Larry Calemine, RPh, BS Pharm
Larry Calemine, RPh, obtained his BS Pharm degree at West Virginia University in 1992 and has spent most of his career focused on ambulatory pharmacy. In 1999, he trained at PCCA's compounding center to increase his knowledge and worked for a compounding pharmacy specialized in altered dosage forms. He obtained certifications in Diabetes, Immunizing, Cardiovascular Risk Management, and MTM through APhA. He developed a discharge pharmacy in 2012 at WVU Medicine's outpatient pharmacy to aid in lowing readmission rates for all causes at Ruby Memorial Hospitals. Larry also started an APPE program with 6 schools of pharmacy to increase clinical outcomes.
During a patient’s life, the probability of developing invasive cancer is 38% for women and 42% for men. There is some promise is that 5-year survival rates for all types of cancer show 20% improvement in whites and 23% in blacks.2 Since the pharmacist is one of the last health care professionals to see the patients before their transition to home, pharmacists are primed to assist in these patient’s health care. For example, newly-diagnosed cancer patients experience a plethora of emotions including fear, worry, anxiety, and depression. The unknown or lack of information can be the very foundation of these emotions.
A pharmacist can play an essential part in education and counseling of these patients to ease their anxiety, starting with explaining the many modalities of cancer treatment that varies from surgery, radiation, chemotherapy, immunotherapy, hormone therapy, stem cell transplant and prescription medication therapy. However, this article will focus on some of the more streamline medications and devices a general cancer patient may be more common to receive to an ambulatory care pharmacist.
Over-the-counter (OTC) Medications
As the increase in number of new cancer cases increases, so will concomitant use of over-the-counter (OTC) medications and herbal products. It is vital, that pharmacists across the nation take note of the growing use of over-the-counter products in oncology patients and garner the knowledge to prepare oneself to counsel and recommend safe and effective products according to treatment regimens.
The primary source of potential drug interactions is based on the pharmacokinetic profile of anticancer medications. Most anticancer medications are metabolized via inhibition or induction of cytochrome P450 liver enzymes, however so are the OTC medications, ultimately leading to potential drug-drug interactions. According to a study conducted in Canada, 27% of ambulatory cancer patients have been exposed to potential drug-drug interactions involving anticancer medications and OTC products. The study went on to state that 82% of patients on anticancer treatments used at least one OTC drug.3
Many patients are instructed by physicians to avoid OTC medications within 3 days of cancer treatments. However, a survey found that 71% of patients took an OTC medication within 3 days prior to chemotherapy. Many of the subjects surveyed had used nasal sprays or hair products due to failure of identifying these products as medications.3,4 As one can see the potential for an oncology patient to mistakenly or knowingly take a substance that reacts with their anticancer treatment is extremely likely. The statistics shows that the number of persons with newly diagnosed cancer is projected to increase and it is the job of pharmacist and health care professionals alike to combat the potential that these patients experience drug interactions due to use of over-the-counter products.
When it comes to cancer treatment regimens many of the medications are paired with some difficult side-effects, from hand-foot syndrome to nausea and vomiting, here are some of the things you as a pharmacist will want to take into consideration when helping patients choose the product that is best for their ailment. The following (not in order) are some of the most common products that will come in question from patients undergoing cancer treatments: stool softeners, laxatives, acetaminophen, pseudoephedrine (decongestants), vitamins, skin care, sunscreens, and last-but-not-least nutrition products. As one can tell, this is not an all-inclusive list by any means and different patients will require different products as well as counseling, however, being familiar with these products will have you more prepared to answer and recommend OTC products to patients in need.
Stool softeners and laxatives come with an array of counseling points and formulations. These are not “one size fits all” products, as mechanisms of action and formulations all have an effect on how the medication will work for the patient. An example of this is patients who cannot swallow tablets and the use of liquid is required or those who have abdominal issues and should seek medical advice before using an OTC stool softener/laxative. Next on the list is acetaminophen, this medication is highly sought after for fever and headaches. However, many oncologists do not recommend the use of acetaminophen as it blocks the presence for febrile neutropenia a maker often used to indicate infection. Nasal Decongestants, especially those containing pseudoephedrine, are commonly used to rid oneself of colds and congestion. Many oncology patients must avoid these medications as they have the ability to affect the heart and cause false abnormalities in a multi-gated acquisition (MUGA) scan. In this day and age, vitamins are everywhere and as many patients have nutritional imbalances they seek the help of vitamins to replace the nutrition they are no longer able to receive. Vitamins can cause a slew of medication related interactions (eg warfarin and vitamin K) including chelating ions interacting and binding many medications. Be very cognizant of what the patients are taking prior to recommending usage of any vitamin supplement.
