Nearly half of U.S. breast cancer patients use pot, CBD, don’t tell doctors
When Brooklyn-based mom and fashion designer Suzanne Weiner began treatment for breast cancer three years ago, her medical marijuana card was her best friend.
“Pot helped me tremendously with the anxiety and stress of my diagnosis,” she said. “I was a mess.” Weiner still smokes marijuana regularly to help lessen the side effects of an ongoing treatment that helps keep her cancer at bay.
She’s not alone. Almost half of all people with breast cancer use marijuana or CBD, often during treatment to ease side effects including pain, anxiety, insomnia and nausea, according to a new online survey.
While Weiner discussed her cannabis use with her doctors, who she said were both knowledgeable and supportive, this isn’t always the case. Many patients don’t talk to their doctors about it, the survey revealed.
This is risky, according to survey author Dr. Marisa Weiss, founder and chief medical officer of Breastcancer.org and Breasthealth.org in Ardmore, Pa.
“Some chemotherapy drugs are broken down by the same part of the liver that cannabis is, and you don’t want to overtax the liver,” she said. And, “smoking or vaping when receiving radiation or other therapies to your chest could affect lung function.”
Cannabis isn’t necessarily bad for you, and it may very well have some benefits, Weiss said.
Like Weiner, 75% of survey respondents who used cannabis said it was extremely or very helpful in relieving their symptoms. “These symptoms are wearing them down thin and interfering with quality of life and ability to finish treatment,” Weiss said.
Of 610 adults who were diagnosed with breast cancer within the past five years, 42% said they used cannabis for symptom relief. Of these, 79% used cannabis products during breast cancer treatment, the survey showed.
Patients used both THC and CBD products, with a majority preferring CBD, or cannabidiol.
CBD is derived from hemp, a cousin of the marijuana plant, but unlike THC, or delta-9-tetrahydrocannabinol, the active component in marijuana, CBD won’t get you high.
On average, survey respondents used more than three types of cannabis products including gummies, inhalables or extracts.
The survey also revealed some disconnects about cannabis.
Nearly half of users thought cannabis could treat cancer — but it can’t. Many assumed it was 100% safe — and it’s not, Weiss said.
A possible reason for these disconnects? Most people got their information on cannabis from family, friends and the internet, not their doctor, the survey revealed.
Weiss said it should be “do ask, do tell” when it comes to cannabis use during cancer treatment.
“It is important to let your doctor know that you have these symptoms and that you want to learn more about cannabis and also ask if there are other therapies for these symptoms,” she said.
People are reluctant to talk to their doctor about cannabis use for several reasons.
“Marijuana is still illegal at the federal level so that may inhibit people from talking to their doctor, and some may be fearful that it could be placed on their medical records,” Weiss said. “Others don’t want to be judged and don’t think their doctor is likely to know much about it anyway.”
If your doctor isn’t willing to at least have the discussion, consider finding one who is knowledgeable about cannabis or is open to learning more, she suggested.
Such knowledge is critical now that cancer is a qualifying condition in nearly all states with medical cannabis programs, Weiss pointed out.
The findings were published Tuesday in the journal Cancer.
While cannabis may help with some symptoms of cancer and/or its treatments, outside experts noted that risks and unknowns remain.
Dr. Stephanie Bernik, chief of breast surgery at Mount Sinai West in New York City, noted there is limited data regarding cannabis use and interactions with chemotherapy.
“Patients should discuss cannabis use with their doctors so that there can be a clear understanding of possible adverse events,” she said. THC risks may include dizziness, racing heartbeats and paranoia, while CBD may cause drowsiness and reduced appetite.
“More studies need to be done to find ideal ways to allow patients to use cannabis in a more controlled fashion,” Bernik said.
Just because something is natural and plant-based doesn’t mean it’s 100% safe, agreed Dr. Nirupa Raghunathan, who runs the medical cannabis clinic at Memorial Sloan Kettering Cancer Center in New York City.
“Cannabis is not necessarily benign, and there can be negative side effects and risks of interactions with your treatment,” she said.
