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Multinational Association of Supportive Care in Cancer (MASCC) guidelines: cannabis for psychological symptoms including insomnia, anxiety, and depression

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Abstract

Purpose

During the treatment of cancer, 18% of patients use cannabis for symptom management. Anxiety, depression, and sleep disturbances are common symptoms in cancer. A systematic review of the evidence for cannabis use for psychological symptoms in cancer patients was undertaken to develop a guideline.

Methods

A literature search of randomized trials and systematic reviews was undertaken up to November 12, 2021. Studies were independently assessed for evidence by two authors and then evaluated by all authors for approval. The literature search involved MEDLINE, CCTR, EMBASE, and PsychINFO databases. Inclusion criteria included randomized control trials and systematic reviews on cannabis versus placebo or active comparator in patients with cancer and psychological symptom management (anxiety, depression, and insomnia).

Results

The search yielded 829 articles; 145 from Medline, 419 from Embase, 62 from PsychINFO, and 203 from CCTR. Two systematic reviews and 15 randomized trials (4 on sleep, 5 on mood, 6 on both) met eligibility criteria. However, no studies specifically assessed the efficacy of cannabis on psychological symptoms as primary outcomes in cancer patients. The studies varied widely in terms of interventions, control, duration, and outcome measures. Six of 15 RCTs suggested benefits (five for sleep, one for mood).

Conclusion

There is no high-quality evidence to recommend the use of cannabis as an intervention for psychological symptoms in patients with cancer until more high-quality research demonstrates benefit.

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References

  1. Martell K, Fairchild A, LeGerrier B et al (2018) Rates of cannabis use in patients with cancer. Curr Oncol 25:219–225

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Kaul M, Zee PC, Sahni SA (2021) Effects of cannabinoids on sleep and their therapeutic potential for sleep disorders. Neurotherapeutics 18:217–227

    Article  PubMed  PubMed Central  Google Scholar 

  3. Daris B, Verboten MT, Knez Z et al (2019) Cannabinoids in cancer treatment: therapeutic potential and legislation. Bosn J Basic Med Sci 19:14–23

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Pawasarat IM, Schultz EM, Firsby JC et al (2020) The efficacy of medical marijuana in the treatment of cancer-related pain. J Palliat Med 23:809–816

    Article  PubMed  Google Scholar 

  5. Sarfaraz S, Afaq F, Adhami VM et al (2005) Cannabinoid receptor as a novel target for the treatment of prostate cancer. Cancer Res 65:1635–1641

    Article  CAS  PubMed  Google Scholar 

  6. Bar-Sela G, Avisar A, Batash R et al (2014) Is the clinical use of cannabis by oncology patients advisable? Curr Med Chem 21:1923–1930

    Article  CAS  PubMed  Google Scholar 

  7. Caputo PM, Rodriguez CS, Padhya TA et al (2021) Medical cannabis as adjunctive therapy for head and neck cancer patients. Cureus 13:e18396

    PubMed  PubMed Central  Google Scholar 

  8. Babson KA, Sottile J, Morabito D (2017) Cannabis, cannabinoids, and sleep: a review of the literature. Curr Psychiatry 19:23

    Article  Google Scholar 

  9. Shannon S, Lewis N, Lee H et al (2019) Cannabidiol in anxiety and sleep: a large case series. Perm J 23:18–041

    Article  PubMed  PubMed Central  Google Scholar 

  10. Suraev AS, Marshall NS, Vandrey R (2020) Cannabinoid therapies in the management of sleep disorders: a systematic review of preclinical and clinical studies. Sleep Med Rev 53:101339

    Article  PubMed  Google Scholar 

  11. Cotè M, Trudel M, Wang C et al (2016) Improving quality of life with nabilone during radiotherapy treatments for head and neck cancers: a randomized double-double blind placebo-controlled trial. Ann Otol Rhinol Laryngol 125:317–324

    Article  PubMed  Google Scholar 

  12. Fallon MT, Lux EA, McQuade R et al (2017) Sativex oromucosal spray as adjunctive therapy in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy: two double-blind, randomized, placebo-controlled phase 3 studies. Br J Pain 11:119–133

