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The American Society of Clinical Oncology (ASCO) has released guidelines for the use of cannabis and cannabinoids in adults with cancer. The guidelines were published in the Journal of Clinical Oncology, and a related Q&A article was published in JCO Oncology Practice.1,2

The guidelines note that cannabis and/or cannabinoids are increasingly being used by cancer patients, but data to support the efficacy and safety of these products remain limited.

The guidelines recommend that clinicians facilitate conversations with patients about their interest in or current use of cannabis and/or cannabinoids to prevent side effects or drug-drug interactions.

Cannabis and cannabinoids should not be used to augment or replace cancer treatment, but they may improve chemotherapy-induced nausea and vomiting when other guideline-recommended options have been exhausted.

Recommendations and Evidence

Health systems and clinicians should provide adult cancer patients with educational resources on cannabis and/or cannabinoids to enable communication and shared decision-making between patients and clinicians (good practice statement).1

Clinicians should routinely and without judgment ask adult cancer patients if they are interested in cannabis and/or cannabinoids, and, if so, provide guidance or resources (based on a good practice statement).1 This recommendation is based on data that suggest anywhere from 20% to more than 40% of adults with cancer may use cannabis products.2

If patients are using cannabis and/or cannabinoids outside of recommendations or evidence-based indications, clinicians should educate patients on recommended use and seek to minimize harm (good practice statement).1 Serious side effects of cannabis products include tachycardia, orthostatic hypotension, severe confusion, and paranoia, which may be more prominent in older adults or those naïve to cannabis and/or cannabinoids.2

Clinicians should advise patients against using cannabis and/or cannabinoids in place of cancer-directed treatment (a strong recommendation based on very low-quality evidence).1

Likewise, cannabis and/or cannabinoids should not be used to augment the effects of cancer therapies, unless being studied as part of a clinical trial (a weak recommendation based on very low quality evidence).1 This is based on a lack of data regarding potential drug-drug interactions in the cancer setting and the impact of these interactions on cancer treatment outcomes.2 In addition, studies have suggested that cannabis and/or cannabinoids may worsen immunotherapy outcomes, including progression-free survival and overall survival, although more data are needed.

If patients are receiving cancer treatments that are moderately or highly likely to cause nausea and vomiting and the patients experience symptoms that are refractory to standard antiemetic treatments, their antiemetic regimen can be augmented with dronabinol, nabilone, or a quality-controlled oral 1:1 THC:CBD extract (weak recommendations based on low- to moderate-quality evidence.1

Unless they are enrolled in a clinical trial, adults with cancer should not take 300 mg or more of oral CBD daily to manage symptom burden (a weak recommendation based on low-quality evidence). This is due to a lack of proven efficacy and the risk of reversible liver enzyme abnormalities, which were observed in a study of adults and children without cancer.

Oral cannabis products have a variable onset from 30 minutes to 2 hours, and effects may last from 5 to 8 hours, so dose stacking should be avoided to prevent side effects.

The guidelines also note that there is insufficient evidence to recommend for or against cannabis and/or cannabinoids in managing cancer treatment-related toxicities or symptoms, including pain, aside from the aforementioned clinical settings or in a clinical trial setting.1

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President Joe Biden has been making his case for reelection to voters by telling them he is good for their pocketbooks, including at the pharmacy counter.

During his State of the Union address, Biden said legislation he signed gave Medicare the power to negotiate lower prescription drug prices.

“That’s not just saving seniors money and taxpayers money,” Biden said, a reference to the Inflation Reduction Act, which passed in 2022. “We cut the federal deficit by $160 billion because Medicare will no longer have to pay those exorbitant prices to Big Pharma.” 

Biden added, “This year, Medicare is negotiating lower prices for some of the costliest drugs.” He called for giving Medicare the power to negotiate prices for 500 drugs over the next decade.

In August, the federal government announced the first 10 drugs that it will negotiate for lower prices as part of the Inflation Reduction Act. A respected source of legislation analysis projects the change will save the government a lot of money, but those dollars haven’t been realized.

