Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

https://doi.org/10.1007/s00432-021-03710-7

REVIEW – CANCER RESEARCH

Cannabinoids in the landscape of cancer

Nagina Mangal1,2 · Simon Erridge1 · Nagy Habib1 · Anguraj Sadanandam2 · Vikash Reebye1 · Mikael Hans Sodergren1

Received: 19 April 2021 / Accepted: 4 June 2021 / Published online: 14 July 2021
© The Author(s) 2021

Abstract
Introduction  Cannabinoids are a group of terpenophenolic compounds derived from the Cannabis sativa L. plant. There is a
growing body of evidence from cell culture and animal studies in support of cannabinoids possessing anticancer properties.
Method  A database search of peer reviewed articles published in English as full texts between January 1970 and April 2021
in Google Scholar, MEDLINE, PubMed and Web of Science was undertaken. References of relevant literature were searched
to identify additional studies to construct a narrative literature review of oncological effects of cannabinoids in pre-clinical
and clinical studies in various cancer types.
Results  Phyto-, endogenous and synthetic cannabinoids demonstrated antitumour effects both in vitro and in vivo. How-
ever, these effects are dependent on cancer type, the concentration and preparation of the cannabinoid and the abundance
of receptor targets. The mechanism of action of synthetic cannabinoids, (−)-trans-Δ9-tetrahydrocannabinol (Δ9-THC) and
cannabidiol (CBD) has mainly been described via the traditional cannabinoid receptors; C ­ B1 and C
­ B2, but reports have
also indicated evidence of activity through GPR55, TRPM8 and other ion channels including TRPA1, TRPV1 and TRPV2.
Conclusion  Cannabinoids have shown to be efficacious both as a single agent and in combination with antineoplastic drugs.
These effects have occurred through various receptors and ligands and modulation of signalling pathways involved in hall-
marks of cancer pathology. There is a need for further studies to characterise its mode of action at the molecular level and
to delineate efficacious dosage and route of administration in addition to synergistic regimes.

Keywords  Cannabinoids · Cancer · Cannabidiol · Tetrahydrocannabinol · Cannabinoid receptors · Endocannabinoid system

Introduction interests rather than scientific or medical reasons (Zuardi

2006). Over recent years, cannabis and its derivatives have
Since time immemorial, the Cannabis plant has been used been used for treating chemotherapy induced nausea and
as a source of fibre, herbal remedy, medicinal and reli- vomiting, epilepsy and multiple sclerosis amongst other
gious purposes (Kalant 2001; Goncalves et al. 2020). In indications (Parker et al. 2011; Kleckner 2019). Increasing
the mid-nineteenth century, O’Shaughnessy and Moreau data from and in vivo studies have started to show evidence
reported positive effects of cannabis on muscle spasms, of cannabis in modulating signalling pathways involved in
vomiting, convulsions, rheumatism, tetanus, and rabies cancer cell proliferation, autophagy, apoptosis and inhibi-
(O’Shaughnessy 1843; Zuardi 2006). However, during the tion of angiogenesis and metastasis (Velasco et al. 2016).
twentieth century, its utilisation in Western medicine started Emerging reports have also indicated synergistic effects
to decline as a result of political prejudices and economic of cannabinoids in combination with antineoplastic drugs
(Moreno et al. 2019; Dariš et al. 2019; Fogli et al. 2006;
Velasco et al. 2012).
* Mikael Hans Sodergren The cannabis plant has been termed as a “storehouse”
m.sodergren@imperial.ac.uk of several pharmacologically relevant compounds (Andre
1
et al. 2016). The unique qualities of each cannabis vari-
Medical Cannabis Research Group, Department of Surgery
and Cancer, Imperial College London, Hammersmith
ety or chemovar are the result of varying concentrations
Campus, London W12 0HS, UK of numerous classes of bioactive molecules, most notably,
2
Systems and Precision Cancer Medicine Team, Division
cannabinoids as shown in Fig. 1, terpenoids and flavonoids
of Molecular Pathology, Institute of Cancer Research, (Chakravarti et al. 2014). Cannabinoids interact directly
London SM2 5NG, UK

13
Vol.:(0123456789)

2508 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Fig. 1  The chemical structures of Cannabigerol (CBG), Cannabidiol chemical features include a dibenzopyran ring and a hydrophobic
(CBD), Tetrahydrocannabinol (Δ9-THC), Cannabichromene (CBC) alkyl chain (Morales et  al. 2017). Aside from Δ9-THC and CBD,
and Cannabinol (CBN)-type neutral, varinic and acidic phytocan- there has been a current focus on the therapeutic properties of some
nabinoids. More than 120 phytocannabinoids have been isolated from minor, varinic and acidic cannabinoids (Andre et  al. 2016; Franco
Cannabis sativa L. which can be distinguished into eleven chemi- et al. 2020). Created with BioRender.com
cal subtypes (Gonçalves et  al. 2020; ElSohly 2017). Their common

with cannabinoid receptors, which include G-protein cou-

pled receptors (cannabinoid receptor 1, C
­ B1 and cannabinoid
receptor 2, C­ B2), ligand-gated ion channels (i.e. vanilloid
cell surface channels) and nuclear receptors (i.e. peroxisome
proliferator-activated receptor gamma, PPARγ) (Moreno
et al. 2019; Śledziński et al. 2018) comprising the endoge-
nous endocannabinoid system (ECS) (Zou and Kumar 2018).
Three major classifications of cannabinoids include phyto-
cannabinoids (plant-based), such as Δ9-tetrahydrocannabinol
(Δ9-THC) and cannabidiol (CBD), endocannabinoids (or
endogenous cannabinoids) which include anandamide
(AEA) and 2-arachidonolyglycerol (2-AG) and synthetic
cannabinoids that mimic the cannabinoid groups (1) and (2)
(Pertwee 2006; Lu and Mackie 2016). Endocannabinoids
play a crucial role in mediating physiological functions
including metabolic, cardiovascular regulation, reproduc-
tion, inflammatory response, immune system and analgesia
(Guindon and Hohmann 2012; Kaur et al. 2016). AEA and
2-AG are degraded by fatty acid amide hydrolase (FAAH)
and monoacylglycerol lipase (MAGL) enzymes (Pisanti
et al. 2013). Modulation of their activity may have poten- Fig. 2  Overview of the components of the endocannabinoid system
tial therapeutic implications and inhibitors are under active (ECS) which include endogenous endocannabinoids; Anandamide
investigation as pharmaceuticals. Synthetic cannabinoids (AEA) and 2-Arachidonoylglycerol (2-AG), its major receptors clas-
have been studied extensively and some have been shown sified into cannabinoid receptors 1 and 2, and non-cannabinoid recep-
tors; GPR55, GPR35, GPR119, GPR18, GPR12, ion channels includ-
to be highly bioactive than their natural counterparts, some ing transient receptor potential cation channel subfamily members;
common ones include WIN55, 212–2 (potent C ­ B1 receptor TRPM8, TRPV1, TRPV2, peroxisome-proliferator-activated recep-
agonist), JWH-018, JWH-073, JWH-133 (CB receptor ago- tors (PPAR). A third component of the system are its enzymes/trans-
nists) and SR141716 or Rimonabant ­(CB1 receptor antago- porters responsible for the synthesis and degradation of endocannabi-
noids including serum albumin, ceramide, cholesterol, diacylglycerol
nist) (Morales et al. 2017), overview shown in Fig. 2. lipase (DAGL), phospholipase C (PLC), monoacylglycerol lipase
Several studies have reported the varying affinities of (MAGL), fatty acid amide hydrolase (FAAH). Created with BioRen-
phytocannabinoids for the classical C ­ B1 and C
­ B2 receptors der.com

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2509

with agonistic and antagonistic behaviours (Morales et al. oxygen species (ROS) signalling (Zhang et al. 2019). Δ9-
2017; Zhao and Abood 2013). However, it is now emerging THC in glioma cells has shown to induce upregulation of
that cannabinoids can interact with multiple orphan G-pro- the p8 protein (involved in ER stress and metastasis) via
tein coupled receptors (GPCRs) including GPR12, GPR18, de novo synthesis of ceramide (Carracedo et al. 2006).
GPR35, GPR55, GPR119, opioid and serotonin receptors From the literature available, it is evident that there is an
(Morales et al. 2017; Zhao and Abood 2013; Console-Bram interplay between cannabinoids downstream effects.
et al. 2014; Brown et al. 2017; Soderstorm et al. 2017; Ferro Overall cannabinoids induce apoptosis to inhibit pro-
et al. 2018; Guerrero-Alba 2019). The interaction of GPCRs liferation, downregulate the vascular endothelial growth
is crucial for maintaining the ECS as it allows the produc- factor (VEGF) pathway affecting angiogenesis and
tion of endocannabinoids from cells through activation of dampen metastasis by inhibiting cell adhesion and migra-
Gq/11 or Gs proteins causing the activation of the cannabi- tion through modifying matrix metalloproteinase 2, 9
noid receptor (Gyombolai et al. 2012). Furthermore, the (MMP2, 9), tissue inhibitor of matrix metalloproteinases
downstream receptor-mediated effects of endocannabinoids 1 (TIMP1), inhibitor of DNA binding 1 (ID1) and induc-
also contribute to the plasticity of the ECS (Lu and Mackie ing ER stress (Velasco et al. 2016). Cancer cells do not
2016). exist in isolation and the tumour microenvironment (TME)
Since the first report of cannabinoids anticancer effects has also been an imperative target for cancer therapy as
(Munson et al. 1975), there have been many studies inves- it can influence the propensity for tumour growth, metas-
tigating phytocannabinoids, endogenous and synthetic tasis and resistance to therapy. The TME is composed of
ones in multiple cancer models. Various signalling path- a host of factors including cancer-associated fibroblasts
ways and changes to internal conditions which favour (CAFs), immune and inflammatory cells, lymph and blood
antitumour activity by cannabinoids have been observed. vasculature, neuroendocrine cells, and extracellular matrix
CBD amongst other cannabinoids has shown to increase (ECM) (Wang et al. 2017). Cancer stem cells (CSCs), a
the de novo synthesis of ceramide through upregulation of subpopulation of stem cells expressing CD44, CD24 and
a plethora of enzymes each catalysing specific biochemical CD133, are tumorigenic with demonstrated resistance to
steps. Ceramide synthases are one of the major group of certain chemotherapeutics and also play a role in metasta-
enzymes involved and reports have revealed an upregula- sis (Yu et al. 2012). Reports have shown the involvement
tion of its six isoforms; CerS 1–6 (Ceramide Synthases of cannabinoids in inhibiting CAFs and CSCs in prostate
1–6) in cancer via cannabinoids (Gomez et al. 2002; Gus- and breast cancer models (Sharma et al. 2014; Moham-
tafsson et al. 2009; Schiffman et al. 2009). However, it madpour et al. 2017; Pietrovito et al. 2020). The aforemen-
is not clear whether specific isoform(s) upregulation cor- tioned effects, however, occur at varying degrees which
relates to the cancer type and whether this is also specific depend on the cancer cell line, the expression levels of
to the type of cannabinoid. An interesting finding from cannabinoid receptors, the type of cannabinoid compound
a report has shown siRNA-induced knockdown of cera- and dosage.
mide synthase 1 (CerS1 isoform) prevented gemcitabine- The aim of this review is to analyse pre-clinical work
induced caspase 9 activation (Senkal et al. 2007; Levy and and outline previous and forthcoming clinical research
Futerman 2010). This could be explored further when con- studies exploring cannabinoids in cancer treatment. Below,
sidering cannabinoids action synergistically with chemo- we outline the research encompassing endogenous and
therapy drugs as ceramide may have the ability to sensitize non-endogenous cannabinoids in which we review the
the cancer cells to chemotherapy agents. Another major proposed mechanisms of action culminated from studies
area of cannabinoids action has been through modulating into various cancers and discuss the need for more clini-
the cell cycle. In a recent report in gastric cancer cells, cal studies to explore the possible therapeutic efficacy of
CBD-induced cell cycle arrest at the G 0–G 1 phase and cannabinoids as a possible treatment for cancer.
retardation in this phase corresponded to a reduction in
CDK2/cyclin E protein levels (Zhang et al. 2019). Apop-
totic changes are prevalent in cannabinoids mechanism of
action which include morphological changes to the cells Method
and cytoplasmic vacuolization, an increase in cleaved cas-
pase-3 and -9 levels and activation of the mitochondrial Research question
apoptotic pathway (Zhang et al. 2019; Schoeman et al.
2020). Endoplasmic reticulum (ER) stress which occurs This narrative review was conducted of available literature
following ceramide synthesis causes downstream apop- reporting the treatment effects of all cannabinoids as either
totic changes and increases in proapoptotic proteins, such a single agent or co-administered with other antitumour
as BAD and Bax, also resulting in an increase in reactive therapies in all cancer types. The aim of this review is

13

2510 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

to analyse and evaluate pre-clinical and clinical research over-activation of the ECS correlates with more aggressive
determining the use of cannabinoids as a potential anti- tumours (Dariš et al. 2019) although other reports have con-
cancer therapy. cluded the contrary (Jung et al. 2013; Tutino et al. 2019).
Cancer is a heterogenous disease and current evidence
Search strategy and inclusion criteria should be interpreted on the basis that different tumour types
have been shown to exhibit various levels of CB receptors
A broad electronic search was conducted on Google Scholar, as well as ECS components. The role of the endogenous
MEDLINE, PubMed and Web of Science articles published endocannabinoids and CB receptors within each cancer sys-
in English between 1st January 1970 and 30th April 2021. tem is specific to the underlying cancer, therefore conflicting
Investigations of cannabinoids use in oncology clinical tri- data can be presented across different cancers. It has also
als were searched using the database, clinicaltrials.gov.uk been reported that some cannabinoids have shown onco-
with the key words; “Cannabinoids and Cancer”, “Cannabis logical effects independent of known CB receptors (Moreno
and Cancer”, “Tetrahydrocannabinol and Cancer”, “CBD et al. 2019; Fogli et al. 2006) implying that there may be
and Cancer” and “THC and Cancer”. The literature search undiscovered cannabinoid receptors implicated in cancer
was performed by two independent researchers (N.M. and pathophysiology.
S.E.) and if any discrepancies were identified then these The characterisation of cannabinoids mechanism of
were resolved by a senior author (M.S.). The reference lists action has been discerned from in vitro and in vivo stud-
of all publications were screened for further relevant ref- ies. Reports of their oncological effects have been observed
erences. The free text search included articles citing both through modulating the hallmarks of cancer (Hanahan and
original research and literature reviews. Inclusion criteria Weinberg 2000, 2011) whilst ∆9-THC trends in inducing
encompassed all reports identifying cannabinoids use in pre- apoptosis and cytotoxicity through CB receptor-dependent
clinical cancer models which includes in vitro, in vivo and pathways; CBD exhibits its activity via orphan GPCRs and
in ovo experimental models, as well as clinical research. non-GPRCs-mediated signalling (Velasco et al. 2012, 2016;
In addition, reports of potential mechanisms of action and Afrin et al. 2020).
signalling pathways involved were also included. Where lit- Studies have reported positive upregulation of cera-
erature reviews were identified, the relevant cited studies mide sphingolipid metabolism, leading to the subsequent
were also identified and included for de novo analysis. arrest of the cell cycle and apoptosis via downstream acti-
vation of signals through extracellular regulated kinase
Data extraction and presentation (ERK) upon cannabinoid action (Calvaruso et al. 2012).
Additional studies have also concluded ∆9-THC’s role in
Two independent researchers (N.M. and S.E.) performed regulating sphingolipid metabolism via serine palmitoyl
the data extraction. Primary research papers reporting half transferase (SPT) (Śledziński et al. 2018) and recent reports
maximal inhibitory concentration ­(IC50) and concentrations have concluded other enzymes of the metabolism of sphin-
where the described effects were observed in pre-clinical golipids to be regulated by cannabinoids (Shaw et al. 2018).
cancer models were included in separate tables for in vitro Dihydroceramides which are metabolic intermediates of
and in vivo investigations. Concentration values are pre- the de novo synthesis pathway have been involved in the
sented as micro-molar concentrations (μM) with their stand- mechanisms of promoting autophagy-mediated cancer cell
ard deviation (S.D.), standard error (S.E), or range except death (Hernández-Tiedra et al. 2016). ∆9-THC increases the
when unreported in the original study. dihydroceramide:ceramide ratio in the endoplasmic reticu-
lum of glioma cells causing pre-apoptotic changes (Hernán-
dez-Tiedra et al. 2016).
Results Activation of the CB receptors causes the induction of
the ER stress-related response and promotes the upregu-
Mechanism of action and signalling pathways lation of the transcription factor p8 (Nupr1), this further
simulates the following transcription factors, activating
The ECS is a complex system composed of different ligands, transcription factor 4 (ATF-4), C/EBP-homologous protein
receptors and ion channels resulting in many signalling path- (CHOP) and pseudokinase tribbles-homologue 3 (TRIB3)
ways subject to modulation from external cannabinoids as (Velasco et al. 2016). The inhibitory interaction of TRIB3
shown in Fig. 3. It is therefore no surprise that there remains and a pro-survival kinase Akt is favoured which leads to
ambiguity in its precise role within cancer pathophysiol- the inhibition of the mammalian target of rapamycin tar-
ogy (Wu 2019). Many pre-clinical studies and histologi- get 1 (mTORC1) favouring cell autophagy. Autophagy is
cal analysis of patient tumours, suggest that an upregula- upstream of apoptosis in cannabinoid-induced cell death
tion in the ­CB1 and ­CB2 receptors, endogenous ligands and as shown in studies where blocking autophagy prevented

