Viscum album L. extracts in breast and gynaecological cancers: a systematic review of clinical and preclinical research

  • Gunver S Kienle1Email author,

    Affiliated with

    • Anja Glockmann1,

      Affiliated with

      • Michael Schink2 and

        Affiliated with

        • Helmut Kiene1

          Affiliated with

          Journal of Experimental & Clinical Cancer Research200928:79

          DOI: 10.1186/1756-9966-28-79

          Received: 06 March 2009

          Accepted: 11 June 2009

          Published: 11 June 2009

          Abstract

          Background

          Viscum album L. extracts (VAE, European mistletoe) are a widely used medicinal plant extract in gynaecological and breast-cancer treatment.

          Methods

          Systematic review to evaluate clinical studies and preclinical research on the therapeutic effectiveness and biological effects of VAE on gynaecological and breast cancer. Search of databases, reference lists and expert consultations. Criteria-based assessment of methodological study quality.

          Results

          19 randomized (RCT), 16 non-randomized (non-RCT) controlled studies, and 11 single-arm cohort studies were identified that investigated VAE treatment of breast or gynaecological cancer. They included 2420, 6399 and 1130 patients respectively. 8 RCTs and 8 non-RCTs were embedded in the same large epidemiological cohort study. 9 RCTs and 13 non-RCTs assessed survival; 12 reported a statistically significant benefit, the others either a trend or no difference. 3 RCTs and 6 non-RCTs assessed tumour behaviour (remission or time to relapse); 3 reported statistically significant benefit, the others either a trend, no difference or mixed results. Quality of life (QoL) and tolerability of chemotherapy, radiotherapy or surgery was assessed in 15 RCTs and 9 non-RCTs. 21 reported a statistically significant positive result, the others either a trend, no difference, or mixed results. Methodological quality of the studies differed substantially; some had major limitations, especially RCTs on survival and tumour behaviour had very small sample sizes. Some recent studies, however, especially on QoL were reasonably well conducted. Single-arm cohort studies investigated tumour behaviour, QoL, pharmacokinetics and safety of VAE. Tumour remission was observed after high dosage and local application. VAE application was well tolerated. 34 animal experiments investigated VAE and isolated or recombinant compounds in various breast and gynaecological cancer models in mice and rats. VAE showed increase of survival and tumour remission especially in mice, while application in rats as well as application of VAE compounds had mixed results. In vitro VAE and its compounds have strong cytotoxic effects on cancer cells.

          Conclusion

          VAE shows some positive effects in breast and gynaecological cancer. More research into clinical efficacy is warranted.

          Background

          Breast and gynaecological cancers (i.e. ovarian, endometrial, cervical, vaginal, vulval, and fallopian cancers) account for a significant amount of morbidity and mortality in women. In Europe an estimated 429,900 cases were diagnosed as breast cancer in 2006 (13.5% of all cancer cases) and 131,900 died from it, despite substantially improved treatment options (surgery, chemotherapy, radiation, hormonal and targeted therapies) [1]. Of female cancer survivors more than half had suffered from breast or gynaecological cancer [2].

          40% to 80% of these patients use complementary therapies additionally to well-established treatments [38]. This includes a variety of medicinal plants, but also acupuncture, psychosocial support, yoga, art therapies and others. These are supportive measures to control symptoms, improve quality of life, boost the immune system, and possibly prolong life. Sufficient evaluation is often lacking, however, of the extent to which these therapeutic goals are achieved, as well as of issues relating to safety and mode of action. Medicinal plants in particular have a long history in the treatment of cancer and other conditions connected with tumours, and also play a major role in the development of new drugs today. Over 60% of currently used anti-cancer agents originally derive from natural sources such as plants, marine organisms and micro-organisms [9].

          Across Europe, Viscum album L. extracts (VAE or European mistletoe, not to be confused with the Phoradendron species or "American mistletoe") are among the most common herbal extracts applied in cancer treatment [3, 7, 8, 10]. Viscum album is a hemi-parasitic shrub and contains a variety of biologically active compounds. Mistletoe lectins (ML I, II and III) have been most thoroughly investigated. MLs consist of two polypeptide chains: a carbohydrate-binding B-chain that can bind on cell surface receptors, which enables the protein to enter the cell [1113]; and the catalytic A-chain which can subsequently inhibit protein synthesis, due to its ribosome-inactivating properties, by removing an adenine residue from the 28S RNA of the 60S subunit of the ribosome [11]. Other pharmacologically relevant VAE compounds are viscotoxins and other low molecular proteins, VisalbCBA (Viscum album chitin-binding agglutinin) [14], oligo- and polysaccharids [15, 16], flavonoids [17], vesicles [18], triterpene acids [19], and others [20, 21]. Whole VAE as well as several of the compounds are cytotoxic and the MLs in particular have strong apoptosis-inducing effects [2224]. MLs also display cytotoxic effects on multidrug-resistant cancer cells (e.g. MDR+ colon cancer cells [25]) and enhance cytotoxicity of anticancer drugs [26, 27]. In mononuclear cells VAE also possess DNA-stabilizing properties. VAE and its compounds stimulate the immune system (in vivo and in vitro activation of monocytes/macrophages, granulocytes, natural killer (NK) cells, T-cells, dendritic cells, induction of a variety of cytokines such as IL-1, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, GM-CSF, TNF-α, IFN-γ (overview see [20, 21]). The cytotoxicity of human natural and lymphokine-activated killer cells, for instance, can be markedly enhanced in vitro by VAE rhamnogalacturonans, which bridge these killer cells with NK-sensitive or insensitive tumour cells [28, 29]. Furthermore, VAE seem to interfere with tumoural angiogenesis [30, 31]. Injected into tumour-bearing animals, VAE and several of their compounds (MLs, a 5 kDa protein not specified further, protein complexes isolated by Vester and colleagues, oligosaccharids) display growth-inhibiting and tumour-reducing effects [20, 21]. Despite extensive experimental analyses of their biological properties, many questions regarding the precise mode of action of VAE still remain.

          For clinical application VAE are made from mistletoes grown on different host trees [Host trees of VAE: Fir (Abies, A); maple (Acer, Ac); almond tree (Amygdalus, Am); birch (Betula, B); whitethorn (Crataegus, C); ash tree (Fraxinus, F); appletree (Malus, M); pine (Pinus, P); poplar (Populus, Po); oak (Quercus, Qu); willow (Salix, S); lime (Tilia, T), elm (Ulmus, U)], either by aqueous extraction, partly combined with fermentation, or by pressing procedures. Depending on host tree, harvesting time and extraction procedure, VAE vary in regard to their active compounds and biological properties. Different commercial VAE preparations are available, and a recombinant ML (rML) drug is currently being developed and tested in clinical trials [32, 33].

          Clinical effects of VAE in cancer have been investigated in a variety of studies and assessed in systematic reviews [3439]. These reviews, however, had inconsistent results, they are outdated, incomplete or concentrate on partial aspects. No review has yet assessed clinical and preclinical effects specifically and comprehensively for breast and gynaecological cancer, although there is widespread usage in these patients [3, 7]. Our primary aim was therefore to assess the potential therapeutic effectiveness of VAE, and their potential biological effects on breast and gynaecological cancer in clinical and preclinical studies.

          Methods

          Design

          Systematic review of clinical and preclinical studies investigating the influence of VAE on breast or gynaecological cancer.

          Search strategy

          We used a systematic process to search the following databases for clinical trials – AMED, Biosis Previews, Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, The NHS Economic Evaluation Database, Health Technology Assessment Database), Embase, Medline/Premedline, NLM Gateway, private databases – from inception of these databases to December 2008 using the terms (MISTLETOE OR VISCUM? OR MISTEL? OR ISCADOR? OR ISCAR OR HELIXOR OR ABNOBA? OR ISCUCIN OR ISOREL OR VISOREL OR ?SOREL OR WELEDA OR WALA OR EURIXOR OR LEKTINOL OR PLENOSOL OR AVISCUMINE) AND (STUDY? OR STUDIE? OR TRIAL OR EVALUAT? OR RANDOM? OR INVESTIG? OR COHORT? OR KOHORT? OR OUTCOME?). The reference list from each potentially eligible study, relevant review article and textbook was checked, and experts in the field and manufacturers of mistletoe preparations were contacted for additional reports.

          Regarding in vitro or in vivo (animal) experiments on anticancer effects, we checked title and abstract, and, where necessary, the whole article of each VAE-related reference in the databases (Medline/Pubmed and comprehensive private databases, using above mentioned terms but without restriction to clinical studies) and in major surveys.

          Selection

          The following selection criteria were used for inclusion of studies in the analysis: (I) prospective randomized or non-randomized controlled clinical trial, or prospective single-arm cohort study (e.g. phase II trial) or pharmaco-epidemiological cohort study; (II) study population with breast or gynaecological cancer, i.e. ovary, uterus, cervix, genital cancer, or cervical intraepithelial neoplasm (CIN); (III) intervention group treated with VAE preparation; (IV) clinically relevant outcome (i.e. survival, disease-free interval, remission, relapse, QoL, or reduction of side effects or immune suppression during cytoreductive therapy); (V) completion of study; (VI) published or unpublished. Studies were excluded if they: only measured toxicity or tolerability (phase I trial), only measured stimulation of immunological parameters, were not conducted on cancer patients, or had a retrospective design (except pharmaco-epidemiological cohort studies). There were no restrictions on language.

          For in vitro and animal experiments the criteria were adapted accordingly; unpublished material was not included however. In vitro experiments were restricted to cancer cells originating from human tumours.

          Validity assessment and data abstraction

          Criteria-based analysis was performed on the selected clinical studies to assess their methodological quality. Analyses were performed independently by two reviewers (GK, HK). There were no major differences in study assessment; disagreements were resolved by discussion. Criteria for assessing strength of evidence in controlled trials were adapted from the National Health Service Centre for Reviews and Dissemination [40] and from criteria for good methodology as already applied in earlier reviews on VAE trials [34, 36, 41]. Quality criteria were adjusted for cohort studies [36]. Data were abstracted by one reviewer (GK) and checked by a second reviewer (AG). When necessary, primary authors of the trials were contacted for additional information.

          Regarding animal experiments we extracted data on study size, animal model, tumour type, tumour transfer, intervention, treatment schedule, outcome, physiological monitoring, side effects, dose-response, randomization, control treatment, blinding of outcome assessment, publication in a peer-reviewed journal, and funding source.

          Results

          Result of literature search

          The literature search identified 306 references describing potential clinical studies (after deletion of duplicates). After deleting references only describing studies on immune modulation or toxicity or tolerability (phase I trial), or only on cancer sites other than breast or gynaecological, with retrospective evaluation, without quantification of results, or only investigating complex treatment regimes, or describing studies already published elsewhere, 48 potential studies were identified that met the inclusion criteria. Two trials [42, 43], conducted in Poland, were excluded because of severe validity concerns: a collaborating scientist questioned the alleged randomization of treatment allocation, and no information could be obtained from the authors to clarify this question. One further RCT (on Lektinol® and breast cancer by Schwiersch et al.) might have met the inclusion criteria but was unpublished and unavailable. Thus it was possible to include 46 studies in this review: 19 RCTs, 16 non-RCTs, and 11 single-arm cohort studies. Of the 46 studies, 43 were published (4 of these only as an abstract), 1 study was retrieved as a doctoral dissertation, and 2 were unpublished reports.

          1632 VAE-related references were checked by title, abstract or whole article, book chapter, or book regarding in vitro or animal studies. Experiments meeting the inclusion criteria were excluded if they were described in another publication, were not published in a scientific journal, scientific book or as a scientific dissertation, were unavailable (some dissertations from the 1950s and 60s), or if they did not present sufficient information.

          Characteristics of included clinical studies

          Tables 1, 2, 3, 4, 5, and 6 show characteristics of the clinical studies. Settings of the studies were mostly academic hospitals, large community hospitals, and specialized cancer hospitals. The studies were mainly conducted in Germany, but also in Austria, Switzerland, USA, Serbia, Russia, Bulgaria, Ukraine, Italy, Egypt, Israel, China, South Korea. Most studies were conducted in more than one centre. In 31 of the 32 studies published since 2000, the funding source was identifiable: three studies had public funding [4446], 17 a combination of public and industry funding, and 11 industry funding alone.
          Table 1

          Randomized Controlled Clinical VAE Trials on Breast and Gynaecological Cancer: Quality Assessment

          Author, Year

          Quality Criteria Fulfilled in StudiesI

          Participants

          ARII

           

          A)

          B)

          C)

          D)

          E)

          F)

          G)

          H)

          I)

          J)

          K)

            

          Tröger 2009 [47]

          +

          -

          -

          (+)

          +

          +

          +

          +

          (+)

          (+)

          +

          95

          6%

          Büssing 2008 [48]

          +III

          -III

          -III

          -III

          (-)III

          -III

          (-)III

          (-)III

          (-)III

          (-)III

          -III

          65

          No data

          Grossarth 2008a [49]

          +

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          76

          21%

          Grossarth 2008b [49]

          +

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          -

          52

          0%

          Grossarth 2007a [50]

          +

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          50

          16%

          Grossarth 2007b [50]

          +

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          48

          17%

          Grossarth 2007c [51]

          +

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          -

          38

          0%

          Grossarth 2006a [52, 53]

          +

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          118

          36%

          Semiglasov 2006 [54]

          +

          -

          (+)

          (+)

          +

          +

          +

          +

          +

          +

          +

          352

          4%

          Auerbach 2005 [55]

          +

          -

          (+)

          (+)

          +

          -

          +

          (+)

          +

          (+)

          +

          23

          30%

          Piao 2004 [56]

          +

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          +

          233

          4%

          Semiglasov 2004 [57]

          +

          -

          (+)

          (+)

          +

          +

          +

          +

          +

          +

          +

          272

          4%

          Borrelli 2001 [58]

          +

          -

          (+)

          (+)

          +

          +

          (+)

          +

          (-)

          (+)

          -

          30

          0%

          Grossarth 2001a [59]

          +

          +

          -

          (-)

          +

          +

          +

          (-)

          +

          +

          -

          34

          0%

          Grossarth 2001b [59]

          +

          +

          -

          (-)

          +

          (-)

          +

          (-)

          +

          +

          -

          98

          20%

          Kim 1999 [60]

          +

          -

          -

          -

          (-)

          -

          (+)

          (+)

          (-)

          (-)

          -

          30IV

          13%

          Heiny 1991 [61]

          +

          -

          (-)

          (-)

          +

          (+)

          +

          (+)

          +

          +

          -

          46

          13%

          Gutsch 1988 [62]

          +

          -

          -

          (-)

          +

          (-)

          +

          +

          (+)

          +

          -

          692

          20%

          Lange 1985 [63]

          +

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          68

          35%

          I A) Protection against selection bias, especially by adequate randomization

          B) Minimization of heterogeneity by pre-stratification or matching

          C) Protection against observer bias by blinding of patient, care provider, and outcome assessor

          D) Protection against performance (treatment) bias by standardization of care protocol, documentation of all co-interventions, blinding of patients and care providers

          E) Protection against measurement (detection) bias by standardization of outcome assessment

          F) Protection against attrition (exclusion) bias, lost patients <10% or by intention-to-treat analysis (including non-adherers as randomized) plus per-protocol analysis (excluding non-adherers) in combination with sensitivity analysis, and by comparison of prognostic characteristics of lost patients and compliers

          G) Effect measurement relevant and well described

          H) Well-described intervention, patient characteristics, disease (diagnosis, stage, duration), previous therapy

          I) Well-described study design

          J) Well-described results

          K) Data quality assured by ICH-GCP guidelines, especially by monitoring

          + = adequately fulfilled, (+) = partly fulfilled, (-) = little fulfilled, - = not fulfilled

          II AR: attrition rate (dropouts, protocol deviations, withdrawals, patients did not receive treatment as allocated).

