The optimal timing of autologous bone marrow transplantation in Hodgkin's disease patients after a chemotherapy relapse

Cep Regimen (Ccnu, Etoposide, Prednimustine) for Relapsed/Refractory Hodgkin's Disease

Aims and background

Although initial treatment of Hodgkin's disease induces a complete remission in most patients, approximately 50% of patients with advanced disease will not achieve a complete remission or will relapse following the first complete remission.

Patients and methods

Twenty-three patients with relapsed/resistant Hodgkin's disease, observed between January 1991 and October 1993, underwent CEP combination chemotherapy (CCNU, etoposide, prednimustine). All patients had previously received MOPP and ABVD regimens, in combination at diagnosis or sequentially (at diagnosis and at the first relapse).

Results

Thirteen (56%) patients achieved complete responses and 4 (18%) had partial responses. Two partial responders obtained a complete remission after a successive autologous bone marrow transplantation. The complete remission was not influenced by the timing of MOPP and ABVD treatments, presence of extranodal involvement or presence of bulky disease, but was affected by the presence of a primary disease refractory to the first standard programs. All the complete responders but 2 were alive and relapse-free at a median follow-up of 15 months; no major toxic effects were recorded.

Conclusions

These data suggest, as did those of other studies, that CEP is an effective regimen in patients with Hodgkin's disease in first or second relapse, also to reduce the tumor burden and to determine chemosensitivity before contingent bone marrow or peripheral blood stem cell support.

Peripheral Blood Stem Cell (PBSC) Mobilization and Transplantation (PSCT) in Patients with Malignant Lymphomas and Solid Tumors

Peripheral blood stem cells can reconstitute bone marrow function after high-dose chemo-Zradiotherapy. We describe 44 patients related with a three-day course of chemotherapy, for hematopoietic stem cell mobilization, consisting of cyclophosphamide or ifosfamide and etoposide (malignant lymphoma and germ cell tumor) or a one-day course of 5-fluorouracil, epirubi-cin and cyclophosphamide (breast cancer), followed by the administration of recombinant human granulocyte colony-stimulating factor (G-CSF).

Maximum numbers peripheral blood stem cells (PBSC) were recruited on day 9-10 of the G-CSF administration. The total number of PBSC cells harvested with median 3.6 leukaphereses was 46 x 104/kg (7.5-136) CFU-GM or 8 x 106/kg (0.7-25.0)CD34+ cells for patients with solid tumors and 26 (4.5-258) CFU-GM's or 6.1 (1-0-39.2) CD34+ cells for patients with malignant lymphomas. Thirty-five patients with malignant lymphomas or solid tumours received high-dose chemotherapy followed by bone marrow and PBSC infusion (n=8) or PBSC cell infusion alone (n=27). The recovery of granulocytes, platelets and reticulocytes after peripheral stem cell transplantation (-PSCT) in addition to or instead of bone marrow, was markedly accelerated compared with the infusion of BM alone. The accelerated haemopoietic recovery was associated with a reduction in platelet and red blood cell transfusion, reduction in fever periods and earlier discharge from hospital. PSCT is an important alternative to autologous bone marrow transplantation (ABMT). This transplantation technique may also allows application of multiple-cycle intensive chemotherapy.

High-Dose Therapy and Autologous Hematopoietic Progenitor Cells Transplantation for Recurrent or Refractory Hodgkin's Lymphoma: Analysis of King Hussein Cancer Center Results and Prognostic Variables

Purpose. to evaluate the outcome of patients with Hodgkin's lymphoma who underwent autologous transplantation at KHCC bone marrow transplant program. Patients and Methods. Over 6 years, 63 patients with relapsed or refractory Hodgkin's lymphoma underwent high dose chemotherapy followed by autologous transplant. There were 25.4% patients in complete remission (CR), 71.4% with chemotherapy responsive disease at the time of transplant. Prior to conditioning regimen, 56% received two chemotherapy lines, and, 44% received more than two lines. Results. The main outcomes of the study are the rate of complete remission at day 100, overall survival (OS), relapse-free survival (RFS), The impact of the following variables on OS and RFS: (a) disease status at the time of transplant, (b) number of chemotherapy lines prior to conditioning, (c) age group, (d) time of relapse < or >12 months were investigated. The CR at day 100 was 57%. The median overall survival for the whole group was 40.6 months; the median RFS was 20 months. The only factor which significantly impacts the study outcomes was the number of chemotherapy lines prior to conditioning on OS in favor of patients received two lines. Conclusion. In our study only the number of chemotherapy lines received before conditioning had statistically significant impact on OS.

Salvage Radiotherapy in Patients With Relapsed and Refractory Hodgkin’s Lymphoma: A Retrospective Analysis From the German Hodgkin Lymphoma Study Group

Purpose

To evaluate treatment outcome and prognostic factors in patients with refractory or first relapsed Hodgkin’s disease (HD) treated with salvage radiotherapy (SRT) alone.

Patients and Methods

From 4,754 patients registered in the database of the German Hodgkin Study Group from 1988 to 1999, 624 patients were identified with progressive disease (n = 202), or with early (n = 170) or late (n = 252) relapsed HD. At first treatment failure, SRT alone was given to 100 patients. Patient characteristics were: median age, 36 years; progressive disease, 47%; early relapse, 23%; late relapse, 30%; and “B” symptoms, 14%. Eighty-five percent of the patients relapsed after cyclophosphamide, vincristine, procarbazine, and prednisone/doxorubicin, bleomycin, vinblastine, and dacarbazine (COPP/ABVD) –like regimens; 8% after bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP) regimens, 7% after first-line radiotherapy alone.

Results

The volume irradiated was mantle field in 43% of patients, inverted-Y in 8%, total nodal irradiation in 12%, and involved-field in 37%. The median SRT dose was 40 Gy (range, 15 to 50 Gy). Seventy-seven patients achieved a complete remission and four patients achieved a partial remission. The 5-year freedom from treatment failure and overall survival (OS) rates were 28% and 51%, respectively. In multivariate analysis, significant prognostic factors for OS were B symptoms (P = .018) and stage at relapse (P = .014). For freedom from second failure (FF2F) Karnofsky performance status (P = .0001) was significant. In patients with limited stage at progression/relapse, duration of first remission was significant (P = .04) for FF2F.

Conclusion

SRT offers an effective treatment for selected subsets of patients with relapsed or refractory HD.

Prognostic factors for disease progression after high-dose chemotherapy and autologous hematopoietic stem cell transplantation for recurrent or refractory Hodgkin's lymphoma

Our purpose was to study the risk factors associated with disease progression after high-dose chemotherapy followed by autologous stem cell transplantation in patients with recurrent or refractory Hodgkin's lymphoma (HL). We analyzed the long-term outcome of 184 patients with recurrent or refractory HL who underwent autologous hematopoietic stem cell transplantation. At the time of transplantation, 82 patients were in first relapse or second remission, 46 patients were refractory to the primary induction chemotherapy, and 56 patients were beyond first relapse or second remission. In 64 patients, the disease had proved refractory to the chemotherapy regimen administered immediately prior to transplantation. The median follow-up of patients who were alive and free of disease at the time of this report was 8.9 years (range, 0.1-19.0 years). At 10 years, the overall and disease-free survival rates were 34% (95% CI 27-42) and 29% (95% CI 22-36) respectively. The major cause of treatment failure was disease relapse. Chemotherapy resistance prior to transplantation, advanced stage, and higher number of chemotherapy regimens administered prior to transplantation were adverse prognostic factors for disease progression. We conclude that autologous transplantation is an effective salvage treatment for recurrent HL.