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2511

Fig. 3  Overview of the downstream activation and crosstalk of sig- of transcription factors CREB and NF-κß. Gα12/13 subunit activates
nalling pathways of cannabinoid and non-cannabinoid receptors. the RhoA/ROCK pathway which regulates PLC, actin cytoskeleton
Activation of the cannabinoid receptors C
­ B1 and ­CB2 (red arrows) via and p38/ATF2 activity. ATF2/p38 inhibits antiapoptotic proteins and
cannabinoids stimulate ERK1/2 signalling which activates p27 and enhances the interaction between Beclin-1 and Vps34 which is also
p21 causing a decrease in cyclins D and E, cdc2 and cdk2 through an inhibited by BCL-2 further enhancing ROS production by activation
increase in pRb, leading to cell cycle arrest. Inhibition of the P13K of the intrinsic apoptotic pathway (Velasco et  al. 2012, 2016). Cre-
pathway leads to a decrease in Akt which inhibits cell proliferation. ated with BioRender.com. TRPV1,2 transient receptor potential cation
Biosynthesis of ceramide takes place at the endoplasmic reticu- channel subfamily V member 1,2, TRPM8 transient receptor poten-
lum through a series of biochemical steps involving many enzymes tial cation channel subfamily members (melastatin) 8, GPR55 orphan
which help to convert dihydroceramides (DhCers) into ceramide. G-protein coupled receptor 55, ROS reactive oxygen species, ER
An increase in ceramide level in turn increases the stress protein p8/ endoplasmic reticulum, p8 protein p8 (Nuclear Protein 1, NUPR1),
Nupr1 and TRIB3 which activates upregulation of ATF4 and CHOP CHOP CCAAT/-enhancer-binding protein homologous protein, ATF4
proteins. A decrease in Akt leads to a downregulation in mTORC1 activating transcription factor 4, TRIB3 tribbles pseudokinase 3, Akt
signalling causing autophagy. Activation of TRPM8 (purple arrows) protein kinase B, mTORC1 mammalian target of rapamycin C1, p21
leads to an increase in ROS production which also induces ER stress. cyclin-dependent kinase inhibitor 1, p27 cyclin-dependent kinase
Stimulation of non-cannabinoid receptor GPR55 (blue arrows) inhibitor 1B, CDK cyclin-dependent kinase, pRb retinoblastoma pro-
through LPI via the subunit Gαq subunit stimulates the production tein; Nuclear factor-kappaß (NF-κß), LPI Lysophosphatidylinositol,
of PLC to release C ­ a2+ and DAG which leads to the activation of DAG diacylglycerol, BAD BCL2-associated agonist of cell death,
MAPK/ERK signalling. This causes gene transcription by activation ROCK rho-associated protein kinase, PLC phospholipase C

cannabinoid-induced apoptosis (Salazar et al. 2009; Vara phosphorylation. The involvement of the MAPK pathway in
et al. 2011). An increase in ceramide level has also been cancer is complex as its response to different stimuli can pro-
associated with ER stress in cannabinoid-induced apopto- duce conflicting outcomes. Brief activation of the ERK cas-
sis in tumour cells (Salazar et al. 2009). In addition, other cade leads to cell survival and proliferation, whilst chronic
environmental stimuli may also promote ER stress which activation is pro-apoptotic (Howlett 2005; Javid et al. 2016).
can lead to the activation of the apoptotic pathway. These CBD has been demonstrated to affect a diverse set of cel-
include a decrease in intracellular ­Ca2+, viral infections, lular targets. First, it inhibits FAAH and FABP (Fatty Acid-
chemotherapy agents and oxidative stress (Schröder and Binding Protein). FAAH is responsible for the breakdown
Kaufman 2005; Śledziński et al. 2018). of anandamide, whilst FABP aids the transport of ananda-
The mitogen-activated protein kinase (MAPK) pathway mide to from extracellular spaces to intracellular targets,
has also been reported in numerous studies to be involved in such FAAH or nuclear PPAR. Both effects result in indi-
cannabinoid response. Serine/threonine protein kinases are rect activation of ­CB1 and ­CB2 receptors through increased
mainly involved in this pathway and act to convert extracel- extracellular concentration of anandamide (Lee et al. 2007;
lular stress into different cellular responses including, cell Pistis and O’Sullivan 2017). Second, CBD activates the
cycle arrest, apoptotic cell death and cytokine production via 5-HT1A serotonin receptor, PPARγ and the transient receptor

13

2512 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

potential cation subfamily channels; TRPV1, TRPV2 and effects (Javid et al. 2016). In support of this, MIA PaCa-2
TRPA1. CBD is also an antagonist of GPR55, transient cells treated with ∆9-THC caused an increase in p8 mRNA
receptor potential cation channel subfamily M member 8 levels in vitro. Knockdown of the p8 gene prevented apop-
(TRPM8) and T-type C ­ a2+ channels. Finally, CBD has also tosis by ∆9-THC in these cells (Carracedo et al. 2006). In
been reported to inhibit adenosine reuptake via multiple pro- addition to p8 and TRIB3 stress-related genes, further ER
posed mechanisms (Lee et al. 2007; Ibeas Bih et al. 2015; stress-inducing genes have been identified and associated
McPartland 2018). Antagonization of GPR55 via CBD has with apoptosis, such as CHOP and ATF-4, where mRNA
been reported to reduce proliferation of pancreatic tumour levels were elevated following ∆9-THC treatment (Ohoko
cells and its activation has been reported to lead to metasta- et al. 2005).
sis in triple-negative breast cancer when stimulated by LPI Cannabinoids in combination with chemotherapy agents
(Zhao and Abood 2013; Ferro et al. 2018; Andradas et al. have shown promising results in pancreatic cancer cell
2016; Falasca and Ferro et al. 2018; Pellati et al. 2018). line studies. One study reported the increase in gemcit-
Below we summarise pre-clinical studies which include both abine activity by synergism with C ­ B1 and C ­ B2 receptor
in vitro and in vivo experimental results in various cancer ligands by a NF-κß-dependent mechanism (Donadelli et al.
models with summaries included in Tables 1 and 2. 2011). This synergistic inhibition of tumour growth was
most marked in gemcitabine-resistant cell lines (Donadelli
Pancreatic adenocarcinoma et al. 2011). Gemcitabine increased cannabinoid-induced
autophagy through a ROS-mediated mechanism and can-
In vitro nabinoids enhanced the apoptotic effect of gemcitabine
(Donadelli et al. 2011). Ferro and co-workers reported the
A study analysing the in vitro effects of synthetic receptor anticancer effects of blocking the putative GPR55 receptor
agonists of ­CB1 and ­CB2, WIN55, 212–2, ACEA and JWH- in pancreatic cancer cells via CBD. A cross between GPR55
015 found they each induced a high level of apoptosis of homozygous knockout and mice which do not harbour the
MIA PaCa-2 cells (Console-Bram et al. 2014). The same TP53 mutation did not reveal any statistical difference in
study showed that a ­CB1 antagonist, N-(piperidin-1-1yl)- survival. Investigators analysed the possible role that p53
5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyra- may play in regulating GPR55. In pancreatic ductal adeno-
zole-3-carboxamide (AM251), induced apoptosis and tran- carcinoma cell lines, they report a negative regulation of
scriptional changes of the genes involved in the janus kinase/ GPR55 with TP53 status, where overexpression of wild-type
signal transducers, activators of transcription signalling p53 in the AsPC-1 cell line (harbouring a TP53 mutation)
network (JAK/STAT) and MAPK signalling pathways in caused a reduction in GPR55 expression. Further analysis
the MIA PaCa-2 pancreatic cancer cell line through activa- revealed the negative regulation was through modulation of
tion independent of the C ­ B1 receptor-independent pathways the micro-RNA miR34b-3p. Pharmacological inhibition of
(Fogli et al. 2006). AM251, which expresses molecular simi- GPR55 via CBD in various pancreatic cell lines, inhibited
larities with cyclo-oxygenase-2 (COX-2) inhibitor celecoxib, anchorage-dependent growth. Treatment with CID16020046
demonstrated a synergistic interaction with 5-fluorouracil (CID), an antagonist of GPR55, revealed similar results in
(5-FU) increasing their anti-cancer activity when adminis- AsPC-1 and HPFA-II and cell cycle arrest at the G ­ 1–S phase
tered in appropriate ratios as demonstrated by a combination in PANC-1 and HPFA-II in a dose-dependent manner. Cyc-
index of 0.52 (Fogli et al. 2006). lin D1, activation of tumour-suppressor protein (RB) was
Dando et  al. report arachidonoyl cyclopropylamide also reduced in CBD treatment and an inhibition of MEK/
(ACPA) and GW, C ­ B1 and C
­ B2 selective agonists, respec- ERK and ERK-dependent pathways was also observed. The
tively, inhibited proliferation and invasion of PANC-1 cells study demonstrates a novel pathway by which gemcitabine
(Dando et al. 2013). Activation of the receptors via cannabi- may be potentiating anticancer effects through inhibiting
noid receptor agonists showed an elevation in 5′ adenosine GPR55 via CBD antagonization (Ferro et al. 2018).
monophosphate-activated protein kinase (APMK) activation
via a ROS-dependent increase of AMP/ATP ratio promot- In vivo
ing cell autophagy and subsequent inhibition of cell growth
(Dando et al. 2013; Brandi et al. 2013). ∆9-THC has been Administration of ∆9-THC at 15 mg/kg/day into a xenograft
shown to induce a reduction in cell viability via apoptosis model of MIA PaCa-2 pancreatic tumour growth showed a
in a dose-dependent manner, specifically via the de novo reduction in the tumour burden (Carracedo et al. 2006). A
synthesized ceramide up-regulation of the p8 and ATF-4, synthetic cannabinoid, WIN55, 212–2 was found to increase
TRIB3 ER stress genes in MIA PaCa-2 and PANC-1 cells the expression of downstream targets of the ER stress-
(Carracedo et al. 2006). The p8 protein has been shown to related pathway involved in apoptosis in pancreatic cancer
increase with ceramide treatment and potentiates anticancer in comparison to healthy controls, demonstrating apoptotic

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2513

Table 1  Pre-clinical in vitro studies encompassing various cannabinoids in cancer models

Cancer Cell line Cannabinoid (s) Inhibitory con- In vitro actions References
centrations

PDAC MIA PaCa2, PANC-1, Δ9-THC, SR141716, 0–5 µM Apoptosis via C­ B2 and Carracedo et al. (2006)
Capan-2, BxPC-3 SR144528 p8, ATF4 and TRIB3
and caspase-3 activa-
tion
AsPC-I, HPFA-II, CBD 0–10 µM Antiproliferative effects Ferro et al. (2018)
PANC-I, BxPC-3 via GPR55
BRAIN Human Glioblastoma, Δ9-THC, AEA, 100 nM–10 µM Accelerated cell prolif- McAllister et al. (2011)
U373-MG HU-210, WIN eration via EGFR and
55,212–2 MMP
Human Glioblastoma, CBD, SR141716, 5–40 µM Antiproliferative effects Singer et al. (2015)
U878MG, U373MG SR144528 correlated to induc-
tion of apoptosis
Human Glioblastoma Δ9-THC, WIN 0.1 nM-2 µM Antiproliferative effects Ellert-Miklaszewska et al. (2021)
multiforme, 55,212–2 and increase of
SF126, U87-MG, apoptosis
U251, SF188,
U373-MG, Human
GBM cultures
Rat C6 glioma cells WIN 55,212–2, WIN 1–30 µM Cell viability reduc- Matas et al. (2007)
55,212–3 tion, morphological
changes to cells
Rat C6 glioma cells Δ9-THC, CBD, CBD- 0–50 µM CBD most potent. Ligresti et al. (2006)
A, CBG, CBC, CBD, CBG and
AM251, JWH-133, CBD-A activated
AM630, SR141716A, TRPV1
SR144528
Murine Neuroblastoma, AEA 1–5 µM Apoptosis and decrease Marcu et al. (2010)
N18TG2 in cleavage of
PARP-1
Human Astrocytoma, Δ9-THC, SR141716 1–10 µM Apoptosis and Salazar et al. (2009)
U87MG autophagy via ER
stress
Human Glioma cancer, Δ9-THC, CBD 0.1–10 µM Inhibition of cell prolif- Qamri et al. (2009)
U251, SF126, U87 eration, apoptosis
Human Glioblastoma, CBD 0–20 µM Decrease in cell inva- Solinas et al. (2013)
U87-MG, T98G sion via MMP-9,
TIMP-1, TIMP-4,
u-PA, PAI-1, VEGF
Human Glioma, T98G, CBD, Δ9-THC (Pure 0–20 µM Increase in radiosensi- Scott et al. (2014)
U87MG, Murine and BDS) tivity associated with
Glioma, GL261 increase in apoptosis
and autophagy
Human Glioblastoma, CBD 0–5 µM Activation of p-p38 Singer et al. (2015)
U251, 3832, 387 pathway, downregula-
Primary glioma stem tion of key stem cell
cells (GSC) lines regulators; Sox2, Id1
and p-STAT3
Human Neuroblastoma, Δ9-THC, CBD 0–50 µg/mL Cell viability reduction Fisher et al. (2016)
SK-N-SH, IMR-32, and apoptosis
NUB-6 and LAN-1
Human Glioblastoma, Δ9-THC, CBD 0–5 µM Very significant López-Valero et al. (2018)
U87MG, Glioblas- reduction of the GIC
toma patient derived population, induction
stem cell like cells of apoptosis
(GIC)

13

2514 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Table 1  (continued)
Cancer Cell line Cannabinoid (s) Inhibitory con- In vitro actions References
centrations

Human Glioma cells, Δ9-THC, CBD, 0.9–3 µmol/L Reduction in cell Torres et al. (2011)
U87MG (U87), A172, SR141716, SR144528 viability and induc-
SW1783, U373MG tion of apoptosis and
(U373), T98G (T98), autophagy
SW1088, and LN405
Human Glioma Δ9-THC, SR141716, 0–2.5 µM Sensitive and resistance Lorente et al. (2011)
cells, GOS3, U87 SR144528 cell line determined
MG (U87), A172, via reduction in cell
SW1783, U118 MG viability
(U118), U373 MG Increased Mdk
(U373), T98G (T98), expression confers
SW1088, CCF- resistance of glioma
STTG1 (CCF) and cells to Δ9-THC
LN405 pro-autophagic and
antitumoural action
BREAST Human Breast adeno- Δ9-THC 0- 20 µM No decrease observed McKallip et al. (2005)
carcinoma, MDA- in cell viability for
MB-231, MCF-7, all cell lines and low
murine mammary level of cannabinoid
carcinoma, 4T1 receptors
Human Breast adeno- Δ9-THC 3 and 5 µM Antiproliferative effects Caffarel et al. (2008)
carcinoma, EVSA-T rely on JunD activity
and participation
of p8
Human Breast adeno- Met-F-AEA, 2.5–20 µM Reduction in cell Santoro et al. (2009)
carcinoma, MDA- SR141716A viability in dose-
MB-231, T47D, dependent manner
murine breast cancer, and decrease of tyros-
TSAE-1 ine phosphorylation
of FAK and Src
Human Breast adeno- SR141716 0.1–1 µM Cell cycle arrest, Sarnataro et al. (2005)
carcinoma, MDA- decreased expression
MB-231, T47D, of cyclins D and E
MCF-7 Antiproliferative effect
requires lipid raft/
caveolae integrity to
occur
Human Breast adeno- Δ9-THC, SR141716, 1–12 µmol/L Reduction in cell pro- Caffarel et al. (2006)
carcinoma, EVSA-T, SR144528 liferation via the C
­ B2
MDA-MB-231, receptor, cell cycle
MDA-MB-468, arrest, induction of
SKBR3, MCF-7, apoptosis
T-47D
Human Breast adeno- Δ9-THC, CBD, CBG, 0–50 µM CBD apoptotic effect Ligresti et al. (2006)
carcinoma, MDA- CBC, AM251, via activation of the
MB-231, MCF-7 JWH-133, AM630, ­CB2 receptor and
SR141716A, TRPV1
SR144528
Human Breast WIN 55,212–2, 0–10 µM All cell lines express Hirao-Suzuki et al. (2020)
adenocarcinoma, JWH-133, AM251, both ­CB1 and ­CB2
MDA-MB-231, SR144528 receptors
MDA-MB-231-Luc, Inhibition of cell prolif-
MDA-MB-468 eration and migration
via COX-2 signalling
and apoptosis

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2515

Table 1  (continued)
Cancer Cell line Cannabinoid (s) Inhibitory con- In vitro actions References
centrations

Human Breast adeno- CBD 1.5 µM Inhibition of cell prolif- Nallathambi et al. (2018)
carcinoma, MDA- eration and invasion
MB231 through modulation
Murine mammary of ERK and ROS,
carcinoma, 4T1.2 downregulation of
Id-1 expression and
upregulation of Id-2
Human Breast adeno- CBD, AM251, AM630, 0–10 µM Decrease in cell Lin et al. (2019)
carcinoma, MDA- Capazepine viability, autophagy
MB-231, SKBR3, and apoptosis via ER
MCF-7, ZR-75–1 stress, inhibition of
Akt, mTOR signal-
ling
Human Breast adeno- CBD 3–15 µM Cell proliferation Grimaldi et al. (2006)
carcinoma, SUM159, decreased, inhibi-
MDA-MB-231-SCP2, tion of the epidermal
MVT-1, murine growth factor (EGF)-
mammary carcinoma, induced cell prolifera-
4T1.2 tion, migration, and
invasion
Human Breast adeno- JWH-015, SR141716, 0–10 µM Decrease in cell McAllister et al. (2011)
carcinoma, MCF-7, SR144528 viability, apoptosis
Murine mammary and reduced ERK1/2
carcinoma, 4T1 levels, effects were
dependent in a
non-Gαi -mediated,
calcium-dependency
Human Breast adeno- AEA, AM251 0–0.5 µM Reduction in ­CD44+/ Mohammadpour et al. (2017)
carcinoma, MDA- CD24−/low/ESA+ can-
MB-231 cer stem cell (CSC)
invasiveness
Human Breast adeno- CBDA, GSK0660, 1–50 µM CBDA inhibits Gazzerro et al. (2010)
carcinoma, MDA- GW501516, ST-247 PPARβ/δ mediated
MB-231 transcriptional activa-
tion and AP-1
Human Breast Cancer, CBD 1–50 µM Co-administration of Fraguas-Sánchez et al. (2020)
MDA-MB-231, ­CBDsol and paclitaxel
MCF-7 or docetaxel showed a
synergistic effect
GASTROIN- Human Colon cancer, SR141716 0.1–20 µM Reduction in cell prolif- Aviello et al. (2012)
TESTINAL DLD-1, CaCo-2, eration and cell cycle
SW620 arrest
Human Colon adeno- CBG, AM251, AM630, 1–50 µM Apoptosis, increase Borelli et al. (2014)
carcinoma, Caco-2, AMTB (TRPM8 in ROS production
HCT 116 antagonist), CBD, and upregulation of
CBDV, CBC CHOP expression
Human Colorectal CBD BS (botanical 0.3–5 µM Antiproliferative Romano et al. (2014)
carcinoma, DLD-1, substance), CBD, effects, no effect on
HCT116 AM630, SR141716, cell viability
SR144528
Human Colorectal CBD 0.1–10 µM PhysO2 cells signifi- Macpherson et al. 2014
cancer, Caco-2 cantly more sensitive
to antiproliferative
effects of CBD than
­AtmosO2
Human Colon cancer, SR141716 0.1–10 µM Inhibition of cell Gazzerro et al. (2010)
DLD-1 proliferation at higher
concentrations

