Comparison of self-report and electronic monitoring of 6MP intake in childhood ALL: a Children’s Oncology Group study

Wendy Landier, Yanjun Chen, Lindsey Hageman, Heeyoung Kim, Bruce C. Bostrom, Jacqueline N. Casillas, David S. Dickens, William E. Evans, Kelly W. Maloney, Leo Mascarenhas, A. Kim Ritchey, Amanda M. Termuhlen, William L. Carroll, Mary V. Relling, F. Lennie Wong and Smita Bhatia

Key Points

  • Self-report overestimated electronically monitored 6MP adherence at least some of the time in a large majority of patients (84.4%).

  • Nonadherers were more likely to overreport 6MP intake (47%) compared with adherent patients (8%).

Publisher's Note: There is an Inside Blood Commentary on this article in this issue.


Adequate exposure to oral 6-mercaptopurine (6MP) during maintenance therapy for childhood acute lymphoblastic leukemia (ALL) is critical for sustaining durable remissions; accuracy of self-reported 6MP intake is unknown. We aimed to directly compare self-report to electronic monitoring (Medication Event Monitoring System [MEMS]) and identify predictors of overreporting in a cohort of 416 children with ALL in first remission over 4 study months (1344 patient-months for the cohort) during maintenance therapy. Patients were classified as “perfect reporters” (self-report agreed with MEMS), “overreporters” (self-report was higher than MEMS by ≥5 days/month for ≥50% of study months), and “others” (not meeting criteria for perfect reporter or overreporter). Multivariable logistic regression examined sociodemographic and clinical characteristics, 6MP dose intensity, TPMT genotype, thioguanine nucleotide levels, and 6MP nonadherence (MEMS-based adherence <95%) associated with the overreporter phenotype; generalized estimating equations compared 6MP intake by self-report and MEMS. Self-reported 6MP intake exceeded MEMS at least some of the time in 84% of patients. Fifty patients (12%) were classified as perfect reporters, 98 (23.6%) as overreporters, 2 (0.5%) as underreporters, and 266 (63.9%) as others. In multivariable analysis, the following variables were associated with the overreporter phenotype: non-white race: Hispanic, odds ratio (OR), 2.4, P = .02; Asian, OR, 3.1, P = .02; African American, P < .001; paternal education less than college (OR, 1.4, P = .05); and 6MP nonadherence (OR, 9.4, P < .001). Self-report of 6MP intake in childhood ALL overestimates true intake, particularly in nonadherent patients, and should be used with caution.

  • Submitted July 8, 2016.
  • Accepted December 29, 2016.
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