Most pediatric oncologists willing to consider medical marijuana for children with cancer

Prasanna Ananth

A majority of pediatric cancer providers endorse the use of medical marijuana for children with advanced cancer, according to results of a multicenter survey published in Pediatrics.

However, providers who are legally eligible to certify medical marijuana use appeared more cautious, results showed.

“Patients and families were asking us about medical marijuana all the time, although we knew there was not a lot of scientific evidence behind it. We wanted to get a better sense of how much it was permeating clinical practice,” Prasanna Ananth, MD, MPH, pediatric oncologist at Yale Cancer Center and assistant professor of pediatrics at Yale School of Medicine, said in a press release.

Ananth and colleagues conducted a survey of 288 pediatric oncology providers (median age, 35 years) in Illinois, Massachusetts and Washington to determine medical marijuana practices, knowledge, attitudes and barriers.

Researchers stratified providers by whether they were legally eligible to certify for medical marijuana (33%).

Thirty percent of providers reported receiving one or more requests for medical marijuana during the previous month; however, only 5% of providers knew state-specific regulations.

Providers who were legally eligible to certify were more likely to know that medical marijuana is against federal laws (P < .0001).

The majority of providers (92%) reported they were willing to help children with cancer access medical marijuana. However, providers who were legally eligible to certify were less likely to report approval of patient medical marijuana use by smoking, oral formulations, as cancer-directed therapy or to manage symptoms (P < .005 for all).

“Medical marijuana may be problematic, especially in children, with its potential for habit formation and its possible effects on the developing brain,” Ananth said in the release. “And yet these children are facing life-threatening illness and suffering from unrelieved symptoms, and we want to optimize our ability to care for them.”

HemOnc Today spoke with Ananth about the study, the potential implications of the findings, and how the ongoing debate about use of medical marijuana specifically relates to pediatric patients with cancer.

 

Question: What prompted this research?

Answer: When I was practicing in Massachusetts, I spoke with my mentor and the senior author of this paper, Joanne M. Wolfe, MD, about the implications of 2012 legislation in Massachusetts, allowing adults and children with life-threatening illness to access marijuana for medical purposes. This study was developed at the cusp of this legislation. A few months later, the state department of public health started to think about how they would grant access to medical marijuana and what the dispensaries would look like, and we started to see an uptake in the number of patients and families who were interested in this. This started us on this path.

 

Q: How did you conduct the research?

A: I collaborated with two experienced investigators — Kelly Michelson, MD, MPH, and Abby Rosenberg, MD, MS — who work at large NCI-designated cancer centers. We designed an electronic survey and sent a link via email to providers who care for children with cancer.

 

Q: What did you find?

A: In general, providers were largely open to considering medical marijuana for children with cancer. They tended to be more open to using medical marijuana in the later stages of illness, when illness is not curable, it is being treated with palliative intent, or near the end of life. The other interesting finding of our study was that there seemed to be a difference of attitudes between providers who were legally able to recommend marijuana vs. those who are not. Providers who are not legally able to recommend medical marijuana were actually more open to considering medical marijuana in oral forms, smoked and as a cancer-directed treatment. This is quite interesting because, unfortunately, there is not a lot of evidence for medical marijuana use in cancer treatment.

 

Q: Why might certain survey respondents feel more inclined than others to support the idea of medical marijuana for pediatric patients with cancer?

A: There was a clear distinction between the providers who could and could not recommend it legally. When a provider is asked to write a recommendation, theoretically there could be repercussions — whether professional or legal — particularly considering that marijuana is federally illegal. At the time the survey was conducted, providers did not appear to be concerned about being prosecuted, but I suspect there may also be some hesitation around being asked to provide a recommendation in the face of very limited evidence on the safety and efficacy of medical marijuana in children.

Q: What are the potential implications of the findings?

A: Because this was not a clinical trial, we cannot make any conclusions about the clinical efficacy of medical marijuana. What we can say is that providers are open to using medical marijuana for children with cancer. Also, we definitely need clinical trials to establish safety and efficacy. Providers in our study were very much in support of developing clinical trials to provide more scientific evidence. One of the major barriers to recommending medical marijuana that was elicited in the survey was the lack of standards around dosing and potency. This is a real challenge when being asked to write a recommendation. There is a lot of variability in formulations and strengths. Another interesting finding was that 30% of providers had received at least one request for medical marijuana within the prior month. Few pediatric studies published prior to this have demonstrated interest to this degree, at least in a population of children with serious illness. This clearly demonstrates that patients and families are interested in medical marijuana and providers are being asked about it quite often. Therefore, it is important for providers to have at least a basic understanding of how to access medical marijuana, what the state laws are, how marijuana is metabolized, and how it interacts with other medications.

 

Q: What do you expect will happen next?

