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In harmony with nature Mistletoe Therapy for Cancer – General Information for Patients Imprint Mistletoe Therapy for Cancer – General Information for Patients 1st Edition 08/2009 Art.-No. 50 603 600 Publisher Weleda AG Corporate Medical Department Postfach 13 20 D-73503 Schwäbisch Gmünd Germany Photographic Source Weleda Archive Schwäbisch Gmünd © Weleda AG 2009 All rights reserved. No part of this brochure “Mistletoe Therapy for Cancer - General Information for Patients” may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior explicit and written permission by Weleda AG. Note Extenisve care has been taken to ensure that the information and recommendations given in this brochure are accurate and up to date. Misprints and errors excepted; guarantee or liability claims excluded. Mistletoe Therapy for Cancer – General Information for Patients 4 Table of Contents • Foreword 6 • Standard therapies in oncology 8 • Complementary cancer therapy with mistletoe 11 • The phytology of mistletoe 13 • Mistletoe substances and their effects 15 • Clinical studies 18 • Practical use of mistletoe preparations 22 • Sources and references 28 • Weleda representatives list 29 5 Foreword Dear reader, In our modern world of medical advancements, many forms of cancer can now be cured. Nevertheless, a cancer diagnosis comes as a great shock for the afflicted individual. Fear, along with fright, arise in its wake. Moreover, patients and their relatives have practical questions for which they often do not find answers: What does this disease mean for me? What conventional therapeutic possibilities are available? What else can I do for myself? How shall I manage my life? Can I be cured? Surgery, chemo-, radiotherapy and in some cases, hormone therapies, are established standard therapies for treating cancer. To support these conventional forms of treatment, many patients also opt for so-called complementary measures (= supplementary treatment measures). The most frequently used is mistletoe therapy, which supports the body‘s own defences during oncological treatment. This can mean, for example, that the tumour is attacked more effectively or the side effects of the chemotherapy or radiotherapy can be reduced. The earlier a complementary therapy is initiated, the more successful it will be. 6 With this brochure, we would like to give you a helping hand, empower you to cope better with your cancer. Furthermore, we would like to show you how the therapeutic success of the tried-andtested standard treatments can be improved with complementary measures, in particular mistletoe therapy. With best wishes Yours, Dr. Bettina Arnold-von Versen 7 Standard therapies in oncology The main objectives of conventional cancer treatment are to destroy the tumour and prevent it from spreading further. The three „standard pillars“ are steel (scalpel), rays (irradiation, radiation) and chemotherapy. Worldwide, decades of experience have already been amassed with these methods of tumour destruction. In conventional cancer treatment, the tumour is initially attacked in these three ways, which are often combined together, used in pairs or used at staggered intervals one after the other. • Surgery During an operation, the cancerous tumour is surgically removed. Complete removal of the tumour is especially important to prevent further spread. For this reason often a substantial amount of healthy tissue is resected along with the tumour. Neighbouring lymph nodes are also removed if cancerous cells have metastasised. However, often lymph nodes close to the tumour are removed as preventative measure. In some cases, it is helpful, to initially reduce the size of the tumour by way of chemo- or radiotherapy in order to operate on it afterwards. Conversely, a tumour, which cannot be completely removed in an operation, can initially be reduced in size surgically so that a secondary course of chemo- or radiotherapy has greater chances of success. 