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Medicinal Cannabis and Liver Enzymes in Advanced Cancer: Evidence from Randomized Trials
Table of Contents
Clinical Takeaway
Medicinal cannabis, whether CBD alone or combined with THC/CBD, did not produce clinically significant elevations in ALT or AST liver enzymes in patients with advanced cancer across both randomized trials. These findings provide reassurance that escalating doses of medicinal cannabis formulations do not appear to cause meaningful liver toxicity in this population. Clinicians can use this data to inform monitoring decisions and safety conversations when considering cannabis-based therapies for patients with advanced malignancy.
#2 Liver enzyme effects of medicinal cannabis in advanced cancer: a substudy of two randomised trials.
Citation: Scarborough Luke et al.. Liver enzyme effects of medicinal cannabis in advanced cancer: a substudy of two randomised trials.. BMJ supportive & palliative care. 2026. PMID: 41429435.
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Abstract: OBJECTIVES: This substudy investigated whether medicinal cannabis causes an elevation in alanine aminotransferase (ALT) or aspartate aminotransferase (AST) in patients with advanced malignancy and determined whether different cannabis formulations (cannabidiol (CBD) alone vs tetrahydrocannabinol (THC)/CBD combination) had differing effects on enzyme levels. METHODS: This analysis used data from two multicentre, randomised, placebo-controlled trials of escalating doses of CBD (MedCan1) or THC/CBD (MedCan2), including 287 patients with advanced cancer. Participants received escalating doses of CBD, THC/CBD or placebo. ALT and AST levels were measured at baseline, day 14 and day 28. RESULTS: Medicinal cannabis did not cause elevation of ALT or AST in patients with advanced malignancy at the doses studied (up to 600 mg CBD/day). No clinically meaningful differences in liver enzyme levels were observed between CBD-only and CBD/THC combination products. Furthermore, no patients in the cannabis groups exceeded the predefined thresholds of 3× upper limit of normal (ULN) (or 5× ULN in those with liver metastases) for ALT or AST. CONCLUSIONS: In patients with advanced malignancy enrolled in two clinical trials, medicinal cannabis products did not have a significant adverse impact on ALT or AST levels during the first 4 weeks of use at the doses studied.
What This Study Teaches Us
In patients with advanced cancer, medicinal cannabis (CBD alone or CBD/THC combinations) did not elevate liver enzymes ALT or AST over 4 weeks at doses up to 600 mg CBD daily. No patient exceeded clinically significant thresholds even in those with liver metastases.
Why This Matters Clinically
Hepatotoxicity concerns are a real barrier to cannabis prescribing in oncology, especially in patients already dealing with liver involvement or multiple medications. This RCT data provides reassurance for clinicians considering cannabis adjunctively in advanced malignancy without needing to monitor liver function obsessively in the short term.
Study Snapshot
| Study Design | Substudy of two multicenter, randomized, placebo-controlled trials (MedCan1 and MedCan2) |
| Population | 287 patients with advanced malignancy; demographics not specified in abstract |
| Intervention | Escalating doses of CBD (up to 600 mg/day) or THC/CBD combination versus placebo |
| Primary Outcome | ALT and AST levels at baseline, day 14, and day 28 |
| Key Result | No elevation of ALT or AST in cannabis groups; no patients exceeded 3x ULN (or 5x ULN with liver metastases) |
Where This Paper Deserves Skepticism
The abstract provides minimal detail on baseline characteristics, dropout rates, or whether participants had preexisting liver dysfunction. The 4-week observation window is reassuring for acute effects but says nothing about longer-term use, which is often how cancer patients consume cannabis. We don’t know the specific dose escalation schedule, and the abstract doesn’t clarify whether liver metastases were equally distributed across arms, which could obscure harm in a subset.
Dr. Caplan’s Take
This is useful, methodologically sound data that addresses a real clinical question. I’m not surprised that short-term, moderate-dose cannabis doesn’t cause enzyme spikes in advanced cancer patients, and the inclusion of those with liver metastases strengthens the signal. That said, I tell patients that four weeks is a snapshot, and we still have limited data on cumulative hepatic effects beyond the first month, particularly in those with underlying liver impairment. I use this study to deprioritize routine liver monitoring as a barrier to trial, but I don’t abandon it entirely if there are other risk factors.
Clinical Bottom Line
In advanced cancer patients, medicinal cannabis at studied doses does not appear to cause clinically significant liver enzyme elevation in the first month. This provides evidence to reassure both clinicians and patients about short-term hepatic safety when considering cannabis as adjunctive therapy.
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