Patients’ perceptions of the efficacy, safety, and quality of the evidence of medicinal cannabis: a survey of Australian cancer patients.

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Joseph Taylor, Elizabeth Fradgley, Ben britton, Jennifer Martin, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4308443/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Despite the increased demand [8], and accessibility [5], to medical cannabis (MC) there is a general consensus among physicians that evidence on its efficacy [10,12,13], and safety [4,11], is lacking. Although research has explored medical professionals’ perceptions of MC [10, 12,13], to our knowledge there is minimal research exploring patients’ perceptions; particularly in an Australian cancer setting [14,15,16,17]. We therefore aimed to explore patients’ perceptions of the efficacy, safety, and evidence for MC. Methods: A prospective cross-sectional questionnaire of Australian cancer patients attending adult oncology outpatient clinics in the Hunter New England Local Health District. Patients were 18 years, or older, and had a confirmed diagnosis of cancer (solid or haematological). Results: 19% of our cohort were using MC. Despite using for symptom control such as pain (61%), and, in some cases perceived anti-cancer activity (12% to cure and 16% to slow the cancer); a minority of users believed that the evidence for either of these indications was of high quality (28% and 29% respectively). A minority of users (31%) were receiving information on MC from clinicians. Most instead rely on resources such as TV, friends, family, social media and websites. Conclusion: This study demonstrated current real world cancer patients’ perceptions on: the evidence for MC, the sources of information used to shape their health beliefs, and compares users to non-users. The results highlight the need for treating teams to combat potential misinformation that patients may be accessing on MC and provide information on treatments with greater evidence. Medicinal marijuana cannabis attitude to health Australia neoplasms Figures Figure 1 Figure 2 Figure 3 Introduction (i) History of MC use Reports of cannabis being used illicitly for medicinal purposes date back to the nineteenth century [ 3 ] and recreational use is reported even earlier [ 1 , 2 ]. Despite this historic interest as a medicinal product, legal access had been one of the main barriers to use [ 19 ]. In 2016, the Australian Therapeutic Goods Association (TGA) approved prescriptions by clinicians using the Special Access Scheme (SAS) [ 5 , 6 , 7 ]. Since this time, demand has rapidly increased with over 250,000 approvals granted between 2017 and 2022 [ 8 ]. (ii) Patterns of MC use and clinicians’ perceptions of benefit and risk Other than chronic non-cancer pain and anxiety, the most common reason for accessing MC in Australia is malignancy and its associated symptoms [ 5 , 6 ]. Despite the increased demand and increased accessibility to MC, there is a general consensus among clinicians that high quality evidence on its efficacy is lacking [ 10 , 12 , 13 ]. There is also concern that MC may have significant adverse events, cause issues with driving, and result in problematic drug interactions [ 4 , 11 ]. (iii) Patient perceptions and the sources of information used to shape these beliefs Although research has been undertaken to explore medical professionals’ perceptions of MC in general [ 10 ], and specifically in a cancer setting [ 12 , 13 ], to our knowledge there is minimal research exploring patients’ perceptions; particularly in an Australian cancer setting [ 14 , 15 , 16 , 17 ]. Materials and Methods (i) Study design and setting We conducted a prospective cross-sectional questionnaire of Australian cancer patients’ perceptions of the efficacy and safety of MC, and the quality of evidence available. The perceptions of users and non-users were directly compared. The questionnaire was distributed between April 2019 to March 2020. The initial survey content was based on a rapid literature review and refined by a stakeholder group which included: clinicians, trial coordinators, and behavioural researchers. The Hunter Cancer Research Alliance (HCRA) Consumer Advisory Panel provided patient feedback and the electronic survey was piloted with six patients. Ethics approval was obtained from the University of Newcastle ethics committee and conducted in accordance with the Declaration of Helsinki. The final version (Appendix 1) included 74 close-ended items. (ii) Patient eligibility and recruitment The questionnaire was distributed to a consecutive sample of patients attending adult oncology outpatient clinics at three tertiary centres within the Hunter New England region of New South Wales, Australia. The Hunter New England Local Health District covers a region of 131,785 square kilometres with a population of over 962,000 [ 18 ]. Eligible participants were: (i) 18 or older; (ii) had a confirmed diagnosis of cancer (solid or haematological); and (iii) had attended the outpatient oncology clinic at least once prior to being recruited for the study. Research assistants invited patients to participate in the study by providing a scripted summary of the study and assisted consenting participants if requested. Due to the items exploring illicit use of cannabis, no identifying patient information was recorded and participants could choose to omit any responses. Informed consent was obtained from all individual participants included in the study. Patients who consented were offered three options to complete the questionnaire which was programmed into REDCap [ 26 ]; (i) using a touchscreen device in waiting rooms or treatment area, (ii) a hyperlink to complete the survey online later, (iii) both options i.e. some now, and some later. (iii) Definition of medicinal cannabis users and survey items Given variability in the definition of medicinal cannabis user across studies, we defined MC users as those that answered “yes” to having used cannabis for any of the following medical reasons related to their cancer diagnosis: pain, tiredness, nausea, lack of appetite, shortness of breath, depression, anxiety, general wellbeing, help to sleep, slow the cancer, cure the cancer, or health related reason other than above (required the respondent to define further using an open-ended comment box). Non-users were defined as those that answered “no” to all of the above questions; which included current, or past, recreational users. Individuals were also provided the option to specify if they had used cannabis recreationally or for other conditions such as arthritis or anxiety. (iv) Statistical analysis Given a lack of data specific to outpatient cancer settings in Australia, this was an exploratory study of MC use and perceptions. A sample size of 289 would provide 95% confidence of detecting a prevalence of cannabis use in 25% of the sample. To avoid the study being underpowered, we aimed to recruit a slightly larger sample: approx. 