Systematic Review on the Cost-Effectiveness of Integrative Oncology
The systematic review by Schad et al. [345] was the first to investigate the cost-effectiveness of integrative oncology interventions within the direct context of the WHO Global Traditional Medicine Strategy 2025–2034. The review was motivated by the increasing global cancer burden and the growing policy relevance of traditional, complementary, and integrative medicine (TCIM). Following PRISMA guidelines, a total of 7,960 publications were screened, and ten health economic studies were ultimately included. These comprised randomized controlled trials, real-world data analyses, and model-based simulations conducted in Europe, Asia, Australia, and the United States. The interventions evaluated included phytotherapeutic approaches such as Viscum album L. (mistletoe therapy), mind-body interventions, psychological support programs, and rehabilitation-based treatment concepts. The findings consistently demonstrated the cost-effectiveness of integrative oncology interventions compared with standard care. Rehabilitation-based and phytotherapeutic approaches showed the most favorable cost-effectiveness profiles, followed by mind-body interventions and psychological programs. The methodological quality of the included studies was generally high. The authors concluded that integrative oncology interventions may not only provide supportive and patient-centered benefits but also have the potential to contribute to more sustainable and value-based cancer care. In the context of the WHO Global Traditional Medicine Strategy 2025–2034, these findings further emphasize the growing health policy relevance of evidence-informed integration of complementary and integrative therapies into modern healthcare systems.
Immunomodulatory Effects of Mistletoe Therapy in the Context of Modern Cancer Treatments
Therapy with Viscum album L. preparations is currently understood as a complex immunomodulatory treatment that may influence both innate and adaptive immune mechanisms [1,5–8]. Preclinical and clinical data suggest that mistletoe lectins, viscotoxins, and polysaccharides can modulate natural killer (NK) cells, dendritic cells, monocytes, and macrophages, among others [1,5]. In addition, effects on cytokine release, apoptosis, and immunogenic cell death have been discussed [1,5–8]. In the context of modern immunotherapies such as PD-1 and PD-L1 checkpoint inhibitors, Viscum album L. is not assumed to act directly on the checkpoint axis itself but rather to improve the immunological prerequisites for an antitumor immune response [1,5,6].
In this context, it has been proposed that both immune checkpoint inhibitors and Viscum album extracts may exert their effects through modulation of innate and adaptive immune mechanisms, albeit via different primary targets. While PD-1 and PD-L1 inhibitors block inhibitory signaling at the T-cell level and thereby reactivate existing antitumor immune responses, Viscum album extracts are thought to act more “upstream,” exerting immunomodulatory effects on dendritic cells, natural killer cells, monocytes/macrophages, and inflammatory signaling pathways [1,5–8]. Consequently, both therapeutic approaches may target immunological mechanisms that are partially complementary.
Particular attention has been given to the potential activation of an immunologically “cold” tumor microenvironment (“immune heating”) through enhanced immune-cell infiltration, improved antigen presentation, and activation of innate immune mechanisms [1,5,6]. In addition, clinical studies and real-world data have reported supportive effects on fatigue, quality of life, and treatment tolerability [5–9]. Current clinical evidence regarding the combination of Viscum album L. and immune checkpoint inhibitors is based predominantly on real-world data [1,5,6]. These studies have thus far demonstrated good tolerability of the combination and, in some cases, favorable effects on patient-reported outcomes [1,5,6].
From an immunological perspective, concomitant corticosteroid therapy is particularly relevant, as it is frequently used in advanced cancer and as supportive medication during systemic treatments [2–4]. Corticosteroids such as dexamethasone exert anti-inflammatory and immunosuppressive effects and may attenuate the activation of NK cells, dendritic cells, and T-cell responses [3,4]. Furthermore, they reduce CD4+ and CD8+ lymphocyte counts and promote changes in the tumor microenvironment toward increased immunosuppression [3,4]. Experimental studies have also shown that dexamethasone may induce a less proliferative, more cytostatic state in tumor cells, potentially rendering them less sensitive to radiotherapy and chemotherapy [2]. In glioblastoma cohorts, corticosteroid use during radiochemotherapy has been associated with reduced overall survival [2,3]. These effects are attributed both to direct alterations in tumor-cell behavior and to clinically relevant immunosuppression [2–4].