Healthy Skin is a condition somewhat over looked. Some cancer treatments can affect healthy skin and can lead to a “Hand and foot syndrome” leading to pain, damaged skin and darkened or discolored skin. Many anticancer medication regimens attack the higher surface areas of the body, hands and feet, causing severe dryness and cracking. These patients will seek out products to moisturize their skin. Cracked skin breaks can be pin points for infection. Advise patients to monitor their skin daily and notify their physician is any signs of infection. Make sure the products they are choosing from do not contain hidden ingredients that many have an interaction with medication they are taking; such things are antibiotics, aluminum ions, and topical steroids. Along with moisturizers, many patients are unaware of the photosensitive effects of their medications and therefore should be reminded to use sunscreen, how to apply it, and its potential to stain clothes.
Last but definitely not least, is nutritional replacement; the market for protein shakes and different bars has increased tremendously in the past decade. Pharmacies have paired with nutrition companies that sell these products and have increased the potential choices for patients. It is handy to remember to try and stick with products that are more natural in formulation and to not completely rely on a shake for nutrition. Pay close attention to those that have increased protein content as certain disease states (CKD) should not consume large amounts of protein. In the end, remember to treat every patient as an individual. No treatment regimen is the same; always check what mediations the patients are on prior to recommending any product. It is of best interest to seek the advice of the physician prior to recommending products to any patient.
Many patients with cancer deal with pain issues. Pain in itself is a broad term, reflecting on the type, location, intensity, and origin of the pain itself. Pain can be acute or chronic. Pain can be a result of the cancer itself or be secondary or other causes, like treatment or procedures.5 Pharmacists are poised to aid patients in learning and understanding their pain management. Often pain management can be sub-therapeutic. Pharmacists can not only assist the patient with their understanding of pain managing but can help the entire healthcare team in proper selection by aiding in pain assessment, maintaining compliance for pain control, and managing side effect that may occur. Adequate communication to the physician and patient is a fundamental step in the journey to keep your cancer patient “pain-free”.
Pharmacists can help by assessing the type of pain your patients has. This assessment can gain information on the intensity, timing, location and definition of your patient’s pain. The type of cancer and organ function can and will define product selection. Cancer pain Guidelines reflect a range of pain medications due to the severity. In general medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen for lower severity to opioids for higher severity can be utilized. 5 The choice of short or longer acting opioids can be an area the pharmacist can aid especially with narrowing insurance formularies. Location of the type of cancer can affect dosage form from to tablet/capsule, transdermal to liquid.
Managing the pain regimen is where the pharmacist plays an important role. Keeping and open communication with the physician and patient ensures a better understanding of the goal to achieve in pain management. A lack of achieving pain control can impede the patient’s ability to rest or sleep further impacting their healthcare. Effective counseling regarding recognizing the signs for pain. The importance of adhering to the directions and recognize the possible side effects that may occur.
Lastly side effects can be especially traumatic to the patient and caregivers. Advising your patients of the potential for constipation, sedation, confusion and nausea. When your patient can recognize the sign of these side effects and can alleviate or manage them, your patients can be more adherent. Pharmacists can recommend or avoid particular laxatives for the patient’s treatment of constipation.
Many barriers exist in proper pain management today. Some of the barriers can be attributed to formulary management, pharmacy access to the medication, affordability of the medicine, patients reluctance to report pain symptoms, concerns about addiction, and controlled substance regulations The pharmacists access directly to the patient can be an avenue to break some of these barriers to allow patients deal with their fight of cancer to be as pain free as possible.
In treating cancer, patients often face a condition known as cachexia. Cachexia by definition is a wasting syndrome of which manifests weakness, significant weight loss and decrease in body mass.6 Up to one-quarter of all cancer patients face a loss of appetite and the wasting syndrome of cachexia is estimated to be the cause of death of up to 40%. 7
Pharmacists are in a good position to help cancer patients with their nutrition. Prior to recommendations, the pharmacist should communicate with the treating physician and also encourage the patient to meet with a registered dietitian for individualized counseling.8 Treatment can be a tough time getting proper nutrients. Cancer treatments can impair or affect the way the patient gets nutrition. Treatments can affect the patient’s tastes, smells and digestion making it hard to maintain weight.7 Even oral lesions may deter eating for some patients.