300 participants in total over the three sites. We considered a P < 0.05 as significant. The survey was programmed into the REDCap database [ 26 ] and analysed using STATA 15 [ 25 ]. Chi Squares were used to examine associations between demographics and MC use. Logistic regression was used to produce odds ratios of MC use predicted by perceptions. Authors had full access to all the data (including statistical reports and tables) in the study. Results (i) Demographics Across the three clinics, 413 patients were approached and 82% consented to participate in the survey. Although 350 patients completed the survey, some patients declined to answer certain questions and item completion varies. MC use was reported by 67 (19%) patients. Table 1 reports participants’ demographic characteristics and compares differences according to medicinal cannabis use (e.g. users versus non-users). Demographics significantly associated with MC use were: male gender (61% of users vs. 45% of non-users, P < .05) and tobacco smoking (73% vs 53% respectively P < .01). Just over half (54%) of users had discussed MC with their clinicians whereas only 10% of non-users had done so. (ii) Reasons for MC use Figure 1 shows the reasons patients selected for using MC. The most common indication chosen was pain (61%) followed by insomnia (48%). Of users, 12% selected “cure the cancer” and 16% “to slow the cancer”. Breathlessness was the least commonly chosen indication (1%). (iii) Perceptions of benefit and risk Figure 2 compares the perceptions of benefit, and risk, between users and non-users. Participants were asked to answer on an 11 point scale, with 0 being no benefit/risk and 10 being immense benefit/risk. For the questions on physical, emotional, cancer progression benefit (Fig. 2 , Graph a, b and c), users most commonly answered “8–10” (i.e. highly beneficial) for all 3 domains and the percentage choosing this option was higher amongst users than for non-users: 72% of users vs 31% of non-users (OR 2.37. CI 0.26–21.83. P = 0.446) for physical, 66% of users vs 33% of non-users (OR 2.24. CI 0.61–8.29. P = 0.226) for emotional, and 40% of users vs 17% of non-users (OR 3.68. CI 1.27–10.63. P = 0.016) for cancer progression. In contrast, non-users most commonly answered “I don’t know”: 54% vs 16% (OR 0.31. CI 0.03–3.04. P = 0.316), 47% vs 10% (OR 0.25. CI 0.06–1.09. P = 0.065), 60% vs 37% (OR 0.97. CI 0.35–2.75. P = 0.960) compared to users respectively for each question. For the question on risk (Fig. 2 , Graph D) the most common answer chosen by users was “0–4” (i.e. low risk), with 82% of users choosing this option compared to only 44% of non-users (OR 0.12. CI 0.13–3.47. P = 0.64). However, as with the questions on benefit (graph a, b and c), the most common answer for non-users was again “I don’t know”: 47% vs 10% (OR 0.12. CI 0.05–0.27. P = < 0.001). (iv) Perceptions of the evidence In addition to the perceived benefits and risks (Fig. 2 ); patients’ perceptions on the quality evidence available on these benefits and risks were explored by asking the following 4 questions (Fig. 3 ): There is high quality information on how MC; (a) affects physical symptoms, or side effects, associated with cancer, (b) affects emotional wellbeing, (c) could slow, or prevent, cancer, (d) poses a risk to cancer patients' general health? The results for all four questions (Fig. 3 . Graph a, b, c and d) show similar trends. Despite using MC, the most common answer for users was “disagree”, and the proportion selecting this response was higher than for non-users. This trend was seen for all four domains; 48% in users vs 38% in non-users (OR 0.74. CI 0.38–1.45. p = 0.377), 48% in users vs 37% in non-users (OR 0.75. CI 0.39–1.43. p = 0.381), 50% in users vs 40% in non-users (OR 0.46. CI 0.22–0.93. p = 0.031) and 57% in users vs 41% in non-users (OR 1.0. CI 0.42–2.32 .p = 0.992) respectively for a, b, c and d. In contrast, the most common answer for non-users was “I don’t know”, and they were more likely to select this answer than users for all four questions: 48% in non-users vs 38% in users (OR 0.74. CI 0.38–1.45. p = 0.377), 48% in non-users vs 37% in users (OR 0.75. CI 0.39–1.43. p = 0.381), 50% in non-users vs 40% in users (OR 0.46. CI 0.22–0.93. p = 0.031) and 57% in non-users vs 41% in users (OR 1.0. CI 0.42–2.32; p = 0.992) for a, b, c and d respectively. (V) Sources of information used to inform patients’ health beliefs The sources of information used by users, and non-users, are reported in Table 2. Nearly all patients (87% and 91% respectively for non-users vs. users) had accessed some form of information on MC. The three most common sources of information selected by users were: “friends or family” (69%), “TV, newspaper or magazine” (48%) and “social media, websites or blogs” (43%). Non-users also selected these as their top three categories, but in a slightly different order and distribution: 41%, 64% and 24% respectively, making “TV, newspaper or magazine” the most common response in this group. Only 31% of users, and 8% of non-users, had received information on MC from their “cancer doctor, cancer nurse, GP, or palliative care physician”. Discussion (i) Demographics and reasons for use Our study cohort (Table 1 ) indicates that 19% of cancer patients are using MC. This demand for MC is consistent with previous cannabis studies in cancer-patient populations both in Australia (8, 17, 19) and internationally (9,15). The demographics statistically associated with use; i.e. male gender and tobacco smoking, are also in line with previous conclusions [ 15 ]. Regarding the reasons for use (Fig. 1 ), our data are also in line with other studies suggesting that issues like: pain and insomnia are common drivers for MC use in patients in general (19, 20], and specifically in cancer patients [ 21 ]. Although a relatively small proportion, it is concerning that some patients thought MC could slow, even cure, their cancer. This is an issue which has been highlighted previously [ 17 ], and is discussed in more detail below. (ii) Perceptions of benefit and risk The results in Fig. 2 show some fascinating trends. In line with previous Australian data, but in a non-cancer population [ 19 ]; and in non-Australian cancer patients [ 14 , 15 , 16 , 22 ], most users felt that MC is highly beneficial for symptom control, and low risk, despite the general consensus from clinicians that there is a lack of evidence to support this claim [ 10 ]. Users are more sceptical on the benefits on cancer progression; but concerningly 40% believed it was highly beneficial for this indication (Fig. 2 C). This is an issue which has been highlighted previously [ 16 , 17 ] and needs to be addressed. Some patients may use MC alongside conventional treatments like chemotherapy and immunotherapy, but others may use as an alternative to conventional treatments or terminate them early. This could have a significant impact on prognosis. The responses for non-users are also interesting. We hypothesised that they would rate the benefits as low, and the risks as high, but the most common response was “I don’t know”. When non-users committed to an answer, i.e. didn’t chose “I don’t know”, they most commonly scored it as highly beneficial, and low risk. This suggests that there is a belief of efficacy, and minimal risk, even in non-users. It is possible that if faced with complex future issues, such as complex or refractory symptoms or disease progression, such patients may have a low threshold for trialling MC. (iii) Perceptions of the quality of evidence available on MC Figure 3 also showed some surprising results, particularly when compared to Fig. 2 . Despite using MC, the majority of users didn’t feel that there was high quality evidence for its efficacy, or safety. It seems that users accept that the quality of evidence is low (Fig. 3 ), yet their personal experience is positive (Fig. 2 ). In contrast, the most common answer in non-users was “I don’t know”; the same trend as in Fig. 2 . (iv) Sources of information utilised to inform patients’ health beliefs Almost all users (91%), but also non-users (87%), had accessed information on MC (Table 2); highlighting it as major area of interest for patients, which clinician’s may underestimate. It is, however, concerning that only a minority received such information from clinicians. This is an issue which has been identified previously; for example in a survey of cancer patients only 15% had received information on MC from their clinicians, despite 75% wanting to receive such information [ 9 ]. There seems to be a reliance on less robust resources like: friends and family, TV, newspapers and social media which have been shown to be unreliable [ 23 , 24 ].The reasons for this need to be further explored. Regardless of the driver for this preference, clinicians need to be more proactive in discussing the pros and cons of MC and educate patients on the best available evidence. (v) Limitations Although our study is robust, we exercise caution over some our conclusions given the limitations inherent in an observational study. Many of the trends we observed failed to reach statistical significance. Additionally, there was a large amount of missing data (i.e. non-responders) for certain questions that could have introduced bias. Unfortunately this was unavoidable, as our ethical considerations meant that patients’ had the choice to abstain from answering. A final limitation is that researchers analysing the data, and writing up the results, were part of the study team and therefore not blinded. Conclusion This study demonstrates current, real world Australian cancer patients’ perceptions on: the evidence for MC, the sources of information used to shape their health beliefs, and compares users to non-users. Surprisingly, our results show that despite using MC for symptom control, and in some cases anti-cancer activity, only a minority of users believe that the evidence for either of these indications was of high quality. Concerningly, only a minority of users were receiving information on MC from clinicians like doctors and nurses, instead relying on resources such as: TV, friends, family, social media and websites which have been demonstrated to be unreliable and often supporting commercial agendas [23, 24]. The results highlight the need to combat potential misinformation that patients may be receiving on MC, provide information on treatments with a greater evidence base, and link patients to support services like the palliative care teams. Further research is needed to explore a number of questions raised by our study: (i) Why are patients using MC despite acknowledging the lack of evidence? (ii) Do those patients that believe there is an anti-cancer effect continue to take their systemic treatment in conjunction with MC, or are they using MC alone? (iii) Why are patients preferring to access information on MC from non-clinical sources, like friends and family, social media, etc; over clinicians? Declarations Author Contribution JT wrote the manuscript and prepared the figures. BB conducted the statistical analysis. BB, JM, SM, MC, PB, EF, JL, GW and CL contributed to designing the study, the literatrue review and collecting the results. All authors reviewed the manuscript. Acknowledgements This work was supported by the Hunter Cancer Research Alliance (HCRA) with infrastructure support provided by the Hunter Medical Research Institute. The HCRA receives funding from Cancer Institute NSW, as a Translational Cancer Research Centre (TCRC), and the University of Newcastle. Data Availability Data is provided within the manuscript or supplmentary information files. References Russo EB. History of cannabis and its preparations in saga, science, and sobriquet. Chem Biodivers. 2007; 4(8): 1614–48. Bonini SA, Premoli M, Tambaro S, Kumar A, Maccarinelli G, Memo M, et al. Cannabis sativa: a comprehensive ethnopharmacological review of a medicinal plant with a long history. 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Cannabis for pain: a cross-sectional survey of the patient information quality on the Internet. J Cannabis Res. 2021 Aug 16;3(1):36. doi: 10.1186/s42238-021-00093-x. PMID: 34399853; PMCID: PMC8369629. StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC https://projectredcap.org/resources/citations/ Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Appendix1.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4308443","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298557862,"identity":"47c7035d-0c54-42bc-830a-eeae3848d052","order_by":0,"name":"Joseph Taylor","email":"data:image/png;base64,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","orcid":"","institution":"Gosford Hospital","correspondingAuthor":true,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Taylor","suffix":""},{"id":298557864,"identity":"ab3c99a6-f6d4-4c52-9acf-645884d114b8","order_by":1,"name":"Elizabeth Fradgley","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Fradgley","suffix":""},{"id":298557866,"identity":"12aa704f-181c-4758-bc80-7f40c25b734f","order_by":2,"name":"Ben britton","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"britton","suffix":""},{"id":298557868,"identity":"172fab2f-cbe6-4449-ae32-953a56485733","order_by":3,"name":"Jennifer Martin","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Martin","suffix":""},{"id":298557870,"identity":"f24188f7-7996-4243-abac-a1684118bd9c","order_by":4,"name":"Catherine