Medical marijuana in pediatric oncology: A review of the evidence and implications for practice

Cannabinoids for symptom management in children with cancer: It's complicated

Data surrounding the use of cannabinoids for symptom management in children with cancer are heterogeneous and extremely limited. Well‐designed clinical trials with specific indications, products, and outcome metrics are required before cannabinoids should be considered in frontline cancer care in children.

Clinical outcomes of medical treatments for progressive desmoid tumors following active surveillance: a systematic review

Approximately 80% of desmoid tumors (DTs) show spontaneous regression or disease stabilization during first-line active surveillance. Medical treatment can be considered in cases of disease progression. This systematic review aimed to evaluate the effectiveness and toxicity of each medical treatment by reviewing only the studies that included progressive disease as the inclusion criterion. We searched the EMBASE, PubMed, and CENTRAL databases to identify published studies for progressive DTs. The disease control rates of the medical treatments, such as low-dose chemotherapy with methotrexate plus vinblastine or vinorelbine, imatinib, sorafenib, pazopanib, nilotinib, anlotinib, doxorubicin-based agents, liposomal doxorubicin, hydroxyurea, and oral vinorelbine for progressive DTs were 71-100%, 78-92%, 67-96%, 84%, 88%, 86%, 89-100%, 90-100%, 75%, and 64%, respectively. Low-dose chemotherapy, sorafenib, pazopanib, nilotinib, anlotinib, and liposomal doxorubicin had similar toxicities. Sorafenib and pazopanib were less toxic than imatinib. Doxorubicin-based chemotherapy was associated with the highest toxicity. Hydroxyurea and oral vinorelbine exhibited the lowest toxicity. Stepwise therapy escalation from an initial, less toxic treatment to more toxic agents is recommended for progressive DTs. Sorafenib and pazopanib had limited on-treatment side effects but had the possibility to induce long-term treatment-related side effects. In contrast, low-dose chemotherapy has some on-treatment side effects and is known to have very low long-term toxicity. Thus, for progressive DTs following active surveillance, low-dose chemotherapy is recommended in young patients as long-term side effects are minor, whereas therapies such as sorafenib and pazopanib is recommended for older patients as early side effects are minor.

Medical cannabis in schools: A qualitative study on the experiences of clinicians

Objectives

Guidance is lacking for medical cannabis use in Canadian schools in both legislation and approach; the impact of ambiguous policy on patient care is unknown. A qualitative study was undertaken to explore the experiences of clinicians who care for school-aged children who take medical cannabis.

Methods

Semi-structured interviews were recorded and transcribed verbatim. Qualitative content analysis performed using the Dedoose qualitative software ascribed meaning units and codes, which were further consolidated into categories and subcategories.

Results

Thirteen physicians were interviewed virtually, representing seven provinces in Canada. The physicians provided care for between five and hundreds of school-aged children who took medical cannabis. The most common indications were refractory seizure disorders and autism. The interviews provided rich descriptions on perceptions of medical cannabis in schools, and in general. Five overarching categories were identified across both domains including variability, challenges (subcategories: lack of knowledge, stigma, lack of policy, and pragmatic challenges), potential solutions (subcategories: treat it like other medications, communication, education, and family support), positive experiences and improvements over time.

Conclusion

In Canada, cannabis-based medicine use in schools still faces important challenges. Effective education, communication, family support and policy refinements that allow cannabis to be treated like other prescription medications are recommended to improve the status quo. These findings will guide the C4T Medical Cannabis in Schools Working Group’s future priorities and initiatives.

Managing Pain and Discomfort in Children with Cancer

PURPOSE OF REVIEW

Approximately 15,600 children are diagnosed with cancer annually. Many of these children have cancer-related pain that improves with cancer treatment, but some develop intractable pain from cancer progression or sequelae from treatment modalities. The purpose of this paper is to provide a critical evaluation of the literature relevant to pain management in children with cancer. We intend to emphasize important and up-to-date findings in pharmacology, interventional pain management, and complementary and alternative medicine.

RECENT FINDINGS

Alternative medications and routes of administration, complementary and alternative medicine techniques, and interventional pain procedures offer possible routes for a multi-pronged pediatric cancer pain management plan, although high-level data is often lacking. To improve pediatric cancer pain management, a multifaceted approach embracing the biopsychosocial model of pain is recommended, incorporating evidence-based pharmacology, complementary and alternative medicine techniques, and if needed, interventional pain procedures.

