The role of the community pharmacist in breast cancer survivorship services

Background: Breast cancer is one of the most common cancers in the UK and incidence is increasing. Efforts to promote early diagnoses along with advances in treatments mean people are surviving for longer with breast cancer. This, coupled with the long-term treatment requirements of the condition, have created increasing demand for primary care-based services to support survivors. The current role of community pharmacists in cancer services focuses largely on prevention and early diagnosis. However, as one of the most accessible healthcare providers in primary care, community pharmacists have potential scope to take on a more significant role in supporting breast cancer survivors. The aim of this study was to identify the opportunities for community pharmacists to develop their role in providing support and improving health outcomes for people living with and after breast cancer. Methods: This mixed methods study took a sequential approach with the findings from each phase informing the design of the next. Phase 1 consisted of a retrospective cohort study. National primary care prescribing data from the Clinical Practice Research Datalink was utilised to explore prescribing patterns in current practice and identify potential healthcare needs of breast cancer survivors. Data were analysed using descriptive statistics. Phases 2 to 4 used qualitative approaches to explore the perspectives of breast cancer survivors, community pharmacists and stakeholders respectively. Phase 2 consisted of focus groups and interviews with survivors, investigating experiences of the breast cancer care received in the community and identifying areas where community pharmacists might have scope to support. In Phase 3, online focus groups were conducted with community pharmacists to explore attitudes and feasibility of new roles or interventions. Phase 4 involved interviews with a range of stakeholders to establish their perspectives on findings and gain insight into future work. Survivor and stakeholder data were digitally audio-recorded, whilst transcripts of the typed discussions from the online community pharmacist focus groups were saved. All qualitative data were analysed using iterative thematic analysis. Findings: National prescribing data revealed that 53% (n=3084) of adjuvant endocrine therapy users with sufficient follow-up did not complete the recommended five years of treatment as per the national guidance. Frequent switching between endocrine therapies was also a concern, with 32% (n=3930) of users switching up to five times. Both are associated with increased risk of recurrence and mortality. As experts in medicines optimisation, the role of the community pharmacist could be key to tackling this issue. Qualitative findings revealed further care needs of survivors, who reported initial information overload then feeling abandoned post-discharge. Additional information and support was required on a range of clinical, emotional and lifestyle-related issues. Early and regular contact with community pharmacists was seen as important in improving care experiences. Community pharmacists and stakeholders noted the importance of providing the right information at the right time. Strategies included appropriate signposting, collaborating with other healthcare providers and charities, tackling public perceptions of roles, and building pharmacist confidence. Potentially feasible interventions included incorporating breast cancer into existing advanced services and healthy living pharmacy campaigns. Conclusions and recommendations: This research has identified considerable scope for community pharmacists to take on a larger role in breast cancer survivorship services, highlighting several potential features of future interventions. Approaches to care should be holistic and person-centred. Increased awareness of survivor care needs amongst community pharmacists is required to encourage proactive conversations with survivors, networking activities and further training. Findings can inform the development of community pharmacy survivorship services and healthcare policy. A more integrated and multidisciplinary approach to care is required, and policymakers and commissioners should consider the benefits of community pharmacy involvement when designing new services and care pathways. Future research should further investigate the feasibility of proposed interventions and consider how they could be incorporated into the changing landscape of pharmacy services