High-dose chemotherapy with hematopoietic rescue as primary treatment for metastatic breast cancer: a randomized trial

Detection of Breast Cancer Cells in the Bone Marrow or Peripheral Blood: Methods and Prognostic Significance

Tumor cells can reach every anatomic district, organ and tissue through the peripheral blood circulation. Tumor cell shedding is considered an early event in the multi-phase process of metastasis, and the possibility of detecting tumor cells in the bloodstream and/or bone marrow before clinical evidence of distant metastases needs to be explored. The use of new sophisticated diagnostic and investigative techniques has boosted the study of tumor cell contamination of bone marrow and peripheral blood. Molecular techniques, such as reverse-transcriptase polymerase chain reaction, may be useful tools to reach this target, but, today, immunocytochemistry is still considered the gold standard to assess new techniques to detect isolated tumor cells in hematopoietic tissue. Little is known about the biology of isolated tumor cells in the peripheral blood or bone marrow. Two crucial points need to be evaluated: the identification of specific markers of breast cancer cells with clonogenic potential and their biologic properties, and the prognostic impact of the detection of isolated tumor cells in the bone marrow or peripheral blood stem cell collections.

Treating breast cancer with cell-based approaches: an overview

INTRODUCTION

Breast cancer is the most common malignancy in women. Despite there being considerable progress in the treatment of this disease, metastatic dissemination is still considered an incurable condition at the present time, causing 500,000 deaths worldwide every year. Although most of the research efforts have been focused on pharmacological approaches, over the last three decades, the use of bone marrow and peripheral blood-derived cell therapy approaches have been attempted and developed. Areas covered: This review will briefly address cell therapy for breast cancer, including autologous stem cell transplantations for overcoming the myelosuppressive effects of high-dose chemotherapy, allogeneic stem cell transplants and adoptive immunotherapy using bone-marrow derived T-cells. Expert opinion: The treatment of breast cancer using bone marrow or peripheral-blood derived cells has evolved from a supportive care approach to allow dose escalation of conventional chemotherapy to a therapeutic strategy aimed at eliciting immune cell mediated anticancer immunity. This latter principle has led to the development of adoptive immunotherapies, either with 'natural' or genetically engineered effectors, which are being intensively investigated for their great potential against several solid tumors, including breast cancer.

Impact of drug development on the use of stem cell transplantation: a report by the European Society for Blood and Marrow Transplantation (EBMT)

Hematopoietic stem cell transplantation (HSCT) is used with increasing frequency in Europe with 40 000 transplants reported in 2014. Transplant-related mortality remains high in allogeneic HSCT (10-20%); high-dose chemotherapy is toxic and demanding for patients. Drug development is accelerating and with limited toxicity of some targeted drugs may replace HSCT, whereas others may function as a 'bridge to transplant'. We analyzed HSCT reported to the activity survey for selected diseases in which major advances in drug development have been made. Tyrosine kinase inhibitors markedly changed the number of allogeneic HSCT in early CML. In myelodysplastic syndromes, hypomethylating agents show no effect on HSCT activity and Janus kinase inhibitors for myeloproliferative neoplasm appear to have only a temporary effect. For CLL autologous HSCT decreased after publication of trials showing improved PFS but no overall survival advantage and allogeneic rates are dropping after the introduction of Bruton kinase and PI3K Inhibitors. Whether these are 'game changers' as was imatinib for CML requires additional follow-up. For myeloma, proteasome inhibitors and new immunomodulatory drugs do not appear to impact transplant rates. Drug development data show different effects on HSCT use; highly effective drugs may replace HSCT, whereas other drugs may improve the patient's condition to allow for HSCT.

Peer review in hematopoietic cell transplantation: are we doing our fair share?

Peer review is believed to be important in maintaining the quality and integrity of research in academic endeavors. Recently, the value of the current peer review process, which is more than 100 years old has come into question. In the field of hematopoietic cell transplantation (HCT), peer review was unable to prevent the publication of the largest and most notorious scientific fraud in our field. In order to assess how the HCT community views and how engaged it is with the peer review process, the American Society of Blood and Marrow Transplantation conducted a survey of all of its members in 2014. The survey was sent to all active members through multiple email communications in August and September 2014. Of a total of 1183 members, 149 responded. Almost all of the respondents had participated in the peer review process, with few respondents declining ever to review manuscripts. The most common cause for declining review requests was lack of time. Most respondents (68%) thought that the current peer review process was relatively fair and unbiased, whereas only 9% of the respondents stated that they did not believe in the peer review process. In conclusion, among the respondents of this survey most felt the peer review process to be valuable and fair, however, the lack of response suggests that further study into improving the peer review process in the field of HCT is warranted in the era of electronic publishing and communication.

Abandonment of high-dose chemotherapy/hematopoietic cell transplants for breast cancer following negative trial results

OBJECTIVE

In 1999, three randomized controlled trials concluded that high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (HDC/HCT) is no better than conventional chemotherapy for women with breast cancer. This study documents the impact of the trials on use of HDC/HCT and describes how hospitals reacted to the trials.

DATA SOURCE

We used patient-level data on 15,847 HDC/HCTs reported to the Center for International Blood and Marrow Transplant Research between 1994 and 2005.

STUDY DESIGN

We report trends in total HDC/HCT procedure volume, compare the time to hospitals' exit from the HDC/HCT market between research and nonresearch hospitals, and document trends in hospital-specific volumes in the 2 years before exit.

PRINCIPAL FINDINGS

HDC/HCT volume declined from 3,108 in 1998 to 1,363 the year after trial results were released. In 2002, only 76 procedures were performed. Teaching hospitals and the hospitals that participated in the trials were no slower to discontinue the procedure compared with nonteaching, nonparticipating hospitals. At the hospital level, volume declined steadily in the months before abandonment.

CONCLUSION

The results suggest that comparative effectiveness research studies that report negative results can reduce spending, but specialists may be reluctant to relinquish cutting-edge technologies.

