Early career pharmacist and cancer survivor Jessica Chapman-Goetz is determined to inspire fellow pharmacists to provide supportive oncology care
It was a sunny summer’s day in December 2015 and Jessica Chapman-Goetz was brimming with excitement at becoming a fully registered pharmacist … but it was at such a momentous moment that she also received a shocking diagnosis.
“It started out to be an excellent day. After four years at university and an intern year, I was finally a registered pharmacist,” Jessica tells AJP.
However she explains that a month prior, she found a lump in her right breast during a routine self-examination.
“Being a health care professional, I firmly believe in practising what I preach so breast checks and pap smears are routine. Lumpy breasts are not uncommon in young women and I was due to go overseas, so I decided to see my GP once I returned,” said Jessica.
“When I saw my GP towards the end of November she immediately sent me for an ultrasound and biopsy. I was optimistic it was nothing.”
The results came back inconclusive and further investigation including a mammogram and core biopsy was required.
But Jessica was optimistic. After all, she didn’t have strong family history.
“Around mid-morning on the day that started so well, I got a call from my breast surgeon asking me to see him that afternoon.
“It was in his rooms that I heard the words ‘you have breast cancer’. It felt just like a scene from a Hollywood movie.
“To this day I can’t describe how it feels to hear those words. Suddenly my world was upside down.”
It was confirmed that she had stage 1 grade 3 invasive ductal carcinoma, which was HER2, estrogen and progesterone receptor positive.
Following her diagnosis, Jessica went through an arduous treatment process that included surgery and chemotherapy.
Initially she had a lumpectomy and sentinel node removal, followed by six months of chemotherapy and 12 months of trastuzumab (Herceptin).
During her treatment she continued to work full-time as pharmacist-in-charge at Terrywhite Chemmart Grange, where she had completed her internship.
Jessica says that her somewhat public cancer journey allowed customers to share their own experiences, and for those who also had cancer to come to her for advice and support.
Her boss Mario Faraone and coworkers were “wonderful” during this time, she says.
“I’ll never forget their demonstration of support by wearing head scarves on my first day of [work] following complete hair loss.”
“This relieved my fears around the new appearance and shared the task of discussing my journey with our regular customers – of whom there were many. I am so grateful to have had them as my ‘pharmily’.
“My cancer journey being so public gave customers the courage to talk about their experiences.
“It was touching to be given that trust and rewarding to breakdown the stigma associated with cancer. The oncology unit nearby kindly referred women to me and this allowed discussion around management of chemotherapy adverse effects including headwear for alopecia.
“It was during this time I realised that community pharmacists can have an integral role in providing supportive care to oncology patients.”
She has now completed most of her treatment, although she continues to have ongoing hormone treatment with tamoxifen.
“Whilst the journey was unbelievably hard, I had incredibly positive experiences that have shaped who I am as a cancer survivor.
“I’ll never forget sitting on the beach the evening [of my diagnosis] on a stunning summer’s day, in disbelief at how my world was changed forever, yet everything around me was unaffected.
“Children still laughed and played, seagulls still flew and the sun still set. I made a promise to myself to try and not let cancer change who I was or define my life.
“This was wishful thinking as inevitably cancer affected every aspect of my life. It affects you physically through surgery and chemotherapy. It affects you mentally. It affects your ability to work. It affects your relationships. It affects your identity and security in the future.
“Cancer indeed changed everything, but I have come out more positive, enthusiastic and passionate than ever. Not only for pharmacy but for life in general.”
Following her work in community pharmacy, Jessica has now transitioned to hospital pharmacy, and currently works at Flinders Medical Centre—Adelaide’s largest Southern hospital.
She continues to be passionate about raising awareness on the role of pharmacists in providing supportive oncology care, including advice on oral chemotherapy and management of common adverse effects.
An active member of the Early Careers Pharmacists Working Group within the SA/NT branch of the PSA, she has utilised this role to undertake professional development sessions on oncology care.
Jessica encourages pharmacists to provide supportive care to oncology patients and breakdown the stigmas associated with cancer.
She says that this will cement pharmacists as vital members of the allied health team.
“Most importantly this will improve patient quality of life, which has enormous impact on such a difficult journey.”
Here she shares some advice to AJP readers on how pharmacists can provide this support.
What are some strategies for safe and effective use of oral chemotherapy?
Oral chemotherapy regimens create the potential for error as dosing can be intermittent or continuous. Even for the same medication, the dosing schedule can vary based on indication.
The use of intermittent dosing has the risk of patients not taking the required rest period from therapy.
