MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

integrative medicine

“Le Figaro” has published two articles (one contra and one pro) authored by ‘NoFakeMed’ (an association of health professionals warning of the danger of fake medicine) signed by a long list of healthcare professionals (including myself) who argue that so-called alternative medicine (SCAM) should be excluded from public healthcare. It relates to the fact that, since last June, a committee set up by the French government has been bringing together opponents and supporters of SCAM. At the heart of the debate is the question of how SCAMs should be regulated, and the place they should occupy in the realm of healthcare. Should they be included or excluded?

Here is the piece arguing for EXCLUSION (my translation):

They’re called alternative medicine, complementary medicine, parallel medicine, alternative medicine, SCAM, and other fancy words. The authorities prefer to call them “non-conventional healthcare practices” (NCSP), or “non-conventional health practices” (NCHP). The choice of terminology is more than just a parochial quarrel: it’s a question of knowing what quality of medicine we want, and whether we agree to endorse illusory techniques whose main argument is their popularity. This raises the question of how to regulate these practices. Some people want to force them into the healthcare system, hospitals, health centres and nursing homes. And they are prepared to use all manner of oratory and caricature to legitimise questionable practices.

Unconventional healthcare practices are on the up, and the number of practitioners and practices has been rising steadily since the 2000s; there are now around 400 therapeutic NHPs. But their success is often due to a lack of understanding of the philosophy behind them, and their lack of effectiveness beyond context effects. This was seen in the debate surrounding homeopathy, which lost much of the confidence placed in it as soon as it stopped to be reimbursed in France and was confronted with the work of popularising it on its own merits among the general public. The ethical imperative of respect for patients means providing them with reliable information so that they can make a free and informed choice.

This raises the question of the place or otherwise to be given to NHPs within the healthcare system. Although there are many different names for them, they are all practices that claim to relate to care and well-being, without having been proven to be effective, and based on theories that are not supported by scientific evidence. Admittedly, the evidence is evolving, and a practice can demonstrate its usefulness in healthcare. This is true, for instance, of hypnosis, whose usefulness as a tool in certain situations is no longer debated since it has become possible to measure and explain both its benefits and its limitations.

However, there is no question of legitimising the entire range of NHPs on the pretext that they are supposedly harmless. Many of them do have adverse effects, sometimes serious, either directly or because they lead to a lack of care. These effects also exist with conventional treatments, but the risks must always be weighed against the proven benefits. The risks associated with NHPs are therefore unacceptable, given their ineffectiveness.

Furthermore, there are abuses associated with NHPs, even if (fortunately!) they are not frequent. Sectarian aberrations are not systematically linked to NHPs, but here again the risk is unacceptable. In its 2021 activity report, Miviludes indicates that 25% of referrals concern the field of health, and that 70% of these relate to SCAM. The number of health-related referrals has risen from 365 in 2010 to 842 in 2015, and exceed 1,000 in 2021.

Conventional medicine is of course not immune to such aberrations, and Miviludes estimates that 3,000 doctors are linked to a sectarian aberration. But the health professional associations have tackled the problem head-on, notably by setting up a partnership with Miviludes and multiple safeguards (verification of diplomas and authorisation to practise, obligation to undergo continuing training, codes of ethics and public health codes, professional justice, declaration of links of interest, etc.). The professional associations have raised awareness of sexual and gender-based violence, universities are providing training in critical reading of scientific articles, and community initiatives are flourishing to improve public information.

We agree that the choices of our patients must be respected, and everyone has recourse to the wellness practices of their choice. But, at the same time, patients have the right when they consult a healthcare professional, a hospital or a health centre, to know that they will be looked after by healthcare professionals offering conscientious, dedicated, evidence-based care.

In view of the current challenges facing our healthcare system, the response must not be to offer more pseudo-medicine on the pretext that people are already using it. The real answer is to rely on evidence, to provide resources for more research, to continue with research, to rely on social work, not to neglect mental health, to improve disease prevention, and to keep pressure groups at bay, whether they come from pharmaceutical companies or the promoters of esoteric, costly and sometimes dangerous practices.

___________________________

Tomorrow, I will translate and comment on the pro-piece that ‘Le Figaro’ today published alongside this article.

 

PS

The list of signatories can be found in the origninal paper.