A: Our next research steps are to hear patient and family perspectives on medical marijuana. We also need a well-designed clinical trial to explore the use of medical marijuana in pediatric-aged patients with serious illness. There are a lot of hurdles to surpass. Yet, we are entering an era in which patients and families are interested in medical marijuana and potentially have access to it. As providers, although we do not necessarily want to sanction treatments that have not been rigorously vetted, we also acknowledge from a compassionate standpoint that we want to help relieve our patients’ symptoms. We know from prior research that children with cancer suffer from unrelieved symptoms, and sometimes our standard medications may not be sufficient. The big challenge is that we are pitted against many decades of research into adolescents and young adults who have used marijuana recreationally, and there are a lot of potential risks of habitual use. This makes it difficult to pursue trials for children, adolescents and young adults.

 

Q: Can you offer some practical advice for the considerations clinicians need to make when their patients ask about the use of medical marijuana?

A: Speaking from the standpoint of a pediatric oncologist, we should recognize that — even if we are not the ones actively recommending medical marijuana — patients have other routes of accessing it. I would never say that a provider should recommend it, because it is difficult to recommend something for which we do not have adequate evidence. At the same time, we want to maintain open dialogue about it. In the cancer context, I generally ask patients if they are on any complementary or herbal remedies. I generally tell my patients to avoid smoked or vaporized forms of marijuana to reduce risk of exposure to carcinogens, fungi or mold. I also would urge providers to tell patients that strengths of medical marijuana formulations can vary, so sometimes things like edibles can be quite strong. I also let my patients know that marijuana is metabolized through the liver and that it can interact with certain medications, so it is important to let us know if they are using marijuana, whether medicinally or for recreation.

 

Q: Is there anything else that you would like to mention?

A: Half of the United States has legalized medical marijuana, and many other countries have legalized both recreational and medical marijuana. We are entering an era in which we are not able to ignore widespread marijuana availability and use. As providers and institutions, we ought to come up with policies on how to approach marijuana inquiries from patients and families. These approaches may vary from one institution to the next, recognizing that the scientific evidence may lag behind state policies around medical marijuana. – by Jennifer Southall

 

Reference:

Ananth P, et al. Pediatrics. 2017;doi:10.1542/peds.2017-0559.

 

For more information:

Prasanna Ananth, MD, MPH, can be reached at Yale Cancer Center,

333 Cedar St., LMP 2082C, New Haven, CT 06510; email: prasanna.ananth@yale.edu.

 

Disclosure: Ananth reports no relevant financial disclosures.

Prasanna Ananth

A majority of pediatric cancer providers endorse the use of medical marijuana for children with advanced cancer, according to results of a multicenter survey published in Pediatrics.

However, providers who are legally eligible to certify medical marijuana use appeared more cautious, results showed.

“Patients and families were asking us about medical marijuana all the time, although we knew there was not a lot of scientific evidence behind it. We wanted to get a better sense of how much it was permeating clinical practice,” Prasanna Ananth, MD, MPH, pediatric oncologist at Yale Cancer Center and assistant professor of pediatrics at Yale School of Medicine, said in a press release.

Ananth and colleagues conducted a survey of 288 pediatric oncology providers (median age, 35 years) in Illinois, Massachusetts and Washington to determine medical marijuana practices, knowledge, attitudes and barriers.

Researchers stratified providers by whether they were legally eligible to certify for medical marijuana (33%).

Thirty percent of providers reported receiving one or more requests for medical marijuana during the previous month; however, only 5% of providers knew state-specific regulations.

Providers who were legally eligible to certify were more likely to know that medical marijuana is against federal laws (P < .0001).

The majority of providers (92%) reported they were willing to help children with cancer access medical marijuana. However, providers who were legally eligible to certify were less likely to report approval of patient medical marijuana use by smoking, oral formulations, as cancer-directed therapy or to manage symptoms (P < .005 for all).

“Medical marijuana may be problematic, especially in children, with its potential for habit formation and its possible effects on the developing brain,” Ananth said in the release. “And yet these children are facing life-threatening illness and suffering from unrelieved symptoms, and we want to optimize our ability to care for them.”

HemOnc Today spoke with Ananth about the study, the potential implications of the findings, and how the ongoing debate about use of medical marijuana specifically relates to pediatric patients with cancer.

 

Question: What prompted this research?

Answer: When I was practicing in Massachusetts, I spoke with my mentor and the senior author of this paper, Joanne M. Wolfe, MD, about the implications of 2012 legislation in Massachusetts, allowing adults and children with life-threatening illness to access marijuana for medical purposes. This study was developed at the cusp of this legislation. A few months later, the state department of public health started to think about how they would grant access to medical marijuana and what the dispensaries would look like, and we started to see an uptake in the number of patients and families who were interested in this. This started us on this path.

 

Q: How did you conduct the research?