It’s also buyer beware when purchasing cannabis products, Raghunathan said. Many CBD products, in particular, don’t contain what is listed on their label.
Your best bet is to buy products through a state-run marijuana dispensary, Raghunathan said.
Marijuana Is a Wonder Drug When It Comes to the Horrors of Chemo
After a successful surgery to remove a cancer-ridden section of Jeff Moroso’s large intestine in the spring of 2013, the oncologist sat down with his patient to prepare him for what would come next: 12 rounds of punishing chemotherapy, once every two weeks for six months—standard practice for the treatment of colon cancer.
Moroso’s oncologist spent most of that appointment writing prescriptions for medications he said would minimize the debilitating side effects of chemotherapy. He gave Moroso scripts for ondansetron (Zofran) and prochlorperazine (Compazine) for nausea, and lorazepam (Ativan) for anxiety and insomnia. Because the nausea drugs are known to cause gastrointestinal problems and headaches, he also recommended three over-the-counter medications for constipation and one for diarrhea, as well as ibuprofen for pain. In total, he instructed Moroso to take more than a dozen prescription and nonprescription drugs and supplements.
Moroso says the first three rounds of treatment were more awful than he could have ever imagined. After chemotherapy, he felt so ill and weak that he could barely stand up, and it took him days to rebound. And the prescription drugs just made him feel worse. “I felt real sick, incapable of doing anything except for lying there and trying to hang on,” says Moroso, who is 70 and now cancer-free.
Moroso couldn’t afford to lose days of work while he was doing his chemo. He’d heard from friends and read in the paper that cannabis can help a patient through chemotherapy, so he got a letter from his oncologist that allowed him to obtain medical marijuana. (He chose coffee beans infused with 5 milligrams of cannabis, a low dose that he took when he felt he had to.) By the seventh round of chemotherapy, Moroso had dumped his prescription pills. “I would get blasted on the stuff and be happy as a clam, no problems,” he says.
A growing number of cancer patients and oncologists view the drug as a viable alternative for managing chemotherapy’s effects, as well as some of the physical and emotional health consequences of cancer, such as bone pain, anxiety and depression. State legislatures are following suit; medical cannabis is legal in 23 states and the District of Columbia, and more than a dozen other states allow some patients access to certain potency levels of the drug if a physician documents that it’s medically necessary, or if the sick person has exhausted other options. A large number of these patients have cancer, and many who gain access to medical marijuana report that it works.
“A day doesn’t go by where I don’t see a cancer patient who has nausea, vomiting, loss of appetite, pain, depression and insomnia,” says Dr. Donald Abrams, chief of hematology-oncology at San Francisco General Hospital and a professor of clinical medicine at the University of California, San Francisco. Marijuana, he says, “is the only anti-nausea medicine that increases appetite.”
It also helps patients sleep and elevates their mood—no easy feat when someone is facing a life-threatening illness. “I could write six different prescriptions, all of which may interact with each other or the chemotherapy that the patient has been prescribed. Or I could just recommend trying one medicine,” Abrams says.
A 2014 poll conducted by Medscape and WebMD found that more than three-quarters of U.S. physicians think cannabis provides real therapeutic benefits. And those working with cancer patients were the strongest supporters: 82 percent of oncologists agreed that cannabis should be offered as a treatment option.
Dr. Benjamin Kligler, associate professor of family and social medicine at Albert Einstein College of Medicine, says there has been enough research to prove that at a bare minimum cannabis won’t actually harm a person. In addition, “given what we’ve seen anecdotally in practice I think there’s no reason we shouldn’t see more integration of cannabis in the long run as a strategy,” he says. “We have this extremely safe, extremely useful medicine that could potentially benefits a huge population.”
Some years ago, Dr. Gil Bar-Sela, director of the integrated oncology and palliative care unit at the Rambam Health Care Campus in Haifa, Israel conducted two rounds of phone interviews with 131 cancer patients who used cannabis while in chemotherapy; just less than 4 percent of participants reported that they experienced a worsening of symptoms when they started using cannabis and the majority said it helped, according to the resulting paper published, in Evidence-Based Complementary and Alternative Medicine in 2013.
