Brown Bag Consult®: Breast Cancer and Additional Stressors

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.

The Case

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.

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.

Brown Bag Consult®

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
• metoprolol 25 mg, twice daily
• ondansetron 4 mg, as needed
• alprazolam 0.5 mg, as needed
• OTC acetaminophen 500 mg, as needed • OTC loperamide, as needed
• duloxetine 60 mg, daily
• letrozole 2.5 mg, daily

Your pharmacy profile shows the following:

• atorvastatin 40 mg, daily
• aspirin 81 mg, EC, daily
• atenolol 25 mg, daily
• ibuprofen 600 mg, twice daily as needed
• letrozole 2.5 mg, daily
• 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?

Jill Drury, PharmD, BCOP, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.