Frequently asked questions and answers
Here you will find a summary of the most important questions and answers on mistletoe therapy for cancer. Click on the grey fields below to view the individual questions. The answers are based on the practical experience of physicians and the results of clinical studies. If your doctor's recommendation differs from the statements made here, you should talk to him about it.
The questions and answers are structured into three major issues:
General questions
What is the status of mistletoe therapy in the concept of holistic cancer therapy?
Mistletoe therapy is an essential part of holistic, i.e. integrative cancer therapy and is intended to be an addition to conventional medical treatment. For example, surgery, chemotherapy, antibody therapy, immunotherapy, radiotherapy and/or (anti)-hormone therapy are established standard methods for treating cancer, which can be usefully combined with additional methods such as mistletoe therapy. The aim of mistletoe therapy is primarily to improve the patient's health-related quality of life. Treatment with mistletoe preparations is most successful the earlier it is initiated.
How long are mistletoe preparations available?
Mistletoe preparations have been used to treat cancer for more than 100 years and are one of the most frequently used herbal medicines in cancer medicine.
What are mistletoe preparations made from?
Mistletoe preparations are aqueous total extracts of the white berried mistletoe (Viscum album L.) from various host trees such as apple tree, oak, ash, pine, fir and elm. More detailed information can be found under the specifications of the various manufacturers.
Why are mistletoe preparations from different host trees available?
Mistletoes are supplied with nutrients by their host tree and therefore differ in their constituents depending on the tree on which they are grown. Depending on the tumour type, mistletoe extracts from different host trees are used to gain the optimal effect at the best possible tolerability.
Are there differences between the mistletoe preparations from different manufacturers?
Yes, they differ in the pharmaceutical processes used by the manufacturers and consequently in their composition. When changing to a different mistletoe preparation, you must therefore follow the same procedure as for starting with the mistletoe therapy. More detailed information can be found under the specifications of the various manufacturers.
Which mistletoe preparation is the right one?
There is no "right" or "wrong" mistletoe preparation. The most common criteria for selecting the mistletoe extract are the type and stage of the tumour, the patient's individual symptoms and situation and, above all, the question of what the mistletoe therapy is intended to achieve. With this background, the best preparation should be determined. People who are sensitive to pharmaceuticals should initially receive a particularly low-dose mistletoe preparation - some manufacturers offer special ranges of preparations with particularly low initial concentrations (so-called series).
What active substances does mistletoe contain?
Mistletoe contains various active substances. Some, such as mistletoe lectins and viscotoxins, have been analysed thoroughly in preclinical studies with regard to their effect in cancer therapy. It also contains peptides, oligo- and polysaccharides, numerous enzymes, sulphur-containing compounds, plant pigments (flavonoids), lignans, triterpenes and other protein compounds, so that the real effect of the total mistletoe extract can only be achieved through the combined action of the individual active substances. Further information on this can be found in the chapter on constituents and their mode of action.
What effects can be observed?
Mistletoe lectins and viscotoxins have a cytotoxic and immunomodulating effect: in vitro studies (in test tubes) have shown that the effect of mistletoe lectins is based on the inhibition of ribosomal protein synthesis and the initiation of natural cell death (apoptosis), while viscotoxins dissolve the cell membrane and thus have a cytolytic effect. The immunomodulating effect of mistletoe extracts is due to the increase in the number and activity of natural killer cells (NK cells) and the increase in the phagocytosis activity (absorption of a larger particle or a cell by another cell) of the granulocytes. The mood-lifting and pain-reducing effect is based on an increased release of beta-endorphins by the body after administration of mistletoe extracts.
Which studies have been carried out on mistletoe therapy?
To date, there are more than 160 clinical studies on the use of mistletoe preparations for various types of tumours available. The results of the majority of studies show an advantage for mistletoe therapy. This indicates that mistletoe preparations are the best-studied drugs in integrative oncology.
What are the indications for mistletoe preparations?
Mistletoe preparations can be used for malignant and benign tumour diseases, for defined precancerous conditions and for recurrence prophylaxis (prevention of relapses) after surgery of the tumour.
What therapeutic effects have mistletoe preparations?
Mistletoe preparations improve the general state of health by
- increase in appetite and weight
- normalisation of sleep, sensation of warmth and performance
- improvement of mental state such as mood, courage to face life, ability to take initiative
- alleviation of tumour-related pain
Mistletoe preparations inhibit the growth of malignant cells in vitro without affecting healthy tissue and thus also serve to prevent relapses. They also increase the body's own immune defence by stimulating bone marrow activity, for example, and thus reduce susceptibility to infection.
Practical use
When should mistletoe therapy be started?
