Jill Drury, PharmD, BCOP

Patients battling cancer should not be overlooked in any pharmacy setting. Many
of these patients are in dire need of support, encouragement, and care coordination. They will endure a grueling process of coping with diagnosis, treatment, and, in cases of recovery, the fear of recurrence. All of these stages will impact the patient emotionally and physically. As the most accessible member of the health care team, the pharmacist can provide information and support that patients with cancer need to get through what might be the most challenging time of their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget.

EM is facing many ups and downs with his treatment options and adverse effects. He presents to you a new list of medications. As the pharmacist, you scan the
list and review it against EM’s medication profile and notice some changes. As you conduct your review, you see concern and stress in EM’s face. You explain the concept of pharmacy brown bag and medication therapy management sessions and ask if he would be interested. EM is interested and informs you that he will bring in all of his oral medications the following day.

EM is looking forward to the opportunity to go over his history and current medication list. He has been feeling tired and depressed on top of feeling anxious because of COVID-19. The pandemic had delayed his cancer diagnosis, a scheduled surgery, and genetic testing, in addition to keeping his young, energetic grandchildren away from him. The stress of balancing life in the COVID-19 world is overwhelming and EM feels very alone. You sympathize, offer support, and suggest EM visit you around 3 pm, which is a slower time at your pharmacy. This will allow you to provide him with the best service and safest care.

EM is a 68-year-old customer of your pharmacy who has become a regular patient at the local community hospital and cancer care clinic. He was diagnosed with stage IV pancreatic cancer 7 months ago and is recovering from chemotherapy. EM lives alone and, because of COVID-19, has not seen his family as often as he wishes. He also found out recently he is 

The next day, EM is waiting in your consultation area. You have done your homework, filled EM’s new prescriptions, opened his medication profile, and can now compare it with what is in EM’s brown bag:

ondansetron ODT 4 mg as needed (filled at cancer clinic pharmacy)

hydrocodone bitartrate-acetaminophen 5/325 mg every 4-6 hours as needed for pain

dronabinol 2.5 mg twice daily before meals (filled at cancer clinic pharmacy)

fentanyl transdermal patch 50 mcg/h as directed every 3 days (filled at cancer clinic pharmacy)

EM admits that he has started smoking again as it helps him with his pain and nerves. You advise EM about the negative impact of smoking and offer to reach out to his care team to adjust his medications for pain and anxiety. EM tells you he already has stage IV cancer and will not quit smoking. You stress the importance of proper pain and anxiety management. EM also is taking too much daily acetaminophen between his OTC acetaminophen and prescription hydrocodone bitartrate-acetaminophen tablets. You review acetaminophen limits and toxicity information.

EM is not consistently taking his atenolol and atorvastatin. He has not seen a cardiologist in over 2 years and he relies on his oncologist and internist for medication refill prescriptions. EM has 4 stents placed when he was in his 50s and has a strong family history of cardiac disease. You take his blood pressure and the best out of 3 reads high in the 170s. EM recently had fluctuations in cholesterol and he talks about changes in his diet. He tells you his appetite is poor and he feels that he hardly eats. EM tells you he feels nauseated and bloated after eating and that makes him feel uncomfortable, so he avoids eating.

You review EM’s dronabinol dose and offer to follow up with the cancer center dietitian for suggestions. He also admits feeling palpitations lately when he is anxious. He has cut out caffeine thinking that was the issue, but the palpitations keep occurring. You urge EM to make a follow-up appointment with his cardiologist for any necessary tests.

You ask EM about his olaparib and his genetic test results. He complained about the medication cost and not understanding what his genetic test means. You offer to reach out to the cancer center to inquire about the test and any assistance that may be available. EM is very appreciative and thanks you.

EM recently received his first dose of the COVID-19 vaccine and is happy to be able to start seeing his family again soon on a regular basis. He thinks that will help his mood, mobility, and outlook on life. He has been consistently taking his antidepression medication and hopes to work with you and his care team to discontinue the medication. You acknowledge that

this is a stressful time and suggest some nonpharmacological ways to reduce stress, help sleep patterns, and ultimately help his spirit. Things like starting a gratitude journal, walking, yoga, or stretching activities sound silly to EM but he acknowledges that they are all good ideas that would make him happier.

EM appreciates your help and suggestions. You offer to contact his providers for necessary follow-up and more support.

is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.

Articles

The pharmacist can provide information and support that patients with cancer need to get through what might be the most challenging time of their lives.