Since some of the proposed effects of Viscum album L. are likewise based on immune activation and inflammatory signaling pathways, it is plausible that high-dose or long-term corticosteroid therapy may attenuate certain immunological effects of mistletoe treatment [2–4]. A similar association has also been reported for immune checkpoint inhibitors. Several real-world analyses in non-small cell lung cancer (NSCLC) demonstrated that systemic corticosteroid therapy at the initiation of PD-1/PD-L1 blockade—particularly at doses ≥10 mg prednisone equivalent per day—was associated with reduced treatment response as well as shorter progression-free and overall survival [10–13]. Proposed mechanisms include immunosuppressive effects on T-cell activation, antigen presentation, and innate immune responses [10–13]. These observations support the hypothesis that concomitant corticosteroid therapy may functionally diminish the effectiveness of immunologically active therapeutic approaches, including immune checkpoint inhibition and potentially Viscum album L. therapy.
Overall, current preclinical, translational, and clinical evidence suggests that Viscum album L. may exert immunomodulatory and supportive effects, particularly in the context of modern immunotherapies. However, its clinical effectiveness may be limited by concomitant immunosuppressive treatments such as corticosteroids. Against this background, prospective studies incorporating immune monitoring, biomarker analyses, and standardized documentation of corticosteroid use are warranted to better understand potential synergistic or attenuating interactions between Viscum album L., immune checkpoint inhibition, and supportive medications, and to facilitate the development of more personalized integrative treatment strategies in the future.
References
[1] Schad F, Thronicke A, Hofheinz RD, Matthes H, Grah C. Immune Checkpoint Blockade Combined with AbnobaViscum® Therapy Is Linked to Improved Survival in Advanced or Metastatic Non-Small-Cell Lung Cancer Patients: A Registry Study in Accordance with the ESMO Guidance for Reporting Real-World Evidence. Pharmaceuticals. 2024;17:1713
[2] Pitter KL, Tamagno I, Alikhanyan K, et al. Corticosteroids compromise survival in glioblastoma. Brain. 2016;139(5):1458–1471
[3] Wong ET, Swanson KD. Dexamethasone—Friend or Foe for Patients With Glioblastoma? JAMA Neurol. 2019;76(3):247–248
[4] Chitadze G, Flüh C, Quabius ES, et al. In-depth immunophenotyping of patients with glioblastoma multiforme: impact of steroid treatment. Oncoimmunology. 2017;6(11):e1358839
[5] Thronicke A, Steele ML, Grah C, Matthes B, Schad F. Clinical safety of combined therapy of immune checkpoint inhibitors and Viscum album L. therapy in patients with advanced or metastatic cancer. BMC Complement Altern Med. 2017;17:534
[6] Thronicke A, Schad F, et al. Combined Immune Checkpoint Blockade and Helixor® Therapy in Oncology: Real-World Tolerability and Subgroup Survival (ESMO GROW). Int J Mol Sci. 2025;26(8):3669
[7] Loef M, Walach H. Quality of life in cancer patients treated with mistletoe: a systematic review and meta-analysis. BMC Complement Med Ther. 2020;20(1):227
[8] Freuding M, Keinki C, Micke O, Buentzel J, Huebner J. Mistletoe in oncological treatment: a systematic review. Part 1: survival and safety. J Cancer Res Clin Oncol. 2019;145:695–707
[9] Rostock M. Die Misteltherapie in der Behandlung von Patienten mit einer Krebserkrankung. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2020;63:535–540
[10] Arbour KC, Mezquita L, Long N, et al. Impact of baseline steroids on efficacy of programmed cell death-1 and programmed death-ligand 1 blockade in patients with non-small-cell lung cancer. Journal of Clinical Oncology. 2018;36(28):2872–2878
[11] Ricciuti B, Dahlberg SE, Adeni A, et al. Immune checkpoint inhibitor outcomes for patients with non-small-cell lung cancer receiving baseline corticosteroids for palliative versus nonpalliative indications. Journal of Clinical Oncology. 2019;37(22):1927–1934
[12] Petrelli F, Signorelli D, Ghidini M, Ghidni A, Pizzutilo EG, Ruggieri L, Cabiddu M, Borgonovo K, Dognini G, Brighenti M, De Toma A, Rijavec E, Garassino MC, Grossi F, Tomasello G. Association of Steroids use with Survival in Patients Treated with Immune Checkpoint Inhibitors: A Systematic Review and Meta-Analysis. Cancers (Basel). 2020 Feb 27;12(3):546. doi: 10.3390/cancers12030546
[13] Fucà G, Galli G, Poggi M, et al. Modulation of peripheral blood immune cells by early use of steroids and its association with clinical outcomes in patients with metastatic non-small cell lung cancer treated with immune checkpoint inhibitors. ESMO Open. 2019;4:e000457
Mistletoe therapy contributes to the paradigm shift in integrative oncology
Mistletoe extracts (Viscum album L.) have been used for decades in integrative oncology, yet a paradigm shift has taken place in recent years through the elucidation of their molecular and immunological mechanisms of action. Between 2020 and 2025, decisive advances transformed mistletoe therapy from a primarily empirically applied method into a scientifically validated adjunct to modern cancer medicine.