Lucas","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Lucas","suffix":""},{"id":298557872,"identity":"8d595a85-6919-4f9c-86f5-94c7622bc36b","order_by":5,"name":"Melissa Carlson","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"","lastName":"Carlson","suffix":""},{"id":298557875,"identity":"b88f8bf0-1feb-408d-98d6-8d15c0710688","order_by":6,"name":"Paula Bridge","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Paula","middleName":"","lastName":"Bridge","suffix":""},{"id":298557877,"identity":"52a4bb2e-523d-4e72-a8ed-57c6f3be03d8","order_by":7,"name":"Sarah Morris","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Morris","suffix":""},{"id":298557879,"identity":"ed7ea60c-c2e0-4cd2-989c-d280d93f594b","order_by":8,"name":"Gareth Watts","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Gareth","middleName":"","lastName":"Watts","suffix":""},{"id":298557881,"identity":"8a560a40-7f23-46a2-b8f3-155c0cb4f969","order_by":9,"name":"James Lynam","email":"","orcid":"","institution":"Calvary Mater Newcastle Hospital","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Lynam","suffix":""}],"badges":[],"createdAt":"2024-04-23 00:21:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4308443/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4308443/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56395886,"identity":"f8595cf5-67f2-40b4-bbff-885c8cf70a71","added_by":"auto","created_at":"2024-05-13 15:42:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42745,"visible":true,"origin":"","legend":"\u003cp\u003eHave you ever used MC for the following reasons? Patients could select more than one option (n = 67)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/879486af3068cade42db3685.jpg"},{"id":56395889,"identity":"95953dd3-d982-44ca-ad22-5ffe313cf3b0","added_by":"auto","created_at":"2024-05-13 15:42:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":173060,"visible":true,"origin":"","legend":"\u003cp\u003eA comparison of the responses between users, and non-users, for the following 4 questions. With 0 being no benefit, and 10 being immense benefit (risk for question d), how beneficial (risky for part d) do you think MC is for: (a) physical symptoms (b) emotional symptoms (c) cancer progression (d) risk to patients’ health?\u003csup\u003e †\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/204749f6a2c63d0989935654.jpg"},{"id":56395891,"identity":"372954d5-e6bf-4e0b-ba87-dd23064e067f","added_by":"auto","created_at":"2024-05-13 15:42:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":182470,"visible":true,"origin":"","legend":"\u003cp\u003eA comparison of the responses between non-users, and users, for the following 4 questions. There is high quality information on how MC; (a) affects physical symptoms, or side effects, associated with cancer, (b) affects emotional wellbeing, (c) could slow, or prevent, cancer, (d) poses a risk to cancer patients' general health?\u003csup\u003e †\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/0f7db86fd7102738141b2322.jpg"},{"id":62549436,"identity":"25042671-9963-4e18-a2bc-bcb71e3649df","added_by":"auto","created_at":"2024-08-15 16:52:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":922209,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/24055cce-0cf2-43b2-aa26-e9d06ad8131e.pdf"},{"id":56395888,"identity":"135ff799-149d-4df1-922b-c45026338b16","added_by":"auto","created_at":"2024-05-13 15:42:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19150,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/93f40e17211bfa8bf54fb758.docx"},{"id":56395890,"identity":"3bef842b-9fd2-4560-bc02-ea19cf2608fc","added_by":"auto","created_at":"2024-05-13 15:42:18","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16874,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/9f62ba1e90a2b94629bd4315.docx"},{"id":56395892,"identity":"663b4263-bed6-4401-a9d0-1065c966654f","added_by":"auto","created_at":"2024-05-13 15:42:19","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":101360,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4308443/v1/28ed6b6b4aaef0911af4132e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patients’ perceptions of the efficacy, safety, and quality of the evidence of medicinal cannabis: a survey of Australian cancer patients.","fulltext":[{"header":"Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e(i) History of MC use\u003c/h2\u003e \u003cp\u003eReports of cannabis being used illicitly for medicinal purposes date back to the nineteenth century [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and recreational use is reported even earlier [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite this historic interest as a medicinal product, legal access had been one of the main barriers to use [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In 2016, the Australian Therapeutic Goods Association (TGA) approved prescriptions by clinicians using the Special Access Scheme (SAS) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Since this time, demand has rapidly increased with over 250,000 approvals granted between 2017 and 2022 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e(ii) Patterns of MC use and clinicians’ perceptions of benefit and risk\u003c/h3\u003e\n\u003cp\u003eOther than chronic non-cancer pain and anxiety, the most common reason for accessing MC in Australia is malignancy and its associated symptoms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite the increased demand and increased accessibility to MC, there is a general consensus among clinicians that high quality evidence on its efficacy is lacking [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. There is also concern that MC may have significant adverse events, cause issues with driving, and result in problematic drug interactions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e(iii) Patient perceptions and the sources of information used to shape these beliefs\u003c/h2\u003e \u003cp\u003eAlthough research has been undertaken to explore medical professionals\u0026rsquo; perceptions of MC in general [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and specifically in a cancer setting [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], to our knowledge there is minimal research exploring patients\u0026rsquo; perceptions; particularly in an Australian cancer setting [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e(i) Study design and setting\u003c/h2\u003e \u003cp\u003eWe conducted a prospective cross-sectional questionnaire of Australian cancer patients\u0026rsquo; perceptions of the efficacy and safety of MC, and the quality of evidence available. The perceptions of users and non-users were directly compared. The questionnaire was distributed between April 2019 to March 2020. The initial survey content was based on a rapid literature review and refined by a stakeholder group which included: clinicians, trial coordinators, and behavioural researchers. The Hunter Cancer Research Alliance (HCRA) Consumer Advisory Panel provided patient feedback and the electronic survey was piloted with six patients. Ethics approval was obtained from the University of Newcastle ethics committee and conducted in accordance with the Declaration of Helsinki. The final version (Appendix 1) included 74 close-ended items.