MASCC guideline: cannabis for cancer-related pain and risk of harms and adverse events

Psychoactive drug use and prognosis in patients with cancer presenting with acute cardiovascular disease

BACKGROUND

The psychoactive drug consumption and the short- and long-term cardiovascular prognosis of patients with cancer admitted for acute cardiovascular events are not well established.

AIMS

To assess the prevalence of psychoactive drug use, in-hospital outcomes and 1-year prognosis in patients with cancer hospitalized for acute cardiovascular events.

METHODS

In a prospective multicentre study of all consecutive patients admitted to intensive cardiac care units, a history of cancer was recorded systematically. The primary outcome was the prevalence of psychoactive drugs detected by urine drug assay. The secondary outcomes were: the rate of in-hospital major adverse events, defined as all-cause death, cardiogenic shock and cardiac arrest; and the 1-year rate of major adverse cardiovascular and cerebrovascular events, defined as cardiovascular death, myocardial infarction and stroke.

RESULTS

Among 1499 patients recruited, 151 had a history of cancer (10%), including 61 (40%) with active cancer and 90 (60%) with cancer in remission. Among patients with a history of cancer, 39 (25.8%) tested positive for at least one psychoactive drug. Using a matching approach based on the likelihood of having a cancer, a history of cancer was not associated with an increased risk of in-hospital major adverse events (odds ratio: 1.54, 95% confidence interval: 0.68-3.45; P=0.3). However, a history of cancer was associated with a higher incidence of 1-year major adverse cardiovascular and cerebrovascular events (hazard ratio: 3.04, 95% confidence interval: 1.63-5.67; P<0.001).

CONCLUSIONS

The prevalence of psychoactive drug use among patients with a history of cancer hospitalized for acute cardiovascular events was 25.8%. A history of cancer was an independent predictor of 1-year major adverse cardiovascular and cerebrovascular events.

Meta-analysis of medical cannabis outcomes and associations with cancer

Background

Growing bodies of evidence suggest that cannabis may play a significant role in both oncological palliative care and as a direct anticarcinogenic agent, but classification as a Schedule I substance has complicated research into its therapeutic potential, leaving the state of research scattered and heterogeneous. This meta-analysis was conducted to determine the scientific consensus on medical cannabis' viability in cancer treatment.

Objective

The aim of this meta-analysis was to systematically assess the existing literature on medical cannabis, focusing on its therapeutic potential, safety profiles, and role in cancer treatment.

Methods

This study synthesized data from over 10,000 peer-reviewed research papers, encompassing 39,767 data points related to cannabis and various health outcomes. Using sentiment analysis, the study identified correlations between cannabis use and supported, not supported, and unclear sentiments across multiple categories, including cancer dynamics, health metrics, and cancer treatments. A sensitivity analysis was conducted to validate the reliability of the findings.

Results

The meta-analysis revealed a significant consensus supporting the use of medical cannabis in the categories of health metrics, cancer treatments, and cancer dynamics. The aggregated correlation strength of cannabis across all cancer topics indicates that support for medical cannabis is 31.38× stronger than opposition to it. The analysis highlighted the anti-inflammatory potential of cannabis, its use in managing cancer-related symptoms such as pain, nausea, and appetite loss, and explored the consensus on its use as an anticarcinogenic agent.

Discussion

The findings indicate a strong and growing consensus within the scientific community regarding the therapeutic benefits of cannabis, particularly in the context of cancer. The consistent correlation strengths for cannabis as both a palliative adjunct and a potential anticarcinogenic agent redefine the consensus around cannabis as a medical intervention.

Conclusion

The consistency of positive sentiments across a wide range of studies suggests that cannabis should be re-evaluated within the medical community as a treatment option. The findings have implications for public health research, clinical practice, and discussions surrounding the legal status of medical cannabis. These results suggest a need for further research to explore the full therapeutic potential of cannabis and address knowledge gaps.

Characterizing Cannabidiol Use in a Breast Cancer Population

INTRODUCTION

Cannabidiol (CBD) is a phytocannabinoid found in the plant Cannabis sativa and is thought to have broad potential therapeutic value. Little is reported on CBD use in patients with breast cancer (BC). This survey study aimed to characterize CBD use patterns and reported benefits among patients with BC, while also identifying barriers and limitations to its use.