Several basic key factors should be thought of when recommending nutrition to cancer patients.Hydration is important in maintaining a body’s immune system and regulating most daily functioning. Oncology patients are at increased risk for dehydration secondary to decreased intake, nausea, vomiting and diarrhea. Pharmacists should teach patients to look for signs of dehydration and recommend ways to avoid this from becoming a bigger problem. Dark or discolored urine can be the most obvious sign of dehydration. One recommendation would be to try drinking smaller amount of fluids at a given time rather than consuming a whole glass of liquid. Electrolytes can aid in retaining the volume of fluid, although other ingredients should be considered when making recommendations, such as caffeine, sugar content and vitamins. Proteins, carbohydrates and fats, although these would-be recommendations without the diagnosis or treatment of cancer, these food categories are worth noting. Protein-rich foods are needed to form and maintain muscles, tissues, red blood cells, enzymes and hormones. During cancer treatment these needs are increased.
To conserve lean muscle tissue, carbohydrate calories are an important source of energy, dietary fiber, and are necessary for vitamin and mineral absorption. Dietary fat intake is essential for digestion and absorption of fat soluble vitamins and minerals. It also improves the taste and satiety of a meal.
If nutritional needs are not being met by food alone, the addition of a nutrient-dense supplement ie Ensure or Boost is beneficial. There are many different nutritional supplements on the market. The patient’s clinical status should be considered when making a recommendation ie digestive and absorptive capabilities, fluid restriction, and medical conditions such as diabetes or renal disease. The patient’s health insurance policy and/or finances should also be part of the conversation. Getting a complete list of a patient’s current medication regimen is important due to adverse reactions with products selected, even due to the vitamins and minerals in the product. Pharmacists are often the last healthcare professionals to see the patients in the course of their care. Pharmacists are very accessible to patients and are a great tool to aid patients not only in their medication regimens but in the products carried in their pharmacies for nutrition supplementation.
Diarrhea associated with cancer can lead to significant malnutrition and dehydration resulting in weight loss, fatigue, renal failure, hemorrhoids and perianal skin blister wounds. 8 In addition to therapy (capecitabine, cisplatin, cytosine arabinoside, cyclophosphamide, daunorubicin, docetaxel, lapatinib, interferon, paclitaxel, topotecan, methotrexate, doxorubicin irinotecan, leucovorin), 9 diarrhea in patients with cancer can be a direct result of; (a) the cancer itself (carcinoid syndrome, colon cancer, lymphoma, medullary carcinoma of the thyroid, pancreatic cancer or pheochromocytoma),10 (b) Surgery-related (celiac plexus block, cholecystectomy, esophagogastrectomy, gastrectomy, whipple procedure, intestinal resection, vagotomy), (c) Radiation-therapy related,11 or bone-marrow transplantation-related. 12 Irrespective of the cause, it is important for the pharmacist to assess the patient in accordance to the National Cancer Institute’s Common Terminology Criteria for diarrhea.
The criteria grade the severity of diarrhea as: Grade 1, for increase of <4 stools per day over baseline; Grade 2, for increase of 4-6 stools per day over baseline; Grade 3, for increase of >7 stools per day over baseline (hospitalization); Grade 4, for life threatening consequences (urgent intervention indicated) and Grade 5, for death. Before counselling patients, it is very important that the pharmacist ascertains the grade status of the patient’s diarrhea. In addition to the grade the pharmacist needs to confirm if the onset of diarrhea was early (< 24 hr after administration of therapy) or late (> 24 hrs after administration of therapy) and after the onset if the diarrhea was persistent (present for > 4 weeks) or non-persistent (present < 4 weeks).
