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Pediatric cancer providers give medical marijuana a cautious thumbs-up

December 11, 2017

New research by Yale Cancer Center (YCC) researchers shows a majority of pediatric cancer providers endorse the potential use of medical marijuana for children with advanced cancer, although providers who are legally eligible to certify its use are more cautious than those who aren’t. The findings also show clinicians would prefer to see much stronger clinical evidence that marijuana treatments can help in relieving symptoms, such as nausea and pain.

The study is a result of a survey of pediatric cancer care providers published first online in the journal Pediatrics, said first author Prasanna Ananth, M.D., M.P.H., a pediatric oncologist at YCC and assistant professor of pediatrics at Yale School of Medicine.

“Patients and families were asking us about medical marijuana all the time, although we knew there wasn’t a lot of scientific evidence behind it,” Ananth said. “We wanted to get a better sense of how much it was permeating clinical practice.”

Ananth launched the survey in fall 2015 with Joanne Wolfe, M.D., M.P.H., who is chief of Pediatric Palliative Care at Dana-Farber Cancer Institute and director of Pediatric Palliative Care at Boston Children’s Hospital.

“There is an urgent need for empiric data regarding medical marijuana’s potential use, and its short and longer-term complications, given the high interest among families of children with cancer,” said Wolfe.

The electronic survey was sent to physicians, nurse practitioners, physician assistants, psychologists, social workers and registered nurses at three National Cancer Institute-designated cancer centers: Dana-Farber, Lurie Children's Hospital of Chicago, and Seattle Children’s Hospital. Most children with cancer in this country receive care at similar academic cancer centers, Ananth noted.

Among the 288 providers who responded to the survey, 30 percent said that patients or their families had asked for medical marijuana at least once in the past month.

Overall, 92 percent of the clinicians were willing to help pediatric patients access medical marijuana, Ananth said. Approval was highest for use of medical marijuana near the end of life or in treatment with palliative intent.

Medical marijuana is approved for various conditions in 29 states and the District of Columbia, but under federal law, it remains a Schedule 1 controlled substance, along with heroin and ecstasy.

State regulations and hospital policies about medical marijuana vary widely, Ananth said. Physicians in the three states where the study was conducted are legally allowed to recommend medical marijuana. In Washington State, nurse practitioners and physician assistants also can do so.

These providers who are eligible to certify marijuana use were significantly less willing (85 percent rather than 92 percent) to help patients access the substance. “This might be due to legal uncertainties about actually recommending the substance, given federal regulations,” Ananth said.

Perhaps surprisingly, 65 percent of all clinicians reported approval of letting children with cancer smoke marijuana. This level of acceptance dropped to 39 percent among providers legally able to certify use of marijuana, who may have been concerned by the risks of carcinogenic substances and lung infections among patients with suppressed immune systems, Ananth noted.

The U.S. Food & Drug Administration (FDA) has approved dronabinol, a synthetic form of marijuana, to help with nausea and vomiting in children with cancer, and the drug is sometimes used off-label to stimulate appetite as well.

But families will sometimes indicate that dronabinol is much less effective than marijuana, which contains many other chemical components, Ananth said. Cannabidiol (CBD) oil, one of these components, is available over the counter.

There is limited clinical evidence that any form of marijuana benefits children with cancer, Ananth emphasized. In the survey, 93 percent of providers agreed on the need for randomized trials that could analyze its potential roles. However, such trials would face many hurdles.

“For starters, we would have to make sure that the product is standardized,” said Ananth. “That's a big problem with medical marijuana, because there are no standards. Even if we could conduct a clinical trial with a standardized product, that product might not be readily available in marijuana dispensaries.”

Additionally, FDA clearance for trials could be difficult to obtain since marijuana is a controlled substance.

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

Co-authors on the paper included Clement Ma, Hasan Al-Sayegh, Ilana Braun and Wendy London of Dana-Farber; Leah Kroon, Victoria Klein, Claire Wharton and Abby Rosenberg of Seattle Children's Hospital; and Elise Hallez and Kelly Michelson of Lurie Children's Hospital of Chicago. Lead funding for the research came from the National Institutes of Health, the David A. Abraham Fund at Dana-Farber, the Patient-Centered Outcomes Research Institute and the American Cancer Society.

About Yale Cancer Center

Yale Cancer Center (YCC) is one of only 49 National Cancer Institute (NCI-designated comprehensive cancer) centers in the nation and the only such center in southern New England. Comprehensive cancer centers play a vital role in the advancement of the NCI’s goal of reducing morbidity and mortality from cancer through scientific research, cancer prevention, and innovative cancer treatment.

About Dana-Farber Cancer Institute From achieving the first remissions in childhood cancer with chemotherapy in 1948, to developing the very latest new therapies, Dana-Farber Cancer Institute is one of the world’s leading centers of cancer research and treatment. It is the only center ranked in the top 4 of U.S. News and World Report’s Best Hospitals for both adult and pediatric cancer care.

Submitted by Renee Gaudette on December 11, 2017