Cost-effectiveness studies in ovarian cancer

Ovarian cancer is the fifth leading cause of cancer-related deaths. The costs associated with this cancer impact both on the affected individual and on the health system. Screening is currently unproven as a strategy for improving outcomes for women with ovarian cancer. Randomized controlled trials, however, are underway, estimating any impact of screening with ultrasound and CA125 on ovarian cancer mortality. Paclitaxel and carboplatin combination, the standard first-line chemotherapy regimen for ovarian cancer, has not been compared with cisplatin and cyclophosphamide regarding the cost-effectiveness and cost-utility, but for paclitaxel and cisplatin, numerous studies have addressed these issues. The estimated incremental costs resulting from these studies fall well within the generally accepted range for new therapies. Although acquisition costs of new chemotherapy drugs exceed those of older drugs, the impact of costly drugs on total costs may be cost saving due to less costs related to supportive and palliative care. The most important costs for the patient, the pain and suffering associated with ovarian cancer and its treatment, are hard to quantify. Nevertheless, patients' quality of life must be considered when making a clinical decision to treat this disease. A review of available cost-effectiveness studies is presented and discussed.

Pediatric Hodgkin's disease--up, up, and beyond

Juan A. del Regato, 1909-1999, was a superb clinician-educator who recognized the radiocurability of Hodgkin's disease but questioned treatment without late effects, particularly in children. The remarkable progress in pediatric Hodgkin's disease today is a tribute to this influential pioneer, who served as a role model to many. Combined modality therapy using low-dose, involved-field radiation and multiagent chemotherapy today results in a 5-year relative survival rate of 94% among American children with Hodgkin's disease. However, several areas hold promise for future advances, including a new pathology classification and biology studies that distinguish classic Hodgkin's disease from other lymphomas; new noninvasive staging techniques, including 18F-fluorodeoxyglucose-positron emission tomography; the definition of risk groups to segregate low-, intermediate-, and high-risk groups on the basis of a prognostic index, facilitating risk-adapted therapy; and myeloablative therapy followed by hematopoietic stem cell transplantation. Currently used for children with relapse, it is associated with a 5-year survival of 65% and should be considered as the initial therapy for high-risk groups. Idiopathic diffuse pulmonary toxicity after autologous transplantation is high among children with an atopic history; thus, atopy should be considered when selecting children appropriate for transplantation. Finally, novel therapies, such as the anti-CD20 antibody, rituximab, may be useful for children with CD20+, lymphocyte-predominant Hodgkin's disease. The universal goal of cure without late effects is realistic for almost all children with Hodgkin's disease today.

Economic aspects of high-dose chemotherapy: a clinician's perspective review

Over the last 15 years, the increased use of high-dose chemotherapy (HDC) has led to a considerable increase in the cost of cancer treatments. After making a general economic analysis of the benefits and costs of healthcare initiatives, this paper considers all of the different phases and elements of HDC, as well as the strategies for reducing basic, indirect and out-of-pocket costs. The cost of HDC has decreased by 40-60% over the last decade and its cost-effectiveness ratios are now similar or only slightly higher than those of other widely accepted medical interventions. However, except in the case of some hematological and paediatric neoplasms, the efficacy of the treatment has not yet been clearly defined and so it should only be used in well-designed clinical trials that should also include prospective cost evaluation measures.

Intensive salvage therapy with high-dose chemotherapy for patients with advanced Hodgkin's disease in relapse or failure after initial chemotherapy: results of the Groupe d'Etudes des Lymphomes de l'Adulte H89 Trial

PURPOSE

To evaluate prospectively the feasibility and efficacy of early intensive therapy, including intensified cytoreductive chemotherapy (CT) and high-dose CT (HDCT) followed by autologous stem-cell transplantation (ASCT), in patients with advanced Hodgkin's disease (HD) who failed to respond completely or relapsed after initial treatment.

PATIENTS AND METHODS

Among 533 eligible patients with newly diagnosed stage IIIB-IV HD enrolled in the H89 trial, all 157 patients with induction failure (IF) (n = 67), partial response (PR) of less than 75% (n = 22), or relapse (n = 68) were included in this study. Planned salvage therapy included mitoguazone, ifosfamide, vinorelbine, and etoposide monthly for two to three cycles followed by high-dose carmustine, etoposide, cytarabine, and melphalan with ASCT.

RESULTS

With a median follow-up of 50 months, the 5-year survival estimates were 30%, 72%, and 76% for the IF, PR, and relapse groups, respectively (P =.0001), 71% for the 101 patients given HDCT, and 32% for the 48 patients treated without HDCT (P =.0001). Multivariate analysis using time-dependent Cox model indicated that B symptoms at progression, salvage without HDCT, and chemoresistant disease before HDCT were significantly associated with shorter overall survival.

CONCLUSION

Early intensive therapy improves the outcomes of patients with advanced HD who failed to respond completely to initial treatment and those who relapsed with adverse prognostic factors. However, for patients with IF and chemoresistant disease, this approach remains unsatisfactory.

Autologous stem cell transplantation for malignancy: a systematic review of the literature

A systematic review of the literature was undertaken to assess what published evidence is currently available to support the increasing use of autologous stem cell transplantation (ASCT), and to evaluate the published data with regard to the comparative cost of high-dose and conventional therapy. The review aimed to identify all published, randomized controlled trials (RCTs) comparing high-dose therapy (HDT) with ASCT versus conventional chemotherapy (CC) in acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin's disease, multiple myeloma, and breast, lung, testicular and ovarian cancer. The review also aimed to identify all studies that had compared the cost of the two treatment strategies. Reports were identified by systematic searches of Cancerlit, Embase and Medline, and handsearching of several conference proceedings. Where possible, pooled odds ratios (ORs) were calculated according to the fixed-effect model. A total of 18 randomized trials were identified in acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin's disease, multiple myeloma, and breast, lung and testicular cancer. Trials were generally small and no disease site had sufficient information to determine reliably whether high-dose therapy with autologous transplant is more effective than CC. Five studies were identified that compared the cost of the two treatments. These found the cost of HDT to be between one and four times higher than that of CC. Further randomized trials are required. Where appropriate, these should include economic assessment and assessments of long-term toxicity.