In May this year, I reported that my ex-friend Michael Dixon had been appointed as HEAD OF THE ROYAL MEDICAL HOUSEHOLD. The story was picked up by Gabriel Pogrund, one of the top investigative journalists of THE SUNDAY TIMES, who published a long article about Dixon yesterday which I encourage you to read in full.

In it he revealed many things about Dixon including, for instance, that some of the academic titles he often carries might not be what they seem. On ‘X’. Pogrund commented that “He [Dixon] faces Qs after three unis could not confirm his academic roles”. The article prompted many other newspapers to report on the matter.

The Guardian, for instance, contacted The Good Thinking Society, which promotes scientific scepticism. Michael Marshall, project director at the society, said: “It [promoting homeopathy] isn’t appropriate. I think the role of the monarchy, if it has one in current society, isn’t to be advocating for their own personal projects and their own personal beliefs or using the power and influence they have to further causes that run directly counter to the evidence that we have. “It’s absolutely unequivocal that homeopathic remedies do not work and just because you happen to be in a position of extreme power and privilege, that doesn’t change that.” Marshall said the appointment was also worrying because it suggested the king might still be supporting complementary medicine behind the scenes. He added: “Before Charles became king, he was the patron of homeopathic organisations, he was an outspoken advocate in favour of homeopathy and pushing back the bounds of science towards pseudoscience. And the argument was that he would stop doing that once he became king. This appears to be a sign that he isn’t going to do that, that he isn’t going to stop. What’s worrying is, as we’ve seen from the black spider memos, Charles is someone who also wields his power and influence quietly behind the scenes as well as publicly, so if this is the kind of step he’s willing to make in public, it raises questions about whether he’s willing to make even more steps in private.”

The Guardian also asked me three questions and I provided my answers in writing:

Q: Do you think it’s appropriate that the king has appointed Dr Michael Dixon to such a prestigious role? If not, why?
A; Surely, the King can appoint who he wants. In the realm of health care, he often seemed to favour people wo promote dubious therapies [Charles, The Alternative King: An… by Ernst, Edzard (amazon.co.uk)
Q: Do you think the king’s public position on homeopathy is problematic? and if so, why?
A: Anyone who promotes homeopathy is undermining evidence based medicine and rational thinking. The former weakens the NHS, the latter will cause harm to society.
Q: Do you think homeopathy has a place in medicine and if not, why? What has your research shown on its efficacy?
A: We and others have shown that homeopathy is not an effective therapy, which has today become the accepted consensus. To me, this means its only legitimate place is in the history books of medicine.

Within hours, the story became an international isse. For example a short article in DER SPIEGEL informed Germany as follows (my translation):

He works with Christian healers and prescribes goat weed for impotence: Dr Michael Dixon looks after the health of the British royal family. Scientists are appalled.

King Charles has appointed a homeopathy advocate as head of the royal medical household and has been heavily criticised by scientists. They call the decision worrying and inappropriate, as reported by the Guardian, among others. Dr Michael Dixon, who promotes faith healing and herbalism in his work as a general practitioner, has quietly held the senior position for a year, writes the Sunday Times. Although 71-year-old Dixon is head of the royal medical household, this is the first time that this role has not been combined with that of a doctor to the monarch. His duties include taking overall responsibility for the health of the King and the entire royal family – and also representing them in discussions with the government. He once invited a Christian healer into his practice to treat chronically ill patients. He also experimented with prescribing devil’s claw for shoulder pain and goat’s weed for impotence, reports the Sunday Times.

Will all this have consequences? Will the King reflect and reconsider his affiliations with those who promote quackery? Will Dixon change?

Personally, I will not hold my breath.

In many parts of the world, vaccination rates have been declining in recent years.

Why?

This study aimed to determine the rates and reasons for parental hesitancy or refusal of vaccination for their children in Türkiye. A total of 1100 participants selected from 26 regions of Türkiye were involved in this cross-sectional study conducted between July 2020 and April 2021. Using a questionnaire, the researchers collected data on:

  • the sociodemographic characteristics of parents,
  • the status of vaccine hesitancy or refusal for their children,
  • the reasons for the hesitancy or refusal.

Using Excel and SPSS version 22.0, they analysed the data with chi-square test, Fisher’s exact test and binomial logistic regression.

Only 9.4% of the participants were male and 29.5% were aged 33-37 years. Just over 11% said they were worried about childhood vaccination, mainly because of the chemicals used in manufacturing the vaccines. The level of concern was greater among those who:

  • got information about vaccines from the internet, family members, friends, TV, radio, and newspapers,
  • used so-called alternative medicine (SCAM).