13

2516 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Table 1  (continued)
Cancer Cell line Cannabinoid (s) Inhibitory con- In vitro actions References
centrations

Human Colon cancer, CBD, WIN 55,212–2 0–15 µM Induction of cellular De Petrocellis et al. (2013)
SW480 ACPP, DUSP1,
DUSP10, cleavage of
PARP, Apoptosis
Human colorectal CBD, SR141716, 0.01–10 µM Reduction in cell Aviello et al. (2012)
carcinoma, Caco-2, AM251, SR144528, viability and expres-
HCT116 AM630, GW9662, sion of phospho-Akt
Capsazepine
Human Colon cancer, SR141716 0–20 µM Inhibition of cell Proto et al. (2017)
HCT116, SW48 growth, increase of
caspase-3 and cleav-
age of PARP
Human Colon cancer, SR141716 0.1–20 µM Reduction in colon Fiore et al. (2018)
HCT116 and DLD-1 CSCs proliferation
Organoids and tumour differenti-
ated cells
Human Hepatocellular Δ9-THC, JWH-015, 1–8 µM Reduction in cell Vara et al. (2011)
carcinoma, HepG2, SR141716, SR144528 viability occurred
HuH-7 via ­CB2 receptor and
autophagy
Human Hepatocellular WIN 55, 212–2, 0, 5 or 10 µM CB2 mediated down- Xu et al. (2016)
carcinoma, BEL7402 AM630, JWH-015 regulation of phos-
phorylated ERK1/2
Human Gastric adeno- AEA, Meth-AEA (R- 0.5–5 µM Concentration-depend- Ortega et al. (2016)
carcinoma, AGS ( +)), CP 55,940 ent effects in cell
morphology and loss
changes
Gastric cancer, WIN 55,212–2 5 µM Inhibition of cell Xian et al. (2016)
SGC7901, AGS cells migration, invasion
and EMT
PROSTATE Human Prostate Can- Δ9-THC, AM251, 0.5–10 µM Reduction in cell via- Ruiz et al. (1999)
cer, PC-3 WIN55,212–2 bility and apoptosis
Human Prostate Can- AEA 1–10 µM Decrease of EGFR Mimeault et al. (2003)
cer, LNCaP, DU145, levels in all cell lines
PC-3 via ­CB1 leading to an
inhibition of EGF-
stimulated growth
Human Prostate Can- MET-AEA, HU-210, 0.05–5 µM Involvement of PI3K Sanchez et al. (2003)
cer, LNCaP JWH-015, SR141716, pathway and modi-
SR144528 fication of androgen
receptor expression
Human Prostate carci- WIN-55,212–2, 1–30 µM Induction in p27/KIP1 Sarfaraz et al. (2006)
noma, LNCaP, PC3 SR141716, SR144528 and downregulation
in cyclin and CDK
levels. Upregula-
tion of ERK1/2 and
inhibition of PI3k/Akt
pathways
Human Prostate cancer, CBC, CBD, CBG, 1–10 µM Decrease in cell viabil- De Petrocellis et al. (2013)
LNCaP, 22RV1, CBN, CBDA, CBGA, ity and activation of
DU-145, PC-3 CBDV, CBGV, THC, the intrinsic apoptotic
THCA, THCV, pathway
THCVA
Human Prostate adeno- AEA, 2-AG, Methanan- 2.5, 5 and Cell cycle arrest and Orellana-Serradell et al. (2015)
carcinoma, PC-3, Pri- damide (AM-356), 10 µM induction of apoptosis
mary cultures; BPH, SR141716
LGG, HGG, PrC

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2517

Table 1  (continued)
Cancer Cell line Cannabinoid (s) Inhibitory con- In vitro actions References
centrations

Human Prostate cancer, WIN 55,212–2, 0- 10 µM WIN prevents neuroen- Morell et al. (2016)
LNCaP, PC-3 SR141716, SR144528 docrine differentia-
tion by downregula-
tion of PI3K/Akt/
mTOR signalling
LUNG Human Lung carci- Δ9-THC, AEA, 0.1–10 µM Increase in cell prolif- Hart et al. (2004)
noma, NCI-H292 HU-210, WIN eration dependent on
55,212–2 EGFR and MMP
Human NSCLC, Δ9-THC 1–20 µM Apoptosis and inhibi- Preet et al. (2008)
EGF-induced, A549, tion of proliferation
SW-1573 via EGF-induced
phosphorylation of
ERK1/2, JNK1/1 and
Akt
Human Lung adenocar- CBD, AM251, AM630, 0–10 µM Decrease in the Ramer et al. (2013)
cinoma, A549, H460 Capsazepine, NS-398 viability of the cells
Primary non-small-cell and upregulation of
lung carcinoma cells COX-2 and PPAR-γ
expression, ­PGE2,
­PGD2, and 15d-PGJ2
Human NSCLC; A549 JWH-015, SR144528 0–5 µM Decreased migratory Ravi et al. (2016)
(epithelial), CALU1 and invasive abilities
(mesenchymal) via reduction in FAK,
VCAM1, MMP2
Human Lung cancer; WIN 55,212–2 5–20 µM Decline in cell viability Müller et al. (2017)
A549 due to apoptosis
BLOOD Human Leukaemia; Δ9-THC 0–100 µM Cell death via activa- Powles et al. (2005)
CEM (acute lympho- tion of MAPK
blastic), HEL-92
(erythroblastic),
HL60 (acute promye-
locytic), MOLT-4
(acute lymphoblastic)
and PBMCs
Human Leukaemia, CBD, SR141716A, 0- 10 µM Significant reduction McKallip et al. (2006)
Jurkat, MOLT-4 and SR144528, CAPZ in cell viability and
murine lymphoma, apoptosis through the
EL-4 ­CB2 receptor
Human Myeloma, WIN 55,212–2 5–50 µM Apoptosis Barbado et al. (2017)
U266, U266-LR7,
RPMI, RPMI-LR5,
MM1.S, MM1.R
Human T acute lymph- CBD 0.01–10 µM Reduction in cell Kalenderoglu et al. (2017)
oblastic leukaemia, viability and cell
Jurkat cycle changes
SKIN Melanoma, A375, Δ9-THC, WIN- 0.5–1 µM Reduction in cell Blázquez et al. (2006)
MelJuso and murine 55,212–2, SR141716, viability, angiogen-
melanoma, B16 SR144528 esis, and metastasis
via CB receptors
Human Melanoma, Δ9-THC, CBD 0–10 µM Decrease in cell Armstrong et al. (2015)
CHL-1, A375, SK- viability
MEL-28BD
Murine squamous, AEA, AMG9810, 2.5- 40 µM Reduction in cell Soliman et al. (2016)
non-melanoma skin AM251, AM630 viability and apopto-
cancer; JWF2 sis via ER stress

13

2518 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Table 1  (continued)
Cancer Cell line Cannabinoid (s) Inhibitory con- In vitro actions References
centrations

Human renal carci- WIN 55,212–2, JWH- 0–25 µM Reduction in cell prolif- Khan et al. (2018)
noma, 786-O, SMKT- 133, SR141716A, eration and induction
R2, SMKT-R3, Caki- AM630 of apoptosis
2, RCC-6, 769-P,
Caki-1, ACHN
Human ovarian cancer, CBD 10–50 µM Inhibition of cell prolif- Fraguas-Sánchez et al. (2020)
SKOV-3 eration
Rat Adrenal Gland; DHA-DA, AEA 0–80 µM NOS activation, Akimov et al. (2021)
PC12 cells increased ­Ca2+
signalling leading to
apoptosis via GPR55
activation
MET-AEA (methanandamide, non-hydrolyzable analogue of AEA), AEA (anandamide), DHA-DA (N-docosahexaenoyl dopamine), AM251 ­(CB1
antagonist), HU-210 ­(CB1 agonist), JWH-015 ­(CB2 agonist), JWH-133 ­(CB2 agonist), WIN 55,212–2 ­(CB1 agonist), SR141716 ­(CB1 inverse
agonist), SR144528 ­(CB2 inverse agonist), N-oleoylethanolamine (NOE) (acidic ceramidase inhibitor), LY294002 (PI3K inhibitor), PD98059
(ERK inhibitor), PBMCs (peripheral blood mononuclear cells), AM630 ­(CB2 antagonist), GW9662 (PPAR-γ antagonist), GSK066 (PPARβ/δ
antagonist), GSK501516 (PPARδ antagonist), AMG9810 (TRPV1 antagonist)

selectivity effect of cannabinoids to cancer cells (Carracedo (Ladin et al. 2016; Millar et al. 2018). In addition, their low
et al. 2006). aqueous solubility and poor stability (sensitivity to light,
The role of other cannabinoid receptors including GPR55 temperature and oxidation) make developing effective for-
has been speculated to be involved in regulating many cancer mulations a problem (Fraguas-Sánchez et al. 2020). The
types including pancreatic cancer. A study by Ferro et al. route of cannabinoid administration remains uncertain as the
revealed genetic ablation of GPR55 in a KPC mouse model oral bioavailability is very low and is subject to a significant
of pancreatic ductal adenocarcinoma (PDAC) significantly first-pass effect in the body (Millar et al. 2018). Therefore,
prolonged survival and KPC mice treated with CBD and alternative routes of administration are required, although
gemcitabine as a combination treatment survived three times it has been reported that intratumour (IT) administration of
longer than control or gemcitabine single treatment (Ferro low doses of cannabinoids has improved efficacy of the drug
et al. 2018). Immunohistochemistry analysis of the tumours as well as survival (Ngwa et al. 2017, 2018; Yasmin-Karim
revealed CBD inhibition of GPR55 affected signalling path- et al. 2018). Successful administration has been reported
ways involved in gemcitabine resistance. CBD was able to when cannabinoids were combined with radiotherapy in
counteract the effect of gemcitabine on ERK phosphoryla- treating pancreatic cancer (Yasmin-Karim et al. 2018).
tion and downregulated the enzyme’s ribonucleotide reduc- A recent study has reported the use of CBD and ∆9-THC
tases 1 and 2 (RRM1/2), a marker for gemcitabine resistance inhibited proliferation of pancreatic cancer and stellate
(Ferro et al. 2018). In line with this, gemcitabine-treated cells. PDL-1 (a key target for immune checkpoint block-
tumours from KPC mice expressed high levels of RRM1 ade) expression was reduced in mice tumours via the PAK-
and reduced levels were observed in KPCG mice upon treat- 1-dependent pathway (p-21 activated kinase 1) activated by
ment with CBD (Ferro et al. 2018). The counteractions of Kirsten rat sarcoma (KRAS). Their findings suggest a nov-
CBD on gemcitabine only occurred when both drugs were elty for the cannabinoids in which KRAS, an undruggable
administered together, suggesting synergistic effects of CBD target expressed in many lethal cancers can be supressed
on gemcitabine’s mode of action in vivo (Ferro et al. 2018). through targeting PAK1 and the suppression of PDL-1 could
Donadelli et al. also reported an enhanced effect with com- be enhanced for immune checkpoint blockade therapy in
bination therapy. ­CB1 antagonist, Rimonabant, combined pancreatic cancers (Yang et al. 2020).
with gemcitabine reduced tumour growth when compared
to single therapy in vivo (Donadelli et al. 2011). An increase Brain cancer
in ROS and autophagy pathways were observed which may
explain the synergistic effects they observed (Donadelli et al. In vitro
2011).
The translation of preclinical data to the clinic remains to Investigation into human glioma cell lines U87 and U373
be somewhat unclear as many factors in cannabinoids phar- administered with CBD led to a decrease in mitochondrial
macokinetics, bioactivity and efficacy remain undetermined oxidative metabolism, cell viability and antiproliferative

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2519

Table 2  Pre-clinical in vivo studies encompassing various cannabinoids in cancer models

In vivo model Cannabinoid (s) Observed changes References

PDAC Immunodeficient nude mice and Δ9-THC, JWH-133, WIN- Reduction in growth of tumour Carracedo et al.
human PDAC cell lines 55,212–2 and induction of apoptosis via (2006)
MIA PaCa-2, PANC-1, Capan-2, activation of the p8-ATF-4TRB3
BxPC-3 proapoptotic pathway
KPC PDAC mouse model (muta- CBD KPC mice treated with combination Ferro et al. (2018)
tions in KRAS, PanIN, TP53) of CBD and GEM survived longer
mice with homozygous deletion than vehicle or GEM alone
of GPR55 created KPCG strain
BRAIN Athymic female CD-1 nude mice CBD, SR141716, SR144528 CBD significantly inhibited the Massi et al. (2004)
and human glioma U87, U373 growth of tumours
cell lines
Nude mice and human astrocy- Δ9-THC Autophagy and apoptosis Salazar et al. (2009)
toma U87MG
Female C57BL/6 and murine CBD, Δ9-THC (Pure and Triple combination of CBD, Δ9- Scott et al. (2004)
glioma GL261 BDS) THC and irradiation significantly
reduced tumour growth
Female Athymic (nu/nu) mice and CBD Increase in the survival rate of mice Singer et al. (2015)
human glioblastoma U251 and bearing GSC xenografts
primary glioma stem cells 3832,
387
Immunodeficient (NOD/SCID) Δ9-THC, CBD Reduction in the growth of tumours Fisher et al. (2016)
mice and human neuroblastoma and increase in activated caspase-3
SK-N-SH cell lines
Nude mice and human glioblas- Δ9-THC, CBD Reduction in tumour growth López-Valero et al.
toma U87MG cell line (2018)
Nude mice and U87, T98 cell lines Δ9-THC, CBD Reduction in tumour growth more Torres et al. (2011)
significant when combined with
temozolomide (TMZ)
Nude mice and U87, T98 cell lines Δ9-THC, SR141716, Silencing of Mdk sensitizes cannabi- Lorente et al. (2011)
SR144528 noid resistant tumours to Δ9-THC
anticancer action, although no
effect on tumour growth
BREAST Female adult BALB/c and SCID- Δ9-THC Increase in tumour growth and McKallip et al. (2005)
NOD mice and murine mam- metastasis due to inhibition of spe-
mary carcinoma 4T1 cific antitumor immune response
Male athymic mice and human Δ9-THC, CBD, CBG, CBC, CBD inhibited tumour growth and Ligresti et al. (2006)
breast adenocarcinoma, SR141716A, SR144528 reduced lung metastasis
MDA-MB-231, MCF-7
Male C57BL/6 N mice and murine Met-F-AEA, SR141716A Reduction of metastatic nodes in Santoro et al. (2009)
mammary carcinoma, TSAE-1 mice
Female adult CD1 nude mice and SR141716 Reduction in tumour volume Sarnataro et al. (2005)
human breast adenocarcinoma,
MDA-MB-231
Severe combined immunodeficient WIN 55,212–2, JWH-133 40–50% reduction in tumour burden, Hirao-Suzuki et al.
CB-17 mice and human breast 65–80% reduction in lung metas- (2020)
adenocarcinoma, MDA-MB-231/ tases
luc/486
Female BALB/cfC3H mice and CBD Significant reduction of primary Shrivastava et al.
murine mammary carcinoma tumour mass and size and lung (2011)
4T1 metastatic foci
Female BALB/c and FVB mice CBD Reduction in the growth of tumours Grimaldi et al. (2006)
and murine mammary carcinoma and vascularity and inhibition of
4T1 lung metastasis
Female BALB/cfC3H mice and JWH-015 Significant reduction in primary McAllister et al.
murine mammary carcinoma tumour burden and metastasis (2011)
4T1

13

2520 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Table 2  (continued)
In vivo model Cannabinoid (s) Observed changes References

