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Text Messaging Helps Keep Women Compliant with Aromatase Inhibitor Therapy

Susman, Ed

doi: 10.1097/01.COT.0000481207.25638.74


SAN ANTONIO–Using an investigative telephone text messaging protocol, clinicians were able to help women diagnosed with breast cancer remain on their endocrine therapy and get them through often difficult musculoskeletal adverse events, researchers reported here (Abstract 5-11-03).

“When the side effects occurred, and they can be severe, many people will just stop the medications and won't report it to the doctor until we see them three months later,” said Lianne Epstein, MPH, a clinical research coordinator at the Yale Cancer Center, New Haven, Conn., at her poster presentation at the 38th San Antonio Breast Cancer Symposium.

But in the 13-week study in which patients were contacted weekly with text messages regarding how they were handling adverse events, 62 percent of the women remained 100 percent compliant in taking their medications. Another 18 percent were more than 80 percent compliant. About 20 percent of the participants were less than 80 percent compliant, considered to be non-compliant, Epstein told OT.

After one week of treatment, 76 percent of the participants were 100 percent compliant, and another 14 percent were at least 80 percent compliant; the others were non-compliant, Epstein reported.

She said that 64 percent of the participants were taking aromatase inhibitors; 36 percent were taking tamoxifen.

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Relaying Side Effects

The average engagement rate—the percentage of patients who responded to the message—was 88 percent, she reported. “Adherence rate in the Breast Cancer Endocrine Therapy Adherence [BETA] Pilot Study participants was high at three months of treatment with endocrine therapy, and rates of engagement were high as well,” she said.

“We believe that the test messaging helped our adherence rates,” she continued. “We were getting to the patients as soon as the effects were starting. We sent text messages. Once a week they received a text saying, ‘Are you experiencing any side effects? How severe are the side effects?’”

Epstein added, “People know their medication is so important for their health—to prevent breast cancer recurrence—but these side effects can be difficult for people. So we are trying to do anything we can do to help improve the care.”

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Response to Daily Message

She and her colleagues enrolled 100 women into the study. Adherence was defined as missing six or more pills per month—less than 80 percent. About 5 percent of the patients discontinued therapy within three months; 2 percent of the patients never started their therapy; one woman experienced disease progression. Patients received a daily message asking if they had taken their medication. Patients reported side effects and their severity weekly; barriers to therapy (such as costs of paying for the medication) were assessed monthly. Responses that appeared concerning were then forwarded to clinic triage nurses.



The responses indicated that the text messaging system was well received. When asked if the application helped with breast cancer treatment, 96 percent of the patients responded positively. All of the patients—100 percent of the 100 patients—agreed that “I found this application easy to use.” Epstein said 96 percent of women agreed with the statement: “This application helped me take my medications.”

No one thought the cost of the text messages was too high; and only 4 percent of the women suggested that the applications took up too much of their time. About 70 percent of the participants said they would like to continue using the application. About a quarter of the patients said that treatment cost too much and/or prevented them from spending money on other things than breast cancer treatment.

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‘Exciting Way to Interact’

Eleonora Teplinsky, MD, Medical Oncologist at Northwell Health Cancer Institute, Lake Success, New York, told OT, “Interruptions in treatment can lead patients to not be compliant with the medication or to discontinue it early before the prescribed 5-10 year period.

“The interactive text messaging tool presented by Epstein et al. is an exciting new way to interact with patients in efforts to improve patient communication and adherence to medications. The results from the completed study and future trials utilizing this tool are eagerly awaited,” Teplinsky said.

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Acceptance Assessment

Epstein said the research team wanted to assess the feasibility and patient acceptance of the text messaging intervention. “Treatment of hormone-receptor positive breast cancer includes 5 to 10 years of adjuvant endocrine therapy,” she noted. “Up to 40 percent of patients may not take endocrine therapy as prescribed.

“Text messaging has been used in other diseases to improve medication adherence,” she continued. “We developed a novel, bi-directional text messaging intervention for breast cancer patients prescribed endocrine therapy to assess real-time adherence, side effects, and barriers to adherence.”

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Study Details

The study enrolled women diagnosed with Stage 1 to Stage 3 hormone-positive breast cancer. The patients were eligible for the study if they had been so diagnosed, if they owned a cell phone, and were initiating endocrine therapy. The women in the study were about 53.4 years of age; about 82 percent of them were white, about 8 percent were black; 93 percent were non-Hispanic. Nine percent of the patients were on Medicare; 25 percent were receiving Medicaid health coverage; and 66 percent of the group had private medical insurance.

About 78 percent of the patients were diagnosed with ductal carcinoma; 17 percent had lobular carcinoma diagnoses. Epstein reported that 87 percent of the women were estrogen receptor-positive and progesterone receptor-positive. The remaining women were estrogen receptor-positive and progesterone receptor-negative; 81 percent were HER2-negative; and 14 percent were HER2 receptor-positive. Three percent of women were diagnosed with Stage 0 breast cancer; 55 percent were diagnosed with Stage 1A 1B; 29 percent were diagnosed with Stage 2A breast cancer; 5 percent were diagnosed with Stage 2B breast cancer; 6 percent were diagnosed with Stage 3A breast cancer. Chemotherapy was administered as adjuvant or neoadjuvant treatment to 44 percent of the patients; 56 percent did not receive chemotherapy.

“Our intervention provides real-life feedback to providers about adherence to and side effects of endocrine therapy, which can be managed immediately,” Epstein said. “Patients found the application helpful, easy to use, and not time consuming.

“Our tool is scalable for large population-based trials. Further evaluation in a randomized control study to assess improvements in adherence is planned,” she said.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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