1. History of Viscum Album Use In Medicine

2. Learning Objectives
Understand why viscum is such an important topic in the field of Integrative Oncology
Understand the long history of safe use of mistletoe in traditional medicine
In particular to dispel the misconception of extreme toxicity of viscum a. through understanding the various species and families referred to collectively as “mistletoe”
Develop and understanding of the historical applications of viscum a. in medicine from antiquities to present
Understand how the botanical specialties of mistletoe lead to its eventual use in oncology care

3. Module Outline Importance of viscum in Integrative Oncology (IO)
Fundamental botanical description of viscum a.
Review of the recorded historical application of viscum in medicine
History of its current use in cancer care

4. The Global Cancer Problem

5. The Global Problem of Cancer
There were 14.1 million new cancer cases, 8.2 million cancer deaths and 32.6 million people living with cancer (within 5 years of diagnosis) in 2012 worldwide.
The overall age standardized cancer incidence rate is almost 25% higher in men than in women, with rates of 205 and 165 per 100,000, respectively.
M. Ervik, F. Lam, J. Ferlay, L. Mery, I. Soerjomataram, F. Bray (2016). Cancer Today. Lyon, France: International Agency for Research on Cancer. Cancer Today. Available from:  accessed [20/12/2017]

6. The Global Problem of Cancer Cont’d
M. Ervik, F. Lam, J. Ferlay, L. Mery, I. Soerjomataram, F. Bray (2016). Cancer Today. Lyon, France: International Agency for Research on Cancer. Cancer Today. Available from:  accessed [20/12/2017]

7. Global Problem of Cancer: Trends in Mortality
M. Ervik, F. Lam, J. Ferlay, L. Mery, I. Soerjomataram, F. Bray (2016). Cancer Today. Lyon, France: International Agency for Research on Cancer. Cancer Today. Available from:  accessed [20/12/2017]

8. Global Problem of Cancer: Understanding ASIR
Ellison, Lawrence, Updating the standard population and its effect on cancer incidence and mortality rates. Statistics Canada, Catalogue no X • Health at a Glance, October 2016 Updating

9. Global Problem of Cancer: Survivorship
American Cancer Society. Cancer Facts & Figures Atlanta: American Cancer Society; 2017.

10. Implications of Survivorship
1 in 4 cancer survivors report reduced QOL due to physical problems
1 in 10 cancer survivors report reduced QOL due to mental/emotional problems
Individuals with more aggressive or invasive treatments and reduce QOL during treatment are at increased risk of long- term QOL impacts
American Cancer Society. Cancer Facts & Figures Atlanta: American Cancer Society; 2017.

11. Importance of Integrative Oncology
Goals:
Reduce Cancer Burden
Interrupt Course of Disease
Treat Locally Affected Areas
Integrative Oncology Patient
Surgery/
Ablative
Therapies
Radiation Therapy
Mind Body Interventions
Diet/Lifestyle
Biological Agents (immune, detoxification, etc.)
Chemotherapy /Targeted Therapy
Goals:
Strengthen the Patient
Enhance Immune Function
Promote Wellness

12. Viscum In IO: Multidimensional Therapeutic
Viscum is one of the most well researched integrative cancer therapeutic
Studies have shown it may have positive impacts on:
Quality of Life
Side Effects of Conventional Care
Survival
Can positively impact patients throughout the treatment spectrum:
Curative
Palliative
Restorative
Preventive (In high risk patient groups)

13. Botanical Properties of Viscum

14. Botanical Description of Viscum Album
Mistletoe is a plant name reference given to a host of hemi-parasitic plants from the following families:
Viscaceae
Loranthaceae
Eremolepidaceae
Mistletoes differ in their geographic distribution, therapeutic actions, and toxicity
Viscum album is from the Viscacea family
Becker, I. I. (1986). Botany of European Mistletoe ( Viscum album L .), 7, 2–7.
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

15. Viscacea: European Mistletoe/North American
The Viscacea family is comprised of 7 genera with a total of 400 species
The Viscum genus is composed of ~100 species
Most species are found in Africa and mainland tropical Asia
There are only a few viscum species which have adapted to european climate – Viscum album the most prominent of those
In North America mistletoe or Phoradendron serotinum, is part of the viscacea family in the genus Phoradendron 
Becker, I. I. (1986). Botany of European Mistletoe ( Viscum album L .), 7, 2–7.
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

16. Botanical Specialties of Viscum: Host Tree Interaction
It is a parasitic plant relying on the host tree to provide it with nutrients
It does not have root but rather sinkers to extract nutrients
After years of infection, viscum reduces growth of the host trees
Viscum album has subspecies that grow specifically on certain host trees
Many trees, especially hardwood, have both mechanical and chemical barriers to viscum infection
A host tree that is susceptible to one viscum infection will often host many (up to 50) further viscum bushes
Susceptibility to viscum appears to be an inherited trait past to host tree progeny
Becker, I. I. (1986). Botany of European Mistletoe ( Viscum album L .), 7, 2–7.