Medical Cannabis in Pediatric Oncology: Friend or Foe?

The antineoplastic effects of cannabis have been known since 1975. Since the identification of the components of the endogenous cannabinoid system (ECS) in the 1990s, research into the potential of cannabinoids as medicine has exploded, including in anti-cancer research. However, nearly all of this research has been on adults. Physicians and governing bodies remain cautious in recommending the use of cannabis in children, since the ECS develops early in life and data about cannabis exposure in utero show negative outcomes. However, there exist many published cases of use of cannabis in children to treat pediatric epilepsy and chemotherapy-induced nausea and vomiting (CINV) that show both the safety and efficacy of cannabis in pediatric populations. Additionally, promising preclinical evidence showing that cannabis has anti-cancer effects on pediatric cancer warrants further investigation of cannabis' use in pediatric cancer patients, as well as other populations of pediatric patients. This review aims to examine the evidence regarding the potential clinical utility of cannabis as an anti-cancer treatment in children by summarizing what is currently known about uses of medical cannabis in children, particularly regarding its anti-cancer potential.

Therapeutic Targets in Diffuse Midline Gliomas-An Emerging Landscape

Simple Summary

Diffuse midline gliomas (DMGs) remain one of the most devastating childhood brain tumour types, for which there is currently no known cure. In this review we provide a summary of the existing knowledge of the molecular mechanisms underlying the pathogenesis of this disease, highlighting current analyses and novel treatment propositions. Together, the accumulation of these data will aid in the understanding and development of more effective therapeutic options for the treatment of DMGs.

Abstract

Diffuse midline gliomas (DMGs) are invariably fatal pediatric brain tumours that are inherently resistant to conventional therapy. In recent years our understanding of the underlying molecular mechanisms of DMG tumorigenicity has resulted in the identification of novel targets and the development of a range of potential therapies, with multiple agents now being progressed to clinical translation to test their therapeutic efficacy. Here, we provide an overview of the current therapies aimed at epigenetic and mutational drivers, cellular pathway aberrations and tumor microenvironment mechanisms in DMGs in order to aid therapy development and facilitate a holistic approach to patient treatment.

Cannabis, a Miracle Drug with Polyvalent Therapeutic Utility: Preclinical and Clinical-Based Evidence

Cannabis sativa L. is an annual herbaceous dioecious plant which was first cultivated by agricultural human societies in Asia. Over the period of time, various parts of the plant like leaf, flower, and seed were used for recreational as well as therapeutic purposes. The main chemical components of Cannabis sativa are termed as cannabinoids, among them the key psychoactive constituent is Δ-9-tetrahydrocannabinol and cannabidiol (CBD) as active nonpsychotic constituent. Upon doing extensive literature review, it was found that cannabis has been widely studied for a number of disorders. Very recently, a pure CBD formulation, named Epidiolex, got a green flag from both United States Food and Drug Administration and Drug Enforcement Administration for 2 rare types of epilepsies. This laid a milestone in medical cannabis research. This review intends to give a basic and extensive assessment, from past till present, of the ethnological, plant, chemical, pharmacological, and legal aspects of C. sativa. Further, this review contemplates the evidence the studies obtained of cannabis components on Alzheimer's, Parkinson's, amyotrophic lateral sclerosis, multiple sclerosis, emesis, epilepsy, chronic pain, and cancer as a cytotoxic agent as well as a palliative therapy. The assessment in this study was done by reviewing in extensive details from studies on historical importance, ethnopharmacological aspects, and legal grounds of C. sativa from extensive literature available on the scientific databases, with a vision for elevating further pharmaceutical research to investigate its total potential as a therapeutic agent.

Cardiac Transplantation and the Use of Cannabis

Cardiac transplantation requires the careful allocation of a limited number of precious organs. Therefore, it is critical to select candidates that will receive the greatest anticipated medical benefit but will also serve as the best stewards of the organ. Individual transplant teams have established prerequisites pertaining to recreational drug, tobacco, alcohol, and controlled substance use in potential organ recipients and post-transplantation. Legalization of cannabis and implementation of its prescription-based use for the management of patients with chronic conditions have been increasing over the past years. Center requirements regarding abstinence from recreational and medical cannabis use vary due to rapidly changing state regulations, as well as the lack of clinical safety data in this population. This is evident by the results of the multicenter survey presented in this paper. Developing uniform guidelines around cannabis use will be imperative not only for providers but also for patients.