There is a reason Biden touted this legislation during his address: Polling by KFF shows that people, regardless of their political leanings, overwhelmingly support the idea of allowing Medicare to negotiate drug prices. But most people don’t know that such negotiations are underway.

Impact of Inflation Reduction Act Will Take Many Years

In August 2022, Biden signed the Inflation Reduction Act, which will allow the federal government to negotiate prices with drugmakers for Medicare. Biden kept his promise to repeal the law that barred Medicare from negotiating prices. 

The nonpartisan Congressional Budget Office projects a 10-year cumulative savings of $161.7 billion from two provisions of the Iaw: a phased-in effort to negotiate with drugmakers for lower prices and a rebate for price increases above the overall inflation rate. (The White House has previously pointed to this analysis.)

However, not all the savings will be permanent. About $44.3 billion over 10 years will be funneled into related provisions that expand access and lower out-of-pocket costs for Medicare beneficiaries.

“Negotiations are still ramping up, so the savings generated by the Inflation Reduction Act negotiation provisions are still in the future,” said Matthew Fiedler, a Brookings Institution expert on the economy and health studies. “The Congressional Budget Office did expect the inflation rebate provisions of the IRA (which are encompassed in the $160 billion) to begin generating modest savings during 2023 and 2024, but there, too, most of the savings are in the future.”

The legislation involves price negotiations for 10 brand-name medications that lack generic equivalents. Those drugs include the blood thinners Eliquis and Xarelto; the diabetes drugs Januvia, Jardiance, and NovoLog; Enbrel, for rheumatoid arthritis; the blood cancer drug Imbruvica; Entresto, for heart failure; Stelara, for psoriasis and Crohn’s disease; and Farxiga, a drug for diabetes, heart failure, and chronic kidney disease.

The CBO has estimated that the negotiated prices will translate to nearly $100 billion in federal savings from 2026 to 2031.

“Biden is jumping the gun on claiming savings for seniors,” said Joe Antos, an expert on health care at the conservative American Enterprise Institute. “Price negotiations haven’t been completed; the new prices for selected drugs aren’t in place until 2026.”

Biden said the legislation is “saving seniors money and taxpayers money,” which could be interpreted to mean it is saving them money now on prescription drugs. But the negotiations for these drugs would define the prices to be paid for prescriptions starting in 2026. For 2027 and 2028, 15 more drugs per year will be chosen for price negotiations. Starting in 2029, 20 more will be chosen a year. 

That said, other provisions in the legislation have already led to savings for seniors, said Tricia Neuman, a senior vice president at KFF:

  • Certain recommended adult vaccines covered under Medicare Part D, such as shingles, are covered at no cost. 
  • The act established a cap on Part D spending that begins phasing in this year. This year, Part D enrollees will pay no more than $3,300 on brand-name drugs. In 2025, the cap for all covered Part D drugs drops to $2,000.
  • The Inflation Reduction Act included the $35-a-month insulin cap, improvements in coverage for low-income beneficiaries, and the inflation rebate.

When we pressed the White House to provide examples of savings that have already occurred, a spokesperson pointed to the insulin cap.

Meanwhile, Antos said that although the Part D rebate has kicked in, the savings come from a small subset of Part D drugs taken by older Americans and that the government reaps the savings, not older Americans.  

“There is no reason to expect that seniors will see significant savings since there’s no obligation for the feds to distribute savings to Part D enrollees,” Antos said.

Our Ruling

Biden said, “We cut the federal deficit by $160 billion because Medicare will no longer have to pay those exorbitant prices to Big Pharma.”

Biden’s statement omits the time frame; the savings have not been realized. The CBO projected 10-year cumulative savings of $161.7 billion from two provisions of the legislation. And as for saving older Americans money on their prescriptions, that hasn’t happened yet. The federal government is negotiating the first 10 drugs with the new prices set to take effect in 2026.

We rate this statement Half True.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Margaret Parsons, one of three dermatologists at a 20-person practice in Sacramento, California, is in a bind. Since a Feb. 21 cyberattack on a previously obscure medical payment processing company, Change Healthcare, Parsons said, she and her colleagues haven’t been able to electronically bill for their services.