The authors concluded that parents in Türkiye have several reasons for hesitating or refusing to vaccinate their children, key among which are concerns about the chemical composition of the vaccines and their ability to trigger negative health conditions such as autism. This study used a large sample size across Türkiye, although there were differences by region, the findings would be useful in designing interventions to counter vaccine hesitancy or refusal in the country.

The fact that SCAM users are more likely to be against vaccinations has been reported often and on this blog we have discussed such findings regularly, e.g.:

The questinon I ask myself is, what is the cause and what the effect? Does vaccination hesitancy cause people to use SCAM, or does SCAM use cause vaccination hesitancy? I think that most likely both is true. In addition the two are linked via a common trait, namely that of falling for conspiracy theories. We know that someone believeing in one such theory is likely to believe in other such notions as well. In my view, both vaccination heaitancy and SCAM can qualify to be called a conspiracy theory.

So-called alternative medicine (SCAM) interventions are often being discussed as possible treatments for long COVID symptoms. However, comprehensive analysis of current evidence in this setting is still lacking. This review aims to review existing published studies on the use of SCAM interventions for patients experiencing long COVID through a systematic review.

A comprehensive electronic literature search was performed in multiple databases and clinical trial registries from September 2019 to January 2023. RCTs evaluating efficacy and safety of SCAM for long COVID were included. Methodological quality of each included trial was appraised with the Cochrane ‘risk of bias’ tool. A qualitative analysis was conducted due to heterogeneity of included studies.

A total of 14 RCTs with 1195 participants were included in this review. Study findings demonstrated that SCAM interventions could benefit patients with long COVID, especially those suffering from neuropsychiatric disorders, olfactory dysfunction, cognitive impairment, fatigue, breathlessness, and mild-to-moderate lung fibrosis. The main interventions reported were self-administered transcutaneous auricular vagus nerve stimulation, neuro-meditation, dietary supplements, olfactory training, aromatherapy, inspiratory muscle training, concurrent training, and an online breathing and well-being program.

The authors concluded that SCAM interventions may be effective, safe, and acceptable to patients with symptoms of long COVID. However, the findings from this systematic review should be interpreted with caution due to various methodological limitations. More rigorous trials focused on SCAM for long COVID are warranted in the future.

The review’s aim is, in my view, nonsense. SCAM is a diverse field which means that the review must capture a wide range of therapies each represented by just one or two primary studies. In turn, this means that general conclusions across all SCAM will be highly questionable, if not misleading.

Furthermore, I find these conclusions odd and irresponsibly misleading. My main reason for this is the poor methodological quality of the primary studies:

  • Four trials were considered to have unknown bias risk for generating the random sequence due to insufficient information about the specific method of randomization used.
  • Only 5 of the trials provided appropriate random allocation concealment.
  • Only 5 trials were blinded to both participants and personnel.
  •  Three trials were rated as unknown risk of bias since insufficient information was provided.
  • Four trials failed to performed outcome assessment blinding.
  • One trial did not report detailed information about drop-out cases and was defined as high risk of bias. 
  • Three study protocols were unavailable and had relevant outcomes that were not reported in the pre-specified way.

Moreover, safety cannot possibly be reliably estimated on the basis of the data. And finally, the statement that SCAM interventions may be effective, as the authors put it, is in my view not a valid conclusion but a silly platitude.

I therefore suggest to re-formulate the conclusion of this review as follows:

At present there is no sound evidence to assume that any SCAM intervention is effective in the management of long COVID.

I was alerted to a new book entitled “Handbook of Space Pharmaceuticals“. It contains a chapter on “Homeopathy as a Therapeutic Option in Space” (yes, I am not kidding!). Here is its abstract (the numbers were inserted by me and refer to the short comments below):

Homeopathy is one of the largest used unorthodox medicinal systems having a wide number of principles and logic to treat and cure various diseases [1]. Many successful concepts like severe dilution to high agitation have been applied in the homeopathic system [2]. Though many concepts like different treatment for same diseases and many more are contradictory to the allopathic system [3], homeopathy has proved its worth in decreasing drug-related side effects in many arenas [4]. Various treatments and researches are carried out on various diseases; mostly homeopathic treatment is used in joint diseases, respiratory diseases, cancer, and gastrointestinal tract diseases [5]. In this chapter, readers will have a brief idea about many meta-analysis results of most common respiratory diseases, i.e., asthma, incurable hypertension condition, rheumatoid arthritis, and diarrhea and a megareview of all the diseases to see their unwanted effects, uses of drugs, concepts, and issues related to homeopathy [6]. Various limitations of homeopathic treatments are also highlighted which can give a clear idea about the future scope of research [7]. Overall, it can be concluded that placebo and homeopathic treatments give almost the same effect [8], but the less severe side effects of homeopathic drugs in comparison to all other treatment groups catch great attention [9].