17. Botanical Specialties of Viscum a.: Morphology
It is evergreen never losing it’s foliage
Viscum usually forms 1 node for each year of growth (internodal distance ~4-8 cm)
It takes 3-4 years after implantation/infection of the host tree for the first node to appear
There are both male and female plants (viscum a is not hermaprhodytic)
It forms dichotomous branching and can develop into a 1 metre sized globe bush
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

18. Viscum Growth/Morphologial Patterns
Chronological Specialties
Photosynthetic Activity Year Round (no stop in winter)
Flowering and Fruit Development Later and Early Winter
Germination rest is absent
Development of vegetative and generative organs
Morphological Specialties
Growth of roots is non-geotropic as sinkers grow in direction of the host tree
Photosynthesis occurs on upper surface and underside of leaves
Growth of shoots is globular or in all directions independent of gravity and light
Formation of organs (flowers, leaves, etc.) is delayed and primitive (no roots, no real seeds, primitive flowers and primitive leaves)
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

19. Toxicity of VA Herb
VA & American Mistletoe have a long history of safe use in traditional medicine
While toxicity has been observed with ingestion of these plants it is usually higher doses
Symptoms include:
Nausea, vomiting, diarrhea, hypertension followed by shock 
A case review of 14 patients with American mistletoe leaf or berry ingestions failed to show any symptoms of toxicity.
Based on that series, ingestion of 1-3 mistletoe berries or 1-2 leaves is unlikely to produce serious toxicity
Of the accidental (pediatric) or intentional exposure of raw plant mistletoe in the past 25 years there were no deaths and 97% were asymptomatic
2 cases of deaths due to mistletoe preparation in past 25 years were due to chronic ingestion of tea preparations
Abdualmjid, R. J., & Sergi, C. (2013). Hepatotoxic botanicals - An evidence-based systematic review. Journal of Pharmacy and Pharmaceutical Sciences, 16(3), 376–404.
Evens, Z. N., & Stellpflug, S. J. (2012). Holiday Plants with Toxic Misconceptions, XIII(December), 538–542.
Hall, A. H., Spoerke, D. G., Rumack, B. H., General, D., & Poison, R. M. (1986). Assessing Mistletoe Toxicity, (November).

20. Traditional Use of Viscum in Medicine

21. Viscum a. Use in Traditional Medicine
Viscum album (along with other mistletoes) have a long history of traditional uses in many cultures
Visum’s unique attribute for flowering and bearing fruit in winter likely marked it as unique
The druids had the most extensive history for the use of mistletoe
The oak tree was sacred to the druids and thus mistletoe became important by association to this tree
Wharf, C., & Kingdom, U. (2011). Assessment report on Viscum album L ., herba, 44 (September).
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

22. Ancient Historical Use of VA
The druids would say “healing all things” in the gathering ceremony for mistletoe
Druidic use focused on the following areas:
General Tonic (likely related to immune support or increasing resistance to infection)
Fertility
Epilepsy
During the Roman conquest of Europe there was a significant exchange of healing methods and viscum a began its use in Greco-Roman society
Celcus (a Roman naturalist) was one of the first to record the use of mistletoe in medicine in De Medicina (50 BC). Illnesses treated:
Cancer like illnesses (as an emollient)
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

23. Modern Historical Use of VA
Paracelcus (1494 – 1541) & John Colbatch (1670 – 1728) – epilepsy
Albrecht von Haller (1708 – 1777) - spasmolytic, gynecological complaints
Gerhard Madhaus ( ) – degenerative and inflammatory joint disease
In the late 19th and early 20th century VA was used for weakness of the heart and later hypertension and arteriosclerosis
Wharf, C., & Kingdom, U. (2011). Assessment report on Viscum album L ., herba, 44(September).
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

24. Modern History of VA Use in Cancer
Steiner posited VA would have potent effects in cancer in lectures provided to doctors in the early 20th century
He had suggested specialized ways of harvesting and processing mistletoe (differing interpretations have led to different viscum preparations)
Consistently he recommended different medications be created from mistletoe plants growing on different host trees
Dr. Ita Wegman developed the first injectable VA for cancer patients
Ramm, H. (2015). Mistletoe through Cultural and Medical History : The All-Healing Plant Proves to Be a Cancer-Specific Remedy, 4, 1–10.
Bussing, Arndt, (2000). Mistletoe: The Genus Viscum. Amsterdam, The Netherlands: Harwood Academic Publishers

25. Conclusion
While improvements are being made in cancer, it is a growing problem for aging populations
Cost effective therapies that not only improve survival, but address issues like quality of life and long-term treatments effects are needed
Viscum has a long history of use in traditional medicine throughout the past 2,000 years
While potentially toxic in large doses of fresh herb, it is safe in the most extremely high doses used clinically