PATIENTS AND METHODS

Individuals seen at the University of Michigan Rogel Cancer Center for a diagnosis of BC accessed the anonymous online survey characterizing current and former CBD use via flyer posted in clinic. Survey questions were adapted from a previously published questionnaire conducted in patients with chronic pain conditions. The survey was accessed between September 2020 and February 2024.

RESULTS

Of 141 evaluable surveys, 68 patients (48.2%) reported prior or current CBD use. The most common reasons for current CBD use were management of pain (75.6%), anxiety (61.0%), and insomnia (58.5%). The biggest median self-reported improvement with use of CBD was in insomnia followed by pain. Patients mainly stopped using CBD because it was ineffective (46.2%), although some stopped due to negative side effects (7.7%).

CONCLUSION

Almost half of patients in this survey study reported previous or current CBD use, with improvements in symptoms. As CBD use increases in the clinical setting, it is important for physicians to help navigate concerns related to its use. Additional research is needed to determine which patient-reported symptoms are most likely to be impacted by CBD.

Pain Assessment and Management in Oncological Practice: A Survey from the Italian Network of Supportive Care in Oncology

Background/Objectives: Cancer pain is prevalent across all stages of the disease, significantly impacting patients' lives. Despite the availability of guidelines, its assessment and management remain suboptimal in many clinical settings. This study aimed to explore how healthcare professionals in Italy assess and manage cancer pain, identifying gaps and educational needs to improve adherence to best practices. Methods: A multidisciplinary Scientific Board designed an online survey comprising 28 items addressing demographics, pain assessment tools, perception of pain, pharmacological management, adverse effects, and barriers to care. The survey targeted oncologists, nurses, radiotherapists, and surgeons within the Italian Network of Supportive Care in Oncology. Data were collected from March to May 2024 and analyzed descriptively. Results: Eighty-five professionals participated, predominantly oncologists (63.5%). Most respondents utilized pain scales, with the Numerical Rating Scale (60.3%) being the most frequent. However, specific tools like the Edmonton Symptom Assessment System (ESAS) were underutilized, possibly due to limited training and time constraints. Factors influencing analgesic choice included patient comorbidities (30.3%) and polypharmacy (28.0%). The main barriers to effective pain management included inadequate training (85.5%) and poor communication between patients and caregivers (40.6%) and within care teams (31.9%). Preventive measures for opioid-induced adverse events were widely employed, with laxatives (52.7%) and antiemetics (40.5%) being the most common. Conclusions: Findings underscore the need for structured training programs, improved communication, and integration of validated assessment tools. A multidisciplinary, proactive approach to cancer pain assessment and management is essential to optimize care and reduce its burden across all disease stages.

Efficiency and safety of cannabinoid medical use: an analysis of discussions and observed trends on Instagram

Background

Cannabis and its derivatives show encouraging therapeutic effects in the treatment of various diseases. However, further studies are needed to better assess their efficacy and safety. A promising base for research in the field of medicine and additional pharmacovigilance is social networks, in which experience and knowledge are exchanged between researchers, doctors, and patients, as well as information about the potential risks and benefits of using drugs for medical purposes is disseminated. The aim of this study was to investigate the reported efficiency and safety of medical use of cannabinoids in patients using posts on the social media Instagram and analyze the observed trends.

Methods

Social media listening platform Apify was used to collect data with hashtags as of June 4, 2024, including posts from 2023 and 2024, with some data extending into later periods, in compliance with a systematic approach to data collection. The analysis of the data obtained from the research was conducted using the RStudio platform.

