Sweats and hot flashes are common in cancer survivors, from those in the adjuvant setting to those living with advanced disease. Pathophysiologic mechanisms are complex. Treatment options are broad-based, including hormonal agents, nonhormonal pharmacotherapies, and diverse integrative medicine modalities.
Mistletoe is a semiparasitic plant that grows on several types of common trees such as apple, oak, pine, and elm. Mistletoe extract has been used since ancient times to treat many ailments (see Question 1).
Mistletoe is one of the most widely studied complementary and alternative medicine therapies in people with cancer. In certain European countries, preparations made from European mistletoe are among the most prescribed drugs for patients with cancer (see Question 1).
Physiologically, sweating mediates core body temperature by producing transdermal evaporative heat loss.[2,3] Sweating occurs in disease states such as fever and in nondisease states such as warm environments, exercise, and menopause. Limited data suggest that sweating occurs in 14% to 16% of advanced cancer patients receiving palliative care, with severity typically rated as moderate to severe.[4,5,6]
Sweating is part of the hot flash complex that characterizes the vasomotor instability of menopause. Hot flashes occur in approximately two-thirds of postmenopausal women with a breast cancer history and are associated with night sweats in 44%.[7,8] For most breast cancer and prostate cancer patients, hot flash intensity is moderate to severe. Distressing hot flashes appear to be less frequent in postmenopausal women with nonbreast cancer.
Approximately 20% of women without breast cancer seek medical treatment for postmenopausal symptoms, including symptoms related to vasomotor instability. Vasomotor symptoms resolve spontaneously in most patients in this population, with only 20% of affected women reporting significant hot flashes 4 years after the last menses. There are no comparable data for women with metastatic breast cancer. Three-quarters of men with locally advanced or metastatic prostate cancer treated with medical or surgical orchiectomy experience hot flashes.
Sweats in the cancer patient may be associated with the tumor, its treatment, or unrelated (comorbid) conditions. Sweats are characteristic of certain primary tumor types such as Hodgkin lymphoma, pheochromocytoma, and functional neuroendocrine tumors (i.e., secretory carcinoids). Other causes include fever, menopause, castration (male), drugs, hypothalamic disturbances, and primary disorders of sweating. Causes of menopause include natural menopause, surgical menopause, or chemical menopause, which in the cancer patient may be caused by cytotoxic chemotherapy, radiation, or androgen treatment. Causes of "male menopause" include orchiectomy, gonadotropin-releasing hormone use, or estrogen use. Drug-associated causes of sweats include tamoxifen, aromatase inhibitors, opioids, tricyclic antidepressants, and steroids. Women who are extensive metabolizers of tamoxifen related to CYP2D6 may have more severe hot flashes than those who are poor metabolizers. Distinct from menopausal effects, hormonal therapies, biologic response modifiers, and cytotoxic agents associated with fever secondarily cause sweats.