8 • Radiotherapy During radiotherapy, high-energy rays are directed at the tumour. The intention is to destroy the malignant cells by damaging the genetic material (DNA). With radiation, it is important to measure the tumour as precisely and as completely as possible. Only then can the effect on surrounding healthy tissue be minimized. In contrast to chemotherapy, in which the drug is dispersed throughout the entire body, most forms of radiotherapy are locally effective. This means that a therapeutic effect only occurs in the area of the body subjected to radiation. Radiotherapy not only affects tumour cells, but also neighboring healthy tissue. Therefore, some side effects from the treatment may occur. Most of these side effects subside after the treatment is completed. • Chemotherapy The aim of chemotherapy is to prevent the proliferation of cancer cells. Chemotherapy drugs, known as cytostatics, can destroy the different tumour cells by influencing their metabolism and/or stopping or substantially slowing down their ability to multiply. To do this, many cytostatic drugs attack the genetic material. Others block important metabolic processes involved in cell division. As these are essential processes, almost all cytotoxins also affect healthy cells. 9 For this reason all tissue which regenerates quickly is impaired to varying degrees. Typical side effects of many cytostatics are temporary damage to blood cell formation as well as hair loss. Nausea and vomiting are also typical side effects from chemotherapy. In addition to these tumour-destructive treatments, (anti-) hormone therapies are also utilised with tumours sensitive to them. This is because many hormones control important processes in the body at a cellular level, such as lowering the blood sugar level, reproduction and growth. Many tumours also show an increased growth rate under the influence of hormones. This hormonal dependency of cancer cells is the starting point for the (anti-) hormone treatments: hormones produced naturally in the body are deactivated in order to inhibit the spread of a tumour. 10 Complementary cancer therapy with mistletoe Conventional cancer treatment aims to remove or destroy a diagnosed tumour. However, the side effects which occur can substantially impair quality of life. This in turn can have a negative effect on the success of the treatment. Mistletoe preparations have been used in cancer treatment since the beginning of the last century. In addition to fighting cancer, the use of mistletoe preparations improves the patient’s quality of life: most patients quickly experience an improvement in their general condition and sleep, appetite as well as performance. Mistletoe can also relieve pain caused by tumours, strengthen the immune system and reduce the side effects from chemo- and radiotherapy. All mistletoe preparations are complete extracts from the twigs, leaves and berries from the white-berry European mistletoe (Viscum album L.). Summer and winter extracts are mixed for anthroposophic preparations. 11 Chemo- / Radiotherapy Surgery Optimal cancer therapy Therapy with mistletoe extract 12 The phytology of mistletoe The white-berry mistletoe grows on deciduous trees and conifers. It occurs very frequently on poplars and apple trees. Only very rarely is it found on elm and oak trees. Of the conifers, it prefers pines and fir trees. It is found throughout Europe. In terms of growth, development and propagation, the mistletoe displays many characteristics which make it very different to „normal plants“, so that Rudolf Steiner, the founder of anthroposophy, had cause to recommend the mistletoe as a medicinal plant in cancer treatment, already since the beginning of the 20th century. The mistletoe is a dioecious plant, meaning that male and female flowers are growing on separate plants. Mistletoes are very slow-growing plants. It is only in the second year of growth that two small leaves appear, whereas the mistletoe flowers emerge first between the fifth and seventh year of growth. Its inflorescence secretes a type of nectar with an aroma similar to orange; this attracts ants and flies which help to ensure pollination. After pollination, the female inflorescence rests until the end of June. The fruits then slowly develop with the green embryo lying within, reaching full maturity in winter when they emerge as white berries. Similarily to humans, it takes a total of nine months for the flower to fully mature. 13 However, the embryo already fully developed in the mistletoe berry cannot force its own way out, rather it is dependent on the coriaceous berry shell being ripped open by a bird. Mistletoe seedlings are very durable and remain germinable for months – provided that they receive sufficient light. 