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Text Messaging in Oncology: A Review of the Landscape

Publication: JCO Clinical Cancer Informatics

Abstract

Text messaging via short messaging service (SMS) is a common route of communication in the United States and offers many advantages to improve health care delivery compared with other forms of mHealth. Text messaging is easy to use, is convenient, is more likely to be viewed than e-mail, and can be tailored to an individual recipient’s needs. Despite evidence that patients with cancer desire more mobile-based communication, there are few examples of successful text messaging interventions in the literature. This narrative review examines the current landscape of SMS-based interventions across the continuum of cancer care, including addressing behavioral change, attendance to screening and follow-up appointments, adherence to treatment, and assessment of symptoms and quality of life. Finally, we explore some of the barriers to implementation of a successful text messaging intervention.
The widespread presence of mobile phones has made instant communication nearly effortless. According to the Pew Research Center, 95% of Americans owned a cell phone in 2016, and 77% owned a smartphone, which corresponds to 261.9 million smartphones sold in 2016, an increase of almost 15% from 2015.1 Nearly all smartphone owners use text messaging at least weekly, and the end result is that more than 6 billion texts are sent in the United States every day. Americans use text messaging twice as much as they call, on average; compared with emails, text messages have an extremely high open rate of 98%.2
Given the pervasiveness of mobile phone ownership, messaging through short message service (SMS) may be the most optimal format through which to communicate with many patients. SMS text messages can deliver a wide variety of information directly to patients, including reminders, alerts, education, and motivational messages, and data from patients can be similarly collected. From a patient perspective, SMS is convenient and does not require great technical knowledge to use. There is no required Internet connection, because messages are sent via cellular network; no need to access a voicemail; and no extra mobile app to be downloaded and learned. Many mobile phone plans now include unlimited texting, so the costs incurred are minimal. With its 98% open rate, SMS text messages are much more likely to be viewed than other means of mass communication, such as e-mail.2 From the health system perspective, text messages can be customized easily and tailored to a particular recipient’s clinical profile and needs or to any time and any place, and text messages are less intrusive than phone calls. Furthermore, with increased access to mobile phones and text messaging, outreach for preventive care and screening could be delivered more easily to hard-to-reach populations and used in developing countries.3,4
Despite evidence that patients with cancer desire more communication via mobile technology, there are few examples of successful text messaging interventions in the literature.3,5,6 The purpose of this narrative review is to examine the current landscape of SMS-based text messaging interventions in the realm of oncology and to discuss some of the challenges of implementation in the current health care system. We first address literature that demonstrates the power of text messaging to affect behavior and then move to cancer-specific interventions that tackle cancer screening, oral therapy adherence, and symptom assessment. Finally, we discuss the challenges related to design, logistics, and security in the implementation of a successful text messaging intervention.

Methods

One of the researchers (S.S.M.) met with a clinical librarian (A.B.) to create a search strategy. A literature search was conducted on October 27, 2017, using PubMed, Ovid Medline, and OVID Embase. The search consisted of both controlled vocabulary (ie, MeSH and Emtree); the terms included text messaging, text messag*, texting, short messag* service, phone messaging, mhealth, neoplasm, medical oncology, cancer, cancers, neoplasm*. The first concept of terms looked at text messaging and relevant terms, and the second concept of terms focused on cancer. These concepts combined yielded 423 unique studies for review. Studies limited to mobile apps or Web-based interventions were excluded, as were studies published in languages other than English. The abstracts of these studies were reviewed for relevance, and 130 studies met criteria for manuscript review. Of these, 66 articles (the journal limit) were selected for inclusion in this narrative review.