Mistletoe therapy is possible at different times in a treatment plan and at different stages of the disease. However, it is advisable to start therapy early, i.e. immediately after diagnosis or before surgery if this is planned. As mistletoe therapy stimulates the immune system and can therefore boost the body's defense, the body is well prepared for the stress that surgery can place on the organism. However, mistletoe therapy can also be started when metastases have already appeared in order to improve the quality of life and strengthen the immune system, which can result, for example, in an increase in appetite and weight, normalisation of sleep quality and stimulation of the vital forces.
Where and how are mistletoe preparations given?
Mistletoe preparations are injected under the skin (subcutaneously), which can also be carried out by the patients themselves after training. In the case of superficial tumours, injections can be made close to the tumour or metastasis, otherwise injections are made at ever-changing injection sites such as the abdominal skin or possibly the thigh. Care must be taken not to inject into inflamed areas of skin or radiation fields where radiotherapy is being carried out at the same time. Cannulas with 0.4 x 19 mm (No. 20) and a 2 ml syringe are recommended here. Mistletoe extracts are also sometimes administered intravenously or injected directly into the tumour (instilled), although there are no official approvals for these forms of application (off-label use).
Do mistletoe preparations always have to be injected?
Mistletoe preparations are approved for subcutaneous injection. In the form of tablets or drops, the protein-containing mistletoe extracts would be "digested" in the stomach and thus become ineffective.
Is the injection painful?
No, at most you will feel a small prick, as the needle used for the injection is very fine and thin. It may be slightly painful if the injection is accidentally given into the skin (intracutaneously) instead of under the skin or if a nerve end is hit. To avoid this, you should be shown how to inject correctly at the start of therapy, as there are a few tricks and tips on how to inject with minimal pain.
Hardening forms at the injection site. Why does this happen?
The hardening is called induration and is caused by the migration of white blood cells into this region. This induration disappears within a few days, usually the day after the injection.
How often are mistletoe preparations injected?
Mistletoe preparations are usually injected two to three times a week. Individual adjustments are made by the treating practitioner. In the first year of treatment, an injection rhythm of three times a week without a break (e.g. Monday, Wednesday, Friday) has proven successful.
At what time of day are mistletoe preparations injected?
If the aim is to stimulate the organism's activity, it is advisable to inject when the body temperature is rising, i.e. between 7 and 9 in the morning. If the warming side of mistletoe is more important, it is advisable to inject at the time of maximum body temperature, i.e. in the evening between 5 and 6 pm. In principle, it is possible to alternate between the two methods. After the injection, you should rest for approx. 30 minutes.
Are there any adverse effects or interactions with other therapies or medications?
No adverse effects or interactions are known to date. Mistletoe therapy can be carried out during chemo-, radiotherapy, (anti)-hormone, antibody y or immunotherapy. In laboratory tests on tumour cells and in practice, no negative effects of mistletoe preparations have been found with the standard chemo and (anti)-hormone therapies. The studies available to date also show that mistletoe therapy can be combined with chemo-, radiotherapy, hormone and antibody therapies, e.g. to minimise their undesirable effects. It was found that the additional mistletoe therapy did not change the side effect rate of the immunotherapy.
What are the effects of mistletoe therapy in the various stages of treatment?
Surgery
As mistletoe therapy may have an immunomodulating effect, it can also be started before a planned surgery (e.g. 14 days before the date of the surgery). Mistletoe therapy is thought to be able to help compensating for the weakening effect of the surgery on the immune system. Approximately 10 days should pass after surgery for wound healing before treatment is continued.
Chemo-/radiotherapy
Mistletoe therapy can be carried out in addition to chemo-/radiotherapy (neo-adjuvant, i.e. before surgery, as well as after surgery, if such is planned) in order to improve tolerability and to alleviate disease- and therapy-related symptoms, which leads to a faster recovery. After these procedures have been completed, mistletoe therapy can be continued for a longer period of time as part of aftercare.
Can mistletoe preparations be administered simultaneously with pain medication?
Mistletoe preparations can be combined with all common pain medications. However, preparations containing the active ingredients diclofenac or ibuprofen should be avoided if possible, as these substances can lead to an undesirable inhibition of the immunomodulating mistletoe effect.
Can mistletoe therapy alleviate pain?
It may be possible to reduce the dose of pain medication during mistletoe therapy. The intensity of the pain depends on the tumour growth, general condition and physical condition. As the patient's condition improves and energy levels return, the pain will also decrease.
How long does the treatment last?
Mistletoe therapy is continued for as long as the tumour disease persists. In addition, it has proven successful to continue the therapy depending on the risk of recurrence (relapse risk). In most cases, this means continuing the therapy from the time of diagnosis or after the surgery. The intensity and duration of treatment must be discussed with the therapist responsible/accompanying the patient on an ongoing basis.
What are the signs of effective dosing?