But self-reported data like this is limited when it comes to proving the clinical impact of cannabis. Patients may be biased in their opinions that cannabis is effective, may not accurately document their use of the drug, or may confuse the effects with those of the cancer treatment. In addition, symptoms such as pain are subjective and difficult for a physician to measure.
A paper published recently in JAMA analyzed the findings of 79 studies on cannabinoids for a variety of indications, including nausea and vomiting from chemotherapy, appetite stimulation for patients with HIV/AIDS, chronic pain and multiple sclerosis, among other conditions. This review, which accounted for 6,462 patients, found most who used cannabinoids reported improvements to symptoms compared with patients in placebo groups. However, the researchers say these improvements were not statistically significant. The analysis also indicated that cannabinoids had limited impact on symptoms of nausea and vomiting, and a number of patients reported adverse effects from the drug, including dizziness, disorientation, confusion and hallucinations.
Perhaps the biggest challenge in understanding marijuana stems from the fact that it is not a bespoke drug designed to act in a specific way on the body — it’s a complex plant that appears to provide a wealth of health benefits. The cannabis sativa plant contains more than 85 cannabinoids, a variety of chemical compounds that also exist in the body. Just as opioid pills activate the opioid receptors (and limit a person’s perception of pain), cannabinoids in marijuana activate the cannabinoid receptors, located throughout the body, including in the brain, liver and immune system.
To date, we really know about only two of these cannabinoids: tetrahydrocannabinol and cannabidiol. Research into THC and CBD has led to the development of drugs such as dronabinol (Marinol), a synthetic cannabinoid approved by the U.S. Food and Drug Administration for nausea and vomiting from chemotherapy and as an appetite stimulant, anti-nausea and anti-pain medication for AIDS patients. Nabiximols (Sativex), another cannabinoid drug, is THC and CBD that is derived from the plant and delivered as a mouth spray. It’s available in Europe and several other countries—but not yet FDA-approved—for multiple sclerosis patients to treat neurological pain and spasticity. One study on nabiximols for the treatment of cancer-related pain produced disappointing results. However, the GW Pharmaceutical Company, the maker of Sativex, is pushing through with further trials to evaluate the drug as a potential adjunctive therapy for opioids for pain management in patients with advanced cancer.
But how other cannabinoids work together is still much of mystery, says Dr. David Casarett, a professor of medicine at the University of Pennsylvania’s Perelman School of Medicine and the author of Stoned: A Doctor’s Case for Medical Marijuana. This means researchers aren’t entirely sure why the plant could help people manage symptoms like nausea and pain. “Marijuana is not as much of a science as it should be,” he says.
In large part, says Casarett, that’s because medical marijuana has proved to be most effective in palliative care, the medical specialty that focuses on managing symptoms of disease and improving a patient’s quality of life—and there is very little funding for palliative care in this country. “That’s changing slowly,” he says, “but it’s still much easier to get funding to test disease-modifying treatments than it is to develop and test palliative therapies, including cannabis.”
We are starting to get some idea of the palliative power of cannabis, Abrams says. “The reason we think we have this whole pathway of the receptors and the endocannabinoids is to get us to forget things, and particularly to get us to forget pain,” he says. In addition, cannabinoids relieve symptoms of nausea because that’s also a physiological reaction stemming from the central nervous system.
With the public perception of marijuana changing rapidly, barriers to studying the plant’s medicinal potential are beginning to fall. Earlier this spring, for example, the Obama administration announced it would remove some of the restrictions on medical marijuana research. In the meantime, though, it is clear that marijuana has a unique and important role to play in cancer care.
“People are realizing that even when patients do well in terms of survival, there’s a lot of suffering along the way that needs to be addressed,” says Casarett. “For many patients, [marijuana] is an opportunity to take control over their disease and symptom management when they can’t get the relief they need from the health care system.”