High dose chemotherapy with G-CSF in refractory Hodgkin's disease

This study analyzed the long-term results in patients with Hodgkin's disease (HD) who were resistant or refractory to conventional chemotherapy and who were treated with intensive, non-myeloablative chemotherapy with granulocyte colony-stimulating factor (G-CSF) as hematological support. The study population included 86 patients who were treated with combination chemotherapy with high doses: BCNU, 300 mg/m2, on day 1, vincristine 1.4 mg/m2, and bleomycin 10 mg/m2 on days 1, 7, 14 and 21; etoposide 500 mg/m2, i.v., on days 14 and 15; and ifosfamide 4 g/m2, and epirubicin 180 mg/m2, on day 29. G-CSF 5 ug/kg/day, was used to ameliorate severe myelosuppression on days 3 to 13, 16 and 26 and 29 to 38. If a complete response was observed, two cycles of IOPP (ifosfamide 1.5 g/m2, i.v., on days 1 and 8; vincristine 1.4 mg/m2, i.v. on days 1 and 8; prednisone 60 mg/m2, p.o., daily, days 1 to 14 and procarbazine 100 ng/m2, p.o., daily, days 1 to 14 vere given as consolidation therapy. At 8-years, the overall survival rate vas 58% (50 out of 86 patients) being 38 and 76% in patients whose initial complete response was shorter or longer that 12 months, respectively or in 44% of induction failures. Hematological toxicity grade III or IV was observed in all cycles. However hematological recovery was already evident (median on day 13). Only transitory delay in continuing therapy was observed (median 3.9 days). Twenty-two patients developed infection-related granulocytopenia but no therapy related deaths were observed. G-CSF was well tolerated. This study indicates that the hematopoetic growth factor, G-CSF, was sufficient to act as hematological support in patients who received intensive, but non-myeloablative chemotherapy. In our opinion intensive chemotherapy without autologous transplant procedures can be considered in patients with refractory Hodgkin's disease because complete response rate and overall survival times are similar to more aggressive but more toxic regimens.

Cost-effectiveness analysis of paclitaxel and cisplatin versus cyclophosphamide and cisplatin as first-line therapy in advanced ovarian cancer. A European perspective

Paclitaxel is a new cytotoxic agent that has demonstrated significant activity in advanced ovarian cancer. The aim of this study was to determine the cost structure of advanced ovarian cancer and the cost-effectiveness of paclitaxel-cisplatin (PC) combination therapy compared with a standard cyclophosphamide-cisplatin (CC) regimen at first-line therapy. The analysis was performed separately for six European countries: Germany, Spain, France, Italy, The Netherlands and the U.K. The study was conducted from the national health service payer's perspective. The total cost of treatment per patient (six cycles of chemotherapy) in the six European countries varied between a minimum of US$4,926 in the U.K. and US$12,578 in Germany for the CC regimen and between US$13,038 and US$24,487 for the PC regimen (April 1996). Since the new regimen improved life expectancy by 1.283 years compared with CC, the incremental cost-effectiveness of PC was calculated to be between US$6,403 per 5-year saved in the U.K. and US$11,420 per life-year saved in Italy. Overall, the cost-effectiveness of PC compares favourably with other oncological interventions. The findings of this study suggest that healthcare decision makers should consider paclitaxel, in combination with cisplatin, as a cost-effective first-line therapy for patients with advanced ovarian cancer.

Early intensive therapy with autologous stem cell transplantation in high-risk Hodgkin's disease: long-term follow-up in 35 cases

Thirty-five adult patients with high-risk HD (HD) defined by (1) Ann Arbor stage IV or bulky nodal disease (tumor/thorax ratio > 0.45) and (2) no or partial response (PR) (< 75%) to the initial 3 courses of ABVD, received an early intensive therapy with autologous stem cell transplantation (ASCT). Thirty patients were considered as partial responders and 5 as refractory to initial chemotherapy. Conditioning regimen consisted of chemotherapy alone (CBV in 11 patients before 1993, BEAM in 13 patients since 1993) followed by adjuvant radiotherapy: 40 Gy) on the initial sites of bulky disease, or 12 Gy total body irradiation plus 120 mg/kg cyclophosphamide in 11 patients with disseminated extra-nodal disease. All 30 patients in PR at the time of ASCT experienced prolonged complete remission (CR). One patient died in CR from an acute myocardial infarction 48 months after ASCT. Four out of the 5 patients with refractory disease at the time of ASCT experienced rapid progression of HD leading to death in 3 cases. After 6 years of CR post-ASCT, the last refractory patient died of myelodysplastic syndrome diagnosed 2 years after intensive therapy. With a median follow-up for surviving patients of 51 months (range: 11-111), the cumulative probability of 8-year overall survival is 75.6% for the entire group of patients, 94.1% for the chemosensitive ones, and 0% for the primary refractory (P < .0001). The cumulative probability of 8-year event-free survival is 79.9% for the entire group of patients, 94.1% for the chemosensitive ones, and 0% for the primary refractory (P < .0001). We conclude that early intensive therapy with ASCT is feasible in patients with high-risk HD and induces a high cure rate in chemosensitive patients. In primary refractory patients, new therapeutic approaches are warranted.

Salvage radiotherapy for Hodgkin's disease following chemotherapy failure

PURPOSE

This study aims to: 1) assess failure-free survival (FFS), overall survival (OS), and failure pattern after salvage radiotherapy (SRT) for patients with Hodgkin's disease (HD) who fail chemotherapy (CT); 2) identify patients suitable for SRT as an alternative to more aggressive salvage regimens.

METHODS AND MATERIALS

Between 1978 and 1992, 52 patients with relapsed/refractory HD following 26 CT received SRT at the Peter MacCallum Cancer Institute. Patient characteristics at diagnosis were: median age (range 12-63); male-31, female-21; Stage I-4, II-16, III-25, or IV-7. Prior to SRT 27 patients had received the equivalent of both MOPP and ABV(D). The duration of initial complete response (CR) from CT was greater than 12 months in 22 patients. SRT (dose 34-42 Gy) was given to active disease sites.

RESULTS

Five-year FFS and OS rates following SRT were 26 and 57%, respectively. Five-year FFS and OS rates of 36 and 75%, respectively, were achieved in patients who relapsed in supradiaphragmatic nodal sites without B symptoms; in a subset of patients with initial Stage I-II disease the FFS and OS rates were 50 and 86%, respectively. On multivariate analysis significant factors for FFS were B symptoms at the time of SRT (p = 0.003), extranodal involvement (p = 0.011) and histology (p = 0.018). For OS significant factors were B symptoms (p = 0.0007), age (p = 0.014) and number of prior CT regimens (p = 0.03).

CONCLUSION

The relatively poor results of SRT in terms of FFS justify the use of alternative salvage strategies for most patients with Hodgkin's disease who fail CT. However, SRT offers a low morbidity, potentially curative option for a subset of patients. Our data suggest that patients most suitable for SRT are those with relapse in supradiaphragmatic nodal sites and no B symptoms.

Autologous bone marrow transplantation in advanced Hodgkin's disease

Autologous bone marrow transplantation (ABMT) has been proposed as an alternative treatment of resistant/refractory Hodgkin's disease (HD). Thirty-seven patients in various phases of HD underwent autografting in our Center: fourteen received a CBV conditioning regimen, the others BCNU or VP16 followed by cyclophosphamide and TBI. Three patients died before engraftment, 28 (75.67%) achieved CR and 6 showed persistent disease. As of March 1996, 18 patients had died and 13 were in continuous CR. The median event-free survival (EFS) and 3-year EFS chances were respectively 9 months and 31.3% in the series as a whole, 14 months and 40% in primary resistant disease, 9 months and 28.4% in responsive relapse, and 3 months and 22.2% in resistant relapse. As many of these patients had failed to respond to third-line therapies, their EFS figures are primarily attributable to the therapeutic efficacy of ABMT. Furthermore, since the EFS curves are better in patients seemingly characterized by a lower chance of chemoresistance, our data favour the use of ABMT in the earlier phases of HD.

