The Pharmacist Said “No”

The Pharmacist Said “No”

Anne Katz, PhD, RN, FAAN

Sep 18, 2014

It’s not often that I find myself speechless. I have heard all sorts of stories in my office—as a sexuality counselor, I am often humbled by the trust that people place in me and how much they disclose about their private lives. But one conversation I had with a patient literally made my jaw drop.

The patient is a postmenopausal woman with stage III breast cancer. She had a mastectomy followed by radiation and chemotherapy and is now on an aromatase inhibitor. Like many women taking an aromatase inhibitor, she has significant vulvo-vaginal atrophy resulting in dyspareunia. Unlike other women with a similar history, she has not experienced a reactive loss of libido. She is very much in love with her partner—observing the two of them together in my office was joyful. They looked at each other often, finished each other’s sentences, and reminded me again how fortunate I am to do the work that I do.

I knew from the referral letter I had received from her oncologist that she had been prescribed local estradiol tablets at a low dose to treat the vulvo-vaginal atrophy. This in itself was unusual; most of the oncologists I have encountered do not prescribe local estrogen at all, and in fact, some warn me in their referral letters that I should under no circumstances even mention this treatment to the patient. But that’s a discussion for another day. . .

This woman had been using the tablets twice a week for about two months and told me that she thought that perhaps things were getting a little better. And that’s when she said that she had some difficulty getting the medication. I looked at her quizzically and motioned with my hand that she should continue.

“Well,” she said, “the pharmacist refused to fill the prescription.”

That’s when my jaw dropped and I lost all capacity for speech.

I know that pharmacists have refused to provide women with emergency contraception in some jurisdictions. I also know that some pharmacists refuse to dispense oral contraceptives to young women. This is allowed by law in some states, while in others it is permitted only if there is another pharmacy where the prescription can be filled. Some states allow the religious beliefs of the pharmacist to have an impact on their work. But why would a pharmacist refuse to fill a prescription written by an oncologist for a medication that has no religious connotations?

The provision of local estrogen to women with breast cancer is controversial. There are also geographic prescribing practices; I have spoken to physician groups across North America, and in some areas, prescribing local estradiol is an accepted practice, while in others, it is extremely rare. In a study of 285 gynecologists, 89% regarded the use of local estrogen therapy to be safe for women with breast cancer and would use it themselves if they had breast cancer (Streicher, 2013).

But should a pharmacist not talk to the prescribing physician before taking a unilateral decision that prevented a patient from taking medication prescribed to improve her symptoms and quality of life? The patient told me that she contacted her oncologist and told her what had transpired at the pharmacy. It then took some time for the oncologist to speak to the pharmacist, and eventually her prescription was filled. However, this caused her a significant amount of distress and trust was lost; she initially lost trust in her oncologist after hearing the pharmacist’s refusal. After talking to her oncologist again, she no longer trusts the pharmacist.

There were other ways for the pharmacist to deal with this. He/she could have called the oncologist and asked for clarification in case the prescription was wrong. He/she could have explained to the patient (customer) that he/she had concerns and wanted to talk to the oncologist before filling the prescription. Or the pharmacist could have filled the prescription and trusted the oncologist. Or should the oncologist have included a note on the prescription that the prescriber and the patient were aware of the potential risks of the medication for this particular patient?

In the end, she used the medication and her sex life is improving. Her relationship with the pharmacist has not.


Streicher, L. Physician attitude regarding local estrogen therapy for treatment of personal vaginal atrophy in the presence of breast cancer. Abstract #14; Journal of Sexual Medicine 2013; 10 (sup; 2: 158-178).


The ideas and opinions expressed on the ASCO Connection Blogs do not necessarily reflect those of ASCO. None of the information posted on is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice on does not constitute an endorsement of any kind by ASCO. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.


Susannah E. Koontz, PharmD, BCOP

Sep, 22 2014 2:43 PM

I read with great interest this blog post on the morning of September 18.

