Understanding Medicinal Cannabis in Cancer Carevoice.ons.org/news-and-views/understanding-medicinal-cannabis-in-cancer-care

Medicinal cannabis, a topic that remains largely unstudied in human trials in the United States,is slowly becoming introduced in areas of health care and oncology in states that havelegalized it for medical and adult recreational use.

However, withouta breadth of knowledge or research behind cannabis, healthcareprofessionals may be at a loss when patients ask about its medicinal use as part of theirtreatment protocols. Without the answers to rudimentary cannabis questions, many patientsare forced to look elsewhere for information—which can often lead to misinformation, potentialunwanted drug interactions, and more. As many as 25% of patients with cancer may be usingcannabis in states where it’s legal; 60% of patients with cancer would like informationregarding medicinal use of cannabis, yet only 15% received any information about cannabisfrom their doctor or nurse.

Additionally, the more common term marijuana itself carries with it decades of institutional,cultural, and societal connotations. Cannabis, the plant genus from which ingestible forms ofmarijuana are harvested, is actually three different plants—cannabis indica, cannabis sativa,and cannabis ruderalis. Cannabis sativa, often referenced for its psychoactive effects whichare associated with the compound tetrahydrocannabinol (THC), has also been recognized as apotential medicinal treatment for pain and cramps in Chinese texts dating back to 3000 BC.Using a blanket term like marijuana to describe the effects of medicinal cannabis can rob anydiscussion of the scientific nuance needed to explore it.

Two nurses, among many, have recognized the gap in available education and knowledge,and they’re working to answer common—and uncommon—questions about medicinalcannabis use in cancer care.

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The Human Endocannabinoid System

To understand and define medicinal cannabis use, oncology nurses need to start at the basic,molecular level to recognize the physiology of how cannabis works in the body. ONS 42ndAnnual Congress speaker Carey S. Clark, PHD, RN, AHN-BC, associate professor of nursingat the University of Maine at Augusta and president-elect of the American Cannabis NursesAssociation, encourages nurses to learn about the human endocannabinoid system (ECS) andits relation to the body.

“For some people, medicinal cannabis can look a little bit like a ‘snake oil’ treatment, as itseems to help with so many different health and illness issues,” Clark says. “This is why it is soimportant for nurses to understand the basics of the human ECS, which is the largest receptorsystem in the body. Our bodies make our own cannabis-like substances, namely A-AG andanandamide, that interact with the ECS receptors—CB1 and CB2—to help maintainhomeostasis throughout the entire body. When we have an endocannabinoid deficiency, or wearen’t making enough A-AG and anadamide, we are more likely to become sick. At that point,we may need to supplement with exogenous phytocannabinoids—of which there are many;cannabis is just one—to help support our body’s ability to maintain homeostasis.”

ONS member Kristin Wohlschlagel, RN, CHPN, oncology, hospice, and palliative care nurse atGreen Health Consultants in Lafayette, CA, notes that most medical professionals aren’t evenaware of the ECS.

Carey S. Clark, PHD, RN, AHN-BC

“One thing that made me realized a lack ofacceptance and information was when I bought a$120 textbook—one of the top biology andphysiology books used in medical colleges in thepast five years—and there wasn’t a singlereference to the ECS,” Wohlschlagel says.“Recently, I was communicating with aresearcher, and I mentioned that there might becannabinoid receptors on some tumor cells and B cells in patients with leukemia and othercancers, including HER2+ breast cancers. She immediately dismissed our conversation,saying, ‘I’m not interested in medicinal cannabis. I am interested in immunotherapy.’ When lmentioned that is exactly what I was trying to encourage this oncology investigator inAustralia to know, the fact that cannabinoids are involved in immune function in some veryimportant ways, I was met with silence. I wasn’t encouraging the use of cannabis at all, I wastrying to discuss the cannabinoid receptors as it possibly relates to tamoxifen resistance insome HER2+ breast cancer cases as well as some other high-grade tumor types, becausethere’s research possibly linking the two. I realized then that had the scientists who’ddiscovered this receptor system named it something else—without a reference to the wordcannabis—it would probably be fully ingrained in our medical culture by now.”   

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Both Wohlschlagel and Clark emphasize that the ECS plays a large role in maintaininghomeostasis in the body. Although it gained its name from certain receptors binding withcannabis, other factors also support the health of the ECS.

“We can potentiate the optimal functioning of our ECS by exercising, reducing stress,manipulating our diets—particularly to include omega-3 fatty acids in balance with omega-6fatty acids, caryophyllene, and flavonoids, of which most folks do not get enough—doing yogaor meditation, and receiving acupuncture or osteopathic treatments,” Clark notes.

Kristin Wohlschlagel, RN, CHPN

The Benefits of Medicinal Cannabis in Cancer Care

Knowing how, where, and when medicinal cannabis can be used in cancer care can becomplex. According to Clark, it’s highly dependent on state laws.

“Considering the 29 states that allow some form of medical or recreational use of cannabis, theherb is being used for everything from cancer palliation, to seizure management, issuesrelated to glaucoma, end-of-life care, cachexia, Parkinson disease, and as a medicine to helpmanage opiate dependence and tolerance,” Clark says.