Apart from the very poor English of the text and the fact that it has as good as nothing to do with the subject of ‘Homeopathy as a Therapeutic Option in Space’, I have the following brief comments:

  1. I did not know that homeopathy has ‘a wide number of logic’ and had alwas assumed that there is only one logic.
  2. Successful concepts? Really?
  3. So, homeopaths believe that the ‘allopathic system’ treats the same diseases uniformly? In this case, they should perhaps read up what conventional medicine really does.
  4. I am not aware of good evidence showing that homeopathy reduces drug related adverse effects.
  5. No, homeopathy is used for all symptoms – Hahnemann did not believe in treating disease entities – and mostly for those that are self-limiting.
  6. I love the term ‘incurable hypertension condition’; can somebody please explain what it is?
  7. The main limitation is that homeopathy is nonsense and, as such, does not really require further research.
  8. Not ‘almost’ but ‘exactly’! But thanks for pointing it out.
  9. Wishful thinking and not true. Firstly, the author forgot about ‘homeopathic aggravations’ in which homeopaths so strongly believe. Secondly, I know of many non-homeopathic treatments that are free of adverse effects when done properly.

Altogether, I am as disappointed by this article as you must be: we were probably all hoping to hear about the discovery showing that homeopathy works splendidly in space – not least because we have known for a while that homeopaths seem to be from a different planet.

Congratulations to Joseph Prahlow, MD, who is the winner of the Excellence in Homeopathy Award! Here are the conclusions of his winning essay. Special thanks to Hermeet Singh and Boiron for their prize donation.

Despite the many obstacles and challenges which face homeopathy in the 21st century, the homeopathic community should be emboldened and encouraged by the fact that there are also many opportunities for the advancement of homeopathy as an alternative choice in health care.

Proclaim the Truth:  Homeopathy Actually Works

Notwithstanding the challenges involved (especially for a student) in arriving at the correct simillimum for a case, let alone the appropriate follow-up and case management, the truth of the matter is that homeopathy does, in fact, work!  Those of us who have been the beneficiaries of homeopathic care, or who have seen the benefits in others, know with no doubt whatsoever that homeopathy represents a truly amazing form of alternative medicine that is able to successfully treat patients having a wide range of health concerns, including some very ill individuals. And it’s not just based on “experience” or “perception,” although such evidence should not be discounted.  Numerous studies show the effectiveness of homeopathy.6-9 The fact that homeopathy actually works represents one of the biggest and most important opportunities for homeopathy. The corresponding challenge relates to “getting the word out” into the general community as well as the medical community.  Instead of homeopathy being the “last resort,” it should increasingly become the “first choice” amongst patients. Only by “spreading the word” of its success can this become a reality.

What intrigued me here was the evidence that an award-winning homeopath believes might justify the claim that

“Numerous studies show the effectiveness of homeopathy”

6. Mathie RT, Lloyd SM, Legg LA, et al. Randomised placebo-controlled trials of individualized homeopathic treatment: systematic review and meta-analysis. Syst Rev. 2014 Dec 6;3:142. doi: 10.1186/2046-4053-3-142.

As we have discussed previously that meta-analysis is phoney and created a false-positive result by omitting at least two negative studies.

7. Taylor JA, Jacobs J. Homeopathic ear drops as an adjunct in reducing antibiotic usage in children with otitis media. Glob Pediatr Health 2014 Nov 21;1:2333794X14559395. doi: 10.1177/2333794X14559395.

This study had the notorious A+B versus B design and thus was unable to test for specific effects of homeopathy. Moreover, the lead author, Dr Jennifer Jacobs, was a paid consultant to Standard Homeopathic Company.

