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Rapid Responses: Rapid Responses published:
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A General Practitioner's Experience
- Stefan A Geider (23 December 2006)
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Evidence is not substitute for intuition – both may empower the healing art
- Eran Ben-Arye (25 December 2006)
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How to try getting importance
- Reinhard W. SCHWARZ, MD (26 December 2006)
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Evidence is no substitute for fairness
- Stephan Quentin (31 December 2006)
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Missed opportunity
- Gene S Feder (3 January 2007)
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A patient's response
- S Mitchell (4 January 2007)
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Let's be fair
- Mark J Hancock (6 January 2007)
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Cum hoc, ergo propter hoc
- Gunver S Kienle (10 January 2007)
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Use of mistletoe: Bad Clinical Practice in cancer
- Michael Stimpel (15 January 2007)
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Iscador (mistletoe) continues to be popular
- Dr. Herbert H. Nehrlich (16 January 2007)
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A patient's response part 2
- S Mitchell (19 January 2007)
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Mistletoe after Christmas - still controversial
- Rainer Stange, D-14109 Berlin Germany (23 January 2007)
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Effect of Mistletoe on Cervical cancer (n =1)
- S Sundar (16 July 2007)
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Stefan A Geider, GP Camphill Medical Practice AB15 9EP
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I am a GP working within an NHS practice which last year gained the Royal College of General Practitioner’s Quality Practice Award. This same practice provides an integrated approach to healthcare encompassing anthroposophic medicine. Therefore, I was puzzled by Professor Ernst’s comments on anthroposophic medicine and on Mistletoe treatment in particular in his editorial ‘Mistletoe as a treatment for cancer. Has no proved benefit, and can cause harm'.
I do not see my experience of 10 years in practice reflected in the picture painted by Professor Ernst. For example having treated over 400 patients with Mistletoe therapy, many of whom come referred by GPs, oncologists and MacMillan nurses, I have not encountered the severe adverse reactions highlighted in the article. On the contrary, patients regularly comment on the positive benefits that Mistletoe treatment has brought them and therefore, I too would be interested to see more research on Mistletoe therapy.
Along with other colleagues working within anthroposophic medicine, I would welcome the opportunity to respond to the issues raised by Professor Ernst in a future issue of the BMJ.
By the way, I am not averse to Professor Ernst’s suggested ‘alternative’ use for mistletoe - as a Christmas decoration and for kissing under!
Competing interests: None declared |
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Eran Ben-Arye, The Complementary and Traditional Medicine Unit; The Department of Family Medicine; Faculty of Me Clalit Health Services, Haifa and Western Galilee District., Israel 35013
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I read Professor Ernst's editorial with much interest. I am a family medicine practitioner who integrates complementary medicine within two public primary care clinics in Northern Israel serving 1900 patients. Along my studies and practice of Anthroposophic medicine I never found that its agenda is "alternative" or "substitute" to conventional medicine. In contrast to the citation chosen by the author, Anthroposophic medicine is broadly viewed as a bio-psycho-social-spiritual extension of medicine. The using of the term "intuition" is misleading. Words like intuition, thinking , feeling and willing are conceptualized in Anthroposophy to ideas which reflect saltugenetic notions rather than their ordinary meaning. It is true that Viscum Album, Mistletoe, is viewed by its broad connectedness with the four members in man and not merely as a bio-medical anti-cancer remedy. Moreover, Mistletoe, is used not only to act on cancer cells but to promote an inner dialogue between patients and themselves, their families and their physicians. Prof. Ernst intention to promote complementary evidence-based medicine is deeply acknowledged but should be complemented with cognition-based approach, which also relates to concepts of meaning, narrative and sense of coherence. May the two agendas integrate and enrich the art and science of healing. Eran Ben-Arye M.D. The Complementary and Traditional Medicine Unit The Department of Family Medicine Faculty of Medicine, Technion-Israel Institute of Technology, Haifa. and Clalit Health Services, Haifa and Western Galilee District., Israel Competing interests: None declared |