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e(ii) Patient eligibility and recruitment\u003c/h2\u003e \u003cp\u003eThe questionnaire was distributed to a consecutive sample of patients attending adult oncology outpatient clinics at three tertiary centres within the Hunter New England region of New South Wales, Australia. The Hunter New England Local Health District covers a region of 131,785 square kilometres with a population of over 962,000 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEligible participants were: (i) 18 or older; (ii) had a confirmed diagnosis of cancer (solid or haematological); and (iii) had attended the outpatient oncology clinic at least once prior to being recruited for the study. Research assistants invited patients to participate in the study by providing a scripted summary of the study and assisted consenting participants if requested. Due to the items exploring illicit use of cannabis, no identifying patient information was recorded and participants could choose to omit any responses. Informed consent was obtained from all individual participants included in the study. Patients who consented were offered three options to complete the questionnaire which was programmed into REDCap [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]; (i) using a touchscreen device in waiting rooms or treatment area, (ii) a hyperlink to complete the survey online later, (iii) both options i.e. some now, and some later.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e(iii) Definition of medicinal cannabis users and survey items\u003c/h2\u003e \u003cp\u003eGiven variability in the definition of medicinal cannabis user across studies, we defined MC users as those that answered \u0026ldquo;yes\u0026rdquo; to having used cannabis for any of the following medical reasons related to their cancer diagnosis: pain, tiredness, nausea, lack of appetite, shortness of breath, depression, anxiety, general wellbeing, help to sleep, slow the cancer, cure the cancer, or health related reason other than above (required the respondent to define further using an open-ended comment box). Non-users were defined as those that answered \u0026ldquo;no\u0026rdquo; to all of the above questions; which included current, or past, recreational users. Individuals were also provided the option to specify if they had used cannabis recreationally or for other conditions such as arthritis or anxiety.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e(iv) Statistical analysis\u003c/h2\u003e \u003cp\u003eGiven a lack of data specific to outpatient cancer settings in Australia, this was an exploratory study of MC use and perceptions. A sample size of 289 would provide 95% confidence of detecting a prevalence of cannabis use in 25% of the sample. To avoid the study being underpowered, we aimed to recruit a slightly larger sample: approx. 300 participants in total over the three sites. We considered a P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 as significant.\u003c/p\u003e \u003cp\u003eThe survey was programmed into the REDCap database [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and analysed using STATA 15 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Chi Squares were used to examine associations between demographics and MC use. Logistic regression was used to produce odds ratios of MC use predicted by perceptions. Authors had full access to all the data (including statistical reports and tables) in the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e(i) Demographics\u003c/h2\u003e\n \u003cp\u003eAcross the three clinics, 413 patients were approached and 82% consented to participate in the survey. Although 350 patients completed the survey, some patients declined to answer certain questions and item completion varies. MC use was reported by 67 (19%) patients. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e reports participants\u0026rsquo; demographic characteristics and compares differences according to medicinal cannabis use (e.g. users versus non-users). Demographics significantly associated with MC use were: male gender (61% of users vs. 45% of non-users, P\u0026thinsp;\u0026lt;\u0026thinsp;.05) and tobacco smoking (73% vs 53% respectively P\u0026thinsp;\u0026lt;\u0026thinsp;.01). Just over half (54%) of users had discussed MC with their clinicians whereas only 10% of non-users had done so.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e(ii) Reasons for MC use\u003c/h2\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the reasons patients selected for using MC. The most common indication chosen was pain (61%) followed by insomnia (48%). Of users, 12% selected \u0026ldquo;cure the cancer\u0026rdquo; and 16% \u0026ldquo;to slow the cancer\u0026rdquo;. Breathlessness was the least commonly chosen indication (1%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e(iii) Perceptions of benefit and risk\u003c/h2\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e compares the perceptions of benefit, and risk, between users and non-users. Participants were asked to answer on an 11 point scale, with 0 being no benefit/risk and 10 being immense benefit/risk. For the questions on physical, emotional, cancer progression benefit (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Graph a, b and c), users most commonly answered \u0026ldquo;8\u0026ndash;10\u0026rdquo; (i.e. highly beneficial) for all 3 domains and the percentage choosing this option was higher amongst users than for non-users: 72% of users vs 31% of non-users (OR 2.37. CI 0.26\u0026ndash;21.83. P\u0026thinsp;=\u0026thinsp;0.446) for physical, 66% of users vs 33% of non-users (OR 2.24. CI 0.61\u0026ndash;8.29. P\u0026thinsp;=\u0026thinsp;0.226) for emotional, and 40% of users vs 17% of non-users (OR 3.68. CI 1.27\u0026ndash;10.63. P\u0026thinsp;=\u0026thinsp;0.016) for cancer progression. In contrast, non-users most commonly answered \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;: 54% vs 16% (OR 0.31. CI 0.03\u0026ndash;3.04. P\u0026thinsp;=\u0026thinsp;0.316), 47% vs 10% (OR 0.25. CI 0.06\u0026ndash;1.09. P\u0026thinsp;=\u0026thinsp;0.065), 60% vs 37% (OR 0.97. CI 0.35\u0026ndash;2.75. P\u0026thinsp;=\u0026thinsp;0.960) compared to users respectively for each question.