Stakeholder’s Perspective: Pharmacy

The diagnosis of cancer is arguably one of the most emotionally exhausting and potentially psychologically debilitating medical conditions we may experience during our lifetime. However, the impact of this diagnosis is not limited to the patient and frequently resonates among family members, friends, and caregivers as well. When the impact of cancer on the human condition is combined with the knowledge that healthcare practitioners are frequently unable to detect psychological distress in this patient population, the effects can be profound.¹

In the accompanying article, Dr Hansen notes that diagnosed psychological conditions, especially depression, are commonplace in oncology, with at least 50% of cancer patients and 10% of caregivers affected at some point during the illness. This psychological distress has a clear impact on quality of life and may ultimately compromise the patient’s ability or motivation to continue cancer-related therapy by impacting fatigue, pain management, loss of mobility, increased dependence on others, etc.² In our practice, one of the issues we preemptively address with good success is anxiety related to chemotherapyinduced nausea and vomiting (CINV).

Some sources have described CINV as the most bothersome adverse effect associated with chemotherapy and one experienced by a majority of cancer patients.³ Inevitably, patients are familiar with the concept of CINV even before discussion of chemotherapy is initiated, often due to the widespread availability of information on the Internet or from personal anecdotes relayed by friends or family members treated for cancer prior to the current generation of antiemetic therapies. The resulting anxiety associated with a patient’s expectation of nausea can be quite significant. In fact, this hypothesis was evaluated in a 2004 study published in the journal Cancer that demonstrated that patients who believed CINV would be a major problem were up to 5 times more likely to experience severe nausea than those patients who believed it was “very unlikely.”⁴ Thus, recognition of a patient’s concerns with regard to CINV is important as we strive to ensure effective information delivery (also noted by Dr Hansen to be a potential challenge to cancer patients) to alleviate these concerns. For this reason, significant time is dedicated to education of our patients on the prophylaxis of CINV, availability of PRN antiemetics, patient reporting of severe CINV, and an understanding that additional prophylaxis of CINV may be considered with future cycles of chemotherapy. As a result, over the past several years the incidence of anxiety related to CINV has been greatly diminished in our practice.

Appropriate education and improved communication methods are obviously not the sole method of remedying patient problems with regard to the psychosocial issues associated with cancer but may contribute to the enhancement of psycho-oncology services provided in cancer centers. Much as our global attention to cancer screening and prevention has become an important focus in the war against cancer, so too perhaps should we focus on ensuring that patients are well educated regarding cancer therapies and potential complications and more closely monitored for psychological symptoms that require immediate intervention.

References

1. Newell S, Sanson-Fisher RW, Girgis A, et al. How well do medical oncologists’ perceptions reflect their patients’ reported physical and psychosocial problems? Data from a survey of five oncologists. Cancer. 1998;83:1640-1651.
2. Ryan DA, Gallagher P, Wright S, et al. Sensitivity and specificity of the Distress Thermometer and a two-item depression screen (Patient Health Questionnaire- 2) with a ‘help’ question for psychological distress and psychiatric morbidity in patients with advanced cancer [published online ahead of print September 15, 2011]. Psychooncology.
3. Akechi T, Okuyama T, Endo C, et al. Anticipatory nausea among ambulatory cancer patients undergoing chemotherapy: prevalence, associated factors, and impact on quality of life. Cancer Sci. 2010;101:2596-2600.
4. Roscoe J, Bushunow P, Morrow G, et al. Patient expectation is a strong predictor of severe nausea after chemotherapy: a University of Rochester Community Clinical Oncology Program study of patients with breast carcinoma. Cancer. 2004;101:2701-2708.