8. Sorrentino L, Piraneo S, Riggio E, et al. Is there a role for homeopathy in breast cancer surgery? A first randomized clinical trial on treatment with Arnica montana to reduce post-operative seroma and bleeding in patients undergoing total mastectomy. J Intercult Ethnopharmacol 2017 Jan 3;6(1):1-8. doi: 10.5455/jice.20161229055245.

This study showed no significant result in the intention to treat analysis. The positive conclusion seems to be based on data dredging only.

9. Frass M, Lechleitner P, Grundling C, et al. Homeopathic treatment as an add-on therapy may improve quality of life and prolong survival in patients with non-small cell lung cancer: a randomized, placebo-controlled, double-blind, three-arm, multic0-e1955enter study. Oncologist 2020 Dec 25(12):e1930-e1955. doi: 10.1002/onco.13548.

This study is since months under investigation for fraud. The reasons for this have been discussed previously.

Perhaps the award winning author should chance the crucial sentence into something like:

Numerous studies have shown how homeopaths try to mislead the public?

In any case, please do not let this stop you from reading the full paper by the award-winning author. I promise you that it will create much hilarity.

What does homeopathy offer our modern ailing world?

NOTHING!

Suzanne Somers, born Suzanne Marie Mahoney on October 16, 1946 in San Bruno, California, was an American actress, author and businesswoman.  Somers has published several best-selling self-help books, such as I’m Too Young for This! and The Natural Hormone Solution to Enjoy Menopause. In 2001, it was reported that she had breast cancer and was opting for so-called alternative medicine (SCAM) to treat it, In particular, she used Iscador, a preparation of mistletoe that we have discissed many times before on this blog, e.g.:

In an interview with Larry King in 2001, Somers revealed that she had been receiving treatment for a year. She also explained that she refused to go through with chemotherapy and instead used SCAM. “I decided to find alternative things to do,” she continued. “Because I have done so much work in my books about hormones, and that hormonal balance is why people gain or lose weight, and, it was my belief that a balanced environment of hormones prevents disease. And the first thing they said to me, we are taking of off all hormones. I said no, I’m going to continue taking my hormones, which is the first thing against the common course…”

Recently, it was reported that Somers has died of cancer aged 76. Earlier this year, Somers said they had “used the best alternative and conventional treatments to combat it [her cancer].” But now, a source close to the star shares that many around her didn’t like it. Somers’ friends tried to convince her to ditch SCAM in favor of chemotherapy. “She was advised by several people to consider the more conventional approach, but she did not listen,” a source close to Somers told the Daily Mail. The source continued, “She has always rejected chemo, so it wasn’t even an option. Her friends and loved ones urged her to reconsider so many times during her cancer battles and at the end.” A statement read. “Her family was gathered to celebrate her 77th birthday on October 16th. Instead, they will celebrate her extraordinary life, and want to thank her millions of fans and followers who loved her dearly.”

Perhaps this sad case is an apt occasion for rephrasing the warning that I posted only a few days ago:

be very cautious about using SCAMs for cancer and seek professional advice, preferably NOT from a SCAM provider.

 

This study investigated whether Tongxinluo,a traditional Chinese medicine compound that has shown promise in in vitro, animal, and small human studies for myocardial infarction, could improve clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The randomized, double-blind, placebo-controlled clinical trial was conducted among patients with STEMI within 24 hours of symptom onset from 124 hospitals in China. Patients were enrolled from May 2019 to December 2020; the last date of follow-up was December 15, 2021.

Patients were randomized 1:1 to receive either Tongxinluo or placebo orally for 12 months. A loading dose of 2.08 g was given after randomization, followed by the maintenance dose of 1.04 g, 3 times a day, in addition to STEMI guideline-directed treatments. The primary end point was 30-day major adverse cardiac and cerebrovascular events (MACCEs), a composite of cardiac death, myocardial reinfarction, emergent coronary revascularization, and stroke. Follow-up for MACCEs occurred every 3 months to 1 year.

Among 3797 patients who were randomized, 3777 (Tongxinluo: 1889 and placebo: 1888; mean age, 61 years; 76.9% male) were included in the primary analysis. Thirty-day MACCEs occurred in 64 patients (3.4%) in the Tongxinluo group vs 99 patients (5.2%) in the control group. Individual components of 30-day MACCEs, including cardiac death, were also significantly lower in the Tongxinluo group than the placebo group. By 1 year, the Tongxinluo group continued to have lower rates of MACCEs and cardiac death. There were no significant differences in other secondary end points including 30-day stroke; major bleeding at 30 days and 1 year; 1-year all-cause mortality; and in-stent thrombosis. More adverse drug reactions occurred in the Tongxinluo group than the placebo group, mainly driven by gastrointestinal symptoms.