[Fraudulent studies, unpublished data and their effect on the development of guidelines and evidence-based recommendations]

Publication bias and scientific fraud are major threats to valid guidelines, especially guideline recommendations. Both topics have so far not been investigated systematically. It is assumed that guideline authors underestimate the potential influences on the validity of their recommendations. On the basis of questions and the example of depression guidelines the potential influence of publication bias will be outlined and discussed. Formal consensus processes which are used to phrase and grade recommendations might protect guideline recommendations against the influence of publication bias and might thereby imply one major difference to systematic reviews. Based on the examples of Werner Bezwoda and Scott S. Reuben, who fabricated studies in breast cancer and analgesia, it can be estimated that scientific fraud has no or only minimal effect on the recommendations given in clinical guidelines. Either the fraudulent work is in line with other (true) studies, which consequently leads only to an overestimation of the quantity of evidence in the guideline. Or the faked study is the only piece of evidence available, which guideline authors would then regard as an insufficient basis for a clinical recommendation. Although publication bias and scientific fraud had no influence on the example guidelines, guideline authors should be aware of this possibility and control this problem by systematically reviewing the evidence, critically appraising primary studies, and formulating prudent recommendations.

Clinical features of surgical resection for pulmonary metastasis from breast cancer

BACKGROUND AND OBJECTIVES

Metastatic breast cancer has been defined as a systemic disease. The discussion concerning the resection of lung metastases in patients with breast cancer is controversial. To confirm the role of resection of pulmonary metastases from breast cancer and to identify possible prognostic factors, we reviewed our institutional experience.

METHODS

Between 1991 and 2007, 41 patients with pulmonary metastases from breast cancers underwent complete pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm the role of metastasectomy and to analyze prognostic factors for overall survival after metastasectomy.

RESULTS

All patients were female with a median age of 55 years (range, 35-81 years). The overall survival rate after metastasectomy was 51% at 5 and 10 years. On multivariate analysis, fewer than four pulmonary metastases and a disease-free interval of more than 3 years were significantly favorable prognostic factors for overall survival (p=0.023 and 0.024, respectively).

CONCLUSIONS

The current practice of pulmonary metastasectomy for breast cancers in our institution was well justified. Pulmonary metastasectomy in patients with previous breast cancer might be justified when fewer than four pulmonary metastases or a disease-free interval of more than 3 years.

Randomized trial of high-dose chemotherapy with autologous peripheral-blood stem-cell support compared with standard-dose chemotherapy in women with metastatic breast cancer: NCIC MA.16

PURPOSE

We conducted a multicenter, randomized trial to compare progression-free survival (PFS), overall survival (OS), and quality of life in women with metastatic breast cancer (MBC) receiving high-dose chemotherapy plus autologous stem-cell transplantation (ASCT; HDCT) compared with standard-dose therapy.

PATIENT AND METHODS

Between April 1997 and December 2000, 386 women with MBC and no prior chemotherapy for metastatic disease were registered. After initial response to anthracycline- or taxane-based induction chemotherapy, 224 patients were randomly assigned: 112 to high-dose cyclophosphamide, mitoxantrone, and carboplatin chemotherapy and ASCT (HDCT), and 112 to standard therapy (ST). Median age was 47 years (range, 25 to 67 years). Thirty two percent of women randomly assigned had estrogen and progesterone receptor-negative breast cancer, 42% had visceral metastases, and 58% had bone metastases. Complete remission rates before random assignment were 11% for those receiving HDCT and 12% for those receiving ST.

RESULTS

After a median follow-up of 48 months, 79 deaths were observed in the HDCT arm and 77 deaths were observed in the ST arm; seven patients (6%) in the HDCT arm died as a result of toxicity. The median OS was 24 months for the HDCT arm (95% CI, 21 to 35 months) and 28 months for ST (95% CI, 22 to 33 months; hazard ratio [HR], 0.9; 95% CI, 0.6 to 1.2; P = .43). PFS was 11 months for HDCT and 9 months for ST (HR, 0.6 in favor of HDCT; 95% CI, 0.5 to 0.9; P = .006).

CONCLUSION

HDCT did not improve OS in women with MBC when used as consolidation after response to induction chemotherapy.

High-dose chemotherapy: how resistant is breast cancer?

This report reviews clinical experience with high-dose chemotherapy with stem-cell support in breast cancer and attempts to integrate clinical and molecular biological observations into a model of drug resistance. Despite the remarkable initial chemosensitivity of breast cancer, the majority of patients with advanced breast cancer die of their disease. In trials to date, high-dose chemotherapy has not been able to overcome primary drug resistance and patients with disease progression during induction therapy benefit little from further high-dose therapy. On the other hand, high-dose chemotherapy produces improved objective response rates compared with standard-dose chemotherapy due to converting some partial responses achieved by standard-dose induction therapy to complete response. This suggests that high-dose chemotherapy may overcome partial clinical drug resistance and may result in a more complete elimination of chemosensitive cells. Whether increased complete response rates will translate into higher cure rates and increased overall survival remains to be unequivocally demonstrated. There are multiple clinical patterns of drug failure including continued growth during chemotherapy, partial response followed by a period of stable disease, initial complete response with subsequent recurrence within a few months or after several years. Different mechanisms of drug resistance may operate at different stages of the disease and predispose patients to different clinical patterns of failure. A model of clonal progression of cancer is proposed that could explain several intriguing features of clinical drug resistance. We hypothesize that drug-sensitivity is an acquired characteristic of neoplastic cells and that a 'physiological drug-resistant' state may precede drug sensitivity at early stages of neoplastic transformation. Some recurrences may, in this context, represent progression of physiologically drug-resistant clones to sensitivity and subsequently to 'pathologic resistance' to chemotherapy. Optimal therapy to delay or prevent recurrence may differ depending on the stage and biology of the tumor and may include combinations of cytotoxic drugs and chemopreventive agents to arrest progression of early physiologically drug-resistant neoplastic stem cells.