A: I collaborated with two experienced investigators — Kelly Michelson, MD, MPH, and Abby Rosenberg, MD, MS — who work at large NCI-designated cancer centers. We designed an electronic survey and sent a link via email to providers who care for children with cancer.

 

Q: What did you find?

A: In general, providers were largely open to considering medical marijuana for children with cancer. They tended to be more open to using medical marijuana in the later stages of illness, when illness is not curable, it is being treated with palliative intent, or near the end of life. The other interesting finding of our study was that there seemed to be a difference of attitudes between providers who were legally able to recommend marijuana vs. those who are not. Providers who are not legally able to recommend medical marijuana were actually more open to considering medical marijuana in oral forms, smoked and as a cancer-directed treatment. This is quite interesting because, unfortunately, there is not a lot of evidence for medical marijuana use in cancer treatment.

 

Q: Why might certain survey respondents feel more inclined than others to support the idea of medical marijuana for pediatric patients with cancer?

A: There was a clear distinction between the providers who could and could not recommend it legally. When a provider is asked to write a recommendation, theoretically there could be repercussions — whether professional or legal — particularly considering that marijuana is federally illegal. At the time the survey was conducted, providers did not appear to be concerned about being prosecuted, but I suspect there may also be some hesitation around being asked to provide a recommendation in the face of very limited evidence on the safety and efficacy of medical marijuana in children.

 

PAGE BREAK

Q: What are the potential implications of the findings?

A: Because this was not a clinical trial, we cannot make any conclusions about the clinical efficacy of medical marijuana. What we can say is that providers are open to using medical marijuana for children with cancer. Also, we definitely need clinical trials to establish safety and efficacy. Providers in our study were very much in support of developing clinical trials to provide more scientific evidence. One of the major barriers to recommending medical marijuana that was elicited in the survey was the lack of standards around dosing and potency. This is a real challenge when being asked to write a recommendation. There is a lot of variability in formulations and strengths. Another interesting finding was that 30% of providers had received at least one request for medical marijuana within the prior month. Few pediatric studies published prior to this have demonstrated interest to this degree, at least in a population of children with serious illness. This clearly demonstrates that patients and families are interested in medical marijuana and providers are being asked about it quite often. Therefore, it is important for providers to have at least a basic understanding of how to access medical marijuana, what the state laws are, how marijuana is metabolized, and how it interacts with other medications.

 

Q: What do you expect will happen next?

A: Our next research steps are to hear patient and family perspectives on medical marijuana. We also need a well-designed clinical trial to explore the use of medical marijuana in pediatric-aged patients with serious illness. There are a lot of hurdles to surpass. Yet, we are entering an era in which patients and families are interested in medical marijuana and potentially have access to it. As providers, although we do not necessarily want to sanction treatments that have not been rigorously vetted, we also acknowledge from a compassionate standpoint that we want to help relieve our patients’ symptoms. We know from prior research that children with cancer suffer from unrelieved symptoms, and sometimes our standard medications may not be sufficient. The big challenge is that we are pitted against many decades of research into adolescents and young adults who have used marijuana recreationally, and there are a lot of potential risks of habitual use. This makes it difficult to pursue trials for children, adolescents and young adults.

 

Q: Can you offer some practical advice for the considerations clinicians need to make when their patients ask about the use of medical marijuana?

A: Speaking from the standpoint of a pediatric oncologist, we should recognize that — even if we are not the ones actively recommending medical marijuana — patients have other routes of accessing it. I would never say that a provider should recommend it, because it is difficult to recommend something for which we do not have adequate evidence. At the same time, we want to maintain open dialogue about it. In the cancer context, I generally ask patients if they are on any complementary or herbal remedies. I generally tell my patients to avoid smoked or vaporized forms of marijuana to reduce risk of exposure to carcinogens, fungi or mold. I also would urge providers to tell patients that strengths of medical marijuana formulations can vary, so sometimes things like edibles can be quite strong. I also let my patients know that marijuana is metabolized through the liver and that it can interact with certain medications, so it is important to let us know if they are using marijuana, whether medicinally or for recreation.

 

Q: Is there anything else that you would like to mention?

A: Half of the United States has legalized medical marijuana, and many other countries have legalized both recreational and medical marijuana. We are entering an era in which we are not able to ignore widespread marijuana availability and use. As providers and institutions, we ought to come up with policies on how to approach marijuana inquiries from patients and families. These approaches may vary from one institution to the next, recognizing that the scientific evidence may lag behind state policies around medical marijuana. – by Jennifer Southall

 

Reference:

Ananth P, et al. Pediatrics. 2017;doi:10.1542/peds.2017-0559.

 

For more information:

Prasanna Ananth, MD, MPH, can be reached at Yale Cancer Center,

333 Cedar St., LMP 2082C, New Haven, CT 06510; email: prasanna.ananth@yale.edu.

 

Disclosure: Ananth reports no relevant financial disclosures.