Dietary Supplement Use During Chemotherapy and Survival Outcomes of Patients With Breast Cancer Enrolled in a Cooperative Group Clinical Trial (SWOG S0221)

Abstract

Purpose: Despite reported widespread use of dietary supplements during cancer treatment, few empirical data with regard to their safety or efficacy exist. Because of concerns that some supplements, particularly antioxidants, could reduce the cytotoxicity of chemotherapy, we conducted a prospective study ancillary to a therapeutic trial to evaluate associations between supplement use and breast cancer outcomes.

Methods: Patients with breast cancer randomly assigned to an intergroup metronomic trial of cyclophosphamide, doxorubicin, and paclitaxel were queried on their use of supplements at registration and during treatment (n =1,134). Cox proportional hazards regression adjusting for clinical and lifestyle variables was used. Recurrence and survival were indexed at 6 months after enrollment using a landmark approach.

Results: There were indications that use of any antioxidant supplement (vitamins A, C, and E; carotenoids; coenzyme Q10) both before and during treatment was associated with an increased hazard of recurrence (adjusted hazard ratio [adjHR], 1.41; 95% CI, 0.98 to 2.04; P = .06) and, to a lesser extent, death (adjHR, 1.40; 95% CI, 0.90 to 2.18; P = .14). Relationships with individual antioxidants were weaker perhaps because of small numbers. For nonantioxidants, vitamin B12 use both before and during chemotherapy was significantly associated with poorer disease-free survival (adjHR, 1.83; 95% CI, 1.15 to 2.92; P < .01) and overall survival (adjHR, 2.04; 95% CI, 1.22 to 3.40; P < .01). Use of iron during chemotherapy was significantly associated with recurrence (adjHR, 1.79; 95% CI, 1.20 to 2.67; P < .01) as was use both before and during treatment (adjHR, 1.91; 95% CI, 0.98 to 3.70; P = .06). Results were similar for overall survival. Multivitamin use was not associated with survival outcomes.

Conclusion: Associations between survival outcomes and use of antioxidant and other dietary supplements both before and during chemotherapy are consistent with recommendations for caution among patients when considering the use of supplements, other than a multivitamin, during chemotherapy.

FIG 1.

Study schema for participants included in the Diet, Exercise, Lifestyle and Cancer Prognosis (DELCaP) analysis, an observational study ancillary to SWOG S0221, a randomized treatment trial for high-risk breast cancer. CRA, clinical research associate; Q1, questionnaire 1 completed at registration in the trial before initiation of chemotherapy; Q2, questionnaire 2 completed at completion of active treatment (approximately 6 months after registration in S0221; ‘other’ patients were collapsed into other categories). *Other: mental disability, loss of vision, physician removed patient from study, dropped on suspicion of metastasis.

FIG 2.

Product limit estimates for use of antioxidant supplements and (A) disease-free survival (DFS) and (B) overall survival (B) and for use of multivitamins and (C) DFS and (D) OS. NN, neither before nor during; NY, not before but during; YN, before but not during; YY, both before and during.

FIG 3.

Product limit estimates for use of vitamin B12 supplements and (A) disease-free survival (DFS) and (B) overall survival (OS) and for use of iron supplements and (C) DFS and (D) OS. NN, neither before nor during; NY, not before but during; YN, before but not during; YY, both before and during.