Quality of Life and Neutropenia in Patients with Early Stage Breast Cancer: A Randomized Pilot Study Comparing Additional Treatment with Mistletoe Extract to Chemotherapy Alone

Background: Chemotherapy for breast cancer often deteriorates quality of life, augments fatigue, and induces neutropenia. Mistletoe preparations are frequently used by cancer patients in Central Europe. Physicians have reported better quality of life in breast cancer patients additionally treated with mistletoe preparations during chemotherapy. Mistletoe preparations also have immunostimulant properties and might therefore have protective effects against chemotherapy-induced neutropenia. Patients and Methods: We conducted a prospective randomized open label pilot study with 95 patients randomized into three groups. Two groups received Iscador® M special (IMS) or a different mistletoe preparation, respectively, additionally to chemotherapy with six cycles of cyclophosphamide, adriamycin, and 5-fluoro-uracil (CAF). A control group received CAF with no additional therapy. Here we report the comparison IMS (n = 30) vs. control (n = 31). Quality of life including fatigue was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30). Neutropenia was defined as neutrophil counts <1,000/μl and assessed at baseline and one day before each CAF cycle. Results: In the descriptive analysis all 15 scores of the EORTC-QLQ-C30 showed better quality of life in the IMS group compared to the control group. In 12 scores the differences were significant (p < 0.02) and nine scores showed a clinically relevant and significant difference of at least 5 points. Neutropenia occurred in 3/30 IMS patients and in 8/31 control patients (p = 0.182). Conclusions: This pilot study showed an improvement of quality of life by treating breast cancer patients with IMS additionally to CAF. CAF-induced neutropenia showed a trend to lower frequency in the IMS group.


Introduction Background
Quality of life is frequently deteriorated during and after chemotherapy for cancer. 1 Besides nausea, emesis and pain, fatigue is a frequent complaint, reported by 70%-100% of the patients. 2 Recent research has shown that fatigue lasts for months after the last cycle of chemotherapy. 2 Three types of fatigue are distinguished: general, physical, and mental; the latter being related to reduced activity, depression, anxiety, and mood disorders. 3,4 Fatigue, insomnia and daytime sleepiness are augmented during and after chemotherapy with cyclophosphamide and 5-FU combined with methotrexate (CMF) or anthracyclines (CAF). 5 One can conclude that fatigue is one of the major concerns for patients with cancer. 6,7 Mistletoe therapy Physicians have reported better quality of life in breast cancer patients additionally treated with mistletoe preparations during chemotherapy, compared to patients receiving chemotherapy alone. [8][9][10][11][12] Mistletoe preparations also have immunostimulant and DNA-protecting properties 13,14 and might therefore have protective effects against chemotherapy-induced neutropenia. 15 In Central Europe, mistletoe preparations are widely used for adjuvant cancer therapy, especially by breast cancer patients. In Germany, 70% of cancer patients use unconventional treatments, and randomized trials of mistletoe preparations are difficult to conduct because of non-compliance and low recruitment rates due to therapy preferences. [16][17][18][19] Mistletoe preparations 10,16 as adjunct to CMF 12,16 or other chemotherapies for breast cancer and other types of cancer 10 have been examined in a few clinical studies showing a benefit in EORTC-QLQ-C30 16 and other quality of life scores. 10,12 This randomised clinical trial assessed mistletoe effects during CAF chemotherapy for breast cancer. The aim was to explore whether the EORTC-QLQ-C30 is a suitable instrument to detect differences between patients with early breast cancer receiving CAF with and without additional mistletoe therapy and whether such study is feasible in Serbia, a country where mistletoe preparations are not available.

Methods Objectives
The objectives of this pilot study were to determine the clinical response (quality of life including fatigue) and neutropenia in breast cancer patients during CAF. Our hypotheses were: Breast cancer patients receiving mistletoe preparations during six cycles of consecutive treatment with CAF will show a better quality of life including fatigue, and less neutropenia compared to patients receiving CAF alone.

Design
We conducted a prospective randomized open label study with equal-size randomization into three groups. All three groups received six cycles of CAF. In addition, one group received Iscador ® M special (IMS), another group received a different mistletoe preparation and a control group had no additional therapy. Here we report the comparison IMS vs. control.

