Dietary supplement use and documentation in a breast cancer survivorship clinic.

PURPOSE: Breast cancer survivors take vitamins and supplements to bolster their general health and to decrease the risk of cancer recurrence. Healthcare providers are frequently unaware of their patients non-prescription supplement use. The aim of this study was to study the type and the documentation of patients' dietary supplements and vitamins in the electronic medical record (EMR).
METHODS: 50/51 female breast cancer survivors seen over a 7 week period consented to the study. Mean age was 70 and mean years since diagnosis was 13.9. Informed consent and documentation of supplement and vitamin use was obtained by the nurse practitioner the day before the visit. Study data were collected and managed using REDCap electronic data capture tools hosted at Weill Cornell Medicine.
RESULTS: Of the 50 study patients, 90% were taking one or more vitamins and/or supplements (mean = 2.4, range = 1-9). The most common were Vitamin D, calcium, and vitamin C. Reasons for vitamin and supplement use included the recommendation by their physician or friend and prevention of bone loss or catching a cold. Five patients mentioned immunity or prevention of COVID-19. The patient reported list was compared with the medication list used by multiple providers in the electronic medical record (EMR). None of the 50 study patients had an accurate list of their vitamins and supplements in the EMR.
CONCLUSION: 90% of the breast cancer survivors in our study were taking dietary supplements for a variety of reasons. None had an accurate list in the EMR. We strongly recommend more attention to accurate and easily accessed vitamin and supplement recording by providers.

Introduction

Women and men who have completed “active” treatment for breast cancer continue to worry about the risk of recurrence and the long-term impact of their therapy [1]. Many patients seek information about dietary supplements to improve their general health and to bolster their “immune health” [2]. As defined by the Federal Drug Administration, dietary supplements are “products taken by mouth that contain a ‘dietary ingredient.’ Dietary supplements include vitamins, minerals, amino acids, herbs and botanicals” [3]. Dietary supplements are the primary complementary and alternative therapy used by cancer survivors in the USA [4]. Studies addressing whether these dietary supplements are beneficial or harmful show inconsistent findings, and many are inconclusive [5]. Physicians are frequently unaware of their patients’ use of dietary supplements. The electronic medical record (EMR) poorly reflects non-prescription dietary supplement use [6].

We studied dietary supplements taken by fifty sequential patients in the Iris Cantor Breast Cancer Survivorship Program at Weill Cornell Medicine NewYork-Presbyterian Hospital. The three aims of this study were to determine which dietary supplements patients were taking and for what reason, to compare the patient’s list with the existing documentation in the EMR and to create an accurate list of the dietary supplements in the EMR for future reference.

Patients and methods

All patients of the Breast Cancer Survivorship Program seen between May 5th and June 24th, 2020 were invited to participate in the study prior to their routine annual visit. The eligibility included the absence of metastatic disease and willingness to provide informed consent. Informed consent was obtained from all individual participants included in the study. The nurse practitioner (NP) conducted a pre-visit telephone call to invite patients to participate in the study. The NP asked the study participants about the names, doses, and reasons for taking the supplements. The data obtained by the NP was put into each patient’s EMR and reviewed during the subsequent clinic visit. Study data were collected and managed using REDCap electronic data capture tools hosted at Weill Cornell Medicine [7]. We recorded the supplements that patients were taking under the medication section of the EMR using free text for the majority of the supplements. We also included the reason for taking each supplement in the patient’s own words. The study was approved by the Weill Cornell Medicine IRB. Informed consent was obtained from all individual participants included in the study. Due to Covid-19, telemedicine was used by the nurse practitioner for 48 of 50 visits to explain the study and obtain informed consent. The physician visit was also conducted through telemedicine for 48 of 50 patients.

Results

Fifty-one women were scheduled for their routine annual survivorship visit during this study period. Fifty of the 51 women, ages 46 to 87 (mean age 70) agreed to participate in the study. The average number of years since the diagnosis of breast cancer was 13.5 (range 0–34). Of the 50 study participants, the mean number of dietary supplements taken was 2.4 (range 0–9). Five patients were taking no supplements, 36 patients were taking 1–3 supplements, 7 patients were taking 4–6 supplements, and 2 patients were taking 7–9 supplements. The four most common supplements taken were vitamin D (41 patients), calcium (21 patients), vitamin C (12 patients), and a multivitamin (8 patients). Twenty-four additional dietary supplements were taken by less than 10% of the patients (Table 1).