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Reinhard W. SCHWARZ, MD, pediatrician Quellengasse 42, 8010 GRAZ/Austria
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Prof. Ernst arguments contra mistletoe seem to be scientifically correct concerning randomized trials.Unfortunately his recommendations for mistletoe don´t reach scientific quality. I wonder, how a professor, as a qualified educated person, is able to substitute own thinking with statistic evidence, which at the best will fetch average evidence.It is interesting, that Prof Ernst seems to have no possibility to accept the individuality of human beeing, though being himself such an individuum. I wonder which influences attack him discussing therapies he never has used in own patients or close relatives. So I propose that he should have his own CHristmastree to be kissed under instead of attacking individual therapies. Competing interests: None declared |
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Stephan Quentin, GP principal Dolphins Practice, Haywards Heath, RH19 4SJ
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I have reviewed the paper Ernst cites in support of his claim that " a wide range of serious adverse reactions have been noted" in the context of injectable mistletoe treatment (Saller, Zu den unerwuenschten Wirkungen von Mistelpraeparaten). I wonder if Ernst actually read it beyond what he was looking for, i.e. material to support his longstanding aversion to anthroposophic medicine in general and mistletoe treatment in particular. It is impossible to form a proper opinion about mistletoe treatment as long as one does not differentiate between real side effects and the effects mistletoe has as an immune stimulating treatment. The intention of the treatment is to provoke a reaction of the immune system. Clinically this is expressed in signs like local redness, swelling, flu-type symptoms and an elevated body temperature. They indicate that the patient is receiving an effective dose. So far no reliable laboratory parameters have been identified which could be used to replace these clinical indicators. It is therefore not surprising that in the 41 studies reviewed in the paper Ernst quotes, estimates on the frequency of side effects range from 0.9% to 43%. It depends on what you call a side effect! The summary of the paper reads as follows (my own translation):" The clinical studies analyzed show that unwanted effects are usually mild and reversible. Most of them show a dose dependence and disappear or decrease with dose reduction or cessation of medication. Under the assumption that a lot of the local reactions can be interpreted as intended responses of the organism, the incidence of unwanted effects is overall much lower than expected" It seems to me that Ernst's claims regarding the dangers of mistletoe treatment and his presentation of the evidence are misleading and lacking in fairness. Competing interests: None declared |
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Gene S Feder, Professor of primary care research and development Barts and the London, Queen Mary's School of Medicine and Dentistry, 2 Newark Street, London E1 2AT
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The topic of mistletoe slipped into the Christmas BMJ with a case report on a known adverse effect of this treatment, highlighting the importance of taking a history that includes the use of complementary therapies. On the back of this case report, we get an editorial on the role of mistletoe in cancer treatment from a professor of complementary medicine. Here was an opportunity to give the reader a balanced assessment of this treatment in the light of new studies. Instead we get a distorted view of the evidence on mistletoe effectiveness and the magnitude of adverse effects. Ernst’s statement that less rigorous mistletoe clinical trials are more likely to show benefit was debatable at the time of his systematic review(1) and is no longer the case with a new generation of studies, at least in relation to improved quality of life.