- Good practice is to put start and stop dates on the dispensing label of the medication, and provide a supply quantity that is equal to the cycle length.
- Consider potential use of dose calendars or reminders, including electronic means such as alerts in mobile phones or apps.
- Counselling at the initial supply and follow-up with each subsequent dispensing should occur to ensure the patient is taking the oral chemotherapy agent appropriately.
Oral chemotherapy drug absorption rates often vary based on food intake. Changes in how a patient takes their medication can significantly impact efficacy by reducing absorption or toxicity by increasing absorption.
Food may alter absorption rates differently for each drug and most studies default to the fasting state, hence this is the most common recommendation.
When counselling patients we need to take into consideration how complex the administration regimen is:
- For example, as per the consumer medication information leaflet: nilotinib (Tasigna®) should be taken in the morning and evening, about 12 hours apart. It must not be taken with food. Take nilotinib at least 2 hours after eating. Do not eat for at least 1 hour after taking it. This will help you absorb the right amount of medicine to effectively treat your condition.
- A patient’s day might look a bit like this:
- 7am: wake up and take the 1st dose of Tasigna
- 8am: breakfast
- Usual daily activities
- 5pm: begin fasting in preparation for the next dose of Tasigna
- 7pm: take the 2nd dose of Tasigna
- 8pm: dinner
- Medication adherence may be compromised if the patient has plans which don’t fit the administration schedule – for instance dinner with friends/family/colleagues at 6pm. The practicality of a regimen should be an integral part of counselling. The patient should be informed that there is some flexibility with dosing as long as no food is consumed for 2 hours pre and 1 hour post each dose of nilotinib because food increases the absorption and therefore risk of toxicity.
“Improved adherence” is a misconception with oral chemotherapy. The elderly may be susceptible to non-adherence due to comorbidities, polypharmacy, poor cognition and lack of home support. The young may have poor insight, other priorities and a lack of social support. Social demographics may impact due to education level, low SES and poor psychological state. The possible consequences of non-adherence include: loss of effect, possible shorter time to relapse and poorer quality of life.
Possible interventions to improve adherence include:
- Identifying the degree of adherence by asking about barriers.
- Using non-confrontational language and keeping communication lines open.
- At every pharmacy/clinic/hospital visit: Offer literature on SEs, refer the patient to support groups, websites and disease-specific organizations without overloading them.
- Involve the multi-d team and reiterate to patient that they have a ‘team’ behind them..
- Address costs: Use available assistance programs, refer to a social worker for access assistance.
- Check if repeats are being filled on time.
- Encourage tools to assist with adherence such as medication packing, apps such as MedAdvisor, alarms / calendars and establishing a daily routine.
What are the most common side effects of chemotherapy and how can pharmacists can help patients manage these?
Chemotherapy adverse effects will vary according to the agent/s being used. However, the common side effects that I have been discussing with potential for management in community pharmacy include mucositis, diarrhea and skin toxicities. Nausea and vomiting is also common with chemotherapy as is alopecia with some agents.
The incidence of diarrhoea is about 60% with oral chemotherapy. It is frequent with tyrosine kinase inhibitors (TKIs) like imatinib. It may be cumulative with other agents and can be dose-limiting.
Non-pharmacological management involves avoidance of foods that cause/aggravate diarrhoea. For instance, dairy, spicy food, alcohol, caffeine and fat. Also, it is important to avoid drugs that induce diarrhoea. For instance, drugs with prokinetic effects like erythromycin and metoclopramide. Laxatives are another obvious example. Oral rehydration is vital. 8 to 10 large glasses of clear liquids per day is suggested. This can be water, sports drinks, clear juices or broth) or patients may prefer to carry a water bottle and sip throughout the day. Educating patients about self-care measures is important also. For instance, instructing the patient to record the number of stools and report symptoms of infection or dehydration.
- Loperamide is sufficient to control treatment-related diarrhoea in the majority of patients. Loperamide is a non analgesic opioid that decreases intestinal motility by directly affecting the smooth muscle of the intestine. A suggested regimen is: 4 mg at the first onset of diarrhoea followed by 2 mg every 4 hours or after every unformed stool and continued until diarrhoea free for 12 hrs. The normal maximum daily dose is 16 mg; however, for chemotherapy induced diarrhoea higher doses may be used for a short period of time. If diarrhoea persists beyond 24 hours, the dose of loperamide should be increased to 2 mg every 2 hours. If diarrhoea persists beyond 48 hours, the patient’s symptoms should be considered complicated and the patient referred to hospital.