Hodgkin's disease

Despite incomplete understanding of the etiology of Hodgkin's disease and its malignant cell of origin, the majority of children and adolescents diagnosed with Hodgkin's disease will be longterm survivors. Staging and treatment for pediatric Hodgkin's disease has evolved over the past 30 years in attempts to reduce late treatment sequelae. Today, most children are clinically staged and treated with multitreatment chemotherapy, either alone or in conjunction with low-dose, involved field radiation therapy. Initial results with "risk-adapted" combined modality regimens limiting chemotherapy cycles and radiation doses and volumes demonstrate maintenance of cure rates for early stage, favorable Hodgkin's disease. Challenges for the future include identification of prognostic factors in patients at risk for treatment failure who may benefit from intensification of therapy.

The true cost of bone marrow transplantation

Bone marrow transplantation is an example of a highly technical therapy that offers hope to patients with bone marrow failure or various malignancies. Bone marrow transplantation is much more costly "up-front" but perhaps not more costly long-term than alternative therapies. Although economic analyses appear relatively simple, interpretation and use can be problematic. Several economic analyses have identified complications that occur frequently and affect the reported cost-effectiveness of high-dose chemotherapy. Efforts to reduce the cost of bone marrow transplantation have focused on new strategies to more effectively control these complications. The introduction of new technologies to speed engraftment, to improve patient selection methods, and the shifting of care to outpatient settings all have resulted in significant reductions in duration of hospital stay, treatment-related mortality, and costs. More studies of long-term outcomes are needed for transplant and nontransplant treatment options to guide present and future applications of this treatment option.

High-Dose Therapy and Autologous Hematopoietic Progenitor Cell Transplantation for Recurrent or Refractory Hodgkin's Disease: Analysis of the Stanford University Results and Prognostic Indices

One hundred nineteen patients with relapsed or refractory Hodgkin's disease (HD) received high-dose therapy followed by autologous hematopoietic progenitor cell transplantation. Three preparatory regimens, selected on the basis of prior therapy and pulmonary status, were employed. Twenty-six patients without a history of prior chest or pelvic irradiation were treated with fractionated total body irradiation, etoposide (VP) 60 mg/kg and cyclophosphamide (Cy) 100 mg/kg. Seventy-four patients received BCNU 15 mg/kg with identical doses of VP and Cy. A group of 19 patients with a limited diffusing capacity or history of pneumonitis received a novel high-dose regimen consisting of CCNU 15 mg/kg, VP 60 mg/kg and Cy 100 mg/kg. Twenty-nine patients (24%) had failed induction therapy and 35 (29%) had progressive HD within 1 year of initial chemotherapy. At 4 years actuarial survival was 52%, event-free survival was 48% and freedom from progression (FFP) was 62%. No significant differences were seen in survival data with the three preparatory regimens. Six patients died within 100 days of transplantation and 5 died at a later date of transplant-related complications. Secondary malignancies have developed in 6 patients, including myelodysplasia/leukemia in four patients and solid tumors in two patients. Regression analysis identified systemic symptoms at relapse, disseminated pulmonary or bone marrow disease at relapse and more than minimal disease at the time of transplantation as significant prognostic factors for overall and event-free survival and FFP. Patients with none of these factors enjoyed an 85% FFP at 4 years compared with 41% for patients with one or more unfavorable prognostic factors (P = .0001). Our results confirm the efficacy of high-dose therapy and autografting in recurrent or refractory HD. Although longer follow-up is necessary to address ultimate cure rates and toxicity, our data indicate that a desire to reduce late effects should drive future research efforts in favorable patients whereas new initiatives are needed for those with less favorable prognoses.

Treatment costs in Hodgkin's disease: a cost-utility analysis

The aim of this study was to estimate costs of treatment for Hodgkin's disease (HD) and the outcome in health in terms of quality-adjusted life-years (QALYs), and compare these to a constructed nontreatment alternative. All 55 patients treated for HD at the oncological unit of the University Hospital of Tromsø between 1985 and 1993 were included. The total treatment costs (medication, hospital stay, hospital hotel stay, radiotherapy, travelling, loss in production, i.e. work) were retrospectively estimated for all patients. In December 1994, the 49 survivors were sent a EuroQol questionnaire recording quality of life: 42 responded. The mean quality of life score was 0.78 on a 0-1 scale, and the mean total cost of treatment was pounds 12512. The total treatment costs were significantly higher in patients with advanced clinical stages of the disease (P = 0.0006), B-symptoms (fever, sweats, weight loss) (P = 0.0027) and relapse (P < 0.0001). The costs of one QALY (with production gains included and using a 10% discount rate) were estimated at pounds 1651. When excluding production gains and using a 5% discount rate, the figures became pounds 1327. This makes HD one of the most cost-effective malignancies to treat.

Intensive therapy and autologous stem cell transplantation for Hodgkin's disease in first relapse after combination chemotherapy

Data from a number of transplant centers has shown that several intensive therapy regimens, supported by autologous stem cell transplantation, have the capability to produce durable responses in a proportion of patients with Hodgkin's disease progressive after combination chemotherapy. Although many questions regarding the optimal use of autotransplantation remain unanswered, the issue of the preferred timing at which to apply transplantation is of critical importance in planning therapeutic strategies for patients with this disease. This paper will focus on the timing options for autotransplantation in Hodgkin's disease. In the absence of a formal Phase III study comparing conventional salvage therapy versus autotransplantation in first relapse patients, the encouraging results from our center and others support the use of transplantation at the time of first relapse after combination chemotherapy. Non-relapse mortality is low in this setting, and the primary problem has been recurrent disease despite transplantation. Risk factors for both disease recurrence, as well as for the probability of progression-free survival, can be defined based on biologic features present at the time of first relapse after chemotherapy, and may provide a basis for improving the current transplant results for first relapse patients. Prolonged follow-up will be important to define the incidence and risk of late toxicities in autografted patients.

High-dose chemotherapy followed by autologous hematopoietic rescue for Hodgkin's disease patients following first relapse after chemotherapy

BACKGROUND

The best results of conventional-dose salvage chemotherapy for Hodgkin's disease have been reported after first relapse. We evaluated the results of high-dose chemotherapy and autologous hematopoietic rescue for Hodgkin's disease patients who had relapsed from an initial chemotherapy-induced complete remission.

PATIENTS AND METHODS

Eighty-five patients received high-dose cyclophosphamide, carmustine, and etoposide (CBV) followed by autologous bone marrow or peripheral blood stem cell transplantation.

RESULTS

Actuarial survival at five years was 51%, and failure-free survival was 40%. Failure-free survival at five years was 90% for patients who received no conventional-dose salvage chemotherapy prior to CBV. Failure-free survival of patients treated initially with a four-drug regimen was not significantly different than patients treated with seven/eight-drug regimens.