\u003c/p\u003e\n \u003cp\u003eFor the question on risk (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Graph D) the most common answer chosen by users was \u0026ldquo;0\u0026ndash;4\u0026rdquo; (i.e. low risk), with 82% of users choosing this option compared to only 44% of non-users (OR 0.12. CI 0.13\u0026ndash;3.47. P\u0026thinsp;=\u0026thinsp;0.64). However, as with the questions on benefit (graph a, b and c), the most common answer for non-users was again \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;: 47% vs 10% (OR 0.12. CI 0.05\u0026ndash;0.27. P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e(iv) Perceptions of the evidence\u003c/h2\u003e\n \u003cp\u003eIn addition to the perceived benefits and risks (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e); patients\u0026rsquo; perceptions on the quality evidence available on these benefits and risks were explored by asking the following 4 questions (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e): There is high quality information on how MC; (a) affects physical symptoms, or side effects, associated with cancer, (b) affects emotional wellbeing, (c) could slow, or prevent, cancer, (d) poses a risk to cancer patients\u0026apos; general health? The results for all four questions (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Graph a, b, c and d) show similar trends. Despite using MC, the most common answer for users was \u0026ldquo;disagree\u0026rdquo;, and the proportion selecting this response was higher than for non-users. This trend was seen for all four domains; 48% in users vs 38% in non-users (OR 0.74. CI 0.38\u0026ndash;1.45. p\u0026thinsp;=\u0026thinsp;0.377), 48% in users vs 37% in non-users (OR 0.75. CI 0.39\u0026ndash;1.43. p\u0026thinsp;=\u0026thinsp;0.381), 50% in users vs 40% in non-users (OR 0.46. CI 0.22\u0026ndash;0.93. p\u0026thinsp;=\u0026thinsp;0.031) and 57% in users vs 41% in non-users (OR 1.0. CI 0.42\u0026ndash;2.32 .p\u0026thinsp;=\u0026thinsp;0.992) respectively for a, b, c and d. In contrast, the most common answer for non-users was \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;, and they were more likely to select this answer than users for all four questions: 48% in non-users vs 38% in users (OR 0.74. CI 0.38\u0026ndash;1.45. p\u0026thinsp;=\u0026thinsp;0.377), 48% in non-users vs 37% in users (OR 0.75. CI 0.39\u0026ndash;1.43. p\u0026thinsp;=\u0026thinsp;0.381), 50% in non-users vs 40% in users (OR 0.46. CI 0.22\u0026ndash;0.93. p\u0026thinsp;=\u0026thinsp;0.031) and 57% in non-users vs 41% in users (OR 1.0. CI 0.42\u0026ndash;2.32; p\u0026thinsp;=\u0026thinsp;0.992) for a, b, c and d respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e(V) Sources of information used to inform patients\u0026rsquo; health beliefs\u003c/h2\u003e\n \u003cp\u003eThe sources of information used by users, and non-users, are reported in Table\u0026nbsp;2. Nearly all patients (87% and 91% respectively for non-users vs. users) had accessed some form of information on MC. The three most common sources of information selected by users were: \u0026ldquo;friends or family\u0026rdquo; (69%), \u0026ldquo;TV, newspaper or magazine\u0026rdquo; (48%) and \u0026ldquo;social media, websites or blogs\u0026rdquo; (43%). Non-users also selected these as their top three categories, but in a slightly different order and distribution: 41%, 64% and 24% respectively, making \u0026ldquo;TV, newspaper or magazine\u0026rdquo; the most common response in this group. Only 31% of users, and 8% of non-users, had received information on MC from their \u0026ldquo;cancer doctor, cancer nurse, GP, or palliative care physician\u0026rdquo;.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e(i) Demographics and reasons for use\u003c/h2\u003e \u003cp\u003eOur study cohort (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) indicates that 19% of cancer patients are using MC. This demand for MC is consistent with previous cannabis studies in cancer-patient populations both in Australia (8, 17, 19) and internationally (9,15). The demographics statistically associated with use; i.e. male gender and tobacco smoking, are also in line with previous conclusions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Regarding the reasons for use (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), our data are also in line with other studies suggesting that issues like: pain and insomnia are common drivers for MC use in patients in general (19, 20], and specifically in cancer patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although a relatively small proportion, it is concerning that some patients thought MC could slow, even cure, their cancer. This is an issue which has been highlighted previously [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and is discussed in more detail below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e(ii) Perceptions of benefit and risk\u003c/h2\u003e \u003cp\u003eThe results in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e show some fascinating trends. In line with previous Australian data, but in a non-cancer population [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; and in non-Australian cancer patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], most users felt that MC is highly beneficial for symptom control, and low risk, despite the general consensus from clinicians that there is a lack of evidence to support this claim [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Users are more sceptical on the benefits on cancer progression; but concerningly 40% believed it was highly beneficial for this indication (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). This is an issue which has been highlighted previously [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and needs to be addressed. Some patients may use MC alongside conventional treatments like chemotherapy and immunotherapy, but others may use as an alternative to conventional treatments or terminate them early. This could have a significant impact on prognosis.