This podcast is made possible by the generous support of Lilly Oncology.
Jamie DePolo: Hello, and welcome to the Breastcancer.org podcast. I’m Jamie DePolo, senior editor at Breastcancer.org. We’re on location at the 2019 American Society of Clinical Oncology Annual Meeting in Chicago. My guest is Dr. Dawn Hershman. She's a member of the Breastcancer.org Professional Advisory Board, and she also leads the breast cancer program at the Herbert Irving Comprehensive Cancer Center at Columbia University, where she's also a professor of medicine and epidemiology. She's also a nationally recognized expert in breast cancer treatment, prevention, and survivorship.
At this ASCO Annual Meeting, Dr. Hershman presented results from a study looking at whether text messaging could increase the number of women who stick to their aromatase inhibitor treatment plans. Dr. Hershman, welcome to the podcast.
Dr. Dawn Hershman: Thank you. Thank you for having me.
Jamie DePolo: So, could you give us some background on this study? Why did you decide to look at text messaging, specifically?
Dr. Dawn Hershman: Well, just as a little bit of background, we certainly know that aromatase inhibitors, and hormonal therapy in general, is really important for women with breast cancer that’s hormone-sensitive. But we also know that it is very hard to complete the 5-year recommended course, let alone 10 years, of therapy. And a substantial number of women stop taking their medicine, and those that continue sometimes take it intermittently. And that can interfere with the efficacy of the medication.
We looked at text messaging because text message studies had been looked at for other types of things to improve outcomes in: smoking cessation, in making sure that people exercise. It’s been looked at for vaccine studies to make sure people get their vaccines on time, and there’ve been a few studies looking at medication adherence, in particular.
The problem with a lot of the prior studies is that they're very short duration. So they’ll do a short-term study that’ll look like it’s very efficacious, but we won’t know if it’s something that can be maintained over a long period of time. Nothing's really been done in the cancer space, and no long-term studies have been done for medication adherence, really, in any setting. But we thought that if you could just remind people and it had an effect, it would be a simple, low-cost solution.
Jamie DePolo: Sure. So, what were the results of your study?
Dr. Dawn Hershman: So, we enrolled women that were postmenopausal, that had been on aromatase inhibitors at least for 30 days, but no more than 2 years. And we followed women for 3 years, every 3 months. And we asked at those 3-months appointments for women to submit a urine sample and to complete patient-reported outcomes. And what’s really important is to know that adherence is difficult to measure, and it’s problematic in study to study. We chose to look at urine biomarkers, so the metabolites of the aromatase inhibitors, thinking that that would give us an indication of people taking it intermittently. But the problem with that kind of a measurement is if somebody doesn’t show up to the appointment, you don’t know if they're still taking their medication or if they’ve stopped taking their medication and stopped coming to appointments altogether.
So, we decided to include that as the primary outcome, but also look at a variety of secondary outcomes — asking people themselves if they stopped, asking providers — and we put different windows around the urinary biomarker to give us a sense. So, our analysis, no matter how we looked at the measurement of adherence, did not show a difference between the groups over the 3-year period. We looked at a time-to-event analysis, and we looked at cross-sectional analyses. Cross-sectional analyses for this is probably a little bit better because it probably represents people that start and stop a little bit better. But you could see from the cross-sectional analysis that at 12 months only about 70% of women were still taking their medications. At 2 years it was about 60%, and at 3 years it was about 55%. But there was no difference between the two arms.
Interestingly, if you asked women if they were… you know, who stopped, only about 10% of women said they stopped taking their medications despite our results with the biomarker studies, and if you asked providers, about 20% said that women stopped taking their medications. So there’s huge variability.
I think we learned some really important things from this study. From a researchers’ perspective, it’s really important that adherence is measured in multiple different ways and that it’s consistent to know whether or not the intervention is effective. The second thing is that when we look at interventions, we can do pilot studies with short-term durations, but to really have an impact on outcome, it has to be an intervention that's sustainable. And if it’s not, then it’s not really going to change the outcome of women with breast cancer.
So we can do small studies and get them published and look like we’ve made an impact, but if we really want to have an impact, we have to really think about things that can be done and sustained in order to be effective. And the reason why text messaging may not be effective is that we live in a world where we’re inundated with messages. We’re just, you know, assaulted with push notifications, and texts, and reminders, and apps, and people do start to tune out. It becomes… you get into this electronic overload state. But I firmly believe that the majority of women that stop their medications really want to be taking it, so telling people more they should be taking it may not be helpful. What we really need is good interventions to control the side effects.
Jamie DePolo: Well, yeah. That’s what I was going to ask. So did your study at all ask the women why they stopped, and I’m assuming it was side effects?
Dr. Dawn Hershman: Right. I mean, we know from the literature that even though there are multiple reasons why people don’t take their medications, the majority of women stop because they have side effects. Some of these other education factors may help people start, that are ambivalent about starting, but in terms of stopping, the majority stop because they develop side effects. And cost can be a factor, but now that they’re all generic and there are other ways of getting it, it probably… this type of intervention doesn’t really get at cost, and it doesn’t really get at side effects.
So, when I think about what we need to do going forward, I think if we’re going to use telehealth and electronic messaging, it has to be to enhance patient-provider communication so that we can intervene on side effects that develop faster.
Jamie DePolo: Okay, because if I’m right, this is one of the first studies to actually look at sort of a reminder method for medication adherence.
Dr. Dawn Hershman: Yes, right. This is the first study to do that.
Jamie DePolo: And it wasn’t looking at side effects, so, I guess, to me, a layperson, not a researcher, it’s not that women are forgetting to take it, it’s that they're actively saying, “I don’t want to take this because of the side effects.”
Dr. Dawn Hershman: Yeah. I mean, it’s probably multi-factorial, you know, and there probably are women that don’t want to take it even if they don’t have side effects. But reminding them to take it doesn’t make them take it any more.
Jamie DePolo: Right, it’s almost like, you know, “I already kind of feel guilty and now you're making me feel guiltier. So, now I really don’t want to do it.”
Dr. Dawn Hershman: Right, yeah, for whatever reason, you know, I think we need to think of our interventions as multi-factorial and more personalized, so that we develop the right type of intervention for the right type of reason why somebody might be stopping.
Jamie DePolo: So where do we, or you… where does research go forward from this? What are the next steps, and do you have anything specifically planned?
Dr. Dawn Hershman: Yeah, I mean, think that we do have studies looking at increasing adherence that are more two-way, that help remind people to take not only their hormone medicines but their other medicines. We’ve done the research that shows people stop taking all their medications, but that can also clue us into the reasons why people may not be taking them. Even though in our text message study we said that, you know, if you're having side effects, let your doctor know. That was one of the texts that was sent out. We really don’t have great treatments for the side effects. We do have some things we can do, but they may not work for everybody.
Jamie DePolo: Right, okay. Yeah, in fact, I spoke to someone yesterday who was a doctor who admitted, “I did not take my aromatase inhibitor for as long as I was supposed to because I could not handle the side effects.” So, it sounds like what you're saying is reminders are good, but we really need to come up with better treatments for side effects.
Dr. Dawn Hershman: That’s exactly right, yes.
Jamie DePolo: Okay. Dr. Hershman, thank you so much. I appreciate your time.
Dr. Dawn Hershman: Sure, absolutely. Happy to be here.
