What’s the Hash on the Little Green Plant and Cancer?

Dr. Diane Reidy-Lagunes:

Cannabis: you may know it as pot, weed, or marijuana. It's an ancient plant used for ritual, medicine, and well, partying for 5,000 years. People undergoing treatment for cancer have turned to cannabis, and the components of these plants, to relieve effects. But spotty legal status makes research funding and conclusive data less than robust. We're going to talk about what we, as cancer docs, know thus far. Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center, and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have straightforward, evidence-based conversations. Our mission is to educate you and empower you and your family members to make the right decisions and live happier, healthier lives. For more information on the topics discussed here, or to send us your questions, please visit us at mskcc.org/podcast. When we think about cannabis, we may think about people getting high for recreational purposes. That's not what we're talking about today. Joining me to get some clarity about the role that cannabis may play for patients with cancer is Dr. Nirupa Raghunathan, the Director of Pediatric Integrated Medicine here at MSK and also Founding Attending for the MSK Medical Cannabis Clinic. Also joining me for the second time is Ethan Zohn, cancer crusher and winner of TV's "Survivor: Africa". Ethan was diagnosed with a brutal type of lymphoma requiring two stem cell transplants. He is now thankfully cured of his disease. Ethan is here to talk to us about his experience with cannabis during and after treatment. In full disclosure, Ethan is now an investor with a maker of CBD products. Nirupa and Ethan, welcome to the show.

Ethan Zohn:

Thank you so much for having us.

Dr. Diane Reidy-Lagunes:

So excited to have you both. Nirupa, I want to start with just some definitions. Can you help me define what is cannabis, and in particularly, those two components that we hear so much about: THC and CBD?

Dr. Nirupa Raghunathan:

So cannabis is a plant. It's a plant like basil is a plant or oregano. It happens to be a plant that has an effect on our body. Cannabis the plant contains 108 other chemicals that are present in it. And so CBD and THC just happen to be two that are more prominent in it, easier to pull from it, easier to study, easier to know more about.

Dr. Diane Reidy-Lagunes:

So when we get to the basics, we have these two components. We have THC and CBD. Let's start with THC, which we typically say is the one that sort of has the psychoactive, makes-you-feel-high component. What can THC do for us in terms of alleviating side effects and making us feel a little bit better?

Dr. Nirupa Raghunathan:

That's a great question. It's been shown to maybe be helpful with nausea and vomiting, particularly related to chemo nausea and vomiting. There's a synthetic THC that was developed about 30, 35 years ago that's available, a pharmaceutical called Marinol. That one is approved by the FDA for nausea and vomiting. We also see it being approved for AIDS anorexia, so weight loss due to AIDS. And then there are some studies from THC that have shown maybe some benefits to pain. That's a little bit harder because its legal status is whatever it is, wherever you are in that moment. It hasn't been studied extensively for pain in the ways we would like. And I think those things are still really early, but those are the things that most people express interest in, in terms of symptoms, the THC.

Dr. Diane Reidy-Lagunes:

Critically important. Absolutely. So pain, nausea, anorexia, those are really big symptoms.

Dr. Nirupa Raghunathan:

And anorexia means like lack of appetite.

Dr. Diane Reidy-Lagunes:

Absolutely. So Ethan, these are real symptoms and side effects that I am sure you had as a patient with lymphoma in 2009. And when you were going through treatment back then, support for legalizing cannabis was just not there. Particularly, you know, things have clearly changed. What was your experience during your first treatments when you decided that you wanted to try this? And any barriers that you had when you were trying to, sort of, seek that approach?

Ethan Zohn:

Definitely. When I was going through treatment, it wasn't widely available. And the doctors at Memorial Sloan Kettering, you know, weren't able to prescribe it for me. I was prescribed Marinol, which had a little bit of an effect, but I'm a firm believer in plant-based wellness, using the whole plant versus using these chemical versions of the actual plant. So growing up, I was never really into smoking weed. I'm a former professional soccer player so it's just never been part of my daily routine, but I tried it recreationally in college. So when I got sick and I was battling these side effects – the exact ones you mentioned, you know, sleepless nights, pain, nausea, little bit anxiety – I was plagued by all these things. And I struggled a little bit with the balance between all the incredible medicine that Sloan Kettering was putting inside my body – synthetics – and then also trying to like take control over my own health and healing with maybe some alternative therapies like plant-based wellness. 'Cause I didn't like taking all the synthetics. I didn't like the way it made me feel. And so when I decided, "Okay, I'm gonna try to use cannabis," I was completely transparent with my doctor, Miguel Perales, and he gave me some of the parameters: don't smoke it, make sure there's no mold in it, know where it came from. But that was impossible 'cause I was literally going to the streets of New York City; like I was going to a drug dealer with a mask, gloves, bald from chemo, hunched over, and I was talking to this guy that sold not only cannabis, but everything else you may want as a drug dealer in New York City. And I don't know where this stuff came from, if it was sprayed or moldy. And so the fear of actually trying to get a medicine that I felt was going to help me, on top of actually going through cancer and doing an illegal activity on top of all of it, was really difficult to manage for me. All I wanted to do was just feel better. And that's exactly what I felt. I was taking a lot of synthetic pills every single night just to get to bed, I was taking more in the morning to get to go back to the hospital for checkups, and just when I started using cannabis – vaporizing it and eating it – it was a game changer for me.