14 Mistletoe substances and their effects Mistletoe extracts exhibit complex effects. For instance, the immune system is stimulated, the toxic effects of the tumour cells are reduced, the psyche is positively influenced and genetic material (DNA) is protected. The effect is due to a number of different biologically active substances. Mistletoe extracts contain approximately 600 different proteins. The most important typical mistletoe proteins are the sugar-containing mistletoe lectins and the viscotoxins, which are among the important active pharmaceutical ingredients of mistletoe. In addition, they also contain numerous enzymes, sulphurous compounds, fats and plant pigments (flavonoids). Thus, lectins are sugar-containing proteins which only occur in this form in mistletoe. They are very similar to the lectin of the castor-oil plant. Lectins inhibit the growth of cancer cells or kill them, meaning they have a “cytostatic” and “cytotoxic” effect, and they affect the immune system (immunomodulation). 15 A distinction can be drawn between three different groups of mistletoe lectins: mistletoe lectin I, II and III with a total of more than 20 different individual components (isolectins). All lectins can stimulate cancer cells to „self-destruction“. „Apoptosis“ of this nature is possible and necessary for all healthy cells. This is because new cells are continually being produced and old cells are continually dying. Cell death and cell division are thus balanced out. Cancer cells have lost this ability and for this reason they reproduce unregulated and begin to proliferate. If the capability for apoptosis in cancer cells is reactivated or restored, the tumour growth can be restricted. Viscotoxins are protein-containing compounds which in terms of their chemical structure are similar to snake venom, in particular cobra venom. The effects of viscotoxins individually are not yet as well researched as the effects of lectins. It is known that viscotoxins destroy cancer cells by breaking up their cell walls (cytotoxic effect). In addition, they can also stimulate the immune system in the same way as lectins. In particular, they increase the activity of natural killer cells and granulocytes (subtype of the white blood cells) so that these can destroy bacteria and, presumably, tumour cells in a much more efficient manner. 16 The mood-brightening and pain-reducing effect can be attributed to an increased release of beta-endorphins (substances similar to morphine) which itself is attributable to the mistletoe extract. The type of host tree as well as the time of harvesting also have a formative effect on the substances contained in the mistletoe. For instance, the oak mistletoe contains more mistletoe lectins than apple tree mistletoe, which in turn contains more than pine mistletoe. In summer, the mistletoe plant has a high content of viscotoxins in contrast to winter, when the content of mistletoe lectins is particularly high. Only the whole extract of the mistletoe deploys the full spectrum of activity in cancer treatment. 17 Clinical studies Currently, well over 100 clinical studies have been carried out with regard to the use of mistletoe extracts with different types of tumours. Mistletoe preparations are thus the best and most extensively researched medicines used in complementary cancer treatment. In the final analysis, the studies predominantly indicate that mistletoe therapy is of benefit. The best documented effects are the reduction in the side effects of conventional treatments such as surgery, chemotherapy and radiotherapy and an improvement in quality of life. In some cases, the appearance of metastases can be delayed and survival time can be prolonged. • Breast cancer A study by Bock et al. (2004) demonstrated the safety and efficacy of a mistletoe preparation in patients with breast cancer. It compared the medical data of women with breast cancer who only received basic oncological treatment after the surgery with the data of patients who also received injections of mistletoe extract. When compared with the control group, the women in the mistletoe group showed substantially fewer side effects caused by conventional treatments (radiotherapy, chemotherapy and hormone therapy) and a longer survival time. The tolerance of the mistletoe therapy was assesed good to very good. 18 • Malignant melanoma Study results from Augustin et al. (2005) show that mistletoe therapy can also be regarded as safe and effective in cases of malignant melanoma. Furthermore, it was determined that skin cancer patients treated with mistletoe extract survived for a clearly longer period of time. In general, the treatment was well tolerated; neither serious side effects nor an increase in tumour growth were observed. In contrast, the incidence rates of metastases were significantly lower in the mistletoe group as compared to control. 