Thromboangiitis Obliterans (Buerger's Disease) in an Adolescent Male

Arterial occlusive disease of the limb is very rare in children. Buerger's disease (BD) is a nonatherosclerotic, segmental inflammatory arteritis affecting the small and medium-sized vessels of the extremities. We report BD in a 16-year-old male presenting with arterial insufficiency of left foot and history of smoking cigarettes and cannabis for 2 years. BD was diagnosed based on history of smoking in combination with clinical, laboratory, and radiologic findings. Pediatric hemato-oncologists should consider BD in the differential diagnosis in adolescents who smoke cigarettes and/or cannabis and present with vascular insufficiency of the hands and/or feet.

Pros and Cons of the Cannabinoid System in Cancer: Focus on Hematological Malignancies

The endocannabinoid system (ECS) is a composite cell-signaling system that allows endogenous cannabinoid ligands to control cell functions through the interaction with cannabinoid receptors. Modifications of the ECS might contribute to the pathogenesis of different diseases, including cancers. However, the use of these compounds as antitumor agents remains debatable. Pre-clinical experimental studies have shown that cannabinoids (CBs) might be effective for the treatment of hematological malignancies, such as leukemia and lymphoma. Specifically, CBs may activate programmed cell death mechanisms, thus blocking cancer cell growth, and may modulate both autophagy and angiogenesis. Therefore, CBs may have significant anti-tumor effects in hematologic diseases and may synergistically act with chemotherapeutic agents, possibly also reducing chemoresistance. Moreover, targeting ECS might be considered as a novel approach for the management of graft versus host disease, thus reducing some symptoms such as anorexia, cachexia, fatigue, anxiety, depression, and neuropathic pain. The aim of the present review is to collect the state of the art of CBs effects on hematological tumors, thus focusing on the essential topics that might be useful before moving into the clinical practice.

Parent and patient perceptions of medical marijuana in the childhood cancer context

BACKGROUND

Medical marijuana (MM) is legal in 34 US jurisdictions. Yet, little is known about patient and parent perceptions of MM in pediatric cancer care. We examined attitudes, beliefs, and experiences regarding MM among parents of children with cancer and adolescent and young adult (AYA) patients, to help frame future research initiatives.

PROCEDURE

In this qualitative study, we conducted semi-structured, one-on-one interviews with parents and AYAs at a comprehensive cancer center. Interviews were audio-recorded, transcribed, and coded using both descriptive and inductive coding approaches. We used content and framework analysis to identify key themes.

RESULTS

Fifteen parents and 15 AYAs enrolled. Participants were generally receptive to MM use, concurrently weighing benefits and risks. Participants most often endorsed MM use for relief of nausea, anorexia, and pain. Simultaneously, participants identified concerns about MM, including potential physiologic and psychological effects on children and lack of research. However, concerns were frequently minimized, relative to chemotherapy or supportive care medications with perceived greater side effect profiles. Many participants expressed uncertainty regarding legal access, citing complex processes to obtain MM. Few participants had discussed MM with their oncologist, instead seeking guidance from the internet, family, or peers. Importantly, we elicited several misconceptions regarding MM, including its utility as cancer-directed therapy.

CONCLUSION

Patients and families are receptive to using MM, motivated by potential for symptom relief and cancer-directed effects. Yet, lack of empiric evidence is a barrier, underscoring the need for robust clinical trial data to support MM recommendations and use.

Family attitudes about and experiences with medical cannabis in children with cancer or epilepsy: an exploratory qualitative study

BACKGROUND

Cannabis is legal for recreational and medical use in Canada. Our aim was to explore family experiences using medical cannabis for children with severe conditions in the context of legalization.

METHODS

We conducted a qualitative study using semistructured interviews between April and July 2019. Participants were parents of children attending BC Children's Hospital oncology or palliative care clinics, recruited through posters, emails or referral. Participants were included if they spoke English and their child used any type of cannabis for medical purposes. Interviews included open-ended questions about the child's cannabis use. Interviews were recorded and transcribed, and thematic analysis was performed using qualitative description.

