One-Way Texting: No Help with Breast Cancer Pill Taking, But…

Maybe Two-Way Texting Will Do the Job!

Nick Mulcahy

June 07, 2019

CHICAGO — Can American breast cancer clinicians solve the thorny problem of adherence to aromatase inhibitors (AIs) by text messaging their patients?

The communications innovation, first conceived in 1984 by a Finnish engineer and implemented in 1992 by a British tech employee, is now part of daily life, which, for many breast cancer patients, also includes taking — or not taking — prescribed AIs to reduce the risk of disease recurrence after surgery.

The barriers to compliance with AIs are significant and include cost and toxicities, especially debilitating joint pain, said Dawn Hershman, MD, medical oncologist, NewYork-Presbyterian and Columbia University Irving Medical Center, New York City.

She spoke here during an oral presentation at the 2019 American Society of Clinical Oncology (ASCO) annual meeting and to Medscape Medical News.

Text messaging is effective in other settings and improves adherence to tobacco cessation, weight loss, sunscreen application, and various medications, she explained.

Furthermore, there are currently about 100 different text messaging and drug adherence studies in the United States, per the NIH RePORTER, Hershman said.

Dr Dawn Hershman

Hershman and colleagues were early participants in the research action, designing a study, funded by the SWOG Cancer Research Network, that randomly assigned 636 women taking AIs to one-way, "passive" text messaging (twice a week for 3 years) or usual care/no texting. Importantly, all of the women had clinic visits every 3 months — and underwent urine analysis to definitively determine AI usage.

That's a key detail, emphasized Hershman.

The literature on AI adherence is wide and deep — and highly flawed, she said, because the majority of previous studies use prescription-refill data as the chief measure of adherence. "A lot of breast cancer patients get auto refills — that doesn't mean they are taking the drugs," she explained.

At ASCO, Hershman reported that, for the primary endpoint of time to adherence failure, there was no difference between the text and no-text groups (hazard ratio, 0.89; P = .15) over 3 years, which is the longest study period ever for this clinical issue.

The rate of failure at 3 years, which was uniformly similar for both text and no-text groups, depended on the tool used to measure it — it was 10% per patient self-reporting, 20% per provider assessment, and 50% by urine analysis (part of the primary endpoint).

In short, texting didn't help women take AIs — by a bunch of measures.

Hershman provided a take-home message: "A simple one-way reminder that doesn't enhance patient–provider communication or personalize behavioral intervention in any way doesn't work."

"We are inundated with information," she continued. "The concept that you can just remind people to do something — and that will change behavior — is unlikely to succeed."

Hershman also provided a formula for success for AI adherence: "If we want to intervene, we need better symptom management. Behavioral interventions are important but need to be long lasting."

Asked for comment, Eleni Andreopoulou, MD, breast oncologist at Weill Cornell Medicine in New York City, had similar thoughts.

"It is likely that a combination of interventions will be needed to improve adherence," she said in an email.

Andreopoulou, who was not associated with the current study, has an open mind about texting: "I do not think that we can conclude that text messaging does not work but rather that trying to modify behavior is a complex process."

Two-Way Texting Study Funded by NCI

Kuang-Yi Wen, PhD, health systems engineer, Kimmel Cancer Center, Jefferson University, Philadelphia, reviewed the SWOG-funded study for Medscape Medical News. "Simple weekly text messaging is not enough," she summarized, echoing Hershman.

Wen is the lead author of a pilot study, published at ASCO as an e-abstract, that tested a novel mobile text messaging-based intervention (TXT2Adhere). The text program, write Wen and colleagues, delivers daily "adherence-promoting and side effect coping tips messages" to patients just starting AIs or tamoxifen after breast cancer surgery. 

The 58-patient randomized trial found that participants in the TXT2Adhere group reported higher hormone therapy adherence at 2 months than the usual care group (93% vs 54%, P < .05).

But this difference between groups disappeared at 3 months, thus falling way short of Hershman's call for behavioral interventions that are long lasting.

However, the modest results — and planned improvements to the TXT2Adhere system — were good enough to land Wen and team a 5-year, multimillion dollar grant from the National Cancer Institute for a larger study (N = 300 patients).

Wen shared the planned enhancements, including:

  • bidirectional text messaging that will "be more interactive and dynamic, with prompts and keywords for participants to actively initiate questions/inquiries back to the system."

  • electronic smart pill bottles to provide "an objective measure of adherence…and more opportunities for our text messaging system to tailor messages to participants (eg, validate "good behavior" or follow up missed dosage). 

  • expanded self-care symptom management tips

Wen said the team also hopes to add an electronic patient-reported outcome (ePROs) collection component linked with the Jefferson telehealth platform "when a symptom is escalating."

The hope is the new approach "would empower women in this journey as they transition from active treatment into survivorship," she said.

Wen has a personal inspiration for her work: "My mom is taking an aromatase inhibitor so I have lots of passion for this research personally as a caregiver as well."

Hershman and other study authors have financial ties to industry but none relevant to the current study. Wen and Andreopoulou have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2019 Annual Meeting: Abstract 6516. Presented June 2, 2019.
Abstract e23061. J Clin Onc. Published online May 26, 2019.

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