This article is one in a series from Newsweek ‘s 2015 Cancer issue, exploring challenges and innovations in cancer treatment and research. The complete issue is available online and at newsstands.
Flower Power: Medical Cannabis for Cancer Side Effect Management
Nearly two decades have passed, but Stacy Sklaver still remembers the overwhelming nausea. Her doctor was treating her breast cancer with a six-month course of the chemotherapies doxoru­bicin, cyclophosphamide and paclitaxel, and she thought the drugs were more likely to kill her than the disease.
“I remember the stuff was so toxic that nurses wore gloves to prevent it from burning the skin on their hands,” says Sklaver, now 60, who typically became nauseated a couple of days after treatment and got no relief from Zofran (ondansetron), the anti-nausea drug her doctor prescribed. “I remember getting up a couple hours after going to bed and spending four hours or more doubled over my toilet and vomiting.”
That was long before the days of legal medical marijuana, but a friend had read that cannabis could help ease nausea, and her doctor said it might work, so Sklaver decided to give it a try. She now regards that as one of the better decisions in her life.
“It didn’t entirely eliminate the nausea and vomiting, but it got pretty close. I could make myself eat,” says Sklaver, who typically smoked a joint before bed a few times a week during the worst part of each chemotherapy cycle and then gave it up after treatment. “It also eliminated the pain that bad nausea creates in every part of your body. I wasn’t functioning normally because I still had the exhaustion, but at least I wasn’t miserable.”
Sklaver’s experience vividly illustrates the one proven effect of cannabis’s most active ingredient in patients with cancer: control­ling nausea and vomiting. Her strong belief that any sick adult should be able to access marijuana legally illustrates why medical marijuana laws have become common in the years since her chemotherapy.
STACY SKLAVER found that cannabis relieved nausea from chemotherapy that prescribed drugs did not.
Thirty-three state legislatures have legal­ized medical marijuana for a wide variety of conditions, and their counterparts in 13 other states allow its use in limited circum­stances. Their actions stem from a growing belief that for patients struggling with symptoms such as pain, anxiety, insomnia and loss of appetite, the positive effects of cannabis outweigh any negatives associated with the drug.
With the exception of data about its anti-nausea and appetite stimulating powers, there is, however, surprisingly little evidence, either positive or negative, regarding the medical uses of cannabis or its active ingre­dients, collectively known as cannabinoids.
Studies of marijuana are relatively few and weak. It’s next to impossible to conduct large, randomized, controlled trials on a substance that the federal government bans, so the research consists mostly of small, short trials; user surveys; and statistical analysis of information collected for other purposes. It might still be possible to make some broad assertions about medical marijuana if most of those researchers had reached similar conclusions, but they didn’t. Some findings, for example, suggest that whole cannabis or individual cannabinoids control cancer pain about as well as opioids; others find no significant effect on pain.
Currently, patients with cancer have just two thoroughly researched, fully validated options for adding marijuana derivatives to their treatment regimens: the medications Marinol or Syndros (dronabinol) and Cesamet (nabilone). Both are standardized, synthetic oral cannabinoids that have been approved by the Food and Drug Administration (FDA) for treating nausea and vomiting caused by chemotherapy. Patients considering the use of other cannabinoids need to talk to their physicians, read the research, consider other relevant factors (like cost) and make their own decisions.
Those who decide in favor of the drug are not alone. “The rise of medical marijuana is much more of a political and popular movement than a medical movement. No dramatic new research justifies the wave of legislation on this issue. It was popular sentiment,” says Mellar Davis, M.D., who wrote a research review on cannabinoids and cancer treatment for the Journal of the National Comprehensive Cancer Network.
THE SEARCH FOR EVIDENCE
Cannabis is a flowering plant that originated in central Asia. The greatest concentrations of cannabinoids typi­cally occur in the flowers and the resin, a viscous goo the plant secretes. (The substance called marijuana, weed or pot consists of dried flower buds, whereas the substance called hashish consists of resin.) People in far-flung parts of the world have been using cannabis flowers and resin for both recreational and medicinal purposes since early in the human experience. Its use as a medicine likely started in Asia around 500 B.C., according to history.com.