Reddening of the skin (also with hardening, itching, swelling or overheating) up to a maximum of 5 cm around the injection site or an increase in temperature up to 38°C may occur. If laboratory parameters are analysed, the increase in leukocytes, especially absolute lymphocytes and, at the start of therapy, eosinophils, is an indication of the positive effect of mistletoe therapy. Furthermore, an improvement in general well-being can usually be observed, which can be accompanied by an increase in appetite and weight, normalisation of sleep, sensation of warmth and performance, reduced susceptibility to infections, a brightening of mood or an increase in courage, self-regulation and initiative. It is to be expected that the local reactions will weaken or disappear in the course of mistletoe therapy.
Do blood levels need to be checked?
Blood levels (differential blood count) are usually determined at the start of mistletoe therapy and checked repeatedly at longer intervals during the course of treatment. However, such laboratory checks are not mandatory. Each doctor decides which tests are necessary in each individual case based on the disease situation.
Does mistletoe therapy affect the tumour markers?
The tumour markers change depending on the course of the disease. If the general condition improves or the tumour decreases in size during mistletoe therapy, the tumour markers may also decrease again.
Side effects
Do mistletoe therapy have side effects, and if yes, which ones?
Side effects cannot be excluded. However, significant adverse effects have rarely been observed with mistletoe therapy when used according to the instructions. If the dosage is too high, so-called excessive local reactions in form of reddening of the skin (sometimes also with hardening and swelling) with a diameter of more than 5 cm are possible. In this case, treatment should only be continued after the symptoms have subsided and at a reduced dose in consultation with the responsible practitioner. The same applies to strong general reactions such as an increase in body temperature to above 38°C. In this case a clarification by the practitioner is also indicated. In rare cases, subcutaneous nodules may form at the injection site.
Allergic reactions are very rare. They can usually be treated by administering antihistamines and temporarily discontinuing mistletoe therapy. Anaphylactic reactions are observed even more rarely.
Mistletoe extracts do not damage the liver (no hepatotoxicity).
How are local reactions differentiated from side effects
A slight reddening and possibly itching at the injection site as well as a moderate rise in body temperature are expected reactions and not signs of intolerance. However, if the local inflammatory reactions at the subcutaneous injection site exceed 5 cm in diameter or the temperature rises above 38°C, a break is indicated until the symptoms have subsided and then the dose should be reduced.
What should be done if the next injection is needed but the redness has not yet subsided?
Normally, injections are always given in alternating areas. Nevertheless, you should wait until the redness from the previous injection has completely subsided before giving the next injection, as otherwise the remaining redness could become so intense that a painful inflammatory reaction develops. Redness that does not subside within two days is often larger than five centimetres and is therefore an indication that the dose of mistletoe extract is too high or that the injection was given incorrectly.
Is the skin redness an allergy?
No, reddening up to a diameter of 5 cm at the injection site is a sign that the immune system is responding to mistletoe therapy.
The red spot itches - is this an indication of an allergic reaction?
No, this is not yet an indication of an allergy. The itching can occur when the localised mild inflammation caused by the mistletoe extract subsides.
Is it harmful if mistletoe therapy causes a fever?
An increased temperature up to 38°C is desirable because the organism is stimulated to regulate the body temperature. This ability is often weakened in cancer patients. Many cancer patients who are always shivering feel comfortably warmed after subcutaneous mistletoe therapy. If temperatures above 38°C persist for more than 3 days, an infectious process or tumour fever should also be considered and mistletoe therapy should therefore be discontinued.
If a higher fever (up to 39.5°C) develops as part of a mistletoe infusion or subcutaneous mistletoe administration with a higher dosage, this may be therapeutically useful. However, this type of therapy is an off-label use and should therefore always be carried out under medical supervision. If the body temperature remains above 38°C for more than three days, a doctor should be consulted.
Can mistletoe therapy promote tumour growth?
No. There is no evidence, neither in laboratory tests nor in the 160 clinical studies that have now been conducted, that mistletoe therapy could promote tumour growth.
When should mistletoe therapy not be used?
Mistletoe therapy should not be used if
- an allergy to mistletoe preparations is known
- acute inflammatory or highly febrile diseases (e.g. pneumonia or infection of the urinary tract): treatment should be discontinued until the signs of inflammation have subsided
- there are persistent infections of the skin, lungs, lymph nodes, nose, urinary tract, mouth and intestines and active autoimmune diseases that are being treated with immunosuppressive therapies
- hyperthyroidism with heart palpitations
exists.
Can mistletoe preparations be used during pregnancy or breastfeeding?
There are no adequate animal studies on the effects of mistletoe preparations on pregnancy, birth and the development of the child after birth, especially on the development of haematopoiesis and the immune system in the unborn child/infant. The possible risk for humans is therefore not known.