Participants
Breast cancer patients in the stages T 1-3 N 0-2 M 0 treated at the Institute of Oncology and Radiology, National Cancer Research Centre of Serbia in Belgrade (IORS) and prescribed six consecutive cycles of CAF after surgery were assessed for eligibility.
Exclusion criteria were pregnancy or lactation, metastases, planned radiation or hormone therapy during six consecutive cycles of CAF, use of immunostimulant or immunosuppressive agents (e.g. corticosteroids) except for nausea and emesis; current use of other investigational agents, clinically relevant physical or mental illness such as serious infections, hepatic, renal or other organ dysfunction or major depression; alcohol abuse, alcoholism, oral or parenteral drug abuse, and methadone treatment.

Randomization
The chance to be allocated to any of the three groups (IMS, other mistletoe preparation, control) was 1:1:1.
For randomization variable block sizes were used. No stratification took place prior to randomization. The randomization sequence was generated by Clinical Research Dr. Tröger (CRDT), using SPSS ® (SPSS ® 14.0.1, SPSS Inc., Chicago, Ill, USA). Allocation concealment was implemented by using sealed envelopes, prepared by CRDT. Patients were enrolled by investigators at the Outpatient Clinic, IORS, while the sealed randomization envelopes were stored in the Department of Study Coordination, IORS and released consecutively for each enrolled patient.
interventions CAF was administered in six cycles with a three-week interval between each cycle. The scheduled dosage was 500 mg Cyclophosphamide, 50 mg Adriamycin, and 500 mg 5-FU per 1 m² skin surface applied at one day. All patients received antiemetic therapy with a single dose of Ondansetrone chloride 8 mg, Dexamethasone 8 mg, and Ranitidine 50 mg, respectively, administered prior to each CAF cycle.
One dropout patient in the control group received only three CAF cycles, while all other patients received the six scheduled CAF cycles. The applied dose intensities (DI) of Cyclophosphamide, Adriamycin, and 5-FU (DI in mean mg/m² per week; ± standard deviation) were 160.8 ± 5.5 mg, 16.1 ± 0.5 mg, and 160.8 ± 5.5 mg, respectively, in the IMS group and 157.1 ± 15.6 mg, 15.7 ± 1.6 mg, and 157.1 ± 15.6 mg, respectively, in the control group. The results correspond to 99% of planned DI in the IMS group and 96% of planned DI in the control group. No other antineoplastic or immunomodulating therapies were applied during the study.
Patients randomly allocated to additional therapy with IMS received Iscador ® M special (IMS; fermented aqueous extract of Viscum album from apple tree, fresh plant material, ratio of plant to extract = 1:5). IMS was manufactured by Weleda AG, Schwäbisch Gmünd, Germany and prepared in 1 ml ampoules for injection, each ampoule containing the fermented extract of 0.01, 0.1, 1, 2, or 5 mg of fresh mistletoe herb, respectively, in isotonic saline solution. IMS was administered by subcutaneous injections of 1 ml IMS into the upper abdominal region three times per week (i.e. Monday, Wednesday, Friday). The patients were instructed to inject IMS themselves. The dosage of IMS was increased stepwise: 2 × 0.01 mg, 2 × 0.1 mg, 11 × 1 mg, 8 × 2 mg, remaining doses 5 mg. Dose-dependent inflammatory reactions at the injection site (redness, swelling, sometimes accompanied by itching) were monitored. If such reactions exceeded 5 cm in diameter, the dosage was decreased or the therapy was paused until the reactions had ceased. An average of 54.1 ± 2.3 injections with altogether 174.80 ± 26.34 mg of IMS per patient were administered in the IMS group.

Outcomes
Outcomes were quality of life and neutropenia. Quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) in the official Serbian translation. 20 The EORTC-QLQ-C30 has 30 questions and is analysed in 15 scores: six scores for functioning and nine symptom scores ( Table 2). The EORTC-QLQ-C30 was documented by the patients at seven visits: before each CAF cycle and three weeks after the 6th CAF cycle. Neutropenia was defined as neutrophil count 1,000/µl in the peripheral blood and assessed one day before each CAF cycle and three weeks after the 6th CAF cycle.

