Liverpool NHS Primary Care Trust funds a Department of Homeopathy, one the last four remaining publicly funded homeopathic hospitals in the UK. It publicises that the clinic in the Old Swan Health Centre can offer homeopathic treatments for everything from arthritis to depression and bowel disorders. There is no good evidence that this is an effective use of public money. Indeed, as was reported in the Guardian yesterday, it looks like the few doctors who support the use of this 19th Century quackery in a modern healthcare system have to depend on misleading representations of the research data in order to justify the expenditure.
Once you appear to believe in one set of nonsense, then you are likely to get involved in all sorts of daft treatments. The Liverpool homeopathy department does not make an exception. On its web page, it tells us that it also offers,
a complementary cancer care service using Iscador which is a mistletoe based anti-cancer treatment. Iscador has been in use as a treatment for cancer since the 1920’s. It is in widespread use in Germany and Switzerland where it is one of the most widely used anti cancer therapies.
Iscador is not a homeopathic treatment, but an approach advocated by one of the greatest mystics and quacks of the 20th Century, Rudolf Steiner.
Steiner was a homeopath who took the ideas of Hahnemann and developed a whole new mystical approach to medicine – anthroposophical medicine. Its pretty bonkers stuff with astral bodies, angels and spirits being at the heart of not only his medicine, but also his beliefs in agriculture. His biodynamic methods involved making fertiliser out of cat skulls and deer bladders. Astrology was central to his thinking. He proposed mistletoe as a cancer treatment as it grows on trees like a cancer. And given his homeopathic beliefs of ‘like cures like’ that was enough evidence for him to get cracking. That is it.
Steiner’s preparation techniques for many of his potions were quite strange. If your farm gets infested with mice, Steiner tells us to “catch a fairly young mouse and skin it . . . at a time when Venus is in the sign of Scorpio”, then to burn the skin and scatter the ash over our fields. “Henceforth, your mice will avoid the field.” For fertilizer you can use a cow horn with crushed quartz and burying it in the field you wish to help. Similarly, mistletoe preparations for cancer treatment needs a mixture of mistletoe sap collected both in the Summer and the Winter. Steiner is quite simply an advocate of voodoo and Liverpool NHS PCT appears to happy to adopt it.
Because Steiner’s beliefs have become very popular in mystical circles, most notably through the schools that follow his equally batty educational philosophy, mistletoe has been used as a popular treatment of cancer with many advocates.
But is there any evidence that it actually works? As usual, when we have a crank cure we will find lot of small studies or deeply flawed studies that make up an evidence base. The studies have been reviewed and there is very little convincing evidence that this treatment does anything for the patient. This is odd given that Liverpool NHS PCT tell us that Iscador can induce cell death in cancer cells, allows immune cell populations affected by cancer to regenerate and protects the DNA of healthy cells. Patients are supposed to “feel better and stronger, sleep better and have less pain”.
In 2006, Edzard Ernst, Professor of Complementary Medicine gave a very straightforward message in the BMJ,
Mistletoe has been tested extensively as a treatment for cancer, but the most reliable randomised controlled trials fail to show benefit, and some reports show considerable potential for harm. The costs of regular mistletoe injections are high. I therefore recommend mistletoe as a Christmas decoration and for kissing under but not as an anticancer drug. At the risk of upsetting many proponents of alternative medicine, I also contend that intuition is no substitute for evidence.
The current Cochrane review of the evidence (2010) shows that despite there being many studies of mistletoe therapy, the trials tend to be of poor quality with lack of randomisation, and poor reporting quality.
The evidence from RCTs to support the view that the application of mistletoe extracts has impact on survival or leads to an improved ability to fight cancer or to withstand anticancer treatments is weak. Nevertheless, there is some evidence that mistletoe extracts may offer benefits on measures of QOL during chemotherapy for breast cancer, but these results need replication.
A review by Ostermann, Raak and Büssing (2009), despite coming to a fairly positive but qualified conslusion about mistletoe, found evidence of significant publication bias by looking at funnel plots. Funnel plots are graphs of the treatment effects found in studies plotted against study size. If researchers are fairly publishing their results it should have a symmetrical shape. If it is skewed, it suggests researchers are withholding less favourable results from publication and, hence, reviews of all studies may conclude that there is a stronger effect than there really is. This is what Osterman saw in the studies of mistletoe.
There are other problems too. Patients who receive mistletoe therapy may suffer from distinct (but apparently fairly mild side effects) such as skin reactions at the injection site. This has the effect that patients enrolled into trials can easily find out if they had the real treatment or a placebo. Knowing whether you received a placebo or not makes it more likely for you to misreport your experiences – that is why trials must be blinded. Hence, we would expect even blinded trials to overstate their benefits.
Given that this is a therapy that was invented from a mystical ramblings of a irrational mind and that its use based on an evidence base riddled with poor quality studies, it would be safe to conclude that mistletoe therapy is of little or no value.
We regularly hear how cancer patients in the NHS are denied therapies because they do not prove to be cost effective under the NICE guidelines. It is quite right that all treatments are subject to scrutiny to ensure public money is being spent in the best manner. Somehow, so called complementary therapies slip under this hurdle and patients are being injected in Liverpool with a drug that is almost certainly worthless. It is not cheap either. The brand of mistletoe injection used by Liverpool PCT is made by Weleda, the company founded by Steiner in the 1920s to flog his preparations. It is still in private hands and based in Switzerland (like all the best Pharma companies) and produces homeopathic, biodynamic and anthroposophical products based on the crackpot mysticism of Steiner. It operates in 53 countries and has over 2,000 employees. Its revenues are hundreds of millions (about $300 million in 2005) and the majority of its pharmaceutical revenue came from mistletoe treatments. I can see no obvious reason why its claims should be treated with less rigour than its Swiss neighbours when it comes to flogging drugs to the NHS.