COLO- Male C57BL/6 N mice, chemically SR141716 Inhibition of tumour growth and Santoro et al. (2009)
RECTAL induced colon cancer reduction in ACF induced colon
cancer
Male athymic (nu/nu) mice and Δ9-THC, JWH-015, Reduction of tumour growth and Vara et al. (2011)
human hepatocellular carcinoma, SR-141716, SR144258 ascites
HepG2 and HuH-7
Male ICR mice and human colo- CBD Reduction in ACF, polyps and Aviello et al. (2012)
rectal carcinoma, Caco-2 and tumour formation in AOM model
HCT116
Male ICR and athymic nude CBG, AM-251, AM-630 CBG inhibited colon cancer growth Borelli et al. (2014)
female mice and human colon
adenocarcinoma, Caco-2 and
HCT 116
Male ICR and athymic nude mice CBD, CBD BS Reduction of AOM induced preneo- Romano et al. (2014)
and human colorectal carcinoma, plastic lesions and overall tumour
DLD-1 and HCT 116 growth
Female SCID mice and human SR141716 Significant reduction in tumour Proto et al. (2017)
colon cancer, HCT116 and growth
SW48 Destabilization of the nuclear locali-
zation of β-Catenin
PROS- Male MR-1 nude mice and pros- CBC, CBD, CBG, CBN, Reduction of the LNCaP xenograft De Petrocellis et al.
TATE tate carcinoma, LNCaP, 22RV1, CBDA, CBGA, CBDV, growth (2013)
DU-145 and PC-3 CBGV, THC, THCA,
THCV, THCVA BDS
Male athymic nude-FOxn1 (nu/nu) WIN 55,212–2, SR-141716, Reduction in rate of growth and size Morell et al. (2016)
mice and human prostate cancer SR-144528 of tumours
LNCaP
LUNG Male C57BL/6 (H-2b) and Δ9-THC, SR141716, Increase in the growth of the 3LL Zhu et al. (2000)
BALB/c mice (H-2d) and SR144528 and L1C2 tumors in vivo
murine Lewis/alveolar cell lung
carcinoma
SCID CB-17 mice and human Δ9-THC, WIN 55,212–2, Inhibition of tumour growth and Preet et al. (2008)
NSCLC, EGF-induced, A549, JWH-133 reduction in lung metastasis
SW-1573
Female NMRI (nu/nu) mice and CBD, AM-251, AM-630 Reduction in tumour growth Ramer et al. (2013)
human Lung adenocarcinoma,
A549, H460
FVB mice and human Non-small JWH-015, SR144528 Reduction in tumour growth and Ravi et al. (2016)
cell lung cancer (NSCLC); metastatic lesions
A549, CALU1. Murine ED1
BLOOD Female adult mice C57BL/6 CBD, SR141716A, Reduction in tumour growth McKallip et al. (2006)
SR144528
SKIN C57BL/6 nude mice and murine Δ9-THC, WIN-55,212–2, Decrease in tumour growth, prolifer- Blázquez et al. (2006)
melanoma, B16 cell line SR141716, SR144528 ation, angiogenesis, and metastasis
Male athymic nude (nu/nu) mice Δ9-THC, CBD Reduction in tumour growth Ramer et al. (2013)
and human melanoma, CHL-1,
A375, SK-MEL-28BD cell lines
NOD/scid/IL-2R gammae WIN 55,212–2 Reduction in tumour growth Barbado et al. (2017)
null (NSG) mice and human
myeloma, U266, U266-LR7,
RPMI, RPMI-LR5, MM1.S,
MM1.R cells
Female C57B6 mice and human AM251 Abrogates lung metastasis formation Marshall et al. (2011)
rhabdomyosarcoma, RD, JR1,
RH6, RH2 (ERMS) and RH30,
RH4, RH41, RH3, and RH28
(ARMS)

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2521

effects correlated to induction of apoptosis (Massi et al. cells but that p53 could also act as an activator or inhibitor
2004). Solinas et  al. investigated CBD in U87-MG and of autophagy and apoptosis and this depends on subcellular
T98G glioma cell lines and reported inhibition of cell pro- localisation and the mutant variant of p53 (Ellert-Miklasze-
liferation and invasiveness, a downregulation of ERK and wska et al. 2021).
Akt signalling and a decrease in the hypoxia-inducible factor
HIF-1α expression (Solinas et al. 2013). In the following In vivo
neuroblastoma cell lines, SK-N-SH, IMR-32, NUB-6 and
LAN-1, CBD and ∆9-THC treatment induced antitumori- In a glioma mouse model treated with CBD daily at 0.5 mg/
genic activity by decreasing cell viability and invasiveness, mouse, Massi and colleagues reported a significant reduc-
arrest of the cell cycle at the ­G1/G0 phase and an increase tion in xenografted human U87 tumour growth in  vivo
in activated caspase-3, albeit CBD was more potent in these (Massi et al. 2004). A further study investigating CBD’s
effects when compared to ∆9-THC (Fisher et al. 2016). Sala- action in tumours from derived glioma stem cells (GSCs)
zar et al. investigated ∆9-THC in the astrocytoma cell line which known to be resistant to therapies, reported in vivoan
U87MG and in vivo where they report autophagy induction increase in the production of ROS leading to the inhibition
via the upregulation of p8 leading to apoptosis and inhibition of cell survival and an increase in the survival rate of mice
of Akt and mTORC1 (Salazar et al. 2009). bearing the GSC xenograft (Singer et al. 2015). They also
A recent study has reported in the following human observed activation of the p-p38 pathway and a downregu-
glioma cell lines A172, U251, U87 MG, U118 MG and lation of stem cell regulators including Sox2, Id-1 (a tran-
LN18, CBD induced autophagic rather than apoptotic cell scription factor involved in cell growth, senescence and dif-
death. Specifically, CBD caused mitochondrial dysfunction ferentiation) and p-STAT3 which inhibited the self-renewal
and lethal mitophagy arrest mechanistically via TRPV4 of the cells (Singer et al. 2015). Although CBD inhibited
with an influx of calcium (Huang et  al. 2021). Further glioma progression, a fraction of therapeutic resistance to
analysis revealed ER stress and in particular the ATF4- CBD in a subset of glioma cells was due to the upregulation
DDIT3-TRIB3-AKT-MTOR axis downstream of TRPV4 of antioxidant response genes (Singer et al. 2015). SK-N-SH
was involved in CBD’s mitophagy effect. Combination of neuroblastoma cell line induced in nude mice treated with
CBD and temozolomide (TMZ) in neurosphere cultures CBD and ∆9-THC led to a reduction in tumour burden and
and mouse models conveyed synergistic effects in reduc- an observed increase in activated caspase-3 (Fisher et al.
ing tumour burden and improving survival rates (Torres 2016). Various forms of cannabinoids have been trialled and
et al. 2011). Their findings suggest a novel TRPV4-CBD- tested to measure the most efficacious form for oncological
mitophagy pathway in glioma and combination of CBD effects and these include a pure (P) form versus a botanical
and TMZ as a potential to explore in future clinical studies. drug substance (BDS) which is an active form of the drug
Additionally, Vrechi and colleagues show CBD stimulates that has been cultivated usually available as a powder, tablet
autophagy signal transduction via crosstalk of ERK1/2 and or elixir. In a study by Scott et al. using P and BDS forms for
AKT kinases and that CBD-induced autophagy was reduced both CBD and ∆9-THC, they report efficacious activity for
in presence of CB receptors and TRPV1 receptor antago- CBD-P in comparison to CBD-BDS and vice versa for ∆9-
nists, AM251, AM630 and capsazepine in neuroblastoma THC (Scott et al. 2014). As discussed earlier in their in vit-
and murine astrocyte cell lines (Vrechi et al. 2021). rofindings, they report similar outcomes in their orthotopic
Kolbe et  al. recently investigated the effects of can- murine model of glioma and in particular they observed a
nabinoids in glioblastoma multiforme (GBM) cells derived significant decrease in tumour volumes when both cannabi-
from primary human tumour samples and to identify pos- noids were administered with irradiation, p < 0.001 (Scott
sible receptors involved. Their findings revealed ∆9-THC et al. 2014). These findings support the anticancer effects of
reduced the number of Ki67 immuno-reactive nuclei, cannabinoid treatment in glioma as a single therapy and also
through GPR55. Their findings suggest that the sensitivity as an addition in combination treatment.
of cannabinoids and receptor-dependent signalling pathways Cannabinoids share the common anticancer effect of
should be considered to reflect the heterogeneity amongst apoptosis in their mode of action; however, it has also
GBM forms which is critical for when evaluating this trans- become apparent that autophagy is also involved. The
lationally to clinic (Kolbe et al. 2021). Mutation-driven process of apoptosis and autophagy interplay, where
cancers are important to take into account when tailoring the survival function of autophagy negatively regulates
specific treatments. In a recent paper, Ellert-Miklaszewska apoptosis and inhibition of apoptosis blocks autophagy
et al. investigated the use of synthetic cannabinoids in GBM (Marino et al. 2014). Salazar and co-workers investigated
which have frequent TP53 or PTEN genetic defects render- ∆9-THC in a murine model of astrocytoma and found that
ing it from chemotherapy treatments. Their experimental autophagy is upstream of apoptosis in cannabinoid-induced
work showed synthetic cannabinoids not only reduce tumour cell death as shown by blocking autophagy, prevented

13

2522 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

cannabinoid-induced apoptosis (Salazar et al. 2009). ∆9- Stress protein p8, however was involved in ∆9-THC antipro-
THC induced the effects of stimulation of ceramide syn- liferative action in a JunD-independent manner, suggesting
thesis de novo, ER stress, upregulation of p8 and TRIB3, a multimodal mechanism of action (Caffarel et al. 2008).
phosphorylation of eIF2α on Ser51 via the activation of the In an interesting report by Blasco-Benito et al., they found
­CB1 receptor (Salazar et al. 2009). A human glioblastoma- ∆9-THC was able to disrupt the HER2–CB2R complex by
induced murine model investigating GICs (glioma initiating selective binding to C ­ B2R. Additionally, they concluded
cells; a subpopulation of cells responsible for the aggres- the antitumour efficacy of a botanical drug preparation to
siveness of GBM) was treated with ∆9-THC, CBD and be more potent than pure ∆9-THC for both cell lines and
TMZ in varying combinations. They reported an effective animal studies (Blasco-Benito et al. 2019). Ligresti et al.
tumour reduction when CBD and ∆9-THC with TMZ were investigated the anticancer properties of plant-based cannab-
co-administered and that treatment with a high ratio of CBD inoids including CBD, CBG, CBC, CBDA and ∆9-THCA in
was most efficacious (López-Valero et al. 2018). addition to assessing the use of enriched CBD or ∆9-THC
cannabis extracts over pure cannabinoids (Ligresti et al.
Breast cancer 2006). Within the breast cancer cell lines, MDA-MB-231
and MCF-7, treated with the above cannabinoids, CBD was
In vitro the most potent in its antiproliferative activity (Ligresti et al.
2006). They also report CBD mediated its apoptotic effects
McKallip et al. investigated the effects of ∆9-THC in human via the following routes: the direct or indirect activation of
breast cancer cell lines MDA-MB-231, MCF-7 and mouse the receptors C ­ B2 and TRPV1, receptor-independent eleva-
mammary carcinoma 4T-1. They reported a low expression tion of intracellular C­ a2+ and ROS generation (Ligresti et al.
of cannabinoid receptors; C ­ B1 and C­ B2 in these cell lines. 2006).
∆9-THC did not affect cell viability in MCF-7 and 4T-1 cell Synthetic agonists or antagonists of cannabinoid recep-
lines but increased the size of a 4T1 primary tumour and tors have been used to study the role of the ECS in cancer
enhanced metastasis in vivo. ∆9-THC exposure caused an signalling and growth. Sarnataro and co-workers investi-
increase in IL-4 and IL-10 cytokines and suppression of cell- gated the effects of Rimonabant, a ­CB1 antagonist, in the
mediated Th1 response by enhancement of Th2 cytokines invasive human breast cancer line MDA-MB-231 and in
due to upregulation in Th2-related genes. These findings the less-invasive lines, T47D and MCF-7 (Sarnataro et al.
suggest exposure to ∆9-THC may increase susceptibility to 2006). Treatment with Rimonabant caused antiprolifera-
breast cancer which does not express cannabinoid receptors tive effects characteristic of ­G1–S-phase cell cycle arrest
and is resistant to ∆9-THC-induced apoptosis (McKallip accompanied by a downregulation in cyclins D and E with
et al. 2005). In another study by Caffarel and colleagues associated upregulation of cyclin-dependent kinase inhibitor
∆9-THC was investigated in the following human breast ­p27KIP1. No observed apoptosis or necrosis occurred in vitro
cancer cell lines; MCF-7, EVSA-T, MDA-MB-231, MDA- (Sarnataro et al. 2006). Additionally, within the invasive
MB468, T-47D and SKBr3. They reported a reduction in cells, these effects were found to be associated with lipid
human breast cancer cell proliferation by arrest of the cell raft/caveolae as previously shown by the group (Sarnataro
cycle at the ­G2–M phase via down-regulation of the cyclin- et al. 2005). Rimonabant caused complete displacement of
dependent kinase (CDK1 or Cdc2) protein and an induction the ­CB1 receptor from lipid rafts and the depletion of cho-
of apoptosis via the ­CB2 cannabinoid receptor which was lesterol by methyl-β-cyclodextrin (MCD) prevented these
highly expressed in the EVSA-T cell line. ­CB2 expression effects (Sarnataro et al. 2006). In cells overexpressing the
was also found to be correlated with tumours that had a ­CB1 receptor, Rimonabant inhibited MAPK signalling and
low response to conventional therapies and that were also decreased ERK1/2 activity (Sarnataro et al. 2006). Pre-treat-
positive for certain prognostic markers including oestrogen, ment with MCD before Rimonabant administration caused
progesterone receptors and the presence of ERBB2/HER-2 a depletion in cholesterol and this reverted the inhibitory
oncogene. The psychotropic effects of cannabinoids are effects on ERK1/2 via Rimonabant, suggesting an interplay
mediated via the ­CB1 rather than ­CB2, suggesting a cannab- between the ­CB1 receptor and lipid raft motility in breast
inoid therapy that would target the ­CB2 receptor would be tumour growth (Sarnataro et al. 2006). JWH-015, an ago-
beneficial (Caffarel et al. 2006). In a follow-up study inves- nist of the C­ B2 receptor, in human MCF-7 mammary car-
tigating the ∆9-THC antiproliferative mechanism, exposure cinoma cells reduced viability by inducing apoptosis inde-
to ∆9-THC upregulated JunD expression, a proto-oncogene pendent of ­Gαi signalling or by pharmacological blockade
which belongs to the AP-1 transcription factor family, in the of ­CB1, GPR55, TRPV1 or TRPA1 receptors and instead
tumour cells. In addition, they also identified the involve- these effects were calcium-dependent and caused changes
ment of the cyclin-dependent kinase inhibitor p27 and testin in MAPK/ERK signalling (Hanlon et al. 2016).
(a tumour-suppressor gene) as candidate targets of JunD.

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2523

CBD has also been shown to downregulate Id-1 in et al. 2015). They observed a reduction in tumour growth
the aggressive human breast cancer line MDA-MB-231 and metastasis and inhibition of the recruitment of total and
through modulation of ERK and ROS pathways leading to M2 macrophages to the stroma of the primary tumour and
a decrease in Id-1 expression and also upregulated Id-2 (a secondary lung metastasis (Elbaz et al. 2015).
transcriptional regulator) (McAllister et al. 2011). Shriv- Cannabinoid’s effect on ER has been evident in many
astava et al. observed a complex interplay between apop- cancer studies, however, the exact mechanism by which
tosis and autophagy in CBD-treated invasive breast cancer this occurs remain elusive. In a recent study by de la Harpe
cells, MDA-MB-231 (Shrivastava et al. 2011). In particu- et al., they found CBD selectively targeted MCF7 cells via
lar, CBD induced ER stress which led to the inhibition of oxidative stress-induced ER stress and UPR (unfolded pro-
AKT and mTOR signalling in vitroindicated by low levels tein response) activation, and these effects were caused by
of phosphorylated cyclin D1, mTOR and 4EBP1 (Shrivas- calcium influx via the TRPV1 receptor as opposed to MDA-
tava et al. 2011). Further analysis revealed CBD inhibited MB-231 cells. This suggests the difference in CBD treatment
the association between beclin1 (central role in autophagy) was dependent on localization of TRPV1 (de la Harpe et al.,
and BCL-2 known to inhibit autophagy through cleavage of 2021).
Beclin-1 and enhanced the interaction between Beclin-1 and
Vps34 favouring autophagy (Shrivastava et al. 2011). Elec- In vivo
tron microscopy revealed morphological changes to MDA-
MB-231 CBD-treated cells which included nuclear con- One of the factors to consider in cannabinoid treatment
densation, margination, increased vacuolization, decrease is the abundance of cannabinoid receptors in the tissue of
in intracellular organelles and enlarged mitochondria evident interest. In a study investigating the effects of ∆9-THC in
of apoptotic activity (Shrivastava et al. 2011). They hypoth- a murine model of mammary carcinoma, it was found that
esized that the event changes in inducing autophagy may the murine mammary carcinoma cell line 4T1 first did not
also cause apoptosis as the cleavage product from Beclin-1 express detectable levels of the cannabinoid receptors C ­ B1
translocates to the mitochondria and induces cytochrome C and ­CB2 and second, these cells were resistant to the cyto-
(Shrivastava et al. 2011). These observations and hypothesis toxicity of ∆9-THC. They also show treatment with ∆9-THC
suggest CBD may be able to control the complex interplay led to an increase in tumour growth and metastasis due to
between autophagy and apoptosis in these breast cancer cells an increase in production of IL-4 and IL-10 which sup-
(Shrivastava et al. 2011). CBD also increased ROS levels pressed the cell-mediated Th1 response by enhancing Th2-
and blockage of ROS inhibited apoptotic and autophagy associated cytokines (McKallip et al. 2005). This finding
pathways (Shrivastava et al. 2011). These effects were inde- was supported by the injection of anti-IL-4 and anti-IL-10
pendent of cannabinoid and vanilloid receptor activation monoclonal antibodies which partially reversed the immune
(Shrivastava et al. 2011). suppression of ∆9-THC in 4T1 cells (McKallip et al. 2005).
Many drugs have failed in clinics for many of the aggres- A study investigating the effects of the endogenous can-
sive cancers due to the recalcitrant TME. The TME plays nabinoid, Met-F-AEA (a metabolically stable anandamide
a major role in contributing to the growth and invasion of analogue) in a highly invasive murine breast cancer model
cancer and in particular tumour-associated macrophages reported a significantly reduced amount and size of meta-
(TAMs) which are a class of immune cells contributing to static nodes and this effect was antagonized by the selective
the immunosuppressive TME through interchange of its two ­CB1 antagonist Rimonabant (Grimaldi et al. 2006). Molecu-
forms: M1 (anti-tumorigenic) and M2 (pro-tumorigenic) lar interrogation in treated cells with the endogenous can-
(Lin et al. 2019). Elbaz and colleagues investigated CBD in nabinoid caused a decrease in tyrosine phosphorylation of
triple-negative breast cancer (TNBC) cell lines SUM159, focal adhesion kinase (FAK) and steroid receptor coactivator
MDA-MB-231-SCP2, MVT-1, 4T1.2 and in murine leukae- (Src) and these effects were mitigated by Rimonabant (Gri-
mia RAW264.7. They observed CBD inhibited EGF-induced maldi et al. 2006). They concluded C ­ B1 receptor agonists
proliferation and chemotaxis in the cell lines, activated by modulating FAK phosphorylation inhibited tumour cell
EGFR, ERK, Akt, and NF-κß pathways in addition to inhibi- invasion and metastasis and therefore ­CB1 receptor activa-
tion of matrix metallopeptidase 2 and 9 (MMP2 and MMP9) tion may represent a novel therapeutic target for the treat-
secretion (Elbaz et al. 2015). A cancer education experiment ment of breast carcinoma and metastasis (Grimaldi et al.
(conditioned media from CBD-treated cancer cells) showed 2006). Rimonabant has also been reported to significantly
a significant reduction in the number of migrated RAW reduce tumour volume in vivo in the invasive human MDA-
264.7 cells towards this medium which also contained lower MD-231 murine model and this effect occurred via the ­CB1R
levels of granulocyte–macrophage colony-stimulating fac- lipid raft/caveolae-mediated mechanism (Sarnataro et al.
tor (GM-CSF) and chemokine ligand 3 (CCL3) cytokines, 2006).
crucial for macrophage recruitment and activation (Elbaz