Uncomplicated diarrhea (grade 1 and 2) could be managed by dietary modifications by counselling patients to eat small frequent meals that do not stimulate the intestines (lactose-containing food, spicy food, alcohol, caffeine containing beverages, high fat or fiber containing food and carbonated drinks). Patients can be encouraged to start on a regimen of the BRAT diet (bananas, rice, apple, toast) accompanied by an increase in intake of water (~ 3 liters per day). Additionally, a pharmacist can recommend the use of probiotic nutritional supplements that can replenish beneficial microorganism within the intestinal flora and thus be beneficial to curb diarrhea. When it comes to medication for treatment of uncomplicated diarrhea, the present standard of care includes loperamide (Imodium), Octreotide (Sandostatin) and deodorized tincture of opium (Opium Tincture). The main goals of these therapies are to inhibit intestinal motility to promote absorption. A pharmacist can also advise patients to take anti-secretory agents that reduce intestinal secretion like bismuth subsalicylate (Pepto-Bismol) with the warning against its use in case the patient is taking other salicylates like aspirin or has bloody stools. In this case, loperamide is the safer alternative that can be suggested by the pharmacist. Complicated diarrhea is generally grade 3 and above but the pharmacist should be aware that a grade 1 or 2 with added risk factor of severe cramping, nausea, fever, bleeding or dehydration should be treated as complicated diarrhea. In these cases, the pharmacist should ask the patients to seek immediate medical help and abstain from self-medicated treatment.
Constipation (fewer than 3 bowel moments a week) associated with cancer can lead to abdominal distension resulting in severe abdominal pain and progress to fecal compaction leading to ischemic necrosis, bleeding and perforation of the intestine.13 Constipation in cancer patients can be due to the (a) cancer itself, (b) it could be a complication arising due to the growing tumor, (c) side effects of the drug treatments and (d) mitigating circumstances of the disease like decreased mobility or organ failure.14 Like diarrhea, there are various grades of severity of constipation, namely: Grade 1, for occasional or intermittent symptoms; Grade 2, for persistent symptoms; Grade 3, for symptoms interfering with daily life activities; Grade 4, for life-threatening consequences and Grade 5, for death. A pharmacist should be aware of this grading system when assessing a patient and recommending medical aid.
As constipation is a very subjective symptom, it becomes very essential that a thorough enquiry be undertaken before a pharmacist dispenses his recommendation. The enquiry should include the patients’ normal bowel moment history, his previous or present use of laxative that has helped relieve constipation, diet and fluid intake and is the constipation accompanied by excessive flatulence, abdominal pain, nausea, vomiting or rectal bleeding. A grade 1 or 2 severity of constipation without any other symptoms can be managed by encouraging the patient to increase dietary fibers like fruits, vegetables and whole grain cereals. Natural laxative mixtures containing raisins, currants, prunes, figs, dates have been shown to assist in natural and regular bowel moments.15 Additionally, the pharmacist can ask the patient to keep a record of their bowel moments and encourage them to increase their fluid intake (contraindicated if the patient has renal or heart disease) and engage in regular exercise (moving from bed to chair is patient is ambulatory).
In addition to this general intervention, therapeutic interventions include bulk-forming laxatives that closely mimic the physiological machinery involved in bowel moment like psyllium (Metamucil), Polycabophil (FiberCon) and methylcellulose (Citrucel). Pharmacist should advice the patients to lookout for symptoms of bloating and abdominal pain (caused due to distention) while on these medications. Emollient laxatives like calcium docusate (Surfak) and Sodium docusate (Colase) help soften stools and thus promote bowel moment. When taking these drugs, the pharmacist should warn against its use in combination with drugs like digitalis or warfarin. Stimulant laxatives are very potent laxative and include senna (Senokot), bisacodyl (Dulcolax) and castor oil. Pharmacist should avoid recommending this laxative when much more gentle bulk-forming laxatives have not been tried in the patient. Finally, osmotic laxative such as saline laxatives, polyethylene glycol compounds are poorly absorbed and thus retain water within the intestine and promotes bowel moments. Adverse effects with these include cramping, flatulence, bloating and colic and the pharmacist should advice patients to stop taking these laxatives as soon as the patients observe one of these symptoms.
Opioids are the gold standard for management of pain in cancer patients but they unfortunately induce constipation that compromise the well-being of the patient. In addition, to use of above mentioned laxatives, pharmacist can educate patients about the use of efficient treatment options like methylnaltrexone (Relistor) that has been demonstrated to be very effective in improving bowel moments in cancer patients.16
It is important for pharmacist to recognize that even though a majority of cancer patients are fatigued and require more sleep, they have harder time falling asleep thus exacerbating their downward health spiral. The reasons for not getting sleep could be pain, worry, depression, anxiety, gastrointestinal, or respiratory disturbance, night sweats, stress or simply the side effects of the medication the patient is prescribed.17 Additionally, sleep disturbance could be pathological in nature associated with tumor growth causing excessive steroid production or tumor invasion causing symptoms of shortness of breath or pruritus.
