. For example, the decline in adherence (lines 304–316) has been acknowledged and compared to other digital health interventions, but the analysis ended before exploring underlying reasons. Potential factors such as digital literacy, socioeconomic background, treatment-related fatigue, or psychological barriers are not addressed, despite relevant based on the demographic characteristics and the disease. Similarly, gamification and real-time monitoring are suggested as possible solutions. these ideas are presented briefly without linking to existing evidence or theory. I recommend that the authors expand the discussion to deeply analyze the factors associated with the decline of adherence, connect findings to prior literature on mHealth in survivorship care, and discuss practical implications for clinical adoption and sustainability.

Overall, the manuscript is clearly written. I suggest a few minor edits to further improve clarity and readability. In lines 110–116, the description of the sample size could be clarified by explicitly noting that this was a convenience sample. In lines 144–146, shifting the phrasing from future to past tense (“the analysis focused on…”) would ensure consistency with the Results section. At line 197, the sentence could be streamlined to “Adherence was analyzed through frequency of app usage” for conciseness. The list of negative feedback items in lines 233–239 would read more smoothly if expressed in a parallel structure (e.g., “compatibility issues, difficulties in symptom tracking, information overload, technical problems, perceived impersonality”). In lines 299, the phrase “feasibility and acceptability” is repeated unnecessarily and could be reworded for variety. Finally, the conclusion in lines 359–367 might be softened to indicate that the app “has the potential to support survivorship outcomes,” which more accurately reflects the exploratory, descriptive nature of the data.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Reviewer comments.docx

Feasibility of the Xemio App for Breast Cancer Survivors in a Clinical Setting: Adherence, Acceptance, and Side Effect Monitoring (CTCAE vs. QoL)

PONE-D-25-09322R1

Dear Dr. Frid,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Anton Pak

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

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-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

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-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

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-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The manuscript titled “Feasibility of the Xemio App for Breast Cancer Survivors in a Clinical Setting: Adherence, Acceptance, and Side Effect Monitoring (CTCAE vs. QoL)” is a well-constructed feasibility study evaluating a digital health tool for breast cancer survivors. The manuscript is clear, methodologically sound for a feasibility design, and addresses a relevant gap in mHealth survivorship tools. The integration of PROMs, CTCAE-based symptom reporting, and usability evaluation is well executed.

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

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