Text Messaging to Address Lifestyle Behaviors

Text messaging can be a powerful tool to change behaviors; many undesirable behaviors, such as smoking, maintaining a sedentary lifestyle, and excess sun exposure, are linked to increased risk of various cancers. Probably the most robust example of a successful text messaging intervention is the TEXT-ME study, which aimed to affect cardiovascular risk factors in patients with documented coronary artery disease. Patients received four text messages per week to give advice, motivational reminders, and support to change their lifestyle behaviors, and the primary end point was LDL cholesterol levels compared with controls. At 6 months, LDL levels were significantly lower and there were significant reductions in systolic blood pressure, body mass index, and smoking as well as significant increases in physical activity.7
In a study of 5,800 smokers, automated text messaging around a planned quit date significantly improved smoking cessation rates, and subsequent follow-up has shown this intervention to be cost effective.8,9 Communication strategies that involve text messaging may be effective to encourage smokers who were previously unsuccessful in quitting to try again.10 Even the National Institutes of Health has developed multiple text messaging programs for at-risk groups.11
Text messaging has shown promise for skin health as well for improved daily sunscreen application, sun protection habits, skin self-examinations, and reduction of indoor tanning, all of which are known environmental risk factors for melanoma and nonmelanoma skin cancers.12-16 For example, a small randomized study examined daily sunscreen application in the general community; it demonstrated a mean daily adherence rate of 56.1% in participants who received daily text message reminders compared with 30.0% who did not.
Encouragement of healthy behaviors in participants who attempt weight loss or weight maintenance via text message in patients with obesity or nonalcoholic fatty liver disease and with urban, low-income new mothers has shown promising results.17-19 In a group of breast cancer survivors, text messages were used after an initial weight loss intervention to support long-term weight loss, physical activity, and dietary behavioral change; these messages were felt to keep participants motivated and accountable to their goals.20

Text Messages to Improve Rates of Follow-up and Cancer Screening

Reminder messages often are relayed by text messaging, both in health care and in other service-based industries. Text messaging before appointments has reduced nonattendance at routine follow-up appointments for chronic disease management and in primary care clinics.21,22 A Cochrane review reported “low to moderate quality evidence” that SMS messaging improves attendance compared with no reminders or postal reminders at a lower cost than telephone reminders.23 Text message reminders to attend appointments are preferred by patients compared with other forms of communication.24
Despite evidence that screening reduces mortality from many types of cancers, achievement of full adherence to screening guidelines remains elusive. However, several authors have reported that text messaging may be a preferred method for communication about screening tests.3,25 The most robust data are available for breast cancer screening. Text messaging has been shown to improve attendance to screening mammogram both in remote locations and in higher-risk populations.5,26,27 In a small, randomized, Korean study, receipt of text messages for 1 week led to an enhanced knowledge of breast cancer and screening guidelines compared with no receipt of text messages;6 months after the intervention, a higher proportion of patients in the text message arm underwent a planned mammogram (40% v 25%).28 Finally, a Spanish study demonstrated a slightly higher uptake of screening mammogram in women who received a text message reminder after their initial invitation to screen.29
Text messaging interventions have been shown to improve screening in other cancer types, including cervical and colorectal cancers.30 Text messaging has been shown to increase HPV vaccination rates in various pediatric populations,31,32 has increased knowledge and use of Pap screening in Asian-American women,33 and improves both HPV vaccination and Pap test completion in high-risk women with HIV.34,35 In women with normal Pap smears, those who received reminder SMS messages had higher rates of undergoing a repeat Pap test than those who received a reminder letter, and a generic text message reminder decreased nonattendance rate at a British colposcopy clinic.36,37 Similarly, randomized studies have shown increased rates of fecal occult blood testing (FOBT) when text messaging is added to usual care; text messaging may be feasible and desired even in older Americans and may lead to enhanced adherence to FOBT in subsequent years.6,38-40 Reminder messages improved screening for colorectal cancer by 42% in clinical population of nearly 2,900 Alaskan Native and American Indian people.41 In the largest randomized study to date in the United Kingdom, a text reminder to return FOBT kits did not result in higher uptake of screening, but the intervention consisted of only a single text message and was sent 8 weeks after initial invitation to screen.42
The majority of these studies were limited to specific populations, including populations considered disadvantaged or hard to reach, and most studies took place outside of the United States. Additional research will clarify the content, the number and frequency, the cost effectiveness, and the efficacy of text messaging in a more generalizable population.

