Lower Utilization Seen for Patients With Breast Cancer Using Remote Monitoring With Texts

Participants were enrolled to test the effectiveness of a remote monitoring app with built-in alerts to the oncology team, with or without tailored text messages, in a population of women prescribed AET. | Image Credit: Rakchanok - stock.adobe.com

A randomized controlled trial utilized a remote monitoring application with alerts for the patients’ care team and tailored text messages to patients, but it did not improve adjuvant endocrine therapy (AET) adherence in women with early-stage breast cancer. However, it did reduce both overall and high-cost health care encounters and office visits without quality of life (QOL) being affected, according to a study published in JAMA.¹

Most breast cancer diagnoses are classified as hormone receptor (HR)–positive tumors. In fact, incidence of HR-positive breast cancer is increasing in the US.²

Oftentimes, long-term AET treatment follows primary treatment to increase patient survival rates and reduce the risk of cancer recurrence. Some forms of AET treatment include tamoxifen and aromatase inhibitors, both of which have demonstrated reduction in the risk of recurrence by up to 50% for patients.³ Individuals classified as at high risk for recurrence are suggested to undergo AET for 10 years after primary treatment.

The ability to monitor adverse symptoms and medication adherence at home, often with the help of technology, is becoming increasingly important.¹ This ongoing data collection allows patients to have more informed discussions with their health care providers, leading to better management of adverse events (AEs) and improved health outcomes.

Results from a randomized clinical trial at Memorial Sloan Kettering Cancer Center from 2007 to 2011 found that integrating patient-reported outcomes (PROs) into routine care allowed patients an early responsiveness that prevented any exacerbation of symptoms.⁴ This study associated increased survival with usual care to using PROs in routine care of patients with breast cancer.

Methods

In the current study, researchers evaluated a mobile app that tracked patient-reported AET adherence and related symptoms that included notifications to the oncology team and integration with the patient’s electronic health records.¹ In a nonblinded randomized controlled trial, participants were enrolled to test the effectiveness of a remote monitoring app with built-in alerts to the oncology team, with or without tailored text messages, in a population of women prescribed AET from November 2018 to June 2021 at a large oncology network serving western Tennessee, northern Mississippi, and eastern Arkansas.

Participants included adult women at an average age of 58.6 years who were randomized into 1 of 3 groups: app, app plus feedback, or enhanced usual care (EUC). Women in the app group received weekly texts reminding them to log into the app to report adherence or any new and changing symptoms within the past week. The app plus feedback group received weekly texts that included educational information, AET adherence–related encouragement, AET-related symptoms, lifestyle tips, social support, and patient-physician communication. Lastly, the EUC group received education about AET and any possible treatment-related symptoms.

Results

Overall, 266 participants completed the intervention and the 1-year follow-up survey. There was 1 participant who identified as American Indian or Alaska Native, 5 who identified as Asian, 102 who identified as Black or African American, 9 who identified as Hispanic ethnicity, and 192 who identified as White. About 21.4% of the population had an income below 200% of the federal poverty line and 19.7% had an educational level of high school diploma or lower.

App Use and Alerts

Participants in the app group logged in on average 18.9 times whereas app plus feedback participants logged in an average of 16.4 times during the 6-month duration (mean difference, 2.49 logins; 95% CI, ­–0.54 to 5.52 logins; P = .11). Both the app group and app plus feedback group had an average of 2 symptom alerts (mean difference, 0.02 alerts; 95% CI, –2.02 to 2.06 alerts; P = .98). There were more missed dose alerts in the app group (1.7) than in the app plus feedback group (0.8) (mean difference, 0.85 alerts; 95% CI, 0.01-1.69 alerts; P = .048).

AET Adherence

Similar measurements of AET adherence across 1 year were found among the 3 groups: 76.6% for EUC, 73.4% for the app (difference vs EUC, –3.3%; 95% CI, –11.4% to 4.9%; P = .43) and 70.9% for the app plus feedback (difference vs EUC, –5.7%; 95% CI, –13.8% to 2.4%; P = .17).

At 1-year follow-up, patients in all groups reported similar rates of taking their AET medication as prescribed. The percentage reporting good adherence was 84.3% in the EUC group, 81.0% in the app group, and 85.2% in the app plus feedback group. There were no statistically significant differences in adherence between the groups.

Health Care Utilization

When adjusted for health care utilization levels, app participants did not have fewer health care encounters after 6 months compared with EUC participants (adjusted difference, −0.65; 95% CI, −1.36 to 0.06; P = .07). However, app plus feedback participants did have significantly fewer compared with EUC patients (adjusted difference, −1.23; 95% CI, −2.03 to −0.43; P = .003).

Additionally, app participants did not have significantly fewer high-cost health care encounters (ie, emergency department visits, urgent care visits, or hospitalizations) at the 1-year follow-up compared with EUC participants (adjusted difference, −0.27; 95% CI, −0.57 to 0.02; P = .07). App plus feedback participants had significantly fewer high-cost health care encounters at the 1-year follow-up compared with EUC participants (adjusted difference, −0.40; 95% CI, −0.67 to −0.14; P = .003).

App participants also did not have fewer office visits at 1-year follow-up when comparing the app group to the EUC participants (adjusted difference, −0.34; 95% CI, −1.10 to 0.43; P = .39), but app plus feedback participants did (adjusted difference, −0.82; 95% CI, −1.54 to −0.09; P = .03).

Symptoms and Management

The study was unable to detect ant statistically significant differences in changes over time by study group for symptom burden, QOL scores, and patient-physician communication.

Over the 6 month intervention, more patients received symptom management in the app plus feedback group (46.1%) compared with the app only (36.7%) and EUC participants (29.8%). The most common management strategy was adding a new prescription medication to manage an AET-related symptom.

Limitations

The study results may not be generalizable to other cancer settings because patients were recruited from a single large, comprehensive cancer center that had already been routinely monitoring patient-reported symptoms during each clinical visit. Recruitment was also limited to only English-speaking patients with access to an internet-connected computer or smartphone. Additionally, the intervention period was considerably short for a medication that is suggested for 5 or more years. The study period began at the start of COVID-19 and resulted in disruptions in care, especially in-person visits. Research failed to collect data on the reason for each health care encounter or whether encounters were related to the patient’s cancer diagnosis or AET use.

The remote monitoring app did not improve AET adherence, but it did reduce the overall and high-cost health care encounters without impacting QOL or increasing the number of appointments. This research is the first to show benefits of remote monitoring when combined with tailored text messages for patients with early-stage breast cancer receiving AET.

References

1. Graetz I, Hu X, Kocak M, et al. Remote monitoring app for endocrine therapy adherence among patients with early-stage breast cancer: a randomized clinical trial. JAMA Netw Open. 2024;7(6):e2417873. doi:10.1001/jamanetworkopen.2024.17873

2. DeSantis CE, Ma J, Gaudet MM, et al. Breast cancer statistics, 2019. CA Cancer J Clin. 2019;69(6):438-451. doi:10.3322/caac.21583

3. Lambert, L.K., Balneaves, L.G., Howard, A. et al. Understanding adjuvant endocrine therapy persistence in breast Cancer survivors. BMC Cancer. 2018;1-13. doi:10.1186/s12885-018-4644-7

4. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017;318(2):197-198. doi:10.1001/jama.2017.7156