Medical Cannabis for Breast Cancer Symptoms and Side Effects

Jamie DePolo: Hello. As always, thanks for listening. Our guest is probably very familiar to many of our listeners. She's Marisa Weiss, MD, who's the founder and chief medical officer of Breastcancer.org. Dr. Weiss is director of breast radiation oncology at Lankenau Medical Center, and she is also qualified to certify patients in the Pennsylvania Medical Marijuana Program.

She joins us today to discuss the breast cancer symptoms and side effect medical cannabis may ease, as well as things to consider if you want to try medical cannabis. Dr. Weiss, welcome to the podcast.

Dr. Marisa Weiss: Thank you for having me, Jamie.

Jamie DePolo: So, first, I want to talk about the components of cannabis. I think everybody's probably seen a whole lot of products with CBD in them, and the products claim to help ease all sorts of pain and nausea and other things. And then I know there's THC, which is the compound that causes the high feeling. So, could you talk a little bit about the differences between CBD and THC and they might be used for?

Dr. Marisa Weiss: Okay. Well, thank you. So, cannabis is a term that describes a family of plants, which includes marijuana, like people are familiar with. As you were saying, people use it for fun, and they use it for medical purposes, and then there is a plant called hemp, which has had industrial uses.

Like, the use the fibers of the stem of the plant to make ropes and burlap and things like that, but it also contains CBD, which is cannabidiol. So, basically, these plants are sisters, and marijuana is different from hemp in that hemp is...you know, there are variations between all the plants, but hemp, by definition, has less than 0.3% THC by weight.

So, that's why hemp is used for industrial purposes and also for CBD, cannabidiol, which is in there, that's not psychoactive, whereas marijuana contains more than 0.3% THC, and in fact, many of the marijuana plants have been bred to contain a lot more than that. But all these plants contain a whole range of molecules, chemicals. CBD is one that is used to help with stabilize nerves and to help with anxiety. It can help with...people can use it for sleep and for anti-inflammatory purposes.

And then THC, tetrahydrocannabinol, is the one that is...produces the high, but it also does help with pain, and it can also help with, as you were saying, nausea, vomiting, with appetite, because it stimulates appetite, and it can make you sleepy. But these two molecules are like, not only they come from the same family of plants, but they're sisters in other ways, because there are a number of products that contain both THC and CBD and other cannabinoids or molecules that are related to them in various combinations, and that they work in synergy, as well.

For example, people say that CBD is sort of like a cushion for THC. That THC, for example, might help with pain and appetite and insomnia, nausea, vomiting, but it can also make you kind of jittery and anxious and maybe even a little paranoid, and maybe the CBD sort of is a balance to that to sort of try to minimize the unpleasant side effects of THC so that there, like, is a yin and a yang to it.

Jamie DePolo: Okay, and I'm assuming, given what you've just said, that somebody needs to look for a product with compounds in it that is tailored to what they want to do with it. So, I know people talk about, like, let's get one with more THC. Let's get one more with more CBD. Am I understanding that correctly?

Dr. Marisa Weiss: Yes.

Jamie DePolo: They really need to think about what you want this to do and then decide on what relationship...or ratio, rather, between the two compounds that you need.

Dr. Marisa Weiss: Right. Right, and just back up for one bit before that. December of 2018, CBD, cannabidiol, was removed from the FDA Controlled Substances Act. Therefore, CBD is more widely available without getting a certification to use medical cannabis in medical cannabis-only states, and basically, you can get it anywhere.

You can get it online, but any THC product which comes from marijuana, your ability to get to it is restricted because, at the federal level, you know, at the government...you know, the federal government level, marijuana is still illegal, even though nearly 40 states have...now have medical cannabis programs, including the state of Pennsylvania, the state of New York, where I'm qualified to certify people for medical cannabis.

The product you select is determined by a number of things. The symptoms for which you're seeking this product. It also is determined by what method of delivery there is. So, for example, if you...for a common...the most common reason why people seek cannabis is pain, and generally speaking, you would need at least some THC in the product for pain, and then you would...so, you would select a product that contains THC in it. Then you have to look at the method of delivery.

So, for example, if you wanted to use a pain cream, like apply a pain cream over, let's say, a painful joint, then those...most of the products that you would buy would be 100% THC cream. That there wouldn't be much CBD in it, and you might...that method of treating pain might be fine for you, but there are other people who may be using cannabis products for the management of pain where they have something, a regimen, where they take every day or on a regular basis to help ease their ongoing discomfort.