She heard Noridian Healthcare Solutions, California’s Medicare payment processor, was not accepting paper claims as of earlier this week, she said. And paper claims can take 3-6 months to result in payment anyway, she estimated.

“We will be in trouble in very short order, and are very stressed,” she said in an interview with KFF Health News.

A California Medical Association spokesperson said March 7 that the Centers for Medicare & Medicaid Services had agreed in a meeting to encourage payment processors like Noridian to accept paper claims. A Noridian spokesperson referred questions to CMS.

The American Hospital Association calls the suspected ransomware attack on Change Healthcare, a unit of insurance giant UnitedHealth Group’s Optum division, “the most significant and consequential incident of its kind against the U.S. health care system in history.” While doctors’ practices, hospital systems, and pharmacies struggle to find workarounds, the attack is exposing the health system’s broad vulnerability to hackers, as well as shortcomings in the Biden administration’s response.

To date, government has relied on more voluntary standards to protect the health care system’s networks, Beau Woods, a co-founder of the cyber advocacy group I Am The Cavalry, said. But “the purely optional, do-this-out-of-the-goodness-of-your-heart model clearly is not working,” he said. The federal government needs to devote greater funding, and more focus, to the problem, he said.

The crisis will take time to resolve. Comparing the Change Healthcare attack to others against parts of the health care system, “we have seen it generally takes a minimum of 30 days to restore core systems,” said John Riggi, the hospital association’s national adviser on cybersecurity.

In a March 7 statement, UnitedHealth Group said two services — related to electronic payments and medical claims — would be restored later in the month. “While we work to restore these systems, we strongly recommend our provider and payer clients use the applicable workarounds we have established,” the company said.

“We’re determined to make this right as fast as possible,” said company CEO Andrew Witty.

Providers and patients are meanwhile paying the price. Reports of people paying out-of-pocket to fill vital prescriptions have been common. Independent physician practices are particularly vulnerable.

“How can you pay staff, supplies, malpractice insurance — all this — without revenue?” said Stephen Sisselman, an independent primary care physician on Long Island in New York. “It’s impossible.”

Jackson Health System, in Miami-Dade County, Florida, may miss out on as much as $30 million in payments if the outage lasts a month, said Myriam Torres, its chief revenue officer. Some insurers have offered to mail paper checks.

Relief programs announced by both UnitedHealth and the federal government have been criticized by health providers, especially hospitals. Sisselman said Optum offered his practice, which he said has revenue of hundreds of thousands of dollars a month, a loan of $540 a week. Other providers and hospitals interviewed by KFF Health News said their offers from the insurer were similarly paltry.

In its March 7 statement, the company said it would offer new financing options to providers.

Providers Pressure Government to Act

On March 5, almost two weeks after Change Healthcare first reported what it initially called a cybersecurity “issue,” the Health and Human Services Department announced several assistance programs for health providers.

One recommendation is for insurers to advance payments for Medicare claims — similar to a program that aided health systems early in the pandemic. But physicians and others are worried that would help only hospitals, not independent practices or providers.

Anders Gilberg, a lobbyist with the Medical Group Management Association, which represents physician practices, posted on X, formerly known as Twitter, that the government “must require its contractors to extend the availability of accelerated payments to physician practices in a similar manner to which they are being offered to hospitals.”

HHS spokesperson Jeff Nesbit said the administration “recognizes the impact” of the attack and is “actively looking at their authority to help support these critical providers at this time and working with states to do the same.” He said Medicare is pressing UnitedHealth Group to “offer better options for interim payments to providers.”

Another idea from the federal government is to encourage providers to switch vendors away from Change Healthcare. Sisselman said he hoped to start submitting claims through a new vendor within 24 to 48 hours. But it’s not a practicable solution for everyone.

Torres said suggestions from UnitedHealth and regulators that providers change clearinghouses, file paper claims, or expedite payments are not helping.

“It’s highly unrealistic,” she said of the advice. “If you’ve got their claims processing tool, there’s nothing you can do.”

