Brown Bag Consult®: Colorectal Cancer Risks 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.

THE CASE

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
• fluoxetine (Prozac), 20 mg/d
• polyethylene glycol and electrolyte solution (CoLyte; Pendopharm G.I. Solutions), on hold
• atorvastatin (Lipitor; Pfizer), 40 mg/d
• 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:

• OTC multivitamin daily
• 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?

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