A review by Hong et al. 2025 shows that mistletoe preparations induce immunogenic cell death, characterized by endoplasmic reticulum stress, increased exposure of calreticulin, translocation of heat shock proteins, and up to a sevenfold release of ATP [344]. In addition, they inhibit key glycolytic enzymes, influence the expression of oncogenes such as Myc, and regulate cell cycle genes via plant-derived microRNAs. On the level of immune modulation, mistletoe preparations shift the balance from immunosuppressive M2 to pro-inflammatory M1 macrophages and enhance the activity of γδ T cells as well as NK cells. These effects are particularly pronounced in 3D culture models, underscoring their clinical relevance.
The authors of the review emphasize that real-world data have played a crucial role in driving this paradigm shift, as they demonstrate consistent survival benefits, improved treatment adherence, and favorable safety profiles when mistletoe extracts are combined with standard and modern cancer therapies. Clinical data confirm that combining mistletoe with modern therapies improves both survival and quality of life. For example, in non-small cell lung cancer, median overall survival doubled when mistletoe was added to PD-1/PD-L1 checkpoint inhibitors, while biomarker-positive subgroups experienced up to a 91% reduction in mortality risk. Further successes were achieved in rectal and pancreatic cancers through synergistic combination therapies. A Phase I trial at Johns Hopkins University also confirmed the safety of intravenous administration. Advances in metabolomics, chronobiology, and AI-assisted analyses are opening new avenues for standardization and individualization.
Overall, the review makes clear that mistletoe therapy is no longer solely part of traditional medicine but is increasingly evolving into an integrative, evidence-based, and precision-oriented component of modern oncology [344].
Mistletoe extract induces immunogenic cell death in vitro
The induction of immunogenic cell death (ICD) is essential for the response to cytoreductive therapies and the initiation of long-term remissions by eliminating the varying degrees of tumour tissue unresponsiveness to the immune system. The resulting cell alterations are associated with apoptotic cell death, autophagy and necroptosis as well as typical intracellular changes such as a stress response of the endoplasmic reticulum (ER) and the induction of reactive oxygen species (ROS). The activation of these signalling pathways can increase the immunogenicity of tumour cells causing the immune system to re-idenify them as a target. Therapeutic ICD stimuli, such as certain chemotherapeutic agents (including anthracyclines), targeted therapies, photodynamic and radiation therapies, activate the ER stress response and apoptosis, leading to the cellular expression of damage associated molecular patterns (DAMPs). In order to investigate whether mistletoe extracts can induce the characteristics of an ICD in cancer cell lines, the present in vitro study was carried out. For this, three human breast cancer cell lines (SKBR3, MDA-MB-231, MCF-7) and one murine melanoma cell line (B16F10) were incubated for 24 or 48 hours with different doses (from 1.25 to 500 µg/ml) of the aqueous, fermented Viscum album extract Iscador Qu (VAE). The ICD-activating paclitaxel (1.25 to 2.5 µM ) and tunicamycin (2.5 to 5 µM) were used as positive controls. To determine if VAE induces ribotoxic stress, the expression of ER stress regulators (p-eIF2a, ATF4 and CHOP), the expression of DAMPS (calreticulin, Hsp70, Hsp90, HMGB1, ATP), apoptosis and the induction of mitochondrial ROS were analysed [342].