Listen to all the voices: an advocate's perspective on early access to investigational therapies

In this issue of the journal, The Society for Clinical Trials, whose members are clinical investigators and regulators in academia, government and industry, has published the rationale for their opposition to US Senate bill S. 1956, the so-called "ACCESS" act, which would allow the marketing of therapies that have undergone only Phase I studies (dose finding and toxicity testing) in humans, to patients with "serious and life-threatening" disease who have exhausted other treatment options. While this bill reflects the views and efforts of some cancer advocates and their supporters, it does not represent the beliefs of the cancer advocacy community overall. The essay that follows is inspired by the need for other voices from the patient and advocacy communities to be heard in this debate.

High-dose therapy for breast cancer - a case of suspended animation

The role of high-dose chemotherapy in breast cancer is still controversial despite 20 years of clinical studies. Several nonrandomized studies had demonstrated improvement for patients with primary breast cancer. This led to the premature acceptance of high-dose therapy as a new standard of care for patients with high-risk breast cancer. There followed a phase of disillusionment after some of the randomized studies did not show any significant benefit and after a case of scientific misconduct. High-dose chemotherapy studies in breast cancer have been unpopular for the last 5 years. There is new evidence that warrants a new critical look. Fourteen randomized studies with a total of 5,592 patients have been carried out in patients with high-risk breast cancer on adjuvant therapy. Some of them showed significant improvement; others are coming to maturation now. In all randomized studies high-dose therapy in metastatic breast cancer leads to an equivalent or better disease-free survival, but because of their low power, none of these studies achieved an improvement in overall survival. It is thus necessary to perform a meta-analysis of all these studies to acquire insight into the choice of high-dose regimens. It is further necessary to look at the biology of breast cancer in the context of high-dose chemotherapy studies.

High dose chemotherapy and autologous bone marrow or stem cell transplantation versus conventional chemotherapy for women with metastatic breast cancer

BACKGROUND

There is a hypothesis that high dose chemotherapy with autologous bone marrow or peripheral stem cell transplantation (autograft) may improve survival for women with metastatic breast cancer.

OBJECTIVES

To compare the effectiveness of high dose chemotherapy and autologous bone marrow or stem cell transplantation with conventional chemotherapy for women with metastatic breast cancer.

SEARCH STRATEGY

We used the Cochrane Breast Cancer Group search strategy, adding these terms: bone marrow transplantation, stem cell transplantation, autologous stem cell support. The following databases were searched: MEDLINE (until November 2004), EMBASE (until November 2004), ASCO (American Society of Clinical Oncology) (1995-2004) and the COCHRANE LIBRARY (Issue 4 2004). We searched the Cochrane Breast Cancer Group database and cooperative research groups' websites for unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing the effectiveness of high dose chemotherapy and autograft with conventional chemotherapy for women with metastatic breast cancer. Studies included one or more of the following outcomes: treatment related mortality, overall or progression-free survival at 1, 2, 3, 5 or 7 years, morbidity, quality of life measures, time to tumour progression, overall survival time.

DATA COLLECTION AND ANALYSIS

Six randomised controlled trials met the inclusion criteria. Two independent reviewers extracted data.

MAIN RESULTS

In total 438 eligible women were randomised to receive high dose chemotherapy with autograft and 412 were randomised to receive conventional treatment. There were fifteen treatment-related deaths among the high dose group and two in the control (conventional dose) group (RR 4.07 (95% CI 1.39, 11.88)). There was no statistically significant difference in overall survival between the high dose and control groups at one year, three years or five years. At one and five years of follow up, there was a statistically significant difference in event-free survival, favouring the high dose group (one year: RR 1.76 (95% CI 1.40, 2.21); five years: RR 2.84 (95% CI 1.07, 7.50). Toxicity was more severe in the high dose group. Only one of the trials has followed up all women for five years and further data are awaited.

AUTHORS' CONCLUSIONS

Although there is statistically significant evidence that high dose chemotherapy and autograft improves event free survival compared to conventional chemotherapy, there is no statistically significant evidence of benefit in overall survival for women with metastatic breast cancer. High dose chemotherapy with bone marrow or stem cell transplantation should not be given to women with metastatic breast cancer outside of clinical trials.

High-dose chemotherapy of cyclophosphamide, thiotepa and carboplatin (CTCb) followed by autologous stem-cell transplantation as a consolidation for breast cancer patients with 10 or more positive lymph nodes: a 5-year follow-up results

PURPOSE

The benefit of consolidation high-dose chemotherapy (HDC) for high-risk primary breast cancer is controversial. We evaluated the efficacy and safety of consolidation HDC with cyclophosphamide, thiotepa and carboplatin (CTCb) followed by autologous stem-cell transplantation (ASCT) in resected breast cancer patients with 10 or more positive lymph nodes.

MATERIALS AND METHODS

Between December 1994 and April 2000, 22 patients were enrolled. All patients received 2 to 6 cycles of adjuvant chemotherapy after surgery for breast cancer. The HDC regimen consisted of cyclophosphamide 1,500 mg/m(2)/day, thiotepa 125 mg/m(2)/day and carboplatin 200 mg/m(2)/day intravenous for 4 consecutive days.

RESULTS

With a median follow-up of 58 months, 11 patients recurred and died. The median disease-free survival (DFS) and median overall survival (OS) were 49 and 69 months, respectively. The 5-year DFS and OS rates were 50% and 58%, respectively. The 12 patients with 10 to 18 involved nodes had better 5-year DFS (67%) and OS (75%) than 10 patients with more than 18 involved nodes (30% and 38%, respectively). The most common grade 3 or 4 nonhematologic toxicity was diarrhea, which occurred in 5 patients (23%). No treatment-related death was observed.

CONCLUSION

Consolidation HDC with CTCb followed by ASCT for resected breast cancer with more than 10 positive nodes had an acceptable toxicity but does not show promising survival.