RESULTS

Ten interviews were completed with 9 mothers and 1 mother-father pair. The age range of the children was 22 months to 16 years. The primary reasons for cannabis use were epilepsy (6 children) or chemotherapy management (4 children). Five major themes were identified. 1) Child and family context, and cannabis as a last resort: children were seen as severely ill; parents sought cannabis out of desperation and responsibility to their child. 2) Varied information sources informed decision-making: parents lacked resources from health care providers and sought support from social media, industry and other families. 3) Cannabis as an ambiguous medicine: cannabis was viewed as both a serious drug that doctors should prescribe and as a natural alternative health product, safe to pursue alone. 4) Perceived effects: parents perceived medical benefits with few concerns about adverse effects. 5) Legal and financial challenges: parents were willing to obtain cannabis despite high costs and uncertain legality.

INTERPRETATION

Parents of children with severe conditions pursued medical cannabis despite obstacles and needed unbiased information to access alone. Scientific investigation is needed to develop pediatric medical guidelines to inform decisions.

Attitudes and beliefs about medical cannabis among social work students: Cross-national comparison

OBJECTIVES

Worldwide, considerable attention is being given to cannabis use for medical conditions. In the current study, we sought to assess attitudes and beliefs about MC among social work students from the US and Israel.

METHODS

We sought to assess attitudes and beliefs about MC among a sample of 417 social work students (230 from the US and 187 from Israel) who voluntarily participated in an anonymous online survey. Chi-square tests were used to analyze differences between groups.

RESULTS

Most of the US and Israeli participants (84.3 % and 96.7 %, respectively) reported no formal education about MC; and, they would recommend MC for their clients. Participants who reported any cannabis use, compared to non-users, were more likely to believe MC could benefit physical or mental health and less inclined to believe use of the substance poses serious physical or mental health risks. Secular, compared to religious students, believed it has more benefits for physical and/or mental health.

CONCLUSIONS

Our findings evidence a considerable dearth of formal evidence-based education about cannabis for medical conditions in two university-based cohorts, despite beliefs in MC as useful for physical and mental health conditions. Efforts to develop curricula and training programs for social work students are needed since they will be among key professionals addressing client needs from health care and counseling perspectives.

The Role of Cannabinoids as Anticancer Agents in Pediatric Oncology

Simple Summary

The endocannabinoid system (ECS) is a complex signaling pathway system involved in the regulation of multiple functions in both normal tissues and cancer. Δ9-tetrahydrocannabinol and cannabidiol are plant-derived cannabinoids that possess some efficacy against adult cancer, in part via modulation of the ECS, and may be less toxic agents compared to other treatments used in oncology. To date, there are minimal studies that have investigated these drugs in the pediatric cancer setting. Indeed, there are currently no preclinical or clinical studies examining the effects of cannabinoids in pediatric brain cancer, although there is some evidence that they can alleviate symptoms associated with childhood cancer therapy, such as vomiting and nausea. Given there is accumulating evidence that cannabis use during adolescence is associated with poor mental and cognitive health, there is a present and urgent need to investigate the safety and efficacy of cannabinoids in pediatric oncology to provide guidance to families and physicians.

Abstract

Cannabinoids are a group of chemicals that bind to receptors in the human body and, in turn, modulate the endocannabinoid system (ECS). They can be endogenously produced, synthetic, or derived from the plant Cannabis sativa L. Research over the past several decades has shown that the ECS is a cellular communication network essential to maintain multiple biological functions and the homeostasis of the body. Indeed, cannabinoids have been shown to influence a wide variety of biological effects, including memory, pain, reproduction, bone remodeling or immunity, to name a few. Unsurprisingly, given these broad physiological effects, alterations of the ECS have been found in different diseases, including cancer. In recent years, the medical use of cannabis has been approved in different countries for a variety of human conditions. However, the use of these compounds, specifically as anticancer agents, remains controversial. Studies have shown that cannabinoids do have anticancer activity in different tumor types such as breast cancer, melanoma, lymphoma and adult brain cancer. Specifically, phytocannabinoids Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) has been shown to induce apoptosis and inhibit proliferation of adult cancer cells, as well as modulate angiogenesis and metastasis. Despite increasing evidence that cannabinoids elicit antitumor effects in adult cancers, there is minimal data available on their effects in children or in pediatric cancers despite public and clinical demand for information. Here we describe a comprehensive and critical review of what is known about the effects of cannabinoids on pediatric cancers, highlight current gaps in knowledge and identify the critical issues that need addressing before considering these promising but controversial drugs for use in pediatric oncology.