- Diphenoxylate and atropine (Lomotil®) is an alternative to loperamide; however, loperamide appears to be more effective and has been recommended in treatment guidelines.
Consisting of papules and pustules affecting the face and upper body, this rash is the most common cutaneous reaction with EGFR inhibitors. Agents which inhibit the epidermal growth factor receptor (EGFR) include monoclonal antibodies like cetuximab and oral small molecule EGFR inhibitors like gefitinib/erlotinib. Acneiform rash occurs as a result of direct EGFR inhibition, and not as an allergic reaction to the therapy. It is associated with a strong inflammatory element and is usually sterile although secondary infection may occur.
Prevention of dermatological toxicity in the early weeks is important. Patients should be educated to:
- moisturise the skin with an alcohol-free moisturising/emollient cream
- avoid sun exposure as rash may be more severe in areas of skin that are exposed to sunlight (i.e. the face and upper chest)
- apply sunscreen (PABA free, SPF 30+, UVA and UVB protection) to skin before going outdoors
- wear loose protective clothing e.g. long sleeve shirt, hat when outside
- bath or shower in lukewarm water and use a bath/shower oil instead of shower gel or soap which can dry the skin
- wear loose-fitting cotton clothing
- avoid over the counter acne preparations (retinoids and benzoyl peroxide) as these can exacerbate rash
Treatment of mild acneiform rash may include:
- Moisturizing the skin and protecting it from sunlight
- Applying topical hydrocortisone 1-2.5% cream
- AND/OR topical clindamycin 1% gel/lotion or 0.75% metronidazole cream twice daily to the affected area/s
- Oral antibiotics such as doxycycline 100mg BD or minocycline 100mg daily for a minimum of 4 weeks and continuing for the duration of treatment.
- Dose adjustment of oral chemotherapy drug may be required for severe toxicity.
Ranges from mild inflammation to bleeding ulceration. Possible causative agents include capecitabine, erlotinib, imatinib, lapatinib, methotrexate, sunitinib.
Prevention of mucositis involves diet modification to avoid rough, spicy, salty and acidic food. Smoking and alcohol should also be avoided.
Oral hygiene is vital. This includes:
- Regular brushing of teeth with a soft or electric toothbrush after meals and before bed
- Rinsing the mouth after each meal (at a minimum) and before bed with a bland mouth rinse, such as 1/2 teaspoon of salt to one glass (200mL) water or 1 teaspoon of sodium bicarbonate (baking soda) to one glass (200mL) water
- The lips may be moistened with vaseline, soft paraffin or lip salve
- The patient needs to maintain adequate fluid intake
Treatment of mucositis involves:
- Using a mouthwash at least 4 times a day
- Adequate pain relief. Pain relieving agents should be administered at regular time intervals and not on an ‘as needed’ basis
- Monitoring of fluid and electrolyte balance (and administration of replacement fluids where necessary)
- Referral to a dietitian
- Regular review by a dentist throughout treatment
- Oropharyngeal pain can be the most significant patient symptom of antineoplastic therapy related mucositis. Early recognition and treatment of pain continues to be an important part of the management of oral mucositis. Topical analgesia includes Difflam alcohol free mouthwash or xylocaine viscous. Systemic analgesia includes non-opioid or low dose opioids if tolerated. NOTE: for patients experiencing difficulty with swallowing, use alternative route of administration (topical patches).
What are some other ways pharmacists can help support oncology patients?
- Effectively managing chemotherapy-induced AEs significantly improves patient quality of life. Pharmacists (whether hospital or community based) have a role to play in supporting oncology patients. Don’t be afraid to ask. Patients often rely on anecdotal advice from support forums which may be dangerous and not evidence based.
- Recognising the impact on mental health for both the individual and their friends/family. Pharmacists can refer to counselling services such as those at Cancer Council.
- At Terrywhite Chemmart Grange we stock the Christine Headwear range to assist the management of alopecia. This was another way to support women going through cancer treatment and opened communication lines about the management of other adverse effects.
Where should pharmacists go for more information?
- EviQ: is a freely available online Australian government resource of cancer treatment protocols developed by multidisciplinary teams of cancer specialists. It has a goal to improve patient outcomes and reduce treatment variation. EviQ provides evidence-based information to support health professionals in the delivery of cancer treatments available at the time treatment decisions are being made including on dosing regimens, drug-drug and drug-food interactions and side effects. Patient information is also available
- Additional information can be obtained from:
If you would like to get in contact with Jessica, she is on Instagram at @thebreastpharmacist
See more information on breast awareness and self-examination here.