Results

The analysis covered 1,466 posts containing hashtags related to cannabinoids. The posts studied were categorized as follows: 33.08% focused on advertising and commercialization, 25.58% on personal experience, 21.35% on other topics, and 19.99% contained educational content. An analysis of overall content relevance found that the majority of Instagram posts (81.79%) related to cannabis and cannabinoid hashtags are relevant. Most of the Instagram posts studied were posters, followed by personal photos and videos. The analysis shows that English dominates the studied category (70.74% of posts), while German, French, Spanish, and other languages also occupy a significant place, emphasizing the importance of a multilingual approach in content analysis. It has been revealed that organizations publish a larger percentage of posts under this study, with a higher percentage of relevance. Personal experience stories receive a significant number of "likes" indicating a strong emotional connection between audience and content. Instagram discussions about cannabinoid treatment support evidence from scientific studies about their effectiveness in treating a range of diseases, such as epilepsy with Lennox-Gastaut and Dravet syndromes, multiple sclerosis, cancer, and HIV-cachexia, nausea and vomiting caused by chemotherapy. At the same time, they emphasize the need for further clinical studies to better assess safety, side effects, and optimal dosages. Advertising and commercial posts can contribute to increased cannabis use, highlighting the need to raise awareness of risks and strengthen preventive measures.

Conclusion

Analysis of content on the social media Instagram can complement traditional scientific research by providing information on the real use of cannabis and its derivatives, contributing to the development of safe and effective recommendations for its use.

Opposing Effects of Cannabidiol in Patient-derived Neuroendocrine Tumor, Pheochromocytoma/Paraganglioma Primary Cultures

CONTEXT

Treatment options for advanced neuroendocrine tumors (NETs), pheochromocytomas and paragangliomas (PPGLs) are still limited. In recent years, antitumor effects of cannabinoids have been reported; however, there are only very limited data available in NETs or PPGLs.

OBJECTIVE

Investigation of the effects of cannabidiol (CBD) on patient-derived human NET/PPGL primary cultures and on NET/PPGL cell lines.

METHODS

We established primary cultures derived from 46 different patients with PPGLs (n = 35) or NETs (n = 11) who underwent tumor resection at 2 centers. Treatment of patient primary cultures with clinically relevant doses (5 µM) and slightly higher doses (10 µM) of CBD was performed.

RESULTS

We found opposing effects of 5 µM CBD: significant antitumor effects in 5/35 (14%) and significant tumor-promoting effects in 6/35 (17%) of PPGL primary cultures. In terms of antitumor effects, cluster 2-related PPGLs showed significantly stronger responsivity to CBD compared to cluster 1-related PPGLs (P = .042). Of the cluster 2-related tumors, NF1 PPGLs showed the strongest responsivity (4/5 PPGL primary cultures with a significant decrease in cell viability were NF1-mutated). We also found opposing effects of 10 µM CBD in PPGLs and NETs: significant antitumor effects in 9/33 of PPGL (27%) and 3/11 of NET (27%) primary cultures and significant tumor-promoting effects in 6/33 of PPGL (18%) and 2/11 of NET (18%) primary cultures.

CONCLUSION

We suggest a potential novel treatment option for some NETs/PPGLs but also provide evidence for caution when applying cannabinoids as supportive therapy for pain or appetite management to cancer patients and possibly as health supplements.

Clinical Benefits and Safety of Medical Cannabis Products: A Narrative Review on Natural Extracts

Interest in medical cannabis and cannabis-based medicinal products (CBMPs) has increased greatly in recent years. Two cannabinoids are of principal importance; delta-9-tetrahydrocannabinol (∆9-THC), the primary psychoactive component, and also cannabidiol (CBD), considered non-intoxicating. Each has distinct mechanisms of action and different therapeutic potentials. CBMPs differ in their ∆9-THC and CBD components; predominantly ∆9-THC, balanced formulations with equivalent ∆9-THC and CBD elements, and CBD-predominant products. In this narrative review, we evaluate the published evidence for the clinical benefits of CBMPs and overall benefits in well-being. We also review the overall safety profile and discuss the potential for dependence with CBMPs. Evidence can be drawn from a wide range of randomized and other controlled studies and from observational real-world studies. Most data from observational registry studies are supportive of ∆9-THC-based products (∆9-THC-predominant or balanced CBMPs) in the management of chronic neuropathic pain. Balanced products are also effective in reducing spasticity in multiple sclerosis. Most CBMPs show benefit in providing symptomatic benefits in reducing anxiety, nausea, and in improving sleep, but the place of specific products is more subtle, and choice guided by specific circumstances. Symptomatic improvements are accompanied by improved quality of life and well-being. Safety data indicate that CBMPs are generally well tolerated in most patients without specific contraindications. The majority of adverse effects are non-serious, and transient; most are principally associated with ∆9-THC and are dose-dependent. In contrast to recreational cannabis use, there is little evidence from clinical studies that CBMPs have any potential for dependence.