Use of Cannabis and Cannabinoids in Patients With Cancer

OBJECTIVE

To review pharmacology, available dosage forms, efficacy, and safety of cannabis and cannabinoids in cancer patients.

DATA SOURCES

In PubMed (1965 to June 2020) the search was conducted using the search terms cannabidiol, cannabis, CBD, dronabinol, endocannabinoids, medical marijuana, nabiximols, nabilone, THC, and cancer. Abstracts from article bibliographies were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies conducted in humans evaluating cannabis and cannabinoids for cancer treatment or related symptoms were considered. Reference lists in relevant articles, package inserts, guidance documents, and addditional articles evaluating cannabis and cannabinoids were identified.

DATA SYNTHESIS

Cannabis and cannabinoid effectiveness can be attributed to active components delta-9-tetrahydrocannabinol and cannabidiol. Multiple dosage forms exist, each with different properties contributing to efficacy and safety differences. No data supports use as anticancer agents, and mixed efficacy results have been reported when used in cancer patients with nausea, pain, and anorexia. Inclusion of medicinal and synthetic products, small sample sizes, varying patient populations, and different dosage forms, doses, and drug combinations. These products are well tolerated, and adverse effects depend on the main active component.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Healthcare professionals need to identify appropriateness, monitor, and document use of cannabis and cannabinoids similar to other drug therapies as well as educate the patients/ caregivers about potential benefits and risks.

CONCLUSIONS

Current evidence for use of medical cannabis and cannabinoids in cancer patients is weak. However, healthcare professionals are in an ideal role to monitor and educate patients using medical cannabis and cannabinoids.

Nutritional traditional and complementary medicine strategies in pediatric cancer: A narrative review

Traditional and complementary medicine (T&CM) strategies are commonly used by pediatric cancer patients. Nutritional approaches to T&CM include bioactive compounds, supplements, and herbs as well as dietary approaches. Pediatric cancer patients and their families commonly request and use nutritional T&CM strategies. We review the potential risks and benefits of nutritional T&CM use in pediatric cancer care and provide an overview of some commonly used and requested supplements, including probiotics, antioxidants, cannabinoids, vitamins, turmeric, mistletoe, Carica papaya, and others. We also discuss the role of specific diets such as the ketogenic diet, caloric restriction diets, whole-food diets, and immune modulating diets. There is a growing body of evidence to support the use of some T&CM agents for the supportive care of children with cancer. However, further study is needed into these agents and approaches. Open communication with families about T&CM use is critical.

Predicting Physicians' Intentions to Recommend Medical Cannabis

CONTEXT

Although medical cannabis (MC) policies continue to evolve around the world, the integration of MC into clinical practice remains highly debated within the medical community.

OBJECTIVES

Relying on the Theory of Planned Behavior (TPB), this study aim was to identify underlying factors that influence physicians' intentions to recommend MC to patients and to examine whether there are differences in the strength of these associations across three medical specialties (family medicine, oncology, and pain medicine).

METHODS

247 physicians completed questionnaires including measures of TPB constructs (attitudes, subjective norms, and perceived behavioral control) and intentions to recommend MC to two clinical vignettes describing medical background of a cancer and a chronic pain patient. Regression models were used to measure the extent to which perceived knowledge and TPB constructs predict physicians' intentions to recommend MC.

RESULTS

Physicians' intentions to recommend MC to the cancer patient vignette was higher than their intentions to recommend to the chronic pain patient vignette. Intentions to recommend MC to the patient with cancer were associated with more favorable attitudes toward MC, whereas intentions to recommend MC to the patient with chronic pain were associated with more favorable attitudes, higher levels of perceived control, and lower levels of perceived knowledge.

CONCLUSION

Clinical practices related to MC may be influenced by nonmedical factors, and this may be particularly prevailing in the field of chronic pain, suggesting that MC may be particularly contentious in this field.