Beyond its association with symptom management, including pain and nausea control, someresearch studies have discovered that cannabis may cut tumor growth and size. This wasfound to be the case in mice in an American Association for Cancer Research study.Furthermore, small sample research administered THC to patients with glioblastoma and sawencouraging results. However, both studies recognized the need for further research in thearea.

How Oncology Nurses Can Learn More About Cannabis in

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Cancer Care“Some patients with tumors in their brains or leptomeningeal regions from HER2-positivebreast cancer have been reporting surprisingly good results when using THC-rich cannabisalongside conventional treatments like radiotherapy,” Wohlschlagel says. “I have met with theresearchers involved in this, and patients were reporting results that correlated with whatpreclinical research indicated might happen. Beyond that, most of the success stories that Ihad seen previously indicated an association with the HER2-positive or triple-negative breastcancer cases, with fewer good responses on THC with the double-positive or ER- and PR-positive cases that were not also HER2-positive.”

Currently, medicinal cannabis drugs like dronabinol have been approved for use in patientswith cancer to stimulate appetite. Moreover, other forms of medicinal cannabis have shown toameliorate pain and reduce nausea and vomiting. However, the main issue facing medicinalcannabis is the need for further research, which is impacted by the current U.S. DrugEnforcement Administration (DEA) schedule I status of the plant.  

Barriers Facing Cannabis Education and Research

Wohlschlagel’s journey to cannabis education was difficult in the beginning. She noticed adearth of knowledge available about cannabis in clinical care.

“I work in Hawaii, which is a medicinally legalized state, but I noticed that we didn’t have anytraining related to cannabis, and, in fact, there weren’t even dispensaries nearby,”Wohlschlagel notes. “Other than the general awareness that medicinal cannabis had beenused for pain and nausea control, there wasn’t much available. More to the point, people whowere using cannabis were using the smoked form, which didn’t seem appealing for us toencourage.”

Through online resources, European research findings, and frank discussions among onlinemedical groups, including the American Cannabis Nurses Association, Wohlschlagel foundmore and more information. However, she still recognizes the difficulty that oncology nursesface when searching for clinical resources about the ECS and cannabis use in practice.

Clark often fields questions from oncology professionals, many pertaining to dronabinol forpatients with cancer.

“Dronabinol is a synthetic form of THC and is missing other components—namelycannabinoids and terpenes—that interact with the ECS and help support homeostasis,” Clarksays. “Many patients cannot get dronabinol because the cost is prohibitive and their insurancewill not cover the medicine. Eventually there will be more readily available pharmacologic-based cannabinoid medicines available to patients, but much of the research in this area isbeing thwarted by the federal status of cannabis as a schedule I drug.”

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Schedule I drugs are defined as substances or chemicals with no identified or acceptedmedical uses. Currently, DEA categorizes cannabis alongside other schedule I drugs likeheroin, lysergic acid diethylamide, methylenedioxymethamphetamine, and peyote. Identifyingcannabis as such limits federally funded research, like studies through the National Institutesof Health and the National Cancer Institute, dedicated to understanding the drug’s potentialclinical benefits and limitations.

Know Your Medicinal Cannabis State LawsOne fundamentally important component for medicinal cannabis in practice is understandingthe laws in your state. Each state will have different restrictions, limitations, or prohibitionsregarding cannabis. Find out more at NORML.org.

The Future of Medicinal Cannabis

With every answer associated with medicinal cannabis, two more questions seem to follow.The available research is limited, and that means nurses have to take it upon themselves to beleaders in patient education and practice knowledge.

“Nurses need to educate themselves about the ECS and begin to get comfortable with howcannabis works in the body to share this knowledge with patients, their caregivers, and otherhealthcare professionals,” Clark says. “Nurses should be familiar with medicinal cannabis lawsand programs in their state and how to refer a patient for a medical recommendation. Nursesshould also educate themselves around dosing of cannabis for palliation, methods ofingestion, safety concerns, and medication interactions.”

“I’ve spoken with more than 600 patients who reported using cannabis in their breast cancertreatment,” Wohlschlagel says. “What was shocking was that these cases ran the gamut: somepeople were getting worse because they were avoiding conventional treatment in lieu ofcannabis or attempting to self-treat with huge doses of THC-rich medicines but without anyapparent success and were afraid to stop, even though it was clear they should. On the otherhand, some were reporting stage 4 breast cancer that disappeared after introducing cannabisinto their treatment. What’s important for patients to know is that this isn’t a magical cure for allcancer. But without further research, we have no way of even knowing what we’re able to offerpatients.”

Oncology nurses will face increasingly frequent questions about medicinal cannabis use fortheir patients with cancer. As more states pass laws that relax drug prohibition on cannabis,more patients will come ready with questions—and it’s up to oncology nurses to be preparedwith the answers they need.

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Understanding Medicinal Cannabis in Cancer CareThe Human Endocannabinoid SystemThe Benefits of Medicinal Cannabis in Cancer Care

How Oncology Nurses Can Learn More About Cannabis in Cancer CareBarriers Facing Cannabis Education and Research

Know Your Medicinal Cannabis State LawsThe Future of Medicinal Cannabis