Management of sleep disorder will start with pharmacist education of the patient based on cognitive behavioral therapy for insomnia.18 This includes advising the patient to restructure their negative thoughts and worry less about getting less sleep (Cognitive strategy). The patient can be advised by the pharmacist to have better control of their routine before sleep and can include: (a) avoid caffeine or alcohol before bedtime; (b) trying to exercise (just getting up and taking a few steps, yoga or swimming) a few hours before sleep; (c) Wind down activities towards the end of the day (Behavioral strategy). And finally the pharmacist can impart basic sleep hygiene education such as: (a) sleeping and waking up at regular times (this will be further helped by maintaining a sleep diary); (b) Creating a dark, cool comfortable sleep environment; (c) avoid watching television or netsurfing before bedtime; (d) Avoiding frequent naps during daytime. Also, it is very imperative that the pharmacist advices the patient to be compliant about taking prescribed sleeping medicine and pain relievers at the same time before bedtime.
The medications that are commonly used to promote sleep include the non-benzodiazepine benzodiazepine receptor agonist, benzodiazepines, melatonin receptor agonist, Anti-histamines, tricyclic antidepressants, second generation anti-depressant and antipsychotic. While dispensing these medications the pharmacist should make sure they counsel the patients regarding the risk of dependence, rebound insomnia when stopped and toxicity arising from mixing them with either alcohol or other sedatives In addition to these, the pharmacist can recommend dietary supplements that might help in sleep like melatonin, kava-kava, valerian or cannabis-based medicine nabiximols (Sativex). Unfortunately, nabiximols is only available for investigational use in United States and the evidence to use melatonin and other herbal supplements to alleviate insomnia is still inconclusive. The pharmacist can also encourage the patient to indulge in therapeutic massage which can not only help improve sleep but may also help reduce pain and anxiety. Also, pharmacist can recommend mind-body therapies like meditation, relaxation, yoga or tai chi to improve sleep quality. Usually the best response is to use a multimodal approach that uses both pharmacological and non-pharmacological management and the patient will benefit by the pharmacist educating them about both these avenues to help them sleep better.
Cancer-related anxiety in patients is the feeling of worry, fear and nervousness that is generally aggravated by stress.19 A pharmacist should be aware that anxiety can manifest in the patient any time during his diagnosis, treatment or relapse and thus should be very vigilant to observe for the signs and symptoms in patients. In addition to just a normal physiological response to cancer, anxiety can also be caused due to the cancer itself (central nervous system metastases, dyspnea associated with lung cancer) or due to medications like corticosteroids that are prescribed to the patient. As many as 44% of cancer patients have reported feeling anxiety, highlighting the prevalence and the need for better management. 20
A pharmacist can evaluate if a patient has low-level anxiety or high level anxiety by inquiring about the patients feeling of moodiness or stress (low-level) or feeling of doom (high-level). Also, if the patient complaints about trouble sleeping, feeling restlessness or having trouble sleeping (low level) as opposed to patients having chest pains, shortness of breath or heart palpitations (high level). Once the pharmacist has ascertained the severity of anxiety he should look at the patients’ medical history and prescription records. Medications like corticosteroids, bronchodilators, beta-adrenergic receptor stimulants and neuroleptic drugs can induce anxiety as their side effects. Also, withdrawal from opioids, benzodiazepines, barbiturates, nicotine and alcohol can cause agitation and anxiety in patients. Cancer like pheochromocytomas, pituitary micro-adenomas, non-hormone secreting pancreatic cancers and lung cancers can cause anxiety symptoms. In such situational cases, the pharmacist can recommend the oncologist to stop the medications or to prompt treatment of these side effects to alleviate anxiety.