CONCLUSION

These results appear to be better than those reported for conventional-dose salvage chemotherapy. High-dose therapy followed by autologous bone marrow or peripheral blood stem cell transplantation should be considered for any patient with relapsed Hodgkin's disease, regardless of the length of initial remission, or type of initial chemotherapy. Certain patients, especially those with minimal disease, may benefit by proceeding directly to transplantation after relapse, without first receiving conventional-dose salvage chemotherapy.

Cost-effectiveness of palliative chemotherapy in advanced gastrointestinal cancer

BACKGROUND

Chemotherapy may relieve tumor-related symptoms, may improve quality of life and prolong survival in advanced gastrointestinal cancer. The extent of such improvements is unclear despite the extensive use of this treatment modality, and there are no studies concerning the economic cost of any gain achieved in the quantity and quality of life by chemotherapy.

PATIENTS AND METHODS

Between January 1991 and May 1992, 61 patients with inoperable cancer (18 gastric, 22 pancreatic or biliary, and 21 colorectal) were randomized to either primary chemotherapy in addition to best supportive care or to best supportive care. Chemotherapy was allowed in the latter group if the supportive measures did not achieve palliation. All economic costs for medical care were prospectively recorded, and marginal cost-effectiveness analyses were performed.

RESULTS

More patients in the primary chemotherapy group (19/33, 58%) had improved/prolonged high quality of life (QoL-patient, minimum duration 4 months) than in the best supportive care group (8/28, 29%, p < 0.05). Overall survival and quality-adjusted survival were significantly longer in the primary chemotherapy group (median 9 vs. 4 months, p < 0.05), and median 7 vs. 2 months, p < 0.05, respectively). When analysed by cancer site, survival was significantly prolonged in gastric cancer patients (median 10 vs. 4 months, p < 0.02), but not in colorectal (median 12 vs. 6 months, p = 0.1) and pancreatic-biliary cancer patients (median 8 vs. 5 months, p = 0.8). The average cost for all medical care was approximately 50% higher in the primary chemotherapy group, but the average cost per day was the same in the two groups. Hospitalization accounted for most of the costs in both groups. The incremental costs per gained year of life was SEK 166,400 ($21,300), per gained quality-adjusted year of life SEK 157,200 ($20,200), and per QoL-patient SEK 160,300 ($20,600). These costs were lower for gastric and colorectal cancer patients, and much higher for pancreatic-biliary cancer patients.

CONCLUSIONS

The results of this study suggest that palliative chemotherapy is cost-effective in patients with advanced gastric and colorectal cancer. Knowledge about survival and quality of life benefits is still limited in patients suffering from gastric and pancreatic-biliary cancer.

Autologous bone marrow transplantation

Autologous bone marrow transplantation has become a very popular and successful treatment for many patients with lymphomas and other malignancies. The current indications, pretreatment regimes, and laboratory manipulations are discussed as well as the application of gene transfer to eliminate selected genetic diseases and detect disease relapse.

Phase-II trial with M-CAVe-CEC as a salvage chemotherapeutic regimen for early relapsed or primary refractory Hodgkin's disease

A substantial number of patients with Hodgkin's disease (HD) do not respond adequately to standard therapy. Patients who relapse later than 1 year after completion of treatment have a good chance of achieving a second complete remission (CR). The prognosis of patients with primary refractory HD or relapse within 1 year, however, is poor. The long-term results of autologous bone marrow transplantation (ABMT) in these patients have not yet been established. Therefore, we conducted a phase-II study among 15 patients with primary refractory or early relapsed HD, in which they were treated with a two-drug sequential regimen not cross-resistant with MOPP. The patients received two to six courses of methotrexate, cyclophosphamide, adriamycin, vinblastine, CCNU, etoposide, and chlorambucil (M-CAVe-CEC). Seven patients (47%) achieved a CR, including a patient with additional radiotherapy. Actuarial overall survival was 58 and 41%, respectively, and failure-free survival 38% at 2 and 5 years. Gastrointestinal toxicity was acceptable. Dose reductions were necessary in up to 60% of courses given. These preliminary results suggest that the M-CAVe-CEC regimen may be a more effective salvage regimen as compared with other regimens for primary refractory or early relapsed HD. Larger studies, possibly with hematopoietic growth factors, are required to determine its value in comparison to ABMT.

The hematopoietic stem cell transplantation in Hodgkin's disease: questions and controversies

Most patients with Hodgkin's disease (HD) are cured with chemotherapy and/or radiotherapy. However, half of those with advanced stage disease (IIIB, IV) do not respond adequately to treatment or relapse. Salvage therapy used in such cases gives from 10% to 50% complete remission but only 10% long term survival. The results of bone marrow transplantation reported in acute leukemia and non-Hodgkin's lymphoma encouraged some authors to develop this new therapeutic strategy in Hodgkin's disease. In the early 1980's promising results were achieved when refractory and relapsed patients were selected to receive myeloablative therapy followed by bone marrow transplantation. Today, high dose chemotherapy with hematopoietic stem cell transplantation (HSCT) is used more and more often in poor prognosis Hodgkin's disease. After a review of the literature concerning the results of transplantation in Hodgkin's disease, we develop the numerous problems associated with this procedure which remain to be solved such as: the optimal indication, the timing of HSCT, the type of graft, the conditioning regimen, the place of radiotherapy and the optimal use of hematopoietic growth factors. We conclude with future prospects.

Identification of risk factors in patients treated for first relapse of Hodgkin's disease

This review focuses on potential risk factors in patients relapsing with Hodgkin's disease after a first chemotherapy/radiation therapy induced complete remission. This patient group usually presents with highly treatment responsive disease and has become one of the target groups for consideration of salvage high dose chemotherapy with stem cell/autologous marrow support (HDC/ABMT). It is currently not clear to which patients in first relapse this treatment should be offered. The knowledge of certain risk factors could be of great help in assessing such patients. A first group of risk factors are those assessable at initial diagnosis: sex, age, histology, Ann Arbor stage, tumour bulk and some laboratory parameters. A second group of risk factors are those present at the time of relapse: time to relapse, extent of disease at relapse, B-symptoms and performance status, extra nodal lesions at relapse or a relapse within an irradiated field. Age below 50 years seems to exert a small influence on outcome but becomes a major problem above that. There is a small number of characteristics such as the time from the end of initial treatment to relapse or B-symptoms at relapse which seem to be the most prominent factors predicting for freedom from second failure (FF2F). Patients who relapse more than one year after finishing primary chemotherapy and who are free of B symptoms at relapse have a quite favourable outcome after salvage treatment. If their disease is not bulky and is confined entirely to a modest number of previously unirradiated lymph node sites, wide field irradiation offers a reasonable chance of disease control. If their recurrence is bulky, extra-nodal or in a previously irradiated site, the patient's prognosis after HDC/ABMT is excellent. Patients who relapse less than one year after primary chemotherapy or with B symptoms at the time of relapse have a less satisfactory outcome after any available salvage treatment. Trials comparing various HDC/ABMT regimens or novel approaches built on standard dose chemotherapy and irradiation are needed to find better treatments for such patients. Such patients with early or symptomatic relapses who cannot be enrolled in prospective comparative trials should be offered HDC/ABMT while we search for better treatments. Larger trials with a prospective analysis of the risk factors are needed for us to be able to decide which treatment will be the optimal choice for our patients.