(2)(3) While there is heterogeneity between different trials, this is not a function of study quality and may be explained by type and dosage of mistletoe, duration of treatment and follow up, outcome measures, type and stage of malignancy. Ernst has also exaggerated the potential for harm; pharmacovigilance and longitudinal cohort studies(4) show a very low incidence of significant adverse effects. Who is claiming that intuition is a “substitute for evidence”? Instead of ad hominem attacks on anthroposophic clinical researchers, it would be more constructive for Ernst to engage with the methodological challenges of research on mistletoe(5)and encourage the funding of larger and better designed randomised trials. Reference List (1) Ernst E, Schmidt K, Steuer-Vogt MK. Mistletoe for cancer? A systematic review of randomised clinical trials. Int J Cancer 2003; 107(2):262-267. (2) Semiglazov 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;26:1519-1529. (3) Piao BK, Wang YX, Xie GR, Mansmann U, Matthes H, Beuth J et al. 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. (4) Augustin M, Bock PR, Hanisch J, Karasmann M, Schneider B. Safety and efficacy of the long-term adjuvant treatment of primary intermediate- to high-risk malignant melanoma (UICC/AJCC stage II and III) with a standardized fermented European mistletoe (Viscum album L.) extract. Results from a multicenter, comparative, epidemiological cohort study in Germany and Switzerland. Arzneimittelforschung 2005;55:38-49. (5) Kienle GS, Kiene H, Albonico H-U. Anthroposophic medicine: effectiveness, utility, costs, safety. New York:Schattauer; 2006 Competing interests: In 2001 I was paid by Weleda to chair a guideline development group on the use of mistletoe |
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S Mitchell, Ex-cancer patient Stirling, Scotland
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In 2003 I was diagnosed with breast cancer. I underwent surgery, chemotherapy, and radiotherapy. As the two tumours were oestrogen- positive and as I was pre-menopausal I was given tamoxifen and Zoladex for two years. All these treatments have now finished and I am at present having no treatment. Would mistletoe injections be beneficial to me? Well no one has yet given me enough evidence of its benefit, and by evidence I mean scientific evidence from robust, repeatable, double-blind studies with good sample sizes. If there is any such evidence out there please give me the references. Does mistletoe do any direct harm? I'm not certain as the evidence appears contradictory but I take exception to the GP who said that he had treated over 400 patients and non of them had any of the severely adverse reactions mentioned in Professor Ernst's article. This is a fallacy known as naive induction. Just because this GP's patients haven't experienced severe adverse reactions doesn't mean other people won't. Does mistletoe do any indirect harm? Yes, I think it does. Firstly the promoting of mistletoe without robust scientific evidence opens the door to other therapies with no robust scientific evidence - from shark cartilage and reiki to apricot kernels and crystal therapy - some of which might be harmful even if mistletoe isn't. Secondly, mistletoe, in common with other complementary and alternative medicines, doesn't seem to have an end date. This continual treatment means that at no point can a patient emotionally and intellectually leave cancer behind and get on with the rest of their lives. They become trapped in a cycle of fear and dependence; they fear what will happen if they stop treatment and so carry on with the treatment which in turn fuels the fear of what might happen if they stop. So, on balance there seems to be no (or at best conflicting) evidence of the benefits of mistletoe, conflicting evidence on whether mistletoe causes direct harm and my own personal concerns about whether it causes indirect harm. Somehow I don't think I'll be injecting mistletoe quite yet. Happy New Year Competing interests: None declared |
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Mark J Hancock, medical student Dudley, West Midlands
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Though tucked in my drawer is a philosophy degree, I was not tempted to take exception to Dr. Geider who is working actively with mistletoe preparations in his practice when he described his patients' positive experiences. I could call this "naive induction" but this is a misuse of logic. Dr. Geider is offering his perspective on mistletoe use - something that needs to be added to Prof. Ernst's statements for even an attempt at a fair look at mistletoe therapy. Competing interests: None declared |
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Gunver S Kienle, Senior Research Scientist, MD, Dr. med. IFAEMM (Institute for Applied Epistemology and Medical Methodology), D-79189 Bad Krozingen, Germany