13

2524 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

In a human MDA-MB-231 breast carcinoma xenografted In human colorectal cell lines, Caco-2 and HCT116, CBD
tumour model, both CBD and CBD enriched extract treat- treatment protected DNA from oxidative damage, reduced
ment induced apoptosis, inhibited the growth of tumours and cell proliferation and increased endocannabinoid levels via
metastasis in vivo (Ligresti et al. 2006). CBD has also been ­CB1, TRPV1 and PPARγ (Romano et al. 2014). In addi-
shown to modulate transcriptional activity downstream in tion, CBD treatment of colorectal carcinoma cell line DLD-
breast cancer. A study by McAllister and colleagues investi- 1, reduced cell proliferation (Macpherson et al. 2014). An
gated CBD treatment of a murine model of metastatic breast interesting study investigated the antiproliferative effects of
cancer and found CBD inhibited Id-1 gene expression in the CBD in Caco-2 cell line in various oxygen environments
primary tumour and lung metastasis in vivo through modula- and found the antitumour effects of CBD to be greater in
tion of the ERK and ROS pathways (McAllister et al. 2011). ­PhysO2 than A ­ tmosO2. They conclude that CBD induced a
Caffarel et al. have shown using a genetically engineered mitochondrial production of ROS in P ­ hysO2 cells, suggest-
animal model of ErbB2-driven metastatic breast cancer ing that the cellular redox environment can influence how
(MMTV-neu mice), ∆9-THC and JWH-133 (selective ­CB2 CBD induced antiproliferative effects in P­ hysO2 to A
­ tmosO2
agonist) reduce metastatic progression via AKT pathway cells (Nallathambi et al. 2018). This study demonstrates the
inhibition (Caffarel et al. 2010). important role microenvironments play in cell cultures when
Cannabinoids mechanistic actions have been reported studying the pharmacokinetics and mechanism of drugs.
to be CB-independent with studies reporting other chan- Macpherson and colleagues report the increase in sensitiv-
nels through which they may activate their oncological ity to CBD-induced antiproliferative effects through changes
effects, such as GPR55 or vanilloid channels. Hanlon and to cell energetics, from a drop in oxygen and a loss in mito-
co-workers report using JWH-015, a C ­ B2 agonist, signifi- chondrial membrane integrity in cells under the atmospheric
cantly reduced tumour burden and metastasis of murine condition to the increase in ROS in mitochondria under low
mammary carcinoma 4T1 cells in immunocompetent mice oxygen conditions (Nallathambi et al. 2018).
and these effects were dependent on calcium and induced Purified cannabinoids have been mainly reported in
changes to MAPK/ERK signalling which were independent inducing apoptosis, inhibiting proliferation and metastasis
of G-protein-coupled signalling, CB or vanilloid receptors in many cancer types, however, other forms such as unheated
(McAllister et al. 2011). extracts of the plants have been less studied. Nallathambi
and colleagues identified unheated extract fractions (F7:
Other gastrointestinal (GI) cancers THCA, F3: CBGA) from C. sativa which displayed cyto-
toxic effects in colorectal cancer cell lines, HCT116 and
In vitro CCD-18Co and adenomatous polyps but reduced activity on
normal colon cell lines (Nallathambi et al. 2018). Combina-
In a study investigating human colorectal cancer cells tion treatment analysed by the Bliss independence model,
using the lines DLD-1, CaCo-2 and SW620, treatment exhibited more potent cytotoxic effects which included cell
with Rimonabant significantly reduced cell proliferation cycle arrest, cell death and a reduction in genes involved in
and induced death. In DLD-1 cells, treatment resulted in the Wnt signalling pathway (Proto et al. 2017).
­G2–M-phase cell cycle arrest without inducing apopto-
sis or necrosis (Aviello et al. 2012). Further investigation In vivo
revealed an increase in mitotic catastrophe characterized by
changes in the following, cyclin B1, PARP-1 (involved in Rimonabant treatment in a mouse model of azoxymethane-
DNA repair) Aurora B (involved in the attachment of the induced colon carcinogenesis caused a significant reduc-
mitotic spindle in prophase), phosphorylated p38/MAPK tion in aberrant crypt foci formation, which is a neoplastic
and Chk1 (checkpoint kinase 1) in a time-dependent man- precursor to colorectal cancer and additionally observed
ner (Aviello et al. 2012). Rimonabant, can therefore medi- inhibitory effects with changes to mitotic and DNA-dam-
ate cancer tumour growth via mitotic catastrophe inducing age checkpoints in their cell lines as mentioned previously
cell-cycle arrest during spindle assembly and DNA-damage (Aviello et al. 2012). Another study investigated the syn-
checkpoints (Aviello et al. 2012). thetic cannabinoids effects on the Wnt/β-catenin pathway, a
In hepatocellular carcinoma cell lines, HepG2 and Huh-7, signalling pathway involved in the formation of colorectal
treatment with ∆9-THC and JWH-015 (synthetic ­CB2 recep- cancer (Borelli et al. 2014). The administration of rimona-
tor agonist) reduced cell viability through activation of the bant in HCT116 xenografts caused a significant reduction
­CB2 receptor. Autophagy was subsequently induced by the in tumour growth and destabilized the nuclear localization
upregulation of TRIB3, stimulation of adenosine monophos- of β-catenin in vivo by inhibiting the canonical Wnt path-
phate-activated kinase (AMPK) and Akt/mTORC1 inhibi- way (Borelli et al. 2014). This study suggests a novel use
tion (Vara et al. 2011).

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2525

for cannabinoids in treating colorectal cancer harbouring the effects of bicalutamide and docetaxel (standard drugs
mutations in β-catenin. for treatment of prostate carcinoma) against LNCaP and
In a murine model of hepatocellular carcinoma, treatment DU-145 xenograft tumours and when given alone reduced
with JWH-015 and ∆9-THC, both cannabinoids reduced sub- LNCaP xenograft size. CBD administered between 1 and
cutaneous xenograft growth; however, this effect was not 10 µM induced apoptosis and markers of intrinsic apoptotic
observed when autophagy was pharmacologically inhibited pathways (PUMA, CHOP expression and intracellular C ­ a2+).
(Vara et al. 2011) indicating the importance of cell death in In LNCaP cells, the pro-apoptotic effect of CBD was only
both cannabinoids reducing tumour burden in vivo. Further- partly due to TRPM8 antagonism and was accompanied
more, administration of the cannabinoids also led to a reduc- by down-regulation of AR, p53 activation and elevation of
tion in ascites (abnormal build-up of fluid in the abdomen) ROS. LNCaP cells differentiated to androgen-insensitive
formation (Vara et al. 2011). In support of the mechanisms neuroendocrine-like cells were more sensitive to CBD-
observed in the HCC cell lines, Salazar et al. investigated ∆9- induced apoptosis (De Petrocellis et al. 2013).
THC in the astrocytoma cell line U87MG and in vivo where
they report autophagy induction via the upregulation of p8 Gynaecological cancers
leading to apoptosis and inhibition of Akt and mTORC1
(Salazar et al. 2009). In vitro
The effect of CBD in gastrointestinal cancers has also
been studied. In a study by Aviello et al., CBD treatment in The effects of ∆9-THC were also investigated in aggres-
an azoxymethane (AOM)-induced murine model of colon sive endometrial cancer. Zhang et al. report in HEC-1B
cancer, reduced aberrant crypt foci, polyps, tumour growth and An3ca aggressive endometrial cancer cell lines a high
and led to a decrease in expression of inducible nitric oxide level of cannabinoid receptor expression and treatment with
synthase (iNOS) and phosphorylated Akt with an upregula- ∆9-THC inhibited cell viability and motility by inhibiting
tion in caspase-3 (Aviello et al. 2012). CBG’s anticancer epithelial-mesenchymal transition (EMT) in addition to
effect has been observed in colon cancer models. Borelli down-regulation of the MMP9 gene in inhibiting metasta-
et al. evaluated the antineoplastic effects in xenograft models sis. These findings suggest regulation and targeting of the
of colon cancer and observed a reduction tumour growth, MMP9-related pathways via ∆9-THC treatment may inhibit
however due to the limitation in the model, they further metastasis in this aggressive cancer type (Zhang et al. 2018).
tested CBG in an AOM colon murine model which mimics A recent study investigated the oncological effects of CBD
the tumour in situ and found CBG completely abolished the as a monotherapy and in combination with chemotherapy
formation of aberrant crypt foci and reduced the number drugs in ovarian cancer, administered as Poly lactic-co-
of tumours (Borelli et al. 2014). In addition, Romano et al. glycolytic acid (PGLA)-microparticles (Fraguas-Sánchez
tested the effects of the BDS form of CBD, which contains et al. 2020). Their results show the combination of paclitaxel
a high content of CBD on colorectal cancer growth in both (PTX) with CBD to be effective in vitro and in ovo (Fraguas-
xenograft and AOM models. They also observed a reduc- Sánchez et al. 2020). CBD administered as microparticles
tion in tumour growth, preneoplastic lesions and polyps was more efficacious than in single solution and in ovo, PTX
(Macpherson et al. 2014). resulted in a 1.5-fold tumour growth inhibition whereas in
combination with CBD this increased to a twofold decrease,
Prostate cancer suggesting a promising therapy to explore in treating ovarian
cancer as it provides the advantageous effect of using a lower
In vitro dose of the antineoplastic drug whilst maintaining the same
efficacy (Fraguas-Sánchez et al. 2020).
∆9-THC induced apoptosis in a PC-3 prostate cancer cell
line in a dose-dependent manner (Sreevalsan et al. 2011). Clinical studies
CBD’s pro-apoptotic nature has been shown to be phos-
phate-dependent in prostate and colon cancer cells (De Pet- The anticancer effects of cannabinoids have so far been lim-
rocellis et al. 2013). In LNCaP (prostate) and SW480 (colon) ited to preclinical studies and translation to the clinic has
cancer cell lines, the growth and mRNA expression of sev- remained stagnant. The first report of the use of cannabi-
eral phosphatases inhibited cannabinoid-induced PARP noids on cancer patients was a pilot study that investigated
cleavage (De Petrocellis et al. 2013). De Petrocellis et al. ∆9-THC on nine terminal patients with recurrent glioblas-
investigated CBD’s effect in prostate carcinoma cell lines; toma where standard therapy remained unhopeful as a cura-
LNCaP, 22RV1 (positive for androgen receptor), DU-145 tive (Guzmán et al. 2006). These patients underwent intrac-
and PC-3 (negative for androgen receptor). CBD treat- ranial administration of ∆9-THC, as this route was deemed
ment significantly decreased cell viability and potentiated the safest and patients did not exhibit any of the associated

13

2526 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Table 3  Overview of clinical trials for investigation of cannabinoids in cancer. Key search terms included: “Cancer and Cannabinoids, Cannabis,
Cannabidiol, Tetrahydrocannabinol” (www.​clini​caltr​ials.​gov)
Trial name Conditions Phase n Study Drug Location Status NCT no.
type

A Pilot Study of Brain I 33 Interven- Dronabinol North Carlina, Com- NCT00314808

Dronabinol for Neoplasms|Nausea|Vomiting tional USA pleted
Adult Patients
With Primary
Gliomas
A Phase 1 Study Solid Tumour I 40 Interven- Dexanabinol|Other: Leeds/Newcastle/ Com- NCT01489826
of Dexanabinol tional Cremophor Glasgow pleted
in Patients With
Advanced Solid
Tumours
A Safety Study of Cancer I/II 6 Interven- Sativex Leeds/Bristol/ Com- NCT01812603
Sativex in Com- tional London pleted
bination With
Dose-intense
Temozolomide
in Patients With
Recurrent Glio-
blastoma
A Safety Study of Cancer I/II 21 Interven- Sativex|Placebo Germany Com- NCT01812616
Sativex Com- tional pleted
pared With Pla-
cebo (Both With
Dose-intense
Temozolomide)
in Recurrent
Glioblastoma
Patients
A Pharmacoki- Head and Neck Squamous I 10 Interven- Sativex London Termi- NCT01975688
netic Study of Cell Carcinoma tional nated
Single Doses of
Sativex in Treat-
ment-induced
Mucositis
Assessment of Safety|Tolerability|Pharmacok I 40 Interven- Dexanabinol, Nottingham Com- NCT02054754
Single Doses of inetics|Cancer tional Placebo pleted
Oral Dexanabi-
nol in Healthy
Subjects
A Study: Pure Solid Tumor II 60 Interven- Cannabidiol Israel Unknown NCT02255292
CBD as Single- tional status
agent for Solid
Tumor
A Study of Dexa- Hepatocellular I 112 Interven- Dexanabinol| Switzerland/Ger- Unknown NCT02423239
nabinol in Com- Carcinoma|Pancreatic tional Sorafenib| many/Spain status
bination With Cancer Nab-paclitaxel|
Chemotherapy Gemcitabine
in Patients
With Advanced
Tumours
A Study to Assess Advanced Cancer I 0 Interven- Sativex United Kingdom With- NCT02432612
the Pharma- tional drawn
cokinetic (PK)
Properties of
Sativex® in
Patients With
Advanced
Cancer

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2527

Table 3  (continued)
Trial name Conditions Phase n Study Drug Location Status NCT no.
type

Study on Cannabi- Ulcerative Colitis|Crohn’s – 31 Observa- N/A Austria Com- NCT02735941

noid Receptor Disease|Colon Cancer tional pleted
Expression in
Gastrointestinal
Diseases
The Effect of Neoplasms II 32 Interven- THC and CBD Denmark Unknown NCT03245658
Cannabis in Pan- Pancreatic|Cachexia; tional Mixture status
creatic Cancer Cancer|Cannabis|Appetite
Loss|Palliative
Medicine|Morbidity|Mortality
Tolerability of Glioblastoma I 1 Interven- Cannabis| Temozo- New York, USA Termi- NCT03246113
Cannabis in tional lomide| Radiation nated
Patients Receiv- Therapy
ing Concurrent
Chemoradiation
for Glioblastoma
Medical Cannabis Head and Neck Cancer – 30 Observa- Cannabis New York, USA Recruit- NCT03431363
During Chemo- tional ing
radiation for
Head and Neck
Cancer
TN-TC11G Glioblastoma I/II 30 Interven- TN-TC11G| Spain Not yet NCT03529448
(THC + CBD) tional Temozolomide recruit-
Combination Oral Product| ing
With Temo- Radiotherapy
zolomide and
Radiotherapy in
Patients With
Newly-diagnosed
Glioblastoma
A Study of the Cancer of Pancreas|Cancer I/ II 160 Interven- Cannabidiol| Orlando/Florida, Not yet NCT03607643
Efficacy of of Liver|Cancer of tional Bortezomib| Leu- USA recruit-
Cannabidiol Rectum|Cancer of covorin| 5-FU| ing
in Patients Colon|Cancer, Gall Oxaliplatin|
With Multi- Bladder|Myeloma Bevacizumab|
ple Myeloma, Multiple|Glioblastoma Irinotecan|
Glioblastoma Multiforme Gemcitabine|
Multiforme, and Temozolomide
GI Malignancies
Cannabis Use in Solid Tumor, Adult – 30 Observa- Cannabis Colorado, USA Recruit- NCT03617692
Cancer Patients tional ing
Pilot, Syndros, Bone Metastases|Breast Early 20 Interven- Syndros Arizona, USA Recruit- NCT03661892
Decreasing Use Cancer|Pain I tional ing
of Opioids in
Breast Cancer
Subjects With
Bone Mets
Pharmacokinetic Cancer and other ailments – 10 Observa- Registry|Other: PK Philadelphia/ Termi- NCT03886753
(PK) and Phar- tional microsampling of Pennsylvania, nated
macodynamics blood USA
(PD) Study of
Ilera Specific
Products

13

2528 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

Table 3  (continued)
Trial name Conditions Phase n Study Drug Location Status NCT no.
type

