Symptom Tracking for Patient-Reported Outcomes in Cancer: User-Centered Design of the AthenaCompanion Web Application.

Background: Routine monitoring of patient-reported outcomes (PROs) during cancer treatment improves symptom control and quality of life, yet real-world uptake and sustained engagement with PRO monitoring remain suboptimal. Gamification has been shown to improve engagement with digital health interventions. User-centered design approaches are needed to ensure that gamified PRO tools are acceptable, usable, and responsive to patient and clinician needs, especially for older adult users. Objective: This study aimed to develop a gamified symptom monitoring web application for older adult patients with cancer using a multiphase, iterative, and user-centered approach. Methods: The overall study design was a mixed-methods user-centered design study involving 3 phases. From 2022 to 2026, participants were recruited across online and clinical settings using multiple strategies, including ResearchMatch (Vanderbilt University Medical Center), clinician referrals, professional networks, and outreach through the electronic health record at an academic medical center. Phase 1 was a survey of older adults with chronic health conditions. They reported on symptom severity, mobile health (mHealth) preferences, and gamification preferences, which were analyzed descriptively. Phases 2 and 3 involved semistructured interviews with older adult cancer survivors and clinicians, respectively, to identify actionable feedback, followed by iterative usability testing with older adult cancer survivors. Results: In Phase 1, older adults (n=216) with chronic conditions reported high frequency of mobile phone use (across 11 mobile phone behaviors, mean 6.1, SD 1.63 where 6 indicates daily use) and generally favorable attitudes toward gamification (across 18 gameful design elements, means ranged from 2.8-4.3 on a 1-5 scale and SDs ranged from 0.75-1.12), with learning elements rated most appealing (mean 4.3/5, SD 0.75). Concerns about a gamified mHealth app included data privacy and perceived trivialization of health. Phase 2 interviews (n=7) demonstrated strong interest in longitudinal symptom visualization and clinician-sharable reports; gamified content was viewed as engaging by most participants but was preferred as optional. In Phase 3, iterative clinician interviews (n=5) and patient usability testing (n=9) led to substantial refinements, including simplified navigation, enhanced visual accessibility, further guidance on score interpretation with embedded educational videos, and de-emphasis of the gamified travel learning component. Across usability testing rounds, the number of user experience problems per interview decreased from 17 to 4, indicating improved usability. Conclusions: Using a multiphase, mixed methods, user-centered design process, we developed AthenaCompanion (Northwestern University with The Ohio State University), a gamified web application for PRO monitoring tailored to older adults undergoing cancer treatment. Across surveys and interviews, patients emphasized the importance of clinical utility, clarity of symptom feedback, and low-pressure, optional gamification elements. This work demonstrates the feasibility of integrating gamification into PRO monitoring and provides a foundation for future work evaluating long-term usability, engagement, and clinical effectiveness in real-world oncology care.