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The author of the editorial (1) has repeatedly published lists of alleged horrible side effects of mistletoe treatment, which, at a closer look, turn out to be either harmless reactions, or misinterpretations, or not referring to mistletoe therapy at all. (2) The new list of “serious adverse reactions” published in the BMJ (1) is also not supported by empirical data. One of the two references explicitly states that “no severe side effects were observed”. The other reference, unpublished, refers to a survey which was also published as a book-chapter. (3) It reports, besides some well known side effects of mistletoe treatment (frequent harmless or occasional allergic or very rare anaphylactic reactions, see overview (4)), many anecdotal suspected adverse events (not adverse reactions!): There are no details reported, no information on diagnoses, treatments or any other medical data. Almost nothing is known apart from the fact that the causal relationship to mistletoe therapy was not assessed – except in a patient with flue-like symptoms who also happened to have a viral infection, and a patient with thrombocytopenia after induction of heparin treatment. Of course, countless adverse events occur in cancer patients. They are often ill, have many symptoms, and receive numerous medications. “Cum hoc, ergo propter hoc” is a logical fallacy. Regarding mistletoe efficacy, the quoted reviews are outdated or incomplete, do not refer to the recent trials, or even specifically exclude all trials on anthroposophic mistletoe preparations. (4) The in vitro studies seen as suggestive of mistletoe-induced tumour cell proliferation have been criticised for technical deficiencies; several replication studies failed to confirm any of their results (e.g. (4;5)). Incorrect, too, is the statement that mistletoe would be used as an alternative treatment. Mistletoe is mostly used in addition to conventional oncological treatment, which is regularly applied also in anthroposophic medicine. (4) Reference List (1) Ernst E. Mistletoe as a treatment for cancer. Br Med J 2006; 333:1282-1283. (2) Kienle GS, Hamre HJ, Kiene H. Anthroposophical Medicine: A systematic review of randomised clinical trials. Wien Klin Wochenschr 2004; 116:407-408. (3) Saller R, Kramer S, Iten F, Melzer J. Unerwünschte Wirkungen der Misteltherapie bei Tumorpatienten - Eine systematische Übersicht. In: Scheer R, Bauer R, Becker H, Fintelmann V, Kemper FH, Schilcher H, editors. Fortschritte in der Misteltherapie. Aktueller Stand der Forschung und klinischen Anwendung. Essen: KVC Verlag, 2005: 367-403. (4) Kienle GS, Kiene H, Albonico HU. Anthroposophic Medicine: Effectiveness, Utility, Costs, Safety. Stuttgart, New York: Schattauer Verlag, 2006. (5) 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. Arzneim -Forsch /Drug Res 2006; 56(6A):435-440. Dr. med. Gunver S. Kienle, MD Institute for Applied Epistemology and Medical Methodology (IFAEMM), Schauinslandstr. 6 D-79189 Bad Krozingen Germany Gunver.Kienle@ifaemm.de Competing interests: The author has written a Health Technology Assessment Report on Anthroposophic Medicine on behalf of the Swiss Federal Social Insurance Office. IFAEMM conducted research projects with mixed funding by foundations, health insurance companies, and Weleda, Wala, or Helixor. |
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Michael Stimpel, Professor of Medicine, Director German Centre of Integrative and Preventive Medicine, D-66346 Puettlingen
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Many thanks to Dr. Ernst for his clear-cut statement on the present scientific status of mistletoe as a complementary treatment in cancer (1). We agree that the wealth of data on the clinical use of mistletoe in cancer does not allow the conclusion that any marketed extracts have any beneficial effect on the outcome in patients with cancer. Based on the present state of knowledge, it rather seems that there is no effect of mistletoe as an anticancer drug, since outcome in cancer does not significantly differ, for example, between the USA and Germany, the latter being a country with very high numbers of mistletoe users, the first, a country, in which mistletoe is only approved for the use in controlled clinical trials. The truth is that from a scientific point of view we presently do not know whether mistletoe is effective in cancer or not. To have promising preclinical data is one thing (2), to prove efficacy, effectiveness and safety in the clinical setting is a different one. As Dr. Ernst stated, it is therefore odd that insurances in Germany are willing to pay for mistletoe in cancer. Instead of increasing the costs in the health system, we recommend to better invest the money into well-designed clinical outcome studies with pharmacologic defined preparations of mistletoe as an add-on therapy to conventional treatment. At least, when it comes to pharmacologic treatment we owe our patients more than just intuition. That is why the worldwide medical community agreed upon quality standards in drug development by implementing the GCP/ICH (Good Clinical Practice /International Conference on Harmonization) and the Clinical Trial Directive (Directive 2001/20/EC) of the European Commission. The use of mistletoe in cancer is Bad Clinical Practice. 