CASE 1: SAW PALMETTO FOR PROSTATE CANCER PREVENTION
Q: PK is a 78-year-old man who complains of frequent urination, especially at night. His urine stream stops and starts frequently, making him feel as if he never fully urinates. PK says that he recently received a diagnosis of an enlarged prostate, and his doctor started him on tamsulosin (Flomax). In addition, PK is concerned that his enlarged prostate will lead to prostate cancer. A few of his friends take saw palmetto for prostate health. PK wants to know whether any evidence shows that taking saw palmetto decreases the risk of prostate cancer, with the additional benefit of helping him urinate normally. What recommendations do you have?

A: In the VITAL cohort, a study conducted in Washington from 2000 to 2002, more than 35,000 men aged 50 to 76 years without a diagnosis or history of prostate cancer completed a questionnaire evaluating their baseline use of supplements.1 After a median follow-up of 6.1 years, investigators found that the use of saw palmetto was not associated with a lower risk of prostate cancer.1 However, they discovered that grape-seed supplementation may be associated with a reduced risk.1 Regarding urinary symptoms, a Cochrane review of 32 randomized controlled trials comprising more than 5000 men determined that saw palmetto was not effective for treating urinary symptoms, improving urinary flow, or reducing prostate size.2 PK should be counseled to look for improvements in urinary symptoms with tamsulosin, adhere to his medications, and receive routine prostate screenings.


CASE 2: BLACK COHOSH FOR BREAST CANCER PREVENTION
Q: 
RW is a 58-year-old postmenopausal woman who is looking for something natural to prevent breast cancer. Her gynecologist recently started her on estrogen hormone therapy for bothersome hot flashes. RW tried nonhormone therapy in the past without relief. She is willing to give the hormones a chance because the hot flashes are causing her significant discomfort. However, RW read that estrogen therapy increases the risk of breast cancer, making her very concerned, as both of her grandmothers died from breast cancer. RW says that she receives a mammogram every 6 months as preventive care. She heard that black cohosh may reduce the risk of breast cancer and wants to know whether she should start it. What recommendations do you have?

A: A recent systematic review of 3 prospective and population-based observational studies evaluating black cohosh and breast cancer found conflicting evidence of either a decreased risk of breast cancer or no association.3 In addition, the VITAL cohort, mentioned in the previous case, of nearly 35,000 women aged 50 to 76 years without a diagnosis or history of breast cancer completed a questionnaire evaluating their baseline use of supplements.4 After a median follow-up of 6 years, investigators found that the use of black cohosh was not associated with a lower risk of breast cancer.4 However, they found that fish oil supplementation may be associated with a reduced risk.4 Given the conflicting evidence, RW should discuss these findings with her provider for a risk-benefit evaluation. In addition, she should be encouraged to adhere to a healthy lifestyle, continue receiving mammograms and routine health screenings, and follow up with her provider if she thinks she is experiencing any changes in her health.


CASE 3: IRINOTECAN-INDUCED DIARRHEA
Q: 
BB is a 72-year-old woman who is complaining of diarrhea. She recently received a diagnosis of colorectal cancer, and her doctor started her on a chemotherapy regimen containing irinotecan. BB’s first round of chemotherapy was 5 days ago. She reports 4 loose stools per day accompanied by mild cramps and nausea over the past 3 days. BB denies a decrease in fluid and food consumption or a fever. Her doctor told her that she mostly likely would have diarrhea and, if it was mild, to ask for loperamide at the pharmacy. BB wants to know what dosage she should follow and what adverse effects to watch for. What recommendations do you have?