Dr. Diane Reidy-Lagunes:

Did it actually eliminate some of the medications? The so-called synthetic narcotics or other pain medications that you were taking?

Ethan Zohn:

Oh yeah. I was taking Zofran for nausea, Ativan for anxiety, Percocet for pain, Ambien for sleep. And then I'd be ripping an Adderall in the morning just have enough energy to go visit Dr. Perales to get my checkups. And so when I started like eating edibles, it changed it. Like I was hungry, I actually was nicer to be around so it was helpful to the people around me as well, I could sleep, I had more energy, I was less anxiety. And I'm not gonna say it's a cure-all, like it's the best thing on the face of the planet. There needs to be a lot more research to go into it, to kind of prove the efficacy of it, but it definitely made me feel better and I was able to wean myself off some of those drugs I just mentioned.

Dr. Diane Reidy-Lagunes:

Nirupa, how does one even prescribe the cannabis? I mean, Ethan clearly didn't know what he was looking for. The drug dealer clearly didn't know how to prescribe it for his anxiety and nausea-associated chemotherapy.

Dr. Nirupa Raghunathan:

In my experience, unfortunately, sometimes even the people who you would go to don't know as much as they should. And that's a really hard place for us to be in because we do want to be able to help, but when you don't have a ton of data and you just want to help somebody, sometimes it feels like it's still a crazy wild guessing game. What Ethan is alluding to, or speaking of, is an evolution in access that's been happening over the last decade, right? But to answer your question Diane, it depends on the state you're in. If I was to answer for New York, which is where I certify, you go to a certifying provider – I happen to certify at MSK – and that certifying provider has gone through a little bit of training. But each state is different; the quality of the training they're getting in each state can be quite variable. And then if that provider believes the person is a candidate for reasons of their diagnosis and their symptoms, they issue just a certificate. The certificate then allows a person access to a dispensary, and you meet with a dispensary pharmacist and they're the ones who are suggesting the specific product. Then people are able to get that product and use it. And this is where I get to be all technical: use it within state lines. Because if you take cannabis from whatever state you got it and you move it to another state, it is technically drug trafficking.

Dr. Diane Reidy-Lagunes:

Even with your prescription, you cannot?

Dr. Nirupa Raghunathan:

No. Now do people chase down someone who's crossing a straight line from Massachusetts to Connecticut and look at their suitcases? No, but from the federal standpoint, anything that's moved across state lines becomes a federal issue.

Dr. Diane Reidy-Lagunes:

Yeah. And there have definitely been stories of folks, particularly where it's not yet legal and prescribed by an MD to use for real medical purposes, who ended up in jail. So that's real, absolutely important to emphasize that. So you're prescribing medical cannabis. Do you have a way to measure? I mean like you said, the data is so limited. How do you even know how much a patient should tolerate or take?

Dr. Nirupa Raghunathan:

I start with dosing, and largely around nausea and vomiting. That tends to be the major reason people come in, and honestly, some of the medications we use for so many other things are constipating and that's really distressing, and thankfully cannabis isn't. Then we go up. We go slowly. That's the other reason I tend to like the oils, because you can start very low. If we used a pill, a tablet, and then I was like, "Oh, this tablet's 5 milligrams. Can you cut it to 1.5?" And they look at you like, "How would I even do that?" Whereas with a dropper, I can say, "Oh, can we start at like 1 or 1 and a half, and move a little bit in that way?" The dispensary pharmacists actually can be quite a bit of a resource as well because they are specifically trained in cannabis and they're supposed to be able to help counsel as well.

Dr. Diane Reidy-Lagunes:

And Ethan, did you have any idea? I mean, clearly you didn't have droppers at the time. How did you figure it out? How did you know what amount you needed?

Ethan Zohn:

For me, it was definitely an experiment. However, what I love about what's happening in the industry now, as the doctor was saying, is that there are so many different ways to use cannabis and CBD, and it's getting to a point where you can't really dial in the dosage of how you want to use it. Granted, that's going to be different for every person who uses it – what time of day, how much food you've eaten, your body weight, all that stuff – however, you know you can get a 5 milligram dose, 10, 20, 50, whatever you may need to help you feel better. And like you said, you can do it under the tongue, you can inhale it, you can eat it, there's sub-dermal patches, there's nasal sprays, there's inhalers, there's suppositories. So there are multiple different ways to use this plant to help you feel better.