\u003c/p\u003e \u003cp\u003eThe responses for non-users are also interesting. We hypothesised that they would rate the benefits as low, and the risks as high, but the most common response was \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;. When non-users committed to an answer, i.e. didn\u0026rsquo;t chose \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;, they most commonly scored it as highly beneficial, and low risk. This suggests that there is a belief of efficacy, and minimal risk, even in non-users. It is possible that if faced with complex future issues, such as complex or refractory symptoms or disease progression, such patients may have a low threshold for trialling MC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e(iii) Perceptions of the quality of evidence available on MC\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e also showed some surprising results, particularly when compared to Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Despite using MC, the majority of users didn\u0026rsquo;t feel that there was high quality evidence for its efficacy, or safety. It seems that users accept that the quality of evidence is low (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), yet their personal experience is positive (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In contrast, the most common answer in non-users was \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;; the same trend as in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e(iv) Sources of information utilised to inform patients\u0026rsquo; health beliefs\u003c/h2\u003e \u003cp\u003eAlmost all users (91%), but also non-users (87%), had accessed information on MC (Table\u0026nbsp;2); highlighting it as major area of interest for patients, which clinician\u0026rsquo;s may underestimate. It is, however, concerning that only a minority received such information from clinicians. This is an issue which has been identified previously; for example in a survey of cancer patients only 15% had received information on MC from their clinicians, despite 75% wanting to receive such information [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere seems to be a reliance on less robust resources like: friends and family, TV, newspapers and social media which have been shown to be unreliable [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].The reasons for this need to be further explored. Regardless of the driver for this preference, clinicians need to be more proactive in discussing the pros and cons of MC and educate patients on the best available evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e(v) Limitations\u003c/h2\u003e \u003cp\u003eAlthough our study is robust, we exercise caution over some our conclusions given the limitations inherent in an observational study. Many of the trends we observed failed to reach statistical significance. Additionally, there was a large amount of missing data (i.e. non-responders) for certain questions that could have introduced bias. Unfortunately this was unavoidable, as our ethical considerations meant that patients\u0026rsquo; had the choice to abstain from answering. A final limitation is that researchers analysing the data, and writing up the results, were part of the study team and therefore not blinded.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates current, real world Australian cancer patients’ perceptions on: the evidence for MC, the sources of information used to shape their health beliefs, and compares users to non-users.\u003c/p\u003e\n\u003cp\u003eSurprisingly, our results show that despite using MC for symptom control, and in some cases anti-cancer activity, only a minority of users believe that the evidence for either of these indications was of high quality. Concerningly, only a minority of users were receiving information on MC from clinicians like doctors and nurses, instead relying on resources such as: TV, friends, family, social media and websites which have been demonstrated to be unreliable and often supporting commercial agendas [23, 24].\u003c/p\u003e\n\u003cp\u003eThe results highlight the need to combat potential misinformation that patients may be receiving on MC, provide information on treatments with a greater evidence base, and link patients to support services like the palliative care teams.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther research is needed to explore a number of questions raised by our study: (i) Why are patients using MC despite acknowledging the lack of evidence? (ii) Do those patients that believe there is an anti-cancer effect continue to take their systemic treatment in conjunction with MC, or are they using MC alone? (iii) Why are patients preferring to access information on MC from non-clinical sources, like friends and family, social media, etc; over clinicians?\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJT wrote the manuscript and prepared the figures. BB conducted the statistical analysis. BB, JM, SM, MC, PB, EF, JL, GW and CL contributed to designing the study, the literatrue review and collecting the results. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThis work was supported by the Hunter Cancer Research Alliance (HCRA) with infrastructure support provided by the Hunter Medical Research Institute. The HCRA receives funding from Cancer Institute NSW, as a Translational Cancer Research Centre (TCRC), and the University of Newcastle.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplmentary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRusso EB. History of cannabis and its preparations in saga, science, and sobriquet. Chem Biodivers. 2007; 4(8): 1614\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eBonini SA, Premoli M, Tambaro S, Kumar A, Maccarinelli G, Memo M, et al. Cannabis sativa: a comprehensive ethnopharmacological review of a medicinal plant with a long history. J Ethnopharmacol. 2018;227:300\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eSeddon T, Floodgate W. Regulating cannabis. Cham: Springer International Publishing; 2020. Available from: http://link.springer.com/10.1007/978-3-030-52927-7\u003c/li\u003e\n\u003cli\u003eBridgeman MB, Abazia DT. Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting. P T. 2017 Mar;42(3):180-188. PMID: 28250701; PMCID: PMC5312634.\u003c/li\u003e\n\u003cli\u003eArnold JC, Nation T, McGregor IS. Prescribing medicinal cannabis. Aust Prescr. 2020 Oct;43(5):152-159. doi: 10.18773/austprescr.2020.052. Epub 2020 Sep 29. Erratum in: Aust Prescr. 2020 Dec;43(6):225. PMID: 33093741; PMCID: PMC7572192.\u003c/li\u003e\n\u003cli\u003eTGA. Medicinal cannabis Canberra, Australia: Department of Health Australian Government; 2021 [cited 2021 August]. Available from: https://www.tga.gov.au/medicinal-cannabis.\u003c/li\u003e\n\u003cli\u003eSenate Community Affairs References Committee. Current Barriers to Patient Access to Medicinal Cannabis in Australia. In: Australia Po, (ed). Canberra, Australia: Senate Printing Unit; 2020.\u003c/li\u003e\n\u003cli\u003eHallinan, C.M.; Bonomo, Y.A. The Rise and Rise of Medicinal Cannabis, What Now? Medicinal Cannabis Prescribing in Australia 2017\u0026ndash;2022. Int. J. Environ. Res. Public Health 2022, 19, 9853. https://doi.org/10.3390/ijerph19169853\u003c/li\u003e\n\u003cli\u003ePergam SA, Woodfield MC, Lee CM, et al. Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use. Cancer. 2017;123:4488-4497.\u003c/li\u003e\n\u003cli\u003eMartin JH, Bonomo Y, Reynolds AD. Compassion and evidence in prescribing cannabinoids: a perspective from the Royal Australasian College of Physicians. Med J Aust 2018;208:107-9. 