A: BB can be classified with mild to moderate uncomplicated diarrhea. She may start with loperamide 4 mg, followed by 2 mg every 2 to 4 hours or after each loose stool, not to exceed 16 mg per day. The most common adverse effects that BB may experience are abdominal cramps, constipation, dizziness, and nausea. She should stay hydrated by consuming 8 to 10 glasses daily of clear liquids with electrolytes, such as Gatorade and soup broth. In addition, BB should eat frequent small, bland meals comprising applesauce, bananas, plain pasta, rice, or toast. Advise her to stop loperamide after 12 hours free of diarrhea. However, if BB’s symptoms do not improve after 12 to 24 hours, she can increase the loperamide dosage to 2 mg every 2 hours. If the diarrhea persists 12 to 24 hours later despite the higher dosage of loperamide, she should call her doctor for further evaluation.5


CASE 4: SMOKING CESSATION IN LUNG CANCER
Q: 
FG is a 64-year-old man looking for something to help him quit smoking. He smokes a pack per day and inhales his first cigarette upon waking. FG has a 40-year pack history and recently received a diagnosis of lung cancer. His oncologist is recommending chemotherapy and advised FG that his chances of survival will improve if he quits smoking. FG tried quitting cold turkey unsuccessfully 3 times more than 20 years ago. He says he wants to see his grandchildren grow up and is willing to do whatever it takes to quit. FG asks for information about programs in the community for smoking cessation. What recommendations do you have? 

A: FG can try numerous OTC nicotine replacement products, including gum, lozenges, and the patch. Data have demonstrated improved abstinence rates with combination therapy. The patch has the best adherence rate and should be started at 21 mg because FG smokes >10 cigarettes per day. Advise him to apply the patch upon waking and wear it for 16 to 24 hours. If he experiences difficulty sleeping, he may remove it prior to bedtime. FG can also use the 4-mg gum or lozenge because he has his first cigarette within 30 minutes of waking. A minimum of 9 pieces per day is recommended, with a maximum of 24 pieces of gum and 20 lozenges per day. Counsel FG on the proper administration of the gum and lozenge and to avoid drinking or eating for 15 minutes prior to use.6 A good resource is the CDC website, which has information on many programs to quit smoking. These include a mobile app (quitSTART), a phone number (800-QUIT-NOW), and a texting service (SmokefreeTXT).7
 
Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Caitlyn Bloom, PharmD, BCACP, AE-C, is a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care clinical pharmacist at RWJBarnabas Health, part of the Barnabas Health Medical Group in Eatontown, New Jersey.

Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care specialist at RWJBarnabas Health, part of the Barnabas Health Medical Group.


REFERENCES
  1. Brasky TM, Kristal AR, Navarro SL, et al. Specialty supplements and prostate cancer risk in the vitamins and lifestyle (VITAL) cohort. Nutr Cancer. 2011;63(4):573-582. doi: 10.1080/01635581.2011.553022.
  2. Tacklind J, Macdonald R, Rutks I, Stanke JU, Wilt TJ. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2012;12:CD001423. doi: 10.1002/14651858.CD001423.pub
  3. Fritz H, Seely D, McGowan J, et al. Black cohosh and breast cancer: a systematic review. Integr Cancer Ther. 2014;13(1):12-29. doi: 10.1177/1534735413477191.
  4. Brasky TM, Lampe JW, Potter JD, Patterson RE, White E. Specialty supplements and breast cancer risk in the VITamins And Lifestyle (VITAL) cohort. Cancer Epidemiol Biomarkers Prev. 2010;19(7):1696-1708. doi: 10.1158/1055-9965.EPI-10-0318.
  5. Benson AB III, Ajani JA, Catalano RB, et al. Recommended guidelines for the treatment of cancer treatment-induced diarrhea. J Clin Oncol. 2004;22(14):2918- 2226. doi: 10.1200/JCO.2004.04.132.
  6. US Department of Health & Human Services. Treating tobacco use and dependence: 2008 update. Tobacco Use and Dependence Guideline Panel. 2008.
  7. Smoking and tobacco use. CDC website. cdc.gov/tobacco/quit_smoking/how_to_quit/resources/index.htm. Updated December 11, 2017. Accessed September 21, 2019.