Purpose of Review
As the legalization of medical cannabis continues across the USA, oncology care providers will be increasingly asked to provide recommendations regarding its use in the cancer setting. In this article, we review recent literature that analyzes cannabis use specifically in patients with cancer and provide an accessible guide for clinicians, researchers, and patients.
We aimed to answer questions about the availability of cannabis in the USA, the trials supporting its use in the cancer setting, and the important factors to consider related to safety. Thirty states plus the District of Columbia have established comprehensive medical cannabis programs, each with different regulations and products available. In June 2018, Epidiolex, a cannabis extraction product containing 99% CBD, was approved to treat refractory seizures; however, whole-plant products and non-prescription extraction products dominate the market. Recent randomized, placebo-controlled studies of nabiximols (Sativex) in patients with refractory cancer-pain have largely shown no significant benefits. Conversely, large observational studies suggest patients with cancer using cannabis report significant improvement of many common symptoms. Cannabis use appears well tolerated, with few serious adverse effects reported.
Though prospective clinical trials are needed to provide the robust data required to establish the proper role of cannabinoid and cannabis-based therapy in cancer patients, physicians can draw upon the knowledge currently available to have informed discussions with their patients.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
•• Pergam SA, et al. Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use. Cancer. 2017;123(22):4488–97 This recent publication analyzes survey data from 926 responding patients in Washington State. The findings point toward significant usage across patient backgrounds, the importance of legalization in the choice to use cannabis, and the desire for more information for clinicians.
•• Braun IM, et al. Medical oncologists’ beliefs, practices, and knowledge regarding marijuana used therapeutically: a nationally representative survey study. J Clin Oncol. 2018;36(19):1957–62 In a national survey send to 400 medical oncologists, Braun et al. analyze the beliefs of oncologists regarding medical cannabis and its use among cancer patients. Of the 63% who replied, only 30% felt they had adequate information to make clinical recommendations; however, almost 50% make recommendations to patients for medical cannabis. Further research, education, and policies are needed to increase clinician knowledge of cannabis.
Zylla, D., et al., Oncology clinicians and the Minnesota Medical Cannabis Program: a survey on medical cannabis practice patterns, barriers to enrollment, and educational needs. 2018. Under Review. Abstract at https://dspace.library.colostate.edu/bitstream/handle/10217/189670/ICR2018_program.pdf?sequence=1&isAllowed=y.
Wilkie G, Sakr B, Rizack T. Medical marijuana use in oncology: a review. JAMA Oncol. 2016. https://doi.org/10.1001/jamaoncol.2016.0155.
Abrams DI. Integrating cannabis into clinical cancer care. Curr Oncol. 2016;23(2):S8–S14.
• Kramer JL. Medical marijuana for cancer. CA Cancer J Clin. 2015;65(2):109–22 This thorough review has over 151 citations that outline the potential benefits of cannabis for treating cancer-related symptoms, its role in fighting cancer, and potential dangers of cannabis usage. Similar to our paper, this review focuses on clinical trials rather than the underlying mechanism.
• http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx . This website from the National Conference of State Legislatures provides comprehensive yet understandabale outline of the laws regarding cannabis usage in states that have legalized it in addition to those with pending proposals. This website is consistently updated, and provides links directly to government proposals for those that seek futher information.
•• National Academies of Sciences, E., and Medicine, The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. 2017. This book is perhaps the most comprehensive look at cannabis research as of 2017. Numerous health effects, both positive and negative, are analyzed and ranked based on the amount of evidence to support them. While a lot of quality research is included, a consistent theme is the need for more research.
Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan ED, Potts R, Fallon MT. Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manag. 2010;39(2):167–79.
Portenoy RK, Ganae-Motan ED, Allende S, Yanagihara R, Shaiova L, Weinstein S, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, graded-dose trial. J Pain. 2012;13(5):438–49.
Johnson JR, Lossignol D, Burnell-Nugent M, Fallon MT. An open-label extension study to investigate the long-term safety and tolerability of THC/CBD oromucosal spray and oromucosal THC spray in patients with terminal cancer-related pain refractory to strong opioid analgesics. J Pain Symptom Manag. 2013;46(2):207–18.
Lynch ME, Cesar-Rittenberg P, Hohmann AG. 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 Manag. 2014;47(1):166–73.
•• Fallon MT, et al. 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. 2017;11(3):119–33 This manuscirpt describes results from two well-conducted trials that compare sativex to placebo in managing cancer-related pain. Of note, 399 patients were randomized in study 1, and 216 were randomized in study 2. Across this large sample size, the researchers arrived at the conclusion that sativex was unable to effectively provide analgesia compared to placebo. However, it was more effective specifically amongst the younger patients, and those from the United States, which may point to the varying efficacy of cannabis.