High-Dose Chemotherapy and Autologous Stem Cell Rescue for Metastatic Breast Cancer

During 1990-1999, we treated 60 patients with breast cancer who had distant metastases with high-dose chemotherapy and autologous stem cell rescue (HDC) after they had responded to induction chemotherapy. HDC regimens were MiTepa (60 mg/m2 mitoxantrone by continuous intravenous infusion over 3 days plus 300 mg/m2 thiotepa intravenously over 2 hours daily x 3 days) and ICE (12 g/m2 ifosfamide, 1800 mg/m2 carboplatin, 2 g/m2 etoposide; all 3 by continuous intravenous over 4 days). At a median follow up >8 years, the median failure-free survival (FFS) was 13.9 months, median overall survival (OS) 29.1 months, 5-year FFS 12%s and 5-year OS 25%. Thirty-three patients underwent tandem (T) transplants; 27 underwent a single (S) HDC. Median ages for these 2 groups were 45 and 48 years; bone and liver metastases were more prevalent in the T cohort, whereas lung metastases were more prevalent in the S cohort. At a median follow up of 6.5 years for the S group and >9 years for the T group, there were 52 deaths. FFS was better for T: median 15.7 versus 7.7 months (p2 = 0.010) as was OS: median 32.7 versus 17.7 months, 2-year survival 68% versus 41%, and 5-year survival 32% versus 15% (p2 = 0.010). As a group, patients with distant metastatic breast cancer who underwent tandem transplants had a better posttransplant survival than patients who underwent a single HDC.

Relevance of high-dose chemotherapy in solid tumours

Drug resistance is a major problem in the treatment of solid tumours. Based on a steep dose-response relationship for especially alkylating agents on tumour cell survival, high-dose chemotherapy was considered of interest for the treatment of solid tumours. Results of phase 1 and 2 studies with high-dose chemotherapy in a variety of tumour types showed good response rates. Nowadays, several phase 3 studies are available especially in metastatic and high-risk breast cancer patients. The high expectations of high-dose chemotherapy did not come true. This review analyses results of randomised studies and comments on the discrepancy between findings in patients versus those in tissue culture. Potential factors involved are the presence of tumour stem cells with different characteristics from more mature tumour cells, limitations in drug escalation in the clinic, transplant mortality, trial design and tumour cell contamination of the haematopoietic stem cell transplant. Maturation of the results from recent studies indicating a more modest benefit in, e.g., adjuvant breast cancer balanced versus long-term side effects will ultimately determine the role of high-dose chemotherapy in certain solid tumours. In case of well-defined indications for high-dose chemotherapy, further selection of patients based on patient and tumour characteristics as well as the introduction of new agents will most likely play a role.

Up-front tandem high-dose chemotherapy compared with standard chemotherapy with doxorubicin and paclitaxel in metastatic breast cancer: results of a randomized trial

PURPOSE

The role of high-dose chemotherapy (HDCT) in metastatic breast cancer remains controversial. Trials with late intensification HDCT have failed to show an advantage in overall survival. This study was initiated to compare up-front tandem HDCT and standard combination therapy in patients with metastatic breast cancer.

PATIENTS AND METHODS

Patients without prior chemotherapy for metastatic disease were randomly assigned to standard combination therapy with doxorubicin and paclitaxel (AT) or double HDCT with cyclophosphamide, mitoxantrone, and etoposide followed by peripheral-blood stem-cell transplantation. HDCT was repeated after 6 weeks. Patients were stratified by menopausal and hormone-receptor status. The primary objective was to compare complete response (CR) rates.

RESULTS

A total of 93 patients were enrolled onto the trial. Intent-to-treat CR rates for patients randomized to HDCT and AT were 12.5% and 11.1%, respectively (P = .84). Objective response rates were 66.7% for patients in the high-dose group and 64.4% for patients in the AT arm (P = .82). In an intent-to-treat analysis, there were no significant differences between the two treatments in median time to progression (HDCT, 11.1 months; AT, 10.6 months; P = .67), duration of response (HDCT, 13.9 months; AT, 14.3 months; P = .98), and overall survival (HDCT, 26.9 months; AT, 23.4 months; P = .60). HDCT was associated with significantly more myelosuppression, infection, diarrhea, stomatitis, and nausea and vomiting, whereas patients treated with AT developed more neurotoxicity.

CONCLUSION

This trial failed to show a benefit for up-front tandem HDCT compared with standard combination therapy. HDCT was associated with more acute adverse effects.

Module six: special issues

The objective of this module is to cover ground that was not covered in-depth in any of the other modules, including: scientific misconduct, issues concerning the publication and ownership of research results (authorship guidelines - who is eligible to be considered an author, or contributor to a scientific paper etc.), special problems occurring in social science and epidemiological research, and the problems pertaining to conflicts of interest the various players in biomedical research activities could encounter.

High-dose chemotherapy of cyclophosphamide, thiotepa, and carboplatin (CTCb) followed by autologous stem-cell transplantation for metastatic breast cancer patients: a 6-year follow-up result

PURPOSE

The benefit of high-dose chemotherapy (HDC) for metastatic breast cancer (MBC) is controversial. We evaluated the efficacy and safety of HDC with cyclophosphamide, thiotepa, and carboplatin (CTCb) followed by autologous stem-cell transplantation (ASCT) for MBC patients.

MATERIALS AND METHODS

From September 1994 to December 1999, 23 MBC patients were enrolled. All the patients received 2 to 10 cycles of induction chemotherapy. Before transplantation, 12 patients were in complete response (CR), nine were in partial response (PR), and two had progressive disease (PD). The HDC regimen consisted of cyclophosphamide 1,500 mg/m(2)/day, thiotepa 125 mg/m(2)/day and carboplatin 200 mg/m(2)/day intravenously for 4 consecutive days.

RESULTS

After ASCT, 13 patients (56%) had a CR, five (22%) had a PR, three (13%) had no change, while two (9%) showed a PD. Seventeen patients relapsed or progressed during the median follow-up of 78 months. The median progression-free survival (PFS) time was 11 months and the median overall survival (OS) time was 23 months. The 5-year PFS and OS rates were 22% and 25%, respectively. On the multivariate analyses, less than 4 involved lymph nodes was predictive of a better PFS and OS.