In all cell lines, the effect of VAE was concentration-dependent and led to a significantly increased exposure of three DAMPs (calreticulin, Hsp70 and Hsp90) on the surface of early apoptotic cells. Treatment with VAE resulted in phosphorylation of the ER stress protein eIF2α in all tested cancer cell lines and increased calreticulin exposure on the surface of pre-apoptotic SKBR3 breast cancer and B16F10 mouse melanoma cells. The ER stress protein CHOP was significantly induced by VAE (400 µg/ml) in the triple-negative breast cancer cell line MDA-MB-231, but not in the other cell lines. In the breast cancer cell line SKBR3, the expression of the ER stress protein ATF4 was significantly reduced by VAE (20 and 30 µg/ml). In addition, VAE increased mitochondrial ROS production and ATP release. HMGB1 release was not induced by VAE.
In this in vitro study, the potential of a mistletoe extract to induce surrogate markers for immunogenic cancer cell death was demonstrated for the first time.
Effect of Mistletoe Therapy in Combination with Immune Checkpoint Inhibitors in Advanced NSCLC
Immune checkpoint inhibitors (ICIs), such as PD-1/PD-L1 inhibitors (e.g., pembrolizumab, nivolumab, atezolizumab, etc.), have significantly improved survival rates in patients with non-small cell lung cancer (NSCLC). However, ICI resistance remains a challenge, limiting the effectiveness of these therapies. Consequently, efforts continue to enhance the efficacy of ICIs and improve survival outcomes. One potential approach is the combination of immune checkpoint blockade (ICB) with adjuvant mistletoe therapy, which is increasingly being recognized as an integrative component in oncology. Recent real-world data (RWD) studies from a German oncology registry (Netzwerk Onkologie, NO) reveal promising results for the combination of ICIs with mistletoe preparations, highlighting their potential as an integrative approach in oncology.
In an RWD study involving 415 patients, the combination of ICI therapy and mistletoe therapy was associated with a significant survival benefit. Patients receiving this combination achieved a median overall survival of 13.8 months compared to 6.8 months in patients receiving ICI therapy alone. Analyses revealed a 40% reduction in mortality risk (adjusted hazard ratio, aHR: 0.60; 95% confidence interval, 95% CI: 0.43–0.85; p = 0.004), with an even greater effect observed in PD-L1-positive patients receiving first-line therapy (56% risk reduction; HR: 0.44; 95% CI: 0.26–0.74; p = 0.002) [332]. In a second RWD study examining a combination of ICIs with the mistletoe preparation abnobaVISCUM, an even greater effect was observed, with a 75% risk reduction in PD-L1-positive patients receiving first-line therapy (aHR: 0.25; 95% CI: 0.11–0.60, p = 0.02) [340].
The potential synergistic effects observed in this real-world study between ICI and mistletoe therapy are attributed to the complementary immunomodulatory and pro-apoptotic properties of mistletoe therapy. Mistletoe therapy may, among other effects, reduce PD-L1 expression, thereby enhancing the efficacy of PD-1/PD-L1 inhibitors, as well as target tumor cells by inhibiting signaling pathways such as the AKT/β-catenin axis. However, these hypotheses require further experimental validation.
A key advantage of this real-world study is its practical, real-world perspective on the effectiveness of integrative oncology approaches. It is the first study to demonstrate a positive correlation between the combination of PD-1/PD-L1 inhibitors and mistletoe therapy (specifically, abnobaVISCUM in the second publication) with prolonged survival in NSCLC patients. However, the non-randomized design of the study limits its validity, as patient group allocation could be influenced by various patient characteristics, potentially leading to bias. Nevertheless, potential confounders were accounted for using multivariable logistic regression methods.
The findings underscore the potential of mistletoe therapy as an adjunct to ICI therapy, particularly in patients with PD-L1-positive tumors. Prospective, randomized trials are necessary to confirm the observed effects and further investigate the mechanisms underlying this synergy.