Lichtman AH, Lux EA, McQuade R, Rossetti S, Sanchez R, Sun W, et al. 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 Manag. 2018;55(2):179–88 e1.
Zutt M, Hänßle H, Emmert S, Neumann C, Kretschmer L. Dronabinol for supportive therapy in patients with malignant melanoma and liver metastases. Hautarzt. 2006;57(5):423–7.
Meiri E, Jhangiani H, Vredenburgh JJ, Barbato LM, Carter FJ, Yang HM, et al. Efficacy of dronabinol alone and in combination with ondansetron versus ondansetron alone for delayed chemotherapy-induced nausea and vomiting. Curr Med Res Opin. 2007;23(3):533–43.
Duran M, Pérez E, Abanades S, Vidal X, Saura C, Majem M, et al. Preliminary efficacy and safety of an oromucosal standardized cannabis extract in chemotherapy-induced nausea and vomiting. Br J Clin Pharmacol. 2010;70(5):656–63.
Jatoi A, Windschitl HE, Loprinzi CL, Sloan JA, Dakhil SR, Mailliard JA, et al. Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a north central cancer treatment group study. J Clin Oncol. 2002;20(2):567–73.
Walsh, D., J. Kirkova, and M.P. Davis, The efficacy and tolerability of long-term use of dronabinol in cancer-related anorexia: a case series, in J Pain Symptom Manage. 2005: United States. p. 493–5.
Cannabis In Cachexia Study, G, et al. 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. 2006;24(21):3394–400.
Maida V, Ennis M, Irani S, Corbo M, Dolzhykov M. Adjunctive nabilone in cancer pain and symptom management: a prospective observational study using propensity scoring. J Support Oncol. 2008;6(3):119–24.
Brisbois TD, de Kock IH, Watanabe SM, Mirhosseini M, Lamoureux DC, Chasen M, et al. Delta-9-tetrahydrocannabinol may palliate altered chemosensory perception in cancer patients: results of a randomized, double-blind, placebo-controlled pilot trial. Ann Oncol. 2011;22(9):2086–93.
Bar-Sela G, et al. The medical necessity for medicinal cannabis: prospective, observational study evaluating the treatment in cancer patients on supportive or palliative care. Evid Based Complement Alternat Med. 2013;2013:510392.
• Cote M, et al. Improving quality of life with nabilone during radiotherapy treatments for head and neck cancers: a randomized double-blind placebo-controlled trial. Ann Otol Rhinol Laryngol. 2016;125(4):317–24 This study of 56 patients with head and neck cancers compares the effectiveness of nabilone versus placebo in managing symptom burden related to treatment. It was found that quality of life was not improved with nabilone; however, patients did not have the ability to individually titrate to their desired dosage.
•• Bar-Lev Schleider L, et al. Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. Eur J Intern Med. 2018;49:37–43 This large study analyzes data regarding cannabis usage among 2970 cancer patients in Israel. The researchers conclude that cannabis is effective in the palliative setting, with a quality of life scores improving from 20% (at baseline) to 70% (after six months taking cannabis). Beyond effectiveness, this paper provides valuable information regarding the demographics of this population, including cancer diagnosis, comorbidities, and other measures.
Zhang H, et al. Association of marijuana use with psychosocial and quality of life outcomes among patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg. 2018. https://doi.org/10.1001/jamaoto.2018.0486.
Anderson, S., et al., Impact of medical cannabis on patient-reported symptoms for cancer patients enrolled in Minnesota’s Medical Cannabis Program. Under Review, Abstract at. 2018. https://dspace.library.colostate.edu/bitstream/handle/10217/189670/ICR2018_program.pdf?sequence=1&isAllowed=y. Accessed 16 August 2018.
Guzman M, et al. A pilot clinical study of Delta9-tetrahydrocannabinol in patients with recurrent glioblastoma multiforme. Br J Cancer. 2006;95(2):197–203.
Foroughi M, Hendson G, Sargent MA, Steinbok P. Spontaneous regression of septum pellucidum/forniceal pilocytic astrocytomas—possible role of Cannabis inhalation. Childs Nerv Syst. 2011;27(4):671–9.
Singh Y, Bali C. Cannabis extract treatment for terminal acute lymphoblastic leukemia with a Philadelphia chromosome mutation. Case Rep Oncol. 2013;6(3):585–92.
Twelves C, et al. A two-part safety and exploratory efficacy randomized double-blind, placebo-controlled study of a 1:1 ratio of the cannabinoids cannabidiol and delta-9-tetrahydrocannabinol (CBD:THC) plus dose-intense temozolomide in patients with recurrent glioblastoma multiforme (GBM). J Clin Oncol. 2017;35(15_suppl):2046-2046.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018651s029lbl.pdf. Access 16 August 2018.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/018677s011lbl.pdf. Accessed 16 August 2018.