          III Assessment based only on an abstract

          IV Discrepancy in patient numbers in two presentations (30 and 33), with corresponding discrepancy of results

          Table 2

          Non-Randomized Controlled Clinical VAE Studies on Breast and Gynaecological Cancer: Quality Assessment

          Author, Year

          Quality Criteria Fulfilled in StudiesI

          Participants

          ARII

          Design/control for confounding

           

          A)

          B)

          C)

          D)

          E)

          F)

          G)

          H)

          I)

          J)

          K)

             

          Grossarth 2008c [49]

          (+)

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          -

          200

          5%

          Prospective pair-matching

          Grossarth 2008d [49]

          (+)

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          282

          27%

          Prospective pair-matching

          Loewe-Mesch 2008 [64]

          -

          -

          -

          (-)

          +

          (-)

          +

          +

          (+)

          +

          -

          82

          20%

          Self-selected treatment allocation, no adjustment

          Grossarth 2007d [50]

          (+)

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          198

          24%

          Prospective pair-matching

          Grossarth 2007e [50]

          (+)

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          -

          132

          6%

          Prospective pair-matching

          Grossarth 2007f [51]

          (+)

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          -

          212

          4%

          Prospective pair-matching

          Grossarth 2007g [51]

          (+)

          +

          -

          (-)

          +

          +

          +

          (+)

          +

          +

          -

          140

          6%

          Prospective pair-matching

          Grossarth 2006b [52, 53]

          (+)

          +

          -

          (-)

          +

          (-)

          +

          (+)

          +

          +

          -

          210

          20%

          Prospective pair-matching

          Büssing 2005 [65]

          (-)

          -

          -

          (-)

          +

          +

          (+)

          (+)

          (+)

          +

          +

          105

          7%

          Comparison of two different hospitals. Pair-matching for analysis

          Grossarth 2001c [59]

          (+)

          +

          -

          (-)

          +

          +

          +

          -

          +

          +

          -

          792

          4%

          Prospective pair-matching

          Salzer 1987 [66]

          (+)

          -

          -

          (-)

          +

          -

          +

          -

          -

          (+)

          -

          155

          not shown

          Alternating treatment allocation

          Fellmer 1966 [67]

          -

          -

          -

          (-)

          +

          -

          +

          +

          -

          -

          -

          924

          15%

          Treatment allocation by neutral attending physician

          Majewski 1963 [68]

          (+)

          -

          -

          (-)

          +

          -

          +

          -

          -

          -

          -

          III

          not shown (15%)IV

          Alternating treatment allocation

          Retrolective pharmaco-epidemiological cohort studies

          Beuth 2008 [69]

          -

          (+)

          -

          -

          (-)

          -

          (+)

          (-)

          (+)

          (+)

          +

          681

          V

          Multivariate adjustment only for one main outcome ("complaints")

          Bock 2004 [70]

          -

          (+)

          -

          -

          (-)

          -

          (+)

          +

          (+)

          (+)

          +

          1442

          V

          Multivariate adjustment

          Schumacher 2003 [71, 72]

          -

          (+)

          -

          -

          (-)

          -

          (+)

          +

          (+)

          (+)

          +

          689

          V

          Propensity score adjustment

          I–II Abbreviations as in Table 1.

          III Number of study patients not indicated; mistletoe group included 155 patients.

          IV Numbers given only for mistletoe group.

          V Not applicable for retrolective studies.

          Table 3

          Controlled Clinical Studies on VAE Treatment in Breast and Gynaecological Cancer: Survival

          Site

          Stage

          Intervention (evaluable patients)

          Survival Outcomes

          Author, year, reference

             

          Years (median)

          Hazard ratio

          5-year survival and others

          P-value

          95% CI

           

          Randomized controlled trials

          Breast

          T1a-3, N0, M0

          Iscador (38)

          14.8

          0.65

           

          0.2

          0.34–1.25

          Grossarth 2006a [52, 53, 135]

            

          None (38)

          13.8

               
           

          IIIA–IIIB

          Iscador (17)

          6.3

          0.46

           

          0.13

          0.16–1.31

          Grossarth 2001a [59, 135, 166]

            

          None (17)

          2.3

               
           

          T1-3, N0-3, M0, local recurrence

          Surgery, radiationI, Helixor (192)

          Not applicableII

           

          69.1% 5-year survival

          0.048

           

          Gutsch 1988 [62]

            

          Surgery, radiationI, CMF (177)

            

          67.7% 5-year survival

          0.025

            
            

          Surgery, radiationI (274)

            

          59.7% 5-year survival

             

          Breast, others

          All stages

          Iscador (39)

          3.5 (mean)

            

          0.04

           

          Grossarth 2001b [59]

            

          None (39)

          2.5 (mean)

               

          Cervix

          IVA-B

          Iscador (19)

          1.83

          0.46

           

          0.12

          0.18–1.21

          Grossarth 2007c [51]

            

          None (19)

          1.92

               

          Uterus

          IA-C

          Iscador (30)

          6.29

          0.36

           

          0.014

          0.16–0.82

          Grossarth 2008a [49]

            

          None (30)

          5.17

               
           

          IVA-B

          Iscador (26)

          1.5

          1

           

          0.99

          0.46–2.16

          Grossarth 2008b [49]

            

          None (26)

          2.0

               

          Ovary

          IA–IC

          Iscador (21)

          6.75

          0.40

           

          0.058

          0.15–1.03

          Grossarth 2007a [50]

            

          None (21)

          5.58

               
           

          IV

          Iscador (20)

          2.75

          0.33

           

          0.033

          0.12–0.92

          Grossarth 2007b [50]

            

          None (20)

          1.58

               

          Non-randomized controlled studies

          Breast

          T1-3, N0, M0

          Iscador (84)III

          11.75

          0.42

           

          0.0002

          0.27–0.68

          Grossarth 2006b [52, 53, 135]

            

          None (84)

          10.13

               
           

          Local recurrence, N0, M0

          Iscador (29)IV

          5.17

            

          0.0025

           

          Grossarth 2001b [59, 135]

            

          None (29)

          4.33

               
           

          T1-4, N>1, M0

          Iscador (38)IV

          4.04

            

          0.0516

           

          Ø same study

            

          None (38)

          3.17

               
           

          TX, NX, M1

          Iscador (53)IV

          3.08

            

          0.0056

           

          Ø same study

            

          None (53)

          2.17

               
           

          I–III

          Iscador, (76)

            

          29% alive 1985, after 11–14 years

          not shown

           

          Salzer 1987 [66]

            

          Radiation, hormone (79)

            

          24% alive 1985, after 11–14 years

             

          Cervix

          IB-IVA

          Iscador (102)III

          7.17

          0.41

           

          <0.0001

          0.27–0.63

          Grossarth 2007f [51]

            

          None (102)

          5.92

               
           

          IV

          Iscador (66)III

          2.33

          0.54

           

          0.015

          0.32–0.89

          Grossarth 2007g [51]

            

          None (66)

          1.83

               
           

          I–III

          Radiation, Iscador (81)

            

          83% 5-year survival

          0.05

           

          Fellmer 1966 [67]

            

          Radiation (709)

            

          69% 5-year survival

             

          Uterus

          IIIA–IVB

          Iscador (95)III

          2.75

          0.61

           

          0.023

          0.39–0.93

          Grossarth 2008c [49]

            

          None (95)

          1.67

               
           

          IA-C

          Iscador (103)III

          8.75

          0.41

           

          <0.0001

          0.26–0.63

          Grossarth 2008d [49]

            

          None (103)

          6.67

               

          Ovary

          IA–IC

          Iscador (75)III

          6.83

          0.47

           

          0.0002

          0.31–0.69

          Grossarth 2007d [50]

            

          None (75)

          5.83

               
           

          IV

          Iscador (62)III

          1.79

          0.62

           

          0.077

          0.37–1.05

          Grossarth 2007e [50]

            

          None (62)

          1.17

               

          Genital

          All stages

          SurgeryI, radiationI, Iscador (155)

            

          Disease-specific survival partly improved

          not shown

           

          Majewski 1963 [68]

            

          SurgeryI, radiationI,(not shown)

                

          Retrolective pharmaco-epidemiological cohort studies

          Breast

          I–III

          Conventional therapy, Iscador (710)

           

          0.46

           

          0.038

          0.22–0.96

          Bock 2004 [70]

            

          Conventional therapy (732)

                
           

          I–IV

          Conventional therapy, Eurixor (219)

            

          No difference observedV

            

          Schumacher 2003 [71, 72]

            

          Conventional therapy (470)

                

          I Co-intervention (i.e. radiation) applied to part of the group

          II Not applicable since more than 50% alive at study termination

          III Data from complete set of patient pairs reported

          IV Data only from patient pairs with strict matching reported

          V No difference could be found due to limited observation time (median < 10 months)

          CMF: Cyclophosphamide, methotrexate, 5-fluorouracil

          P-value, 95% CI (confidence interval): Statistical significance of difference between mistletoe (or other verum) and control group.

          Table 4

          Controlled Clinical Studies on VAE Treatment in Breast and Gynaecological Cancer: Tumour Behaviour or Pleurodesis

          Site

          Stage

          Intervention (evaluable patients)

          Outcome

          P-value

          95% CI

          Author, year, reference

          R EMISSION

                

          Randomized controlled trials

          Breast, ovary, lung

          T1–4, N0–3, M0–1

          ChemotherapyI, Helixor A (115)

          Remission rate: no difference

            

          Piao 2004 [56]

            

          ChemotherapyI, Lentinan (109)

              

          Ovary, others

          Inoperable

          Radiation, cisplatin, holoxan, Helixor (23)

          10% complete remission

          48% partial remission

          5% progress

            

          Lange 1985 [63]

            

          Radiation, cisplatin, holoxan (21)

          17% complete remission

          48% partial remission

          4% progress

             

          Pleural effusionII

          Advanced

          Helixor (11)

          82% complete remission

          9% partial remission

          <0.05 III

           

          Kim 1999 [60]

            

          Doxycycline, meperidine, lidocaine (15)

          40% complete remission

          27% partial remission

             

          D ISEASE-FREE INTERVAL, TIME TO EVENT, RECURRENCE (H AZARD RATIO )

          Randomized controlled trials

          Breast

          T1a-3, N0, M0

          Iscador (38)

          Time to local recurrences: 0.44

          lymphatic metastases: 0.27

          distant metastases: 0.50

          all events (incl.death) 0.65

          0.18

          0.0048

          0.061

          0.012

          0.14–1.44

          0.11–0.67

          0.24–1.03

          0.47–0.91

          Grossarth 2006a [52, 53]

            

          None (38)

              

          Non-randomized controlled trials

          Breast

          T1–3, N0, M0

          Iscador (84)

          Time to local recurrences: 0.42

          lymphatic metastases: 0.22

          distant metastases: 0.36

          all event (incl.death) 0.66

           

          0.21–0.83

          0.10–0.47

          0.21–0.62

          0.55–0.79

          Grossarth 2006b [52, 53]

            

          None (84)

              

          Cervix

          IB-IVA

          Iscador (102)

          Time to local recurrences: 1.42

          lymphatic metastases: None

          distant metast.:1 in Iscador group

          all event (incl.death) 0.32

          0.61

          n.a.

          n.a.

          <0.0001

          0.37–5.39

          n.a.

          n.a.

          0.22–0.48

          Grossarth 2007f [51]

            

          None (102)

              

          Retrolective pharmaco-epidemiological cohort study

          Breast

          I–III

          Conventional therapy, Helixor (167)

          Recurrence, metastases, reoperation: no difference

            

          Beuth 2008 [69]

            

          Conventional therapy (514)

              
           

          I–III

          Conventional therapy, Iscador (710)

          Recurrence: 0.98

          Dist. metast. 0.65

          0.947

          0.172

          0.60–1.62

          0.35–1.21

          Bock 2004 [70]

            

          Conventional therapy (732)

              
           

          I–IV

          Conventional therapy, Eurixor (219)

          Time to relapse: 0.28

          0.012

          0.10–0.76

          Schumacher 2003 [71, 72]

            

          Conventional therapy (470)

              

          I Chemotherapy: see table 5

          II Plural effusion indicates treatment site (primary cancer site: 4 × breast, 1 × cervix, 23 × lung, 1 × stomach, 1 × unknown primary)

          III Side effects in Helixor and doxocycline group: pain in 6 and 14, fever in 3 and 6, burning sensation in 0 and 5 patients respectively; difference statistically significant (p < 0.05)

          P-value, 95% CI (confidence interval): Statistical significance of difference between mistletoe (or other verum) and control group.

          Table 5

          Controlled Clinical Studies on VAE Treatment in Breast and Gynaecological Cancer: Reduction of side effects of chemotherapy, radiation or surgery; QoL

          Site

          Stage

          Intervention (evaluable patients)

          Reduction of side effects of chemotherapy, radiation or surgery

          QoL (*during chemotherapy, radiation)

          Author, year, reference

             

          Outcome

          P-value

          Measurement scale and outcome

          P-value

          95% CI

           

          Randomized controlled trials

          Breast

          T1–3, N0–2, M0

          CAF, Iscador or Helixor (59)

          Neutropenia

          15%

          0.195

          EORTC QLQ-C30* (Pain*, diarrhoea*, role*, insomnia*, nausea/vomiting*)

          0.0438 to

          0.0003

           

          Tröger 2009 [47]

            

          CAF (30)

           

          27%

                  
           

          No data

          (F)EC, Iscador M (32)

          EC-associated inhibition of granulocyte function: no difference.

          Reduction of EC-related side effects (nausea, constipation, pain, stomatitis).

          Lymphocytes, retching, emesis: no difference

          >0.27

          EORTC QLQ-C30*, BR 23*, Rhodes Index*: no difference

          No data

          No data

          Büssing 2008 [48]

            

          (F)EC (33)

            

          "significant"

                 
           

          T1a-3, N0, M0

          Iscador (38)

             

          Self-regulation questionnaire,

          Hazard-ratio

          0.35

           

          0.05–0.60

          Grossarth 2006a [52, 53]

            

          None (38)

                    
           

          T1–3, N0-N+, M0

          CMF, Lektinol 15 ng ML (169)

          Haematological parameters, hospitalization, paracetamol, metoclopramid: no difference.

          Leucopenia ↓ (trend)

          FACT-G*

          ↑ 4.4

          GLQ-8* sum

          ↓ 28.9

          Spitzer uniscale*

          ↓ 12.2

          KPS*

          No difference

          <0.0001

           

          Semiglasov 2006 [54]

            

          CMF, placebo (168)

             

          FACT-G*

          ↓ 5.11

          GLQ-8* sum

          ↑ 94.8

          Spitzer uniscale*

          ↑ 10.8

              
           

          T1–2, N0–1, M0

          CMF, radiation, Helixor A (11)

          CMF-induced NK-cell decrease ↓ SCE-increase ↓

          other immune markers: no difference

           

          0.005

          n.s.