And maybe that's a tincture, which is like a cannabis-infused oil that you just put underneath the tongue, usually in a coconut oil base or a hemp oil base. But then let's just say that person has an acute episode. So, like, let's say their baseline pain is taken care of, but let's say they have breakthrough, acute pain that really is getting in their way and they need immediate relief. Well, the only type of cannabis delivery that gives you immediate relief, that is available commercially, is inhalational products.

So, either smoking or vaping or these other types of volcanos or inhalational-type products, because those kick in within a few minutes, but don't last that long. Whereas, if you use the tincture as a regular solution for regular pain that's predictable, that usually takes about anywhere from half an hour or 45 minutes to an hour, an hour and a half to kick in, but it can last five to six to seven hours, depending on what dose you take.

Jamie DePolo: Okay. Got you. Now, you've mentioned pain. Are there other symptoms and side effects specific to breast cancer that cannabis has been shown to help? And I know the research is lacking because of federal law, but that you've seen, either in research or anecdotally with your patients?

Dr. Marisa Weiss: Yeah. Well, as you were saying, there's not a lot of high-quality research in the cannabis world because of the restrictions, because of it being an illegal product, and clinical studies usually happen in hospitals, which are conservative environments, and they don't want to have any illegal substance on campus unless it is a designated research site, but even then, it's a pain in the neck to do.

And then it's hard to get funding to do that research, but in any case, we do have research, for example, on the ability of cannabis to manage pain that is related to, let's say, diabetes, or you know, other types of...common type of peripheral neuropathy, pain in the hands and the feet. As an example, we just did a clinical trial at my hospital looking at CBD versus placebo in the treatment of chemotherapy-induced peripheral neuropathy.

And the CBD taken three times a day, 45 milligrams three times a day, pharmaceutical-grade quality, it was an Ananda Hemp product, that eased the numbness and tingling component of the discomfort that people experienced from the most commonly used...some of the most commonly-used chemotherapies, like Taxol and oxaliplatin and some of the platin-based chemotherapies. So, in a study that we did at Breastcancer.org, we asked our community, what do you...what are you using...what do you know about it, and for what symptoms are you using it?

And of the over 600 people who participated in that survey study, 42% said, yes, I'm using cannabis to deal with side effects of treatment, like pain, nausea, vomiting, insomnia, anxiety, and problems sleeping, and then people were saying maybe they weren't using it to get high. They just wanted relief, and some of those symptoms might come from the cancer itself. For example, if you have metastatic breast cancer that involves the bone, that's painful. It can be painful. So, that was one reason why people use those products.

So, about, as I said, 42% of people were using the cannabis, and those were the most common side effects for its use, and about 79% of that 42%, those people were using it actually during treatment, and only 39% of the people who were using it talked to their doctor and shared that they were actually using this stuff during their treatment, which could be problematic, because the treatment for breast cancer can be rough and tough, and that's why people are using it.

So, let's say you have nausea, vomiting, and the pharmaceutical cannabis products didn't do the trick and now you're looking for natural cannabis, like marijuana from a dispensary, or a lot of people get it from their relatives or their neighbor, someone they know, and if you're using cannabis, but the nausea and vomiting's not improving, and it may get worse, it could be that you actually are developing nausea, vomiting from the cannabis rather than the cannabis' ability to relieve the nausea, vomiting from the chemo.

So, it can get confusing if you're the person who has nausea, vomiting as a side effect from cannabis on top of nausea, vomiting as a side effect from chemo, because then doctors could say, like, I don't know what's going on here. Like, I thought you were using this for nausea, vomiting. Now it's worse, and what you need to know is that if you're the kind of person whose body gets nausea, vomiting from cannabis, you've got to stop using it, because the only way to get rid of that nausea, vomiting from cannabis is to stop using the cannabis.

Also, you know, during COVID, when people were getting COVID and they were getting vaccinated and they were getting chemo...and using inhalation products is not a good idea to be using that while you're...you have something else going on in your lungs. So, that's another example of, like, things that we have to be careful of.

Jamie DePolo: Sure, that makes sense. So, Marisa, you've mentioned nausea and vomiting. Are there other side effects that cannabis can cause?

Dr. Marisa Weiss: Cannabis has side effects. So, one thing is, is that, you know, if you've been smoking or using in one way or another and you're in a group of people, you may find yourself repeating yourself over and over again, laughing, you know, uncontrollably, you know, just becoming very silly, and that might be...that might become noticeable among people who are not using it. If you're not part of a party or part of another get-together and you're feeling the effects of it and no one else is, that might be a side effect that people notice.

