Cancer-related fatigue in patients treated with mistletoe extracts: a systematic review and meta-analysis

Support Care Cancer. 2022 Aug;30(8):6405-6418. doi: 10.1007/s00520-022-06921-x. Epub 2022 Mar 3.


Purpose: Cancer-related fatigue remains one of the most prevalent and distressing symptoms experienced by cancer patients. Effective treatments for cancer-related fatigue are needed. The objective of this meta-analysis is to determine the impact of mistletoe extracts as a pharmacological treatment for the management of cancer-related fatigue.

Methods: We included randomized clinical trials (RCTs) and non-randomized studies of interventions (NRSIs) in cancer patients. Inclusion criteria were cancer-related fatigue severity or prevalence as an outcome and testing of mistletoe extracts compared to control groups. We searched Medline (EuropePMC), Embase, the Cochrane Central Register of Controlled Trials,, and through October 2020. We assessed the risk of bias using the Cochrane risk of bias tools for RCTs and NRSIs and conducted a meta-analysis.

Results: We performed one meta-analysis with 12 RCTs, including 1494 participants, and one meta-analysis with seven retrospective NRSIs, including 2668 participants. Heterogeneity between the studies was high in both meta-analyses. Most studies had a high risk of bias. A random-effects model showed for RCTs a standardized mean difference of -0.48 (95% confidence interval -0.82 to -0.14; p = 0.006) and for NRSIs an odds ratio of 0.36 (95% confidence interval 0.20 to 0.66; p = 0.0008).

Conclusion: Treatment with mistletoe extracts shows a moderate effect on cancer-related fatigue of similar size to physical activity. These results need to be confirmed by more placebo-controlled trials. Future trials should investigate different treatment durations and their effect on cancer-related fatigue in post-treatment cancer survivors.

Trial registration: This meta-analysis has been registered under the PROSPERO registration number CRD42020191967 on October 7, 2020.

Keywords: Cancer; Cancer-related fatigue; Meta-analysis; Mistletoe extract; Quality of life; Viscum album.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Fatigue / drug therapy
  • Fatigue / etiology
  • Humans
  • Mistletoe*
  • Neoplasms* / complications
  • Neoplasms* / therapy
  • Plant Extracts / therapeutic use
  • Treatment Outcome


  • Plant Extracts