Dr. Diane Reidy-Lagunes:

Awesome. Okay. So let's switch gears and discuss the second component of the plant that is CBD. So Nirupa, this one doesn't make you feel high, correct?

Dr. Nirupa Raghunathan:

It doesn't make you feel high. It can have a psychological effect. As most people describe it to me, and some of the studies show, maybe kind of an easing of anxiety. Some people don't even say it's an easing of anxiety as much as they feel chilled out. Some of them just feel like, "Oh, I just feel like I'm better adjusted during the day." These are not scientific, let me be very clear. Like there aren't studies and maybe there aren't really great scales to say I'm more chilled out than I was before. It doesn't make you high, but there are some studies that have shown high doses have helped for like performance anxiety before a test or speech or a podcast. And then there's also some studies that have looked at it actually for pain, but showed maybe some benefit to sleep and increased sleep quality. But again, it's so new that we don't have this beautiful recipe where you say, "Okay, if I put two drops in, this is what I get out." Like every person's different. It's really unfortunate. With the support of really good studies, you could get a little bit of a curve.

Dr. Diane Reidy-Lagunes:

Ethan, you had talked about the benefit that it provided when you were undergoing such brutal treatments. What about post-treatment, sort of the survivorship stage? We've had, on other pods, folks talking about how sometimes after the treatment is when the walls feel like they're coming down. There may be anxiety, there may be other issues. Did you still use medical cannabis, and if so, for what?

Ethan Zohn:

I definitely struggled with the "after cancer" that you're talking about. I was plagued with extreme anxiety, fear of relapse, and it got to a point where it was just affecting my life in an incredibly negative way. I had trouble just communicating with the world outside of my walls, like you said. And I got into CBD, not THC – I was using CBD in a tincture form, which is a liquid that goes underneath your tongue – and I using that every single day like a multivitamin. And for me, it felt like I could take a deep breath. I could focus a little bit more, I could plan for the future a little bit, and it just kind of reduced that anxiety and fear.

Dr. Diane Reidy-Lagunes:

Interesting. Nirupa, it does feel like everywhere you turn, there's another company that's trying to emphasize CBD products and different labels. And it's a little bit of the wild west in terms of like, how does one even know? I mean, obviously you're going to go to a prescriber first, but then you go to any dispensary? Like is there anything you can share in terms of discerning quality about these different products, and what might be important before a patient just goes to a certain place? Or do they ask their doc about that kind of recommendation?

Dr. Nirupa Raghunathan:

That's a great question. One of the things that I find so interesting is like, once I point out to someone how much there is out there, they're like, "Oh my God, it's everywhere." But the real hard thing here is that- just a little bit of background: In 2018, CBD no longer was considered what we call schedule one, which is considered the worst of the worst in terms of illegal drugs. And so because it was declassified from that, it became something that could be grown and made and classified as hemp. But the FDA, at the same time, did not decide how they wanted to regulate it. So what the FDA does – Food and Drug Administration – is they designate whether something is a food, a drug, or a supplement. CBD has yet to be classified, which means it doesn't have a specific standard to meet, which leaves manufacturers open to interpret that however they want to. So this is one of those things where it becomes consumer responsibility, buyer beware. There are a handful of organizations that attempt to do some quality checks: an organization called Consumer Lab, there's an organization called The U.S. Hemp Authority. I always like to make sure, caveat, I have no affiliation with any of these groups. I have like no reason to even mention their names, except that U.S. Hemp Authority has some sort of certification process. These quality certification-type groups pop up for supplements as well, but it does it for CBD.

Dr. Diane Reidy-Lagunes:

Ethan, any guidance from you, in your perspective as a consumer?

Ethan Zohn:

Yeah. With the CBD part of it, you can pretty much get it anywhere; you can get at a gas station, you can get at a pharmacy, you can get it at a dispensary. And there are varying levels of potency and purity. Like I'm going to buy in any product, I am going to read the back label – I'm gonna make sure it's third-party tested, maybe it's organic, maybe it's full plant, the way it's processed, less chemicals, more natural – I look at all that stuff before I'm making a choice to purchase a type of product. And then it's across the board: low and slow. Start low, in terms of the dosage. It's not like a one hit wonder. It's not like taking a crazy pain pill and you just feel like no pain. CBD is something that's kind of built up a little bit in your system. So I always suggest, you know, try a little bit every day, every other day, for a month. Give it that long. You know, track how you're feeling in certain environments – before you go to sleep, are you hungry, your anxiety – just take note of yourself. Be present and aware of who you are and what's going on in your life. And just kind of evaluate if it's working. If it's not working, you maybe either need to up the dose. If you're sleeping all the time, you need to lower the dose. And that similarly goes with the THC side of everything. But with that, I would definitely lean on whoever you're talking to in a cannabis dispensary, a medical dispensary, and follow the rules of your doctor. But low and slow is the way to go.