          EORTC QLQ-C30*

           

          No difference, data not shown

          not shown

           

          Auerbach 2005 [55]

            

          CMF, radiation, placebo (9)

                    
           

          T1–3, N0-N+, M0

          CMF, Lektinol 5 ng ML (66)

          Haematological parameters, hospitalization, paracetamol, metoclopramid: no difference. immune markerers: CD4, CD4/CD8, NK-cell-activity: significant ↑

            

          GLQ-8* sum

          No difference

           

          Spitzer uniscale*

          No data

          QLQ C-30*

          No difference

          <0.05

           

          Semiglasov 2004 [57]

            

          CMF, Lektinol 15 ng ML (65)

             

          GLQ-8* sum

          Superior 60,8mm

           

          Spitzer uniscale*

          Superior 16,4 mm

              
            

          CMF, Lektinol 35 ng ML (64)

             

          GLQ-8* sum

          No difference

           

          Spitzer uniscale*

          No data

              
            

          CMF, placebo (66)

                    
           

          IIIA–IIIB

          Iscador (17)

             

          Self-regulation questionnaire (score 1–6)

           

          2.92 → 3.7

           

          0.13

           

          Grossarth 2001a [59]

            

          None (17)

               

          2.87 → 2.99

              
           

          IV

          Iscador spezial (20)

             

          Spitzer score questionnaire

           

          ~5 → 7.2

           

          <0.05

           

          Borrelli 2001 [58]

            

          Placebo (10)

               

          ~5.2 → 4.8

              
           

          Advanced

          VEC, Eurixor (21)

          Leukopenia ↓

          Platelets: no difference

           

          ≤ 0.001

          QoL index* (superior)

           

          Anxienty scale* (superior)

           

          ≤ 0.01

           

          Heiny 1991 [61]

            

          VEC, placebo (19)

                    

          Breast, others

          All stages

          Iscador (39)

             

          Self-regulation questionnaire

          (score 1–6)

           

          3.41 → 3.87

           

          0.02

           

          Grossarth 2001b [59]

            

          None (39)

               

          3.85 → 3.62

              

          Breast, ovary, lung

          T1–4, N0–3, M0–1

          ChemotherapyI, Helixor A (115)

          Chemotherapy-related adverse events

          28

          not shown

          FLIC-score*

          ↑ 9

          TCM-score*

          ↑ -1

           

          KPS* increase in % of patients

          50%

          FLIC 0.014

          TCM 0.0007

          KPS 0.002

           

          Piao 2004 [56]

            

          ChemotherapyI, Lentinan (109)

          Chemotherapy-related adverse events

          77

           

          FLIC-score*

          ↑ 4,7

          TCM-score*

          0

           

          KPS* increase in % of patients

          32%

             

          Ovary

          IA–IC

          Iscador (21)

             

          Self-regulation questionnaire, (score 1–6) median difference

           

          0.58

          0.0002

          0.30–0.90

          Grossarth 2007a [50]

            

          None (21)

                    

          Ovary, others

          Inoperable

          Radiation, cisplatin, holoxan, Helixor (23)

          Nausea ↓,

          vomiting ↓,

          depression of leucopoiesis ↓

           

          0.005, 0.08,

          0.003

          KPS*

          67% → 76% (p = 0.0008II)

            

          not shown

           

          Lange 1985 [63]

            

          Radiation, cisplatin, holoxan (21)

              

          70% → 74% (p = 0.12II)

               

          Cervix

          IVA-B

          Iscador (19)

             

          Self-regulation questionnaire, (score 1–6) median difference

          0.7

           

          0.014

          0.15–1.05

          Grossarth 2007c [51]

            

          None (19)

                    

          Uterus

          IA-C

          Iscador (30)

             

          Self-regulation questionnaire, (score 1–6) median difference

          0.4

           

          0.0012

          0.15–0.70

          Grossarth 2008a [49]

            

          None (30)

                    

          Non-randomized controlled studies

          Breast

          T1–3, N0, M0

          Iscador (84)

             

          Self-regulation questionnaire

          Hazard-ratio

          0.20

           

          0.031

          0.00–0.35

          Grossarth 2006b [52, 53]

            

          None (84)

                    
           

          I–II

          Surgery, CMF/EC, Iscador (33)

          CMF/EC-induced lymphocyte decrease ↑,

          platelet decrease ↓

          n.s,

          0.01

          EORTC QLQ-C30*, BR 23*

          Reduced increase of nausea/vomiting, general side effects of CMF/EC

           

          0.02

          0.02

           

          Loewe-Mesch [64]

            

          Surgery, CMF/EC (33)

                    

          Breast (suspected)

           

          Surgery, Iscador M spezial (47)

          Prevention of surgery-associated inhibition of granulocyte function (PMA- and E.coli-stimulated oxidative burst)

          <0.0001,<0.001

                

          Büssing 2005 [65]

            

          Surgery (51)

                    

          Ovary

          IA–IC

          Iscador (75)

             

          Self-regulation questionnaire, (score 1–6) median difference

          0.30

           

          <0.026

          0.10–0.60

          Grossarth 2007d [50]

            

          None (75)

                    

          Cervix

          IB-IVA

          Iscador (102)

             

          Self-regulation questionnaire, (score 1–6) median difference

          0.25

           

          <0.0005

          0.15–0.35

          Grossarth 2007f [51]

            

          None (102)

                    

          Uterus

          IA-C

          Iscador (103)

             

          Self-regulation questionnaire, (score 1–6) median difference

          0.65

           

          <0.0005

          0.4–0.95

          Grossarth 2008d [49]

            

          None (103)

                    

          Retrolective pharmaco-epidemiological cohort study

          Breast

          I–III

          Conventional therapy, Helixor (167)

             

          Odds ratio for occurrence of disease- or treatment associated symptoms: 0.508

           

          0.319–0.811

          Beuth 2008 [69]

            

          Conventional therapy (514)

                    
           

          I–III

          Conventional therapy, Iscador (710)

          Adverse drug reactions ↓, Odds ratio: 0.47

          95% CI 0.32–0.67

          Odds ratio for being symptom-free 3.56 (vomiting, headache, exhaustion, depression, concentration, sleep, dizziness, irritability) ↑

           

          2.03–6.27

          Bock 2004 [70]

            

          Conventional therapy (732)

                    
           

          I–IV

          Conventional therapy, Eurixor (219)

             

          Symptom mean score improved (nausea, appetite, stomach pain, tiredness, depression, concentration, irritability, sleep)

          <0.0001

           

          Schumacher 2003 [71, 72]

            

          Conventional therapy (470)

                    

          I Chemotherapy (referring to the study by Piao et al.) – breast cancer: CAP, CAF (CAP: Cyclophosphamide, doxorubicin, cisplatin; CAF: Cyclophosphamide, doxorubicin, 5-fluorouracil); ovarian cancer: CP, IcP (CP: Cyclophosphamide, cisplatin, IcP: Ifosfamid, carboplatin); non-small cell-lung cancer: VP, MViP (VP: Vinorelbine, cisplatin; MViP: Mitomycin, vindesine, cisplatin).

          II Statistical significance of pre-post difference within each group

          QoL: Quality of life; KPS: Karnofsky Performance Status Scale SCE: Sister chromatid exchange; ↑: increase; ↓: decrease. P-value, 95% CI: Statistical significance of difference between mistletoe (or other verum) and control group; n.s.: not statistically significant; EC: Epirubicin, cyclophosphamide (F: 5-fluorouracil); VEC: Vindesine, epirubicin, cyclophosphamide; CMF: Cyclophosphamide, methotrexate 5-fluorouracil; CAF: Cyclophosphamide, doxorubicin, 5-fluorouracil.

          Table 6

          Single-Arm Cohort Studies (e.g. Phase II Trials) on VAE Treatment in Breast and Gynaecological Cancer

          Author, Year

          TreatmentI

          SiteII

          OutcomeIII

          NIV

          Quality Criteria FulfilledVI

           

          Preparation

          Injection site

          Dosage

          Escalating dosage

          Duration

           

          CR

          PR

          NC

          PD

          QoL

           

          L

          M

          N

          O

          P

          Q

          Breast, Ovary, CIN

          Mansky 2008 [44, 73]

          Helixor

          (& gemcitabine)

          sc

          Up to 250 mg, daily

          Yes

          9 w

          Breast, others

          0%

          10%

          47%

          43%

           

          27

          (+)

          +

          +

          -V

          (+)

          (+)

          Schink 2006 [45]

          Helixor

          (& surgery)

          sc

          3/week, varying individually

          Yes

          Up to 2 years

          Breast, colon

          -

          -

          -

          -

          IIIa

          40

          +

          +

          (+)

          (+)V

          (+)

          -

          Schöffski 2004 [32]

          Aviscumine

          iv

          10 – 6400 ng/kg, 2/w

          Yes

          3–24 w, median 6 w

          Ovary, breast, others

          0%

          0%

          30%

          70%

           

          37

          +

          (+)

          +

          +

          +

          +

          Mahfouz 1999 [74]

          Viscum fraxini

          sc or it

          1 × 45 mg/w

          No

          16–136 w

          Breast

          8%

          54%

          35%

          4%

          26

          (+)

          (+)

          +

          (+)

          +

          +

          Mahfouz 1998 [75]

          Abnobaviscum Fr

          sc

          1 × 45 mg/w

          No

          17 w

          Breast

          0%

          44%

          33%

          22%

          9

          -

          (-)

          (+)

          -

          -

          (+)

          Finelli 1998 [76]

          Lektinol

          sc

          2,5 μl/kg, 2/w

          No

          Up to 12 w

          Breast, others

          -

          -

          -

          -

          884

          +

          +

          +

          -

          +

          +

          Portalupi 1995 [77]

          Iscador M

          sc

          2 × 1 ng MLI/kg bw × w

          No

          16 w

          CIN I–III

          41%

          27%

          27%

          5%

           

          22

          +

          +

          +

          +

          +

          (+)

          Malignant effusion

          Bar-Sela 2006 [46]

          Iscador M

          ip

          10 mg

          No

          repeatedly

          Ascites (ovary, others)

          Increase of interval between two successive paracenteses from 7 to 12 days, p = 0.001IIIb

             

          IIIc

          23

          (+)

          (+)

          +

          (+)

          +

          +

          Werner 1999 [78]

          Abnobaviscum Fr

          ipl

          1 × 75 mg/w

          No

          3–8 w

          Pleural effusion (breast, others)

          88%

             

          32

          +

          +

          +

          -

          (+)

          (+)

          Stumpf 1994 [79]

          Helixor A, M or P

          ipl

          100–1000 mg

          Yes

          repeatedly

          Pleural effusion (breast, others)

          61%

          11%

          22%

            

          18

          +

          +

          +

          (+)

          +

          +

          Friedrichson 1995 [80]

          Helixor A, M

          ip

          100–1000 mg, 2/w

          Yes

          repeatedly

          Ascites (ovary, others)

          70%

             

          12

          (+)

          (-)

          +

          -

          (-)

          +

          I sc: subcutaneous, it: intratumoural, ipl: intrapleural, ip: intraperitoneal; iv: intravenous infusion; bw; body weight; w: week

          II CIN: cervical intraepithelial neoplasia. Stage: advanced, except in Portalupi 1995, and partly Schink 2006 and Finelly 1998; plural effusion and ascites indicates treatment site

          III CR: complete, PR: partial remission, NC: no change, PD: progredient disease, QoL: quality of life, ↗: improved, ↘ impaired

          IIIa Especially physical functioning, role, fatigue, appetite

          IIIb Median values, comparable abdominal circumference and symptom score or drained fluid before or during each paracentesis respectively

          IIIcTrend improvement in symptom score, especially abdominal pain, abdominal pressure, and waking up at night due to shortness of breath

          IV N: Number of participants

          V Concomitant conventional oncological cytoreductive therapies in some of the patients

          VI L Well-described patient characteristic and disease (diagnosis, stage, duration), prognostic factors

          M Outcome parameter relevant and well described

          N Well-described intervention

          O Concomitant therapies well described

          P Outcome clearly described, temporal relationship between applied therapy and observed outcome precisely described

          Q Selection of patients excluded

          + = adequately fulfilled, (+) = partly fulfilled, (-) = little fulfilled, - = not fulfilled

          Controlled studies

          The 19 RCTs [4763] (Table 1) encompassed 2420 participants, 16 non-RCTs [4953, 59, 6472] (Table 2) encompassed over 6399 participants (the sample size of one control group was not published). Cancer sites studied were breast (n = 20), uterus (n = 4), ovary (n = 6), cervix (n = 4), and genital (n = 1). One RCT investigated malignant pleural infusion. 4 studies not only investigated gynaecological or breast cancer but other cancer types as well.

          Stages ranged from early-detected to advanced disease. 33 studies had two arms, one trial had three, and one four arms. Endpoints were: survival (22 studies), tumour remission, recurrence or time to recurrence or metastases (8 studies), pleurodesis (1 study), QoL or coping with disease (11 studies), QoL or tolerability of concomitant chemotherapy, radiotherapy or surgery (13 studies). Length of follow-up varied from three days in one trial to – usually – months or years.

          All treatment groups received conventional care when indicated, and most patients had undergone prior surgery. In 16 studies (9 RCTs and 7 non-RCTs) the combination of VAE treatment and concurrent chemotherapy, radiotherapy or surgery was investigated. 13 of these studies assessed reduction of side effects from these cytoreductive therapies. Three trials directly compared VAE treatment versus chemotherapy treatment or versus radiation and hormones [60, 62, 66]. In most studies VAE therapy was used at least partly in an adjuvant setting after surgery or radiotherapy.

          The commercial VAE applied were Iscador®, Helixor®, Eurixor® or Lektinol®. VAE dosage mostly followed general recommendations, starting with low doses and increasing to an individually still well-tolerated dosage, or treating according to lectin-content (in 6 trials) or leaving treatment modalities to the physician's discretion, which, it can likewise be assumed, followed general recommendations. VAE was injected subcutaneously except in three trials employing intravenous infusion or intrapleural instillation [48, 60, 65]. Treatment duration was often not specified and depended on primary endpoint and related follow-up, ranging from one single application (in one trial [65]) to repeated applications over months and years. Control groups either received no further comparison treatment (n = 27), additional placebo application (n = 5), doxycycline (n = 1), Lentinan (n = 1) or radiation and hormones (n = 1). 4 trials had double-blinded treatment application.

          Single-arm studies

          11 prospective cohort studies [32, 4446, 7380] (Table 6) included 1,130 patients. Cancer sites studied were breast (n = 6), ovary (n = 1), CIN (n = 1), malignant pleural effusion (n = 2) and malignant ascites (n = 2). 8 studies investigated several cancer types. Tumour stages were advanced or inoperable except in three studies. In most studies patients had received conventional treatment some time previously. Directly preceding or concurrent anti-cancer treatment had been applied in two studies (gemcitabine [44], surgery [45]). Nine studies assessed tumour remission; seven reported QoL or symptomatic relief. Two studies primarily investigated the toxicity profile, pharmakokinetics and potential interactions of either the combination of gemcitabine and VAE [44, 73] or of rML [32], and secondarily assessed tumour behaviour. The commercial VAE remedies were Abnobaviscum®/Viscum fraxini, Iscador, Helixor, Lektinol or Aviscumine® (rML). VAE were applied subcutaneously (n = 6), intratumourally (n = 1), intrapleurally (n = 2), intraperitoneally (n = 2) or as an intravenous infusion (n = 1). Dosage depended on the preparation and mode of application; some treated according to lectin content, others started with a low dosage and increased successively, or started with high dosage and applied it consistently once weekly. For intrapleural and intraperitoneal (repeated) application, VAE was diluted in 5 to 15 ml or 100 ml solution. Treatment duration and follow-up ranged from weeks to, most commonly, months or years.

          Quality assessment

          Table 1, 2 and 6 summarize the validity assessment. Methodological quality differed substantially in the reviewed studies. 19 trials had randomized treatment allocation. The RCTs were mostly small (median sample size n = 60, range 23–692), particularly when investigating survival (median n = 52). Although RCTs investigating QoL were only slightly larger (median n = 68), they nevertheless encompass 4 trials that largely met modern standards of clinical trials and three of them had a sample size above 200. In four of the RCTs the patients and physicians were blinded; three further RCTs had an active or a placebo control-treatment. – 16 studies were non-randomized (median sample size n = 203, range 82–1442), 15 of them had controlled for confounding by close prospective (in one case retrospective) pair matching, by alternating treatment allocation and by multivariate analysis or propensity score (though in one study only for the main outcome parameter [69]). – Assurance of data quality according to ICH-GCP ("Good Clinical Practice") or GEP ("Good Epidemiological Practice") guidelines was reported in 5 RCTs and 4 non-RCTs. Eight of the RCTs and 8 of the non-RCTs were embedded in the same large epidemiological cohort study. Most studies did not present a clear documentation of co-interventions. Regarding the other quality aspects, most studies – especially the more recent ones – were reasonably well designed and conducted.

          In the single-armed studies, study quality was reasonably good except in an unpublished report [80] and in an abstract publication [75] with too little information. Two studies had applied VAE in combination with or subsequent to conventional cancer treatment and one study had explored CIN, which has high spontaneous remission rates.