Medical marijuana use for pediatric oncology patients: single institution experience

Medical marijuana (MM) is widespread in many medical fields, including oncology, with limited use in pediatric oncology where research is scarce and often shows conflicting results. This research focuses on alleviating side effects of anticancer treatment as an integral part of supportive and palliative care of children with cancer. We report our experience with MM treatment in 50 children, adolescents, and young adults with different types of cancer during 2010-2017. The main indications for prescriptions were nausea and vomiting, decreased mood, disturbed sleep, and pain. The medication was supplied to 30 patients via oil drops (60%) and 11 via smoking (22%), followed by vaporization, capsules, or combinations of various routes. Positive effects were reported by verbal children and parents in 80% of cases. MM was generally well tolerated with few patients reporting toxicity, with the most common adverse reactions being burning in the throat and anxiety attacks in subjects who chose to smoke the product. We conclude that MM may serve as a potentially useful complementary therapy to conventional supportive treatment of children suffering from cancer at the end of life. Further research is needed on the safety and efficacy and the consequences of prolonged use in pediatric populations.

Medical Cannabis Certification in a Large Pediatric Oncology Center

In Minnesota, medical cannabis was approved for use in 2014. From July 2015 to February 2019, our center certified 103 pediatric and young adult patients for the use of medical cannabis under the qualifying conditions of cancer and treatment-related symptoms. Here, we provide a review of the literature on medical cannabis use in pediatric and young adult cancer patients. We also provide demographic data on our patients certified for medical cannabis. The most common diagnoses were leukemia/lymphoma (36%), brain tumors (37%), and malignant solid tumors (26%). The most common indications were chemotherapy-related nausea, pain, and cancer cachexia. The age range at certification was 1.4-28.7 years (median 15.3 years). The time from cancer diagnosis to certification ranged from 0.5-197 months (median 8.9 months). The majority (94%) were certified during their first line of treatment. In the 32 patients who died from recurrent or progressive cancer, the time from certification to death was 1.3-30.3 months (median 4.4 years). Despite requesting certification, a subset (24%) never had medical cannabis dispensed. In our experience, pediatric and young adult oncology patients are interested in medical cannabis to help manage treatment-related symptoms. Ongoing analysis of this data will identify the therapeutic efficacy of medical cannabis.

Safety and efficacy of nabilone for acute chemotherapy-induced vomiting prophylaxis in pediatric patients: A multicenter, retrospective review

OBJECTIVES

To describe the safety and efficacy of nabilone given to pediatric patients to prevent acute chemotherapy-induced nausea and vomiting (CINV).

METHODS

A multicenter, retrospective review of pediatric patients who received nabilone for acute CINV prophylaxis between December 1, 2010 and August 1, 2015 was undertaken. One course of nabilone was evaluated per patient. Adverse effects associated with nabilone use were noted. The proportion of patients who experienced complete acute chemotherapy-induced vomiting (CIV) control during the acute phase was determined. The acute phase was defined as starting with the first chemotherapy dose and continuing until 24 h after administration of the last chemotherapy dose of the chemotherapy block.

RESULTS

One hundred ten eligible patients (median age: 14.0 years, range: 1.1-18.0 years; 65 male) were identified. Most (109/110) received nabilone plus a 5-HT3 antagonist for CINV prophylaxis. Adverse effects associated with nabilone were experienced by 34% (37/110) of children. All were of CTCAE Version 4.03 Grade 2 or less. Sedation (20.0%), dizziness (10.0%), and euphoria (3.6%) were the most commonly reported adverse events. Nabilone was discontinued in 10 patients due to an adverse event. The proportions of patients receiving highly or moderately emetogenic chemotherapy who experienced complete acute CIV control were 50.6% (42/83) and 53.8% (14/26), respectively.

CONCLUSION

Adverse events associated with nabilone were common but of minor clinical significance. Acute CIV control in children receiving nabilone as a part of their antiemetic regimen was poor. Future work should focus on implementation of guideline-consistent CINV prophylaxis and treatment.

Medical Marijuana Use in a Community Cancer Center

Purpose:

The primary purpose of this study was to compare the incidence of marijuana use between patients with early- versus advanced-stage cancers. Differences in adverse effects, drug-drug interactions, and drug-disease interactions between those who use marijuana and those who do not were also compared.

