Investigating documentation of alcohol and non-medical substance use in oncology treatment: an electronic health record review

Purpose Little is known about non-tobacco substance use (SU) and its treatment in cancer patients. National guidelines address tobacco only, and assessment of SU in cancer patients is not standardized. It is not clear how oncology clinicians assess, document, and follow-up on SU. Methods We conducted an electronic health record review of patients enrolled in a smoking cessation trial at one large hospital site (N=176). Chart review of oncology treatment notes assessed whether SU assessment was documented, the content of the documentation/assessment (e.g., frequency of use), and details about documentation (e.g., where/who documented). Results Sixty-nine percent (121/176) of cancer patients had SU documented. Many patients (42%, 74/176) had only one substance documented; 66% (116/176) had alcohol use documented. For a substantial minority of patients (43/176; 24%), the provider did not specify the substance assessed (e.g., drug use, illicits). SU was primarily documented by physicians (84%, 102/121), in routine progress notes (56%, 68/121), in the social history section of the note (84%, 102/121). Only 4 patients had a documented SU follow-up plan. When examining the subset of patients who reported problematic alcohol use (N= 27), the content of documentation was inconsistent (e.g., number of drinks/day vs. qualitative descriptors of use). Conclusions About 1/3 of oncology patients did not have SU assessment documented. SU other than alcohol use was infrequently documented, many clinicians documented SU but did not specify substance type, and few clinicians documented a follow-up plan for problematic SU. Oncology settings should utilize standardized assessment and referral for SU treatment.

Automated summary

Little is known about the assessment and treatment of non-tobacco substance use in cancer patients. This study found that about one-third of oncology patients did not have substance use assessment documented. Many clinicians documented use but did not specify the substance type, and few clinicians documented a follow-up plan for problematic substance use. Standardized assessment and referral methods should be used in oncology settings.