    Article  PubMed  PubMed Central  Google Scholar 

  13. Lichtman AH, Lux EA, McQuade R et al (2018) Results of a double-blind, randomized, placebo-controlled study of nabiximols oromucosal spray as an adjunctive therapy in advanced cancer patients with chronic uncontrolled pain. J Pain Symptom Manage 55:179-188.e1

    Article  PubMed  Google Scholar 

  14. Zylla DM, Eklund J, Gilmore G et al (2021) A randomized trial of medical cannabis in patients with stage IV cancers to assess feasibility, dose requirements, impact on pain and opioid use, safety, and overall patient satisfaction. Support Care Cancer 29:7471–7478

    Article  PubMed  Google Scholar 

  15. Hauser W, Welsch P, Klose P et al (2019) Efficacy, tolerability and safety of cannabis-based medicines for cancer pain. A systematic review with meta-analysis of randomized controlled trials. Schmerts 33:424–436

    Article  Google Scholar 

  16. Johnson JR, Burnell-Nugent M, Lossignol D et al (2010) Multicenter, double-blind, randomized. Placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of the THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage 39:167–179

    Article  PubMed  Google Scholar 

  17. Portenoy RK, Ganae-Montan ED, Allende S et al (2012) Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, graded-dose trial. J Pain 13:438–449

    Article  CAS  PubMed  Google Scholar 

  18. Ungerleider JT, Andrysiak T, Fairbanks L et al (1982) Cannabis and cancer chemotherapy: a comparison of oral delta-9-THC and prochlorperazine. Cancer 50:636–645

    Article  CAS  PubMed  Google Scholar 

  19. Ungerleider JT, Fairbanks LA, Andrysiak T et al (1985) THC or Compazine for the cancer chemotherapy patient-the UCLA study. Part II: patient drug preference. Am J Clin Onco 8:142–147

    Article  CAS  Google Scholar 

  20. Jatoi A, Windschitl HE, Loprinzi CL et al (2002) Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a north central cancer treatment group study. J Clin Oncol 20:567–573

    Article  CAS  PubMed  Google Scholar 

  21. Strasser LD, Possinger K et al (2006) Comparison of orally administered cannabis extract and delta-9-tetrahydrocannabinol in treating patients with cancer-related anorexia-cachexia syndrome: a multicenter, phase III, randomized, double-blind, placebo-controlled clinical trial from the Cannabis-In-Cachexia-Study-Group. J Clin Oncol 24:3394–3400

    Article  CAS  PubMed  Google Scholar 

  22. Lynch ME, Cesar-Rittenberg P, Hohmann AG (2014) A double-blind, placebo-controlled, crossover pilot trial with extension using an oral mucosal cannabinoid extract for treatment of chemotherapy-induced neuropathic pain. J Pain Symptom Manage 47:166–173

    Article  PubMed  Google Scholar 

  23. Johnson JR, Lossignol D, Burnell-Nugent M et al (2013) An open-label extension study to investigate the long-term safety and tolerability of the THC/CBD oromucosal spray and oromucosal THC spray in patients with terminal cancer-related pain refractory to strong opioid analgesics. J Pain Symptom Manage 46:207–218

    Article  PubMed  Google Scholar 

  24. Brisbois TD, de Kock IH, Watanabe SM et al (2011) Delta-9-tetrahydrocannabinol may palliate altered chemosensory perception in cancer patients: results of a randomized, double-blind, placebo-controlled pilot trial. Ann Oncol 22:2086–2093

    Article  CAS  PubMed  Google Scholar 

  25. Turcott JG, Del Rocío Guillen Núñez M, Flores-Estrada D et al (2018) The effect of nabilone on appetite, nutritional status and quality of life in lung cancer patients: a randomized, double-blind clinical trial. Support Care Cancer 26:3029–3038

    Article  PubMed  Google Scholar 

  26. Schloss J, Lacey J, Sinclair J et al (2021) A phase 2 randomized clinical trial assessing the tolerability of two different ratios of medical cannabis in patients with high grade gliomas. Front Oncol 11:649555. https://doi.org/10.3389/fonc.2021.649555