Mary Mayhew, president of the Florida Hospital Association, said her members have built up sophisticated systems reliant on Change Healthcare. Switching processes could take 90 days — during which they’ll be without cash flow, she said. “It’s not like flipping a switch.”

Nesbit acknowledged switching clearinghouses is difficult, “but the first priority should be resuming full claims flow,” he said. Medicare has directed its contractors and advised insurers to ease such changes, he added.

Health care leaders including state Medicaid directors have called on the Biden administration to treat the Change Healthcare attack similarly to the pandemic — a threat to the health system so severe that it demands extraordinary flexibility on the part of government insurance programs and regulators.

Beyond the money matters — critical as they are — providers and others say they lack basic information about the attack. UnitedHealth Group and the American Hospital Association have held calls and published releases about the incident; nevertheless, many still feel they’re in the dark.

Riggi of the AHA wants more information from UnitedHealth Group. He said it’s reasonable for the conglomerate to keep some information closely held, for example if it’s not verified or to assist law enforcement. But hospitals would like to know how the breach was perpetrated so they can reinforce their own defenses.

“The sector is clamoring for more information, ultimately to protect their own organizations,” he said.

Rumors have proliferated.

“It gets a little rough: Any given day you’re going to have to pick and choose who to believe,” Saad Chaudhry, an executive at Maryland hospital system Luminis Health, told KFF Health News. “Do you believe these thieves? Do you believe the organization itself, that has everything riding on their public image, who have incentives to minimize this kind of thing?”

What Happens Next?

Wired Magazine reported that someone paid the ransomware gang believed to be behind the attack $22 million in bitcoin. If that was indeed a ransom intended to resolve some aspect of the breach, it’s a bonanza for hackers.

Cybersecurity experts say some hospitals that have suffered attacks have faced ransom demands for as little as $10,000 and as much as $10 million. A large payment to the Change Healthcare hackers could incentivize more attacks.

“When there’s gold in the hills, there’s a gold rush,” said Josh Corman, another co-founder of I Am The Cavalry and a former federal cybersecurity official.

Longer-term, the attack intensifies questions about how the private companies that comprise the U.S. health system and the government that regulates them are defending against cyberthreats. Attacks have been common: Thieves and hackers, often believed to be sponsored or harbored by countries like Russia and North Korea, have knocked down systems in the United Kingdom’s National Health Service, pharma giants like Merck, and numerous hospitals.

The FBI reported 249 ransomware attacks against health care and public health organizations in 2023, but Corman believes the number is higher.

But federal efforts to protect the health system are a patchwork, according to cybersecurity experts. While it’s not yet clear how Change Healthcare was hacked, experts have warned a breach can occur through a phishing link in an email or more exotic pathways. That means regulators need to consider hardening all kinds of products.

One example of the slow-at-best efforts to mend these defenses concerns medical devices. Devices with outdated software could provide a pathway for hackers to get into a hospital network or simply degrade its functioning.

The FDA recently gained more authority to assess medical devices’ digital defenses and issue safety communications about them. But that doesn’t mean vulnerable machines will be removed from hospitals. Products often linger because they’re expensive to take out of service or replace.

Senator Mark Warner (D-Va.) has previously proposed a “Cash for Clunkers”-type program to pay hospitals to update the cybersecurity of their old medical devices, but it was “never seriously pursued,” Warner spokesperson Rachel Cohen said. Riggi said such a program might make sense, depending on how it’s implemented.

Weaknesses in the system are widespread and often don’t occur to policymakers immediately. Even something as prosaic as a heating and air conditioning system can, if connected to a hospital’s internet network, be hacked and allow the institution to be breached.

But erecting more defenses requires more people and resources — which often aren’t available. In 2017, Woods and Corman assisted on an HHS report surveying the digital readiness of the health care sector. As part of their research, they found a slice of wealthier hospitals had the information technology staff and resources to defend their systems — but the vast majority had no dedicated security staff. Corman calls them “target-rich but cyber-poor.”

“The desire is there. They understand the importance,” Riggi said. “The issue is the resources.”

HHS has proposed requiring minimum cyberdefenses for hospitals to participate in Medicare, a vital source of revenue for the entire industry. But Riggi says the AHA won’t support it.