Assessment of adverse events (Ae)
Adverse events were assessed by interviewing the patients and by analysing the laboratory results at each visit. Local reactions to IMS less than 5 cm in diameter were not considered as adverse events.

sample size
A sample size of 90 patients (30 per group) was considered to be sufficient for this pilot study.

Blinding
The study was not placebo controlled because the typical and time-dependent reactions following s.c. injections of mistletoe extracts (reactions at the injection site, increased body temperature, flu-like symptoms) cannot be imitated by a pseudo-placebo. (data not shown). All results of the statistical analysis have exclusively hypothesis-generating character.
For each quality of life score (EORTC QLQ-C30), the mean change from baseline during follow-up in each group was compared between the IMS group, the group with the other mistletoe preparation and the control group, using nonparametric marginal models according to Brunner 21 with therapy as whole-plot factor and time as sub-plot factor and a possible interaction between these two factors (results not shown). As a sensitivity assessment, a parametric covariance pattern model was also applied and found to qualitatively concur with the nonparametric results. For a better representability, the estimates of this parametric model will be shown. Post-hoc analyses of differences between the IMS group and control group were performed using the Dunnett T3-Test.
Neutropenia was assessed by measuring the number of patients with neutrophils 1,000/µl during the study. For neutropenia, the group difference between IMS group and control group was analysed by Fisher's exact test according to the sequential rejective Holm procedure.

Adherence to regulations
The study was approved by the Ethics Committee of the National Cancer Research Center of Serbia without modifications (date: 3 October 2005) and by the Serbian Drug Agency (date: 01 November 2005). Due to its pilot character, this study was not registered in a public study registry. The study was conducted in compliance with the Declaration of Helsinki, Good Clinical Practice guidelines, and national laws. A patient insurance was provided for all participants. All patients provided signed informed consent prior to inclusion. CRDT was responsible for planning, conduct, monitoring, and analysis of the study. Two audits at CRDT and one at the study site were performed by the two sponsors during the study. No violation of Good Clinical Practice was detected.

Results
Recruitment, participant flow, assessment, and numbers analysed From 14 December 2005 to 15 February 2007 a total of 123 breast cancer patients were prescribed CAF and assessed for eligibility at the study centre IORS. 28 patients were not included and 95 patients were included and randomized into 3 groups: CAF and IMS (n = 30), CAF and another mistletoe preparation (n = 34), and CAF without additional therapy (n = 31). One patient in the control group was withdrawn from further CAF therapy after three cycles of CAF because of heart disease (Fig. 1).

Baseline data of the patient groups
The IMS group and the control group did not differ significantly regarding age, tumour stage, body mass index, physical status, vital signs, previous diseases, EORTC-QLQ-C30 scores (Table 1). No neutropenia was detected at baseline.

Quality of life during chemotherapy
During chemotherapy with CAF a deterioration of quality of life occurred in all 15 EORTC-QLQ-C30 scores in the control group and in six scores in the IMS group. A clinical relevant deterioration of at least 5 points was found in eight scores of the control group and in two scores in the IMS group (Table 3). The most pronounced deteriorations were observed for nausea/emesis (17.2 score points) and fatigue (8.2) after the 2nd cycle of CAF and insomnia (13.1) and diarrhoea (11.9) after the 3rd cycle.
In the adjusted analyses, mean differences from baseline were compared between the two groups for each EORTC-QLQ-C30 score: All 15 comparisons favoured the IMS group, 12 comparisons showed significant differences with p-values ranging from 0.017 to 0.001. Clinically relevant differences of at least 5 points favouring the IMS group were observed for nine EORTC-QLQ-C30 scores ( Table 2).
In descriptive analyses, the differences from baseline for each score at each of the six follow-up assessments were compared between the two groups: 86 out of 90 differences favoured the IMS group, while four differences favoured the control group (Fig. 2). Furthermore, the maximum between-group difference for each EORTC-QLQ-C30 score during follow-up was analysed: All 15 differences favoured the IMS group: maximum differences of at least 15 points were found in four scores (Role Function, Social Function, Pain, and Insomnia), 10-15 point differences were found in five scores (Global Health, Emotional function, Constipation, Diarrhoea, Appetite loss), and differences 10 points were found in the remaining six scores.

neutropenia during chemotherapy
Neutropenia (1,000/µl) was detected three times in three different patients of the IMS group and nine times in eight different patients of the control group. The patients with neutropenia are comparable across the groups (Table 3). Odds ratio for the proportion of patients with neutropenia in IMS group vs. control group was 0.32 (95% confidence interval 0.08-1.35).
Using Fisher's exact test according to the sequential rejective Holm procedure, a trend (p = 0.182) towards less neutropenia in the IMS group was found.

