A remotely delivered, behaviorally designed game-based intervention was found to increase physical activity and may have implications for cardiovascular health among Black and Hispanic breast and prostate cancer survivors with cardiovascular risk factors compared with attention control, according to the ALLSTAR trial published in JACC: CardioOncology by Fanaroff et al.
The investigators noted that Black and Hispanic cancer survivors who have received cardiotoxic therapies face a higher risk of cardiovascular events than non-Hispanic White survivors, likely due to a combination of greater cardiovascular risk factors and lower levels of physical activity. Factors such as reduced fitness, stamina, and strength related to prolonged inactivity during treatment and the toxic effects of chemotherapy, psychosocial stressors, and individual and structural social determinants of health may make it difficult for these populations to engage in sufficient exercise, they explained.
“[Gamification is a] scalable and sustainable intervention [that] could be a useful component of strategies to reduce cardiovascular risk in cancer survivors,” the investigators remarked.
Study Details
Between May 2022 and February 2025, Black and Hispanic survivors of breast and prostate cancer who had undergone cardiotoxic cancer therapy and had at least one cardiovascular risk factor were enrolled in the study. They were provided with a wearable device to track daily steps, established a baseline activity level, chose an individualized step goal increase, and were randomly assigned to either attention control (n = 76) or gamification (n = 74).
The study population had a mean age of 64 years. Overall, 81% were female, 64% identified as Black, and 35% as Hispanic.
The gamification group was entered into a game designed using principles from behavioral economics to overcome barriers to behavior change—an approach that has been shown to increase physical activity in previous studies; after 24 weeks, participants stopped the game but continued receiving daily text messages noting their step count from the previous day for 12 additional weeks. Those randomly assigned to the attention control group received daily text messages for 36 weeks reporting their step count from the previous day.
The study included a 24-week intervention period followed by a 12-week postintervention follow-up. The primary outcome was the change in mean daily steps from baseline throughout the intervention period.
Key Findings
The gamification vs control group showed a greater change from baseline in mean daily steps during the intervention period (759 steps/day more, 95% confidence interval [CI] = 209–1,309 steps/day; P = .007). This difference was also observed during the follow-up period, though it was not statistically significant (581 steps/day more, 95% CI = −47–1,208 steps/day; P = .070).
Participants who received the gamification intervention also demonstrated a larger increase in weekly minutes of moderate-to-vigorous physical activity. During the intervention, the increase was 16 minutes (95% CI = 4–29 minutes/week; P = .010), and during follow-up, it was 11 minutes (95% CI = 0–22 minutes/week; P = .048).
“In Black and Hispanic breast and prostate cancer survivors, a gamification intervention incorporating principles from behavioral economic theory meaningfully increases physical activity compared with attention control over a 6-month intervention period,” the investigators concluded. They added, “Further research is needed to determine whether increases in routine daily physical activity reduce the incidence of cardiovascular events in this high-risk population.”
Alexander C. Fanaroff, MD, MHS, of the University of Pennsylvania, Philadelphia, is the corresponding author of the JACC: CardioOncology article.
Disclosure: The study was funded by grants from the American Heart Association Strategically Focused Research Network Award in Cardio-Oncology. For full disclosures of the study authors, visit jacc.org.