New book publication
Vademecum of Anthroposophic Medicines
The fully updated and expanded Vademecum of Anthroposophic Medicines was published in October 2024 in two coloured volumes with more than 1,900 pages and more than 200 images.
Volume 1 lists 1,976 medical indications and 678 medicinal products with detailed information on formulation, pharmaceutical form, dosage and authorised indications.
All information is based on the currently available product ranges from manufacturers and magistral pharmacies.
Volume 2 about mistletoe therapy has been extensively restructured and expanded by the oncologist Dr. Marion Debus. In the first part, the main oncological clinical pictures such as skin, brain, ear, nose and throat, thoracic and gastrointestinal cancers, neuroendocrine neoplasias and cancers, breast cancer, gynaecological cancers, renal cell cancer, bladder cancer, prostate cancer, lymphomas and sarcomas are described in detail. In addition, the specific main principle, the efficacy of mistletoe therapy according to clinical trials, the presentation of drug therapy concepts and significant case vignettes are presented and the most important scientific publications are referenced. The second part of the second volume describes the principles and usage of mistletoe therapy in the context of individualised, patient-centred integrative oncology. Preparation selection, dosage, application, effect and, if necessary, side effect management as well as human aspects are described in detail. The third part gives an introduction to the substances, pharmaceutical processes and active principles of anthroposophic pharmacotherapy.
The Vademecum is equally suitable for beginners and advanced users and provides comprehensive orientating, informative and practical information.
The two coloured volumes with free access to the web app for 12 months are available for 98.00 euros plus shipping costs at https://shop.vademecum.org/. A personalised QR code, which can be found on the bookmark in the first volume, leads to the online version of the vademecum.
Lung cancer
Combination of Viscum album L. therapy with immune checkpoint inhibitors in patients with advanced or metastatic non-small cell lung cancer: a real-world data study
Immunotherapy with PD-1/PD-L1 inhibitors has been shown to significantly improve the survival rates of non-small-cell lung cancer (NSCLC) patients in advanced or metastasised stages. Therefore, the overall survival data of these patients were analysed in this Real-World Data (RWD) study in order to assess the influence of add-on mistletoe therapy to treatment with PD-1/PD-L1 inhibitors on the clinical outcome [332]. IA total of 415 patients were included in the study, 193 receiving anti-PD-1/PD-L1 therapy combined with mistletoe extracts and 222 receiving anti-PD-1/PD-L1 therapy alone (control group). The patients in the combinatorial group lived seven months longer (median overal survival 13.8 months) in comparison to the control group (median overal survival 6.8 months) and the adjusted hazard of death was reduced significantly by 40 percent. It was reduced by further 16 percent in patients with PD-L1-positive tumours (tumour cell proportion value ≥ 1%) who received first-line anti-PD-1/PD-L1 therapy and add-on mistletoe therapy.
Pancreatic cancer
Patients with advanced pancreatic cancer treated with mistletoe and hyperthermia in addition to palliative chemotherapy: a retrospective single-centre analysis
Despite advances in treatment, pancreatic cancer remains associated with poor survival rates. Therefore, in this monocentric retrospective analysis conducted at the Medical Faculty of Heidelberg University, the influence of mistletoe therapy and hyperthermia in addition to chemotherapy in patients with advanced or metastatic pancreatic cancer was investigated [331]. Of a total of 206 patients, 142 were included in the survival analysis. Twenty-five of these received chemotherapy alone, 48 received combined chemotherapy/mistletoe therapy, 50 received combined chemotherapy/mistletoe therapy plus hyperthermia and 1 chemotherapy plus hyperthermia. The median survival times with additional mistletoe therapy of 11.2 months (p = 0.02) and with additional mistletoe and hyperthermia of 18.9 months (p < 0.001) were significantly longer compared to treatment with chemotherapy alone (8.6 months). While the survival times of the group treated only with chemotherapy compare well with data from pivotal trials and register data, the results of the study suggest that the additional use of mistletoe therapy and hyperthermia could significantly improve survival in advanced pancreatic cancer compared to chemotherapy alone. However, due to the retrospective study design and the limited sample size, further prospective studies are needed to confirm these results.