I empathize with both Dr. Katz and the pharmacist as I can see myself in both their shoes, having been in similar situations at some point in my career as either a "giver" or "receiver" of medication orders.  From the prescriber's perspective, it is frustrating when a prescribed therapy does not reach the patient in the intended manner - regardless of the reason.  Equally so, from the dispensing pharmacist's perspective, it can be nerve-wracking to carry out a medication order where the harm potentially outweighs the benefit -- particularly when the order is controversial or not well-established.

This isn't the forum to debate the merits of topical estradiol therapy for the management of vaginal atrophy in a patient with a history of breast cancer.  Nor is it the place to drill-down on the chain of events to see what could have been done better.  Public finger-pointing does not help anyone in this particular situation.

But this case does highlight the need for both effective communication and continuing education among healthcare providers caring for cancer patients - a need that can be addressed with all of us working together.  Dr. Katz eloquently lists some thoughtful suggestions on how an increased level of communication could have avoided the misunderstanding.  This case should also remind us that many patients do not receive all of their care at tertiary cancer centers where healthcare professionals may be more attuned to cutting-edge oncology disease state management and supportive care interventions.  As a result, the educational needs of healthcare practitioners vary across the continuum according to discipline, practice site, years of experience and many other factors.

Many of us in ASCO also hold memberships in other stakeholder oncology organizations that take continuing education seriously and do it well, much like ASCO itself.  For me, the Hematology/Oncology Pharmacy Association (HOPA) is my "home" for continuing pharmacy education (although I greatly benefit from the educational offerings provided through ASCO, ASH, ASBMT, etc., albeit without the provided credits counting towards maintenance of my pharmacist license or board certification).  HOPA is comprised of more than 2,000 pharmacy professionals and "seeks to promote and advance hematology/oncology pharmacy to optimize the care of individuals affected by cancer."  HOPA is currently partnering with ASCO to conduct the drug shortages survey.

Here lies a wonderful opportunity.  Might there be a chance in the near future for ASCO to partner with organizations such as HOPA and ONS to provide educational programming in a multidisciplinary fashion addressing timely topics - including effective communication, therapeutic controversies and many others?  Each of us can also promote collaborative education through our own organizations with a focus to reach our colleagues practicing outside the field of oncology.

As I reflect on Dr. Katz's original post, my concerns about the situation she describes are blended with optimism as to what can lie ahead with all professionals collaborating on these important issues.

Thank you,

Susannah E. Koontz, Pharm.D., BCOP
Principal & Consultant - Pediatric Hematology/Oncology & HSCT
Koontz Oncology Consulting LLC
Houston, TX

Michael Vozniak

Sep, 22 2014 10:06 PM

As I read your blog post, I had many of the same questions and thoughts about how the interaction and communication between the oncologist, patient and pharmacist could have been improved.  While there are many opportunities here, this interaction is not representative of the vast majority of interactions between pharmacists and other healthcare professionals or patients. 
Pharmacists provide care in a variety of settings and require varied clinical knowledge and expertise depending upon the setting.  Pharmacists most visible work environment is working in community or retail pharmacies.  However, many pharmacists undergo advanced training and/or board certification to provide care to patients with specialized needs, such as patients with cancer.  Depending upon your work setting, you may routinely, occasionally or never work with a hematology/oncology pharmacist.  Recently, a scope of practice document detailing the roles of oncology pharmacists was published (Holle, 2014)
The Hematology/Oncology Pharmacy Association (HOPA) was founded 10 years ago and its mission is for all individuals affected by cancer to have a hematology/oncology pharmacist as a member of their care team.  One of HOPA’s goals is professional development.  Dr. Koontz’s suggestion of multidisciplinary educational programming addressing timely topics between ASCO, ONS and HOPA would be welcome.  HOPA recognizes that not all pharmacists have specialized training in oncology, but realizes that our colleagues who work in the community or retail pharmacy setting often provide care for patients with cancer.  HOPA will work to identify opportunities to expand the breadth and reach of our educational offerings to pharmacists so that together we can all take exceptional care of patients. 
Michael Vozniak, PharmD, BCOP
President, Hematology/Oncology Pharmacy Association
Holle LM, Boehnke Michaud L.  Oncology pharmacists in health care delivery; vital members of the cancer care team.  J Onocl Prac. 2014 May;10(3):e142-5.

Back to Top