METHODS

RESULTS

Of 211 total respondents, 95 (45%) reported LC on their present income, and 116 (55%) reported NLC on their present income. Respondents had diverse cancer diagnoses as seen in Table 1 (breast 25.4%, lung 15.1%, colorectal 9.8%, prostate 8.8%). Approximately 61% were 60 years old or older (with a median age of 62 years), 52% were female, 95% were white, and 40% were retired. Most respondents (57%) had stage IV disease. Some characteristics differed between the LC and the NLC group: Those NLC were less likely to be married or partnered (60% vs. 88%), less likely to be 60 years old or older (53% vs. 71%), less likely to be retired (28% vs. 54%), more likely to be unemployed (7% vs. 0%) or disabled (35% vs. 7%), and to have lower incomes (47% vs. 8% with annual incomes <$50,000).

DISCUSSION

In this survey study of patients with cancer registered in a state medical cannabis program, we found that individuals not living comfortably on their present income had higher monthly out-of-pocket costs for cannabis and were more likely to stop using cannabis or use it less than they would like; and this group more often cited cost as a reason for cannabis use disruptions. The overwhelming majority of patients reported improvements across a range of cancer symptoms and over half had used cannabis daily during their cancer treatments. Virtually no respondents reported worsening symptoms from cannabis use.

Our study adds to a growing body of literature suggesting that medical cannabis may be a promising intervention to alleviate cancer symptoms (Abrams, 2018; Anderson et al., 2019; Bar-Lev Schleider et al., 2018; Steele et al., 2019). Our study is one of the first to highlight financial challenges that come along with cannabis use: in our study population, those not living comfortably on their income reported higher costs related to cannabis, more often reported use disruptions (about half of NLC respondents), and more often cited costs as a reason for those disruptions. These findings are even more concerning as we also found that those not living comfortably on their income were younger, more likely to be disabled or unemployed, and less likely to be partnered – i.e., those not living comfortably on their income included some vulnerable patient subgroups. The annual enrollment fee of up to $200 for the state program may further add to the financial burden. However, while all patients in our survey paid the $200 annual fee, this fee was discontinued by the MCP in July 2023 when Minnesota passed a recreational cannabis law and shows that costs for cannabis may drop when cannabis becomes recreationally legal.

Together, our findings raise questions around health equity with regards to access to medical cannabis among those with cancer. If cannabis is indeed effective to reduce cancer symptoms, all patient groups, and especially those most vulnerable, should have access to cannabis if they wish to, calling for interventions to make medical cannabis more affordable. For example, uncontrolled pain remains a large challenge for patients with cancer, with many seeking out alternative/integrative therapies suggested in National Comprehensive Cancer Network guidelines (Nahin et al., 2016; Sedhom et al., 2021). Like cannabis, many of these therapies often lack insurance coverage and lead to more financial toxicity. For instance, acupuncture costs over $100 per session and requires weekly visits, leading to similar monthly costs for patients using daily cannabis (Fan et al., 2019).

Despite nearly 20% of patients with cancer use cannabis (Martell et al., 2018; Pergam et al., 2017), little is known about the type of products purchased and financial implications for patients. State medical programs generally require more regulatory oversight including comprehensive product testing for purity and potency, leading to higher overall costs for patients. THC-dominant products and those administered via a vaporizer typically have higher costs. Research conducted in the MCP and other programs showed a wide variety of products and routes being utilized by patients (Anderson et al., 2019; Bar-Lev Schleider et al., 2018; Pergam et al., 2017; Zylla et al., 2021). Patients in our survey also use various products and routes and generally appear to utilize oral products with a high THC:CBD ratio. Vaporizer administration is faster acting compared to the oral route but has a shorter duration of control (Grotenhermen, 2003). Therefore, given the shorter duration of effect, there is concern there would be less of a sustained benefit for chronic symptom control among patients using an inhalation route of administration. As such, the increased rate of vaporizer use in NLC patients may lead to more frequent use and higher overall monthly costs.

More research and clinical education are needed to show patients, providers, and policymakers how cannabis impacts overall symptom burden. Specific dosing regimens for various symptoms would help patients obtain optimal dosing earlier on and lead to less trial and error. Most patients desire cannabis education and guidance from their cancer care team, yet often end up relying on family, friends, and online sources (Pergam et al., 2017) given great variability in medical cannabis knowledge and training for cannabis dispensary staff workers (Braun et al., 2022). These gaps in professional knowledge may result in patients resorting to a “trial and error” approach that requires purchase of products that are ultimately unnecessary. For example, cannabis monthly costs depend largely on the total amount of THC purchased and frequency of use. Having safe, cost-effective cannabis dosing guidelines may also entice a larger pool of patients to try cannabis. Lowering the overall cost of medical cannabis through improved insurance coverage or discounted fees/rates for patients with cancer (especially those at lower income levels) could improve accessibility and reduce potential economic barriers that make cannabis unobtainable for many patients.

Our study has limitations. This was a cross-sectional study with a limited sample size that was 95% White in one geographic area and state program; our findings should be replicated in larger studies of diverse samples. This lack of racial diversity makes generalizing results difficult. We were unable to address the added economic challenges and potential legal fears that minorities may face when considering a purchase of cannabis. There is a possibility of selection bias in that cannabis users who were more enthusiastic about the effects of cannabis on their symptoms may have been more likely to participate in the study. Further, continuing controversies around the legal status of medical cannabis may have made some potential respondents hesitant to participate, even though we ensured confidentiality in our consent form. We cannot rule out reverse causality in that it is possible that those who report more use or unmet need for cannabis perceive lower levels of living comfortably as a result. Our survey did not explore decision making on how patients selected products/doses, or how much experimentation they needed to reach a cannabis regimen that worked for them. Respondents had a median time in the state program off over 8 months suggesting that the reported cannabis products and monthly costs likely indicated their final “ideal” regimen. Future studies should attempt to track cannabis use from the time of initial purchase to the most recent purchase to determine how product type, route of administration and total THC/CBD dose evolves over time. As stated earlier, the survey did not address other important social determinants of health that could impact overall financial wellness. As this survey took place during the COVID-19 pandemic, it is possible one’s comfort of living (especially amongst those with a cancer diagnosis) may have been significantly altered further impacting their interest or ability to purchase cannabis.