Riding the cancer journey together

Cancer diagnoses can be quite intense on patients and their families. Due to the severity and urgency of this disease, we often find patients’ other chronic comorbidities being left unaddressed to the detriment of their quality of life. Advancements in cancer treatment mean we more often find patients being diagnosed on routine imaging/check-ups. They present as asymptomatic, so the diagnosis can come as a shock that tips the patient over the edge. In this blog, I want to discuss the pharmacist’s role as cement, preventing patients from slipping through the cracks of the healthcare system by focusing on cancer’s collateral damage—chronic disease management and non-cancer-related acute concerns. This is part of the real fallout from COVID-19 that too few are discussing. I want to provide you with practical advice/recommendations to implement as you care for your patients diagnosed with cancer and throughout their cancer journey. I want to take you with me on a ride. Let’s get started. Read: 'Next big wave': Radiation drugs track and kill cancer cells My focus as a healthcare provider and clinician for all of my patients is not just on being clinically sharp, but on providing them with information and education. Information is power. I’ve realized we are now in the “why” generation. People always ask questions and always want to know the why. Why is the sky blue? Why is it that our kids should not eat five chocolate bars, even though it is Halloween night? Why does the AstraZeneca COVID vaccine cause Vaccine Induced Immune Thrombocytopenia? Why is it that some people who smoke throughout their entire lives are cancer free and yet others who are extremely cautious about their health can be the most sick? Why is it that you are not able to take the burden of disease away from your loved ones and apply it to yourself so that you don’t have to see them suffer? Asking why is always good; the more questions we ask, the more informed we become and hopefully, the closer we get to the right answer. The word cancer carries so much weight. In fact, it was coined by the Greek “father of medicine,” Hippocrates, who coined the terms “carcinos” and “carcinoma” based on the finger-like spreading projections of cancer that reminded him of a crab. The Roman physician, Celsus, later translated the term to Latin, in which the word for crab is cancer. Cancer can feel like a dark cloud that has killed so many people, ruined so many families, and driven others into bankruptcy. Cancer is an entity from which one can foreshadow certain life events, so it is very important to act quickly; not just for the cancer, but holistically, for the entire patient. Read: QUIZ: Test your prostate cancer knowledge There are some real hands-on care pointers anyone can implement immediately. I want you to feel more comfortable and less afraid of the term “cancer.” I also want to focus more on the “why” than on the statistics. Stats help capture attention and highlight the problem, but by answering the “why,” we can learn more and remember experiences. Cancer is a subject we should be able to speak about comfortably, just as we speak about diabetes, hypertension, or any other chronic condition. Why are we so afraid of cancer? What differentiates cancer from diabetes or amputation or CABG (coronary artery bypass graft) or stroke or bipolar? Pick your poison… except you can’t. It is mostly a draw of the cards. To put things into perspective, here are the facts from the Canadian Cancer Society: Almost half of Canadians are expected to develop cancer during their lifetime 44% of men and 43% of women For context, of those currently reading this article, 1 in every 2 of us will likely develop cancer… almost half the readers. Let that sink in. 1 in 4 Canadians, or 25% of Canadians, is expected to die from cancer The top 4 types of cancers implicated that account for about 50% of all cancer cases are: lung, colorectal, breast, prostate. Cancer is the leading cause of death in Canada and Is responsible for 28.2% of all deaths, with heart disease in 2nd at 18.5% Cancer is neither rare nor unusual. When a patient presents to you in your pharmacy for a recommendation, for treatment, for advice, and does so repeatedly and for the same issue, this should be a red flag for you. You should slow down and start thinking about other potential causes and refer the patient as necessary. Don’t brush patients off. And don’t allow patients to brush themselves off and ignore the messages their body is telling them. And don’t give up. Let me give you an example: Read: Canada's breast cancer screening policy based off flawed study: researchers Patient case scenario: 61-year old female. Medical history consists of diabetes, asthma, GERD, dyslipidemia, sarcoidosis. She