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JCO Clin Cancer Inform. 2017 Nov;1:1-10. doi: 10.1200/CCI.17.00015.

Bidirectional Text Messaging to Monitor Endocrine Therapy Adherence and Patient-Reported Outcomes in Breast Cancer.

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Sarah S. Mougalian, Lianne N. Epstein, Erin W. Hofstatter, Michael P. DiGiovanna, Andrea L.M. Silber, Kerin Adelson, Lajos Pusztai, and Cary P. Gross, Yale Cancer Center, Yale University; Sarah S. Mougalian, Kerin Adelson, and Cary P. Gross, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University, New Haven, CT; Ami P. Jhaveri, Lancaster General Health, Penn Medicine, Lancaster; Maysa Abu-Khalaf, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA; and Gang Han, Texas A&M University School of Public Health, College Station, TX.



Up to 40% of patients with breast cancer may not adhere to adjuvant endocrine therapy. Therapy-related adverse effects (AEs) are important contributors to nonadherence. We developed a bidirectional text-message application, BETA-Text, that simultaneously tracks adherence, records symptoms, and alerts the clinical team.


We piloted our intervention in 100 patients. The intervention consisted of text messages to which patients responded for 3 months: daily, evaluating adherence; weekly, evaluating medication-related AEs; and monthly, regarding barriers to adherence. Concerning responses prompted a telephone call from a clinic nurse. The primary objective was to assess patient acceptance of this intervention using self-reported surveys. To compare participants with the general population at our institution, we assessed 100 consecutively treated patients as historical controls using medical record review.


We approached 141 consecutive patients, 100 (71%) of whom agreed to participate and 89 of whom completed the intervention. A majority of patients reported that the intervention was easy to use (98%) and helpful in taking their medication (96%). Four patients discontinued therapy before 3 months, and 93% of patients who continued therapy took ≥ 80% of their medication. The frequency of AEs reported by participants via text was higher than that reported in clinical trials: hot flashes (72%), arthralgias (53%), and vaginal symptoms (35%). Approximately 39% of patients reported one or more severe AE that prompted an alert to the provider team to call the patient.


A daily bidirectional text-messaging system can monitor adherence and identify AEs and other barriers to adherence in real time without inconveniencing patients. AEs of endocrine therapy, as detected using this texting approach, are more prevalent than reported in clinical trials.

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