          Characteristics of the preclinical studies

          The in vitro cytotoxicity of different VAEs as well as isolated or recombinant lectins or their A-chain, viscotoxins, or other protein fractions were tested with different methods in a variety of human breast, ovarian, uterine, vulvar and cervical cancer cells [12, 20, 22, 81110] (Table 7).
          Table 7

          In-vitro Studies on Cytotoxicity of VAE in Human Breast or Gynecological Cancer Cells

          Tumour cell

          VAE

          Result

           

          Reference

          Breast cancer

          MFM-223

          Iscador Qu, M, A

          Iscador P

          ML I

          IC50

          0.05–0.12 mg/ml

          1.89 mg/ml

          38 ng/ml

          [22]

           

          Iscador M, Qu,

          Abnobaviscum Fr

          Inhibition of proliferation

          0.1–1 mg/ml

          0.01–1 mg/ml

          [81]

          KPL-1

          Iscador Qu, M, A

          Iscador P

          ML I

          IC50

          0.1–0.3 mg/ml

          1.94 mg/ml

          141 ng/ml

          [22]

           

          Iscador M, Qu,

          Abnobaviscum Fr

          Inhibition of proliferation

          1 mg/ml

          0,1–1 mg/ml

          [81]

           

          Iscucin® A, M, P, C, Po, T, Qu, S

          Cytotoxicity

          0.1 mg/ml

          [82]

           

          Iscador M

          ML I

          No stimulation of cell proliferation

          0.05–5 ng ML/ml

          0.01–5 ng/ml

          [83]

          MCF-7

          Iscador Qu, M, A

          Iscador P

          ML I

          IC50

          0.09–0.12 mg/ml

          1.61 mg/ml

          410 ng/ml

          [22]

           

          Lektinol

          IC50

          >10 ng ML I/ml

          [84]

           

          Iscador Qu, M, P

          (max. 1 or 1.5 mg/ml)

          Inhibition of S-phase progression

          Induction of apoptosis

           

          [8587]

           

          Iscador M

          Iscador P

          ML I

          Iscador Qu

          IC50

          No influence

          185 μg/ml

          no activity

          0.003 μg/ml

          0.0015–15 μg/ml

          [88, 89]

           

          Viscotoxin isoforms (A1, A2, A3, B, 1-PS)

          Viscotoxin isoform U-PS

          GI50

          LC50

          0.02–0.8 μg/ml

          0.6 to >1 μg/ml

          no activity

          [90]

           

          ML I A chain

          Inhibition of proliferation

          0.5 μg/ml

          [91]

           

          ML I, ML II, ML III

          Inhibition of proliferation

          1–10 ng/ml

          [91]

           

          TNF & ML I (100 ng/ml)

          Potentiation of TNF-cytotoxicity

           

          [92]

           

          Lektinol

          IC50

          0.003 μg/ml

          [93]

           

          Helixor P

          ML I

          IC50

          > 150 μg/ml

          0.086 μg/ml

          [94]

           

          Iscucin M, P, C, Po, T, Qu, S

          Iscucin A, Pi

          Cytotoxicity

          0.1 mg/ml

          no activity

          [82]

          MCF-7/ADR

          Lektinol

          IC50 (SRB assay)

          0.3 E-4 μg/ml

          [93]

          MAXF 401NL

          Helixor P

          ML I

          IC50

          0.66 μg/ml

          0.003 μg/ml

          [94]

           

          Iscador M

          Iscador P

          ML I

          Iscador Qu

          IC50

          >70% growth inhibition

          < 3 μg/ml

          no activity

          0.353 E-4 μg/ml

          10 μg/ml

          [88, 89]

          MAXF 401

          Lektinol

          IC50

          < 0.1 E-4 μg/ml

          [93]

          MAXF 1162

          Lektinol

          IC50

          < 0.1 E-4 μg/ml

          [93]

          MAXF 449

          Lektinol

          IC50

          0.2 E-4 μg/ml

          [93]

          MAXF MX1

          Lektinol

          IC50

          < 0.1 E-4 μg/ml

          [93]

          MDA-MB-231

          Lektinol

          IC50

          0.7 E-4 μg/ml

          [93]

           

          Helixor P

          ML I

          IC50

          135 μg/ml

          0.041 μg/ml

          [94]

          MDA-MB-468

          Helixor P

          ML 1

          IC50

          47 μg/ml

          0.006 μg/ml

          [94]

          MDA-MB-486-HER2

          Iscador M

          Inhibition of epidermal growth factor-induced proliferation

          0.5 μg/ml

          [95]

          Colo-824

          Iscador M

          ML I

          No stimulation of cell proliferation

          0.05–5 ng ML/ml

          0.01–5 ng/ml

          [83]

          HCC-1937

          Iscador Qu, M, A

          Iscador P

          ML I

          IC50

          0.1 to 0.3 mg/ml

          2.14 mg/ml

          320 ng/ml

          [22]

           

          Iscucin A, M, P, C, Po, T, Qu, S

          Cytotoxicity

          0.1 mg/ml

          [82]

          BT474

          Helixor M, A

          Cytotoxicity (WST-1)

          Maximum (80 and 100%) with 25 mg/ml

          [96]

          Primary breast cancer

          Iscador M, Qu

          Abnobaviscum Fr

          Mitochondrial activity (MTT)

          50–80% with 0.1–0.001 mg/ml

          [81]

           

          Abnobaviscum M

          Inhibition of proliferation

          0.5–50 μg/ml

          [97]

           

          ML I

          Inhibition of proliferation

          1–50 ng/ml

          [20, 98]

          T47D

          ML I, II, III

          IC50

          > 0.1 – 1 ng/ml

          [99]

           

          ML I A-chain

          Inhibition of proliferation

          10 ng/ml

          [91]

          BT549

          ML I A-chain

          Inhibition of proliferation

          500 ng/ml

          [91]

          HBL100

          ML I A-chain

          Inhibition of proliferation

          100 ng/ml

          [91]

          Breast cancer cells

          ML II, ML III, viscotoxins

          Cytotoxicity

           

          [100]

          Ovarian cancer

          OVXF 1619L

          Helixor P

          ML I

          IC50

          119 μg/ml

          0.100 E-3 μg/ml

          [94]

          OVXF 899L

          Helixor P

          ML I

          IC50

          >150 μg/ml

          0.229 μg/ml

          [94]

          SKOV-3 (HER-2 expression)

          Recombinant ML I

          IC50

          Induction of apoptosis

          0.033 ng/ml

          [101]

          OVCAR3

          Iscador Qu, M

          (max. 1 or 1.5 mg/ml)

          Inhibition of S-phase progression,

          Induction of apoptosis

          No clear effect

          [87]

          OVXF 899

          Lektinol

          IC50

          0.3 E-3 μg/ml

          [93]

          OVXF 1353

          Lektinol

          IC50

          0.01 μg/ml

          [93]

          OVXF 1023

          Lektinol

          IC50

          < 0.1 E-4 μg/ml

          [93]

          SKOV3

          Lektinol

          IC50

          < 0.1 E-4 μg/ml

          [93]

          Primary ovarian cancer

          Abnobaviscum M

          Inhibition of proliferation

          5 μg/ml

          [97]

          Uterine cancer

          UXF 1138L

          Iscador M

          Iscador P

          ML I

          Iscador Qu

          IC50

          Growth inhibition >30%

          6.8 μg/ml

          No activity

          0.16 E-4 μg/ml

          15 μg/ml

          [88, 89]

          UCL SK-UT-1B

          Helixor P

          ML I

          IC50

          > 150 μg/ml

          0.038 μg/ml

          [94]

          SK-UT-1B

          Lektinol

          IC50

          0.6–5.5 ng ML I/ml

          [84]

           

          ML I

          Inhibition of proliferation

          0.5–500 ng/ml

          [98, 102]

           

          Iscador M

          ML I

          No stimulation of cell proliferation

          0.05–5 ng ML/ml

          0.01–5 ng/ml

          [83]

          SK-UT-1

          ML I

          Inhibition of proliferation

          0.5–500 ng/ml

          [98, 102]

          MES-SA

          ML I

          Inhibition of proliferation

          0.5–500 ng/ml

          [98, 102]

          Primary uterus cancer

          Abnobaviscum M

          Inhibition of proliferation

          5–50 μg/ml

          [97]

          Vulvar cancer

          SK-MLS-1

          Lektinol

          IC50

          2 to >5 ng ML I/ml

          [84]

           

          ML I

          Inhibition of proliferation:

          0.5–500 ng/ml

          [98, 102]

           

          Iscador M

          ML I

          No stimulation of cell proliferation

          0.05–5 ng ML/ml

          0.01–5 ng/ml

          [83]

          Cervical cancer

           

          HeLa

          TNF & ML I (100 ng/ml)

          Potentiation of TNF-cytotoxicity

          [92]

           

          ML I

          Inhibition of protein synthesis

          100 μg/ml

          [12, 103]

           

          Protein fractions

          Complete inhibition of DNA-, RNA-synthesis

          Proliferation

          1 μg/ml

          no effect

          [104]

           

          Viscotoxins

          IC50

          0.2–1.7 μg/ml

          [105]

           

          Helixor M

          Growth inhibition

          ≥ 0.01 mg/ml

          [106]

           

          Isorel®

          Cytotoxicity

          30 μg/μl

          [107]

           

          Isorel A, M, P,

          ML I

          Cytotoxicity

          > 1 μl/ml

          > 1 μg/ml

          [108]

           

          Iscador M

          Helixor M

          VAE M

          LC50

          16 μg/ml

          35,4 μg/ml

          3,9 μg/ml

          [109, 110]

           

          Iscador M, Qu

          Abnobaviscum Fr

          Growth inhibition

          0.1–1 mg/ml

          0.01 mg/ml

          [81]

          GI50: 50% growth inhibitory concentration

          LC50: 50% lethal concentration

          IC50: 50% inhibitory concentration

          MCF-7/ADR: adriamycin(doxorubicin)-resistant MCF-7 cell line

          HER: human epidermal growth factor receptor

          Animal studies

          43 studies were found. 9 of these were excluded as they investigated: tumour-bearing eggs [111], pre-incubation of tumour cells with VAE [112, 113], different cancer types without differentiating the results accordingly [114], or isolated VAE proteins that were unstable [115]. Of the remaining 34 experiments [96, 111, 116134] (Tables 8 and 9), 28 had been conducted in mice and 6 in rats. 22 experiments had included 788 animals, (5–20 per treatment group), one included 282 VAE-treated animals (number of control animals were not reported), the other reports gave no details. 32 experiments investigated breast tumours (15 of these Ehrlich carcinoma, ECa), one uterus epithelioma and one ovarian cancer. 28 had used murine tumour models, 5 were of human origin and 1 an autochthonous model (methylnitrosurea-induced tumourigenesis). 24 experiments investigated whole VAE (two of these VAE-activated macrophages), two investigated isolated MLs, two rMLs, two investigated other isolated proteins, and four investigated polysaccharides ("Viscumsäure"). VAE were applied systemically in 17 experiments (subcutaneous, intraperitoneal, intratumoural on opposite site, intramuscular), local at the tumour site in 15 experiments (intraperitoneal, intratumoural, intramuscular), and without specification in two studies.

          Table 8

          Animal Studies of VAE on Breast or Gynaecological Cancer (transplanted human or murine tumours or primary autochthonous tumour)

          Tumour, site

          Animal

          VAE, application and dosage

          Tumour growth

          T/C

          Survival

          ILS

          Other outcomes

          Reference

          Human breast

          Mice

               

          MAXF 449, sc

          Nude mice

          Local Abnobaviscum Qu 8 or 4 or 2 mg/kg, it, qd * 3

          6 to 20%

            

          [116]

            

          Systemic Abnobaviscum Qu 8 mg/kg, it, qd * 3

          78%

             

          MAXF 449, sc

          Nude mice

          Abnobaviscum M 8 mg/kg, sc, qd * 3 * 2 w

          68%

            

          [116]

          BT474, sc

          Mice (BALB/c)

          Helixor M or A 5 mg, it, qd * 3 * 2 w

          29 to 52%

            

          [96]

          Murine breast

                

          Carcinoma, sc, iv

          Mice (CBA/HZgr)

          Isorel M, 3 mg, sc, qod * 21

          No difference

           

          Lung-metastases: VAE vs. control: 13.4 vs. 37.5

          [117]

          Carcinoma, sc

          Mice (CBA/HZgr)

          Isorel M, 1400 mg/kg, 2 w

          20%

            

          [118]

          Carcinoma, sc

          Mice (CBA/HZgr)

          Isorel M, 140 mg/kg

            

          Recurrence after resection, VAE vs. control: 47% vs. 78%

          [118]

          Carcinoma, iv

          Mice (CBA/HZgr)

          Isorel M, 140 mg/kg, ip

            

          52 lung-metastases

          [118]

            

          Endoxan, 50 mg/kg

            

          23 lung-metastases

           
            

          Isorel M, 140 mg/kg & Endoxan 50 mg/kg

            

          10 lung-metastases

           
            

          Control

            

          76 lung-metastases

           

          C3H adenocarcinoma, 16/C

          Mice (B6C3F1)

          Iscador M, 50 or 100 mg/kg, ip, qd, day 1–14

          28%

          15 to 20%

           

          [119]

          RC adenocarcinoma, sc

          Mice (DBA)

          VAE I, sc

          20 to 40%

            

          [111]

          ECa, ip

          Mice (NMRI)

          VAE (supracritical CO2 extraction), 2 mL/kg, ip, qd, starting day -7, day 0, or day 7

          65 to 100%II

            

          [120]

          ECa, ip

          Mice (BALB/c)

          Iscador, 15 μg, ip, day -1

           

          108%

           

          [121]

            

          Sodium caseinate & Iscador, 15 μg, ip, day -1

           

          no death

            
            

          Sodium caseinate, day -1

           

          0%

            

          ECa, ip

          Mice (BALB/c)

          Iscador, 15 μg, ip, day 6

           

          82%

           

          [121]

            

          Sodium caseinate, day 6

           

          7%

            

          ECa, ip

          Mice (BALB/c)

          Iscador-activated macrophages, ip, day 6

           

          49%

           

          [121]

            

          Non-activated macrophages, ip, day 6

           

          4%

            

          ECa, ip

          Mice (BALB/c)

          Iscador activated macrophages, ip, day 6, 10, 14

           

          98%

           

          [121]

            

          Non-activated macrophages, ip, day 6, 10, 14

           

          9%

            

          ECa, sc

          Mice (BALB/c)

          Iscador, 15 μg, it, day 7

            

          Severe necrosis, infiltration of lymphocytes and macrophages

          [122]

          ECa, sc

          Mice (Swiss)

          Iscador M, 1.66 mg, im, qod * 5 or 10

          3 to 10%

            

          [123]

          ECa, ip

          Mice (Swiss)

          Iscador M, 1.66 mg, ip, qod * 10

           

          76%

           

          [123]

          ECa, ip

          Mice (Swiss)

          Iscador M, 25 or 50 mg/kg, ip, qd * 14

           

          69 to 97%

          No tumour-free mice

          [119]

          ECa, ip

          Mice (Swiss)

          Iscador M, sc, cumulative dose 4, 5, 150, or 200 mg

           

          -4 to 0%

           

          [124]

          ECa, sc

          Mice

          VAE, it, 0.1–0.2 ccm, qod * 6–10

            

          Complete remission & no recurrence: 27%

          [125, 126]

          Murine breast

          Rats

               

          Walker carcinosarcoma 256; sc

          Rats (Sprague Dawley)

          Iscador M, sc, cumulative dose 11, 16, 500, or 750 mg or combination of Iscador M, sc, cumulative dose 11 or 500 mg & Cetraria praeparata, cumulative dose 3 or 164 mg

          93 to 115%

          -16 to 8%

           

          [124]

          Dunning DMBA-5A; sc

          Rats

          Iscador M, 2.5–15 mg, ip, qd

          No difference

           

          Less tumour viability

          [127]

          Walker carcinosarkoma 256

          Rats

          Iscador M, 0.005–0.5 mg, im, qd

          No difference

           

          Metastases: no difference

          [128]

          Autochthonous

                

          Methylnitrosurea-induced

          Rats (Sprague Dawley)

          Iscador M c. Arg., sc, 0,2 ml/day, 50 mg/week * 6 weeks

          75%

          -16%

           

          [124]

          sc: subcutaneous; im: intramuscular; it: intratumoural; ip: intraperitoneal; iv: intravenous; w: week;

          qod: every other day; qd: every day; T/C: treated tumour/control tumour; ILS: increase in life span

          All experiments did have control groups, but these were only mentioned if necessary for results

          I Part of a screening programme for substances with anticancer activity (1,000 plant extracts from 107 plant species)

          II Relating to volume of ascites; effects greatest with therapy started on day -7

          Table 9

          Animal Studies of VAE Compounds in Breast or Gynaecological Cancer (transplanted human or murine tumours)

          Tumour, site

          Animal

          VAE

          Tumour growth

          T/C (%)

          Survival

          Other outcomes

          Reference

          Human breast tumour

          Breast

          Mice

          rML 0,3 ng/kg – 3 μg/kg, ip, qd * 5 * 2–4 w

          No effect

            

          [129]

          Murine breast tumour in mice

          C3L5, adenocarcinoma; sc

          Mice (C3H7HeJ)

          ML I, 1 ng/kg, sc, q3d, day 7–19

          160

           

          27.6 lung-metastases

          [130]

            

          IL-2, twice 6 × 104 IU/mouse, ip q8h 2 * qd * 5

          43

           

          2.3 lung-metastases

           
            

          Combination of ML 1 & IL-2

          37

           

          2.3 lung-metastases

           
            

          Control

            

          7.5 lung-metastases

           

          ECa, ip

          Mice (ICR)

          ML I, 80 ng, ip, day 1

           

          70% died after 50 days

           

          [131]

            

          A-chain of ML I, 100 μg, ip, day 1

           

          80% died after 57 days

            
            

          B-chain of ML I, 10 μg, ip, day 1

           

          80% died after 58 days

            
            

          Control

           

          100% died after 20 days

            

          ECa, sc

          Mice (BALB/c)

          VAE 5 kDa peptides, 2 μg, it, day 7

            

          Severe necrosis, infiltration of lymphocytes and macrophages

          [122]

          ECa, ip

          Mice (CD-1)

          Vester' Proteins, ip, 0.1 or 1 or 10 μ/kg, qd * 10

           

          ILS: 0, 33, and -33%I

           

          [132]

          ECa

          Mice

          Polysaccharide („Viscumsäure“), ip, qd * 6

          Slight effect

            

          [133]

          Adenocarcinoma EO 771

          Mice

          Polysaccharide („Viscumsäure“), ip, qd * 6

          Moderate effect

            

          [133]

          Murine breast tumour in rats

          Walker Carcinosarcoma

          Rats

          Polysaccharide („Viscumsäure“), ip, qd * 6

          Moderate effect

            

          [133]

          Other gynaecological tumour

          Ovary, SoTü 3, ip

          Mice (SCID)

          rML 30 ng/kg, ip, qd * 5 * 12

           

          35% mice alive at day 84

          40% tumour-free mice at day 84

          [134]

            

          rML 150 ng/kg, ip, qd * 5 * 12

           

          10% mice alive at day 84

          10% tumour-free mice at day 84

           
            

          rML 500 ng/kg, ip, qd * 5 * 12

           

          75% mice alive at day 84

          65% tumour-free mice at day 84

           
            

          Control

           

          15 mice alive at day 84

          10% tumour-free mice at day 84

           

          Uterusepithelioma T-8 Guérin

          Rats

          Polysaccharide ("Viscumsäure"), ip, qd * 6

          Moderate effect

            

          [133]

          All experiments did have control groups, but these were only mentioned if necessary for results.

          sc: subcutaneous; it: intratumoural; ip: intraperitoneal; iv: intravenous; w: week;

          qod: every other day; qd: every day; T/C: treated tumour/control tumour; ILS: increase in life span.