is on Metformin 1g po BID, Linagliptin 5mg po daily, Dapagliflozin 10mg po daily, Gliclazide MR 30mg po daily prn with supper for elevated sugars, Budesonide/Formoterol 200mcg, 2 inhalations BID, Tiotropium 2.5mcg, 2 inhalations daily, Esomprazole 40mg po daily, and Pravastatin 20mg po daily. She presents to you requesting you liaise with her GP regarding intolerable vasomotor symptoms associated with menopause: hot flashes, night sweats, heat intolerance, irritable mood. Upon questioning to assess what is best for the patient, you ask about breast cancer history. She reports her mother was diagnosed with breast cancer and passed away from it. RED FLAG. STOP. Option 1: You tell her she is not a candidate for hormone therapy. You suggest non-hormonal therapy to her doc with Escitalopram 10mg po qhs. She starts it, and symptoms improve after 2 weeks. Rewind…. Option 2. Option 2: You tell her she is not a candidate for hormone therapy. You suggest non-hormonal therapy to her doc with Escitalopram 10mg po qhs. You tell her you’ll send it to the GP as a recommendation. You ask more about the breast cancer history. You ask if she gets annual mammograms, since she is deemed high risk with her positive family history and her mother diagnosed at less than 50 years old. She says that the breast cancer screening program at the hospital always sends her letters at home telling her to get a mammogram. She knows she has cysts and has breast pain sometimes but she’s fed up with it. Every time she gets the mammogram, it reminds her of her mom, and it increases her anxiety so much that she just ignores it. She says she’s 61 and it doesn’t matter. You firmly advise her to get tested, for peace of mind, and explain that, even if (God forbid) she’s diagnosed with breast cancer, if detected early, there is almost a 100% chance of survival at five years. If diagnosis is delayed due to delayed screening, the chance of survival at five years declines to 20%. Pick your poison. Ignorance is NOT bliss. It is always better to find out early, no matter how stressful. Read: Managing skin toxicities caused by immune checkpoint inhibitor cancer treatments She reluctantly agrees and goes home to book a mammogram assessment. Two weeks later, she comes to the pharmacy and yells at you. Now they are referring her for an MRI and breast biopsy because something looks suspicious. She doesn’t want to do the MRI because she’s claustrophobic so she refused against the MD’s advice. You reassure her that you will send a recommendation to the family doc for a medication to calm her nerves the night before, the day of and during the MRI. You also remind her again of the benefit of early detection, and of how her family needs her. Three weeks later, after an MRI, three ultrasounds, two mammograms, and multiple biopsies, she’s been given the diagnosis of invasive lobular carcinoma in situ, with multifocal disease. In other words, she’s been diagnosed with invasive breast cancer. She undergoes an urgent left total mastectomy of the left breast... This is why we do our jobs. This is why we have to be the patient’s advocate. They don’t know what they don’t know. You can literally save lives! Information is knowledge… and knowledge is power. Never forget ***Early cancer detection and screening saves lives. Early cancer detection and screening saves lives. Early cancer detection and screening saves lives. Cancer can spread fast.*** NOTE: If you are a female reading this and are 50 years of age or older, and have not had a mammogram in the last two years, I urge you to go and get one done. At least in the province of Ontario, patients can self-refer. I know that different provinces have varying breast cancer screening thresholds and cut offs (e.,g, in Ontario the age is 50, but B.C. starts screening at age 40). Regardless, please refer to your local and regional screening guidelines for details, and get screened. Read: Antihistamines improve response to immunotherapy in cancer patients The pharmacist as cementWhen someone presents to the pharmacy with a new script or tells you of a new cancer diagnosis, pull down your mask, stop typing or documenting and look them straight in the eye. Go into an office if necessary. If a family member of a patient who is diagnosed with cancer presents to the pharmacy, ask the family member “how are YOU doing in all of this?” A diagnosis of cancer is a lifelong journey for a patient AND their family; it changes their collective lives forever. Part of collateral damage from cancer is that when the individual is diagnosed, responsibilities shift and it affects everyone else in their circle. When a serious diagnosis is delivered, it doesn’t mean we neglect the rest of the body. In my religion, in Islam, there is a quote from Prophet Muhammad that