The authors concluded that in patients with STEMI, the Chinese patent medicine Tongxinluo, as an adjunctive therapy in addition to STEMI guideline-directed treatments, significantly improved both 30-day and 1-year clinical outcomes. Further research is needed to determine the mechanism of action of Tongxinluo in STEMI.

Tongxinluo is mixture of various active ingredients, including

  • ginseng,
  • leech,
  • scorpion,
  • Paeonia lactiflora,
  • cicada slough,
  • woodlouse bug,
  • centipede,
  • sandalwood.

With chaotic mixtures of this type, it is impossible to name all the potentially active ingredients, list their actions, or identify the ones that are truly relevant. According to the thinking of TCM proponents, this would also be the wrong way to go about it – such mixtures work as a whole, they would insist.

Tongxinluo is by no means a mixture that has not been studied before.

A previous systematic review of 12 studies found that Tongxinluo capsule is superior to conventional treatment in improving clinical overall response rate and hemorheological indexes and is relatively safe. Due to the deficiencies of the existing studies, more high-quality studies with rigorous design are required for further verification.

A 2022 meta-analysis indicated that the mixture had beneficial effects on the prevention of cardiovascular adverse events, especially in TVR or ISR after coronary revascularization and may possibly lower the incidence of first or recurrent MI and HF within 12 months in patients with CHD, while insufficient sample size implied that these results lacked certain stability. And the effects of TXLC on cardiovascular mortality, cerebrovascular events, and unscheduled readmission for CVDs could not be confirmed due to insufficient cases. Clinical trials with large-sample sizes and extended follow-up time are of interest in the future researches.

A further meta-analysis suggested beneficial effects on reducing the adverse cardiovascular events without compromising safety for CHD patients after PCI on the 6-month course.

Finally, a systematic review of 10 studies found that the remedy is an effective and safe therapy for CHD patients after percutaneous coronary interventions.

So, should we believe the new study with its remarkable findings? On the one hand, the trial seems rigorous and is reported in much detail. On the other hand, the study (as all previous trials of this mixture) originates from China. We know how important TCM is for that country as an export item, and we know how notoriously unreliable Chinese research sadly has become. In view of this, I would like to see an independent replication of this study by an established research group outside China before I recommend Tongxinluo to anyone.

Let’s not forget:

if it sound too good to be true, it probably is!

 

Mistletoe, an anthroposophical medicine, is often recommended as a so-callled alternative medicine (SCAM) for cancer patients. But what type of cancer, what type of mistletoe preparation, what dosage regimen, what form of application?

The aim of this systematic analysis was to assess the concept of mistletoe treatment in published clinical studies with respect to indication, type of mistletoe preparation, treatment schedule, aim of treatment, and assessment of treatment results. The following databases were systematically searched: Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL, and “Science Citation Index Expanded” (Web of Science). The researchers assessed all studies for study types, methods, endpoints and mistletoe preparations including their ways of application, host trees and dosage schedules.

The searches revealed 3296 hits. Of these, 102 publications with a total of 19.441 patients were included. The researchers included several study types investigating the application of mistletoe in different groups of participants: cancer patients with any type of cancer were included as well as studies conducted with healthy volunteers and pediatric patients. The most common types of cancer were:

  • breast cancer,
  • pancreatic cancer,
  • colorectal cancer,
  • malignant melanoma.

Randomized controlled studies, cohort studies and case reports make up most of the included studies. A huge variety was observed concerning the type and composition of mistletoe extracts (differing pharmaceutical companies and host trees), ways of applications and dosage schedules. Administration varied widely, e. g. between using mistletoe extract as sole treatment and as concomitant therapy to cancer treatment. The researchers found no relationship between the mistletoe preparation used, host tree, dosage, and cancer type.

A variety of different mistletoe preparations was used to treat cancer patients. Due to the heterogeneity of the mistletoe preparations used, no comparability between different studies or within single studies using different types of mistletoe preparations or host trees is possible. Moreover, no relationship between mistletoe preparation and type of cancer can be observed. This results in a severely limited comparability of studies with regard to the different cancer entities and mistletoe therapy in oncology in general. Analyzing the methods sections of all articles, there are no information on how the selection of the respective mistletoe preparation took place. None of the articles provided any argument which type of preparation (homeopathic, anthroposophic, standardized) or which host tree was chosen due to which selection criteria. Considering preparations from different companies, funding may have been the reason of the selection.