Oral Anti-cancer Therapies

During the past decade, there has been a tremendous increase in the development, availability, and use of oral antineoplastic medications. Oral therapies may make up more than 25% of all anticancer therapies, but, as a result, ensuring adherence and persistence has become an increasingly critical challenge to address. One study reported that adherence to self-administered chemotherapeutics was as low as 43%.43,44 Patients not only must contend with adverse effects and remember to take medication but also must cope with dosing schemes that can be difficult—with days or weeks off in between cycles, or doses to be taken only on days of radiation. Finally, the underlying disease process can hinder adherence (eg, the use of temozolamide in patients with glioblastoma). Adherence is critical to achieve optimal outcomes in oncology; multiple studies have shown that decreased adherence affects survival.45,46
Text messaging nearly doubles the odds of oral medication adherence, as demonstrated in a meta-analysis that included 2,742 patients in 16 randomized clinical studies of text messaging interventions to promote adherence. However, none of these studies examined patients with cancer (six studies were in patients with HIV, and five studies were in cardiovascular disease).47 In a small pilot study of daily SMS to patients on oral anticancer agents, self-reported adherence increased during the 8 weeks of study, and these patients reported fewer adverse effects than patients in the control group.48 Mobile apps have been developed to assist with oral chemotherapy education, to provide strategies for dealing with adverse effects, and to promote optimal adherence.49,50
For breast oncology in particular, a mainstay of treatment for hormone-responsive breast cancer is oral endocrine therapy for at least 5 years. Inability to remember to take the medication may be a major contributor to suboptimal adherence.51 In 2010, a randomized trial of biweekly unidirectional text messaging was opened by the Southwest Oncology Group with improved adherence in women on adjuvant anastrozole as the goal.52 In this study, twice weekly text messages were sent to patients, and messages ranged from simple reminders to emotional support messages; results of this study are expected soon. However, nonadherence in this population also may result from severe adverse effects, particularly in young women. Other, more individualized, text messaging platforms have been developed that aim not only to serve as a reminder for patients to take medication but also to assess adverse effects and barriers to adherence.53,54 Plans for randomized controlled clinical trials to assess the efficacy of these bidirectional messaging interventions are underway.
A recent, large, pragmatic trial of three low-cost reminder devices in patients with chronic disease showed that simple reminder strategies are not enough to improve adherence, which suggests that other factors may be at play.55 High-tech prescription bottles with cellular connectivity may play a role, particularly in oncology, although experience is limited and clinical data are lacking. Linking text messaging to other means of electronic adherence monitoring may improve adherence; this strategy has been used with antiretroviral medication in patients with HIV and resulted in significant improvement in adherence.56

Assessment of Symptoms

Because cancer therapies are more likely to cause troublesome adverse effects, frequent ambulatory assessment of patients is important. Several studies have shown that patients with cancer are interested in using the Internet and mobile phones for assistance with therapy. In one study of women with metastatic breast cancer, 86.3% of surveyed patients had an at least neutral opinion toward use of the Internet, and more than half were willing to report adverse effects via the Internet.57 In a small, single-site study, 68 patients undergoing chemotherapy in Singapore were monitored by SMS for 5 days after the administration of moderately or highly emetogenic chemotherapy; as a result of enhanced assessment, nearly one third of patients were contacted by pharmacists because of poorly controlled nausea.58 Much of the existing literature focuses on mobile apps; apps have been developed for self-reporting about adverse effects of chemotherapy treatment59 and symptoms related to lymphedema after breast cancer treatment,60 and an app exists to support patients with head and neck cancer undergoing active treatment.61
Feasibility studies of pain assessment with bidirectional SMS in terminally ill cancer patients have been performed and allowed for rapid adjustment of pain medications for severe symptoms.62 Mobile phone–based pain management applications to control cancer pain (measured by the Brief Pain Inventory) are being studied.63 Reporting symptoms related to cancer treatment may enhance a patient’s feeling of involvement in his or her own care.59

Challenges to Implementation of Text Message Interventions

Several barriers to implementation of a text message intervention exist. Title II of the Administrative Simplification of the Health Insurance Portability and Accountability Act (HIPAA) regulates the use and disclosure of protected health information (PHI) in all electronic transactions and communications. Ensuring privacy is of paramount importance to an intervention that is compliant with these mandates. Mobile phone numbers themselves are PHI, and any software and datastores that handle this information must be implemented with appropriate safeguards.64
Guidelines for text messaging are unclear under HIPAA, and experts are divided as to whether standard text messaging, even with encryption, password protection, and patient de-identification, is compliant with HIPAA.65-67 Text messages can be encrypted at the origin and at the recipient, but data transmitted en route are not encrypted and are subject to third-party compromise. If a text message intervention uses an application programming interface available from companies like Twilio, a Business Associate Agreement may be required to hold the company responsible in the event of data breach. Regardless of one’s interpretation of HIPAA, privacy and security should be addressed early in the process, and engagement of the information technology department at one’s institution early in the development is critical.
Certain applications, such as Signal (Open Whisper Systems) and WhatsApp (Facebook), offer end-to-end encryption of text-based messages, in which messages are encrypted at their origin with the recipient’s public key, remain encrypted in transit, and can only be decrypted by the recipient’s private key on his/her own device. However, this requires that specific applications be downloaded and used on participating smartphones, because these are Internet-based, rather than SMS-based, text messages. Unlike SMS-based text messages, such Internet-based text messages are not possible on feature (flip) phones. As the prevalence of smartphones increases, Internet-based text messaging is likely to become much more commonplace.
Text messaging interventions may be unidirectional, in which messages are sent to the participants but a response is not recorded, or bidirectional, in which users participate in an exchange back and forth with a person or software-based agent. It is not possible to block the sending of a return SMS text message, so participants must clearly understand that such responses will not be received by a human at the study. Some text messaging providers allow for custom software to receive and process text messages; in such cases, it is possible to design software to return an automatic response that reminds users to call. For bidirectional interventions, patients need to acknowledge that texts should not replace urgent phone calls or emergency medical services. Any robust bidirectional intervention may require a coordinator or other gatekeeper to ensure patient safety, and this may require more resources. Any intervention, even outside of a research setting, must be accompanied by a user agreement and consent.
There are a number of additional logistic concerns. With text messaging interventions, mobile phone numbers must be kept up to date. Many families may share a mobile phone, so there is no guarantee that mobile phones are password protected or are in the possession of their owner. Messages are automatically stored on phones and could be readily accessible. Many smartphones are setup to display a newly received message for a brief time on their screens; when mobile phones are left in public view, the content of such messages may be read by those other than the intended recipient. Many patients may pay month-to-month, so text messages might not be delivered if a bill is not paid. Finally, and importantly, text messaging lacks the personal touch and empathy that can be granted by an in-person encounter.

