Background: Them is controversy whether high-dose chemotherapy and a blood
cell or bone marrow autotransplant is a better treatment than conventional-
dose chemotherapy for women with local/regional or metastatic breast cancer
. Subject selection and time-to-treatment biases make definitive comparison
impossible. Recent results of randomized trials are contradictory.
Objective: Determine appropriateness of high-dose chemotherapy and a blood
cell or bone marrow autotransplant in women with breast cancer. Panelists:
Nine breast cancer experts from diverse geographic sites and practice setti
Evidence: Boolean MEDLINE searches of 'breast cancer' and 'chemotherapy' an
d/or 'blood cell' or 'bone marrow transplants'. Process: We used a modified
Delphi-panel group judgement process. Clinical variables were permuted to
define 2058 clinical settings. Each panelist rated appropriateness of high-
dose therapy and an autotransplant versus conventional therapy on a 9-point
ordinal scale (1: most inappropriate, 9: most appropriate). An appropriate
ness index was developed based on median rating and amount of disagreement.
The relationship of appropriateness indices to the permuted clinical varia
bles was considered by analysis of variance and recursive partitioning.
Conclusions: In women with local/regional breast cancer autotransplants wer
e rated: 1) appropriate in those with greater than or equal to 10 cancer-in
volved lymph nodes; 2) uncertain in those with 4-9 cancer-involved nodes; a
nd 3) inappropriate in women with less than or equal to 3 cancer-involved l
ymph nodes. In women with metastatic breast cancer autotransplants were rat
ed: 1) appropriate in those with metastases to 'favorable' sites (skin, lym
ph node, pleural and a complete or partial response to chemotherapy; 2) unc
ertain in women with metastases to 'unfavorable' sites (lung, liver, or cen
tral nervous system) and a complete response to chemotherapy or those with
bone metastases and a complete or partial response or stable disease after
chemotherapy; and 3) inappropriate in other settings.