Efficacy and Pancreatic Cancer Non- III 140 Interven- Dronabinol in Oral Austria Recruit- NCT03984214
Safety of Dron- resectable|Chemotherapy- tional Dosage Form| ing
abinol in the induced Nausea and Placebo in Oral
Improvement of Vomiting|Pancreatic Cancer Dosage Form
Chemotherapy- Metastatic
induced and
Tumor-related
Symptoms in
Advanced Pan-
creatic Cancer
Dibenzyl Trisul- Stage IV Prostate Early 104 Interven- Dibenzyl trisul- Jamaica Unknown NCT04113096
phide (GUINE- Cancer|Stage IV Colon I tional phide capsules| status
AHEN WEED) Cancer|Stage IV Breast Placebo
for Stage IV Cancer|Stage IV Cancer of
Cancer the Cervix
Effect of Hemp- Chemotherapy- II 100 Interven- Hemp-based CBD| Pennsylvania, USA Recruit- NCT04398446
CBD on Patients induced Peripheral tional Placebo oral ing
With CIPN Neuropathy|Colorectal tablet
Cancer Stage II|Colorectal
Cancer Stage III|Breast
Cancer|Ovarian
Cancer|Uterine Cancer
Epidiolex (CBD) Prostate Cancer I 18 Interven- Epidiolex Oral Kentucky, USA Recruit- NCT04428203
in Patients With Recurrent|Prostate tional Liquid ing
Biochemically Cancer|Prostate Adenocar-
Recurrent Pros- cinoma
tate Cancer

psychoactive effects (Guzmán et al. 2006). In-depth analysis 2021). Nevertheless, the observations warrant the need for
of two patients’ tumours revealed molecular effects associ- further clinical trials to help establish safe and efficacious
ated with cannabinoids antitumour action, which included routes of administration, patient sub-stratification and to
decreased cell proliferation, stimulation of apoptosis and explore its possible synergistic effects with other antitumour
autophagy (Guzmán et al. 2006). Although positive effects agents as shown in pre-clinical data. Table 3 summarises
were observed, the small case number hinders any statisti- clinical trials investigating cannabinoids including synthetic
cally significant conclusions to be drawn from this study. versions, CBD and ∆9-THC in cancer treatment.
A recently published completed clinical study inves-
tigated the safety and preliminary efficacy of nabiximols
oromucosal cannabinoid spray and dose intense (DIT) TMZ Conclusion
in patients with first recurrence glioblastoma (Twelves et al.
2021). The study included an open label arm where patients Plant-based, endogenous and synthetic cannabinoid com-
received nabiximols (n = 6) and a randomised, double- pounds have shown merits in not only alleviating the
blind, and placebo-controlled arm (n = 12 and n = 9). Up to unwanted side effects of antineoplastic drug regiments, but
12 sprays/days with DIT for 12 months were administered have also shown promising evidence in decreasing tumour
and the safety, efficacy and pharmacokinetics of TMZ were burden, and one in vivo study so far concludes increasing
observed. Study reports a 33% of nabiximols and placebo- survival rates in mice. The antitumour effects of cannabi-
treated patients were progression free for 6 months and sur- noids trend in modulating processes which include apoptosis
vival at 1 year for nabiximols was 83% and 44% for placebo and autophagy through first stimulating de novo synthesis
patients and no effects of nabiximols on TMZ were reported. of ceramide which induces activation of ER stress-related
Although nabiximols spray was tolerable in GBM patients, a signalling proteins further leading to the inhibition of the
major limitation to the study was the small size of enrolled AKT/mTORC1 axis promoting cell cycle arrest and addi-
patients, specifically 21 across 9 sites and there was no pre- tional mechanisms, such as cell death and aging. Other path-
determined power calculation to the study to define the mini- ways involved mechanistically are activation of MAPK/ERK
mum number of patients for statistical power (Twelves et al. signalling through calcium induction. Strategies that would

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2529

optimize the anticancer effects of cannabinoids through Andradas C, Blasco-Benito S, Castillo-Lluva S, Dillenburg-Pilla P,
interference of these signalling cross-talks may prove use- Diez-Alarcia R, Juanes-García A, García-Taboada E, Hernando-
Llorente R, Soriano J, Hamann S, Wenners A, Alkatout I, Klap-
ful for therapeutic intervention. Nevertheless, we found that per W, Rocken C, Bauer M, Arnold N, Quintanilla M, Megías
these effects were reached differently downstream depend- D, Vicente-Manzanares M, Urigüen L, Gutkind JS, Guzmán
ing on the type of cancer, the dosage of the compound and M, Pérez-Gómez E, Sánchez C (2016) Activation of the orphan
which receptor/ligands were activated. We also found the receptor GPR55 by lysophosphatidylinositol promotes metastasis
in triple-negative breast cancer. Oncotarget 7(30):47565–47575.
co-administration of cannabinoids with chemotherapy drugs https://​doi.​org/​10.​18632/​oncot​arget.​10206
enhanced the potency of these effects. These synergistic Andre CM, Hausman J-F, Guerriero G (2016) Cannabis sativa: the
effects should be targeted for translation to clinical applica- plant of the thousand and one molecules. Front Plant Sci 7:19.
tion, especially in cancers which are refractory to chemo- https://​doi.​org/​10.​3389/​fpls.​2016.​00019
Armstrong JL, Hill DS, McKee CS, Hernandez-Tiedra S, Lorente M,
therapy. Various extracted forms of cannabinoids from C. Lopez-Valero I, Eleni Anagnostou M, Babatunde F, Corazzari
sativa have shown varying cytotoxic effects which should M, Redfern CPF, Velasco G, Lovat PE (2015) Exploiting can-
be explored in more detail in future studies as majority of nabinoid-induced cytotoxic autophagy to drive melanoma cell
the evidence originates from studies investigating mainly death. J Invest Dermatol 135(6):1629–1637. https://​doi.​org/​10.​
1038/​jid.​2015.​45
∆9-THC and CBD’s actions. Whilst the emerging evidence Aviello G, Romano B, Borrelli F, Capasso R, Gallo L, Piscitelli F, Di
of phytocannabinoid anticancer effects are promising, there Marzo V, Izzo AA (2012) Chemopreventive effect of the non-
remains a paucity of clinical evaluation which must be psychotropic phytocannabinoid cannabidiol on experimental
overcome. colon cancer. J Mol Med (berl) 90(8):925–934. https://​doi.​org/​
10.​1007/​s00109-​011-​0856-x
Barbado MV, Medrano M, Caballero-Velázquez T, Álvarez-Laderas
I, Sánchez-Abarca LI, García-Guerrero E, Martín-Sánchez J,
Funding  There were no sources of funding associated with this Rosado IV, Piruat JI, Gonzalez-Naranjo P, Campillo NE, Páez
manuscript. JA, Pérez-Simón JA (2017) Cannabinoid derivatives exert a
potent anti-myeloma activity both in vitro and in vivo. Int J Can-
Declarations  cer 140(3):674–685. https://​doi.​org/​10.​1002/​ijc.​30483
Blasco-Benito S, Moreno E, Seijo-Vila M, Tundidor I, Andradas C,
Caffarel MM, Caro-Villalobos M, Urigüen L, Diez-Alarcia R,
Conflict of interest  On behalf of all authors, the corresponding author Moreno-Bueno G, Hernández L, Manso L, Homar-Ruano P,
states that there is no conflict of interest. McCormick PJ, Bibic L, Bernadó-Morales C, Arribas J, Canals
M, Casadó V, Canela EI, Guzmán M, Pérez-Gómez E, Sánchez
Code of availability  Not applicable. C (2019) Therapeutic targeting of HER2-CB 2R heterom-
ers in HER2-positive breast cancer. Proc Natl Acad Sci USA
Open Access  This article is licensed under a Creative Commons Attri- 116(9):3863–3872. https://​doi.​org/​10.​1073/​pnas.​18150​34116
bution 4.0 International License, which permits use, sharing, adapta- Blázquez C, Carracedo A, Barrado L, Real PJ, Fernández-Luna JL,
tion, distribution and reproduction in any medium or format, as long Velasco G, Malumbres M, Guzmán M (2006) Cannabinoid
as you give appropriate credit to the original author(s) and the source, receptors as novel targets for the treatment of melanoma. FASEB
provide a link to the Creative Commons licence, and indicate if changes J 20(14):2633–2635. https://​doi.​org/​10.​1096/​fj.​06-​6638f​j e
were made. The images or other third party material in this article are Borrelli F, Pagano E, Romano B, Panzera S, Maiello F, Coppola D, De
included in the article’s Creative Commons licence, unless indicated Petrocellis L, Buono L, Orlando P, Izzo AA (2014) Colon car-
otherwise in a credit line to the material. If material is not included in cinogenesis is inhibited by the TRPM8 antagonist cannabigerol, a
the article’s Creative Commons licence and your intended use is not Cannabis-derived non-psychotropic cannabinoid. Carcinogenesis
permitted by statutory regulation or exceeds the permitted use, you will 35(12):2787–2797. https://​doi.​org/​10.​1093/​carcin/​bgu205
need to obtain permission directly from the copyright holder. To view a Brandi J, Dando I, Palmieri M, Donadelli M, Cecconi D (2013) Com-
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. parative proteomic and phosphoproteomic profiling of pancre-
atic adenocarcinoma cells treated with CB1 or CB2 agonists.
Electrophoresis 34(9–10):1359–1368. https://​doi.​org/​10.​1002/​
elps.​20120​0402
Brown KJ, Laun AS, Song Z-H (2017) Cannabidiol, a novel inverse
References agonist for GPR12. Biochem Biophys Res Commun 493(1):451–
454. https://​doi.​org/​10.​1016/j.​bbrc.​2017.​09.​001
Afrin F, Chi M, Eamens AL, Duchatel RJ, Douglas AM, Schneider Caffarel MM, Sarrió D, Palacios J, Guzmán M, Sánchez C (2006)
J, Gedye C, Woldu AS, Dun MD (2020) Can hemp help? Low- Delta9-tetrahydrocannabinol inhibits cell cycle progression
THC cannabis and non-THC cannabinoids for the treatment of in human breast cancer cells through Cdc2 regulation. Cancer
cancer. Cancers (basel) 12(4):1033. https://d​ oi.o​ rg/1​ 0.3​ 390/c​ ance​ Res 66(13):6615–6621. https://​doi.​org/​10.​1158/​0008-​5472.​
rs120​41033 CAN-​05-​4566
Akimov MG, Gamisonia AM, Dudina PV, Gretskaya NM, Gaydaryova Caffarel M, Andradas C, Mira E, Pérez-Gómez E, Cerutti C, Moreno-
AA, Kuznetsov AS, Zinchenko GN, Bezuglov VV (2021) GPR55 Bueno G, Flores JM, García-Real I, Palacios J, Mañes S, Guzmán
receptor activation by the N-acyl dopamine family lipids induces M, Sánchez C (2010) Cannabinoids reduce ErbB2-driven breast
apoptosis in cancer cells via the nitric oxide synthase (nNOS) cancer progression through Akt inhibition. Mol Cancer 9:196.
over-stimulation. Int J Mol Sci 22(2):622. https://​doi.​org/​10.​ https://​doi.​org/​10.​1186/​1476-​4598-9-​196
3390/​ijms2​20206​22 Caffarel M, Moreno-Bueno G, Cerutti C et al (2008) JunD is involved
in the antiproliferative effect of Δ9-tetrahydrocannabinol on

13

2530 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

human breast cancer cells. Oncogene 27:5033–5044. https://​doi.​ increases effects of gemcitabine. Oncogene 37(49):6368–6382.
org/​10.​1038/​onc.​2008.​145 https://​doi.​org/​10.​1038/​s41388-​018-​0390-1
Calvaruso G, Pellerito O, Notaro A, Giuliano M (2012) Cannabinoid- Fiore D, Ramesh P, Proto MC, Piscopo C, Franceschelli S, Anzelmo
associated cell death mechanisms in tumor models (review). Int S, Medema JP, Bifulco M, Gazzerro P (2018) Rimonabant kills
J Oncol 41(2):407–413. https://​doi.​org/​10.​3892/​ijo.​2012.​1476 colon cancer stem cells without inducing toxicity in normal colon
Carracedo A, Lorente M, Egia A, Blázquez C, García S, Giroux V, organoids. Front Pharmacol 8:949. https://d​ oi.o​ rg/1​ 0.3​ 389/f​ phar.​
Malicet C, Villuendas R, Gironella M, González-Feria L, Piris 2017.​00949
MA, Iovanna JL, Guzmán M, Velasco G (2006) The stress- Fisher T, Golan H, Schiby G, PriChen S, Smoum R, Moshe I, Peshes-
regulated protein p8 mediates cannabinoid-induced apoptosis of Yaloz N, Castiel A, Waldman D, Gallily R, Mechoulam R, Toren
tumor cells. Cancer Cell 9(4):301–312. https://d​ oi.o​ rg/1​ 0.1​ 016/j.​ A (2016) In vitro and in vivo efficacy of non-psychoactive can-
ccr.​2006.​03.​005 nabidiol in neuroblastoma. Curr Oncol 23(2):S15-22. https://d​ oi.​
Chakravarti B, Ravi J, Ganju RK (2014) Cannabinoids as therapeutic org/​10.​3747/​co.​23.​2893
agents in cancer: current status and future implications. Onco- Fogli S, Nieri P, Chicca A, Adinolfi B, Mariotti V, Iacopetti P, Breschi
target 5(15):5852–5872. https://​doi.​org/​10.​18632/​oncot​arget.​ MC, Pellegrini S (2006) Cannabinoid derivatives induce cell
v5i15 death in pancreatic MIA PaCa-2 cells via a receptor-independent
Console-Bram L, Brailoiu E, Brailoiu GC, Sharir H, Abood ME (2014) mechanism. FEBS Lett 580(7):1733–1739. https://​doi.​org/​10.​
Activation of GPR18 by cannabinoid compounds: a tale of biased 1016/j.​febsl​et.​2006.​02.​024
agonism. Br J Pharmacol 171(16):3908–3917. https://d​ oi.o​ rg/1​ 0.​ Fraguas-Sánchez AI, Fernández-Carballido A, Simancas-Herbada R,
1111/​bph.​12746 Martin-Sabroso C, Torres-Suárez AI (2020) CBD loaded micro-
Dando I, Donadelli M, Costanzo C, Dalla Pozza E, D’Alessandro particles as a potential formulation to improve paclitaxel and
A, Zolla L, Palmieri M (2013) Cannabinoids inhibit energetic doxorubicin-based chemotherapy in breast cancer. Int J Pharm
metabolism and induce AMPK-dependent autophagy in pancre- 25(574):118916. https://​doi.​org/​10.​1016/j.​ijpha​rm.​2019.​118916
atic cancer cells. Cell Death Dis 4(6):e664. https://​doi.​org/​10.​ Franco R, Rivas-Santisteban R, Reyes-Resina I, Casanovas M, Pérez-
1038/​cddis.​2013.​151 Olives C, Ferreiro-Vera C, Navarro G, Sánchez de Medina V,
Dariš B, Tancer Verboten M, Knez Ž, Ferk P (2019) Cannabinoids Nadal X (2020) Pharmacological potential of varinic-, minor-,
in cancer treatment: therapeutic potential and legislation. Bosn and acidic phytocannabinoids. Pharmacol Res 158:104801.
J Basic Med Sci 19(1):14–23. https://​doi.​org/​10.​17305/​bjbms.​ https://​doi.​org/​10.​1016/j.​phrs.​2020.​104801
2018.​3532 Gazzerro P, Malfitano AM, Proto MC, Santoro A, Pisanti S, Caruso
de la Harpe A, Beukes N, Frost CL (2021) CBD activation of TRPV1 MG, Notarnicola M, Messa C, Laezza C, Misso G, Caraglia M,
induces oxidative signaling and subsequent ER stress in breast Bifulco M (2010) Synergistic inhibition of human colon cancer
cancer cell lines. Biotechnol Appl Biochem. https://​doi.​org/​10.​ cell growth by the cannabinoid CB1 receptor antagonist rimona-
1002/​bab.​2119 bant and oxaliplatin. Oncol Rep 23(1):171–175
De Petrocellis L, Ligresti A, Schiano Moriello A, Iappelli M, Verde Gómez del Pulgar T, Velasco G, Sánchez C, Haro A, Guzmán M (2002)
R, Stott CG, Cristino L, Orlando P, Di Marzo V (2013) Non- De novo-synthesized ceramide is involved in cannabinoid-
THC cannabinoids inhibit prostate carcinoma growth in vitro and induced apoptosis. Biochem J 363(Pt 1):183–8. https://​doi.​org/​
in vivo: pro-apoptotic effects and underlying mechanisms. Br J 10.​1042/​0264-​6021:​36301​83
Pharmacol 168(1):79–102. https://​doi.​org/​10.​1111/j.​1476-​5381.​ Gonçalves ECD, Baldasso GM, Bicca MA, Paes RS, Capasso R, Dutra
2012.​02027 RC (2020) Terpenoids, cannabimimetic ligands, beyond the Can-
Donadelli M, Dando I, Zaniboni T, Costanzo C, Dalla Pozza E, Scupoli nabis plant. Molecules 25(7):1567. https://d​ oi.o​ rg/1​ 0.3​ 390/m
​ olec​
MT, Scarpa A, Zappavigna S, Marra M, Abbruzzese A, Bifulco ules2​50715​67
M, Caraglia M, Palmieri M (2011) Gemcitabine/cannabinoid Grimaldi C, Pisanti S, Laezza C, Malfitano AM, Santoro A, Vitale M,
combination triggers autophagy in pancreatic cancer cells Caruso MG, Notarnicola M, Iacuzzo I, Portella G, Di Marzo V,
through a ROS-mediated mechanism. Cell Death Dis 2(4):e152. Bifulco M (2006) Anandamide inhibits adhesion and migration
https://​doi.​org/​10.​1038/​cddis.​2011.​36 of breast cancer cells. Exp Cell Res 312(4):363–373. https://​doi.​
Elbaz M et al (2015) Modulation of the tumor microenvironment and org/​10.​1016/j.​yexcr.​2005.​10.​024
inhibition of EGF/EGFR pathway: novel anti-tumor mecha- Guerrero-Alba R et al (2019) Some prospective alternatives for treat-
nisms of Cannabidiol in breast cancer. Mol Oncol 9(4):906–919. ing pain: the endocannabinoid system and its putative receptors
https://​doi.​org/​10.​1016/j.​molonc.​2014.​12.​010 GPR18 and GPR55. Front Pharmacol 9:1496. https://​doi.​org/​10.​
Ellert-Miklaszewska A, Ciechomska IA, Kaminska B (2021) Synthetic 3389/​fphar.​2018.​01496
cannabinoids induce autophagy and mitochondrial apoptotic Guindon J, Hohmann A (2012) The endocannabinoid system and pain.
pathways in human glioblastoma cells independently of defi- CNS Neurol Disord Drug Targets. https://d​ oi.o​ rg/1​ 0.2​ 174/1​ 8715​
ciency in TP53 or PTEN tumor suppressors. Cancers 13(3):419. 27097​89824​660
https://​doi.​org/​10.​3390/​cance​rs130​30419 Gustafsson K, Sander B, Bielawski J, Hannun YA, Flygare J (2009)
Ellert-Miklaszewska A, Ciechomska IA, Kaminska B (2021) Syn- Potentiation of cannabinoid-induced cytotoxicity in mantle cell
thetic cannabinoids induce autophagy and mitochondrial apop- lymphoma through modulation of ceramide metabolism. Mol
totic pathways in human glioblastoma cells independently of Cancer Res MCR 7(7):1086–1098. https://d​ oi.o​ rg/1​ 0.1​ 158/1​ 541-​
deficiency in TP53 or PTEN tumor suppressors. Cancers (basel) 7786.​MCR-​08-​0361
13(3):419. https://​doi.​org/​10.​3390/​cance​rs130​30419 Guzmán M, Duarte MJ, Blázquez C, Ravina J, Rosa MC, Galve-Rop-
ElSohly MA et  al (2017) Phytochemistry of Cannabis sativa erh I, Sánchez C, Velasco G, González-Feria L (2006) A pilot
L. Prog Chem Org Nat Prod. https:// ​ d oi. ​ o rg/ ​ 1 0. ​ 1 007/​ clinical study of Delta9-tetrahydrocannabinol in patients with
978-3-​319-​45541-9_1 recurrent glioblastoma multiforme. Br J Cancer 95(2):197–203.
Falasca M, Ferro R (2016) Role of the lysophosphatidylinositol/GPR55 https://​doi.​org/​10.​1038/​sj.​bjc.​66032​36
axis in cancer. Adv Biol Regul. https://​doi.​org/​10.​1016/j.​jbior.​ Gyombolai P et al (2012) Regulation of endocannabinoid release by
2015.​10.​003 G proteins: a paracrine mechanism of G protein-coupled recep-
Ferro R et al (2018) GPR55 signalling promotes proliferation of pan- tor action. Mol Cell Endocrinol. https://​doi.​org/​10.​1016/j.​mce.​
creatic cancer cells and tumour growth in mice, and its inhibition 2011.​10.​011

