By John Taenzler, Ph.D.

In October 2018, a survey was conducted among 87 oncologists (ONCs) in 19 of the States where medical marijuana (MMJ) has been approved and available.  An objective of this research was to assess the depth of knowledge about cannabis pharmacology, state-specific regulations, and attitudes of national medical organizations toward MMJ.

In examining and assessing the perceptions and attitudes of these ONCs towards MMJ, physicians were asked about their current use of MMJ for their patients and given their current knowledge-base how likely they are to recommend MMJ in the future to patients with cancer.  These questions were used to segment ONCs based on their future willingness to recommend MMJ.

• Willing ONCs (n=48)
• On-the-fence ONCs (n=18)
• Unwilling ONCs (n=21)

Current Use of MMJ

Overall, 38% of ONCs in the USA say they currently recommend MMJ to their cancer patients, 17% have done so in the past, but 45% have never recommended MMJ.  While “Willing ONCs” have a larger number of patients who are specifically using MMJ for a medical need (45 patients per ONC, vs. 23 for “On-the-fence ONCs” and 20 of “Unwilling ONCs”[1]), there is no statistical difference among ONCs regarding the total number of patients taking MMJ across a three-month period (69 patients, on average).

[1]Statistically significant (p<0.013).

Despite no differences in total patient volume using MMJ, ONCs willing to recommend MMJ have many more patients asking about using MMJ over a 3-month period (n=60 patients per ONC) than do ONCs who are “On-the-Fence” (n=16 patients) or “Unwilling ONCs” (n=2 patients).  While the willingness to discuss MMJ with their patients appears to have no correlation with how many of ONCs’ patients ultimately try MMJ, ONC’s knowledge of and openness toward MMJ undoubtedly has an impact on the benefits and struggles experienced by patients.

The question is then raised, what can be done to 1) encourage current prescribers to expand their use, 2) encourage “On-the-Fence” prescribers of the benefits of MMJ, and 3) overcome barriers faced by unwilling prescribers.

ONC Profiles

During the survey, ONCs were presented with a list of topics regarding MMJ, and each was asked to rate their familiarity with each topic, specify which topics they have discussed with enquiring patients, and indicate which topics would most impact their future recommendations for MMJ.  These topics ranged across a number of themes, including:

• Cannabis Pharmacology
• Cannabis Regulations
• Medical Industry’s Stance on MMJ
• Clinical Claims of Cannabis

Analysis reveals key distinguishing characteristics among the three segments of ONCs.

The ONCs currently willing to recommend MMJ to their cancer patients are significantly more familiar with many of the topics regarding cannabis than are other ONCs.  Further, due to their familiarity with MMJ, willing ONCs have discussed nearly all topics with more patients than have other ONCs.

Data that would most influence willing ONCs’ future prescribing includes information about the medical benefits (claims) for cannabis, how products are tested, and a few pharmacology topics. Data needs in priority order include:

1. How cannabis is tested
2. Data for anti-inflammatory and immunomodulating properties and the impact of cannabis on malignancies
3. Data on the pharmacology of CDB and the human endocannabinoid system.
4. Short-term risks of MMJ

Profile:   ONCs currently willing to recommend MMJ to their cancer patients are generally comfortable with the logistics of acquiring a MMJ Card and where patients can find MMJ. This comfort with recommending MMJ is revealed in their willingness to widely discuss MMJ with their patients.

They are now seeking more data to substantiate the medical claims made for MMJ and to gain a more thorough understanding of how cannabis is tested.  While these willing ONCs seemed to have had positive experience with recommending MMJ, they recognize that their observations need to be validated by large, long-term studies.

ONCs who are unsure whether or not to recommend MMJ to their cancer patients have low to moderate familiarity with cannabis topics. As such, these ONCs discuss MMJ with the fewest number of patients.  Half (50%) of these ONCs have not discussed any of the MMJ topics with patients.

Data that would most influence these ONCs’ future decisions about MMJ include (in priority order):

1. The psychoactive properties of cannabis
2. The impact of cannabis on malignancies
3. Volume of MMJ that can be purchased
4. Pharmacology of THC and CBD
5. Endorsements by the medical industry
6. Risks of MMJ (both short- and long-term)

Profile:   ONCs currently on-the-fence about whether or not to recommend MMJ in the future are uninformed about MMJ overall.  As such, they seem to not have well-formed opinions (positive or negative) about cannabis. Left to their own, with 1 or 2 bad patient experiences, they could easily become unwilling to consider MMJ for their patients.

To move them into the “willing” category of ONCs, “On-the-Fence ONCs” need detailed data behind the science of cannabis (e.g., pharmacology of components and how cannabis works clinically for cancer patients).  These ONCs are most receptive to endorsements by the medical industry and would be influenced by positive feedback.

ONCs who are unwilling to recommend MMJ to their cancer patients are slightly more informed about MMJ than are on-the-fence ONCs.  In addition, they appear very unwilling to proceed with recommending MMJ until their colleagues and the medical industry as a whole have endorsed MMJ.

Overall familiarity with MMJ topics among “Unwilling ONCs” is spotty, at best. There are a few topics where their familiarity is moderate (e.g. long- and short-term safety of MMJ, logistics of acquiring MMJ, and endorsement of the medical community). However, their familiarity is significantly below other ONCs for most other topics.

Topics that may lessen the opposition toward MMJ among these unwilling ONCs include the following (in priority order):

1. Endorsements by the American Medical Association (AMA)/National Institute of Health (NIH) and by American Society for Clinical Oncology (ASCO)/National Comprehensive Cancer Network (NCCN)
2. Learning the clinical impact of MMJ on malignancies
3. Risks of MMJ (both short- and long-term)

Profile:   ONCs currently unwilling to recommend MMJ in the future seem to have an overall negative opinion about MMJ (maybe due to having patients with unacceptable side effects) or have received bad information about MMJ.  These ONCs have spotty familiarity with various cannabis topics but are almost completely ignorant of others.

In order to counter the unwilling ONCs’ opposition to MMJ, their concerns will need to be addressed prior to educating them on the details about the science behind cannabis.

Conclusions

As shown in the study findings, information is key to encouraging ONCs’ to recommend MMJ for their patients.  Given the low level of understanding of various cannabis topics, companies looking to market to healthcare providers need to understand the current knowledge-based of targeted physicians in order to craft messaging that is most compelling to each.

 

Currently only 4 in 10 ONCs (see figure above) feel confident addressing patients’ questions about MMJ, but only 8% say they feel very confident.  As expected, due to their greater understanding of MMJ, ONCs willing to recommend the treatment are significantly more confident (54%) than “Unwilling ONCs” (28%) or “On-the-Fence ONCs” (22%).

As demonstrated in the pharmaceutical industry, focusing on the education of physicians in overcoming their hesitancy and other barriers to recommending MMJ pays dividends by:

• Increasing the confidence of physicians in being able to address patients’ questions about MMJ;
• Building a level of trust between healthcare provider and suppliers of MMJ by demonstrating suppliers’ investment into patient care; and
• Ultimately increasing profits by focusing physicians’ recommendations toward those companies who have repeatedly demonstrated their commitment to the healthcare community.