Lung cancer
Evaluation of quality of life in lung cancer patients receiving radiation and Viscum album L.: a real‑world data study
This monocentric real-world data study included patients with histologically confirmed primary lung cancer who had evaluable data sets on self-reported quality of life available at least at the time of initial diagnosis (T0) and 12 months later (T1) [320]. A total of 112 patients were included, with 27 patients who received neither radiotherapy nor mistletoe therapy serving as the reference group, 29 patients who received mistletoe therapy without radiotherapy, 32 patients who received radiotherapy but no mistletoe therapy and 24 patients who received both radiotherapy and mistletoe therapy. The assessment of changes in quality of life (EORTC-QLQ C30) after 12 months showed a significant improvement of 27 points for pain ( p = 0.006) and 17 points for nausea/vomiting (p = 0.005) in patients who received radiotherapy and mistletoe therapy. Significant improvements of 15 to 21 points for role function (p = 0.03) as well as physical (p = 0.02), cognitive (p = 0.04) and social functioning (p = 0.04) were also observed in patients who received mistletoe therapy but no radiotherapy. Further information can be found under Clinical studies/Lung cancer.
Meta-analysis on mistletoe therapy for breast cancer
Quality of life in breast cancer patients treated with mistletoe extracts: a systematic review and meta-analysis
With breast cancer being the most common type of cancer in women, this meta-analysis investigated for the first time whether mistletoe extracts, which are already listed in several cancer guidelines, can also improve the quality of life of breast cancer patients. For this purpose, randomised clinical trials (RCTs) and non-randomised studies of intervention (NRSIs) were included to compare the quality of life of breast cancer patients treated with standard of care plus add-on mistletoe extracts to control groups treated with standard of care only. Nine RCTs with 833 and seven NRSIs with 2,831 patients were included. A medium effect size on the quality of life of breast cancer patients with low heterogeneity between the studies was found, with an effect size comparable to or even larger than other interventions such as physical activity. Further information can bei found under Meta-analyses and systematic reviews oder Clinical studies/Breast cancer.
Breast cancer and other gynecological tumors
Safety study on combined administration of targeted therapy with mistletoe extracts (Helixor) in breast cancer and other gynecological tumors
A first clinical experience with additive mistletoe therapy (Helixor) to targeted therapy in 242 patients with breast cancer or other gynecologic cancer entities is now available (216). In a Real-World Data study (RWD study) from the Network Oncology Registry, in which one group of patients received only targeted therapies (n=160) and the other additionally mistletoe therapy (n=82), the side effect rate as well as dose reduction adjustments and therapy discontinuations of the targeted therapy including monoclonal antibodies, tyrosine kinase inhibitors, checkpoint inhibitors, CDK4/6 inhibitors or PARP inhibitors were determined in both groups. It was found that the additional mistletoe therapy did not change the side effect rate of the targeted therapy. Furthermore, no adverse events and a trend towards better adherence to targeted therapy were observed in the group receiving the combined therapy (targeted therapy plus mistletoe extracts). This RWD study is the first of its kind to also highlight the safety profile of newer targeted therapy groups such as CDK 4/6 inhibitors as well as PARP inhibitors in combination with mistletoe extracts. Overall, the data indicate that additional mistletoe therapy with Viscum album L. extracts does not alter the safety profile of targeted therapy in breast cancer and other gynecologic tumors. Further studies involving combined therapy in additional tumor entities are planned.
Chylous ascites ssociated with pancreatic duodenectomy
Sclerotherapy of chylous ascites associated with pancreatic duodenectomy by intraperitoneally injected Viscum album L.