 Brown Bag Consult®: Pancreatic Cancer and Mental Well-Being

Pharmacists working in an oncology outpatient clinic have counseling opportunities similar to those that are often abundant in a community retail setting. For example, medication reconciliation is a form of brown bagging and medication therapy management (MTM). Both can be used to advance communication and to prevent errors. As does any counseling session, medication reconciliation helps ensure that a patient’s medications are safe and that the patient fully understands how to take them. By engaging in medication reconciliation, the clinic pharmacist can prevent errors that occur when a patient’s medications include prescription drugs, over-the-counter (OTC) drugs, herbals, and dietary supplements. The process allows for a holistic checking of omissions, duplications, dosing errors, adherence, and drug interactions. In all, the services provided by a clinic pharmacist can enhance communication between providers and patients to ensure that care is communicated and coordinated.

Many oncology patients are in need of support, encouragement, and care coordination. They will endure a grueling process of coping with diagnosis, treatment, and, in cases of recovery, the fear of recurrence. All of these stages will impact the patient both emotionally and physically. As the most accessible member of the health care team, the pharmacist can provide cancer patients with the information and support they need to get through what might be the most challenging time of their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget.

Aged 68 years, PV is a customer who is loyal to her community pharmacy. She has also just become a patient at the local oncology clinic, having been recently received a diagnosis of metastatic hormone receptor–positive, HER2-negative breast cancer. In addition to her diagnosis, other factors have made PV feel very stressed and depressed: COVID-19 has made seeking comfort from her family feel impossible, and she is worried about getting sick and requiring hospitalization.

PV stops at the pharmacy during your shift and presents to your team a new list of medications along with her current laboratory data. PV explains that she just left the clinic and that these are her most up-to-date documents. As the pharmacist, you page through the papers and notice a medication reconciliation performed by another pharmacist. You review it against PV’s profile at your pharmacy and notice changes.

As you conduct your review, you explain the concept of pharmacy brown bag and MTM sessions to PV and ask if she would be interested. You tell
her you are offering these services virtually at the moment and are happy to set up an opportunity to connect. PV is interested and wants to review her medications with you the following day. PV has been reading about metastatic breast cancer online and all the information has been making her anxious. Her daughter-in-law is a health care provider and PV normally asks her questions about cancer and other conditions she does not understand. Yet, with everything going on, she doesn’t want to be a bother. She is happy you are willing to help her. You suggest PV meet with you at 2 PM, which is a slower time in your pharmacy, and send her a digital invite to talk at that time. This will allow you to provide her with the best service and care.

The next day, PV is waiting to connect. Having done your homework, you have filled PV’s medications, reviewed discontinued medications, opened her medication profile, and have access to her laboratory data and medication reconciliation. You compare that with what PV is showing you on the computer screen:

aspirin 81 mg, enteric-coated (EC), daily • rosuvastatin 10 mg, daily

OTC acetaminophen 500 mg, as needed • OTC loperamide, as needed

Your pharmacy profile shows the following:

ribociclib 600 mg, daily for 21 days (receiving from a specialty pharmacy due to insurance restrictions)

The goal of a brown bag session is the discovery of discrepancies. Awareness can now allow you to make a number of short- and long-term suggestions. Your advice may improve communication between PV and her multiple providers. Overall, this communication may improve PV’s quality of life and reduce her risk for adverse effects, adverse events, and hospital admissions. PV is willing to have you act as a liaison between her and her providers.

The first step is to follow up with PV’s providers to make them aware of your brown bag session discoveries and the suggestions you have regarding PV’s plan of care. Time will be your biggest challenge, and you will need to find a way to incorporate these complex clinical opportunities into the workflow. Loyalty and patient satisfaction are priceless, and they are worth the energy to help PV.

What are some general suggestions you have that came up after reviewing PV’s brown bag medications? What laboratory data might have helped you?

PV is concerned about frequent laboratory monitoring and adverse effects she read about concerning ribociclib. PV doesn’t understand the different types of metastatic breast cancer and all the different treatment options. How do you encourage PV to use her oncologist as a resource to explain her treatment plan?

PV tells you she is using more alprazolam than was suggested, due to her anxiety and nausea from “all the pills.” She is also very depressed and fatigued. PV has consistent bone pain in her legs making it hard to exercise and to enjoy being outside. COVID-19 restrictions have compromised many of her activities and being limited to her home has been very hard on her socially, mentally, and physically.

PV tells you she has not checked her blood pressure over the year and often feels very fatigued. Because she is so tired, she drinks a lot of beverages with caffeine—yet she experiences palpitations every time she does so. PV explains that her cholesterol was last checked more than a year ago and her numbers were not ideal, but her “good cholesterol” was high.

You explain to PV that blood pressure monitoring and having her cholesterol checked yearly is important for her heart health. As your visit is virtual, you cannot check her blood pressure. You recommend an easy self-use cuff. PV promises to follow up with you and also to make an appointment with her cardiologist. You suggest that PV avoid caffeine in the meantime.