10.5694/mja17.01004\u003c/li\u003e\n\u003cli\u003eVolkow ND, Baler RD, Compton WM, et al. Adverse health effects of marijuana use. N Engl J Med. 2014;370:2219\u0026ndash;2227.\u003c/li\u003e\n\u003cli\u003eHewa-Gamage D, Blaschke S, Drosdowsky A, et al. A Cross-sectional Survey of Health Professionals\u0026apos; Attitudes toward Medicinal Cannabis Use as Part of Cancer Management. Journal of law and Medicine. 2019 Jul;26(4):815-824. PMID: 31682359.\u003c/li\u003e\n\u003cli\u003eHallinan CM, Gunn JM, Bonomo YA. Implementation of medicinal cannabis in Australia: innovation or upheaval? Perspectives from physicians as key informants, a qualitative analysis. BMJ Open. 2021 Oct 22;11(10):e054044. doi: 10.1136/bmjopen-2021-054044. PMID: 34686558; PMCID: PMC8543680.\u003c/li\u003e\n\u003cli\u003eCortellini A, Porzio G, Cofini V, et al. What cancer patients actually know regarding medical cannabis? A cross-sectional survey with a critical analysis of the current attitudes. Journal of Oncology Pharmacy Practice. 2019;25(6):1439-1444. doi:10.1177/1078155219843161\u003c/li\u003e\n\u003cli\u003eManyau MC, Changadzo KP, Mudziti T. Perceptions and prevalence of marijuana use among cancer patients managed at an outpatient department in Zimbabwe: A brief report. J Oncol Pharm Pract. 2022 Aug 9:10781552221118026. doi: 10.1177/10781552221118026. Epub ahead of print. PMID: 35944143.\u003c/li\u003e\n\u003cli\u003eSukrueangkul A, Phimha S, Panomai N, Laohasiriwong W, Sakphisutthikul C. Attitudes and Beliefs of Cancer Patients Demanding Medical Cannabis Use in North Thailand. Asian Pac J Cancer Prev. 2022 Apr 1;23(4):1309-1314. doi: 10.31557/APJCP.2022.23.4.1309. PMID: 35485690; PMCID: PMC9375599.\u003c/li\u003e\n\u003cli\u003eLuckett, T. , Phillips, J. , Lintzeris, N. , Allsop, D. , Lee, J. , Solowij, N. , Martin, J. , Lam, L. , Aggarwal, R. , McCaffrey, N. , Currow, D. , Chye, R. , Lovell, M. , McGregor, I. \u0026amp; Agar, M. (2016). Clinical trials of medicinal cannabis for appetite‐related symptoms from advanced cancer. Internal Medicine Journal, 46 (11), 1269-1275. doi: 10.1111/imj.13224.\u003c/li\u003e\n\u003cli\u003eNSW health government. NSW health government website, accessed 10 February 2023, https://www.health.nsw.gov.au/lhd/Pages/hnelhd.aspx \u003c/li\u003e\n\u003cli\u003eLintzeris, N., Mills, L., Suraev, A. et al. Medical cannabis use in the Australian community following introduction of legal access: the 2018\u0026ndash;2019 Online Cross-Sectional Cannabis as Medicine Survey (CAMS-18). Harm Reduct J 17, 37 (2020). https://doi.org/10.1186/s12954-020-00377-0\u003c/li\u003e\n\u003cli\u003eSexton M, Cuttler C, Finnell JS, Mischley LK. A Cross-Sectional Survey of Medical Cannabis Users: Patterns of Use and Perceived Efficacy. Cannabis Cannabinoid Res. 2016 Jun 1;1(1):131-138. doi: 10.1089/can.2016.0007. PMID: 28861489; PMCID: PMC5549439.\u003c/li\u003e\n\u003cli\u003eBraun, IM, Nayak, MM, Revette, A, Wright, AA, Chai, PR, Yusufov, M, Pirl, W, Tulsky, JA. Cancer patients\u0026apos; experiences with medicinal cannabis\u0026ndash;related care. Cancer. 2020. https://doi.org/10.1002/cncr.33202\u003c/li\u003e\n\u003cli\u003eZarrabi AJ, Welsh JW, Sniecinski R, Curseen K, Gillespie T, Baer W, McKenzie-Brown AM, Singh V. Perception of Benefits and Harms of Medical Cannabis among Seriously Ill Patients in an Outpatient Palliative Care Practice. J Palliat Med. 2020 Apr;23(4):558-562. doi: 10.1089/jpm.2019.0211. Epub 2019 Sep 20. PMID: 31539298.\u003c/li\u003e\n\u003cli\u003eNg JY, Tahir U, Lum N. The quality of health information provided on web sites selling cannabis to consumers in Canada is poor. Harm Reduct J. 2022 Dec 12;19(1):138. doi: 10.1186/s12954-022-00691-9. PMID: 36503517; PMCID: PMC9743698.\u003c/li\u003e\n\u003cli\u003eNg JY, Dzisiak DA, Saini JB. Cannabis for pain: a cross-sectional survey of the patient information quality on the Internet. J Cannabis Res. 2021 Aug 16;3(1):36. doi: 10.1186/s42238-021-00093-x. PMID: 34399853; PMCID: PMC8369629.\u003c/li\u003e\n\u003cli\u003eStataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC\u003c/li\u003e\n\u003cli\u003ehttps://projectredcap.org/resources/citations/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medicinal marijuana, cannabis, attitude to health, Australia, neoplasms ","lastPublishedDoi":"10.21203/rs.3.rs-4308443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4308443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eDespite the increased demand [8], and accessibility [5], to medical cannabis (MC) there is a general consensus among physicians that evidence on its efficacy [10,12,13], and safety [4,11], is lacking. Although research has explored medical professionals’ perceptions of MC [10, 12,13], to our knowledge there is minimal research exploring patients’ perceptions; particularly in an Australian cancer setting [14,15,16,17]. We therefore aimed to explore patients’ perceptions of the efficacy, safety, and evidence for MC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA prospective cross-sectional questionnaire of Australian cancer patients attending adult oncology outpatient clinics in the Hunter New England Local Health District. Patients were 18 years, or older, and had a confirmed diagnosis of cancer (solid or haematological).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e19% of our cohort were using MC. Despite using for symptom control such as pain (61%), and, in some cases perceived anti-cancer activity (12% to cure and 16% to slow the cancer); a minority of users believed that the evidence for either of these indications was of high quality (28% and 29% respectively). A minority of users (31%) were receiving information on MC from clinicians. Most instead rely on resources such as TV, friends, family, social media and websites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis study demonstrated current real world cancer patients’ perceptions on: the evidence for MC, the sources of information used to shape their health beliefs, and compares users to non-users. The results highlight the need for treating teams to combat potential misinformation that patients may be accessing on MC and provide information on treatments with greater evidence.\u003c/p\u003e","manuscriptTitle":"Patients’ perceptions of the efficacy, safety, and quality of the evidence of medicinal cannabis: a survey of Australian cancer patients.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-13 15:42:13","doi":"10.21203/rs.3.rs-4308443/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a135a4d-242e-480b-b0e6-206c053a9af1","owner":[],"postedDate":"May 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-15T16:44:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-13 15:42:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4308443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4308443","identity":"rs-4308443","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}