The Pharmaceutical Journal Vol 267 No 7169 p510-525
13 October 2001

BPC 2001 summary

Complementary medicines and the treatment of cancer

Introducing the morning session, Jo Barnes, research fellow, centre for pharmacognosy and phytotherapy, School of Pharmacy, University of London, said she was delighted to see complementary medicine on the programme again at the Conference and that this reflected that the area had implications for pharmacists. The theme for the sessions was a topical one as there were reliable data showing that complementary medicines and therapies were often taken by patients with cancer.

Dr SOSIE KASSAB, director of complementary cancer services, Royal London Homoeopathic Hospital (RLHH), focused on the use of preparations of a standardised mistletoe extract (Iscador, Weleda Group) at RLHH for the management of patients with cancer. Dr Kassab emphasised “Iscador is not a miracle cure” and that there is a need to be realistic about what complementary medicine can and cannot treat. Her approach when talking to patients about Iscador treatment is to keep peoples’ hopes up, but not to give false expectations.

The RLHH is encouraging general practitioners to prescribe Iscador preparations on the National Health Service. Sometimes this has led to problems with community pharmacists, some of whom are not aware of these preparations and where to obtain them. Guidance on prescribing Iscador has recently been published.¹

Fermented mistletoe extract

Iscador contains a specially processed fermented aqueous extract of mistletoe (Viscum album) from a range of host trees (see below).

Specific products (prepared from different host trees) are prescribed for different malignancies. The product is normally given by subcutaneous injection into the abdomen or thigh, avoiding inflamed or irradiated areas of skin. Preparations for oral administration are also available.

According to Dr Kassab, there are several ways of monitoring the patients’ responses to Iscador. Self-reporting of symptoms could be used as a guide, as well as objective and subjective assessments of general condition, such as appetite, weight gain, sleep quality and pain. Cutaneous reactions (redness and swelling) at the site of the injection are likely, and are thought to indicate that the patient is responding. A slight increase in temperature following injection can also occur. However, there is no consensus about the most appropriate blood tests to use to monitor therapy.

There have been few reports of suspected adverse drug reactions over the past 30 years. However, this could be due to underreporting. There are “theoretical” interactions between Iscador products and monoamine oxidase inhibitors, interferon and Echinacea preparations. Use with warfarin is contra-indicated.

Immunostimulant effects

Dr MAURICE ORANGE, medical director, Park Attwood Clinic, Worcestershire, described the background and philosophy of anthroposophic medicine, an approach to health and healing developed by Rudolf Steiner (1861–1925), and how the use of mistletoe fits into this approach. Dr Orange said that Iscador could be regarded as an immunostimulant. The main constituents of mistletoe are lectins and viscotoxins. In vitro studies have demonstrated that these compounds may stimulate apoptosis in diseased cells and have necrotic effects, although these activities are difficult to demonstrate in vivo. Iscador is not, however, an alternative to conventional treatment, although some patients choose it over other approaches.

Dr Orange was asked what evidence is available to support the effects of mistletoe in patients with cancer. He referred to a German cohort study involving over 10,000 patients with cancer, including cancers of the colon, rectum, stomach or breast, who had received Iscador, other mistletoe treatment, or who had not been treated with mistletoe.² The results appeared to suggest that survival time was longer for patients treated with Iscador than for patients in the other groups. However, Dr Orange did not discuss the limitations of this study.

Also mentioned in response to the question on evidence was a systematic review of 11 controlled trials of preparations of mistletoe extracts in patients with various cancers, for example, gastric, colorectal and cervical.³ Of these, 10 trials reported results in favour of mistletoe treatment over control treatment, although many of the trials were judged to have methodological limitations. The remaining trial was the one of highest quality. It found no difference between the two groups.

Cancer care

Dr ANDREW MANASSE, clinical lead, Cavendish centre for cancer care, Sheffield, discussed more broadly the role of complementary therapy in the care of patients with cancer. Patients with cancer seeking complementary medicine fall into two groups: those looking for a cure (who seek to use complementary medicine as an alternative to conventional treatment), and those wishing to use complementary medicine in addition to conventional medicine for symptom relief. The majority fall into the latter group, he said.

Based on data collected from the Cavendish centre, Dr Manasse noted that there is no clear relationship between a patient’s diagnosis (ie, the particular type of cancer) and the type of complementary therapy used. This is not surprising as complementary therapies are selected according to patient characteristics which are not diagnosis-related, he said. Dr Manasse emphasised that it is important to realise that complementary medicine is only helpful for patients with cancer when it is used appropriately and by therapists who are suitably trained and experienced.

Dr LEE KAYNE, a community pharmacist from Glasgow, chaired the afternoon session. He said that he regularly dispensed prescriptions for Iscador written by GPs and hospital physicians, and that he was often asked for information on the product, how it worked and what was the evidence to support its use.

Iscador and breast cancer

Mr RAINIER DIERDORF, research and development director, Weleda Group, Switzerland, described an epidemiological study exploring the effects of Iscador in addition to standard cancer treatment (eg, radiotherapy, chemotherapy, hormone therapy), compared with standard cancer treatment alone, in the postoperative treatment of patients with breast cancer. The trial was a multicentre, retrospective, cohort study carried out in Germany and Switzerland. Investigators trawled through medical records to identify eligible patients and extract relevant data (ie, patients who had already received basic cancer therapy, with or without Iscador). The primary efficacy parameter was defined as a reduction in the side effects of standard cancer treatments by Iscador. In total 1,607 patients were included in the study (827 in the treatment group, 780 in the control group). According to Mr Dierdorf, an initial analysis of 1,442 eligible patients suggested that the frequency and severity of side effects of standard cancer treatment were reduced in those patients who had also received Iscador.
— Contributed by Jo Barnes, who chaired the session.

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