Methods:

Patients age 18 years and older who were receiving chemotherapy were asked to complete an electronic self-reported questionnaire. In addition to questions about patient demographics, current adverse effects, cancer type and stage, comorbidities, performance status, treatment regimen, and general marijuana use, those patients who used marijuana within the last 30 days (current marijuana users) were asked additional questions about the route and frequency of marijuana administration, about reason(s) for use, about possession of a marijuana card, and if they had received any counseling about marijuana. Drug-drug and drug-disease interactions were also analyzed.

Results:

The overall incidence of marijuana use was 18.3% (32 of 175 patients). The incidence of marijuana use in patients with early- versus advanced-stage cancers was 19.6% (11 of 56 patients) versus 17.6% (21 of 119 patients; P = .75). Patients who use marijuana reported more pain, nausea, appetite issues, and anxiety. There were more drug-drug interactions associated with marijuana use, primarily with concurrent CNS depressants. The frequency of drug-disease interactions between those who use marijuana versus those who do not was similar.

Conclusion:

Approximately one in five patients with cancer who were receiving chemotherapy were using marijuana, and the frequency was equal in early- and advanced-stage cancer groups. The risks versus benefits should be discussed with all patients who use marijuana.

Medical cannabis: An oxymoron? Physicians' perceptions of medical cannabis

BACKGROUND

Medical cannabis policies are changing in many places around the world, and physicians play a major role in the implementation of these policies. The aim of this study was to gain a deeper understanding of physicians' views on medical cannabis and its possible integration into their clinic, as well as to identify potential underlying factors that influence these perceptions.

METHODS

Qualitative narrative analysis of in-depth interviews with twenty-four Israeli physicians from three specialties (pain medicine, oncology and family medicine).

FINDINGS

Physicians disclosed contrasting narratives of cannabis, presenting it as both a medicine and a non-medicine. These divergent positions co-existed and were intertwined in physicians' accounts. When presenting cannabis as a non-medicine, physicians drew on conventional medicine and prohibition as narrative environments. They emphasized the incongruence of cannabis with standards of biomedicine and presented cannabis as an addictive drug of abuse. In contrast, physicians drew upon unconventional medicine and palliative care as narrative environments while presenting cannabis as a medicine. In this narrative, physicians emphasized positive hands-on experiences with cannabis, and pointed to the limits of conventional medicine.

CONCLUSION

Physicians did not have a consolidated perspective as to whether cannabis is a medicine or not, but rather struggled with this question. The dualistic narratives of cannabis reflect the lack of a dominant narrative environment that supports the integration of cannabis into medical practice. This may in turn indicate barriers to the implementation of medical cannabis policies. An awareness of physicians' views and the different levels of their willingness to implement medical cannabis policies is essential for policy developments in this evolving field.

Provider Perspectives on Use of Medical Marijuana in Children With Cancer

BACKGROUND

Although medical marijuana (MM) may have utility in the supportive care of children with serious illness, it remains controversial. We investigated interdisciplinary provider perspectives on legal MM use in children with cancer.

METHODS

We sent a 32-item, cross-sectional survey to 654 pediatric oncology providers in Illinois, Massachusetts, and Washington characterizing MM practices, knowledge, attitudes, and barriers. Forty-eight percent responded; 44% (n = 288) were included in analyses. Providers were stratified by status as legally eligible to certify (ETC) for MM. We used Fisher's exact and Wilcoxon rank tests and univariate and multivariate logistic regression models for group comparisons.

RESULTS

The provider median age was 35 years (range 22-70 years); 33% were ETC (83 physicians; 13 Washington state advance practice providers). Thirty percent of providers received ≥1 request for MM in the previous month. Notably, only 5% of all providers knew state-specific regulations. ETC providers were more likely to know that MM is against federal laws (P < .0001). Whereas most providers (92%) reported willingness to help children with cancer access MM, in adjusted models, ETC providers were less likely to indicate approval of patient MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms (P < .005 for all). Forty-six percent of all providers cited the absence of standards around formulations, potency, or dosing to be the greatest barrier to recommending MM.

CONCLUSIONS

Most pediatric oncology providers are willing to consider MM use in children with cancer and receive frequent inquiries. However, ETC providers endorse less favorable attitudes overall. The absence of standards is an important barrier to recommending MM.