CONCLUSION

HDC with CTCb for MBC has acceptable toxicity; however, this treatment does not show a survival benefit.

High-dose chemotherapy with autologous hematopoietic stem-cell support compared with standard-dose chemotherapy in breast cancer patients with 10 or more positive lymph nodes: first results of a randomized trial

PURPOSE

Investigation of high-dose chemotherapy (HD-CT) followed by autologous hematopoietic stem-cell support compared with standard-dose chemotherapy (SD-CT) as adjuvant treatment in patients with primary breast cancer and 10 or more positive axillary lymph nodes.

PATIENTS AND METHODS

Between November 1993 and September 2000, 307 patients were randomized to receive (following four cycles of epirubicin 90 mg/m(2) and cyclophosphamide 600 mg/m(2), intravenously every 21 days) either HD-CT of cyclophosphamide 1500 mg/m(2), thiotepa 150 mg/m(2), and mitoxantrone 10 mg/m(2), intravenously for 4 consecutive days followed by stem-cell support; or SD-CT in three cycles of cyclophosphamide 500 mg/m(2), methotrexate 40 mg/m(2), and fluorouracil 600 mg/m(2) intravenously on days 1 and 8, every 28 days. The primary end point was event-free survival.

RESULTS

After a median follow-up of 3.8 years, 144 events with respect to event-free survival have been observed (HD-CT: 63 events; SD-CT: 81 events). The first event of failure (HD-CT v SD-CT) was an isolated locoregional recurrence (nine v 11), a distant failure (52 v 68), and death without recurrence (two v two). The estimated relative risk of HD-CT versus SD-CT was 0.75 (95% CI, 0.54 to 1.06; P =.095). Overall survival showed no difference (HD-CT: 40 deaths; SD-CT: 49 deaths).

CONCLUSION

There was a trend in favor of HD-CT with respect to event-free survival, but without statistical significance. Further follow-up and a meta-analysis of all randomized studies will reveal the effect of HD-CT as compared with SD-CT as adjuvant treatment in high-risk primary breast cancer.

Review of current authorship guidelines and the controversy regarding publication of clinical trial data

Publication of clinical trial data is the final step in the scientific method and an important method by which pharmaceutical and biotechnology companies, i.e., drug sponsors, disseminate information about their products. Because of the nature of large, multicenter trials, multiple investigators from many institutions may be considered as authors of these papers. Controversy concerning the rights of academic institutions and the rights of drug sponsors has been widely debated. This chapter summarizes the controversy and the current policies.

Should we continue to study high-dose chemotherapy in metastatic breast cancer patients? A critical review of the published data

Data from eight randomised trials on high-dose chemotherapy (HDC) for metastatic breast cancer (MBC) have been published, but only seven studies are evaluable after the Bezwoda trial was discredited. Moreover, overall survival (OS) has been evaluated in only four out of seven studies since three had a crossover design. OS was similar for the HDC and standard-dose chemotherapy (SDC) group in the four evaluable trials, while disease-free survival (DFS) was improved in the HDC group in six of the seven trials. The delay in relapse for patients with metastatic disease represents an important clinical outcome; furthermore, since none of the reported studies randomised more than 220 patients, their statistical power may have been too limited to detect meaningful survival differences. Finally, preliminary experiences have shown that HDC seems to be the ideal platform upon which to build novel therapies. In conclusion, HDC remains an important field of clinical research for breast cancer patients with stage IV disease and, from the studies reported in this article, there is some evidence for offering this therapeutic modality to selected patients who are interested in a medically aggressive approach.

Uncontrolled local disease after salvage treatment for ipsilateral breast tumour recurrence

AIM

Uncontrolled local disease (ULD) following breast conservation constitutes a clinical problem with a major impact on quality of life. The current study analysed the outcome following treatment of ipsilateral breast tumour recurrence (IBTR) and the risk for ULD with the aim to identify risk factors for ULD.

METHODS

In a cohort of 5502 patients treated for invasive breast cancer Stage I-II with breast-conserving surgery 1976-1998 in Stockholm, 307 patients with subsequent IBTR were identified. The majority (n = 219) had received postoperative radiotherapy. Twenty-six per cent of the patients received adjuvant tamoxifen, for 2 or 5 years, and 9% received adjuvant polychemotherapy. Median follow-up time was 11(2-23) years. 50/307 patients developed ULD, defined as the appearance of clinically manifest invasive adenocarcinoma in the remaining breast or on the ipsilateral chest wall which could not be eradicated within 3 months of detection. Multivariate linear logistic regression was used in the statistical analysis to identify prognostic factors for ULD.

RESULTS

Five years following the diagnosis of IBTR the cumulative incidence of ULD was 13%. Five independent risk factors for ULD were identified; non-surgical treatment of IBTR, disseminated disease concurrent with IBTR, axillary lymph node metastases (at primary breast conservation), time < 3 years between breast conservation and IBTR, no adjuvant endocrine therapy. Eighty-eight per cent of the patients were treated with salvage mastectomy (n = 207) or re-excision (n = 62). The cumulative incidence at 5 years of ULD following salvage mastectomy and salvage re-excision were 10% and 16% respectively compared to 32% among patients treated non-surgically. Following IBTR, the 5-year overall survival among patients with local control was 78% in contrast to 21% among patients with ULD.

CONCLUSION

Uncontrolled local disease is an infrequent but important outcome following breast-conserving surgery. Primary postoperative radiotherapy reduces the risk for IBTR and is therefore recommended as part of the primary treatment to avoid both IBTR and ULD. In addition to radiotherapy, adjuvant therapy reduces the risk for IBTR and thereby the risk for subsequent ULD. Patients with IBTR, independent of concurrent distant metastases, should when feasible be recommended for salvage surgery as it provides superior local control compared to salvage systemic therapy alone.

