Digital Health to enhance adjuvant endocrine therapy adherence in breast cancer

Introduction. Despite the availability of many effective adjuvant endocrine therapies (AET), which reduce the risk of breast cancer (BC) recurrence during the post-acute treatment phase, non-adherence is continuously reported (31%-73%). Most effective medication adherence-enhancing interventions (MAEI) did not lead to large improvements in adherence or clinical outcomes as they fail to identify the dynamic behaviour of medication adherence. Often MAEIs were created without the end-user’s involvement and/ or theory-based frameworks. Using Patient-provider involvement and interprofessional concepts to manage medication adherence is key in research and implementation of MAEI into the healthcare setting. Therefore, the overall aim of the present thesis was to use a patient-provider involvement approach and a theory-based framework to develop a digital MAEI for AET in BCS and test its feasibility. Method. The presented research used a scoping review to identify current MAEI and to synthesize their effectiveness. After, a contextual analysis of AET use in BC survivors was conducted to analyse current digital health usability patterns and level of acceptance towards a digital MAEI supporting AET in BCS and HCP. A theory-driven framework (Behaviour change wheel) then defined the problem of AET adherence in behavioural terms, identified intervention options and determined content and implementation options. Finally, a digital MAEI was constructed based on the previous studies' results a digital MAEI and its feasibility was explored. Results. BC survivors claimed increased support from healthcare professionals. MAEIs’ components change over time depending on the adherence phase of the adjuvant endocrine therapy. MAEI during initiation should envisage AET beliefs and habit creation. During implementation, MAEI intervention should focus on side-effect coping strategies and patient-healthcare provider interaction. BC survivors and healthcare providers would accept to use of a digital MAEI for AET. Preferences were multifaceted digital MAEI; AET management (e.g. adherence and side-effects), medical information, social support network, and interaction with a healthcare provider. Specific behaviour change techniques tackling these needs are Prompts/cues, pharmacological and social support, instructions, goal setting feedback and habit formation. Thus using the contextual analysis and the behaviour change wheel constituted to the development of a real-time digital MAEI for BCS taking AET. Discussion. Digital interventions may be a game changer for medication adherence as they offer new ways of measuring adherence, collecting patient-reported outcomes and experiences, and providing intervention directly in the patient ecosystem, thus limiting patient burden. Another beneficial aspect of digital medication adherence technology is the ‘timing’. Digital medication adherence technologies have the potential to intervene in the moment of need providing the intervention of need. Future MAEI research projects need to follow implementation research principles and involve the system level. Luxembourg specifically needs to raise medication adherence awareness across all levels, implement accessible medication adherence assessment databases, restructure the follow-up care for BC survivors and encourage an interprofessional healthcare ecosystem.