Perception and Utilization of Cannabinoids in Patients Undergoing Radiation Treatment: Our Patients Are Curious

PURPOSE

Limited studies have described the utilization of cannabinoids among patients with cancer. This survey study aimed to characterize utilization patterns and perceptions of cannabinoid use for treatment-related side effects among patients receiving radiation treatment.

METHODS AND MATERIALS

This was an anonymous survey study of patients who were undergoing or recently completed radiation treatment at a comprehensive cancer center. Data on cannabinoid use during cancer treatment, reasons for the use of cannabinoids, perceived effects of cannabinoids, and formulations of usage were collected and summarized using descriptive statistics.

RESULTS

Of the 431 respondents, 111 (25.8%) patients reported cannabinoid use since their cancer diagnosis. Among the cannabinoid users, a majority (73.9%) experienced improvement in symptoms; 38.7% had better relief of cancer-treatment symptoms from cannabinoids in comparison to their prescription medications, and 16.2% lowered the amount of prescription pain medications needed after using cannabinoids. Cannabinoids appeared to be most effective in helping patients manage sleep (76.6%) and anxiety (72.1%). When asked about whether physicians should be discussing cannabinoid use, 45.1% of cannabinoid users wanted to speak with their doctors regarding its utilization. For patients who did not report cannabinoid use, a large majority (83.1%) never had discussions with their doctors regarding its utilization as part of their cancer care, and 34.8% wanted to learn more about cannabinoids from their doctors.

CONCLUSIONS

About 1 in 4 patients with cancer reported cannabinoid use to assist in symptom control. A majority had subjective alleviation of treatment-related symptoms from cannabinoid use. Regardless of cannabinoid use, a sizable percentage of patients never had any discussions about cannabinoids with their oncologists, with some expressing interest in learning more. Guidelines are needed to assist radiation oncologists on how cannabinoids may play a role in caring for patients.

Perceptions, prevalence, and patterns of cannabis use among cancer patients treated at 12 NCI-Designated Cancer Centers

BACKGROUND

The legal climate for cannabis use has dramatically changed with an increasing number of states passing legislation legalizing access for medical and recreational use. Among cancer patients, cannabis is often used to ameliorate adverse effects of cancer treatment. Data are limited on the extent and type of use among cancer patients during treatment and the perceived benefits and harms. This multicenter survey was conducted to assess the use of cannabis among cancer patients residing in states with varied legal access to cannabis.

METHODS

A total of 12 NCI-Designated Cancer Centers, across states with varied cannabis-access legal status, conducted surveys with a core questionnaire to assess cannabis use among recently diagnosed cancer patients. Data were collected between September 2021 and August 2023 and pooled across 12 cancer centers. Frequencies and 95% confidence intervals for core survey measures were calculated, and weighted estimates are presented for the 10 sites that drew probability samples.

RESULTS

Overall reported cannabis use since cancer diagnosis among survey respondents was 32.9% (weighted), which varied slightly by state legalization status. The most common perceived benefits of use were for pain, sleep, stress and anxiety, and treatment side effects. Reported perceived risks were less common and included inability to drive, difficulty concentrating, lung damage, addiction, and impact on employment. A majority reported feeling comfortable speaking to health-care providers though, overall, only 21.5% reported having done so. Among those who used cannabis since diagnosis, the most common modes were eating in food, smoking, and pills or tinctures, and the most common reasons were for sleep disturbance, followed by pain and stress and anxiety with 60%-68% reporting improved symptoms with use.

CONCLUSION

This geographically diverse survey demonstrates that patients use cannabis regardless of its legal status. Addressing knowledge gaps concerning benefits and harms of cannabis use during cancer treatment is critical to enhance patient-provider communication.