Intensive therapy and autotransplantation in Hodgkin's disease

Intensive therapy and autologous marrow or peripheral blood stem cell transplantation is often utilized in Hodgkin's disease patients whose disease has progressed after primary conventional chemotherapy. A number of studies have described long-term disease-free survival in up to 50% of transplanted patients. High-dose chemotherapy conditioning regimens such as "CBV" or "BEAM" have been used more often than regimens containing total body irradiation. Usually unpurged autologous bone marrow has been utilized as the source of hematopoietic stem cell reconstitution, although recently the use of "primed" peripheral blood stem cells has increased markedly. The challenges of transplant-related toxicity and recurrence of disease post-transplant are discussed, as well as possible strategies to reduce these problems. The use of autologous transplantation is discussed in three clinical settings: patients who have failed to enter a complete remission (CR) after primary chemotherapy, those who have relapsed within 12 months of attaining a CR and those who have relapsed after a longer (i.e., > or = 12 months) first CR. When compared with conventional salvage chemotherapy, transplantation appears to produce a higher long-term disease-free survival rate in all of these patient groups. However, assessment of an advantage for autotransplantation, particularly in patients with long first remissions, is difficult without a Phase III trial. On the other hand, recently updated results from our center indicate that 72% of patients relapsing after long initial remissions benefit from autotransplantation at this point in their disease course, and that transplant-related mortality is low in this setting. Other issues addressed include the potential role of autologous transplantation as consolidation therapy in selected high-risk patients in an initial CR, as well as the utility of conventional chemotherapy and involved-field radiotherapy in conjunction with autotransplantation.

Results of CAV regimen (CCNU, melphalan, and VP-16) as third-line salvage therapy for Hodgkin's disease

BACKGROUND

A prospective study was conducted to assess the efficacy and toxicity of a salvage regimen consisting of CCNU, Melphalan, and VP-16 (CAV) given at 28-day intervals in patients with Hodgkin's disease (HD) relapsing after primary therapy or refractory to the alternating MOPP/ABVD regimen.

PATIENTS AND METHODS

This study included 58 patients (median age: 34 years), with resistant or relapsing HD. Primary therapy had consisted of alternating MOPP/ABVD (81%) or MOPP alone (19%); 38% of patients were relapsing from prior complete remission (CR) while 62% had resistant disease. Extranodal disease was present in 55% and B-symptoms in 72% of patients; one-fifth had bulky disease and/or bone marrow involvement. The CAV was used as first salvage in half of the patients.

RESULTS

Complete remission was obtained in 17 patients (29%); unfavorable factors for CR in univariate analysis were the presence of bulky disease and the failure to achieve CR with prior therapy. Nine patients (53% of remitters) have subsequently relapsed with a 10-month median duration of CR. The 3-year overall survival after CAV was 25% with an 18-month median survival; significant differences in survival were found according to the extent of disease, the presence of B-symptoms and the HD status (prior sensitive or resistant disease, first or subsequent relapse). Seven patients are long-term remitters (12%), and one of them has been given high-dose chemotherapy and autologous bone marrow transplantation at relapse after CAV. The CAV toxicity was mostly hematological; severe pancytopenia occurred in six cases with two cases of fatal infections and one of fatal hemorrhage.

CONCLUSION

CAV therapy was moderately effective as third-line salvage in patients with HD resistant to alternating MOPP/ABVD or previously given two different regimens for relapse; the toxicity was mostly hematological and supportive therapy was needed in one-third of the patients.

Continuous infusion ABDIC therapy for relapsed or refractory Hodgkin's disease

BACKGROUND

Patients whose Hodgkin's disease is refractory to standard combination chemotherapy usually have a poor prognosis. These patients are generally considered for bone marrow transplantation if the disease is still sensitive to chemotherapy.

METHODS

Between May 1988 and January 1992, 19 patients with refractory or relapsed Hodgkin's disease were treated with a regimen of doxorubicin, bleomycin, dacarbazine, lomustine, and prednisone (ABDIC). The ABDIC regimen as modified for continuous infusion by Hagemeister consisted of doxorubicin 25 mg/m2 by continuous infusion daily for 2 days, dacarbazine 200 mg/m2 by continuous infusion daily for 5 days, bleomycin 5 U/m2 intravenously on days 1 and 5, CCNU 40 mg/m2 on day 1, and prednisone 40 mg/m2 daily on days 1-5. Treatment was repeated every 28 days.

RESULTS

At the time of treatment, mean age was 30.5 years (range 19-70), and time to ABDIC from initial diagnosis was 5.6 years (range 1-14). The mean number of prior chemotherapy regimens was 2.7 (range 1-5), and three of the patients had had autologous bone marrow transplantation before ABDIC: All patients had earlier received either mechlorethamine, vincristine, procarbazine, and prednisone or a regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine, and 16 had received both. The mean number of ABDIC cycles was 3.9 (range 2-12). Total response rate was 63%, with 10 patients having partial response and 2 having complete response of 12 and 27 months' duration. Seven patients subsequently underwent bone marrow transplantation; two of these are free of disease at 35 and 41 months. The treatment was well tolerated; major toxicities were nausea and bone marrow suppression.

CONCLUSION

ABDIC is an active and well tolerated therapy in patients with relapsed or refractory Hodgkin's disease, including those previously treated with ABVD. More importantly, perhaps, ABDIC as cytoreductive therapy followed by bone marrow transplantation offers the possibility of long term disease free survival in this heavily pretreated patient population.

Haematological toxicity of radiotherapy following high-dose chemotherapy and autologous bone marrow transplantation in patients with recurrent Hodgkin's disease

17 patients with recurrent Hodgkin's disease received 21 courses of radiotherapy (RT) 1-23 months after high-dose chemotherapy and autologous bone marrow transplantation. WHO grade III-IV haematological toxicity, of median duration 38 days (range 4-236), was observed following 10 courses of radiotherapy in 9 patients. This haematological morbidity could be predicted with an 80.0% sensitivity when the pre-RT white cell count was < 5 x 10(9)/l or the platelet count < 100 x 10(9)/l. It occurred in 9/11 patients with initial stage III-IV disease, including all 6 given extended radiotherapy fields, but in no patients with initial stage II disease (chi 2 = 9.35, P < 0.005). Age, histology, the presence of B symptoms, performance status, previous radiotherapy or chemotherapy, the interval between autologous bone marrow transplantation and radiotherapy, the high-dose regimen used, and the radiotherapy dose or field size, did not appear to affect haematological toxicity. The median survival was 18 months from the date of starting radiotherapy. 7 patients remain alive and progression-free 8-51 months (median 21 months) after radiotherapy. Radiotherapy may contribute to durable remissions in patients with relapsed or residual Hodgkin's disease after autologous bone marrow transplantation, but significant haematological toxicity may be expected in those with mild pancytopaenia prior to radiotherapy, particularly with initial stage III or IV disease.