If you're taking it for sleep at night, like you're using an edible and you have to wake up in the middle of the night to pee, you might find yourself sort of bumping into walls and dizzy on the way to the bathroom and back, which can result in a higher risk of falling if you're not careful. Some people get paranoid that...you know, that they get anxious panic attacks, paranoia. You know, they have anxiety. They get worried about things that can escalate, get out of control. That could be a side effect.

For anybody who's had a recent cardiac event, like a heart attack or some kind of issue with your heart, you have to know that cannabis, marijuana, can increase your heart rate, and if you're within six months or so of having a heart attack, that cannabis does have a...put you at higher risk for having another heart-related issue.

So, it's not something you should be using if you've had a recent cardiac issue, and likewise, if you've had mental health challenges and you're already prone to, let's say, paranoia, a lot of anxiety and worries and symptoms like that, panic attacks, cannabis can make those symptoms worse, and so, that's...that is important to know.

It's also important to know that one issue with cannabis is leaving it around and having children or your support staff or whoever else is in the...who lives with you or works with you using it, not knowing what it is, because a lot of the stuff looks like candy, like, particularly the gummies, and the names of the products are often very fantastical, like, you know, the Spinning Rainbow or something like that. It doesn't sound like a medical name.

Jamie DePolo: I've known some people whose dogs got into their gummies.

Dr. Marisa Weiss: Yes. Yes.

Jamie DePolo: So, yes, very important to keep it away.

Dr. Marisa Weiss: Yes, and also, another side effect of using cannabis is overuse. Two examples of overuse would be let's just say you're someone who's been dealing with breast cancer and you want a solution to some of these issues we've talked about. Pain, nausea, vomiting, insomnia, anxiety, let's just say, and you...the last time you used it was, like, when you were a teenager, and now you're just getting back into this whole world again. So, today's marijuana is a lot stronger than it used to be.

So, even if you take it in the same amount as you think you did in the past, you could end up with a higher dose than what you expected, and you might have more side effects and feel out of control, more out of control than you expected that you would feel. Another situation like that could be you took one gummy, let's say, half an hour or 45 minutes ago. You feel nothing, and then you wait a little bit longer, and you're like, well, this isn't working. I'm going to take another one.

Well, as soon as the first one kicks in, let's say, an hour after you took it or maybe an hour and a half after you took it, then you're going to feel the effects of the first gummy you took, and then if you took a second one, because you thought the first one wasn't working well enough, that's also going to kick in an hour, hour and a half after you take it. So, now you've got double the dose that you never thought you were getting. So, you might feel really disoriented and scared. The good news is that you generally will recover fully from maybe taking more than you thought you needed to take.

You could go to sleep. Some people take a hot shower. Some people eat a lot of food to sort of slow down the metabolism and to speed up the excretion of the products, but generally speaking, people don't have serious side effects from an overdose, unless...when I say overdose, like, taking more than you thought you should or that was...or you were more sensitive to the regular dose. But of course, you don't want to be doing anything dangerous while you're feeling high. Like, you don't want to be cooking or leaving a stove on or running up and down the stairs.

You shouldn't be driving. You shouldn't be taking care of a baby. If you're pregnant, you shouldn't be using cannabis at all, even, you know, hemp products, like CBD. They're not known to be safe, and if you're a young kid and you got a developing brain, then, you know, there is...there are concerns that cannabis can get in the way of your cognitive development, your ability to think and how that evolves over time. So, those are some concerns to be aware of.

Jamie DePolo: Sure. Now, I know, in the survey, that Breastcancer.org did, we found out that a lot of people were using cannabis while they were receiving breast cancer treatment. Do we know if cannabis interacts with any breast cancer medicines?

Dr. Marisa Weiss: So, yes. We found out that 42% of people who completed the survey were using cannabis, and 79% of those people were using it during treatment, and cannabis is broken down by the liver. So, if you're using other products that are also broken down in the same part of the liver, then it's possible that there can be a what we call drug-drug interaction. That the two things you're taking may interfere with each other, or they may amplify the effects of one another.

So, for example, you can't take a blood thinner called Coumadin or Warfarin while you're using cannabis, because the liver may not be able to manage the metabolism, getting rid of both products after you've used it, and as a result, you may have too much blood thinning going on, which is unsafe. I wouldn't smoke anything, tobacco or cannabis inhalational products, while you're receiving radiation to the breast or to the chest, because there could be an interaction between the radiation and the smoke or the vaporized products. Those are just some examples of things I would be careful about.

Jamie DePolo: Sure, and that's why, as you mentioned earlier, that's why it's so important to talk to your doctor if you are using cannabis, just so your doctor can tell you about these things.