Pisanti S, Malfitano AM, Ciaglia E, Lamberti A, Ranieri R, Cuomo G, et al. Cannabidiol: state of the art and new challenges for therapeutic applications. Pharmacol Ther. 2017;175:133–50.
https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611046.htm. Accessed 16 August 2018.
https://leaflinelabs.com/our-medication/. Accessed August 16 2018.
https://minnesotamedicalsolutions.com/wp-content/uploads/2018/04/MinnMed-Price-List_4.24.18.pdf. Accessed 16 August 2018.
Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770–804.
https://www.webmd.com/pain-management/news/20180507/cbd-oil-all-the-rage-but-is-it-safe-effective#1. Accessed 16 August 2018.
Bonn-Miller MO, Loflin MJE, Thomas BF, Marcu JP, Hyke T, Vandrey R. Labeling accuracy of cannabidiol extracts sold online. JAMA. 2017;318(17):1708–9.
https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm484109.htm. Accessed 16 August 2018.
Piper BJ, Beals ML, Abess AT, Nichols SD, Martin MW, Cobb CM, et al. Chronic pain patients’ perspectives of medical cannabis. Pain. 2017;158:1373–9.
https://www.businessinsider.com/cost-first-fda-approved-marijuana-medication-epidiolex-2018-8. Accessed 16 August 2018.
Pain S. A potted history. Nature. 2015;525(7570). https://www.nature.com/articles/525S10a.
Noyes R Jr, Brunk SF, Avery DH, Canter A. The analgesic properties of delta-9-tetrahydrocannabinol and codeine. Clin Pharmacol Ther. 1975;18(1):84–9.
Noyes R Jr, et al. Analgesic effect of delta-9-tetrahydrocannabinol. J Clin Pharmacol. 1975;15(2–3):139–43.
Sallan SE, Zinberg NE, Frei E 3rd. Antiemetic effect of delta-9-tetrahydrocannabinol in patients receiving cancer chemotherapy. N Engl J Med. 1975;293(16):795–7.
Kluin-Neleman JC, Neleman FA, Meuwissen OJ, Maes RA. Delta 9-tetrahydrocannabinol (THC) as an antiemetic in patients treated with cancerchemotherapy; a double-blind cross-over trial against placebo. Vet Hum Toxicol. 1979;21(5):338–40.
Todaro B. Cannabinoids in the treatment of chemotherapy-induced nausea and vomiting. J Natl Compr Cancer Netw. 2012;10(4):487–92.
Chakravarti B, Ravi J, Ganju RK. Cannabinoids as therapeutic agents in cancer: current status and future implications. Oncotarget. 2014;5(15):5852–72.
Munson AE, Harris LS, Friedman MA, Dewey WL, Carchman RA. Antineoplastic activity of cannabinoids. J Natl Cancer Inst. 1975;55(3):597–602.
Abrams DI, Guzman M. Cannabis in cancer care. Clin Pharmacol Ther. 2015;97(6):575–86.
Blake A, et al. A selective review of medical cannabis in cancer pain management. Ann Palliat Med. 2017. https://doi.org/10.21037/apm.2017.08.05.
Maida V, Daeninck PJ. A user’s guide to cannabinoid therapies in oncology. Curr Oncol. 2016;23(6):398–406.
https://www.hhs.gov/opioids/about-the-epidemic/index.html. Accessed August 16, 2018.
Elikkottil J, Gupta P, Gupta K. The analgesic potential of cannabinoids. J Opioid Manag. 2009;5(6):341–57.
• Bradford AC, et al. Association between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018;178(5):667–72 Demonstrates that the legalization of medical cannabis is associated with a statistically significant decrease in the prescription of opioids, specifically by looking at data from the Medicare Part D population. There was a greater decrease in opioid prescriptions in states that had more permissive dispensaries. This is a significant finding as doctors, policymakers, and the general public look to combat the opioid epidemic.
Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668–73.
http://www.health.state.mn.us/topics/cannabis/about/ipreport.pdf. Accessed 16 August 2018. See Page 7.
•• https://www.cancer.gov/about-cancer/treatment/cam/hp/cannabis-pdq#section/all. Accessed 16 August 2018. This government website is the premier location to find up-to-date information regarding medical cannabis in the cancer population. Individualized sections provide citations and analysis for a variety of symptoms. With a simple click, the page becomes the “patient version”, which is a useful resource to provide patients.
The authors thank Justin Eklund, Aminah Jatoi, and Mary Van Beusekom for their critical review of this manuscript.
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Palliative Medicine
About this article
Cite this article
Steele, G., Arneson, T. & Zylla, D. A Comprehensive Review of Cannabis in Patients with Cancer: Availability in the USA, General Efficacy, and Safety. Curr Oncol Rep 21, 10 (2019). https://doi.org/10.1007/s11912-019-0757-7
- Palliative care