Dr. Nirupa Raghunathan:

Diane, if I might add, in terms of quality, theoretically, the CBD-only products out of a dispensary, they have to meet a certain quality standard laid out by the state because the state is regulating. There is some level of regulation that can sometimes, you know, ease people's concerns.

Ethan Zohn:

And there are cannabis consultants out there that have no affiliation to a hospital or dispensary. They're like unbiased, so you can call them up, you can do zoom consultations, tell them what you're dealing with, and they can help you figure out which direction you want to go into. I actually went and I took a consultation with a cannabis nurse, and she definitely directed me and helped me make some of those decisions.

Dr. Diane Reidy-Lagunes:

Who should not be taking CBD or medical cannabis, Nirupa?

Dr. Nirupa Raghunathan:

I would say, if you have anything that's up with your liver or your kidney, I would make sure you're speaking to a provider about it because CBD and THC are both processed through the liver. They affect what we call liver enzymes that are important for the processing of medications. And I've seen some research in Israel that looked at immunotherapy with cannabis and found actually decreased response rates. And so it's a question of whether cannabis interferes somehow at the cellular, like, molecular level with how those immunotherapies work.

Dr. Diane Reidy-Lagunes:

Got it. Ethan, I would love to hear your thoughts. You know, one of the problems with narcotics, for example, is when you use it for inappropriate reasons. There's a lot of concern, for example, in adolescents using cannabis for recreational reasons. Anything that you've noticed Ethan, like in terms of your own warning signals?

Ethan Zohn:

It's not addictive in the sense like an opioid would be addictive, but I think the ritual around cannabis and routines that you get into when using on a daily basis could be addictive.

Dr. Diane Reidy-Lagunes:

Yeah. I hear you. And Nirupa, anything to add on that?

Dr. Nirupa Raghunathan:

I agree. And I think that the idea that the truth is anything can be psychologically addictive. That's why you see like addiction to speed, addicted to gambling, addicted to sugar. Anything can be psychologically appealing in that way, and so you have to know yourself and know what those signs are. And while you may not have a physical dependence on cannabis, meaning you're going to go through this intense withdrawal, that doesn't mean I haven't seen people who say like, they have no idea why they can't stop.

Dr. Diane Reidy-Lagunes:

Got it. Alright, we're going to end with some true or false here. It is a gateway to bigger drugs and bigger things, that is medical cannabis. True or false?

Ethan Zohn:

Uh, if you consider happiness, you know.

Dr. Nirupa Raghunathan:

I would say, like, false with a caveat. I think that if you're going to take a gateway, you'll probably find a gateway.

Dr. Diane Reidy-Lagunes:

That's right. This one's for you, Nirupa. Does cannabis treat cancer? We talked a lot about the side effects in alleviating or mitigating those risks, but can it actually treat the cancer itself? And do we have any evidence of, sort of, so-called anti-cancer properties for medical cannabis?

Dr. Nirupa Raghunathan:

It has no evidence for treating it all by itself.

Dr. Diane Reidy-Lagunes:

Ethan, true of false: cannabis is completely harmless.

Ethan Zohn:

False.

Dr. Diane Reidy-Lagunes:

Nirupa, cannabis causes cancer. True or false?

Dr. Nirupa Raghunathan:

I love this thing because Ethan's able to be much more certain and I'm a doctor and I can't, for the life of me, ever be so certain like that. I would say maybe smoking it. It depends on how much you smoke because, you know, it's the combustion that potentially causes tissue damage that can lead to cancer. But in larger population studies, it definitely doesn't show up the way tobacco does.

Dr. Diane Reidy-Lagunes:

Nirupa and Ethan, thank you so much for joining me today. I learned so much from the both of you.

Dr. Nirupa Raghunathan:

Thank you. It was a pleasure being here and I hope people ask their doctors if they have questions about cannabis.

Ethan Zohn:

Thanks so much for having us. And I just want to let everyone know nature is the world's pharmacy so get involved with it.

Dr. Diane Reidy-Lagunes:

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information, or to send us any questions you may have, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing this podcast at Apple Podcasts or wherever you listen to your podcasts. Any products mentioned on this podcast are not official endorsements by Memorial Sloan Kettering. These episodes are for you, but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes. Onward and upward.