19 • Intestinal and pancreatic cancer Current study results are now also demonstrating the efficacy and safety of mistletoe extracts in patients with intestinal (colorectal) cancer and pancreatic cancer. The patients in the mistletoe group showed considerably fewer side effects caused by conventional treatments than those in the control group. For example, in the mistletoe group, only approximately 19% of the colorectal cancer patients and only 14% of the pancreatic cancer patients developed side effects caused by chemotherapy and/or radiotherapy, whereas in both control groups almost 50% suffered from these side effects. Likewise, disease- and therapyrelated symptoms, such as nausea, vomiting, loss of appetite, depression, fatigue, sleep disturbances and back pain occurred at a much lower frequency than in the control group, the physical performance of the patients was better, they spent much less time in hospital and survived longer with a better quality of life at the same time. The mistletoe therapy was also well tolerated. Only very few of the patients reacted to the mistletoe extract with side effects such as dizziness, fatigue, depression, slight fever or itching. With almost a quarter of the patients, so-called local reactions occurred at the injection site; these were always slight to medium in terms of intensity and subsequently subsided completely. No major side effects were observed (Bock et al. 2007, Matthes et al. 2007). 20 21 Practical use of mistletoe preparations The mistletoe extract is administered by injection, as the sensitive natural substances would be destroyed by the digestive juices of the human intestine. It is easy to learn how to inject beneath one’s own skin (subcutaneously). However, please ensure that the first self-injection is carried out together with the doctor treating you. Your doctor can show you exactly where to inject and what you have to do. Always adhere strictly to the treatment plan given to you by your doctor. Generally, the mistletoe preparation is injected three times per week, preferably in the morning. What factors must you be aware of when self-injecting? The application of mistletoe extracts requires a strictly subcutaneous injection technique. Suitable injection sites are: • abdomen region • upper side of the thigh Change the injection site regularly in order to prevent tissue irritation. 22 If cool storage is needed, the ampoule should be warmed up to room temperature before administration. It is recommended to remove it early enough from refrigeration or warm the ampoule in the hands. Reddening around the injection site (maximum 5 cm in diameter) can occur temporarily and is not a cause for concern, but rather indicates a normal reaction to exogenous substances. In general, this local reaction should have faded away by the time of the next injection. Change the injection site for the next injection. For each injection you need the following utensils: • • • • • an ampoule of mistletoe extract a small syringe (2 ml) a short, fine-gauged needle (0.4 mm x 20 mm, no. 27 G1/2) disinfectant and swab a small band-aid (if required) 23 Injection technique Preparation Lay out the utensils required! Place the needle (canula) with cap on the syringe. Opening the ampoule First of all, the neck of the ampoule is opened under the coloured dot. While holding the coloured dot upwards, bend the ampoule backwards by applying slight pressure. Drawing up the injection liquid The mistletoe preparation is now drawn up into the syringe via the needle (remove cap beforehand) (see photograph). Next, remove the air still present in the syringe: hold the syringe vertically with the needle upwards. Air bubbles at the side or at the bottom of the syringe can be moved upwards by gently tapping the syringe and then removed by slowly pressing the plunger. Subcutaneous injection Your doctor will indicate the best sites for injection. 