A cannabis plant contains more than 400 chemical entities, including more than 60 cannabinoids. The vast majority of research to date has focused on just two of them: tetrahydrocannabinol (THC) and cannabidiol (CBD). Both THC and CBD contain 30 hydrogen atoms, 21 carbon atoms and two oxygen atoms, but they’re arranged a bit differently, so they bind to different receptors in the body. THC binds directly to canna­binoid receptor 1, which sends signals to the brain, creating the psychoactive effects that are gener­ally described as “getting high.” CBD binds to cannabinoid receptor 2, which does not get users high.
These receptors are there to bind to the natural cannabinoids (similar to plant cannabinoids) that our bodies manufacture. These cannabinoids are among many neurotransmitters (such as dopamine, for instance) made by our brains and other tissues, which bind to receptors and enable different aspects of brain physiology related to mood, emotion and more.
Most studies done on the subject agree that THC significantly reduces nausea, vomiting and weight loss due to chemotherapy and other conditions. The largest of those trials led to the FDA approvals of dronabinol and nabilone. (Dronabinol is identical to the THC in cannabis, although it’s made in a factory rather than extracted from a plant, whereas nabilone is a man-made molecule that acts very much like THC in the body.) An analysis that combined results from 30 trials involving a collective 1,366 patients found that among patients taking chemotherapy, THC better controlled nausea and/or vomiting than the anti-nausea drugs prochlorpera­zine, metoclopramide, chlorpromazine, thiethylperazine, haloperidol, domperidone or alizapride.
The evidence that THC can safely reduce cancer-related pain is decidedly more mixed. Positive results include those of an observational study that found significantly less cancer-related pain in 47 nabilone users than in 65 nonusers. A review of nine pain-reduction trials, five of which focused on cancer pain, concluded that THC controlled pain about as well as codeine but noted that depressant effects on the central nervous system often limited the use of THC; the researchers described most of its side effects as “psychotropic.” Other analyses of multiple trials, however, revealed just a small benefit, and THC, used in conjunction with opioids, did no better than placebo and opioids in a trial that randomly assigned 177 opioid-using patients with cancer to take THC, placebo or Sativex (nabiximols), which combines THC and CBD.
Sativex, which is approved in many countries but not the U.S., significantly reduced cancer-related pain in that study, but it’s no magic bullet. Other randomized trials of the drug found few significant benefits for pain stemming from cancer and other conditions in more than 500 patients.
Researchers looking into dronibanol, nabilone and every other form of THC all conclude that it has significant mind-altering properties. Some patients find that these improve mood and spur relaxation. Though there is little evidence of patients becoming addicted to or abusing either FDA-approved drug, these effects come with significant drawbacks: Some patients hate them, they render all users unable to legally drive a car, and they leave some unable to work productively.
None of those downsides come with CBD, which is regulated in many states like a supplement such as echinacea or green tea extract. Would-be users can find dozens of formulations on Amazon.com that are advertised as able to reduce pain or improve sleep, all for under $50. However, as with many other supplements, there is little regulatory oversight to guarantee that the bottles’ contents match their labels, and little scientific evidence supports their efficacy. That may change, however. The FDA recently approved Epidiolex, a pharmaceutical company’s version of CBD, for the treatment of seizures related to two rare conditions. Researchers have also begun to study a range of possible benefits of CBD usage, including pain relief and immuno­modulation, but right now, scant published data suggests that isolated CBD can help any of the symptoms associated with cancer.
DOES CANNABIS FIGHT CANCER?
Some preliminary work does suggest that CBD may help stave off some types of cancer. Researchers have found that CBD induces programmed cell death in breast cancer cells cultivated in the lab; inhibits expression of the Id-1 gene, interfering with the proliferation and invasion of breast cancer cells; and protects against induced colon cancer in mice.