Cannabinoids and triple-negative breast cancer treatment

Triple-negative breast cancer (TNBC) accounts for about 10-20% of all breast cancer cases and is associated with an unfavorable prognosis. Until recently, treatment options for TNBC were limited to chemotherapy. A new successful systemic treatment is immunotherapy with immune checkpoint inhibitors, but new tumor-specific biomarkers are needed to improve patient outcomes. Cannabinoids show antitumor activity in most preclinical studies in TNBC models and do not appear to have adverse effects on chemotherapy. Clinical data are needed to evaluate efficacy and safety in humans. Importantly, the endocannabinoid system is linked to the immune system and immunosuppression. Therefore, cannabinoid receptors could be a potential biomarker for immune checkpoint inhibitor therapy or a novel mechanism to reverse resistance to immunotherapy. In this article, we provide an overview of the currently available information on how cannabinoids may influence standard therapy in TNBC.

Cannabis use after a cancer diagnosis in a population-based sample of cancer survivors

PURPOSE

This study aimed to characterize the prevalence and correlates of cannabis use and the methods and reasons for use among recently diagnosed cancer survivors in a population sample within Washington state.

METHODS

We identified individuals diagnosed with invasive cancers in the prior 6 to 17 months from April 2020 to December 2020 using the Seattle-Puget Sound Surveillance, Epidemiology, and End Results (SEER) cancer registry. Participants (n = 1,515) completed a questionnaire, including demographics, medical history, cannabis use, and other substance use. Cancer characteristics and date of diagnosis were obtained from SEER registry data. We calculated weighted prevalence estimates and logistic regression models to evaluate correlates of cannabis use.

RESULTS

Overall, 41.3% of survivors reported cannabis use at any time after diagnosis, most commonly via edibles (60.5%) and smoking (43.8%). The most frequently reported reasons for use were sleep (54.5%), mood, stress, anxiety, and depression (44.3%), pain (42.3%), and recreation (42.3%). Cannabis use was associated with younger age, race (White vs. Asian), less education, former or current smoking, consuming more than 2 alcohol-containing drinks per day, having late-stage cancer, and cancer site.

CONCLUSION

In this first evaluation of cannabis use in a registry-linked, population-based sample of survivors of all cancer types, based in a state where recreational and medical cannabis have been legal for a decade, approximately 2 in 5 survivors reported post-diagnosis use. Given how common cannabis use is among cancer survivors, there is a great need to understand its impact on cancer treatment outcomes and the overall health of cancer survivors.

Cannabinoid products for pain management: recommendations from the São Paulo State Society of Anesthesiology

There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions.

Integrative Therapies in Cancer Care: An Update on the Guidelines

INTRODUCTION

ASCO and the Society for Integrative Oncology have collaborated to develop guidelines for the application of integrative approaches in the management of anxiety, depression, fatigue and use of cannabinoids and cannabis in patients with cancer. These guidelines provide evidence-based recommendations to improve outcomes and quality of life by enhancing conventional cancer treatment with integrative modalities.

METHODS

All studies that informed the guideline recommendations were reviewed by an Expert Panel which was made up of a patient advocate, an ASCO methodologist, oncology providers, and integrative medicine experts. Panel members reviewed each trial for quality of evidence, determined a grade quality assessment label, and concluded strength of recommendations.

RESULTS

Strong recommendations for management of cancer fatigue during treatment were given to both in-person or web-based mindfulness-based stress reduction, mindfulness-based cognitive therapy, and tai chi or qigong. Strong recommendations for management of cancer fatigue after cancer treatment were given to mindfulness-based programs. Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial. The recommended modalities for managing anxiety included Mindfulness-Based Interventions (MBIs), yoga, hypnosis, relaxation therapies, music therapy, reflexology, acupuncture, tai chi, and lavender essential oils. The strongest recommendation in the guideline is that MBIs should be offered to people with cancer, both during active treatment and post-treatment, to address depression.

CONCLUSION

The evidence for integrative interventions in cancer care is growing, with research now supporting benefits of integrative interventions across the cancer care continuum.

Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer.

METHODS

The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008.

RESULTS

A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation.