    Article  PubMed  PubMed Central  Google Scholar 

  27. Whiting PF, Wolff RF, Deshpande S et al (2015) Cannabinoids for medical use. Syst Rev Meta-Anal JAMA 313:2456–2473

    CAS  Google Scholar 

  28. Russo EB (2011) Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br J Pharmacol 163:1344–1364

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Bhattacharyya S, Wilson R, Appiah-Kusi E et al (2018) Effect of cannabidiol on medial temporal, midbrain, and striatal dysfunction in people at high risk of psychosis: a randomized clinical trial. JAMA Psychiat 75:1107–1117

    Article  Google Scholar 

  30. Murillo-Rodrìguez E (2008) The role of CB1 receptor in the regulation of sleep. Prog Neuropsychopharmacol Biol Psychiatry 32:1420–1427

    Article  PubMed  Google Scholar 

  31. Bitencourt RM, Takahashi RN (2018) Cannabidiol as a therapeutic alternative for post-traumatic stress disorder: from bench research to confirmation in human trials. Front Neurosci 12:502

    Article  PubMed  PubMed Central  Google Scholar 

  32. Spindle TR, Cone EJ, Goffi E et al (2020) Pharmacodynamic effects of vaporized and oral cannabidiol (CBD) and vaporized CBD-dominant cannabis in infrequent cannabis users. Drug Alcohol Depend 211:107937

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Sarris J, Sinclair J, Karamacoska D et al (2020) Medicinal cannabis for psychiatric disorders: a clinically-focused systematic review. BMC Psychiatry 20:24. https://doi.org/10.1186/s12888-019-2409-8

    Article  PubMed  PubMed Central  Google Scholar 

  34. Walsh Z, Gonzalez R, Crosby K et al (2017) Medical cannabis and mental health: a guided systematic review. Clin Psychol Rev 51:15–29

    Article  PubMed  Google Scholar 

  35. Botsford SL, Yang S, George TP (2020) Review: cannabis and cannabinoids in mood and anxiety disorder: impact on illness onset and course, and assessment of therapeutic potential. Am J Addict 29(1):9–26

    Article  PubMed  Google Scholar 

  36. Gage SH, Hickman M, Zammit S (2016) Association between cannabis and psycosis:epidemiologic evidence. Biol Psychiatry 79:549–556

    Article  PubMed  Google Scholar 

  37. Leweke FM, Piomelli D, Phlisch F et al (2012) Cannabidiol enhances anandamide signaling and alleviates psychotic symptoms of schizophrenia. Transl Psychiatry 2:e94

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. McGuire P, Robson P, Jerzy Cubala W et al (2018) Cannabidiol (CBD) as an adjunctive therapy in schizophrenia: a multicenter randomized controlled trial. Am J Psychiatry 175:225–231

    Article  PubMed  Google Scholar 

  39. Boggs DL, Surti T, Gupta A et al (2018) The effects of cannabidiol (CBD) on cognition and symptoms in outpatients with chronic schizophrenia a randomized placebo controlled trial. Psychopharmacology 235:1923–1932

    Article  CAS  PubMed  Google Scholar 

  40. Cooper RE, Williams E, Seegobin S et al (2017) Cannabinoids in attention-deficit/hyperactivity disorder: a randomized-controlled trial. Eur Neuropsychopharmacol 27:795–808

    Article  CAS  PubMed  Google Scholar 

  41. Gibbs M, Winsper C, Marwaha S (2015) Cannabis use and mania symptoms: a systematic review and meta-analysis. J Affect Disord 171:39–47

    Article  PubMed  Google Scholar 

  42. Zuardi A, Crippa J, Dursun SM et al (2010) Cannabidiol was ineffective for manic episode of bipolar affective disorders. J Psychopharmacol 24:135–137

    Article  CAS  PubMed  Google Scholar 

  43. Jetly R, Heber A, Fraser G et al (2015) The efficacy of nabilone, a synthetic cannabinoid, in the treatment of PTSD-associated nightmares: a preliminary randomized, double-blind, placebo-controlled cross-over design study. Psychoneuroendocrinology 51:585–588

    Article  CAS  PubMed  Google Scholar 

  44. Cameron EC, Hemingway SL (2020) Cannabinoids for fibromyalgia pain: a critical review of recent studies (2015–2019). J Cannabis Res 2:19

