Brown Bag Consult: Supporting a Patient's Fight Against Nonresectable Metastatic Head, Neck Cancer

Patients with cancer should not be overlooked in any pharmacy setting. These patients are in need of resources, help, and hope. They endure a grueling process of coping with their diagnosis, treatment, changes in treatment, and, in cases of recovery, the fear of recurrence. All these stages can affect patients emotionally and physically.

Patient GV, aged 65 years, has been in disbelief since receiving his diagnosis, and his wife has been overwhelmed with the diagnosis and the frequency of doctor visits. On top of this, GV had planned on retiring from work at the end of the year because his daughter and son-in-law are expecting a baby—GV has been really looking forward to being a grandparent.

GV confides in you that he feels very depressed and is upset the cancer was not caught earlier. Over a year ago, he started having symptoms and thought his persistent sore throat was due to COVID-19. He was tested for COVID-19 multiple times, and all tests came back negative.

Gradually, GV’s symptoms became more painful and uncomfortable, making it hard to eat solid food and to talk at times. Once COVID-19 precautions had been lightened in GV’s area and he was fully vaccinated, he started making routine health care appointments again.

As he began to make these appointments, he noticed his gums were sore around his teeth where he had had dental work done in the past. His wife told him he had bad breath, which was unusual given his regular oral hygiene. The dentist was the first on his call list.

You sympathize with GV after hearing about his situation. You explain that you and his providers are always there to help and answer questions at each step of his illness. GV appreciates your listening and presents a new list of medications and his current laboratory data. He explains that he just left the clinic and that these are his most up-to-date documents.

You look through the papers and notice a medication reconciliation performed by the oncology clinic pharmacist. You review it against GV’s profile at your pharmacy and notice multiple changes.

As you conduct your review, you see the concern and confusion in GV’s face. Upon seeing this, you explain the concept of pharmacy brown bag and medication therapy management sessions and ask whether he would be interested. GV is relieved. He tells you he would like to receive this type of support and will bring his wife and his medications along with him for the session the following day to get your advice. You suggest GV visit around 2 pm; it’s a slower time in your pharmacy and will allow you to provide the best service and care possible.

Brown Bag Consult

The next day, GV and his wife are waiting in your consultation area. Having done your homework, you have filled GV’s new medications, reviewed discontinued medications, opened his medication profile, and accessed his laboratory data and medication reconciliation.

You compare what is in GV’s brown bag with your information:

• Atorvastatin 40 mg daily
• Metoprolol 50 mg twice daily
• Niacin as dietary supplement
• OTC Cepacol lozenge as needed
• OTC ibuprofen pm as needed
• OTC Chloraseptic spray as needed
• OTC omeprazole 20 mg daily
• OTC acetaminophen 500 mg as needed

Your updated pharmacy profile inclues:

• Ondansetron ODT 4 mg as needed
• Atorvastatin 10 mg daily
• Atenolol 25 mg daily
• Lorazepam 0.5 mg as needed
• Duloxetine 30 mg once daily for one week, then 60 mg daily

During the consult, GV and his wife mention that they appreciate your time. Because his wife helps with GV’s medical care and general well-being, she shares some of her concerns with you.

She admits that GV is still smoking. He is not happy about his wife mentioning this and defensively says he is only smoking cigars. You explain the negative impact of smoking and offer help if and when he is ready to quit smoking. You also explain that smoking will not help his blood pressure or cancer diagnosis, so it may be time to prioritize trying to quit.

GV tries to change the subject and talks to you about eating. His throat hurts and the pain often prevents him from eating despite his strong appetite. He admits using many OTC sore throat medications, knowing they offer only temporary relief. Using them has almost become a bad habit, and GV feels dependent on them despite knowing that his cancer is causing the issue.

You acknowledge the OTC throat medications and suggest GV allow you to follow up about pain management options that may be more effective. GV has lost weight and wants to prevent a dramatic weight loss once he starts chemotherapy and radiation next week. You show him and his wife various protein shakes, ones that other patients have told you taste good, and recommend those for the time being.

You offer to help GV follow up with a nutrition expert so they can help his wife with a plan because she manages the household shopping and cooking. You also mention the new antinausea medication GV has been prescribed and describe how to use it under the tongue, which may help him increase his calorie intake. GV thinks this will be helpful because he has trouble swallowing a lot of pills.

You let GV know that once he starts chemotherapy, a lot may change very quickly as his body adjusts to new medications and fights the cancer. GV understands and tells you that his wife will update you if he needs further help.

You mention the new antidepressant and anxiety medications he has been prescribed. GV hates that he must take these but understands he will need help with his mood and spirit during the fight against his cancer. You encourage him to monitor how he feels and to stay positive as much as possible.

You mention that although you know it is hard, even small amounts of exercise can elevate his mood. Reading, stretching, and time with family can all be very helpful in bringing joy to his life, you add.

The goal of a brown bag session is to discover discrepancies. The information that comes out of the session can allow you to make a number of short-term and long-term suggestions, while also supporting improved communication between GV and his multiple providers. Overall, this may improve GV’s quality of life and reduce unnecessary doctor calls or visits.

GV is willing to have you act as a community liaison between him and his providers. The first step is to follow up with his providers to make them aware of your brown bag session discoveries and the suggestions you have regarding GV’s plan of care. Time will be your most challenging factor and you will need to find a way to incorporate these complex clinical opportunities into your workflow. Loyalty and patient satisfaction are priceless and worth the energy to help GV.

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