“We oppose unfunded mandates and oppose the use of such a harsh penalty,” he said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Equitable access to care as well as improvements in cancer diagnosis and primary prevention strategies could prevent more than 2 million cancer deaths in women each year, according to a report published in The Lancet.1

Researchers studied premature cancer death in 2020 among women from 185 countries who had 36 cancer types.1,2 Of the 2.3 million women who died prematurely, an estimated 1.5 million could have avoided premature death via primary prevention or early detection strategies, and the remaining 800,000 deaths could have been prevented if women had equitable access to cancer care, according to researchers.

“[B]eing a woman impacts timely cancer care, more than being a man,” said Lancet report author Karla Unger-Saldaña, MD, of the National Cancer Institute of Mexico in Mexico City.

“[T]here are many mechanisms behind this — starting with different access to education, health literacy, cancer awareness, and gender roles that interfere with women’s ability to seek care,” she added.

Women Experience Delays in Cancer Diagnosis

“[W]omen tend to be disadvantaged from first access to care for cancer, even starting from diagnosis,” said Lancet report author Verna Vanderpuye, MD, of Korle Bu Teaching Hospital in Accra, Ghana.

Studies have suggested that several cancers tend to be diagnosed later in women than in men. Women tend to have longer times from first presentation to diagnosis for gastrointestinal, genitourinary, lung, hematologic, and other cancers.3-7

For example, in a UK study of 18,618 patients, women had delayed diagnoses of lymphoma, bladder cancer, colorectal cancer, gastric cancer, head and neck cancer, and lung cancer.7

Studies have also shown that women are more likely than men to first present with cancer symptoms at emergency rooms, with the greatest disparities seen for lung and gastrointestinal cancers.8,9

These delays in diagnosis can mean that women are diagnosed with cancer at later stages than men. Research has shown that women are diagnosed with colon, rectal, and bladder cancer at later stages than men.10-14

Delays in diagnosis may be partly explained by a lack of screening. For example, researchers found that health care providers are less likely to have discussions about lung cancer screening with women than with men.15 In addition, although screening has been shown to reduce the incidence of cervical cancer, many countries have not implemented widespread screening.16,17    

How Sexism Impacts Access to Cancer Care

Sexism has been shown to impact women’s access to any type of health care, and this includes cancer care.1

“Disrespectful or even discriminatory health care resulting from health care providers’ gender biases and stereotypes” affects women’s ability to receive the care they need, Dr Unger-Saldaña noted.

Studies have shown that women’s health concerns are less likely to be taken seriously and managed appropriately than men’s.18,19 Women’s symptoms are more likely to be perceived as psychosocial, women are more likely to receive non-specific diagnoses, and they are more likely to be given prescriptions for psychoactive drugs.

A cancer-specific example of overlooking women’s health concerns is how physicians have delayed the diagnosis of breast cancer by inappropriately reassuring patients that a palpable mass is benign without performing a biopsy.20

Research has also suggested that women with cancer are more likely than their male counterparts to experience adverse events related to cancer treatment, to report inadequate pain management, and to have their sexual health concerns overlooked.21-23

“[I]n the area of breast and gynecologic cancers, only very recently have people focused on sexual health and sexual side effects of cancer treatment,” said Gita Suneja, MD, of the University of Utah in Salt Lake City, who was not involved in the Lancet report. “These are life-altering treatments that affect sexual health profoundly, yet we have long neglected women’s health and well-being.”

“Patriarchal ideas about women and women’s complaints often manifest in prevalent mistreatment, disrespect, negligence, and abuse of female patients by medical staff,” the authors of the Lancet report wrote. “These types of experiences can damage patients’ trust in health care providers and influence the patients’ willingness to participate in cancer screening or seek care for cancer symptoms.”

Another potential cause of suboptimal cancer care for women is the fact that they have been underrepresented in research, so cancers in women may not be as well understood as cancers in men.24,25 The causes of breast cancer, for example, are not well understood, despite the fact that breast cancer was the most commonly diagnosed cancer worldwide in 2020.1,26

“I think one of the key takeaways from our work was the degree to which sex and gender have not been adequately considered in cancer research, practice, and policy making,” said Lancet report author Ophira Ginsburg, MD, of the National Cancer Institute in Bethesda, Maryland. “We underestimated the massive role that gender-based and intersectional power dynamics play in the interactions of women with the cancer health system.”