    Article  PubMed  PubMed Central  Google Scholar 

  45. Khurshid H, Qureshi IA, Jahan N et al (2021) A systematic review of fibromyalgia and recent advancements in treatment: is medicinal cannabis a new hope? Cureus 13:e17332

    PubMed  PubMed Central  Google Scholar 

  46. Giossi R, Carrara F, Padroni M et al (2022) Systematic review and meta-analysis seem to indicate that cannabinoids for chronic primary pain treatment have limited benefit. Pain Ther 11:1341–1358

    Article  PubMed  PubMed Central  Google Scholar 

  47. Kosiba JD, Maisto SA, Ditre JW (2019) Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: systematic review and meta-analysis. Soc Sci Med 233:181–192

    Article  PubMed  Google Scholar 

  48. Allsop JD, Copeland J, Lintzeris N et al (2014) Nabiximols as an agonist replacement therapy during cannabis withdrawal: a randomized clinical trial. JAMA Psychiat 71:281–291

    Article  CAS  Google Scholar 

  49. Podda G, Constantinescu CS (2012) Nabiximols in the treatment of spasticity, pain and urinary symptoms due to multiple sclerosis. Expert Opin Biol Ther 12:1517–1531

    Article  CAS  PubMed  Google Scholar 

  50. Trigo JM, Soliman A, Quilty LC et al (2018) Nabiximols combined with motivational enhancement/cognitive behavioral therapy for the treatment of cannabis dependence: a pilot randomized clinical trial. PLoS One 13:e0190768

    Article  PubMed  PubMed Central  Google Scholar 

  51. Sharpe L, Sinclair J, Kramer A et al (2020) Cannabis, a cause for anxiety? A critical appraisal of the anxiogenic and anxiolytic properties. J Transl Med 18:374

    Article  PubMed  PubMed Central  Google Scholar 

  52. Hitchcock L. Anxiety, inflammation and stress. 2018. Available from https://clinicaltrials.gov/ct2/show/NCT03491384?cond=Anxiety&intr=Cannabis&rank=2

  53. ACTRN12617000825358 (2021) The cannabidiol youth anxiety pilot study (CAPS):a 12-week open label pilot study of the safety, tolerability and efficacy of cannabidiol for anxiety disorders. https://clinicaltrials.gov/ct2/show/NCT03549819

  54. Kedzior KK, Laeber LT (2014) A positive association between anxiety disorders and cannabis use or cannabis use disorders in the general population–a meta-analysis of 31 studies. BMC Psychiatry 14:136

    Article  PubMed  PubMed Central  Google Scholar 

  55. Saugy M, Avois L, Saudan C et al (2006) Cannabis and sport. Br J Sports Med 40(Suppl 1):i13-15

    Article  PubMed  PubMed Central  Google Scholar 

  56. Choi S, Huan BC, Gamaldo CE (2020) Therapeutic use of cannabis on sleep disorders and related conditions. J Clin Neurophysiol 37:39–49

    Article  PubMed  Google Scholar 

  57. Degenhardt L, Wayne H, Lynskey M (2003) Exploring the association between cannabis use and depression. Addiction 98:1493–1504

    Article  PubMed  Google Scholar 

  58. Moore THM, Zammit S, Lingford-Hughes A (2007) Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet 370:319–328

    Article  PubMed  Google Scholar 

  59. Conroy DA, Kurth ME, Strong DR et al (2016) Marijuana use patterns and sleep among community-based young adults. J Addict Dis 35:135–143

    Article  PubMed  PubMed Central  Google Scholar 

  60. Ergisi M, Erridge S, Harris M et al (2022) UK Medical Cannabis Registry: an analysis of clinical outcomes of medicinal cannabis therapy for generalized anxiety disorder. Expert Rev Clin Pharmacol 18:1–9

    Google Scholar 

  61. Bergamaschi MM, Queiroz RG, Chagas MH et al (2011) Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology 36:1219–1226

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Crippa JA, Derenusson GN, Ferrari TB et al (2011) Neural basis of anxiolytic effects of cannabidiol (CBD) in generalized social anxiety disorder: a preliminary report. J Psychopharmacol 25:121–130