Serum lactate dehydrogenase level as a prognostic factor in Hodgkin's disease

The efficacy of currently available treatments for Hodgkin's disease (HD) has led to a substantial modification in the prognosis of this disease; nevertheless there is still a group of patients that cannot be cured with conventional treatments and who will be candidates for alternative therapy. In the present work we analysed the prognostic influence of the most relevant clinico-biological characteristics of HD in a consecutive series of 137 patients diagnosed and treated in a single institution. Univariate analyses identified six variables with significant prognostic influence, both on achieving complete remission (CR) and overall survival (OS); LDH > 320 U ml-1, age > 45 years, stages IIB, III and IV, extranodal involvement, alkaline phosphatase > 190 UI dl and ESR > 40 mm h. In addition, Hb < 12.5 gr dl-1 and abdominal disease were statistically relevant for CR while a poor performance score (ECOG > or = 2) affected a lower survival. In the multivariate analysis only LDH, age and the clinical stage retained a significant prognostic influence for achieving CR, while the two first factors above, together with performance status were the variables with independent prognostic value with respect to OS. Moreover, only LDH > 320 U ml-1 had prognostic influence in the probability of relapse and disease free survival (DFS), both in the univariate and multivariate analyses. According to the three independent factors obtained in the multivariate analysis for CR (LDH, age and stage) a predictive model was established that allows the stratification of patients into two prognostic groups: one with poor prognosis that includes patients with the three adverse prognostic factors, or two if one of them was elevated LDH, and the other with good prognosis that includes the remaining patients. This model was also able to separate two independent groups of patients with respect to OS and to DFS. In conclusion, the present study shows that LDH is one of the most important prognostic factors in HD.

High-dose sequential chemo-radiotherapy with peripheral blood progenitor cell support for relapsed or refractory Hodgkin's disease--a 6-year update

BACKGROUND

Very few studies using high-dose therapy and autologous bone marrow transplantation have a long (i.e., > 3 years) follow-up. We report here the 6-year update of a study employing high-dose sequential chemo-radiotherapy in 25 patients with poor-risk Hodgkin's disease.

PATIENTS AND METHODS

All patients were either refractory (7 patients) or partial responders (9 patients) or early relapses (9 patients) following induction chemotherapy consisting of MOPP/ABVD in 20 patients and MOPP/ABVD followed by salvage CEP for the remaining 5 patients. The high-dose chemo-radiotherapy regimen employed consisted in the rapid sequential administration of high-doses of cyclophosphamide, methotrexate, etoposide and total body irradiation plus melphalan.

RESULTS

As compared to 4-year results, the 6-year probabilities of relapse-free survival, freedom from progression and overall survival were almost superimposable. In fact, during the two additional years elapsed since prior survey, only one event occurred (fatal cerebral hemorrhage) that was unrelated to Hodgkin's disease. In particular, the proportion of patients remaining event-free was 78% for those with short initial complete response and 31% for patients who had failed initial MOPP/ABVD. According to previous experience, both groups have a very low or no chance of long-term event-free survival when treated with standard-dose salvage chemotherapy.

CONCLUSIONS

The very favorable long-term results of the high-dose sequential regimen together with its excellent tolerability and lack of early or late fatal toxicities, will assist clinicians in defining optimal timing for high-dose therapy in the management of Hodgkin's disease. According to a revised cost/benefit analysis, it would appear that, at present, the best timing of high-dose sequential therapy in patients failing MOPP/ABVD is at first early relapse.

High dose chemotherapy followed by autologous hematopoietic rescue in Hodgkin's disease: long-term follow-up in 128 patients

BACKGROUND

There is little long-term follow-up information after autologous transplantation for Hodgkin's disease. We evaluated the influence of various prognostic factors and examined the outcome in 128 such patients.

PATIENTS AND METHODS

Patients received high dose cyclophosphamide, carmustine, and etoposide followed by autologous hematopoietic rescue.

RESULTS

Patients have been observed between 50-130 months (median 77 months) following transplantation. Overall survival at four years is estimated as 45 percent, and failure-free survival as 25 percent. The best results were seen in patients with a good performance status, who had failed at most one prior chemotherapy regimen. Failure-free survival at four years is estimated as 53 percent for this group. Relapses more than 24 months after transplantation were seen in 11 patients. Five patients developed myelodysplastic syndromes. Three patients became pregnant after the transplant.

CONCLUSIONS

Prolonged failure-free survival may be observed following high dose chemotherapy and autologous hematopoietic rescue in patients with Hodgkin's disease. Superior results were seen in patients without extensive prior chemotherapy and in those with a good performance status. Late relapses and deaths from secondary myelodysplastic syndromes mandate prolonged follow-up after autologous transplantation for Hodgkin's disease.

The tolerability of continuous intravenous infusion of interleukin-3 after DHAP chemotherapy in patients with relapsed malignant lymphoma. A phase-I study

The objective of this phase-I study was to establish the maximum tolerable dose of recombinant human interleukin-3 (rhIL-3) after salvage chemotherapy in patients with malignant lymphoma. Twenty-one patients with relapsed Hodgkin's disease or intermediate/high-grade non-Hodgkin's lymphoma received rhIL-3 after the second cycle of DHAP chemotherapy (cisplatin, cytosine-arabinoside, dexamethasone). Cycles 1 and 3 were given without rhIL-3. The rhIL-3 was administered as a continuous intravenous infusion for 10 days starting 48 h after chemotherapy in cycle 2. Five different dose levels of rhIL-3 (0.25, 1.0, 2.5, 5.0, and 10.0 micrograms/kg/day) were sequentially tested. At the three lowest dose levels one double-blinded placebo was included for every four patients per dose level. Low-grade fever occurred in 15/21 patients, unrelated to the dose of rhIL-3. Nausea and vomiting (grade 1-2) occurred in seven patients. Headache was dose related, with 3/4 patients at a dose of 10 micrograms/kg/day experiencing troublesome grade-2 headache precluding further dose escalation. Facial flushing developed in 3/8 patients at the highest dose levels of rhIL-3. There was a significant increase in eosinophil count during rhIL-3 (p = 0.03 cycle 2 vs cycle 1 and p = 0.002 cycle 2 vs cycle 3) without accompanying clinical signs of symptoms. No increase in basophil count was observed. There were no increased plasma levels of interleukin-6 or macrophage colony-stimulating factor (M-CSF) during rhIL-3. We conclude that rhIL-3 can be safely administered as a continuous intravenous infusion for 10 days after DHAP chemotherapy. Dose-limiting side effects, especially headache, occur at a dose of 10 micrograms/kg/day.

Late relapses in Hodgkin's disease: outcome of patients relapsing more than twelve months after primary chemotherapy

BACKGROUND

Patients with Hodgkin's disease whose initial complete remissions (CR) after primary chemotherapy were longer than 1 year are thought to have better prognoses than patients whose initial remissions were shorter than 1 year. However, only a few studies have analyzed the long-term survival in addition to the results of retreatment in patients relapsing after CR lasting more than 1 year.

PATIENTS AND METHODS

We analyzed the data of 40 patients with Hodgkin's disease who were treated in a single institution and whose CR were > 1 year after primary chemotherapy. Therapy at relapse was not standardized: of 36 patients evaluable for response, 29 received second-line chemotherapy and 7 received radiotherapy alone.