Combination of high-dose chemotherapy and monoclonal antibody in breast-cancer patients: a pilot trial to monitor treatment effects on disseminated tumor cells

BACKGROUND

Tumor relapse occurring in high-risk breast cancer patients after high-dose chemotherapy (HDC) and autologous stem-cell transplantation may arise from cells resistant to chemotherapy, as well as from tumor cells reinfused with autologous stem cell grafts. This pilot study was designed to investigate whether ex vivo immunomagnetic purging of PBSC and subsequent immunotherapy with MAb 17-1A is feasible and can reduce the number of disseminated tumor cells in BM.

METHODS

Twelve high-risk breast-cancer patients, seven in Stage II/III and five in Stage IV (UICC breast cancer classification) underwent surgery of the primary tumor and received two cycles of induction chemotherapy, followed by HDC. After each cycle of induction chemotherapy PBSC were collected and incubated with Ab-coated immunomagnetic beads, to remove contaminating tumor cells. Prepared stem-cell grafts were transplanted 24 h after completion of HDC. After recovering from HDC all 12 patients received a total dose of 900 mg MAb 17-1A within 4 months. The effect of in vivo purging with MAb 17-1A after HDC was controlled by examining bone aspirates of the patients with an immunocytochemical assay, allowing the detection of one cytokeratin-positive tumor cell in 10(6) total nucleated cells (TNC).

RESULTS

Tumor cells were found in 5/12 BM aspirates prior to chemotherapy and even after HDC. Further monitoring of BM aspirates for cancer cells during Ab therapy showed a consistent reduction of tumor cells in four out of these five patients. After a median clinical follow-up of 41 (32-48) months all four patients are alive. These results are different from those of a historical control group of six patients with breast cancer treated with the same chemotherapy schedule, but without 17/1A consolidation. In comparison with the patients from the study group, all patients of this control group revealed a significantly increased number of tumor cells in BM (p < 0.01) after HDC during follow-up of 5 (3-7) months. These preliminary results indicate that induction chemotherapy, followed by HDC, may reduce disseminated tumor cells in BM.

DISCUSSION

Immunotherapy with MAb 17-1A after HDC may further eliminate residual disease without severe toxicity.

Critical review of current treatment strategies for advanced hormone insensitive breast cancer

Breast cancer is the most common cancer diagnosis in American women. Over the past several decades, there has been a steady increase in the incidence of this disease. Fortunately, the death rates in the last decade has showed a decrease. Patients with breast cancer now have more treatment options and a better chance of long term survival than ever before. Patients with metastatic disease are considered candidates for chemotherapy if they are symptomatic, have rapidly progressing or bulky disease, or if they are inappropriate candidates for hormonal therapy either because of negative hormonal receptor status or progression of disease on hormonal therapies. Patients are often treated with a chemotherapy regimen until progression of disease, or prohibitive toxicity, at which time the therapy is changed to a second or a third line therapy. This manuscript will provide a review of the current treatment strategies for advanced hormone insensitive breast cancer.

High-dose chemotherapy and stem cell support for breast cancer: where are we now?

To date, there is no definitive evidence that high-dose chemotherapy and haematopoietic stem cell support offers a survival advantage over conventional-dose chemotherapy for metastatic or high-risk primary breast cancer. Studies of metastatic disease discussed in this review have an adequate duration of follow-up given the short natural history of metastatic breast cancer. Thus, the results of these studies are unlikely to change with a longer observation period. On the other hand, studies of high-dose chemotherapy in the treatment of high-risk primary breast cancer need longer follow-up in light of the longer natural history of this type of disease. Results of unpublished studies and longer follow-up of available studies may still demonstrate a survival advantage for high-dose chemotherapy in patients with metastatic or high-risk primary breast cancer. We continue to encourage participation in innovative clinical studies.

Current trends in hematopoietic stem cell transplantation in Europe

Major changes have occurred in the transplantation of hematopoietic stem cells (HSCs) during the last decade. This report reveals the changes, reflects current status, and provides medium-term projections of HSC transplantation (HSCT) development in Europe. Data on 132 963 patients, 44 165 with allogeneic HSC transplant (33%) and 88 798 with an autologous HSC transplant (67%), collected prospectively from 619 centers by the European Group for Blood and Marrow Transplantation (EBMT) in 35 European countries between 1990 (4234 HSCTs) and 2000 (19 136 HSCTs) illustrate utilization of HSCT. HSCT increased in all European countries and for all indications. There were major differences depending on disease indication and donor type. Transplantation rates (numbers of HSCTs per 10 million inhabitants) varied from less than 1 for some rare indications to 37.7 +/- 4.1 for acute myeloid leukemia in allogeneic HSCT or 95.5 +/- 13.5 for non-Hodgkin lymphoma in autologous HSCT. There were indications with a steady, continuing increase and others with initial increase but subsequent decrease. Projections on medium-term development for each disease based on a weighted sensitivity analysis predict an ongoing increase in allogeneic HSCT except for chronic myeloid leukemia. In autologous HSCT they predict an increase for lymphoproliferative disorders, acute myeloid leukemia, myelodysplastic syndromes, and some solid tumors but a decrease for most solid tumors, acute lymphoid leukemia, and chronic myeloid leukemia. Transplantation rates can be predicted with reasonable sensitivity for most disease indications. Despite marked changes in the rapidly developing field of HSCT, this information on current use, trends, and midterm predictions forms a rational basis for patient counseling and health care planning.

