CCSN Submission to the Task Force on Marijuana Legalization and Regulation

On August 29, 2016, the Canadian Cancer Survivor Network made a submission to the Task Force on Marijuana Legalization and Regulation. The text of our submission follows.

The Canadian Cancer Survivor Network (CCSN) is a charitable organization of cancer patients, survivors, caregivers, families, friends, community partners and sponsors who work together to take action to promote the very best standard of care, support follow up and quality of life for patients and survivors.

CCSN works to ensure that patients and survivors can easily access tools to understand decision-making processes for positive change on issues critical to optimal patient care; that they are supported to make a difference through working with others to take action on those issues; that they are able to obtain current knowledge about cancer diagnosis, treatment, options and outcomes and are able to work together to end disparities in patient care and treatment.

CCSN and medical marijuana

When the Mahihuana for Medical Purposes Regulations (MMPR) was introduced, CCSN became concerned about patients’ access to marijuana. From that time, CCSN has created resources to provide patients with up-to-date information and educational tools to enable them to understand the swiftly shifting environment.

Currently, CCSN provides information and educational activities on access to medical marijuana through a Medical Cannabis section on its website (http://survivornet.ca/en/cancer_basics) as well as providing updates on medical marijuana as part of its Promoting Cancer Patient Engagement through Educational Webinars series.

Medical users of marijuana

There are several issues related to the medical use of marijuana that are unique and that are of concern to CCSN.

Stigma as an illegal drug

The illegality and subsequent stigma attached to marijuana has influenced how Canadians think about medical marijuana, including those people who may benefit from medical cannabis products. This poses an access impediment to individuals who may benefit from medical cannabis products but who are reluctant to raise the issue with their health care provider (HCP), ask for a prescription from their family doctor or other HCP, or fear recriminations from family members.

An additional stigma can occur if patients are required to smoke marijuana, given that smoking itself has rightfully acquired strong stigmatization of its own. CCSN believes that medical marijuana should be available in many forms so that patients can choose the format that best fits them and to which their illness responds.

Lack of research and clinical trials

Medical cannabis is unique in Canada in that it has not gone through the rigorous health technology assessment (HTA) that all other drugs do through the pan-Canadian Oncology Review (pCODR) for oncology drugs or the Canadian Agency for Drugs and Technologies in Health (CADTH) followed by provincial/territory consideration and approval. The result is that there is a lack of research not only on the effects of medical marijuana but also on the quite different products, given that marijuana itself contains “…hundreds of chemical substances, among which are over 100 known as ‘cannabinoids’.”[i]

Although research on the safety and efficacy of medical marijuana is being conducted, there are still many unanswered questions which often make it difficult for HCPs to prescribe medical cannabis and for patients to be certain that they are deriving therapeutic benefits from it.

Healthcare professionals lack of knowledge about medical marijuana

As mentioned above, the lack of evidence of therapeutic benefits from medical cannabis and their lack of knowledge about appropriate strains and doses has inhibited many HCPs from prescribing medical cannabis, and patients themselves lack knowledge of the different types of medical cannabis being produced in Canada today. HCPs are neither informed nor educated about medical marijuana strains being developed to treat various medical conditions.

CCSN is concerned that many patients who may benefit from medical marijuana are not able to find doctors or other HCPs willing or able to prescribe it, even those HCPs working in areas where there is strong anecdotal evidence and some clinical evidence that medical cannabis has therapeutic value, like oncologists, rheumatologists, orthopedists and HCPs who treat epilepsy as well as family doctors and general practitioners.

Patients lack of knowledge about medical marijuana and continuing access issues

Since there has been a lot of media attention paid to both medical and recreational marijuana in recent years, CCSN is concerned that many individuals who might benefit from medical marijuana are not able to access it legally, and will therefore attempt to access marijuana illegally and use it for medical purposes. This possibility is enhanced when patients are not able to obtain prescriptions from their HCPs. In this situation, patients are in a hit-and-miss situation, given that they have no knowledge of or control over the THC level in the illegal marijuana they have access and the impurities that it may contain.