Table 1

Dietary supplements taken by less than 10% of patients

Vitamins	Minerals	Herbs and botanicals	Hormones	Miscellaneous
Biotin	Magnesium	Black elderberry	Melatonin	Coenzyme Q10
Folic Acid	Selenium	Chinese Herbal Tea		Fish oil
Lutein	Zinc	Coxamin		Glucosamine
Vitamin B12		Cranberry		Probiotics
Vitamin E		Curcumin		Sorbitol
Vitamin K		Ginseng Root Powder
		Rosemary
		Shiitake Extract
		Turmeric

Patients reported a variety of reasons for their dietary supplement use. Some patients stated the supplement was recommended by their medical provider or a friend, some did not know why they were taking a specific supplement, and some reported that they had “always taken it”. Many stated that the supplement was a preventative measure against bone loss or catching a cold. Five patients mentioned immunity or prevention of COVID-19 (Table 2).

Table 2

Patient reasons for taking dietary supplements

Bone and joint health: 23

Physician recommendation: 10

General health: 6

“Always taken vitamins”: 5

Hair and/or nail strength: 5

Strengthen immune system: 5

Heard or read it’s good for you: 5

Not sure: 3

Miscellaneous (insomnia, bladder symptoms, advancing age): 2 each

One each:

Lung health

Macular degeneration

Digestion

Constipation

Anti-inflammatory purposes

“Because it is good for my heart”

The majority of the participants had multiple providers who entered medications in the EMR prior to the study visit. We compared the patient’s accurate, updated dietary supplement list recorded by the study NP with the medication list in the EMR documented by previous providers. Of the fifty participants in our study, none had an accurate list of dietary supplements in their EMR prior to the study visit day.

Discussion

Dietary supplement use among cancer survivors is common. Du et al. report that 70.4% of cancer survivors take dietary supplements, compared to 50% of the general population [8]. Breast cancer survivors consistently report the highest use of dietary supplements compared to survivors of other cancers [2, 6]. Ninety percent of our study participants were taking one or more supplements (mean 2.4, range 1–9).

Breast cancer survivors take dietary supplements for various reasons. Studies show that supplement use is often tied to the hope of preventing recurrence as reported by the LEAN study [9, 10]. In our study, prevention of cancer recurrence was not cited as a reason for dietary supplement use. The most common reason for taking supplements among our patients was bone health. We think this difference between our patients and those of the LEAN study reflects the maturity of our group with a median age of 70 and a mean time since diagnosis of almost 14 years. This compares to the LEAN study, where the median age was 58 years and the time since diagnosis was 2.9 years [11]. The younger patients with a more recent diagnosis of breast cancer may be more concerned about trying to prevent recurrence with supplement use than our older population with an average of 13.5 years since diagnosis. Other reasons for supplement use among our study participants included “I read it was good for me” or “to help my hair and nails”. Additional reasons included “immune health” and protection against COVID-19. Only one participant mentioned prevention of heart disease as a reason for taking dietary supplements (Table 2). This was surprising as heart disease is the main cause of death in women (12).

In our study, none of the participants had an accurate list of dietary supplements in their EMR. Studies by others confirm that the majority of physicians are not aware of their patients’ use of dietary supplements [5]. This may be due to physicians and other medical providers not asking patients about supplement use, or physician belief that this information is not important enough to be recorded in the medical record. In addition, physicians may not feel competent to counsel patients on supplement use. We also believe patients are hesitant to tell their medical providers about supplement use unless specifically asked. Finally, electronic medical records do not provide a simple way for the busy medical provider to record the dietary supplements at each visit.

A review of an accurate list of supplements at the time of the survivorship visit allows the medical oncologist, the oncology nurse practitioner, or the primary care provider to consider possible deleterious interactions between supplements and medications such as tamoxifen and aromatase inhibitors [11]. Furthermore, discussion of supplements will help patients feel confident that the investment they are making in their health is worthwhile. This conversation may also lead to a discussion of topics of general health such as osteoporosis and, importantly, fear of cancer recurrence. A simple patient guide that outlines the pros and cons of supplement usage, such as the FDA 101 guide may be provided for patients to widen their knowledge base [3]. In addition, an accurate list of dietary supplements in the EMR may be important for health care research in the future. This would not be possible at the current level of vitamin and supplement documentation in the EMR.

Our study of supplement use in this cohort of breast cancer survivors confirms Velicer et al.’s observation that breast cancer survivors commonly take dietary supplements and that their medical providers are unaware of which supplements they are taking [6]. The EMR potentially provides us with innovative ways to gather data entered by the patient and the medical provider about supplement use. Continuing education of medical providers about documentation of dietary supplement use will increase patient satisfaction and ultimately improve patient care.

In conclusion, ninety percent of the fifty breast cancer survivors enrolled in this study reported that they were taking dietary supplements. A total of 28 supplements were reported, four of which were commonly used. No study participant had an accurate list of their dietary supplements in the EMR prior to the day of their study visit. We recommend that all dietary supplements should be recorded and acknowledged. We also recommend that there be a documentation method in the EMR to make this convenient and satisfactory for the medical providers.