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

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.

Case

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 BRCA-positive.

Brown Bag Consult®

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:

• atorvastatin 20 mg daily
• ondansetron ODT 4 mg as needed (filled at cancer clinic pharmacy)
• alprazolam 0.5 mg as needed
• OTC acetaminophen 500 mg as needed
• OTC ibuprofen 200 mg as needed
• OTC loperamide as needed
• 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)

Your pharmacy profile:

• atorvastatin 20 mg daily
• alprazolam 0.5 mg as needed
• atenolol 25 mg daily
• hydrocodone bitartrate-acetaminophen 5/325 mg every 4-6 hours as needed for pain
• ibuprofen 600 mg twice daily
• sertraline 50 mg daily
• zolpidem 5 mg at bedtime as needed
• olaparib 300 mg twice daily

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.

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