          I Application of 10 μg/kg of proteins had toxic effects

          These experiments had been conducted in Germany, Switzerland, Austria, USA, India, Croatia and Serbia. 9 of the 34 experiments reported the funding source, 8 of these had public funding and one a combination of public and industry funding. 19 had been published since 1990 and 15 before (1938–1989). 21 were published in peer-reviewed and 2 in other journals, 6 were published in scientific reference books, 1 as a conference abstract, and 4 in a patent specification. Published information was often insufficient and sometimes extremely sparse. 6 experiments reported randomized treatment allocation. Regarding the control group, placebo treatment was described in 13 experiments – five of these with identical application schedule to the verum treatment -, no treatment in 11 experiments, and 9 experiments gave no information. None of the experiments reported a blinded outcome assessment (but randomized treatment allocation and blinded outcome assessment are generally routine practice).

          Outcome

          We found substantial heterogeneity of the studies in terms of intervention, patient characteristics, clinical diagnosis, measured outcomes, design, methodological quality and potential positive and negative biases. We therefore regarded quantification of effect size by combining results as unreliable and decided on a non-quantitative synthesis and discussion. A subgroup of studies (2 RCTs, 2 non-RCTs on breast cancer), with a comparable design (all originating in the same epidemiological cohort study) had already been analysed in a quantitative meta-analysis [135].

          Results of controlled clinical studies are shown in Table 3 (survival), Table 4 (tumour behaviour) and Table 5 (QoL and tolerability of conventional cancer treatment); results of single-arm studies are shown in Table 6.

          Results of the preclinical studies are presented in Tables 7, 8 and 9.

          Breast cancer

          Clinical studies: Survival (Table 3) was investigated by 4 RCTs and 3 non-RCTs (one of these is shown with three subgroups in Table 3): Two RCTs reported a statistically significant benefit of VAE (of these one also included other tumour sites, and the other suffered from a major attrition rate without preventing bias by an intention-to-treat analysis), and two RCTs reported a small positive trend. The results of the latter two RCTs were also combined in an individual patient data meta-analysis; the result just missed significance (HR: 0.59, 95% CI: 0.34–1.02, p = 0.057) [135]. Two non-RCTs had observed a statistically significant benefit, and one a small positive trend. The results of two non-RCTs were additionally combined in an individual patient data meta-analysis, and showed highly significant results (HR: 0.43, 95% CI: 0.34–0.56, p < 0.0005) [135]. Tumour behaviour (Tables 4 and 6) was investigated by two RCTs, four non-RCTs and 4 single-arm studies. Four of the controlled studies combined VAE and conventional cancer treatment. These studies partly reported a benefit regarding disease recurrence and time to disease relapse and partly no difference; none found a disadvantage. Two single-arm studies reported tumour remission in 44–62% of patients after local application of high dosage VAE. Another study found no remission after the application of rML. QoL and the reduction of side effects of chemotherapy, radiation and surgery (Tables 5 and 6) were assessed by 11 RCTs, 6 non-RCTs and 4 single-arm studies: 19 of these 21 studies reported a benefit, mostly statistically significant, one study reported no QoL-benefit but a reduction of side effects, and the smallest of these studies found no difference. Three major pharmaco-epidemiological studies investigated patient charts and found reduced disease- and therapy-associated symptoms in VAE-treated groups.

          In preclinical studies (Tables 7, 8, and 9) VAE and VAE compounds showed cytotoxic effects in cancer cells. VAE also counteracted growth factor-induced proliferation and migration in breast cancer cells [95]. In mice, VAE inhibited tumour growth in most cases, especially when applied locally and in high dosage. Survival was prolonged in most cases, and numbers of metastases and local recurrences were reduced after application of VAE or of VAE-activated macrophages; one study found no benefit. All experiments using local VAE application found a benefit in relation to survival and tumour-growth inhibition. In rats, no clear benefit of VAE could be seen. Results from applying isolated or recombinant VAE compounds were inconsistent: some moderate effects of proteins (e.g. lectins) or polysaccharides were observed in relation to survival and tumour growth, while others observed none or possibly also adverse outcomes.

          Cervical cancer

          Clinical studies: Survival (Table 3) was investigated by one RCT and three non-RCTs: all four reported a beneficial outcome which, however, was statistically significant only in the non-RCTs. Tumour behaviour (Table 4) was investigated by one non-RCT, which could not find an effect on disease recurrence or metastases mainly because these events scarcely occurred. One single-arm study reported 41% complete and 27% partial remissions in CIN after VAE application. QoL (Table 5) was assessed in one RCT and one non-RCT; both reported a statistically significant benefit.

          Regarding preclinical studies (Table 7), only HeLa cells were investigated; here VAE and protein fractions showed cytotoxic effects.

          Uterus cancer

          Clinical studies: Survival (Table 3) was investigated by two RCTs and two non-RCTs; three reported a statistically significant benefit while one found no difference. QoL (Table 5) was assessed by one RCT and one non-RCT; both found a statistically highly significant benefit.

          Regarding preclinical studies (Tables 7 and 9), VAE and isolated ML I showed cytotoxic effects in different human uterus cancer cells. Concerning animal experiments, a patent specification mentions "moderate" effects of mistletoe polysaccharides on tumour growth in uterusepithelioma.

          Ovarian cancer

          Clinical studies: Two RCTs and two non-RCTs investigated the influence of VAE on survival (Table 3) and reported a benefit, one of each with statistical significance. Tumour behaviour (Table 4) was investigated by two RCTs, each combining VAE and chemotherapy (plus radiotherapy in one study): these reported comparable outcomes. The influence of VAE on QoL and tolerability of chemotherapy and radiation (Table 5) was investigated by three RCTs and one non-RCT; all of them reported a statistically significant positive effect. In one trial using an aggressive chemotherapy protocol, higher dosages of Cisplatin and Holoxan could be given in the VAE group as the side effects were less intense [63]. One single-arm study applied recombinant lectins in ovarian cancer but found no remission.

          Regarding preclinical studies (Tables 7 and 9), VAE showed cytotoxic effects in various ovarian cancer cells. In SCID mice, rMLs led to increased survival and to more tumour-free animals at the highest and lowest dosage, while no effect was observed at the medium dosage.

          Genital cancer

          Clinical studies: One non-RCT (published in 1963) reported partly improved disease-specific survival (Table 3). Regarding preclinical studies (Table 7), VAE showed cytotoxic effects in vulvar cancer cells.

          Malignant effusion

          Clinical studies: One RCT and four single-arm studies investigated treatment of malignant pleural effusion and ascites (originating from breast or ovarian cancer, among other cancer sites), and all reported substantial remission rates (Tables 4 and 6).

          Safety

          Tolerability was generally good. One case of urticaria and angioedema [56] and one case of "generalized reaction" [69] were described. Otherwise no major side effects or toxicity were reported. Frequent minor, dose-dependent and spontaneously subsiding symptoms included reactions at the injection site (swelling, induration, erythema, pruritus, local pain) and mild flu-like symptoms or fever. In one study, local reactions intensified during concomitant chemotherapy [64]. A higher prevalence of depression was documented in the unadjusted data of a retrolective non-RCT [69] in VAE-treated patients; these patients also had a higher prevalence of other treatments such as hormones. After intrapleural instillation, VAE induced significantly fewer side effects than doxycycline [60]. No indication for an interaction of VAE and chemotherapy could be found (i.e. remission rate) and VAE had no influence on the plasma concentration of gemcitabine [44, 73]. No toxicity was observed in animal studies, except after application of high doses of an isolated protein complex with unknown constituents [132].

          Discussion

          A variety of clinical studies and experiments have investigated the potential therapeutic effects of VAE and its compounds in breast and gynecological cancer, and predominantly reported positive effects. Nevertheless they have to be interpreted with caution and within their context.

          The strongest and most consistent results from VAE in clinical studies concern QoL and improved tolerability of conventional treatment. QoL questionnaires included mostly well established and validated QoL instruments and one on psychosomatic self-regulation. The latter is a 16 item QoL instrument that measures competence and autonomy, in terms of the ability to actively adapt to stressful life situations and to restore well-being. [136] This tool has so far been exclusively used in studies focusing on complementary cancer treatments. Improvement was seen especially in relation to self-regulation, fatigue, sleep, nausea/vomiting, appetite, diarrhoea, energy, ability to work, enjoyment of life, depression, anxiety, pain, and general physical, emotional, and functional well-being (for more details see Kienle GS, Kiene H: Influence of mistletoe treatment on quality of life in cancer patients. A systematic review of controlled clinical studies. Submitted). Regarding the side effects of conventional oncology treatments, reduced hematopoetic damage (i.e. leukopenia) and immuno-suppression was reported by some, but not by all studies. Similar, less chemotherapy-related events were observed in some but not in all studies. Validity of this evidence is quite good. 15 RCTs are available, four of them double-blinded (three of them showing a positive result) and one with an active control treatment. 5 RCTs reported following ICH-GCP guidelines and three of them comprised more than 200 patients each. Questions remain regarding observation or reporting bias, which is of major importance in relation to subjectively assessed outcomes such as QoL and subjective symptoms. Treatment should therefore be blinded; but blinded subcutaneous VAE application can easily be correctly identified by doctors and patients [55, 137], due to its local reactions and mild flu-like symptoms. In the four blinded trials reviewed here, a considerable degree of unblinding was detected by asking patients and physicians in one study [55]; and can be presumed in two other of these trials where substantially more VAE-treated patients reported local reactions than control patients [54, 57]. Other RCTs did not blind treatment application, as blinding is unreliable. Therefore questions will remain in "blinded" as well as in open trials even though in general cancer or non-cancer trials could not detect relevant improvements of QoL or disease symptoms due to suggestive administration of inert substances [138140]. Nevertheless, the frequency, magnitude, duration and conditions of QoL or symptomatic improvement in the course of VAE treatment should be clarified in more detail. Especially relevant might be the further elucidation of possible effects on cancer-related fatigue (see also [141]), which is one of the most disabling conditions in cancer patients, with only few therapeutic options for influencing it effectively [142144]. Regarding simple pre-post assessments of QoL in single-arm studies, it is probably unnecessary to state that they are generally not appropriate for judging influences on QoL, since it is affected by many factors.

          Concerning survival (Table 3), some of the RCTs show a statistically significant benefit while others show a statistical trend or no difference. Most of the non-RCTs (which included larger patient numbers) show a major impact. The validity of the studies is limited because of their small sample size (median only 52 participants per RCT), and because 8 of the 9 RCTs were imbedded in the same (large) epidemiological cohort study. This study was started in the 1970s, before modern standards of data quality control (ICH-GCP, GEP) were established, and it therefore does not fulfil modern standards in this respect. The 9th RCT had enrolled more patients but was conducted even earlier, and suffers from a major attrition rate due to protocol violation [62]; the subsequent analysis followed the "as treated" instead of the "intention-to-treat" principle [145]. Hence bias cannot be excluded. None of the survival studies was blinded, but survival is generally not easily affected by observer bias or suggestive effects [138140]. Seen altogether, although results were consistent, questions regarding survival remain and validity of evidence is moderate at best. An independent, GCP-conform trial with sufficient power would be desirable to further evaluate potential survival benefit.

          Regarding tumour behaviour, evidence from RCTs is scanty; most benefits were shown in non-randomized studies. In single-arm studies of patients with no concomitant conventional cancer treatment, high-dose or local application of whole VAE led to substantial remission of tumour or malignant effusion. This was also observed in animal studies: local application resulted in tumour-growth inhibition and increased survival. However, this application and dosage is not standard and cannot be recommended widely due to potential risks of high dose or local application. With ordinary VAE application, schedule and dosage, spectacular tumour remissions tend to be the exception [20, 36]. No tumour remission was observed after application of rMLs. Remission in CIN cannot be distinguished from spontaneous remission rates, which are frequent in this indication.

          Apart from the discussed issues, the following validity aspects have to be considered: An attrition rate above 10% was present in 10 RCTs. In 5 of these RCTs [4951, 53], patients were excluded before baseline assessment. Here the patients were provisionally enrolled into the matching and pairwise randomization procedure; subsequently they were asked for informed consent, and were excluded from the study if they declined, together with their matched twin. Even though the risk of bias with this procedure is small, as the complete randomization unit (patient pair) is excluded, the preferred conservative quality assessment in this review assessed these studies as not having excluded a drop-out bias. Of the remaining 5 trials, one had protocol violations in about 20% of patients as discussed above [62], and one trial used an aggressive chemotherapy that inevitably had to be halted in several patients [63]. Three trials did not report details.

          To reduce publication bias we also included unpublished studies and conducted a thorough literature search with extensive expert consultations. One unpublished RCT (Lektinol in breast cancer by Schwiersch et al.) could not be included as it was not released by the manufacturer. Beyond this, we cannot rule out the existence of unpublished and unknown RCTs, but we presume that no well-conducted, large-size and valid trials escaped our attention. – Regarding preclinical studies achieving completeness is nearly impossible. These experiments are usually explorative, for instance when plant extracts are chemically analysed for active compounds or for cytotoxic effects; in general only relevant results are published, but not results of non-relevant or non-working models or unstable chemicals. (Even in the reviewed experiments, often not all but only the noteworthy results were presented in detail.)

          Regarding funding, 27 of 28 controlled studies published since 2000 reported their funding source: 11 studies received funding from the pharmaceutical industry alone, 16 studies (all by Grossarth et al.) had both industry and public funding. There was no difference of results depending on funding source.

          Regarding non-RCTs, bias by self-selecting the treatment is usually present in raw data. In particular, patients who choose complementary treatments differ substantially from patients not choosing them [70, 146]. It is therefore indispensable to conduct careful adjustment of baseline imbalances or matching [147149]. This has been done to a varying degree in most studies except in one without any adjustment [64], and in another which only adjusted for the main outcome parameter but not for the other reported results [69]. Without any adjustment, no conclusions can be drawn regarding the applied treatment. When conducted and analysed carefully, non-RCTs can provide valuable information regarding external validity and effectiveness, as they can investigate treatment effectiveness under routine conditions without distortion by the artificial and selective conditions of an RCT's experimental situation [150].

          In preclinical studies, VAE show substantial cytotoxic effects in cells originating from breast and gynaecological cancer, and display tumour-growth inhibition in animal studies. Cytotoxicity, especially of the MLs (which bind on human breast cancer cells [151]), may be the cause of tumour reduction after local, intratumoural application of VAE. If systemically applied, the cytotoxicity of the MLs is of less relevance, as it is inhibited by serum glycoproteins [152] and by anti-ML antibodies [153] which are produced after a few weeks of VAE application. Therapeutic effects of the MLs were inconsistent and not very impressive in the reviewed experiments. However, in other tumour types, MLs have also shown substantial growth-inhibiting effects (e.g. [154157]). Interestingly, in two experiments, the application of VAE-activated macrophages in mice not directly treated with VAE also showed tumour-growth inhibiting effects, while the application of non-activated macrophages had no effects [121]. Similarly in melanoma, the application of VAE-activated splenocytes inhibited metastasis [158, 159].