When anxiety is not situational and of low-level severity, the pharmacist can encourage the patient to find support in the family (someone the patient trust), place of worship (to seek spiritual advice), cancer support group (share cancer-related stories) or the pharmacist can recommend a social worker in the community or cancer center. The pharmacist can encourage the patients to face their fears and to focus on things that make them feel happy. One of the most efficient way of relieving anxiety is by improving the quality of sleep (please see section on sleep aids) or by psychosocial interventions like hypnosis, meditation and progressive relaxation. For high-level severity, the above-mentioned interventions might be inadequate and the use of medication should be recommended by the pharmacist. The commonly prescribed medication for anxiety are short acting benzodiazepines, Intermediate acting benzodiazepines and long acting benzodiazepenes. The use of benzodiazepenes should be cautioned by pharmacist in patients with respiratory impairments. For long-term management of anxiety disorders drugs like fluoxetine, sertraline or venlafaxine should be considered.
The pharmacist, in general, should encourage patients to try both the pharmacological and non-pharmacological interventions to treat their anxiety. All pharmacological interventions need to be tapered down or discontinued once the symptoms have been resolved and before the patient gets addicted to the medication.
Nausea and Vomiting
The incidence of nausea and vomiting in patients with cancer receiving therapy is anywhere between the range of 30% to 90% and can result in a dramatic decrease in the quality of life accompanied by significant morbidity. 21 The general factors associated with the onset of nausea and vomiting can be the cancer itself (tumor growth in the gastrointestinal tract, liver, posterior fossa of the central nervous system), treatment (chemotherapy, opioids) or patient-related (poor history of control of emesis, history of motion sickness, history of chronic alcohol abuse, gender and age). Irrespective of the cause, nausea and vomiting can be classified into acute (emesis within 24 hrs of therapy); delayed (emesis after 24 hrs of therapy); anticipatory (occurs in response to conditioned stimulus); breakthrough (emesis occurs within 5 days of anti-emetics use) and refractory (does not respond to treatment).22
Pharmacists can use the rating system developed by The American Society of Clinical Oncology for chemotherapeutic drugs and their risk for acute and delayed emesis to prepare the patient before chemotherapy round. The high risk group (90% documented cases of emesis) contain carmustine, cisplatin, cyclophosphamide, dacarbazine, dactinomycin, mechlorethamine and stretozotocin; the moderate risk group (30 – 90% documented cases of emesis) contain alemtuzumab, azacitidine, bendamustine, carboplatin, clofarabine, cytarbine, daunorubicin, doxorubicin, epirubicin, idarubicin, ifosfamide, irinotecan and oxaliplatin; the low risk group (10 – 30% documented cases of emesis) contain bortezomib, cabazitaxel, etoposide, fluorouracil, gemcitabine, ixabepilone, methotrexate, mitomycin, mitoxantrone, paclitaxel, panitumumab, pemetrexed, temsirolimus, topotecan and trastuzumab; and, the minimal risk group (<10% documented cases of emesis) contain bevacizumab, bleomycin, busulfan, cetuximab, cladribine, fludarabine, pralatrexate, rituximab, vinblastine, vincristine and vinorelbine. On the day of the treatment, the pharmacist can encourage the patient to engage in deep breathing and meditation to relax. Pharmacist can ask the patients to keep a diary so that they can learn the best time to eat or not to eat before treatment depending on their previous experience. Also, when it comes to food and drinks, the pharmacists should counsel the patient to ingest nutrition that is easy on the stomach. For example, soups (clear broth of chicken, beef or vegetable), main meals ( broiled or baked chicken, rice cereals, crackers, pretzels, oatmeal, pasta or noodle, potatoes, white toast), fruits and sweets (bananas, peaches, pear, gelatin, yogurt) and drinks (tea, water, pedialyte, cranberry or grape juice). In addition, the pharmacist can recommend the patient to try acupuncture (if possible during or after treatment).
Pharmacological agents that are frequently prescribed to cancer patients are 5-hydroxytryptamine receptor antagonist (aprepitant) and dexamethasone combined with or without lorazepam. Pharmacists should encourage the patients to take antinausea medication as recommended even on days the patient is feeling well. Also, the patient can be counselled to stay away from greasy, fried, salty, or spicy food. Smell of hot food maybe bothersome and so the patient can be asked to let the food cool down before eating. And finally, instead of drinking and eating a lot of food in one siting, the pharmacist should counsel the patient to take small sips of water throughout the day and breakdown the meals into 5 to 6 portion during the whole day.