says, referring to an entire nation or community, “when one part of the body suffers, the entire body feels the pain. Therefore, when a fellow human being is suffering, we should all be suffering and help them.” A similar concept applies with our bodies. Our role as community pharmacists should be in focusing on this collateral damage from cancer diagnoses. Each step of the way, we have a role to play. When a patient presents with symptoms of unknown cause or is undergoing testing, our role is to aid in the early detection and discovery by timely referrals, patient education, advocacy and symptom management. When a patient is nervously and anxiously waiting for test results, they get carried away and neglect their other chronic/acute medical conditions. For example: Mental health can be affected (anxiety, depression, social isolation, sleep disorders, decreased appetite). As pharmacists, we can make recommendations or (depending on where you practice) initiate drug therapy for anxiety/depression or sleep disorders or refer for CBT, or counseling. The type of antidepressant or anti-anxiety med you choose should be based on each patient’s main collateral damage complaints (e.g. are they experiencing low energy, insomnia, decreased appetite? These factors will change the type of drug therapy recommended/initiated). Read: Rule out cervical cancer with the HPV detection test For example: Mental health can be affected (anxiety, depression, social isolation, sleep disorders, decreased appetite). As a pharmacist, we can make recommendations or, depending on where you practice, initiate drug therapy for anxiety/depression or sleep disorders or refer for CBT, or counseling. The type of antidepressant or anti-anxiety med you choose should be based on each patient’s main collateral damage complaints (e.g. are they experiencing low energy, insomnia, decreased appetite? These factors will change the type of drug therapy recommended/initiated) Patients will have increased stress, which can mean: • increased cortisol levels leading to increased blood sugars in patients with diabetes, which can lead to diabetes complications • increased blood pressure in hypertensive patients leading to increased headaches, chest pain, exercise intolerance, fatigue • increased chronic pain because of stress and not in the mood to exercise or go out • worsening of psoriasis, irritable bowel, acne •obesity due to stress eating • worsening of GERD • QoL: days missed from school, work, life events All of these are ideal areas where a pharmacist can intervene. In fact, the healthcare system tends to forget about the factors listed above, so it is our duty to focus on the patient holistically and ensure that, just because one body part is in agony, that doesn’t mean we let go of everything else. Remind patients that the better their other conditions are treated and controlled, the lower risk of complications post-op, which makes their cancer journey easier. Read: Older breast cancer patients not getting as much care as younger patients Martin Luther King Jr said “If you can't fly, then run, if you can't run then walk, if you can't walk then crawl, but whatever you do, you have to keep moving forward.” Patients with cancer have to keep moving forward. And we have to remind them of this. That means calling them to check in on them and ensure they are adherent with their meds. If they are overwhelmed or forgetful, initiate blister/compliance packaging. Have an open dialogue with their primary care provider. Here are some key take-away points I hope you can implement in your practices, effective immediately. Be human. People don’t just remember what you said but more importantly, they remember how you made them feel Tell patients to be their own advocates and fight with them every step of the way Ask patients’ caregivers how they are doing, too—cancer affects everyone When counseling patients with cancer, ask direct questions, very much as you would when gathering patient history information. Instead of asking: “Is everything ok?” ask: “Are you having any anxiety (or pain or difficulty sleeping, sugar levels, BP readings, etc.)?” Focus on the collateral damage associated with cancer— chronic disease management and acute non-cancer related complaints This is the COVID fallout that no one discusses in the news: the deterioration of chronic diseases, their lack of management and a delay in important diagnoses, which may in turn lead to more severe complications down the road. Remember, Cancer is NEVER expected. As pharmacists, we can be the cement that prevents patients from slipping through the cracks in the healthcare system.

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Riding the cancer journey together

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Samier Kamar