ASCO guideline helps clinicians address cannabis use ‘head on’ with their patients
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Broader accessibility to and use of cannabis and cannabinoids has created formidable challenges for clinicians who treat people with cancer.
An increasing number of patients are opting to use these products for relief of pain, anxiety or other symptoms — and, in some cases, because they believe it may treat their underlying cancer. However, level-one evidence about the impact of these products in the cancer setting remains limited.
ASCO convened an expert panel to develop clinical practice guidelines to close this gap.
“Access to cannabis and cannabinoids has far outpaced the science supporting their use,” guideline co-chair Eric Roeland, MD, FASCO, FAAHPM, associate professor of medicine in the division of hematology/oncology at Oregon Health & Science University’s Knight Cancer Institute, told Healio. “Another major challenge in the [cancer] space is that it feels taboo to talk about cannabis, and clinicians may be hesitant to do so. Health care systems are not approaching this topic head on.”
Roeland and colleagues searched the scientific literature for systematic reviews, randomized controlled trials, and cohort studies that addressed the safety and efficacy of cannabis and cannabinoids for adults with cancer.
Their guidelines aim to answer several key questions, including how clinicians can better communicate with patients about cannabis; whether cannabis or cannabinoid use by adults can improve cancer-directed treatment; and whether these products can decrease treatment-related toxicities, relieve cancer symptoms, and improve quality of life.
Healio spoke with Roeland about the need for these guidelines, the panel's key recommendations, and what questions remain unanswered.
Healio: How prevalent is cannabis use among adults with cancer?
Roeland: There is wide variation in the reporting of cannabis use in the literature. Based on our review, it was about 40%. However, the challenge is that when we send out surveys, the people who are most likely to respond are those who are using it or are interested in using it.
Healio: Why has scientific evidence regarding cannabis use lagged behind its availability to consumers?
Roeland: We outline multiple reasons in the guidelines. The one that stands out to me is the federal classification of cannabis as a Schedule I substance, aligned with psychedelics and cocaine. Historically, if someone in the United States wanted to research the applications of cannabis to clinical care, they’ve had to apply for a Schedule I license, and then they’d be limited to getting the product from a single farm in Mississippi. There have been reports that the quality of that cannabis is not as good as what patients can now get in dispensaries.
The Biden administration may be approaching that topic and reclassifying cannabis, which could be a game-changer for those wanting to study cannabis further and build the evidence base to support indications for use.
Healio: How has clinician hesitancy to discuss cannabis affected care for people with cancer?
Roeland: Clinicians and health care systems are not providing clear guidance and educational materials to patients and caregivers regarding safe cannabis and cannabinoid use. As clinicians, we frequently talk about very challenging topics with our patients; this is just one of them. Patients already have access to these products, and they use them. Some of us are wondering why we aren’t talking about them. This phenomenon is especially true given the fact that they may be using other routinely prescribed medications, such as opioids and benzodiazepines. When you use cannabis in combination with those drugs, it can increase the risk for delirium, falls or hospitalization. Without clear communication and education from trusted oncologists and oncology teams, patients and caregivers are turning to dispensaries. The people behind the counter at dispensaries are very knowledgeable about cannabis and, frequently, the staff use these products. They may be speaking from firsthand experience, but they lack awareness of cancer treatments and their side effects. Some patients are very fatigued and frail. Adding a medicine like this — which might cause confusion or sedation — can increase the risk for things like falls and ED visits.
Healio: What are some of the key recommendations in the guidelines?
Roeland: Our first real focus was on communication and education. Clinicians routinely face questions regarding cannabis and cannabinoids, and we shouldn’t be afraid to talk about their use.
I don’t feel we should point fingers at oncologists and say, “Here’s another thing you need to do with all your patients,” because I know there are already so many tasks oncologists must address. However, we must partner with health care systems to create evidence-based educational materials and forums for practicing clinicians. We want them to feel more comfortable about all of this.
Another key takeaway is that, overall, the evidence to support the use of cannabis and cannabinoids is low, except in the setting of refractory chemotherapy-induced nausea and vomiting. Notably, there is no high-quality clinical evidence to support the use of cannabis or cannabinoids for treating cancer.
We address this in Appendix 1 of the ASCO guideline. This appendix is a great tool that can be easily accessed through Journal of Clinical Oncology. A clinician can print this one page and hand it to patients.
The last key point is that things are changing. With a possible change in the federal designation of cannabis, we may be able to study this more rigorously, especially in our patient population.
Healio: Is there anything else you’d like to mention?
Roeland: As an oncology community, we need to support the prioritization of research in this space and encourage our patients to participate in clinical trials. We need more information to optimize the care of people living with cancer.
If I could encourage my colleagues to do one thing in the clinic, it would be to try to figure out why their patients want to use cannabis. For some, it can be about improving symptoms, such as appetite, sleep, or pain. However, other patients are actually using cannabis to treat the underlying cancer. Patients are hearing from unvetted sources that cannabis can treat or even cure cancer, especially when taken in very high doses. Any data suggesting an impact on the cancer comes from the preclinical setting. I want to underscore that we have no high-quality, gold-standard clinical data in humans to demonstrate that cannabis can be used instead of evidence-based cancer treatment or even to augment their existing cancer treatment. There is no evidence that it works.
Reference:
For more information:
Eric Roeland, MD, FASCO, FAAHPM, can be reached at @MDRoeland on X (Twitter).
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