24 Open the ampoule Draw up injection fluid Subcutaneous injection (under the skin) 25 Checklist for self-injection • Before injection, the ampoule has to be brought to room temperature. • Before injecting, ensure that there are no air bubbles remaining in the syringe. •Disinfect the injection site with an alcohol swab. • Take a fold of skin between two fingers of one hand and lift this away from the muscle. •Hold the syringe at a 45° angle, and rapidly insert the needle into the skin and underlying adipose tissue. •Retract the plunger of the syringe a little to ensure that you have not hit a blood vessel (which would be indicated by blood in the syringe). • If you have hit a vessel, select an alternative injection site and use a new needle. • Inject the contents of the syringe slowly and steadily. • Once the syringe is empty, hold the alcohol swab at the injection site and remove the needle from the skin. • Press the swab on the injection site for a few seconds. •Replace the needle’s protective cap on the syringe so that nobody can be injured and discard properly. 26 Reactions General reactions After injecting a mistletoe preparation, the body temperature may rise to approx. 38°C (100.4°F) especially when mistletoe therapy is first begun; it generally returns to normal within 24 hours. The reaction signals the Visible reddening of the skin stimulation of the body’s own defence directly following injection mechanisms. Local inflammation There may be slight inflammation around the injection site, with unsharply delimited redness and possible itching. Typical local reaction 4 hours After following injection about 4 hours, the border of the local reaction will become smoother, but itching may reappear. The edge of the local reaction has become flatter after 10 hours and disappears slowly. The redness, however, may still extend further. Typical local reaction 10 hours following injection 27 Sources and references •Augustin M et al: Safety and efficacy of the long-term adjuvant treatment of primary intermediate- to high-risk malignant melanoma (UICC/AJJC stages II and III) with a fermented European mistletoe (Viscum album L.) extract. Arzneim.-Forsch. / Drug Res. 55 (1), 38 – 49 (2005). •Bock PR et al: Treatment with a fermented mistletoe (Viscum album L.) extract as part of long-term supportive care in patients with primary non-metastatic colorectal carcinoma. Phytomedicine 14 (2), 43 (2007). •Bock PR et al: Efficacy and safety of long-term complementary treatment with European mistletoe extract (Viscum album L.) in addition to the conventional adjuvant oncological therapy in patients with primary non-metastatic breast cancer. Arzneim.-Forsch. / Drug Res. 54 (8), 456 – 466 (2004). •Bopp A: Die Mistel – Heilpflanze in der Krebstherapie. Rüffer & Rub Sachbuchverlag, Zürich, 1. Auflage 2006. •Kienle GS, Kiene H: Die Mistel in der Onkologie. Schattauer Verlag Stuttgart, 1. Auflage 2003. •Matthes H et al: Improvement of the palliative supportive care in pancreatic carcinoma patients with a fermented mistletoe (Viscum album L.) extract treatment. Phytomedicine 14 (2), 54 (2007). •Overstolz A: Mistletoe preparations in anthroposophically extended cancer treatment. Verlag für Ganzheitsmedizin Basel / Schweiz, 1st edition 2003. 28 Weleda representatives list For further information • Argentina Weleda S.A. +54 11 4702-1166, [email protected] • Australia Weleda Australien Pty Limited +61 3 9918-0911, [email protected] • Austria Weleda Ges.m.b.H&Co.KG +43 1 256-6060, [email protected] • Belgium Weleda N.V. +32 16 4066-24. [email protected] • Brazil Weleda do Brasil +55 11 3641-4122, [email protected] • Czech Republic Weleda spol s.r.o. +420 257 315-888, [email protected] • Denmark A/S Tødin +45 74 6244-88, [email protected] • France Weleda S.A. +33 389 69-6800, [email protected] • Georgia NaturaPharm Ltd. +995 32 322760, [email protected] • Germany Weleda AG +49 7171 919-414, [email protected] 29 • India Navneet Homoeo Pharmacy +91 11 2644-6067, [email protected] • Israel Bar Ilan Pharmacy +972 9 744-3579, [email protected] • Italy WELEDA Italia S.r.l. +39 02 4877-051, [email protected] • Netherlands Weleda Nederland NV +31 79 363-1313, [email protected] • New Zealand Weleda New Zealand Ltd. +64 6 872-8700, [email protected] • Poland PZA S.A. Multi Pharme +48 86 2167481-86, [email protected] • Spain Weleda S.A. +34 91 358-0358, [email protected] • Sweden WELEDA AB +46 8 522-96100, [email protected] • Switzerland Weleda AG +41 61 705-2121, [email protected] • United Kingdom Weleda U.K., Ltd. +44 115 944-8222, [email protected] • USA Weleda North America. +1 800 241-1030, [email protected] 30 For further information about mistletoe therapy or on the use of mistletoe preparations, consult your doctor or contact your local Weleda (see list pages 29/30). Another helpful address is the web site: www.mistel-therapie.de In harmony with nature Weleda AG, Möhlerstraße 3, 73525 Schwäbisch Gmünd www.weleda.de