Cost-Related Barriers and Intersectionality

Another barrier to optimal care that impacts women more often than men is the cost of care.1 Research has shown that women are more likely than men to have inadequate health insurance and to forgo medical care due to costs.19,27

In one study, women in Latin American countries reported that health care costs prevented them from undergoing breast cancer screening.28 In another study, women in Uganda reported that a lack of money for medical bills and transportation was the main reason they did not seek care for symptoms of breast cancer or cervical cancer.29

Women can also face barriers to care as a result of intersecting identities, such as race, ethnicity, sexual orientation, and gender identity.1 “Of course, gender intersects with other marginalized status to further complicate things,” Dr Unger-Saldaña noted.

For example, an analysis of 36 studies on access to cancer care among Indigenous people in Canada revealed that barriers to cervical cancer screening were “related to histories of trauma and abuse, including sexual and physical abuse, and residential school attendance,” as well as the inability to locate a female health care provider.30

Women belonging to sexual minority groups may also experience barriers that limit their ability to receive cancer care.1 In a US study, 29% of Black sexual minority women reported delays in breast cancer care of more than 3 months, compared with 11% of Black heterosexual women, 10% of White sexual minority women, and 5% of White heterosexual women.31

The Role of Primary Prevention Efforts

Primary prevention strategies — such as avoiding tobacco and alcohol — can prevent cancer deaths in women, but common sex-specific cancers in women are “generally not amenable to primary prevention,” the Lancet report authors noted.1 Overall, the proportion of cancers that are amenable to primary prevention strategies is greater for men than for women.

Women can benefit from interventions to reduce cancer risks, but these interventions must be gender-appropriate, according to the Lancet report authors. Women can benefit from tailored genetic testing, counseling about lifestyle changes, and HPV vaccination, for example.

Eliminating Disparities: Potential Solutions

The Lancet report authors said the report itself is a first step toward addressing disparities in cancer care.1

“The first thing is to bring the discussion to the fore,” Dr Vanderpuye said. “We need to revisit our social norms. We need to look at feminist economics.”

The report includes several recommendations for addressing disparities, such as routinely collecting and reporting data on sex, gender, and other sociodemographic factors in cancer populations; reducing exposures to known cancer risks for women; and devising strategies to increase equitable access to early cancer detection and diagnosis.

The report also recommends ensuring that health systems provide quality cancer care to women and integrating “a gender competency framework into the education and training of the cancer workforce.”

Dr Vanderpuye noted that such frameworks could “increase awareness of gender differences in cancer” and the need to prevent bias in cancer care.

Patient education is another area for improvement highlighted in the report. Educational interventions to increase women’s awareness of screening measures and cancer symptoms could lead to earlier diagnosis.

Dr Vanderpuye also suggested addressing “religious and cultural norms preventing women and girls from accessing timely care” and working to “increase enrollment of women and girls in clinical trials to direct quality care interventions.”32,33

Dr Ginsburg noted that the National Institutes of Health is offering a series of workshops on sex and gender cancer research that anyone can attend.

“This includes basic, translational, and clinical research where even sex as a biological variable has been under-examined as a factor that can influence treatment efficacy and toxicity… and the way that power dynamics influence a woman’s rights and opportunities to understand her cancer risks and to seek and obtain respectful cancer health services from primary and secondary prevention through treatment and survivorship care,” Dr Ginsburg said. 

“There’s much more to be done, and we are hoping this [the Lancet report] will create a movement and generate not only interest but real-world actions to make a transformational change among our many partners, stakeholders, and those who might read the report in the future,” Dr Ginsburg said.

Disclosures: Drs Suneja, Ginsburg, and Unger-Saldaña reported having no conflicts of interest. Dr Vanderpuye and other Lancet report authors disclosed a range of affiliations that can be found in the report.

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