1 Ernst E. Mistletoe as a treatment for cancer. Has no proved benefit and can cause harm. BMJ 2006; 333: 1282-1283. 2 Maldacker J. Preclinical investigations with mistletoe (Viscum album L.) extract Iscador. Arzneimittelforschung. 2006;56(6A):497-507. Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Professor Stimpel states "The truth is that from a scientific point of view we presently do not know whether mistletoe is effective in cancer or not." He then goes on to suggest that we owe our patients more than just intuition. He concludes by declaring the practice of employing mistletoe preparations in cancer treatment as bad clinical practice. Given the dismal successes in cancer treatment today, the glaring lack of efficacy of chemotherapy for most cancers and the continued increase in numbers of new cancer cases, I suggest we use our intuition as well as anything else that just might show a bit of hope and promise. Condemnation without investigation and outright (perhaps arrogant)dismissal of a natural remedy that will do little harm and is still in use precisely because a sufficient number of clinicians believe that it does work is not what the doctor ordered. Competing interests: None declared |
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S Mitchell, Ex-cancer patient Stirling
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I had rather hoped that in putting forward a patient's (or in my case an ex-patient's) point of view that I would add to a fully rounded debate rather than what has turned out to be a two sided argument from opposing entrenched positions. Issues I've raised, particularly on the subject of the potential indirect harm of mistletoe, haven't really been addressed. I'm very surprised at this. Is it, I wonder, because I'm an ex-patient and not a doctor. Competing interests: None declared |
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Rainer Stange, Provisonal head Dept. for Natural Medicine Charité - Universitaestmedizin Berlin and Immanuel-Krankenhaus Berlin, D-14109 Berlin Germany
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Dear Sirs, The case report recently published in this journal by Finall, A.I. et al1 undoubtedly gives an opportunity to reflect on the safety issues involved in mistletoe therapy. However, we may disagree with the interpretation put forward in the editorial by our colleague Edward Ernst in the same issue2. Although one might argue about the existing evidence concerning the clinical significance of its desired effects, evidence about its undesired effects is abundant. Serious adverse reactions following mistletoe applications such as the one cited have usually been attributed to hyperergic and immunologic, specifically excessive inflammatory responses. There seems to be no doubt that the different effects of mistletoe solutions tend toward that direction, as has been shown in many preclinical and clinical studies. Due to the date of their publication, the three reviews cited by Ernst3,4,5 could not have taken three further large randomized controlled trials into consideration6,7,8, all of which are now easily accessible and could have been mentioned in the report. Along with another large, only slightly older trial9, which was reviewed by Ernst5 and Stauder4, we are now able to overlook apx. 1,500 patients treated in recent RCTs with GCP standards on reporting adverse events. This figure does not include the many additional studies that are less recent. In the accounts of these four trials, none of the serious events listed by Ernst is mentioned. In our reference to the probably most careful overview on the topic by Saller10, also cited by Ernst, we judge 39 of the described events to be serious. Kidney failure, mentioned by Ernst, was not among them. An attempt to compare these reports to frequencies of application seems necessary. In Germany, circa 500,000 defined daily doses per year (DDD) of mistletoe solutions have been sold in recent years. We were unable to retrieve data on other countries. Assuming a yearly average of 50 injections per patient, this indicates that approximately 10,000 patients are treated per year. Considering the decades in which mistletoe has been sold, we easily end with a total of more than 100,000 patients treated only in Germany. Thus, the events discussed, in our opinion the 39 reported plus an unknown number unreported, are most probably rather rare (i.e. significantly below 1/1000 per application). We agree that there may be other herbal drugs more useful in cancer treatment than mistletoe. In spite of some hopeful candidates, by far none has been subjected to the scope of clinical and preclinical testing as