Dr. Marisa Weiss: And just so you know, like, in medical school, we don't really learn very much about cannabis. So, for those people who did talk to their doctors, a lot of them were kind of disappointed because the doctors sort of didn't really know much about marijuana or hemp or CBD or THC and the various cannabinoids, and that they end up feeling disappointed with what they heard.

Also, another thing just to be aware of is that, online, there are many claims that cannabis is effective as a treatment against cancer, and about half the people that filled our survey out had that belief, or at least the hope that cannabis was going to be good at fighting cancer, because there's stuff called Rick Simpson Oil and products like that online that are being promoted for its anti-cancer properties.

But that really hasn't been proven, and in fact, I have patients who have been on the Rick Simpson Oil, which is like a really strong, THC-dominant product, and they're high as a kite, and they're completely out of it, and they're...and it's unproven to be effective against cancer, and if you're using that and you're not using proven therapies, you may be missing the opportunity to get the treatment...the best treatment that you need and not just wasting time, but wasting money and messing with your mind, because if you're on heavy doses of Rick Simpson Oil products, you know, then you could really be out of it. Like, really unable to function. Not able to be responsible. Unable to take care of your kids safely or hold down a job.

Jamie DePolo: Sure. Sure. So, do you have tips for people about how to find a dispensary that can best meet their needs?

Dr. Marisa Weiss: Yeah. There are dispensaries everywhere, and they do meet a minimum standard, generally speaking, that the government sets in that particular state. In the state of Pennsylvania, just so you know, any new...newly certified patient needs to meet with a pharmacist at the dispensary to discuss the symptoms you're having, the products they have available, and how you should take them.

Generally speaking, you want to go to a dispensary that is a medical dispensary, and try to meet with someone who's knowledgeable in the products that they have and that is knowledgeable about the symptoms, how best to manage the symptoms that you're experiencing. You want to look at or...the product's certificate of analysis to make sure that the product has been evaluated by a third party to make sure that there are no, like, heavy metals or pesticides or mold or things like that in products that can affect their...how clean they are and how safe they are to use.

You want to make sure that the dose that is on the label is reliable, and when there is third-party testing, when you ask for a certificate of analysis, a COI. There may be a QR code on the product that you get it that way. You want to make sure that the dose in the product is close to what's the dose that's on the label. These dispensaries generally have menus online, and they will also let you know what's in stock and what isn't in stock. So, before you make a trip to the dispensary, you want to make sure that they have available that which you need.

Jamie DePolo: Okay. Got you, and then, finally, to wrap up, I know you mentioned some things that maybe were beyond finding a dispensary, but if you were talking to someone who said, I want to try cannabis, what are the top three things, in your opinion, that people need to consider if they...before they try medical cannabis?

Dr. Marisa Weiss: Try to define the symptoms that they're experiencing. What are the symptoms? What makes it worse? What makes it better? Does the symptom go along with other symptoms? You know, really get a better...a good understanding of what they're up against so that we can figure out the best solution for their situation. And then, you know, have you ever used it before, and how did that go?

And then, if you're going to get it, you want to get it from a reputable source where you get clean product, and that's usually in a dispensary.

You may need to be certified by a cannabis-qualified...a doctor that's qualified to certify you in order to get access to medical cannabis. You might even want to do that in a state where it's legal, because if you've got a medical card, then, usually, you can avoid the tax, or the cost of the product is less if it's medical versus if it's recreational.

And then you may have a job where you're not supposed to be using cannabis, but if you produce a medical card and let them know that you have a medical...that you've got medical reasons for using it and this is part of your medical treatment and you've been certified to use the products and you've got a card that shows that, that usually goes a long way in terms of your ability to use it, even if you have a job that may not be so tolerant of it.

However, there are jobs that have zero tolerance, that it doesn't matter what kind of card you have. You could lose your job if your random drug...urine drug screen were to show that you're using cannabis. And those jobs are jobs like a bus driver for a children's...you know, for a children's bus driver or really, any kind of bus driver, a corrections officer, someone in the military, some teachers, as examples.

Different policies where your work may have zero tolerance, but if you were...let's say, if you're a nurse in a hospital and you want to...you've got a symptom of which you want to use it and if you've got a medical marijuana certification and you go to your HR person and say this is my situation, they might say, well, as long as you...it's part of your medical regimen and you've got medical clearance to use it, then we'll say it's okay, and get that in writing.

Jamie DePolo: Okay. That all sounds very good. Dr. Weiss, thank you so much. This has been really helpful, and I hope anybody who wants to try medical cannabis follows your tips.

Dr. Marisa Weiss: Well, thank you for having me.