PV is definitely someone who needs more counseling and follow-up care. You also discover that PV has never received vaccinations for influenza, shingles, or pneumonia.

Considering time and COVID-19 restrictions, how can you help ensure PV remains adherent now you have helped her get on track toward a better quality of life? What are some new ideas and suggestions you can offer PV to help her mentally and physically cope in this new health care environment?

A patient with multiple providers and health problems seeks a pharmacist’s knowledge for managing her prescribed and OTC drug products.

Brown Bag Consult®: Breast Cancer and Additional Stressors

Affecting both males and females, acute myeloid leukemia (AML) is an aggressive hematologic cancer caused by the proliferation and accumulation of immature precursor blood cells (myeloblasts). Identifying the disease’s signs and symptoms can help patients seek prompt care and ideally reduce its impact.

Pharmacists are often thought of as the most trusted and accessible health care professionals in the community. Because of this perception, they can help patients understand possible signs and symptoms of illness, and assist with follow-up care for those who are diagnosed with AML. 

As the most accessible member of the health care team, the pharmacist can provide patients with cancer with the information and support necessary to get through what could be the most challenging time in their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget.

JP is a 69-year-old man who has been coming to your pharmacy over the past decade. He stops in today to get his first dose of vaccine for coronavirus disease 2019 (COVID-19) and mentions to you that he has been very tired and feels joint pain. He looks frail and you become concerned. He brushes off your concern and explains that he had a negative COVID-19 test a few weeks ago after thinking he had been exposed. He shows you the results, saying maybe his aches are from shoveling snow and general winter blues. Additionally, he has found it mentally hard not being able to travel and see family and has been feeling depressed. JP agrees to check back in with you if he does not start to feel better.

You ask JP, when he picks up his refill medications a week later, how he is feeling. He explains he is still feeling fatigued, has experienced new-onset headaches, and bruises easily. He shows you a large bruise on his right calf as evidence, saying he still feels that his joints hurt.

You offer to call JP’s primary provider to get him in for a checkup and maybe some laboratory work. He tells you he felt fine after his COVID-19 vaccination. You ask him if he would be interested in participating in a brown bag session. You explain what happens during the session and tell JP you are interested in reviewing his medications and lifestyle. This would allow him to maximize his medications, which may also have a positive financial impact and improve his general health. JP nods and appreciates the opportunity to talk with you in depth, one on one. He will schedule a time with you after he follows up with his primary care provider.

JP stops in at the pharmacy for his second COVID-19 vaccination and to tell you he has been diagnosed with AML. Even though the incidence of AML is relatively low, given JP’s age and some other risk factors, his prognosis is poor. This is a shock to JP as he will have to undergo chemotherapy and possibly a transplant if he is eligible. He is worried about his finances, as well as complicated terms such as hypomethylating agents, blast percentage, relapse, and complete response. He doesn’t quite know what it all means for him.

You offer to take some time and help him generally understand AML and review his current medications. JP is thankful for your help, and for the pharmacist-patient relationship. The pandemic has made provider conversations and developing relationships difficult, and he expresses how he feels cared for and appreciates the compassion at your pharmacy.

Upon reviewing JP’s updated medication profile at your pharmacy, you find the following:

Irbesartan/hydrochlorothiazide 300 mg/12.5 mg daily

Alprazolam 0.5 mg as needed for sleep, anxiety

When JP comes in for his scheduled appointment, you notice the following additional medications in his bag:

After reviewing JP’s medications, you realize he would benefit from a follow-up appointment to see how he is processing his AML diagnosis. What can you tell JP about AML and the chemotherapy he may be prescribed? What can you tell JP about possible medications he may need to sustain postremission maintenance?

JP appreciates your help, and trusts your advice and recommendations as he starts his cancer care journey.

, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.

As the most accessible member of the health care team, the pharmacist
can provide patients with cancer with the information and support necessary
to get through what could be the most challenging time in their lives.

Brown Bag Consult®: Acute Myeloid Leukemia and the Community Pharmacist’s Role

Colorectal cancer is one of the most common types of cancer in the United States. The importance of early detection cannot be overemphasized. Recent media reports have disclosed news of cases with negative outcomes, which have sparked public awareness and concern regarding this disease.

Proper screening and education play an important role in helping prevent or reduce the impact of colorectal cancer. Pharmacists are often thought of as the most trusted and accessible health care professionals within the community. Because of this position of authority, pharmacists can help patients by suggesting colorectal cancer screenings and follow-up care for those patients who are at elevated risk.

There are many reasons why eligible patients may not be screened for colorectal cancer. The primary reason is that it simply has never been suggested to them. Pharmacists should communicate the universal message that colorectal cancer screenings save lives.