Dosage or dosage regimens varied strongly in the studies. Due to the heterogeneity of dosage and dosage regimens within studies and between studies of the endpoints the comparability of the different studies is severely limited. Duration of mistletoe treatment varied strongly in the studies ranging from a single dose given on one day to the application of mistletoe preparations for several years. Moreover, the duration of treatment frequently varied within the studies. Mistletoe preparations were administered by different ways of application. Most frequently, the patients received mistletoe preparations subcutaneously. The second most common way was intravenous administration of mistletoe preparations. According to the respective manufacturers, this type of application is only recommended for Lektinol® and Eurixor®. Other preparations were given as off-label intravenous applications. No dosage recommendations from the respective manufacturers were available. Only in two studies the dose schedules were mentioned: according to the classical phase I 3 + 3 dose escalation schedule or in ratio to the body surface area.

The authors concluded that despite a large number of clinical studies and reports, there is a complete lack of transparently reported, structured procedures considering all fields of mistletoe therapy. This applies to type of mistletoe extract, host tree, preparation, treatment schedules as well as indication with respect of type of cancer and the respective treatment aim. All in all, despite several decades of clinical mistletoe research, no clear concept of usage is discernible and, from an evidence-based point of view, there are serious concerns on the scientific base of this part of anthroposophical treatment.

A long time ago, I worked as a junior doctor in a hospital where we used subcutaneous misteloe injections regularly to treat cancer. I remember being utterly confused: none of my peers was able to explain to me what preparation to use and how to does it. There simply were no rules and the manufacurer’s instructions made little sense. I suspected then that mistletoe therapy was a danerous nonsense. Today, after much research has been published on mistletoe, I do no longer suspect it, I know it.

I would urge every cancer patient to stay well clear of mistletoe and those practitioners who recommend it.

Robert Jütte, a German medical historian, has long been a defender of homeopathy and other forms of so-called alternative medicine (SCAM). His latest paper refers to the situation in Switzerland where the public was given the chance to vote for or against the reimbursement of several SCAMs, including homeopathy. I reported previously about this unusual situation, e.g.:

Unsurprisingly, Prof Jütte’s views are quite different from mine. Here is the abstract of his recent paper:

Behind the principle of involving users and voters directly in decision-making about the health care system are ideas relating to empowerment. This implies a challenge to the traditional view that scientific knowledge is generally believed to be of higher value than tried and tested experience, as it is the case with CAM. The aim of this review is to show how a perspective of the history of medicine and science as well as direct democracy mechanisms such as stipulated in the Swiss constitution can be used to achieve the acceptance of CAM in a modern medical health care system. A public health care system financed by levies from the population should also reflect the widely documented desire in the population for medical pluralism (provided that therapeutical alternatives are not risky). Otherwise, the problem of social inequality arises because only people with a good financial background can afford this medicine.

I think that Jütte’s statement that “a public health care system financed by levies from the population should also reflect the widely documented desire in the population for medical pluralism provided that therapeutical alternatives are not risky. Otherwise, the problem of social inequality arises because only people with a good financial background can afford this medicine” is untenable. Here are my reasons:

  • Lay people are not normally sufficiently informed to decide which treatments are effective and which are not. If we leave these decisions to the public, we will end up with all manner of nonsense diluting the effectiveness of our health services and wasting our scarce public funds.
  • Jütte seems to assume that SCAMs that are not risky do no harm. He fails to consider that ineffective treatments inevitably do harm by not adequately treating symptoms and diseases. In serious conditions this will even hasten the death of patients!
  • Jütte seems concerned about inequity, yet I think this concern is misplaced. Not paying from the public purse for nonsensical therapies is hardly a disadvantage. Arguably, those who cannot affort ineffective SCAMs are even likely to benefit in terms of their health.

I do realize that there might be conflicting ethical principles at play here. I am, however, convinced that the ethical concern of doing more good than harm to as many consumers as possible is best realized by implementing the principles of evidence-based medicine. Or – to put it bluntly – a healthcare system is not a supermarket where consumers can pick and chose any rubbish they fancy.

I wonder who you think is correct, Jütte or I?

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