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2531

Hanahan D, Weinberg RA (2000) The hallmarks of cancer. Cell. Kolbe MR, Hohmann T, Hohmann U, Ghadban C, Mackie K, Zöller
https://​doi.​org/​10.​1016/​S0092-​8674(00)​81683-9 C, Prell J, Illert J, Strauss C, Dehghani F (2021) THC Reduces
Hanahan D, Weinberg RA (2011) Hallmarks of cancer: the next genera- Ki67-Immunoreactive Cells Derived from Human Primary
tion. Cell. https://​doi.​org/​10.​1016/j.​cell.​2011.​02.​013 Glioblastoma in a GPR55-Dependent Manner. Cancers (basel)
Hanlon KE, Lozano-Ondoua AN, Umaretiya PJ, Symons-Liguori AM, 13(5):1064. https://​doi.​org/​10.​3390/​cance​rs130​51064
Chandramouli A, Moy JK, Kwass WK, Mantyh PW, Nelson MA, Ladin DA, Soliman E, Griffin L, Van Dross R (2016) Preclinical and
Vanderah TW (2016) Modulation of breast cancer cell viabil- clinical assessment of cannabinoids as anti-cancer agents. Front
ity by a cannabinoid receptor 2 agonist, JWH-015, is calcium Pharmacol 7(7):361. https://​doi.​org/​10.​3389/​fphar.​2016.​00361
dependent. Breast Cancer (dove Med Press) 15(8):59–71. https://​ Lee JLC, Bertoglio LJ, Guimarães FS, Stevenson CW (2017) Can-
doi.​org/​10.​2147/​BCTT.​S1003​93 nabidiol regulation of emotion and emotional memory process-
Hart S, Fischer OM, Axel U (2004) Cannabinoids induce cancer cell ing: relevance for treating anxiety-related and substance abuse
proliferation via tumor necrosis factor α-converting enzyme disorders. Br J Pharmacol 174(19):3242–3256. https://​doi.​org/​
(TACE/ADAM17)-mediated transactivation of the epidermal 10.​1111/​bph.​13724
growth factor receptor. Cancer Res 64(6):1943–1950. https://​ Levy M, Futerman AH (2010) Mammalian ceramide synthases.
doi.​org/​10.​1158/​0008-​5472.​CAN-​03-​3720 IUBMB Life 62(5):347–356. https://​doi.​org/​10.​1002/​iub.​319
Hernández-Tiedra S, Fabriàs G, Dávila D, Salanueva ÍJ, Casas J, Ligresti A, Moriello AS, Starowicz K, Matias I, Pisanti S, De Petrocel-
Montes LR, Antón Z, García-Taboada E, Salazar-Roa M, Lor- lis L, Laezza C, Portella G, Bifulco M, Di Marzo V (2006) Anti-
ente M, Nylandsted J, Armstrong J, López-Valero I, McKee CS, tumor activity of plant cannabinoids with emphasis on the effect
Serrano-Puebla A, García-López R, González-Martínez J, Abad of cannabidiol on human breast carcinoma. J Pharmacol Exp
JL, Hanada K, Boya P, Goñi F, Guzmán M, Lovat P, Jäättelä Ther 318(3):1375–1387. https://d​ oi.o​ rg/1​ 0.1​ 124/j​ pet.1​ 06.1​ 05247
M, Alonso A, Velasco G (2016) Dihydroceramide accumulation Lin Y, Xu J, Lan H (2019) Tumor-associated macrophages in tumor
mediates cytotoxic autophagy of cancer cells via autolysosome metastasis: biological roles and clinical therapeutic appli-
destabilization. Autophagy 12(11):2213–2229. https://​doi.​org/​ cations. J Hematol Oncol 12:76. https:// ​ d oi. ​ o rg/ ​ 1 0. ​ 1 186/​
10.​1080/​15548​627.​2016.​12139​27 s13045-​019-​0760-3
Hirao-Suzuki M, Takeda S, Koga T, Takiguchi M, Toda A (2020) Can- López-Valero I, Saiz-Ladera C, Torres S, Hernández-Tiedra S, García-
nabidiolic acid dampens the expression of cyclooxygenase-2 in Taboada E, Rodríguez-Fornés F, Barba M, Dávila D, Salvador-
MDA-MB-231 breast cancer cells: possible implication of the Tormo N, Guzmán M, Sepúlveda JM, Sánchez-Gómez P, Lorente
peroxisome proliferator-activated receptor β/δ abrogation. J Toxi- M, Velasco G (2018) Targeting glioma initiating cells with A
col Sci 45(4):227–236. https://​doi.​org/​10.​2131/​jts.​45.​227 combined therapy of cannabinoids and temozolomide. Biochem
Howlett AC (2005) Cannabinoid receptor signaling. Handb Exp Phar- Pharmacol 157:266–274. https://​doi.​org/​10.​1016/j.​bcp.​2018.​09.​
macol 168:53–79. https://​doi.​org/​10.​1007/3-​540-​26573-2_2 007
Huang T, Xu T, Wang Y, Zhou Y, Yu D, Wang Z, He L, Chen Z, Zhang Lorente M, Torres S, Salazar M, Carracedo A, Hernández-Tiedra S,
Y, Davidson D, Dai Y, Hang C, Liu X, Yan C (2021) Cannabidiol Rodríguez-Fornés F, García-Taboada E, Meléndez B, Mollejo M,
inhibits human glioma by induction of lethal mitophagy through Campos-Martín Y, Lakatosh SA, Barcia J, Guzmán M, Velasco G
activating TRPV4. Autophagy 25:1–15. https://​doi.​org/​10.​1080/​ (2011) Stimulation of the midkine/ALK axis renders glioma cells
15548​627.​2021.​18852​03 resistant to cannabinoid antitumoral action. Cell Death Differ
Ibeas Bih C, Chen T, Nunn AV, Bazelot M, Dallas M, Whalley BJ 18(6):959–973. https://​doi.​org/​10.​1038/​cdd.​2010.​170
(2015) Molecular targets of cannabidiol in neurological disor- Lu H-C, Mackie K (2016) An introduction to the endogenous can-
ders. Neurotherapeutics 12(4):699–730. https://​doi.​org/​10.​1007/​ nabinoid system. Biol Psychiat 79(7):516–525. https://​doi.​org/​
s13311-​015-​0377-3 10.​1016/j.​biops​ych.​2015.​07.​028
Javid FA, Phillips RM, Afshinjavid S, Verde R, Ligresti A (2016) Can- Macpherson T, Armstrong JA, Criddle DN, Wright KL (2014) Physi-
nabinoid pharmacology in cancer research: a new hope for cancer ological intestinal oxygen modulates the Caco-2 cell model and
patients? Eur J Pharmacol 775:1–14. https://​doi.​org/​10.​1016/j.​ increases sensitivity to the phytocannabinoid cannabidiol. Vitro
ejphar.​2016.​02.​010 Cell Dev Biol Anim 50(5):417–426. https://​doi.​org/​10.​1007/​
Jung CK, Kang WK, Park JM, Ahn HJ, Kim SW, Taek OS, Choi KY s11626-​013-​9719-9
(2013) Expression of the cannabinoid type I receptor and progno- Marcu JP, Christian RT, Lau D, Zielinski AJ, Horowitz MP, Lee J,
sis following surgery in colorectal cancer. Oncol Lett 5(3):870– Pakdel A, Allison J, Limbad C, Moore DH, Yount GL, Desprez
876. https://​doi.​org/​10.​3892/​ol.​2012.​1081 PY, McAllister SD (2010) Cannabidiol enhances the inhibitory
Kalant H (2001) Medicinal use of cannabis: history and current sta- effects of delta9-tetrahydrocannabinol on human glioblastoma
tus. Pain Res Manage 6(2):80–91. https://​doi.​org/​10.​1155/​2001/​ cell proliferation and survival. Mol Cancer Ther 9(1):180–189.
469629 https://​doi.​org/​10.​1158/​1535-​7163.​MCT-​09-​0407
Kalenderoglou N, Macpherson T, Wright KL (2017) Cannabidiol Mariño G, Niso-Santano M, Baehrecke EH, Kroemer G (2014) Self-
reduces leukemic cell size—but is it important? Front Pharmacol consumption: the interplay of autophagy and apoptosis. Nat Rev
8:144. https://​doi.​org/​10.​3389/​fphar.​2017.​00144 Mol Cell Biol 15(2):81–94. https://​doi.​org/​10.​1038/​nrm37​35
Kaur R, Ambwani RS, Singh S (2016) Endocannabinoid system: a Marshall AD, Lagutina I, Grosveld GC (2011) PAX3-FOXO1 induces
multi-facet therapeutic target. Curr Clin Pharmacol. https://​doi.​ cannabinoid receptor 1 to enhance cell invasion and metastasis.
org/​10.​2174/​15748​84711​66616​04181​05339 Cancer Res 71(24):7471–7481. https://​doi.​org/​10.​1158/​0008-​
Khan MI, Sobocińska AA, Brodaczewska KK, Zielniok K, Gajewska 5472.​CAN-​11-​0924
M, Kieda C, Czarnecka AM, Szczylik C (2018) Involvement of Massi P, Vaccani A, Ceruti S, Colombo A, Abbracchio MP, Parolaro
the ­CB2 cannabinoid receptor in cell growth inhibition and G0/ D (2004) Antitumor effects of cannabidiol, a nonpsychoactive
G1 cell cycle arrest via the cannabinoid agonist WIN 55,212–2 cannabinoid, on human glioma cell lines. J Pharmacol Exp Ther
in renal cell carcinoma. BMC Cancer 18(1):583. https://​doi.​org/​ 308(3):838–845. https://​doi.​org/​10.​1124/​jpet.​103.​061002
10.​1186/​s12885-​018-​4496-1 Matas D, Juknat A, Pietr M, Klin Y, Vogel Z (2007) Anandamide
Kleckner AS et al (2019) Opportunities for cannabis in supportive care protects from low serum-induced apoptosis via its degradation
in cancer. Ther Adv Med Oncol. https://​doi.​org/​10.​1177/​17588​ to ethanolamine. J Biol Chem 282(11):7885–7892. https://​doi.​
35919​866362 org/​10.​1074/​jbc.​M6086​46200