mistletoe. There is certainly no reason not to look for more options. Rainer Stange, M.D. Provisonal head Dept. for Natural Medicine Charité - Universitaestmedizin Berlin and Immanuel-Krankenhaus Berlin r.stange@immanuel.de 1) Finall AI, McIntosh SA, Thompson WD. Subcutaneous inflammation mimicking metastatic malignancy induced by injection of mistletoe extract. BMJ 2006 doi: 10.1136/bmj.39044.460023.BE 2) Ernst E: Mistletoe as a treatment for cancer. BMJ 2006;333:1282-1283, doi:10.1136/bmj.39055.493958.80 3) Kleijnen J, Knipschild P. Mistletoe treatment for cancer: review of controlled trials in humans. Phytomedicine 1994;1:255-60 4) Stauder H, Kreuser E-D. Mistletoe extracts standardised in terms of mistletoe lectins (ML I) in oncology: current state of clinical research. Onkologie 2002;25:374-80 5) Ernst E, Schmidt K, Steuer-Vogt MK. Mistletoe for cancer? A systematic review of randomised clinical trials. Int J Cancer 2003; 107(2):262-267 6) Semiglazov 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;26:1519-1529. 7) Piao BK, Wang YX, Xie GR, Mansmann U, Matthes H, Beuth J et al. 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. 8) Augustin M, Bock PR, Hanisch J, Karasmann M, Schneider B. Safety and efficacy of the long-term adjuvant treatment of primary intermediate- to high-risk malignant melanoma (UICC/AJCC stage II and III) with a standardized fermented European mistletoe (Viscum album L.) extract. Results from a multicenter, comparative, epidemiological cohort study in Germany and Switzerland. Arzneimittelforschung 2005;55:38-49. 9) Steuer-Vogt MK, Bonkowsky V, Scholz M, Arnold W. Plattenepithelkarzinome des Kopf-Hals-Bereichs. Mistellektin-1-normierte Viscumtherapie. Deutsches Arzteblatt 2001;98:3036-46. 10) Saller R, Kramer S, Iten F, Melzer J. Unerwünschte Wirkungen der Misteltherapie bei Tumorpatienten - Eine systematische Übersicht. In: Scheer R, Bauer R, Becker H, Fintelmann V, Kemper FH, Schilcher H, editors. Fortschritte in der Misteltherapie. Aktueller Stand der Forschung und klinischen Anwendung. Essen: KVC Verlag, 2005: 367-403. Competing interests: Competing interest: I have spoken at scientific symposiums, organised by Helixor and bisoyn (both mistletoe producers) |
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S Sundar, Consultant Oncologist Dept of Oncology, University Hospitals of Nottingham, NG5 1PB
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I am certainly not a fan of the so-called complementary 'unproven' treatments. (1). I certainly concur with the author about the 'absence of evidence' regarding mistletoe treatment for cancer. (2)(3)(4). I wish to report on a patient who seems to have 'benefited' from mistletoe therapy. A 57 yr old woman presented with vaginal bleeding and a biopsy showed cervical cancer in March 2002. A subsequent MRI scan showed a 3cm cervical cancer with lateral spread to right parametrium. Chemoradiation was recommended, but the patient refused radiotherapy and chemotherapy. She elected to have 'mistletoe injection therapy only' even after she was made aware of the risks. She then continued on regular medical follow up. A year later, she had vaginal bleeding for which she agreed to have a single fraction of radiotherapy. I was expecting rapid tumour progression and possibly metastatic disease at this stage. However, I was surprised when the repeat MRI scan in December 2003 showed no significant tumour progression. The treatment options were discussed with her again and this time she agreed to have the 'full radical course of radiotherapy'. A repeat MRI scan in June 2004 after radiotherapy showed complete tumour response. Another MRI scan in March 2007 has confirmed that she is completely free of tumour. The patient continues on subcutaneous Mistletoe (ISCADOR®) injections. The most likely explanation for non-progression of cancer for more than year without treatment is that the patient's cervical cancer was a 'slow growing' tumour. (5). But I have to admit that I could not rule out an effect (direct or indirect) of mistletoe on cervical cancer. Ref: 1. Sundar S. It's either a proven therapy or an unproven therapy. http://www.bmj.com/cgi/eletters/333/7578/1129#150613. 2. Ernst E. Mistletoe as a treatment for cancer. Has no proved benefit and can cause harm. BMJ 2006; 333: 1282-1283. 3. Ernst E, Schmidt K, Steuer-Vogt MK. Mistletoe for cancer? A systematic review of randomised clinical trials. Int J Cancer 2003;107(2):262-267. 4. Mistletoe Extracts (PDQ®). http://www.cancer.gov/cancertopics/pdq/cam/mistletoe/HealthProfessional/page5#Reference5.8 5. Symonds P, Bolger B, Hole D, Mao JH, Cooke T. Advanced-stage cervix cancer: rapid tumour growth rather than late diagnosis. Br J Cancer 2000; 83: 566-568 Competing interests:
Editorial note
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