Ex vivo expansion of apheresis-derived peripheral blood hematopoietic progenitors

Because the administration of hematopoietic growth factors and the use of stem cell support often fails to alleviate the neutropenic phase induced by cytotoxic drugs, several investigators have attempted to expand ex vivo hematopoietic progenitors for clinical use. These attempts have clearly shown that the cultured cells are functional and can be safely administered to patients, but that the in vivo performance is disappointing and the concept as a whole is not yet clinically useful. The major reasons for these unsuccessful attempts are thought to be cumbersome cell fractionation techniques, contamination, prolonged incubation, and the use of less than ideal cytokine combinations. In response, we have developed a simple procedure for ex vivo expansion of myeloid progenitor cells. In this assay, unfractionated mononuclear cells from apheresis donors are incubated in nonpyrogenic plastic bags for 7 days in the presence of culture medium either containing fetal calf serum or human plasma, granulocyte colony-stimulating factor, and stem cell factor. We have demonstrated that under these conditions the number of colony-forming units (CFU) granulocyte-macrophage (CFU-GM) and of CFU-granulocyte-macrophage-erythroid-megakaryocyte (CFU-GEMM) increased 7- and 9-fold, respectively, by day 7 and the number of burst-forming units-erythroid (BFU-E) increased 2.7-fold by day 5 of culture. Significant increases in the numbers of cells expressing CD34+, CD34+/CD38+, CD34+/CD33+, CD34+/CD15+, and CD34+/CD90+ and significant declines in the numbers of cells expressing CD34+/CD38- and CD19 surface antigens were also observed. The relative numbers of cells expressing T-cell markers and CD56 surface antigen did not change. By using different concentrations of various hematopoietic growth factor combinations, we can increase the number of mature and immature cells of different hematopoietic lineages.

High-dose chemotherapy for solid tumors: results of the EBMT

The European Group for Blood and Marrow Transplantation (EBMT), formerly known as European Group for Bone Marrow Transplantation, was established in 1974 in the Netherlands to share experiences, to promote research and clinical studies and to set up registries in the field of hematopoietic tissue transplantation. At the present time more 400 European and non-European centers are members of the EBMT group. In 1984 a new Working Party was created (Solid Tumors) with the aim to investigate the role of high-dose chemotherapy and stem cell support in the fields of adult and pediatric solid tumors. By January 2000 more than 14000 patients were registered, and at the present time this Registry is the world largest database on this subject. Several phase III randomized clinical trials have recently started on behalf of the Group in different diseases (breast carcinoma, small cell lung cancer, ovarian carcinoma, germ cell tumors and Ewing's family sarcoma). Hundreds of randomized patients will finally produce clearer information on this still experimental therapeutic modality. This paper will describe the EBMT Solid Tumors Working Party Registry updated results as well as the main ongoing studies.

High-dose chemotherapy in advanced breast cancer

Based on in vitro and animals studies which assess dose effect relationship specially for alkylating agent, and on the importance on dose intensity in human protocols, high-dose chemotherapy with stem cell support has been widely evaluated in various tumours, particularly in breast cancer. Moreover, in the last few years, the utilization of hematopoietic growth factors and peripheral stem cells has permitted a large diffusion of this approach. However, there is not yet clear data on the place of such a treatment in breast cancer. Few randomized trials are available, with mature data. Only one shows an advantage for high-dose therapy in metastatic disease. In adjuvant setting, sample sizes are too small or follow-up not long enough to draw any definitive conclusion on the place of high-dose consolidation chemotherapy in breast cancer. In inflammatory breast cancer, which is a much more less frequent disease, encouraging results have been published in phase two studies, looking at pathological response, or in pilot studies. The next few years will give a mature date of randomized trials which evaluate high-dose chemotherapy given after conventional treatment in metastatic or high risk disease. Effort should be done to better evaluate this strategy in terms of cost and quality of life and to design new studies aimed to evaluate front line multiple intensification.

Optimal Management of Primary Breast Cancer

The diagnosis and treatment of breast cancer have changed in response to not only new technologies but also cultural and social aspects of the disease. While breast-conserving surgery and adjuvant therapy are the preferred treatments for many breast cancers, neoadjuvant therapy is often used in advanced disease. In this review we examine the treatment options that are influenced by pathologic and clinical factors. Invasive breast cancer is a potentially curable disease if it is regarded and managed by a multidisciplinary approach from the outset.

Failing to live up to the fanfare? A personal perspective on obstacles to the clinical development of thrombopoietic agents

A number of hematopoietic growth factors have been identified that are active on megakaryocytes and platelets, but only 2, interleukin-11 (IL-11) and thrombopoietin, are being actively pursued clinically, with IL-11 approved for treatment of thrombocytopenia. The development of these agents in general has been disappointing, and in part this reflects the inherent biology of these factors with a failure to match clinical need with physiological function. The delayed action of these factors is also a consequence of the intrinsic biology of megakaryocytes and platelets, and thus is likely to be limiting regardless of which factor is employed. In addition, the development of these agents has occurred at a time when there is something of a decreasing demand for platelets, at least in the context of chemotherapy-induced thrombocytopenia. This decrease is the result of increased use of blood stem cells to support intensive chemotherapy procedures, reduced thresholds for platelet transfusion, and a decreasing role for intensive chemotherapy. These issues are discussed.

Systemic therapy

A large body of data on systemic therapy has been presented and published in the past year, including new information on primary risk reduction, patient selection for adjuvant systemic therapy, and anthracycline-analogs. New data on ongoing adjuvant trials (including taxane studies), unpublished updates from the fourth Oxford Overview in September 2000, and provocative data on ovarian ablation were important features of the November 2000 National Institutes of Health Consensus Development Conference on Adjuvant Therapy for Breast Cancer. Important new data on anti-estrogen therapy, including aromatase inhibitors and pure antiestrogens, further expand the role of the oldest targeted breast cancer therapy. Trastuzumab and other novel compounds are being investigated as single-agents and in combination with conventional systemic approaches. Discussions on the long-term effects of adjuvant therapy have taken center stage also. These and other important ongoing developments since 2000 are examined in this review article.