A 56-year-old female patient with diabetes mellitus, chronic B-virus hepatitis, and subclinical hypothyroidism was diagnosed with a well-differentiated, resectable adenocarcinoma in the pancreatic head and so-called at ampulla of Vater (317). After robot-assisted pylorus-preserving pancreatic head resection, the pathologic findings of the tumor (2.2 x 1.8 cm) revealed a moderately differentiated infiltrating adenocarcinoma of the pancreas with lymphatic and perineural invasion. After surgery, the patient recovered well and was discharged. On day 19 after surgery, the patient was re-admitted to the hospital for chylous ascites as a result of a surgically induced lymphatic vessel injury. During the course of the examinations, the drainage fluid had a milky straw color with a serum ascites albumin ratio of 1.3 g/dL. Ascitic drainage, albumin substitution, and the administration of diuretics and lipid-lowering agents was started. Furthermore, the administration of octreotide and parenteral nutritional adjustments with the aim to improve portal pressure was performed. After initial worsening of ascites, the patient was returned to a general diet on day 89 after surgery. In addition, on days 94, 97, 110, 115, 126, 129, and 132 after surgery, extracts of abnobaVISCUM in increasing doses were injected intraperitoneally through the drainage for lymphatic sclerosis ("Viscum shooting"). At this stage surgical management was excluded due to a predicted morbidity risk of the patient. While ascitic fluid turned a serous color on day 94 after surgery, the amount of drained ascitic fluid also decreased during subsequent mistletoe injections until day 132. The patient was discharged from the hospital in good general condition and showed no signs of recurrence even on day 156 after surgery and at 3-month follow-up. This is the first published case on the treatment of chylous ascites and off-label injection with abnobaVISCUM extracts as a minimally invasive sclerotherapy with only minor side effects.
New systematic review and meta-analysis confirm reduction of cancer-related fatigue with mistletoe extracts
A cancer-related fatigue syndrome (CRF) develops as a result of cancer or therapy, is characterized by tiredness or exhaustion (being not proportional to recent physical activity) and represents one of the most burdensome symptoms in cancer patients. Tiredness and exhaustion do not diminish even with sufficient sleep and can have a strong impact on life. The first-line therapy includes physical activity and psychosocial interventions. According to the S3-Guideline on Complementary Medicine in Oncological Patients, physical activity and sports, tai chi and qigong as well as yoga are recommended as non-pharmacological interventions. Sports and physical activities are not always manageable by oncological patients, e.g. by cachectic patients. Currently, methylphenidate is the only pharmacological treatment with evidence in improving CRF, however consensus on its recommendation against cancer-related fatigue seems to be unclear. Thus, further pharmacological and non-pharmacological solutions are needed. Although a large number of studies have documented positive effects of mistletoe extracts (Viscum album L) in the treatment of cancer-related fatigue, no meta-analysis has so far analysed their results in relation to clinical trials, including non-randomised intervention studies and all types of CRF questionnaires.
Recently (March 2022) a systematic review was published in the journal “Supportive Care in Cancer” on the effect of mistletoe therapy on cancer-related fatigue by Florian Pelzer, Martin Loef, David D. Martin and Stephan Baumgartner [314]. Two random-effect meta-analyses (one with 12 randomised controlled trials and one with 7 non-randomised studies of intervention) were performed. The effect sizes analysed were moderate (randomized: SMD=-0.48, p=0.006) and moderate to large (non-randomised: OR=0.36, p=0.0008). Sensitivity analyses were performed revealing robust results but high inter-study heterogeneity, possibly driven by variances in study population and methodology. Analyses reveal as well that the risk of bias was high for 11 of 12 randomised and serious for all non-randomised trials (confounding risk).
Despite a risk of bias in the included studies, the results of the systematic review and the meta-analyses indicate that mistletoe therapy can statistically significantly reduce cancer-related fatigue compared to the control group. Mistletoe therapy can be recommended as an add-on to physical activity. More information you will find here.
Rectal cancer
Effect of mistletoe extract on tumor response in neoadjuvant chemoradiotherapy for rectal cancer: a cohort study
In this retrospective monocentric observational study the influence of an oak mistletoe extract on the response to neoadjuvant chemoradiotherapy (NCRT) was investigated in 52 patients with locally advanced rectal cancer [318]. Fifteen patients additionally received mistletoe therapy and 37 only chemotherapy. A significantly better tumour response in terms of complete tumor remission was observed in the group with NCRT and add-on mistletoe therapy compared to the group with NCRT only (53.3 % vs. 21.6 %, p = 0.044). In addition, the downstaging was significantly higher in the group with the NCRT plus add-on mistletoe therapy (86.7% vs. 56.8%, p = 0.040). More detailed information you can find under mistletoe therapy for colorectal cancer.