          In general, the predictive reliability of the preclinical studies for clinical application is fairly limited in most instances. Clinical cancer disease is insufficiently mimicked by animal models, with major differences regarding age, general condition, co-morbidity, invasiveness, metastases, antigenicity, immune system etc. The results of preclinical screening, especially for treatment of solid tumours, have therefore been largely disappointing. The models currently regarded as best for cytotoxic substances use patient-derived tumours that grow subcutaneously or orthotopically in nude mice, as in several cases reviewed here. Immuno-active substances may however still be insufficiently assessed in immune-deficient animals, as the main components of the immune system are missing (nude mice, for instance, cannot generate mature T-lymphocytes). Nevertheless, these preclinical experiments can provide important additional information for detecting the possible anti-cancer effects of medicinal plants, their active compounds, their mode of action and potential risks [20, 160162].

          Safety aspects

          Mistletoe therapy was well tolerated in the reviewed studies. Mild flu-like symptoms and local reactions at the injections sites are frequent, dose-dependent and self-limited. Allergic reactions can occur, and a few case reports of anaphylactic reactions exist [163166]. A phase I study, conducted at the NCCAM/NCI, investigated safety, toxicity and drug interactions between VAE and gemcitabine [73] and reported good tolerability, with neither dose-limiting toxicity of the VAE nor any effects on the plasma concentration of gemcitabine [44]. Combination of VAE with chemotherapy or radiotherapy did not negatively influence remission rate in clinical and in animal studies [56, 63, 118]. A higher prevalence of depression in VAE-treated patients in one study was observed in raw data of a self-selected population, without adjustment of baseline imbalances. This difference can be ascribed to variations in the patient population; for instance, they differed markedly in the prevalence of hormone treatment. No toxicity was observed in animal experiments.

          Conclusion

          Preclinical and clinical studies investigating the influence of VAE and its isolated compounds on breast or gynaecological cancer suggest a benefit, with the strongest evidence in relation to QoL and tolerability of conventional anti-cancer treatments. Regarding survival, evidence is less conclusive; most of the clinical studies had a very small sample size (RCTs) and were embedded in the same large cohort study; therefore an independent trial would be needed. Tumour-growth inhibition has been insufficiently assessed in prospective clinical trials. Tumour regression seems not to have been connected with regular low-dose subcutaneous VAE treatment, but with high dose and local application. The latter has not yet been thoroughly assessed and is not generally recommended.

          Abbreviations

          AMED: 

          Allied and Complementary Medicine

          CI: 

          confidence interval

          CIN: 

          cervical intraepithelial neoplasia

          DNA: 

          deoxyribonucleic acid

          ECa: 

          Ehrlich carcinoma

          EORTC QLQ-C30: 

          European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cancer

          EORTC QLQ-BR23: 

          European Organization for Research and Treatment of Cancer Quality of Life Breast Cancer Questionnaire

          FACT-G: 

          Functional Assessment of Cancer Therapy-General

          FLIC: 

          Functional Living Index – Cancer

          GCP: 

          Good Clinical Practice

          GEP: 

          Good Epidemiological Practice

          GLQ-8: 

          Global Life Quality

          GM-CSF: 

          granulocyte macrophage colony-stimulating factor

          HeLa cells: 

          immortal cell line from Henrietta Lacks

          HR: 

          hazard ratio

          ICH: 

          International Conference on Harmonisation

          IFN-γ: 

          interferon-gamma

          IL: 

          interleukin

          kDa: 

          kilodalton

          KPS: 

          Karnofsky performance status scale

          MDR+: 

          multidrug resistant

          ML: 

          mistletoe lectin

          NCCAM: 

          National Center for Complementary and Alternative Medicine

          NCI: 

          National Cancer Institute

          NHS: 

          National Health Service

          NK: 

          neutral killer (cell)

          NLM: 

          National Library of Medicine

          non-RCT: 

          non-randomized controlled trial

          QoL: 

          quality of life

          RCT: 

          randomized controlled trial

          rML: 

          recombinant mistletoe lectin

          SCE: 

          sister chromatid exchange

          SCID mice: 

          Severe Combined Immunodeficiency mice

          T-cells: 

          lymphocytes matured in thymus

          TCM: 

          Traditional Chinese Medicine Index

          TNF-α: 

          tumor necrosis factor-alpha

          TNM: 

          tumor, node, metastasis

          VAE: 

          Viscum album extracts

          VisalbCBA: 

          Viscum album chitin-binding agglutinin.

          Declarations

          Acknowledgements

          This review was funded by the Gesellschaft für Biologische Krebsabwehr and the Software AG Stiftung. We thank Dr. Renatus Ziegler for providing additional data on the studies by Grossarth-Maticek & Ziegler.

          Authors’ Affiliations

          (1)
          Institute for Applied Epistemology and Medical Methodology
          (2)
          Verein Filderklinik e.V, Research Department