Future Directions

Given the prevalence of mobile phones, pharmaceutical companies already may be investing in the power of text messaging as part of patient-supportive materials. For example, the manufacturers of neratinib (Nerlynx; Puma Biotechnology, Los Angeles, CA), a tyrosine kinase inhibitor currently approved for the adjuvant treatment of HER2-positive breast cancer, have included a service to which patients can subscribe to receive medication reminders and motivational messages via text message. Text message reminders could be particularly helpful for pharmaceutical companies that develop medications with difficult or complex dosing schedules.
Bidirectional text messaging is well suited to automatic and adaptive personalization, because the content and timing of texted responses are tailored to the individual patient and context. Several dynamic bidirectional interventions have been developed to collect either patient responses (eg, adverse effects to treatments or other patient-reported outcomes) or their current circumstance (eg, passively detected information from a wearable device). Research to address the efficacy of these dynamic interventions is lacking in the literature now, so future research is necessary.68
Also, clinical research could be enhanced by functionality provided by text messaging. One can imagine interventions that augment patient accrual, retention, and satisfaction with clinical trial processes, serve as reminders for medication adherence, complete study-related tests or patient-reported outcome instruments, or permit long-term follow-up of patients.
In conclusion, text messaging can be a simple and economical way to enhance communication with patients. It has been shown to be both effective and cost-effective, and it may be favored by patients compared with other means of communication. Use of text messaging in conjunction with other innovational tools, such as smart prescription bottles, may improve the delivery of cancer care. Challenges to successful implementation include security and privacy concerns.

Acknowledgment

We thank Alexandria Brackett for her assistance with conducting the literature review.

Authors' Disclosures of Potential Conflicts of Interest

Text Messaging in Oncology: A Review of the Landscape

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc.

Sarah S. Mougalian

Stock and Other Ownership Interests: Gilead Sciences, Coronado Biosciences, Roche
Consulting or Advisory Role: Eisai Research Funding: Genentech, Pfizer

Cary P. Gross

Research Funding: 21st Century Oncology, Johnson & Johnson, Pfizer
Travel, Accommodations, Expenses: Flatiron Health

E. Kevin Hall

Employment: Archetyp Mobility
Stock and Other Ownership Interests: Archetyp Mobility
Consulting or Advisory Role: Boston Technologies

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JCO Clinical Cancer Informatics
Pages: 1 - 9
PubMed: 30652579

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Published online: June 29, 2018

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Authors

Affiliations

Sarah S. Mougalian [email protected]
All authors: Yale University School of Medicine, New Haven, CT.
Cary P. Gross
All authors: Yale University School of Medicine, New Haven, CT.
E. Kevin Hall
All authors: Yale University School of Medicine, New Haven, CT.

Notes

Corresponding author: Sarah S. Mougalian, MD, Yale University School of Medicine Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center 300 George St, New Haven, CT 06511; e-mail: [email protected].

Author Contributions

Conception and design: Sarah S. Mougalian, Cary P. Gross
Collection and assembly of data: E. Kevin Hall
Data analysis and interpretation: Sarah S. Mougalian
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors

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Sarah S. Mougalian, Cary P. Gross, E. Kevin Hall
JCO Clinical Cancer Informatics 2018 :2, 1-9

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