RECOMMENDATIONS

Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

[Pharmacological pain management in cancer patients]

Pharmacological pain therapy in cancer patients is based on guideline recommendations, which, however, do not fully coincide in all aspects due to varying weighting of evidence. The present article discusses current issues including the decreasing significance of the World Health Organization (WHO) analgesic ladder, with its distinction between step 2 and 3 being increasingly questioned. Risks of nonopioid analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in older populations, are discussed. Paracetamol may potentially reduce the effectiveness of immunotherapies. Aspects of administering analgesics via a feeding tube are considered. Recommendations for the treatment of episodic pain, transitioning between different opioids, and some relevant interactions are also discussed.

Cannabis and Cannabinoids in Adults With Cancer: ASCO Guideline

PURPOSE

To guide clinicians, adults with cancer, caregivers, researchers, and oncology institutions on the medical use of cannabis and cannabinoids, including synthetic cannabinoids and herbal cannabis derivatives; single, purified cannabinoids; combinations of cannabis ingredients; and full-spectrum cannabis.

METHODS

A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and cohort studies on the efficacy and safety of cannabis and cannabinoids when used by adults with cancer. Outcomes of interest included antineoplastic effects, cancer treatment toxicity, symptoms, and quality of life. PubMed and the Cochrane Library were searched from database inception to January 27, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 13 systematic reviews and five additional primary studies (four RCTs and one cohort study). The certainty of evidence for most outcomes was low or very low.

RECOMMENDATIONS

Cannabis and/or cannabinoid access and use by adults with cancer has outpaced the science supporting their clinical use. This guideline provides strategies for open, nonjudgmental communication between clinicians and adults with cancer about the use of cannabis and/or cannabinoids. Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial. Cannabis and/or cannabinoids may improve refractory, chemotherapy-induced nausea and vomiting when added to guideline-concordant antiemetic regimens. Whether cannabis and/or cannabinoids can improve other supportive care outcomes remains uncertain. This guideline also highlights the critical need for more cannabis and/or cannabinoid research.Additional information is available at www.asco.org/supportive-care-guidelines.

Review of the Use of Medicinal Cannabis Products in Palliative Care

In this review, we discuss the potential role of cannabis and cannabinoids in the management of cancer-related symptoms. There is limited evidence demonstrating the effectiveness of cannabis-based products in treating cancer-related pain and gastrointestinal symptoms such as nausea, vomiting, and loss of appetite. Regarding the role of cannabis-based products in the treatment of insomnia and mood disorders, most studies looked at these symptoms as secondary outcomes with mixed results. Cannabis-based products have adverse effects, ranging from neuropsychiatric to systemic effects to potential drug interactions.

Immunotherapy and Cannabis: A Harmful Drug Interaction or Reefer Madness?

A retrospective (N = 140) and a prospective (N = 102) observational Israeli study by Bar-Sela and colleagues about cannabis potentially adversely impacting the response to immunotherapy have together been cited 202 times, including by clinical practice guidelines. There have also been concerns on PubPeer outlining irregularities and unverifiable information in their statistics and numerous errors in calculating percentages. This reanalysis attempted to verify the data analysis while including non-parametric statistics. The corrected prospective report contained 22 p-values, but only one (4.5%) could be verified despite the authors being transparent about the N and statistics employed. Cannabis users were significantly (p < 0.0025) younger than non-users, but this was not reported in the retrospective report. There were also errors in percentage calculations (e.g., 13/34 reported as 22.0% instead of 38.2%). Overall, these observational investigations, and especially the prospective, appear to contain gross inaccuracies which could impact the statistical decisions (i.e., significant findings reported as non-significant or vice-versa). Although it is mechanistically plausible that cannabis could have immunosuppressive effects which inhibit the response to immunotherapy, these two reports should be viewed cautiously. Larger prospective studies of this purported drug interaction that account for potential confounds (e.g., greater nicotine smoking among cannabis users) may be warranted.