13

2532 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

McAllister SD, Murase R, Christian RT, Lau D, Zielinski AJ, Alli- O’Shaughnessy WB (1843) On the preparations of the Indian Hemp, or
son J, Almanza C, Pakdel A, Lee J, Limbad C, Liu Y, Debs RJ, gunjah*. Prov Med Surg J. https://​doi.​org/​10.​1136/​bmj.1.​2629.​
Moore DH, Desprez PY (2011) Pathways mediating the effects 1171
of cannabidiol on the reduction of breast cancer cell proliferation, Ohoka N, Yoshii S, Hattori T, Onozaki K, Hayashi H (2005) TRB3,
invasion, and metastasis. Breast Cancer Res Treat 129(1):37–47. a novel ER stress-inducible gene, is induced via ATF4-CHOP
https://​doi.​org/​10.​1007/​s10549-​010-​1177-4 (Erratum in: Breast pathway and is involved in cell death. EMBO J 24(6):1243–1255.
Cancer Res Treat. 2012 May;133(1):401–4) https://​doi.​org/​10.​1038/​sj.​emboj.​76005​96
McKallip RJ, Nagarkatti M, Nagarkatti PS (2005) Δ-9- Orellana-Serradell O, Poblete CE, Sanchez C, Castellón EA, Gallegos
tetrahydrocannabinol enhances breast cancer growth and metas- I, Huidobro C, Llanos MN, Contreras HR (2015) Proapoptotic
tasis by suppression of the antitumor immune response. J Immu- effect of endocannabinoids in prostate cancer cells. Oncol Rep
nol 174(6):3281–3289. https://​doi.​org/​10.​4049/​jimmu​nol.​174.6.​ 33(4):1599–1608. https://​doi.​org/​10.​3892/​or.​2015.​3746
3281 Ortega A, García-Hernández VM, Ruiz-García E, Meneses-García
McKallip RJ, Jia W, Schlomer J, Warren JW, Nagarkatti PS, Nagarkatti A, Herrera-Gómez A, Aguilar-Ponce JL, Montes-Servín E,
M (2006) Cannabidiol-induced apoptosis in human leukemia Prospero-García O, Del Angel SA (2016) Comparing the effects
cells: a novel role of cannabidiol in the regulation of p22phox of endogenous and synthetic cannabinoid receptor agonists on
and Nox4 expression. Mol Pharmacol 70(3):897–908. https://d​ oi.​ survival of gastric cancer cells. Life Sci 15(165):56–62. https://​
org/​10.​1124/​mol.​106.​023937 doi.​org/​10.​1016/j.​lfs.​2016.​09.​010
McPartland JM (2018) ‘Cannabis systematics at the levels of family, Parker LA, Rock EM, Limebeer CL (2011) Regulation of nausea and
genus, and species. Cannabis Cannabinoid Res. https://​doi.​org/​ vomiting by cannabinoids. Br J Pharmacol. https://​doi.​org/​10.​
10.​1089/​can.​2018.​0039 1111/j.​1476-​5381.​2010.​01176.x
Millar SA, Stone NL, Yates AS, O’Sullivan SE (2018) A systematic Pellati F, Borgonetti V, Brighenti V, Biagi M, Benvenuti S, Corsi L
review on the pharmacokinetics of cannabidiol in humans. Front (2018) Cannabis sativa L. and nonpsychoactive cannabinoids:
Pharmacol 26(9):1365. https://d​ oi.o​ rg/1​ 0.3​ 389/f​ phar.2​ 018.0​ 1365 their chemistry and role against oxidative stress, inflammation,
Mimeault M, Pommery N, Wattez N, Bailly C, Hénichart JP (2003) and cancer. Biomed Res Int 2018:1691428. https://​doi.​org/​10.​
Anti-proliferative and apoptotic effects of anandamide in human 1155/​2018/​16914​28
prostatic cancer cell lines: implication of epidermal growth fac- Pertwee RG (2006) Cannabinoid pharmacology: the first 66 years. Br
tor receptor down-regulation and ceramide production. Prostate J Pharmacol. https://​doi.​org/​10.​1038/​sj.​bjp.​07064​06
56:1–12. https://​doi.​org/​10.​1002/​pros.​10190 Pietrovito L et al (2020) Treatment with cannabinoids as a promising
Mohammadpour F et al (2017) Anti-invasion effects of cannabinoids approach for impairing fibroblast activation and prostate cancer
agonist and antagonist on human breast cancer stem cells. Iran J progression. Int J Mol Sci. https://d​ oi.o​ rg/1​ 0.3​ 390/i​ jms21​ 03078​ 7
Pharm Res. https://​doi.​org/​10.​22037/​ijpr.​2017.​2143 Pisanti S et al (2013) The endocannabinoid signaling system in cancer.
Morales P, Reggio PH, Jagerovic N (2017) An overview on medicinal Trends Pharmacol Sci. https://d​ oi.o​ rg/1​ 0.1​ 016/j.t​ ips.2​ 013.0​ 3.0​ 03
chemistry of synthetic and natural derivatives of cannabidiol. Pistis M, O’Sullivan SE (2017) The role of nuclear hormone receptors
Front Pharmacol 8:422. https://​doi.​org/​10.​3389/​fphar.​2017.​ in cannabinoid function. Adv Pharmacol. https://d​ oi.o​ rg/1​ 0.1​ 016/​
00422 bs.​apha.​2017.​03.​008
Morell C, Bort A, Vara D, Ramos-Torres A, Rodríguez-Henche N, Powles T, te Poele R, Shamash J, Chaplin T, Propper D, Joel S, Oliver
Díaz-Laviada I (2016) The cannabinoid WIN 55,212–2 prevents T, Liu WM (2005) Cannabis-induced cytotoxicity in leukemic
neuroendocrine differentiation of LNCaP prostate cancer cells. cell lines: the role of the cannabinoid receptors and the MAPK
Prostate Cancer Prostatic Dis 19(3):248–257. https://​doi.​org/​10.​ pathway. Blood 105(3):1214–1221. https://​doi.​org/​10.​1182/​
1038/​pcan.​2016.​19 blood-​2004-​03-​1182
Moreno E, Cavic M, Krivokuca A, Casadó V, Canela E (2019) The Preet A, Ganju R, Groopman J (2008) Δ9-Tetrahydrocannabinol inhib-
endocannabinoid system as a target in cancer diseases: are we its epithelial growth factor-induced lung cancer cell migration
there yet? Front Pharmacol 10:339. https://d​ oi.o​ rg/1​ 0.3​ 389/f​ phar.​ in vitro as well as its growth and metastasis in vivo. Oncogene
2019.​00339 27:339–346. https://​doi.​org/​10.​1038/​sj.​onc.​12106​41
Müller L, Radtke A, Decker J, Koch M, Belge G (2017) The synthetic Proto MC, Fiore D, Piscopo C et al (2017) Inhibition of Wnt/β-Catenin
cannabinoid WIN 55,212–2 elicits death in human cancer cell pathway and Histone acetyltransferase activity by Rimonabant: a
lines. Anticancer Res 37(11):6341–6345. https://​doi.​org/​10.​ therapeutic target for colon cancer. Sci Rep 7:11678. https://​doi.​
21873/​antic​anres.​12086 org/​10.​1038/​s41598-​017-​11688-x
Munson AE, Harris LS, Friedman MA, Dewey WL, Carchman RA Qamri Z, Preet A, Nasser MW, Bass CE, Leone G, Barsky SH, Ganju
(1975) Antineoplastic activity of cannabinoids. J Natl Cancer Inst RK (2009) Synthetic cannabinoid receptor agonists inhibit
55(3):597–602. https://​doi.​org/​10.​1093/​jnci/​55.3.​597 tumor growth and metastasis of breast cancer. Mol Cancer
Nallathambi R, Mazuz M, Namdar D, Shik M, Namintzer D, Vinay- Ther 8(11):3117–3129. https://​doi.​org/​10.​1158/​1535-​7163.​
aka AC, Ion A, Faigenboim A, Nasser A, Laish I, Konikoff FM, MCT-​09-​0448
Koltai H (2018) Identification of synergistic interaction between Ramer R, Heinemann K, Merkord J, Rohde H, Salamon A, Linnebacher
cannabis-derived compounds for cytotoxic activity in colorectal M, Hinz B (2013) COX-2 and PPAR-γ confer cannabidiol-
cancer cell lines and colon polyps that induces apoptosis-related induced apoptosis of human lung cancer cells. Mol Cancer Ther
cell death and distinct gene expression. Cannabis Cannabinoid 12(1):69–82. https://​doi.​org/​10.​1158/​1535-​7163.​MCT-​12-​0335
Res 3(1):120–135. https://​doi.​org/​10.​1089/​can.​2018.​0010 Ravi J, Elbaz M, Wani NA, Nasser MW, Ganju RK (2016) Cannabinoid
Ngwa W, Kumar R, Moreau M, Dabney R, Herman A (2017) Nano- receptor-2 agonist inhibits macrophage induced EMT in non-
particle drones to target lung cancer with radiosensitizers and small cell lung cancer by downregulation of EGFR pathway. Mol
cannabinoids. Front Oncol 7:208. https://​doi.​org/​10.​3389/​fonc.​ Carcinog 55(12):2063–2076. https://​doi.​org/​10.​1002/​mc.​22451
2017.​00208 Romano B, Borrelli F, Pagano E, Cascio MG, Pertwee RG, Izzo AA
Ngwa W, Irabor OC, Schoenfeld JD, Hesser J, Demaria S, Formenti SC (2014) Inhibition of colon carcinogenesis by a standardized
(2018) Using immunotherapy to boost the abscopal effect. Nat Cannabis sativa extract with high content of cannabidiol. Phy-
Rev Cancer 18(5):313–322. https://​doi.​org/​10.​1038/​nrc.​2018.6 tomedicine 21(5):631–639. https://​doi.​org/​10.​1016/j.​phymed.​
2013.​11.​006

13
Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534 2533

Ruiz L, Miguel A, Diaz-Laviada I (1999) v9-Tetrahydrocannabinol Mol Cancer Ther 10(7):1161–1172. https://​doi.​org/​10.​1158/​
induces apoptosis in human prostate PC-3 cells via a receptor- 1535-​7163
independent mechanism. FEBS Lett. https://​doi.​org/​10.​1016/​ Singer E, Judkins J, Salomonis N, Matlaf L, Soteropoulos P, McAl-
S0014-​5793(99)​01073-X lister S, Soroceanu L (2015) Reactive oxygen species-mediated
Salazar M, Carracedo A, Salanueva ÍJ, Hernández-Tiedra S, Lorente therapeutic response and resistance in glioblastoma. Cell Death
M et al (2009) Cannabinoid action induces autophagy-mediated Dis 6(1):e1601. https://​doi.​org/​10.​1038/​cddis.​2014.​566
cell death through stimulation of ER stress in human glioma Śledziński P, Zeyland J, Słomski R, Nowak A (2018) The current state
cells. J Clin Investig 119(5):1359–1372. https://​doi.​org/​10.​1172/​ and future perspectives of cannabinoids in cancer biology. Can-
jci37​948 cer Med 7(3):765–775. https://​doi.​org/​10.​1002/​cam4.​1312
Sanchez MG, Sanchez AM, Ruiz-Llorente L, Diaz-Laviada I (2003) Soderstrom K, Soliman E, Dross RV (2017) Cannabinoids modulate
Enhancement of androgen receptor expression induced by (R)- neuronal activity and cancer by CB1 and CB2 receptor-inde-
methanandamide in prostate LNCaP cells. FEBS Lett 555:561– pendent mechanisms. Front Pharmacol 8:720. https://​doi.​org/​10.​
566. https://​doi.​org/​10.​1016/​s0014-​5793(03)​01349-8 3389/​fphar.​2017.​00720
Santoro A, Pisanti S, Grimaldi C, Izzo AA, Borrelli F, Proto MC, Soliman E, Henderson KL, Danell AS, Van Dross R (2016) Arachi-
Malfitano AM, Gazzerro P, Laezza C, Bifulco M (2009) Rimona- donoyl-ethanolamide activates endoplasmic reticulum stress-
bant inhibits human colon cancer cell growth and reduces the for- apoptosis in tumorigenic keratinocytes: Role of cyclooxy-
mation of precancerous lesions in the mouse colon. Int J Cancer genase-2 and novel J-series prostamides. Mol Carcinog
125(5):996–1003. https://​doi.​org/​10.​1002/​ijc.​24483 55(2):117–130. https://​doi.​org/​10.​1002/​mc.​22257
Sarfaraz S, Afaq F, Adhami VM, Malik A, Mukhtar H (2006) Cannabi- Solinas M, Massi P, Cinquina V, Valenti M, Bolognini D, Gariboldi
noid receptor agonist-induced apoptosis of human prostate cancer M, Monti E, Rubino T, Parolaro D (2013) Cannabidiol, a non-
cells LNCaP proceeds through sustained activation of ERK1/2 psychoactive cannabinoid compound, inhibits proliferation and
leading to G1 cell cycle arrest. J Biol Chem 281:39480–39491 invasion in U87-MG and T98G glioma cells through a multi-
Sarnataro D, Grimaldi C, Pisanti S, Gazzerro P, Laezza C, Zurzolo C, target effect. PLoS One. 8(10):e76918. https://​doi.​org/​10.​1371/​
Bifulco M (2005) Plasma membrane and lysosomal localization journ​al.​pone.​00769​18
of CB1 cannabinoid receptor are dependent on lipid rafts and Sreevalsan S, Joseph S, Jutooru I, Chadalapaka G, Safe SH (2011)
regulated by anandamide in human breast cancer cells. FEBS Induction of apoptosis by cannabinoids in prostate and colon
Lett 579(28):6343–6349. https://​doi.​org/​10.​1016/j.​febsl​et.​2005.​ cancer cells is phosphatase dependent. Anticancer Res
10.​016 31(11):3799–3807
Sarnataro D, Pisanti S, Santoro A, Gazzerro P, Malfitano AM, Laezza Torres S, Lorente M, Rodríguez-Fornés F, Hernández-Tiedra S, Salazar
C, Bifulco M (2006) The cannabinoid CB1 receptor antagonist M, García-Taboada E, Barcia J, Guzmán M, Velasco G (2011) A
rimonabant (SR141716) inhibits human breast cancer cell prolif- combined preclinical therapy of cannabinoids and temozolomide
eration through a lipid raft-mediated mechanism. Mol Pharmacol against glioma. Mol Cancer Ther 10(1):90–103. https://​doi.​org/​
70(4):1298–1306. https://​doi.​org/​10.​1124/​mol.​106.​025601 10.​1158/​1535-​7163.​MCT-​10-​0688
Schiffmann S, Sandner J, Birod K, Wobst I, Angioni C, Ruckhäberle E, Tutino V, Caruso MG, De Nunzio V, Lorusso D, Veronese N, Gigante
Kaufmann M, Ackermann H, Lötsch J, Schmidt H, Geisslinger I, Notarnicola M, Giannelli G (2019) Down-regulation of can-
G, Grösch S (2009) Ceramide synthases and ceramide levels are nabinoid type 1 (CB1) receptor and its downstream signaling
increased in breast cancer tissue. Carcinogenesis 30(5):745–752. pathways in metastatic colorectal cancer. Cancers 11(5):708.
https://​doi.​org/​10.​1093/​carcin/​bgp061 https://​doi.​org/​10.​3390/​cance​rs110​50708
Schoeman R, Beukes N, Frost C (2020) Cannabinoid combination Twelves C, Sabel M, Checketts D et al (2021) A phase 1b randomised,
induces cytoplasmic vacuolation in MCF-7 breast cancer cells. placebo-controlled trial of nabiximols cannabinoid oromucosal
Molecules (basel, Switzerland) 25(20):4682. https://​doi.​org/​10.​ spray with temozolomide in patients with recurrent glioblas-
3390/​molec​ules2​52046​82 toma. Br J Cancer 124:1379–1387. https://​doi.​org/​10.​1038/​
Schröder M, Kaufman RJ (2005) The mammalian unfolded protein s41416-​021-​01259-3
response. Annu Rev Biochem 74(1):739–789. https://​doi.​org/​10.​ Vara D, Salazar M, Olea-Herrero N et al (2011) Anti-tumoral action
1146/​annur​ev.​bioch​em.​73.​011303.​074134 of cannabinoids on hepatocellular carcinoma: role of AMPK-
Scott KA, Dalgleish AG, Liu WM (2014) The combination of can- dependent activation of autophagy. Cell Death Differ 18:1099–
nabidiol and D 9-tetrahydrocannabinol enhances the anticancer 1111. https://​doi.​org/​10.​1038/​cdd.​2011.​32
effects of radiation in an orthotopic murine glioma model. Mol Velasco G, Sánchez C, Guzmán M (2012) Towards the use of can-
Cancer Ther. https://​doi.​org/​10.​1158/​1535-​7163 nabinoids as antitumour agents. Nat Rev Cancer 12(6):436–444.
Senkal CE, Ponnusamy S, Rossi MJ, Bialewski J, Sinha D, Jiang JC, https://​doi.​org/​10.​1038/​nrc32​47
Jazwinski SM, Hannun YA, Ogretmen B (2007) Role of human Velasco G, Sánchez C, Guzmán M (2016) Anticancer mechanisms of
longevity assurance gene 1 and C18-ceramide in chemotherapy- cannabinoids. Curr Oncol 23:23–32. https://​doi.​org/​10.​3747/​co.​
induced cell death in human head and neck squamous cell carci- 23.​3080
nomas. Mol Cancer Ther 6(2):712–722. https://​doi.​org/​10.​1158/​ Vrechi TAM, Leão AHFF, Morais IBM et  al (2021) Cannabidiol
1535-​7163.​MCT-​06-​0558 induces autophagy via ERK1/2 activation in neural cells. Sci
Sharma M et al (2014) In vitro anticancer activity of plant-derived can- Rep 11:5434. https://​doi.​org/​10.​1038/​s41598-​021-​84879-2
nabidiol on prostate cancer cell lines. Pharmacol Pharm. https://​ Wang M, Zhao J, Zhang L, Wei F, Lian Y, Wu Y, Gong Z, Zhang S,
doi.​org/​10.​4236/​pp.​2014.​58091 Zhou J, Cao K, Li X, Xiong W, Li G, Zeng Z, Guo C (2017)
Shaw J, Costa-Pinheiro P, Patterson L, Drews K, Spiegel S, Kester M Role of tumor microenvironment in tumorigenesis. J Cancer
(2018) Novel sphingolipid-based cancer therapeutics in the per- 8(5):761–773. https://​doi.​org/​10.​7150/​jca.​17648
sonalized medicine era. Adv Cancer Res 140:327–366. https://​ Wu J (2019) Cannabis, cannabinoid receptors, and endocannabinoid
doi.​org/​10.​1016/​bs.​acr.​2018.​04.​016 system: yesterday, today, and tomorrow. Acta Pharmacol Sin
Shrivastava A, Kuzontkoski PM, Groopman JE, Prasad A (2011) Can- 40(3):297–299. https://​doi.​org/​10.​1038/​s41401-​019-​0210-3
nabidiol induces programmed cell death in breast cancer cells Xian X, Huang L, Zhang B, Wu C, Cui J, Wang Z (2016) WIN
by coordinating the cross-talk between apoptosis and autophagy. 55,212–2 inhibits the epithelial mesenchymal transition of

13

2534 Journal of Cancer Research and Clinical Oncology (2021) 147:2507–2534

gastric cancer cells via COX-2 signals. Cell Physiol Biochem Zhang X, Qin Y, Pan Z, Li M, Liu X, Chen X, Qu G, Zhou L, Xu M,
39(6):2149–2157. https://​doi.​org/​10.​1159/​00044​7910 Zheng Q, Li D (2019) Cannabidiol induces cell cycle arrest and
Xu D, Wang J, Zhou Z, He Z, Zhao Q (2015) Cannabinoid WIN55, cell apoptosis in human gastric cancer SGC-7901 cells. Biomol-
212–2 induces cell cycle arrest and inhibits the proliferation and ecules 9(8):302. https://​doi.​org/​10.​3390/​biom9​080302
migration of human BEL7402 hepatocellular carcinoma cells. Zhao P, Abood ME (2013) GPR55 and GPR35 and their relationship
Mol Med Rep 12(6):7963–7970. https://​doi.​org/​10.​3892/​mmr.​ to cannabinoid and lysophospholipid receptors. Life Sci. https://​
2015.​4477 doi.​org/​10.​1016/j.​lfs.​2012.​06.​039
Yang Y, Huynh N, Dumesny C, Wang K, He H, Nikfarjam M (2020) Zhu LX, Sharma S, Stolina M, Gardner B, Roth MD, Tashkin DP,
Cannabinoids inhibited pancreatic cancer via P-21 activated Dubinett SM (2000) Delta-9-tetrahydrocannabinol inhibits anti-
kinase 1 mediated pathway. Int J Mol Sci 21(21):8035. https://​ tumor immunity by a CB2 receptor-mediated, cytokine-depend-
doi.​org/​10.​3390/​ijms2​12180​35 ent pathway. J Immunol 165(1):373–380. https://d​ oi.o​ rg/1​ 0.4​ 049/​
Yasmin-Karim S, Moreau M, Mueller R, Sinha N, Dabney R, Herman jimmu​nol.​165.1.​373
A, Ngwa W (2018) Enhancing the therapeutic efficacy of cancer Zou S, Kumar U (2018) Cannabinoid receptors and the endocan-
treatment with cannabinoids. Front Oncol 24(8):114. https://​doi.​ nabinoid system: signaling and function in the central nervous
org/​10.​3389/​fonc.​2018.​00114 system. Int J Mol Sci 19(3):833. https://​doi.​org/​10.​3390/​ijms1​
Yu Z, Pestell TG, Lisanti MP, Pestell RG (2012) Cancer stem cells. 90308​33
Int J Biochem Cell Biol 44(12):2144–2151. https://​doi.​org/​10.​ Zuardi AW (2006) History of cannabis as a medicine: a review. Rev Bras
1016/j.​biocel.​2012.​08.​022 Psiquiatr. https://​doi.​org/​10.​1590/​S1516-​44462​00600​02000​15
Zhang Y, Zheng W, Shen K, Shen W (2018) ∆9-tetrahydrocannabinol
inhibits epithelial-mesenchymal transition and metastasis by tar- Publisher’s Note Springer Nature remains neutral with regard to
geting matrix metalloproteinase-9 in endometrial cancer. Oncol jurisdictional claims in published maps and institutional affiliations.
Lett 15(6):8527–8535. https://​doi.​org/​10.​3892/​ol.​2018.​8407

13