          References

          1. Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P: Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol. 2007, 18: 581-592. 10.1093/annonc/mdl498.PubMed
          2. Stat Bite: Number of Cancer Survivors by Site, 2003. J Natl Cancer Inst. 2006, 98 (21): 1514-
          3. Fasching PA, Thiel F, Nicolaisen-Murmann K, Rauh C, Engel J, Lux MP, Beckmann MW, Bani MR: Association of complementary methods with quality of life and life satisfaction in patients with gynecologic and breast malignancies. Support Care Cancer. 2007, 55: 1277-1284. 10.1007/s00520-007-0231-1.
          4. Helyer LK, Chin S, Chuim BK, Fitzgerald B, Verma S, Rakovitch E, Dranitsaris G, Clemons M: The use of complementary and alternative medicines among patients with locally advanced breast cancer – a descriptive study. BMC Cancer. 2006, 6: 39-10.1186/1471-2407-6-39.PubMedPubMed Central
          5. DiGianni LM, Garber JE, WIner EP: Complementary and alternative medicine use among women with breast cancer. J Clin Oncol. 2002, 20: 34s-38s.PubMed
          6. Boon HS, Olatunde F, Zick SM: Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005. BMC Woman's Health. 2007, 7: 4-10.1186/1472-6874-7-4.
          7. Molassiotis A, Scott JA, Kearney N, Pud D, Magri M, Selvekerova S, Bruyns I, Fernandez-Ortega P, Panteli V, Margulies A, Gudmundsdottir G, Milovics L, Ozden G, Platin N, Patiraki E: Complementary and alternative medicine use in breast cancer patients in Europe. Support Care Cancer. 2006, 14: 260-267. 10.1007/s00520-005-0883-7.PubMed
          8. Molassiotis A, Browall M, Milovics L, Panteli V, Patiraki E, Fernandez-Ortega P: Complementary and alternative medicine use in patients with gynecological cancers in Europe. International Journal of Gynecological Cancer. 2006, 16: 219-224. 10.1111/j.1525-1438.2006.00309.x.PubMed
          9. Cragg GM, Newman DJ: Plants as a source of anti-cancer agents. Ethnopharmacology. Encyclopedia of Life Support Systems (EOLSS), developed under the Auspices of the UNESCO. Edited by: Elisabetsky E, Etkin NL. 2006, Oxford, UK, Eolss Publishers, [http://​www.​eolss.​net]
          10. Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I, Gudmundsdottir G, Hummerston S, Ahmad AM, Platin N, Kearney N, Patiraki E: Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005, 16: 655-663. 10.1093/annonc/mdi110.PubMed
          11. Endo Y, Tsurugi K, Franz H: The site of action of the A-chain of mistletoe lectin I on eukaryotic ribosomes. FEBS Letters. 1988, 231: 378-380. 10.1016/0014-5793(88)80853-6.PubMed
          12. Stirpe F, Sandvig K, Olsnes S, Pihl A: Action of viscumin, a toxic lectin from mistletoe, on cells in culture. The Journal of Biological Chemistry. 1982, 257: 13271-13277.PubMed
          13. Stirpe F, Barbieri L, Battelli MG, Soria M, Lappi DA: Ribosome-inactivating proteins from plants: present status and future prospects. Biotechnology (N Y). 1992, 10 (4): 405-412. 10.1038/nbt0492-405.
          14. Peumans WJ, Verhaert P, Pfüller U, Van Damme EJM: Isolation and partial characterization of a small chitin-binding lectin from mistletoe (Viscum album). FEBS Letters. 1996, 396: 261-265. 10.1016/0014-5793(96)01108-8.PubMed
          15. Klett CY, Anderer FA: Activation of natural killer cell cytotoxicity of human blood monocytes by a low molecular weight component from Viscum album extract. Arzneimittelforschung. 1989, 39 (12): 1580-1585.PubMed
          16. Mueller EA, Anderer FA: A Viscum album oligosaccharide activating human natural cytotoxicity is an interferon gamma inducer. Cancer Immunol Immunother. 1990, 32: 221-227. 10.1007/BF01741704.PubMed
          17. Orhan DD, Küpeli E, Yesilada E, Ergun F: Anti-inflammatory and antinociceptive activity of flavonoids isolated from VISCUM ALBUM ssp. ALBUM. Z Naturforsch C. 2006, 61 (1-2): 26-30.PubMed
          18. Winkler K, Leneweit G, Schubert R: Characterization of membrane vesicles in plant extracts. Colloids and surfaces B, Biointerfaces. 2005, 45: 57-65. 10.1016/j.colsurfb.2005.07.006.PubMed
          19. Jager S, Winkler K, Pfuller U, Scheffler A: Solubility studies of oleanolic acid and betulinic acid in aqueous solutions and plant extracts of Viscum album L. Planta Med. 2007, 73: 157-162. 10.1055/s-2007-967106.PubMed
          20. Kienle GS, Kiene H: Die Mistel in der Onkologie – Fakten und konzeptionelle Grundlagen. 2003, Stuttgart, New York: Schattauer Verlag
          21. Büssing A, (ed): Mistletoe. The Genus Viscum. 2000, Amsterdam: Hardwood Academic Publishers
          22. Eggenschwiler J, von BL, Stritt B, Pruntsch D, Ramos M, Urech K, Rist L, Simoes-Wust AP, Viviani A: Mistletoe lectin is not the only cytotoxic component in fermented preparations of Viscum album from white fir (Abies pectinata). BMC Complement Altern Med. 2007, 7: 14-10.1186/1472-6882-7-14.PubMedPubMed Central
          23. Büssing A, Schietzel M: Apoptosis-inducing properties of Viscum album L. extracts from different host trees, correlate with their content of toxic mistletoe lectins. Anticancer Res. 1999, 19: 23-28.PubMed
          24. Elsässer-Beile U, Lusebrink S, Grussenmeyer U, Wetterauer U, Schultze-Seemann W: Comparison of the effects of various clinically applied mistletoe preparations on peripheral blood leukocytes. Arzneimittelforschung. 1998, 48 (12): 1185-1189.PubMed
          25. Valentiner U, Pfüller U, Baum C, Schumacher U: The cytotoxic effect of mistletoe lectins I, II and III on sensitive and multidrug resistant human colon cancer cell lines in vitro. Toxicology. 2002, 171: 187-199. 10.1016/S0300-483X(01)00581-9.PubMed
          26. Siegle I, Fritz P, McClellan M, Gutzeit S, Murdter TE: Combined cytotoxic action of Viscum album agglutinin-1 and anticancer agents against human A549 lung cancer cells. Anticancer Res. 2001, 21: 2687-2691.PubMed
          27. Bantel H, Engels IH, Voelter W, Schulze-Osthoff K, Wesselborg S: Mistletoe lectin activates caspase-8/FLICE independently of death receptor signaling and enhances anticancer drug-induced apoptosis. Cancer Research. 1999, 59: 2083-2090.PubMed
          28. Mueller EA, Anderer FA: Synergistic action of a plant rhamnogalacturonan enhancing antitumor cytotoxicity of human natural killer and lymphokine-activated killer cells: Chemical specificity of target cell recognition. Cancer Research. 1990, 50: 3646-3651.PubMed
          29. Zhu HG, Zollner TM, Klein-Franke A, Anderer FA: Enhancement of MHC-unrestricted cytotoxic activity of human CD56+CD3- natural killer (NK) cells and CD+T cells by rhamnogalacturonan: target cell specificity and activity against NK-insensitive targets. J Cancer Res Clin Oncol. 1994, 383-388. 10.1007/BF01240135.
          30. Park W-B, Lyu SY, Kim JH, Choi SH, Chung HK, Ahn SH, Hong SY, Yoon TJ, Choi MJ: Inhibition of tumor growth and metastasis by Korean mistletoe lectin is associated with apoptosis and antiangiogenesis. Cancer Biother Radiopharm. 2001, 16: 439-447. 10.1089/108497801753354348.PubMed
          31. Van Huyen JP, Bayry J, Delignat S, Gaston AT, Michel O, Bruneval P, Kazatchkine MD, Nicoletti A, Kaveri SV: Induction of apoptosis of endothelial cells by Viscum album: a role for anti-tumoral properties of mistletoe lectins. Mol Med. 2002, 8: 600-606.PubMed Central
          32. Schöffski P, Riggert S, Fumoleau P, Campone M, Bolte O, Marreaud S, Lacombe D, Baron B, Herold M, Zwierzina H, Wilhelm-Ogunbiyi K, Lentzen H, Twelves C, European Organization for Research and Treatment of Cancer New Drug Development Group: Phase I trial on intravenous aviscumine (rViscumin) in patients with solid tumors: a study of the European Organization for Research and Treatment of Cancer New Drug Development Group. Ann Oncol. 2004, 15: 1816-1824. 10.1093/annonc/mdh469.PubMed
          33. Schöffski P, Breidenbach I, Krauter J, Bolte O, Stadler M, Ganser A, Wilhelm-Ogunbiyi K, Lentzen H: Weekly 24 h infusion of aviscumine (rViscumin): a phase I study in patients with solid tumours. Eur J Cancer. 2005, 41: 1431-1438. 10.1016/j.ejca.2005.03.019.PubMed
          34. Kienle GS, Berrino F, Büssing A, Portalupi E, Rosenzweig S, Kiene H: Mistletoe in cancer – a systematic review on controlled clinical trials. Eur J Med Res. 2003, 8: 109-119.PubMed
          35. Stauder H, Kreuser E-D: Mistletoe extracts standardised in terms of mistletoe lectins (ML I) in oncology: current state of clinical research. Onkologie. 2002, 25: 374-380. 10.1159/000066058.PubMed
          36. Kienle GS, Kiene H: Complementary Cancer Therapy: A Systematic Review of Prospective Clinical Trials on Anthroposophic Mistletoe Extracts. Eur J Med Res. 2007, 12: 103-119.PubMed
          37. Ernst E, Schmidt K, Steuer-Vogt MK: Mistletoe for cancer? A systematic review of randomized clincial trials. Int J Cancer. 2003, 107: 262-267. 10.1002/ijc.11386.PubMed
          38. Horneber MA, Bueschel G, Huber R, Linde K, Rostock M: Mistletoe therapy in oncology. Cochrane Database Syst Rev. 2008, CD003297-
          39. Lange-Lindberg AM, Velasco Garrido M, Busse R: Misteltherapie als begleitende Behandlung zur Reduktion der Toxizität der Chemotherapie maligner Erkrankungen. GMS Health Technol Assess 2006; 2:Doc18 (20060919). 2006
          40. Khan KS, ter Riet G, Glanville J, Sowden AJ, Kleijnen J: Undertaking Systematic Reviews of Research on Effectiveness. CRD'S Guidance for those Carrying Out or Commissioning Reviews. CRD Report Number 4. 2001, University of York: NHS Centre for Reviews and Dissemination, 2
          41. Kleijnen J, Knipschild P: Mistletoe treatment for cancer – review of controlled trials in humans. Phytomedicine. 1994, 1: 255-260.PubMed
          42. Jach R, Basta A: Iscador QuS and human recombinant interferon alpha (Intron A) in cervical intraepithelial neoplasia (CIN). Przeglad Lekarski. 1999, 56: 86-88.PubMed
          43. Jach R, Basta A, Szczudrawa A: Role of immunomodulatory treatment with Iscador QuS and Intron A of women with CIN1 with concurrent HPV infection. Ginekol Pol. 2003, 74: 729-735.PubMed
          44. Mansky PJ, Wallerstedt DB, Monahan BP, Lee C, Sannes T, Stagl J, Blackman MA, Swain SL, Grem J: Phase I study of mistletoe extract/gemcitabine combination treatment in patients with advanced solid tumors. Onkologie. 2008, 31: 200-10.1159/000119121.
          45. Schink M, Tröger W, Goyert A, Scheuerecker H, Selbmann K, Glaser F: Zusammenhang der NK-Zellaktivität gegen autologe Tumor- und K562-Zellen mit dem klinischen Verlauf unter Misteltherapie. Forsch Komplementärmed. 2006, 13: 147-155. 10.1159/000092624.
          46. Bar-Sela G, Goldberg H, Beck D, Amit A, Kuten A: Reducing malignant ascites accumulation by repeated intraperitoneal administrations of a Viscum album extract. Anticancer Res. 2006, 26: 709-714.PubMed
          47. Tröger W, Matijaševic M, Ždrale Z, Tisma N, Jezdic S: Additional therapy with mistletoe extracts in breast cancer patients receiving chemotherapy: a prospective randomized open label pilot study. Die Mistel in der Tumortherapie 2. – Aktueller Stand der Forschung und klinische Anwendung. Edited by: Scheer R, Alban S, Becker H, Holzgrabe U, Kemper FH, Kreis W, Matthes H, Schilcher H. 2009, Essen, KVC-Verlag, 509-521.
          48. Büssing A, Brückner U, Enser-Weis U, Schnelle M, Schumann A, Schietzel M, Hatzmann W, Hackmann J: Modulation of chemotherapy-associated immunosuppression by intravenous application of Viscum album L. extract (Iscador): a randomised physe II study. European Journal for Integrative Medicine. 2008, 1: S44-S54.
          49. Grossarth-Maticek R, Ziegler R: Randomized and non-randomized prospective controlled cohort studies in matched pair design for the long-term therapy of corpus uteri cancer patients with a mistletoe preparation (Iscador). Eur J Med Res. 2008, 13: 107-120.PubMed
          50. Grossarth-Maticek R, Ziegler R: Prospective controlled cohort studies on long-term therapy of ovarian cancer patients with mistletoe (Viscum album L.) extracts Iscador. Arzneimittelforschung. 2007, 57 (10): 665-678.PubMed
          51. Grossarth-Maticek R, Ziegler R: Prospective controlled cohort studies on long-term therapy of cervical cancer patients with a mistletoe preparation (Iscador®). Forsch Komplementärmed. 2007, 14: 140-147. 10.1159/000102956.
          52. Grossarth-Maticek R, Ziegler R: Prospective controlled cohort studies on long-term therapy of breast cancer patients with a mistletoe preparation (Iscador) – Supplementary materials. 2006, 10.1159/000095378.
          53. Grossarth-Maticek R, Ziegler R: Prospective controlled cohort studies on long-term therapy of breast cancer patients with a mistletoe preparation (Iscador). Forsch Komplementärmed. 2006, 13: 285-292. 10.1159/000095378.
          54. Semiglasov VF, Stepula VV, Dudov A, Schnitker J, Mengs U: Quality of life is improved in breast cancer patients by Standardised Mistletoe Extract PS76A2 during chemotherapy and follow-up: a randomised, placebo-controlled, double-blind, multicentre clinical trial. Anticancer Res. 2006, 26: 1519-1530.
          55. Auerbach L, Dostal V, Václavik-Fleck I, Kubista E, Rosenberger A, Rieger S, Tröger W, Schierholz JM: Signifikant höherer Anteil aktivierter NK-Zellen durch additive Misteltherapie bei chemotherapierten Mamma-Ca-Patientinnen in einer prospektiven randomisierten doppelblinden Studie. Fortschritte in der Misteltherapie. Aktueller Stand der Forschung und klinischen Anwendung. Edited by: Scheer R, Bauer R, Becker H, Fintelmann V, Kemper FH, Schilcher H. 2005, Essen, KVC Verlag, 543-554.
          56. Piao BK, Wang YX, Xie GR, Mansmann U, Matthes H, Beuth J, Lin HS: Impact of complementary mistletoe extract treatment on quality of life in breast, ovarian and non-small cell lung cancer patients. A prospective randomized controlled clinical trial. Anticancer Res. 2004, 24: 303-309.PubMed
          57. Semiglasov VF, Stepula VV, Dudov A, Lehmacher W, Mengs U: The standardised mistletoe extract PS76A2 improves QoL in patients with breast cancer receiving adjuvant CMF chemotherapy: a randomised, placebo-controlled, double-blind, multicentre clinical trial. Anticancer Res. 2004, 24: 1293-1302.PubMed
          58. Borrelli E: Evaluation of the quality of life in breast cancer patients undergoing lectin standardized mistletoe therapy. Minerva Medica. 2001, 92: 105-107.
          59. Grossarth-Maticek R, Kiene H, Baumgartner S, Ziegler R: Use of Iscador, an extract of European mistletoe (Viscum album), in cancer treatment: prospective nonrandomized and randomized matched-pair studies nested within a cohort study. Altern Ther Health Med. 2001, 7: 57-78.PubMed
          60. Kim M-H, Park Y-K, Lee S-H, Kim S-C, Lee S-Y, Kim C-H, Kim Y-K, Kim K-H, Moon H-S, Song J-S, Park S-H: Comparative study on the effects of a Viscum album (L.) extract (mistletoe) and doxycycline for pleurodesis in patients with malignant pleural effusion. 51th Meeting of The Korean Association of Internal Medicine. Translation by Helixor Heilmittel GmbH. Korean Journal of Medicine. 1999, 57: S121-
          61. Heiny B-M: Additive Therapie mit standardisiertem Mistelextrakt reduziert die Leukopenie und verbessert die Lebensqualität von Patientinnen mit fortgeschrittenem Mammakarzinom unter palliativer Chemotherapie (VEC-Schema). Krebsmedizin. 1991, 12: 1-14.
          62. Gutsch J, Berger H, Scholz G, Denck H: Prospektive Studie beim radikal operierten Mammakarzinom mit Polychemotherapie, Helixor und unbehandelter Kontrolle. Dtsch Zschr Onkol. 1988, 94-100.
          63. Lange O, Scholz G, Gutsch J: Modulation der subjektiven und objektiven Toxizität einer aggressiven Chemotherapie mit Helixor. Unpublished Report. 1985
          64. Loewe-Mesch A, Kuehn JH, Borho K, Abel U, Bauer C, Gerhard I, Schneeweiss A, Sohn C, Strowitzki T, Hagens C: Adjuvante simultane Mistel-/Chemotherapie bei Mammakarzinom – Einfluss auf Immunparameter, Lebensqualität und Verträglichkeit. Forsch Komplementärmed. 2008, 15: 22-30. 10.1159/000112860.
          65. Büssing A, Bischof M, Hatzmann W, Bartsch F, Soto-Vera D, Fronk E-M, Gmeindl M, Stein GM: Prevention of surgery-induced depression of granulocyte function by intravenous application of a fermented extract from Viscum album L. in breast cancer patients. Anticancer Res. 2005, 25: 4753-4758.PubMed
          66. Salzer G: 30 Jahre Erfahrung mit der Misteltherapie an öffentlichen Krankenanstalten. Misteltherapie. Eine Antwort auf die Herausforderung Krebs. Edited by: Leroi R. 1987, Stuttgart, Verlag Freies Geistesleben, 173-215.
          67. Fellmer Ch, Fellmer KE: Nachbehandlung bestrahlter Genitalkarzinome mit dem Viscum-album-Präparat "Iscador". Krebsarzt. 1966, 21: 174-185.
          68. Majewski A, Bentele W: Über Zusatzbehandlung beim weiblichen Genitalkarzinom. Zentralbl Gynäkol. 1963, 85: 696-700.
          69. Beuth J, Schneider B, Schierholz JM: Impact of complementary treatment of breast cancer patients with standardized mistletoe extract during aftercare: a controlled multicenter comparative epidemiological cohort study. Anticancer Res. 2008, 28: 523-528.PubMed
          70. Bock PR, Friedel WE, Hanisch J, Karasmann M, Schneider B: Wirksamkeit und Sicherheit der komplementären Langzeitbehandlung mit einem standardisierten Extrakt aus Europäischer Mistel (Viscum album L.) zusätzlich zur konventionellen adjuvanten onkologischen Therapie bei primärem, nicht metastasiertem Mammakarzinom. Ergebnisse einer multizentrischen, komparativen, epidemiologischen Kohortenstudie in Deutschland und der Schweiz. Arzneim – Forsch/Drug Res. 2004, 54: 456-466.
          71. Schumacher K, Schneider B, Reich G, Stiefel T, Stoll G, Bock PR, Hanisch J, Beuth J: Influence of postoperative complementary treatment with lectin-standardized mistletoe extract on breast cancer patients. A controlled epidemiological multicentric retrolective cohort study. Anticancer Res. 2003, 23: 5081-5088.PubMed
          72. Schumacher K, Schneider B, Reich G, Stiefel T, Stoll G, Bock PR, Hanisch J, Beuth J: Postoperative komplementäre Therapie des primären Mammakarzinoms mit lektinnormiertem Mistelextrakt – eine epidemiologische, multizentrische retrolektive Kohortenstudie. Dtsch Zschr Onkol. 2002, 34: 106-114. 10.1055/s-2002-35141.
          73. Mansky PJ, Grem J, Wallerstedt DB, Monahan BP, Blackman MR: Mistletoe and Gemcitabine in patients with advanced cancer: A model for the phase I study of botanicals and botanical-drug interactions in cancer therapy. Integr Cancer Ther. 2003, 2: 345-352. 10.1177/1534735403259061.PubMed
          74. Mahfouz MM, Ghaleb HA, Hamza MR, Fares L, Moussa L, Moustafua A, El-Za Wawy A, Kourashy L, Mobarak L, Saed S, Fouad F, Tony O, Tohamy A: Multicenter open labeled clinical study in advanced breast cancer patients. A preliminary report. Journal of the Egyptian Nat Cancer Inst. 1999, 11: 221-227.
          75. Mahfouz MM, Ghaleb HA, Zawawy A, Scheffler A: Significant tumor reduction, improvement of pain and quality of life and normalization of sleeping patterns of cancer patients treated with a high dose of mistletoe. Ann Oncol. 1998, 9: 129-
          76. Finelli A, Limberg R: Mistel-Lektin bei Patienten mit Tumorerkrankungen. Medizin im Bild Diagnostik und Therapie im Bild. 1998, 1: 1-8.
          77. Portalupi E: Neoadjuvant treatment in HPV-related CIN with Mistletoe preparation (Iscador). Dissertation Universität Pavia 1991/1992. 1995
