Brown Bag Consult®: Breast Cancer Risks and the Pharmacist’s Role

Affecting both male and female individuals, breast cancer is one of the most common types of cancer in the United States. The importance of early detection tools cannot be overemphasized, nor can proper self-screening and mammograms, which play a critical role in helping to prevent deaths from breast cancer.

However, eligible patients may not be screened for several reasons, very often because no one simply suggests a screening. Moreover, certain populations may not have health insurance or access to regular health care, may not be aware of the importance of screenings, or may not realize they are at risk.

As such, pharmacists should communicate the universal message that breast cancer screenings save lives. Often regarded as the most trusted and accessible health care professionals within the community, pharmacists have a unique opportunity to help patients by suggesting breast cancer screenings and follow-up care for those found to be at elevated risk. In addition, they can not only point patients to educational and financial resources but also help relieve anxiety related to the screening process or possible detection and diagnosis.

Pharmacists can also refer patients to qualified health care providers for follow-up care, act as a direct resource, and serve as a prescriber-patient liaison. Finally, collaboration among pharmacists and other health-system health care providers is critical for the holistic care of the patient.

Brown Bag Consult^®: A Case Study in Reducing Breast Cancer Risk in Your Patient Population

Editor’s note: Case is not based on an actual patient.

EM is a 54-year-old woman who came into the pharmacy and mentioned that she found a lump after a recommended breast self-exam. She has no consistent primary care provider other than various nurse practitioners and specialists, whom she sees at the local clinic for other conditions. However, EM adds that she does not feel as if she has trusting relationships with any of those providers.

After some calls, you are able to provide EM with the name of a nearby primary care provider who in turn refers her to an oncologist and a surgeon. EM’s medical history is unremarkable, and she has no family history of cancer in first-degree relatives. A physical exam reveals that EM has a nonfixed mass in the left inferior breast without skin changes or nipple discharge and palpable lymphadenopathy in the left axilla.

A mammogram confirms a left-sided, poorly defined spiculated mass. EM’s ultrasound shows a 5.3-cm solid mass and enlargement of 2 left axillary nodes with thickened cortex.

EM receives a core needle biopsy from the breast mass that confirms grade 3 invasive ductal carcinoma. Her new care team charts the following results:

• Estrogen receptor negative; progesterone receptor negative; HER2 immunohistochemistry, 3+
• Fluorescence in situ hybridization, HER2 copy number 15; HER2:CEP17 ratio, 7
• Fine-needle aspiration of 1 left axillary lymph node is positive for carcinoma.
• Staging: T2bN1M0

Because EM has been coming to your pharmacy for the past 10 years, you have a patient-pharmacist relationship with her. She stops in to follow up with you and share her HER2-positive breast cancer diagnosis. EM thanks you for encouraging her to be proactive about screenings.

You know EM suffers from multiple other disease states and has always had trouble with medication adherence and management. You notice that she seems negative about her upcoming surgery and therapy. EM is worried about the financial implication of her disease state and mentions her stress and lack of support regarding her condition.

You ask EM whether she would be interested in participating in a brown bag consult and tell her that you are interested in reviewing all her medications and lifestyle choices before she undergoes cancer treatment. This will allow you both the opportunity to talk, share concerns, and ideally maximize EM’s medications. The consult may also lead to a positive financial impact and allow EM to feel as if she has a fresh start when it comes to her health.

What’s more, the opportunity to review EM’s medication list and adherence will let you make sure all her providers are aware of her new cancer diagnosis so that she will have a wider support system for any adverse effect management, medication holds, or dose adjustments. EM nods and appreciates the opportunity to talk with you in depth.

Upon reviewing EM’s medication profile at your pharmacy, you find the following:

• Metformin, 1000 mg twice daily
• Furosemide, 80 mg daily
• Enalapril, 10 mg daily
• Fluoxetine, 20 mg daily
• Polyethylene glycol—electrolytes solution, on hold
• Atorvastatin, 40 mg daily

When EM comes in for her scheduled appointment, you notice the following additional medications in her brown bag:

• OTC daily multivitamin
• Used insulin (insulin + insulin glargine) vials, expired July 2019, unlabeled
• Adalimumab, 40 mg subcutaneous every other week, filled by mail-order specialty pharmacy

After reviewing EM’s medications, you realize she would benefit from a medication therapy management (MTM) session and schedule a follow-up appointment. An MTM session will allow you to further communicate with EM’s health care providers, obtain lab values, and further evaluate her medical goals, particularly those related to her breast cancer treatment and care plan.

EM has questions about HER2-positive breast disease. You briefly describe some of the various breast cancer types. EM explains that one of her friends with breast cancer just takes a pill, and EM asks whether she can do that as well. You explain that along with the various breast cancer types come different treatment options that are not interchangeable.

EM is confused about targeted therapies. You discuss the difference between standard oncology therapies and targeted therapies, which offers EM some comfort. You review some of the treatment options her oncologist may discuss and offer to call her oncologist to obtain additional resources and educational support. EM will follow up with you after her surgery with her treatment care plan.

Questions to Consider

• What treatment do you expect EM to receive for her HER2-positive breast cancer diagnosis?
• What kind of supportive care will EM need?
• EM is concerned about the financial impact of her treatment and other chronic conditions. How can you address cost when looking at her current and anticipated medications?
• What hypothetical care plan would you offer EM at 3, 6, and 12 months?

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