    Article  CAS  PubMed  Google Scholar 

  63. Ware NA, Fitzcharles MA, Lawrence J (2020) The effect of nabilone on sleep in fibromyalgia: results of a randomized controlled trial. Anesth Analg 110:604–610

    Article  Google Scholar 

  64. Gross H, Michael E, Faden V et al (1983) A double-blind trial of □9-tetrahydrocannabinol in primary anorexia nervosa. J Clin Psyhopharmacol 3:167–171

    Google Scholar 

  65. AminiLari M, Wang L, Neumark S et al (2021) Medical cannabis for impaired sleep: a systematic review and meta-analysis of randomized clinical trials. Sleep zsab234. https://doi.org/10.1093/sleep/zsab234

  66. Walsh JH, Maddison KJ, Rankin T et al (2021) Treating insomnia symptoms with medical cannabis: a randomizes, crossover trial of the efficacy of a cannabinoid medicine compared to placebo. Sleep 44:zssab149

    Article  Google Scholar 

  67. Suraev A, Grunstein RR, Marshall NS et al (2020) Cannabidiol (CBD) and □9-tetrahydrocannabinol (THC) for chronic insomnia disorder (‘CANSLEEP’ trial): protocol for randomized, placebo-controlled, double-blinded, proof-of-concept trial. BMJ open 10(5):e034421. https://doi.org/10.1136/bmjopen-2019-034421

    Article  PubMed  PubMed Central  Google Scholar 

  68. Palmieri G, Vadalà M, Corazzari V et al (2022) Insomnia treatment: a new multitasking natural compound based on melatonin and cannabis extracts. Clin Ter 173:91–96

    CAS  PubMed  Google Scholar 

  69. Almogi-Hazan O, Or R (2020) Cannabis, the endocannabinoid system and immunity-the journey from the bedside to the bench and back. Int J Mol Sci 21:4448

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Medical Oncology and Haematology, Oncology-Supportive Care Unit, Fondazione IRCCS, Istituto Nazionale Tumori Di Milano, Milan, Italy

    Giulia De Feo

  2. Division of Geriatrics and Palliative Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA

    Amy A. Case

  3. South Australia, Faculty of Health and Medical Sciences, Northern Adelaide Local Health Network, University of Adelaide, Adelaide, Australia

    Gregory B. Crawford

  4. Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    David Hui & Kimberson Tanco

  5. Division of Aged Care, Rehabilitation and Palliative Care, Northern Adelaide Local Health Network, Adelaide, Australia

    Josephine To

  6. University of Pisa, Pisa, Italy

    Andrea Sbrana

  7. Frimley Park Hospital, Frimley, UK

    Bryony Alderman

  8. Department of Pharmacology, Burdwan Medical College, Burdwan, India

    Sandip Mukhopadhyay

  9. Department of Supportive and Palliative Care, PSL University, Institut Curie, Paris, France

    Carole Bouleuc

  10. Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan

    Koji Amano

  11. Clinical Informationist, Geisinger Medical Center, Danville, USA

    Jessica Garsed

  12. Palliative Care Department, Geisinger Medical System, Danville, USA

    Mellar Davis

Authors
  1. Giulia De Feo
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  2. Amy A. Case
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  13. Mellar Davis
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Contributions

Giulia De Feo and Amy Case: review of studies derived from the systematic review, writing the manuscript. Jessica Garsed: as the clinical Informationist performance of the systematic review. Andrea Sbrana, Bryony Alderman, David Hui, Sandip Mukhopadhyay, Carole Bouleuc, Josephine To, Koji Amano, Gregory P. Crawford, Mellar Davis, and Kimberson Tanco: reviewed and edited the manuscript and provided consensus as to the recommendations.

Corresponding author

Correspondence to Mellar Davis.

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De Feo, G., Case, A.A., Crawford, G.B. et al. Multinational Association of Supportive Care in Cancer (MASCC) guidelines: cannabis for psychological symptoms including insomnia, anxiety, and depression. Support Care Cancer 31, 176 (2023). https://doi.org/10.1007/s00520-023-07628-3

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