RESULTS

Sixty-five percent of the patients obtained CR (median duration: 21 months). Sixty-eight percent of the complete responders relapsed again; however, long-lasting third and fourth remissions were observed. All of the 7 patients whose retreatment consisted of radiotherapy alone obtained CR, but only 1 is in continuous CR. The presence of nodular sclerosing histologic subtype, the absence of extranodal involvement and the use of hybrid MOPP/ABVD or ABVD alone as salvage treatment are independently associated with a higher CR rate and a higher probability of 5-year survival. The 5-year survival for all 40 patients is 49%. For the patients obtaining CR, the 5-year survival and the 5-year relapse-free survival are 76% and 25%, respectively. However, the survival curve continues to fall in the succeeding years because of third and fourth relapses and the occurrence of secondary acute leukemia and non-Hodgkin's lymphoma.

CONCLUSIONS

A high percentage of patients relapsing more than 12 months after primary chemotherapy can obtain second CR. Even if most of our patients eventually relapse, third and fourth CRs are not uncommon. However, the long-term survival is low and it is further diminished by secondary leukemia and non-Hodgkin's lymphoma.

Objective evaluation of 3-D radiation treatment plans: a decision-analytic tool incorporating treatment preferences of radiation oncologists

PURPOSE

Selecting the optimal radiation treatment plan from a set of competing plans involves making trade-offs among the doses delivered to the target volumes and normal tissues by the competing plans. Evaluation of 3-dimensional radiation treatment plans is difficult because it requires the review of vast amount of graphical and numerical data. We have developed an objective plan-ranking model based on the concepts of decision analysis.

METHODS AND MATERIALS

Our model ranks a set of tentative radiation treatment plans from best to worst. A figure of merit is computed for each plan based on probabilities of possible clinical complications such as non-eradication of the tumor and radiation induced damage to the nearby healthy normal tissues, and weights which indicate their clinical relevance. This figure of merit is used to rank the plans. Key issues addressed by the model include the incorporation of individual treatment preferences of the radiation oncologist and clinical features of the patient.

RESULTS

A methodology has been established for eliciting the treatment preferences of radiation oncologists. Results of this elicitation, and examples of several plan evaluations are presented. An interactive computer-based tool has been developed as one of a set of tools to assist in the evaluation of 3-dimensional radiation treatment plans.

CONCLUSION

The paper presents a decision-analytic model incorporating radiation oncologists' treatment preferences and an interactive computer-based tool for objectively ranking competing radiation treatment plans. The tool can be used by radiation oncologists for the evaluation of competing plans, or as part of a system which tries to automatically generate optimal treatment plans using mathematical or symbolic techniques.

Patterns of survival in patients with Hodgkin's disease: long follow up in a single centre

BACKGROUND

Prolonged remission can now be induced in the majority of patients with Hodgkin's disease with chemotherapy and/or irradiation. However, there is a significant proportion of patients in whom this approach fails, either at presentation or subsequently. Survival is the definitive endpoint to assess treatment efficacy. In this study, the survival patterns of a large group of consecutive patients treated in a single institution are presented.

RESULTS

The overall median survival was 18.3 years. Clinical remission (complete remission plus good partial remission) was induced in 443 (85%); the median survival of patients in remission has not been reached. Fifty-eight patients achieved responses less than clinical remission with initial therapy (partial response) or had progressive disease, the median survival of this group being 1.4 years. With further therapy, remission was subsequently induced in 10; 5 are still alive, 5 have died between 1.9 years and 14.3 years. Twenty patients died before completion of therapy. Recurrence has been documented in 147 of the patients in remission (following initial therapy) over a median follow up period of 13 years (minimum 5 years). One hundred forty-three of these patients were retreated following recurrence (105 chemotherapy, 28 radiotherapy, 6 combined modality treatment and 4 surgery). Second remission was induced in 109/143 (76%). There was a trend towards better second remission induction in patients whose first remission was longer than 1 year (p = 0.06). The median duration of second remission was inferior to first remission duration (p < 0.001). There was no correlation between duration of first remission and survival following recurrence (p = 0.8) or with duration of second remission (p = 0.54). There was no significant difference in duration of second remission between patients who were initially treated with radiotherapy or chemotherapy (p = 0.3). The median survival following second remission was 12.0 years, being the same for patients with initially localized disease (stages I and II) treated with radiation alone and for patients with advanced Hodgkin's disease (stages III and IV) treated with chemotherapy. Survival after recurrence is significantly better for patients under 50 years at the time of recurrence (p < 0.001). Second recurrence was documented in 46 patients, third remission being reinduced in 22, the median survival of the latter being 5.1 years.

CONCLUSION

These results illustrate the importance of prolonged follow up in defining the clinical course of patients with HD and are vital for planning experimental chemotherapy at the time of treatment failure or recurrence.

The place of high-dose therapy with haemopoietic stem cell transplantation in relapsed and refractory Hodgkin's disease

Conventional salvage therapy in Hodgkin's disease is appropriate in patients who relapse after a first complete remission of greater than one year many of whom who will have good long term survival with no further therapy. Patients who do not achieve CR, who relapse within one year of CR1 or who have a second relapse will have a survival of less than 20% at 5 years and these patients are candidates for high dose therapy (HDT) and Autologous Bone Marrow Transplantation (ABMT) or a second line salvage protocol. Current published and registry data suggests that HDT and ABMT may be superior and there is data from one prospective randomized trial to support this view. The best practice of ABMT to be used in this context must be decided after consideration of; timing, status, source of haematological stem cells, use of haematopoietic growth factors (HGF's) and dose and scheduling of high dose therapy. Confirmatory randomised trials are still urgently required before the optimal strategy for the management of relapsed Hodgkin's disease is defined.

Assessing the cost effectiveness of adjuvant therapies in early breast cancer using a decision analysis model

BACKGROUND

We have developed a decision analysis model that uses the results of available randomized controlled trials to model the natural history of early breast cancer and assess the potential clinical and financial effects of using adjuvant therapies.

PATIENTS AND METHODS

The original model was used to assess the impact of chemotherapy in hypothetical groups of 45-year-old and 60-year-old node-negative, estrogen receptor-negative women. Using the 1992 Early Breast Cancer Trialists' Collaborative Group report, we have expanded and revised the model to assess: 1) the role of tamoxifen alone, chemotherapy alone, or combined therapy in pre-menopausal women, and 2) chemotherapy in elderly women with node-negative, estrogen receptor-negative cancer.

RESULTS

For pre-menopausal women, we found that chemotherapy increases quality adjusted life expectancy and survival by a substantial amount at a cost less than most accepted medical interventions. Combined therapy is beneficial and cost-effective in estrogen receptor-positive cancer. For the elderly, chemotherapy prolongs survival but to a lesser extent compared to younger women. The cost of this benefit is high but within the range of commonly reimbursed procedures for women under age 75 without other co-existing conditions.

CONCLUSIONS

For most patients some form of adjuvant therapy is beneficial and cost-effective. The model builds upon the data derived from collaborative efforts assessing the effectiveness of adjuvant therapies. The model highlights the need for an equal commitment to assessing the economic and quality of life impacts of breast cancer treatments.