Primary care of cancer patients: A pharmacy student’s perspective

The impending wave of an aging population has been referred to time and time again in pharmacy classrooms across Canada. However, this is usually in terms of the predicted increase in patients who will require regular pharmacy services. There are many other implications regarding the aging population in Canada, including the increasing incidence of age-related diseases, such as cancer. Cancer is the leading cause of death in Canada, and approximately 89% of Canadians who are diagnosed with cancer are 50 years of age or older.¹ Although mortality rates have been declining since 1988, this means that there are more Canadians living with cancer today than ever before.^1,2 Preventative measures, such as smoking cessation, screening, targeted therapy and oral chemotherapy agents, have transformed the treatment of cancer from an acute to a chronic disease. As a pharmacy student, I have asked myself where pharmacists fit in the care of those living with cancer.

In community pharmacies, prescriptions for conditions such as diabetes, hypertension and hypothyroidism are commonly dispensed. Counselling and follow-up care for these conditions are second nature to the majority of pharmacists and pharmacy students. However, when faced with a prescription for an antineoplastic agent, I have found myself, and members of the pharmacy team, to be more hesitant and even uncomfortable at times. A Canadian study has found that only 13% of community pharmacists feel that they are adequately prepared to provide care to cancer patients.³ The findings of this study echoed my experience in community pharmacies. Typically, when presented with a prescription for an anticancer agent, a stream of questions would flow through my mind: Do we keep this drug in stock? What’s the usual dose? That depends on the type of cancer and protocol . . . right? What are the relevant toxicities to counsel on? Should I go in-depth, or maybe their oncologist already discussed all of this? This hesitancy in providing care is not solely due to a gap in knowledge in oncology. It is also a consequence of the feeling of uncertainty that many pharmacists in community settings face with regards to their role in caring for cancer patients.

During one of my experiential rotations, I had the opportunity to participate at a regional cancer centre where there was a pharmacist-led counselling service for patients receiving oral chemotherapy agents. The pharmacist-led program provided initial and follow-up counselling for patients and their caregivers, assessment of possible barriers to adherence (e.g., tablet size, cost and insurance), communication with the community pharmacy to ensure supply, assessing for common toxicities, recommending appropriate use of supportive medications and more. Through these interactions, trust was formed, which fostered a therapeutic relationship between patients and the pharmacy team. The experience was humbling, because I was also able to learn from patients and caregivers about what is meaningful to them with regards to their care and ways they have found to cope with side effects from past treatments. At the end of my rotation, I strongly believed that the follow-up component of this program, assessing for common toxicities and providing recommendations or referrals as needed, could be easily implemented in community pharmacies.

There are many tools available to aid pharmacists in community settings who care for cancer patients. For example, guidelines for outpatient cancer care were recently created by community pharmacists.⁴ These practice guidelines provide a set of drug-specific tools to support community pharmacist activities in caring for cancer patients, such as counselling, managing adverse effects, identifying drug interactions and documentation.⁴ In addition, AntiC is a website and mobile application that was created by community and hospital pharmacists to provide short monographs on common oral chemotherapeutic agents. It also risk stratifies the available agents in Canada.⁵ Both the BC Cancer Agency and Cancer Care Ontario have websites and mobile applications that provide in-depth knowledge for health care professionals and general information for patients.^6,7

I believe that community pharmacists have a unique role to provide primary care to cancer patients on oral chemotherapy medications. Pharmacists in the community are often the first point of contact when patients seek out treatment for minor conditions, such as fevers. However, a fever reported by a patient on oral chemotherapy medication may be a sign of an underlying disease process (i.e., febrile neutropenia) requiring referral to an acute care facility. This may not be apparent to the patient, which is why appropriate intervention by a pharmacist could help prevent the emergence of a life-threatening complication. There are many resources available for pharmacists that are beneficial in tailoring counselling sessions, documentation and identifying pertinent drug interactions.^3–5 As new therapies emerge and more patients move from intravenous treatments to prescriptions for oral agents, pharmacists in the community have a duty as primary care providers to provide comprehensive care to cancer patients. ■