In addition, medical marijuana users who were growing their own may still have difficulties with the cost of buying from licenced producers and therefore turn to the illegal market. As mentioned above, this leads to lack of control of the THC level in illegal marijuana and the dangers of impurities it may contain. A medical cannabis production and distribution system must be able to offer not only quality but a pricing system that enables and encourages medical marijuana users to buy the product legally. Canadians who choose to grow their own medical cannabis must have a clear path to inexpensive, regular testing of their product so that they know that it is safe and effective to use. CCSN believes that patients should have access to medical marijuana through a variety of distribution sources.

Medical cannabis in a legalized marijuana landscape

The Canadian Cancer Survivor Network strongly supports a separate regime for users of medical marijuana.

The reasons for this recommendation include:

·         The mandates and uses for recreational cannabis and medical cannabis are quite different. 

o   The legalization of recreational cannabis will provide legal access to cannabis while safeguarding product quality and control over distribution, ensuring the safety of youth by limiting access, and establishing pricing to discourage illegal use.

o   Access to medical cannabis is already a constitutional right. Establishing a separate regime for medical marijuana will recognize and validate that the reasons for medical access are indeed different:

§  Medical marijuana access is dependent on a prescription from a healthcare professional for treatment of a specific illness or symptoms.
§  A separate system would bolster the argument that medical marijuana sales should be zero-rated as are other medical devices and treatments.
§  It would leave the door open for third party coverage of medical marijuana through government formularies and insurance benefits.  
§  It would encourage research on medical uses.
§  It would recognize that in some cases, minors benefit from medical marijuana (e.g., treatment-resistant epilepsy in children).
§  It would encourage pricing that would provide access to all patients without anyone utilizing the illegal market.

For additional information, please contact:

Jackie Manthorne

President & CEO
Canadian Cancer Survivor Network
1750 Courtwood Crescent, Suite 210
Ottawa, ON K2X 2B5
613-898-1871

jmanthorne@survivornet.ca

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[i] Toward the Legalization, Regulation and Restriction of Access to Marijuana Discussion Paper, 2016.

Perception of Fertility Affects Quality of Life in Young, Female Cancer Survivors

Newswise — A new study led by a University of Colorado Cancer Center member recently published in the journal Quality of Life Research shows that in young, female cancer survivors, quality of life is significantly impaired long after treatment. The study compared 59 cancer survivors to 66 healthy controls and found that, as expected, cancer survivors showed higher stress and anxiety than the general population. Of note, survivors reported particular stress around the issues of sexual problems, physical pain and fatigue. The study also measured hormone levels reflecting woman’s number of eggs, and showed that among young, female cancer survivors, those with reassuring fertility status were likely to report higher quality of life once treatment ends.

“What it came down to was a woman’s opinion of her own fertility status after cancer treatment,” says Laxmi Kondapalli, MD, MSCE, director of the CU Cancer Center Oncofertility Program.

See, there was one intervening step between normal ovarian reserve and quality of life: the regularity of a woman’s menstrual cycle after undergoing chemotherapy and/or radiation treatment for cancer. All women lose a certain number of eggs during these treatments, but those with higher baseline reserve are more likely to withstand the treatment with their overall fertility unaffected. Women with lower ovarian reserve at baseline are more likely to have impaired fertility after treatment.

“But it wasn’t the lab and ultrasound markers of ovarian reserve alone that affected quality of life,” Kondapalli says. “It was a woman’s opinion of her fertility status based on her menstrual cycle that had the most impact on quality of life.”

Following cancer treatment, many women think that if they maintain regular menstrual cycles, their fertility is preserved, and that if their menstrual cycles become irregular, then they are likely infertile due to treatment.

“This isn’t necessarily the case, because we are finding that menstrual cyclicity is a poor predictor of fertility status in these young, female cancer survivors,” Kondapalli says. “Survivors may be falsely reassured if they resume normal periods, or they may be unnecessarily stressed if they don’t get regular periods after cancer treatment.”

According to Kondapalli, women with high ovarian reserve are less likely to experience symptoms of early menopause after cancer treatment. And it is these symptoms that go on to influence young patients’ quality of life.

“I think what our study demonstrates is that clearly there are many components that impact a survivor’s quality of life after cancer treatment. Although objective markers of ovarian reserve play an important role, a woman’s perception of her own fertility status was more influential in her overall quality of life,” Kondapalli says.

Understanding the factors that influence quality of life in this population may help identify ways to manage late effects of treatment and improve comprehensive survivorship care.