Adverse events related to iMs injections
Localized skin reactions to IMS exceeding 5 cm diameter occurred in six patients. The frequency of these reactions was 0.49% (eight reactions in 1,618 injections). No other adverse events related to IMS occurred.

Discussion
This randomized pilot study assessed quality of life (EORTC-QLQ-C30) and neutropenia in early breast cancer patients undergoing CAF chemotherapy. Patient has been withdrawn from CAF because of an heart disease.

Randomized n = 95 not randomized
Reasons for not being randomized: -no informed consent: n =11 -Failed the eligibility criteria: n = 9 -no study medication available at the beginning of the study: n = 5 -Travel distance: n = 3  Patients receiving IMS in addition to CAF had significantly better quality of life and showed a trend towards less neutropenia, compared to patients receiving CAF alone. IMS therapy was well tolerated. Strengths of this study include a high recruitment rate, detailed assessments of therapy implementation, high therapy compliance, and very low dropout rates. Since 83% of eligible patients were included and randomized, the results of this study would seem to be generalizable to breast cancer patients (T 1-3 N 0-2 M 0 ) receiving CAF without any other concomitant therapies.
Due to the open-label design, the study cannot distinguish between direct drug effects on quality of life and possible indirect effects from therapy expectations, therapy administration etc. in the IMS group. This is a general limitation to all mistletoe studies: mistletoe injections frequently cause local reactions at the injection site, elevated body temperature and flu-like symptoms. These symptoms cease within hours or days after exposure and may recur on repeated injections. Therefore, patients and physicians can easily guess if mistletoe extracts are administered. This was confirmed in a double-blind study, where all patients in the mistletoe group as well as their physicians were unblinded. 16 A pseudoplacebo causing the same combination of time-limited symptoms-without specific effects on quality of life-has not yet been constructed.
Generally, medication trials are blinded to separate pharmacological effects from placebo effects. However, the lack of blinding may not necessarily have had relevant effects on the results of this study: An updated Cochrane review of randomised trials comparing placebo to no treatment found no significant placebo effects on eight out of ten evaluable indications, small effects on self-reported pain and moderate effects on phobia. Even these effects might have been confounded by biases. [22][23][24] This study was designed as a pilot study, and the limited sample size of 30 patients per group does not allow for hypothesis confirmation. Nevertheless significant differences in 12 of 15 EORTC-QLQ-C30 scores favouring the IMS group were found. Nine of these scores showed a clinically relevant difference of at least 5 points. The latter scores include pain, nausea, emesis and insomnia, which are highly relevant symptoms in patients during chemotherapy with CAF.   An important problem which may occur during chemotherapy with CAF is neutropenia. Neutropenia is the limiting factor for a continuing chemotherapy and may be harmful to the patients. This study is the first randomized trial providing data on the incidence of CAF-induced neutropenia during additive therapy with IMS. A trend towards less neutropenia in the IMS group was found. This should be further investigated in confirmatory studies with adequate sample size. It is recommended to include measurements of neutrophils on day 7, 9 and day 11 after chemotherapy in order to assess the nadir of the neutropenia during CAF therapy.
Future studies of mistletoe effects on quality of life in cancer patients undergoing chemotherapy should also include specific instruments to assess cancer-related fatigue and pain. In our study the effects of IMS on quality of life increased over time with the largest effects observed at the last follow-up visit. A longer follow-up period of 6-12 months might show additional long term benefits of IMS therapy.

conclusions
In this randomized pilot study, additional treatment with mistletoe therapy (Iscador ® M special) improved quality of life and showed a trend towards reduction of neutropenia in patients with early breast cancer receiving CAF chemotherapy. These promising results should be confirmed in a larger study. "LA is different, and hopefully represents a kind of scientific publication machinery that removes the hurdles from free flow of scientific thought."