Findings from studies of lab samples and animals also showed that CBD and THC can slow the progression of brain tumors called glioblastomas, which have a very high number of cannabinoid receptors. The exact mechanism of tumor growth inhibition is unknown. What’s more, a 2018 study in 23 patients with glioblastoma noted that those who used at least 50 mg of cannabinoids per day for at least a month were more likely than other patients to be alive both one year (80 percent versus 74 percent) and two years (73 percent versus 65 percent) after beginning treatment.
On the other hand, preliminary evidence suggests that cannabis may reduce the efficacy of the immunotherapy Opdivo (nivolumab), so patients need to weigh potential costs and benefits and keep their doctors informed of their choices. Opdivo is approved to treat colorectal cancer and is being tested in glioblastoma and breast cancer in clinical trials.
“I’m continuing to track my two groups of glioblastoma patients, and outcomes among the patients who used the higher doses of cannabinoids continue to be good by the very poor standards of glioblastoma patients,” says Nicholas Blondin, M.D., an assistant professor of clinical neurology at Yale School of Medicine. “Is the data from this small observational study proof of benefit? No, not even close. But I believe it’s definitely interesting enough to justify more research.”
THE CHALLENGES OF STUDYING CANNABIS
Blondin’s study illustrates one way that recent laws allowing the use of medical marijuana increase our ability to research its effects: They provide the chance to observe differences in outcomes among patients who do and don’t seek access to dispensaries. Unfortunately for those who wish to perform cannabis research, state laws don’t eliminate the many remaining obstacles to well-controlled trials. The Drug Enforcement Agency (DEA) still classifies cannabis as a schedule 1 drug — it’s considered to have high potential for abuse but no proven medical uses. As a result, researchers who wish to conduct clinical studies of it must file an investigational new drug application with the FDA, obtain a schedule 1 license from the DEA and get approval from the National Institute on Drug Abuse.
Some researchers work through this process to perform quality studies, but not many. A scholarly article that appeared in 2015, just before CURE ® published its last over­view of cannabis in cancer care, sought to round up all the quality research that had been performed on the medical effects of cannabis or natural cannabinoids in human subjects. Its authors scoured 50 years of academic journals and found just two trials that merited inclusion.
In the first study, 50 HIV patients received either three marijuana or three placebo cigarettes daily for five days. (Researchers made the placebos convincing by removing the active ingredients but not the distinctive smell or taste from marijuana.) The actual cannabis reduced the daily pain that patients reported by 34 percent, whereas the placebo reduced pain just 17 percent. For the second study, 39 patients with neuropathic pain took 12 puffs of 1.29 percent vaporized cannabis, 3.53 percent vaporized cannabis or placebo. Both doses of cannabis performed better than placebo and similar to widely used pain medications, but the higher dose produced no better results than the lower dose.
Because of the lack of data and FDA approvals, health insurers generally don’t cover cannabis, even in states where medical marijuana is legal. None of the experts interviewed for this story had heard of a patient getting reimbursed for cannabis expendi­tures, which are significant. Prices vary by state, but estimates online put the monthly cost of medical marijuana above $200.
Still, neither cost nor uncertainty about effectiveness deters a significant percentage of patients with cancer from using medical marijuana. An anonymous survey of adult patients at a large cancer center in Washington state, where medical marijuana is legal, found that 24 percent of 926 respondents had used cannabis in the past year and that 21 percent of them had used it in the past month. Looking just at active users, 70 percent consumed inhaled cannabis products and 70 percent consumed edibles.
Those patients with cancer who do use medical marijuana seem to be pretty satisfied with it. An analysis of data that providers collected from about 2,970 cancer patients who used medical marijuana between 2015 and 2017 looked at why patients turned to cannabis and found the most common symptoms they hoped to treat were sleep problems (78.4 percent), pain (77.7 percent), weakness (72.7 percent), nausea (64.6 percent) and lack of appetite (48.9 percent). After six months of follow-up, 902 patients had died and 682 had stopped the treatment. Of the remaining 1,211, almost all —96 percent — reported an improvement in whatever condition they were trying to treat with cannabis.