          78. Werner H, Mahfouz MM, Fares L, Fouad F, Ghaleb HA, Hamza MR, Kourashy L, Mobarak AL, Moustafa A, Saed S, Zaky O, Zawawy A, Fischer S, Scheer R, Scheffler A: Zur Therapie des malignen Pleuraergusses mit einem Mistelpräparat. Der Merkurstab. 1999, 52: 298-301.
          79. Stumpf C, Schietzel M: Intrapleurale Instillation eines Extraktes aus Viscum album [L.] zur Behandlung maligner Pleuraergüsse. Tumordiagnose u Therapie. 1994, 57-62.
          80. Friedrichson UKH: Intraperitoneal instillation of Viscum album (L.) extrat (mistletoe) for therapy and malignant ascites. Unpublished. Department of Radiology/Oncology, Community Hospital of Herdecke, University Witten/Herdecke. 1995
          81. Knöpfl-Sidler F, Viviani A, Rist L, Hensel A: Human cancer cells exhibit in vitro individual receptiveness towards different mistletoe extracts. Pharmazie. 2005, 60: 448-454.PubMed
          82. Zuzak T, Rist L, Viviani A, Eggenschwiler J, Mol C, Riegert U, Meyer U: Das Mistelpräparat Iscucin® – Herstellung, Analytik, Wirkung in vitro. Der Merkurstab. 2004, 57: 467-473.
          83. Büssing A, Schietzel D, Schietzel M, Schink M, Stein GM: Keine Stimulation in vitro kultivierter Tumorzellen durch Mistellektin. Dtsch Zschr Onkol. 2004, 36: 66-70. 10.1055/s-2004-828263.
          84. Burger AM, Mengs U, Kelter G, Schüler JB, Fiebig HH: No evidence of stimulation of human tumor cell proliferation by a standardized aqueous mistletoe extrakt in vitro. Anticancer Res. 2003, 23: 3801-3806.PubMed
          85. Ramaekers FC, Harmsma M, Tusenius KJ, Schutte B, Werner M, Ramos M: Mistletoe extracts (Viscum album L.) Iscador® interact with the cell cycle machinery and target survival mechanisms in cancer cells. Medicina. 2007, 67: 79-84.
          86. Harmsma M, Gromme M, Ummelen M, Dignef W, Tusenius KJ, Ramaekers FC: Differential effects of Viscum album extract IscadorQu on cell cycle progression and apoptosis in cancer cells. Int J Oncol. 2004, 25: 1521-1529.PubMed
          87. Harmsma M, Ummelen M, Dignef W, Tusenius KJ, Ramaekers FC: Effects of mistletoe (Viscum album L.) extracts Iscador on cell cycle and survival of tumor cells. Arzneimittelforschung. 2006, 56: 474-482.PubMed
          88. Kelter G, Fiebig HH: Absence of tumor growth stimulation in a panel of 26 human tumor cell lines by mistletoe (Viscum album L.) extracts Iscador in vitro. Arzneimittelforschung. 2006, 56 (6A): 435-440.PubMed
          89. Maier G, Fiebig HH: Absence of tumor growth stimulation in a panel of 16 human tumor cell lines by mistletoe extracts in vitro. Anti-Cancer Drugs. 2002, 13: 373-379. 10.1097/00001813-200204000-00006.PubMed
          90. Kahle B, Debreczeni JÉ, Sheldrick GM, Zeeck A: Vergleichende Zytotoxizitätsstudien von Viscotoxin-Isoformen und Röntgenstruktur von Viscotoxin A3 aus Mistelextrakten. Fortschritte in der Misteltherapie. Aktueller Stand der Forschung und klinischen Anwendung. Edited by: Scheer R, Bauer R, Becker H, Fintelmann V, Kemper FH, Schilcher H. 2005, Essen, KVC Verlag, 83-98.
          91. Mukthar D, Pfüller U, Tonevitsky AG, Witthohn K, Schumacher U: Cell biological investigations on the use of mistletoe lectins in cancer therapy. COST 98. Effects of antinutrients on the nutritional value of legume diets. Edited by: Bardocz S, Pfüller U, Pusztai A. 1998, Luxembourg, Office for Official Publications of the European Communities, 187-193.
          92. Pae H-O, Seo W-G, Oh G-S, Shin M-K, Lee H-S, Lee HS, Kim SB, Chung H-T: Potentiation of tumor necrosis factor-α-induced apoptosis by mistletoe lectin. Immunopharmacology and Immunotoxicology. 2000, 22: 697-709. 10.3109/08923970009016433.PubMed
          93. Burger AM, Mengs U, Schüler JB, Fiebig HH: Antiproliferative activity of an aqueous mistletoe extract in human tumor cell lines and xenografts in vitro. Arzneimittelforschung. 2001, 51 (9): 748-757.PubMed
          94. Kelter G, Schierholz JM, Fischer IU, Fiebig H-H: Cytotoxic activity and absence of tumor growth stimulation of standardized mistleteo extracts in human tumor models in vitro. Anticancer Res. 2007, 27: 223-233.PubMed
          95. Hugo F, Schwitalla S, Niggemann B, Zänker KS, Dittmar KEJ: Viscum album extracts Iscador® P and Iscador® M counteract the growth factor induced effects in human follicular B-HNL cells and breast cancer cells. Medicina. 2007, 67: 90-96.
          96. Beuth J, Ko HL, Schneider H, Tawadros S, Kasper HU, Zimst H, Schierholz JM: Intratumoral application of standardized mistletoe extracts down regulates tumor weight via decreased cell proliferation, increased apoptosis and necrosis in a murine model. Anticancer Res. 2006, 26: 4451-4456.PubMed
          97. Scheffler A, Fiebig HH, Kabelitz D, Metelmann HR: Zur direkten Zytotoxizität von Mistelpräparaten. Erfahrungsheilkunde. 1993, 338-346.
          98. Gabius H-J, Darro F, Remmelink M, Andre S, Kopitz J, Danguy A, Gabius S, Salmon I, Kiss R: Evidence for stimulation of tumor proliferation in cell lines and histotypic cultures by clinically relevant low doses of the galactoside-binding mistletoe lectin, a component of proprietary extracts. Cancer Investigation. 2001, 19: 114-126. 10.1081/CNV-100000146.PubMed
          99. Kopp J, Körner I-J, Pfüller U, Göckeritz W, Eifler R, Pfüller K, Franz H: Toxicity of mistletoe lectins I, II and III on normal and malignant cells. Lectins: Biology, Biochemistry, Clinical Biochemistry. Edited by: Van Driessche E, Franz H, Beeckmans S, Pfüller U, Kallikorm A, Bog-Hansen TC. 1993, Hellerup (Denmark), Textop, 8: 41-47.
          100. Wagner H, Jordan E, Zänker KS: Cell-mediated and direct cytotoxicity of purified ingredients of Viscum album. J Cancer Res Clin Oncol. 1987, 53-
          101. Abuharbeid S, Apel J, Sander M, Fiedler B, Langer M, Zuzarte ML, Czubayko F, Aigner A: Cytotoxicity of the novel anti-cancer drug rViscumin depends on HER-2 levels in SKOV-3 cells. Biochem Biophys Res Commun. 2004, 321: 403-412. 10.1016/j.bbrc.2004.06.160.PubMed
          102. Kienle GS, Kiene H: Stellenwert, Dosierung und Gefährlichkeit (Tumorenhancement) des ML I – immunologische Schlußfolgerungen und experimentelle Untersuchungen. Die Mistel in der Onkologie. Fakten und konzeptionelle Grundlagen. 2003, Stuttgart, New York, Schattauer Verlag, 301-332.
          103. Franz H: The in vivo toxicity of toxic lectins is a complex phenomenon. Lectins: Biology, Biochemistry, Clinical Biochemistry. Edited by: Van Driessche E, Franz H, Beeckmans S, Pfüller U, Kallikorm A, Bog-Hansen TC. 1993, Hellerup (Denmark), Textop, 8: 5-9.
          104. Klamerth O, Vester F, Kellner G: Inhibitory effects of a protein complex from Viscum album on fibroblasts and HeLa cells. Hoppe Seylers Z Physiol Chem. 1968, 349 (6): 863-864.PubMed
          105. Konopa J, Woynarowski JM, Lewandowska-Gumieniak M: Isolation of Viscotoxins – Cytotoxic basic polypeptides from Viscum album L. Hoppe Seylers Z Physiol Chem. 1980, 361 (10): 1525-1533.PubMed
          106. Ulrich W, Mechelke F: Reaktion der In-vitro-Kulturen von menschlichen Fibroblasten, HeLa-Zellen und von murinen L-Zellen bei Applikationen eines Präparats aus Viscum album L. Arzneim – Forsch/Drug Res. 1980, 30 (II): 1722-1725.
          107. Jurin M, Zarkovic N, Hrzenjak M, Ilic Z: Antitumorous and immunomodulatory effects of the Viscum album L. preparation Isorel. Oncology. 1993, 50: 393-398. 10.1159/000227217.PubMed
          108. Zarkovic N, Kalisnik T, Kissel D, Konitzer M, Jurin M, Grainza S: Comparison of the effects of Viscum album lectin ML-1 and fresh plant extract (Isorel) on the cell growth in vitro and tumorigenicity of melanoma B16F10. Cancer Biother Radiopharm. 1998, 13: 121-131. 10.1089/cbr.1998.13.121.PubMed
          109. Fritz B, Ulrich W: Flow cytometric Analysis of human cell lines after exposure to preparations from Viscum album. Planta Med. 1989, 55: 100-101. 10.1055/s-2006-961860.
          110. Fritz B: Einfluss von Viscum album L. Präparaten und allopathischen Zytostatika auf Proliferation, Zellzyklus und DNA-Gehalt menschlicher Zellen in vitro. PhD Thesis. 1989, Universität Hohenheim
          111. Taylor A, McKenna GF, Burlage HM: Anticancer activity of plant extracts. Texas reports on Biology and Medicine. 1956, 14: 538-556.PubMed
          112. Franz H: Mistletoe lectins and their A and B chains. Oncology. 1986, 43: 23-34. 10.1159/000226417.PubMed
          113. Seeger PG: Über die Wirkung von Mistelextrakten (Iscador und Plenosol). Erfahrungsheilkunde. 1965, 14: 149-174.
          114. Selawry OS, Schwartz MR, Haar H: Tumor inhibitory activity of products of Loranthaceae (mistletoe). Proceedings of the American Association for Cancer Research. 1959, 62-63.
          115. Snajberk G: Die kanzerostatischen Wirkungen spezieller Viscum-Proteine – Signifikanz und Wirkungsverlust. PhD Thesis. 1980, Ludwig-Maximilians-Universität, München
          116. Drees M, Berger DP, Dengler WA, Fiebig GH: Direct cytotoxicity effects of preparations used as unconventional methods in cancer therapy in human tumor xenografts in the clonogenic assay and in nude mice. Immunodeficient animals: Models for cancer research. Edited by: Arnold W, Köpf-Maier P, Micheel B. 1996, Basel, Karger Verlag, 51: 115-122.
          117. Zarkovic N, Vukovic T, Loncaric I, Miletic M, Zarkovic K, Borovic S, Cipak A, Sabolovic S, Konitzer M, Mang S: An overview on anticancer activities of the Viscum album extract Isorel®. Cancer Biother Radiopharm. 2001, 16: 55-62. 10.1089/108497801750096041.PubMed
          118. Jurin M, Zarkovic N, Borovic S, Kissel D: Immunomodulation by the Viscum album L. preparation Isorel and its antitumorous effects. Grundlagen der Misteltherapie. Aktueller Stand der Forschung und klinische Anwendung. Edited by: Scheer R, Becker H, Berg PA. 1996, Stuttgart, Hippokrates Verlag GmbH, 315-324.
          119. Khwaja TA, Dias CB, Pentecost S: Recent studies on the anticancer activities of Mistletoe (Viscum album) and its alcaloids. Oncology. 1986, 43: 42-50. 10.1159/000226419.PubMed
          120. Cebovic T, Spasic S, Popovic M: Cytotoxic effects of the Viscum album L. extract on Ehrlich tumour cells in vivo. Phytotherapy Research. 2008, 22: 1097-1103. 10.1002/ptr.2464.PubMed
          121. Kuttan G: Tumoricidal activity of mouse peritoneal macrophages treated with Viscum album extract. Immunological Investigations. 1993, 22: 431-440. 10.3109/08820139309063421.PubMed
          122. Kuttan G, Kuttan R: Immunological mechanism of action of the tumor reducing peptide from mistletoe extract (NSC 635089) cellular proliferation. Cancer Lett. 1992, 123-130. 10.1016/0304-3835(92)90224-J.
          123. Kuttan G, Kuttan V, Kuttan R: Effect of a preparation from Viscum album on tumor development in vitro and in mice. Journal of Ethnopharmacology. 1990, 29: 35-41. 10.1016/0378-8741(90)90095-B.PubMed
          124. Berger M, Schmähl D: Studies on the tumor-inhibiting efficacy of Iscador in experimental animal tumors. J Cancer Res Clin Oncol. 1983, 262-265. 10.1007/BF00395755.
          125. Koch FE: Experimentelle Untersuchungen über lokale Beeinflussung von Impfgeschwülsten. Z Krebsforsch. 1938, 325-335.
          126. Koch FE: Experimentelle Untersuchungen über entzündung- und nekroseerzeugende Wirkung von Viscum album. Z Ges Exp Med. 1938, 103: 740-749. 10.1007/BF02609253.
          127. Linder MC, Murillo C: Mistletoe preparations prevent changes in copper metabolism which normally occur in rats with implanted tumors. Abstract 18. Proceedings from the 73rd Annual Meeting of the American Association for Cancer Research – April 28–May 1, 1982. 1982, St. Louis, Missouri, 5-
          128. Seitz W: Die Wirkung von Iscador (Viscum praeparatum M.) auf das Walker-Karzinosarkom der Ratte. Wien Klin Wochenschr. 1975, 87: 131-132.PubMed
          129. Burger AM, Mengs U, Schüler JB, Zinke H, Lentzen H, Fiebig HH: Recombinant mistletoe lectin (ML) is a potent inhibitor of tumor cell growth in vitro and in vivo. Proceedings of the American Association for Cancer Research. 1999, 40: 399-
          130. Timoshenko AV, Lan Y, Gabius H-J, Lala PK: Immunotherapy of C3H/HeJ mammary adenocarcinoma with interleukin-2, mistletoe lectin or their combination. effects on tumour growth, capillary leakage and nitric oxide (NO) production. Eur J Cancer. 2001, 37: 1910-1920. 10.1016/S0959-8049(01)00156-3.PubMed
          131. Franz H: Viscaceae lectins. Advances in lectin research. Edited by: Franz H. 1989, Berlin, Volk und Gesundheit, 2: 28-59.
          132. Vester F: Über die kanzerostatischen und immunogenen Eigenschaften von Mistelproteinen. Krebsgeschehen. 1977, 5: 106-114.
          133. Müller J: Verfahren zur Gewinnung eines Arzneimittels. (C 24971 IVa/30h), 1–12. 24-5-1962. Bundesrepublik Deutschland.
          134. Schumacher U, Feldhaus S, Mengs U: Recombinant mistletoe lectin (rML) is successful in treating human ovarian cancer cells transplanted into severe combined immunodeficient (SCID) mice. Cancer Lett. 2000, 150: 171-175. 10.1016/S0304-3835(99)00387-0.PubMed
          135. Ziegler R, Grossarth-Maticek R: Individual Patient Data Meta-analysis of Survival and Psychosomatic Self-regulation from Published Prospective Controlled Cohort Studies for Long-term Therapy of Breast Cancer Patients with a Mistletoe Preparation (Iscador). eCam. 2008
          136. Büssing A, Girke M, Heckmann C, Schad F, Ostermann T, Kröz M: Validation of the self-regulation questionnaire as a measure of health in quality of life research. Eur J Med Res. 2009, 14 (5): 223-227.PubMedPubMed Central
          137. Rostock M, Huber R: Randomized and double-blind studies – demands and reality as demonstrated by two examples of mistletoe research. Forsch Komplementarmed Klass Naturheilkd. 2004, 11 Suppl: 18-22. 10.1159/000080571.
          138. Chvetzoff G, Tannock I: Placebo Effects in Oncology. J Natl Cancer Inst. 2003, 95: 19-29.PubMed
          139. Kienle GS, Kiene H: The powerful placebo effect. Fact or fiction?. J Clin Epidemiol. 1997, 50: 1311-1318. 10.1016/S0895-4356(97)00203-5.PubMed
          140. Hróbjartsson A, Gøtzsche P: Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med. 2001, 344: 1594-1602. 10.1056/NEJM200105243442106.PubMed
          141. Wode K, Schneider T, Lundberg I, Kienle GS: Mistletoe treatment in cancer-related fatigue: a case report. Cases Journal. 2009, 2: 77-10.1186/1757-1626-2-77.PubMedPubMed Central
          142. Stone R, Richardson A, Ream E, Smith AG, Kerr DJ, Kearney N: Cancer-related fatigue: Inevitable, unimportant and untreatable? Results of a multi-centre patient survey. Ann Oncol. 2000, 11: 971-975. 10.1023/A:1008318932641.PubMed
          143. Carroll JK, Kohli S, Mustian KM, Roscoe JA, Morrow GR: Pharmacologic treatment of cancer-related fatigue. Oncologist. 2007, 12: 43-51. 10.1634/theoncologist.12-S1-43.PubMed
          144. Mustian KM, Morrow GR, Carroll JK, Figueroa-Moseley CD, Jean-Pierre P, Williams GC: Integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue. Oncologist. 2007, 12: 51-67. 10.1634/theoncologist.12-S1-52.
          145. Sheiner LB, Rubin DB: Intention-to-treat analysis and the goals of clinical trials. Clin Pharmacol Ther. 1995, 57: 6-15. 10.1016/0009-9236(95)90260-0.PubMed
          146. Pampallona S, von Rohr E, van Wegberg B, Bernhard J, Helwig S, Heusser P, Huerny C, Schaad H, Cerny T: Socio-demographic and medical characteristics of advanced cancer patients using conventional or complementary medicine. Onkologie. 2002, 25: 165-170. 10.1159/000055227.PubMed
          147. Concato J, Shah N, Horwitz RI: Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med. 2000, 342: 1887-1892. 10.1056/NEJM200006223422507.PubMedPubMed Central
          148. Benson K, Hartz AJ: A comparison of observational studies and randomized, controlled trials. N Engl J Med. 2000, 342: 1886-10.1056/NEJM200006223422506.
          149. Kunz R, Oxman AD: The unpredictability paradox: review of empirical comparisons of randomised and non-randomised clinical trials. BMJ. 1998, 317 (167): 1185-1190.PubMedPubMed Central
          150. Rothwell PM: External validity of randomised controlled trials: "To whom do the results of this trials apply?". Lancet. 2005, 365: 82-93. 10.1016/S0140-6736(04)17670-8.PubMed
          151. Fritz P, Dippon J, Kierschke T, Siegle I, Mohring A, Moisa A, Murdter TE: Impact of mistletoe lectin binding in breast cancer. Anticancer Res. 2004, 24: 1187-1192.PubMed
          152. Frantz M, Jung M-L, Ribéreau-Gayon G, Anton R: Modulation of mistletoe (Viscum album L.) lectins cytotoxicity by carbohydrates and serum glycoproteins. Arzneimittelforschung. 2000, 50 (5): 471-478.PubMed
          153. Olsnes S, Stripe F, Sandvig K, Pihl A: Isolation and characterization of Viscumin, a toxic lectin from Viscum album L. (mistletoe). The Journal of Biological Chemistry. 1982, 257: 13263-13270.PubMed
          154. Seifert G, Jesse P, Längler A, Reindl T, Lüth M, Lobitz S, Henze G, Prokop A, Lode HN: Molecular mechanisms of mistletoe plant extract-induced apoptosis in acute lymphoblastic leukemia in vivo and in vitro. Cancer Lett. 2008, 264: 218-228. 10.1016/j.canlet.2008.01.036.PubMed
          155. Thies A, Dautel P, Meyer A, Pfuller U, Schumacher U: Low-dose mistletoe lectin-I reduces melanoma growth and spread in a scid mouse xenograft model. Br J Cancer. 2008, 98: 106-112. 10.1038/sj.bjc.6604106.PubMedPubMed Central
          156. Pryme IF, Bardocz S, Pusztai A, Ewen SW: Suppression of growth of tumour cell lines in vitro and tumours in vivo by mistletoe lectins. Histol Histopathol. 2006, 21: 285-299.PubMed
          157. Rostock M, Huber R, Greiner T, Fritz P, Scheer R, Schueler J, Fiebig HH: Anticancer activity of a lectin-rich mistletoe extract injected intratumorally into human pancreatic cancer xenografts. Anticancer Res. 2005, 25: 1969-1975.PubMed
          158. Antony S, Kuttan R, Kuttan G: Inhibition of lung metastasis by adoptive immunotherapy using Iscador. Immunological Investigations. 1999, 28: 1-8. 10.3109/08820139909022718.PubMed
          159. Antony S, Kuttan R, Kuttan G: Role of natural killer cells in Iscador mediated inhibition of metastasis by apoptive immunotherapy. Immunological Investigations. 2000, 29: 219-231. 10.3109/08820130009060863.PubMed
          160. Teicher BA, ed: Tumor models in cancer research. 2001, Totowa, New Jersey: Humana Press
          161. Srivastava PK: Immunotherapy of human cancer: lessons from mice. Nature Immunology. 2000, 1: 363-366. 10.1038/80795.PubMed
          162. Céspedes MV, Casanova I, Parreño M, Mangues R: Mouse models in oncogenesis and cancer therapy. Clin Transl Oncol. 2006, 8: 318-329. 10.1007/s12094-006-0177-7.PubMed
          163. Stein GM, Berg PA: Adverse effects during therapy with mistletoe extracts. Mistletoe. The Genus Viscum. Edited by: Büssing A. 2000, Amsterdam, Hardwood Academic Publishers, 195-208.
          164. Bauer C, Oppel T, Rueff F, Przybilla B: Anaphylaxis to viscotoxins of mistletoe (Viscum album) extracts. Ann Allergy Asthma Immunol. 2005, 94: 86-89.PubMed
          165. Hutt N, Kopferschmitt-Kubler M, Cabalion J, Purohit A, Alt M, Pauli G: Anaphylactic reactions after therapeutic injection of mistletoe (Viscum album L.). Allergol Immunopathol (Madr). 2001, 29: 201-203.
          166. Grossarth-Maticek R, Ziegler R: Randomised and non-randomised prospective controlled cohort studies in matched-pair design for the long-term therapy of breast cancer patients with a mistletoe preparation (Iscador): a re-analysis. Eur J Med Res. 2006, 11: 485-495.PubMed

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