Supporting gut health with medicinal cannabis in people with advanced cancer: potential benefits and challenges

The side effects of cancer therapy continue to cause significant health and cost burden to the patient, their friends and family, and governments. A major barrier in the way in which these side effects are managed is the highly siloed mentality that results in a fragmented approach to symptom control. Increasingly, it is appreciated that many symptoms are manifestations of common underlying pathobiology, with changes in the gastrointestinal environment a key driver for many symptom sequelae. Breakdown of the mucosal barrier (mucositis) is a common and early side effect of many anti-cancer agents, known to contribute (in part) to a range of highly burdensome symptoms such as diarrhoea, nausea, vomiting, infection, malnutrition, fatigue, depression, and insomnia. Here, we outline a rationale for how, based on its already documented effects on the gastrointestinal microenvironment, medicinal cannabis could be used to control mucositis and prevent the constellation of symptoms with which it is associated. We will provide a brief update on the current state of evidence on medicinal cannabis in cancer care and outline the potential benefits (and challenges) of using medicinal cannabis during active cancer therapy.

Factors Affecting the Decision on Cannabis Use in Gynecologic Cancer Patients After the Legalization of Cannabis

OBJECTIVE

To characterize the patterns of cannabis use among gynecologic cancer patients, in terms of potential factors influencing their decision-making on cannabis use, the reasons for use or non-use, and sources of information on cannabis use.

METHODS

From March to July 2022, gynecologic cancer patients at a clinic were interviewed and classified into 3 groups: current users, ex-users, and never-users. The received data included: demographic data, cannabis use details, reasons for using and not using, adverse events, satisfaction, and intent to use. Univariate and multivariate analysis were used to identify risk factors influencing decision-making.

RESULT

Among 240 participants, 11.67% were classified as current users, 28.33% as ex-users, and 60% as never-users. The significant factors influencing cannabis use decisions were advanced stage and receiving information on cannabis, regardless of the information source. The satisfaction derived from cannabis was due to the enhancement of mood and physical activity, improvement in sleep quality, stimulation of appetite, and mitigation of adverse events associated with cancer treatment. Approximately 60% of users aimed for a cancer cure. The main reasons for quitting were inability to obtain cannabis and absence of persistent cancer symptoms.

CONCLUSION

Among Thai patients with gynecologic cancer, 40% had a history of cannabis use. Advanced cancer stage was an independent factor for decision-making on cannabis use. Sources of information on cannabis are non-healthcare providers. Many patients intended to use cannabis for cancer cure. Also, many were satisfied with use because of a relief of unwanted symptoms, indirectly suggesting improvement in quality of life. The main reason for quitting was unavailability. The main reason for never trying was a concern of interference with treatment. Our results may guide the direction of strategy of cannabis use among patients with gynecologic cancers.

Drug Interactions of Tetrahydrocannabinol and Cannabidiol in Cannabinoid Drugs

BACKGROUND

Cannabinoid drugs containing tetrahydrocannabinol (THC), or its structural analogues, as monotherapeutic agents or as extracts or botanical preparations with or without cannabidiol (CBD) are often prescribed to multimorbid patients who are taking multiple drugs. This raises the question of the risk of drug interactions.

METHODS

This review of the pharmacokinetics and pharmacodynamics of interactions with cannabinoid drugs and their potential effects is based on pertinent publications retrieved by a selective literature search.

RESULTS

As THC and CBD are largely metabolized in the liver, their bioavailability after oral or oral-mucosal administration is low (6-8% and 11-13%, respectively). The plasma concentrations of THC and its active metabolite 11-OH-THC can be increased by strong CYP3A4 inhibitors (verapamil, clarithromycin) and decreased by strong CYP3A4 inductors (rifampicin, carbamazepine). The clinical significance of these effects is unclear because of the variable plasma level and therapeutic spectrum of THC. The metabolism of CBD is less dependent on cytochrome P450 enzymes than that of THC. THC and CBD inhibit CYP2C and CYP3A4; the corresponding clinically relevant drug interactions probably are likely to arise only with THC doses above 30 mg/day and CBD doses above 300 mg/day.

CONCLUSION

Potential drug interactions with THC and CBD are probably of little importance at low or moderate doses. Strong CYP inhibitors or inductors can intensify or weaken their effect. Slowly ramping up the dose of oral cannabinoid drugs can lessen their pharmacodynamic interactions, which can generally be well controlled. Administration by inhalation can worsen the interactions.