Given the stress that patients with cancer must overcome, pharmacists are in the best position to provide them with the required motivation and assist them in being compliant with their medication. Pharmacists can help search for accurate medical information about treatment options (conventional and supplementary) that are available for their patients. Pharmacists are in a position to identify problems like anxiety and address this issues by either recommending the appropriate intervention, or referring the patient to a counsellor or an oncologist for further treatment. Also, pharmacists are able to advise patients on their OTC medication or dietary supplements (herbal or conventional) that are very commonly used by cancer patients. In light of this, it is worthwhile to note that additional training provided to pharmacist to actively engage, explore and address the psychosocial issues in cancer patients would greatly improve the healthcare outcomes of these patients.
Written with Rajesh R Nair PhD, WVU Dept. of Microbiology and Chadrick Small, PharmD Candidate Charleston Wv School of Pharmacy
1. American Cancer Society. Cancer Facts & Figures 2016. Atlanta: American Cancer Society; 2016.
2. Smith RA, Andrews KS, Brooks D, Fedewa SA, et al. Cancer screening in the US: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians, 2017 Wiley Online Library, Accessed 3/1/2017
3. R. W .F. van Leeuwen, E. L. Swart, E. Boven, F. A. Boom, M. G. Schuitenmaker, J. G. Hugtenburg; Potential drug interactions in cancer therapy: a prevalence study using an advanced screening method. Ann Oncol. 2011; 22 (10): 2334-2341. doi: 10.1093/annonc/mdq761, accessed 3/1/2017
4. Hanigan, MH, dela Cruz, BL, Thompson, DM, Farmer, KC, Medina, PJ. Use of prescription and nonprescription medications and supplements by cancer patients during chemotherapy: questionnaire validation. J Onc Pharm Pract. 2008; 14(3), 123-130. Accessed 3/1/2017
5. Cleary J. Cancer Pain Management. Cancer Control, March/April, 2000, Vol 7, No 2. Accessed 05/05/2017
6. National Cancer Institute, https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq
7. Yanosik MA, WVU Cancer Institute, Mary Babb Randolph Cancer Center.
8. Shafi MA, Bresalier RS, The gastrointestinal complications of oncologic therapy. Gastroenterol Clin North Am. 2010. 39(3): p. 629-47.
9. Wadler S., et al., Recommended guidelines for the treatment of chemotherapy-induced diarrhea. J Clin Oncol. 1998. 16(9): p. 3169-78.
10. Mercadante S., Diarrhea in terminally ill patients: pathophysiology and treatment. J Pain Symptom Manage. 1995. 10(4):298-309.
11. Makrauer FL, et al, Does local irradiation affect gastric emptying in humans? Am J Med Sci. 1999. 317(1): p. 33-7.
12. De Petris G., Corominas Cishek A, Dzeletovic I. Severe diarrhea following bone marrow transplantation is not always caused by GVHD. Gastroenterology, 2014.146(7): p. e5-6.
13. Leung L, et al., Chronic constipation: an evidence-based review. J Am Board Fam Med. 2011. 24(4): p. 436-51.
14. Portenoy RK, Constipation in the cancer patient: causes and management. Med Clin North Am. 1987. 71(2): p. 303-11.
15. Beverley L. and Travis I. Constipation: proposed natural laxative mixtures. J Gerontol Nurs. 1992. 18(10): p. 5-12.
16. Gatti A. and A.F. Sabato, Management of opioid-induced constipation in cancer patients: focus on methylnaltrexone. Clin Drug Investig. 2012. 32(5): p. 293-301.
17 Vena C., et al., Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment. Oncol Nurs Forum. 2004. 31(4): p. 735-46.
18 Smith MT, et al., Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry, 2002. 159(1): p. 5-11.
19. Schag CA, Heinrich C. Anxiety in medical situations: adult cancer patients. J Clin Psychol. 1989. 45(1): p. 20-7.
20. Stark D, et al., Anxiety disorders in cancer patients: their nature, associations, and relation to quality of life. J Clin Oncol, 2002. 20(14): p. 3137-48.
21. Schwartzberg L., Addressing the value of novel therapies in chemotherapy-induced nausea and vomiting. Expert Rev Pharmacoecon Outcomes Res, 2014. 14(6): p. 825-34.
22. Kris MG, Urba SG, Schwartzberg LS. Clinical roundtable monograph. Treatment of chemotherapy-induced nausea and vomiting: a post-MASCC 2010 discussion. Clin Adv Hematol Oncol. 2011. 9(1):1-1.