Additionally, certain groups of patients, for example, do not have health insurance or regular health care, are not aware of the importance of screenings, or may not realize they are at risk. Patients may also fear colorectal cancer screenings because of bowel preparation procedures and possible embarrassment because of the nature of the screening. You can also find many patients self- treating colorectal cancer symptoms in the OTC aisle.

All these issues can easily be discussed during patient-pharmacist counseling sessions. Pharmacists can help provide educational and financial resources, and relieve any anxiety related to the screening process. Pharmacists can recommend colorectal cancer screening tips and tools to reduce risk and unnecessary worry. They can refer patients to qualified health care providers for follow-up care, as well as act as a prescriber-patient liaison. Pharmacists can also review the proper instructions for any colorectal screening preparation medications.

Reducing Colorectal Cancer Risk in Your Patient Population

Community pharmacists have the responsibility to help patients differentiate between modifiable and nonmodifiable risk factors during counseling sessions. There are many modifiable risk factors that reduce the risk of colorectal cancer. For example, diets high in processed meats, such as deli meat and hot dogs, lead to increased risk of colorectal cancer.

It also is important for pharmacists to encourage and consistently reinforce healthy lifestyles. Pharmacists should discourage inactivity, heavy alcohol consumption, tobacco use, and diets high in red meat. Vegetables and fruits should be encouraged.

Additionally, pharmacists should be able to identify eligible patients for colorectal screenings through nonmodifiable risk factors. Common nonmodifiable risk factors include advanced age, certain races or ethnicities, and family and personal medical histories. Age can often be a controversial risk factor in cancer screening guidelines. However, if a patient has signs and symptoms that cannot be linked to other conditions, and risks ultimately are not ruled out, the pharmacist should make a referral for screening.

TD is a 58-year-old woman who has been coming to your pharmacy for 5 years. During this time, you have observed her making poor lifestyle choices, and noticed that she has become less adherent to various drug regimens for managing her depression and hypertension. TD admits she lacks interest in managing her conditions and often just buys items in the OTC aisle. She doesn’t like asking for help.

You noticed in your last counseling session that TD generally lacks positive energy and seems negative about therapies and screenings. When you ask, TD tells you that she has never had a mammogram, nor has she ever been screened for colorectal cancer. TD is worried about the financial impact of her health overall and mentions stress related to her sister’s recent death from cancer. You ask TD the type of cancer, but she does not know. TD only says that it was tremendously sad to watch her sister deteriorate and that she died relatively soon after her diagnosis.

You ask TD if she would be interested in participating in a brown bag session. You explain what will happen and tell TD you are interested in reviewing her medications and lifestyle. This will allow her to maximize her medications, which may also have a positive financial impact. TD nods and appreciates the opportunity to talk with you in depth. She schedules a time with you for the next day to bring in all her medications.

Upon reviewing TD’s medication profile at your pharmacy, you find the following:

furosemide (Lasix; Validus Pharmaceuticals), 20 mg/d

enalapril (Vasotec; Bausch Health), 10 mg/d

polyethylene glycol and electrolyte solution (CoLyte; Pendopharm G.I. Solutions), on hold

alprazolam (Xanax; Pfizer), 0.5 mg/d as needed

When TD comes in for her scheduled appointment, you notice the following additional medications in her brown bag:

Various unlabeled OTC antacids, fiber pills, and calcium tablets

OTC loperamide (Imodium A-D; Johnson & Johnson), 2 mg

OTC esomeprazole (Nexium; GlaxoSmithKline), 20-mg capsules

After reviewing TD’s medications, you realize TD would benefit from a medication therapy management (MTM) session, and you schedule a follow-up appointment. An MTM session will allow you to further communicate with TD’s health care providers, obtain lab values, and further evaluate TD’s medical goals, particularly those related to her cancer risks. An MTM session will also give you the opportunity to offer detailed hypertension education, as requested by TD.

TD tells you she has a blood pressure cuff at home but doesn’t understand how to use it accurately. You tell her you are happy to look at the cuff and instruct her. In the meantime, after looking through TD’s brown bag, you ask about all the OTC medications.

TD admits she has terrible gastrointestinal (GI) distress after meals and is often too ashamed to talk about how uncomfortable it makes her feel. She admits she eats very poorly, with lots of fast food or prepared meals. TD thinks her GI issues lead to her anxiety and depression, because she always has to watch what she eats and where she is when she eats. TD feels that if she takes “a lot of” medicine, she can prevent episodes. TD also mentions, when asked, that she is afraid to get a mammogram, telling you she heard from friends that “they hurt.”

You emphasize the importance of screenings and say that getting her on a healthy track means getting them done. TD commits to following up with you and with her screenings so you can be of more help.

What additional advice, if any, would you provide to TD?

Pharmacists should communicate the universal message that colorectal cancer screenings save lives.