High-dose sequential epirubicin and cyclophosphamide with peripheral blood stem cell support for advanced breast cancer: results of a phase II study

The aim of this study was to evaluate the feasibility of a high-dose intensity and high-dose density multicycle epirubicin and cyclophosphamide regimen with peripheral blood stem cells (PBSC) and haematopoietic growth factor (G-CSF) support in advanced breast cancer patients. From August 1994 to September 1999, 56 breast cancer patients (8 stage IIIB and 48 stage IV) received 205 courses of cyclophosphamide 3 g x m(-2) and epirubicin 100 mg x m(-2) every 14 days. G-CSF 5 microg x kg(-1) x day(-1) was administered from day 3 to neutrophil recovery. 4 courses were planned. PBSC were collected after course 1, and reinfused after courses 3 and 4, with > or = 2 x 10(6) CD34+ PBSC x kg(-1) required for each reinfusion. 48 patients (86%) received all 4 planned courses. Early withdrawal was consecutive to infectious complications (n = 4), severe asthenia (n = 3), haemorrhagic cystitis (n = 1). A median number of 10.8 x 10(6) CD34+ PBSC x kg(-1) (range, 3-80) was harvested with 1 or 2 apheresis in 48 patients (94%). Median relative dose intensity was 91.3% (range, 72-102%). Grade 4 neutrophil toxicity was observed in 100% of patients. Febrile neutropenia was observed in 40% of courses (median duration 2 days). Red blood cells and platelets had to be transfused in 54% and 27% of courses, respectively. There were no toxic deaths. Objective response rate was 69% in stage IV patients (31/45 evaluable pts), with a 16% complete response rate. Their median progression-free and overall survivals were 22.5 and 37 months, respectively. This epirubicine-containing high-dose regimen appeared feasible, albeit with high toxicity. Time-related progression parameters exceed commonly reported ones. Controlled studies of upfront sequential high-dose chemotherapy are still needed to evaluate its real benefit.

The controversy over high-dose chemotherapy with autologous bone marrow transplant for breast cancer

In the 1990s more than 41,000 patients underwent high-dose chemotherapy plus autologous bone marrow transplant (HDC-ABMT) for breast cancer, despite a paucity of clinical evidence of its efficacy. Most health plans reluctantly agreed to cover the treatment in response to intensive political lobbying and the threat of litigation. The results of five recent major randomized trials showed that HDC-ABMT offers no advantage over standard-dose treatment for breast cancer. Our experience with HDC-ABMT coverage cautions against allowing politics to overwhelm science in the area of evaluating experimental procedures, and against relying on the courts as a means of resolving disagreements about coverage of these interventions.

A short course of induction chemotherapy followed by two cycles of high-dose chemotherapy with stem cell rescue for chemotherapy naive metastatic breast cancer: sequential phase I/II studies

Two cycles of high-dose chemotherapy with stem cell support (HDC) may increase the total dose delivered and dose intensity. A brief induction phase and different non-cross-resistant agents for each HDC cycle were used to avoid drug resistance. Twenty-six women with metastatic BC had induction and stem cell mobilization with two cycles of doxorubicin/G-CSF given every 14 days. Patients with stable disease or better after induction received HD CTCb followed by HD melphalan and dose-escalated paclitaxel. At 475 mg/m(2) of paclitaxel by 24-h infusion, dose-limiting transient peripheral sensory neuropathy was encountered. No toxic deaths occurred. Complete and near complete response after completion of therapy was achieved in 22 (85%) of 26 patients. The median EFS was 38 months. The median OS has not yet been reached. At a median follow-up of 33 (25-43) months, actuarial EFS and OS were 54% (95% confidence interval (CI), 39-69%) and 69% (95% CI, 56-79%), respectively. This double transplant approach lasts only 14 weeks and is feasible, safe, and tolerable. Whilst selection biases may in part contribute to favorable EFS and OS, a randomized comparison of standard therapy vs double transplant in both metastatic and locally advanced breast cancer is warranted.

Characterization of the T-cell repertoire in autologous graft-versus-host disease (GVHD): evidence for the involvement of antigen-driven T-cell response in the development of autologous GVHD

Administration of cyclosporine A (CsA) after autologous stem cell transplantation elicits an autoimmune syndrome with pathology similar to graft-versus-host disease (GVHD). This syndrome, termed autologous GVHD, is associated with the appearance of autoreactive T cells directed at major histocompatibility class (MHC) class II antigens. In the rat model of autologous GVHD, clonal analysis reveals that the effector T cells are highly conserved and recognize a peptide from the invariant chain peptide presented by MHC class II. Although human autologous GVHD effector T cells share a similar phenotypic specificity, clonality of the response in humans has not been determined. To examine the human effector T-cell response, the T-cell repertoire of peripheral blood lymphocytes was assessed by complementarity-determining region 3 (CDR3) size distribution analysis and T-cell clonotype analysis in 26 patients treated with CsA after transplantation. Autologous GVHD developed in 3 of 4 patients with human leukocyte antigen (HLA)-DRB1*0701, and clonal expansions of beta-chain variable region (BV)16(+) T cells were shared. Clonal expansions within BV15(+) and BV22(+) T cells were also detected in 4 of 6 patients with HLA-DRB1*1501 and in 3 of 4 patients with HLA-DRB1*0401, respectively. Sequencing of BV16 cDNA for which the CDR3 size pattern exhibited apparent clone predominance revealed an identical CDR3 peptide sequence in 2 different patients, one with HLA-DRB1*0701 and the other with HLA-DRB1*1502. These findings indicate that the discrete antigen-driven expansion of T cells is involved in autologous GVHD. (Blood. 2001;98:868-876)

An on-site audit of the South African trial of high-dose chemotherapy for metastatic breast cancer and associated publications

PURPOSE

The randomized study reported by Bezwoda et al of high-dose chemotherapy (HDC) for treatment of metastatic breast cancer was audited on site to verify the study results. Additional published studies were reviewed to determine whether they had been subject to the required institutional oversight.

PATIENTS AND METHODS

Ninety patients were reported to have been randomized and treated on this trial. A log of the names, hospital numbers, entry dates, and regimen received had been provided by the principal investigator. A search of more than 15,000 sets of medical records available from two Johannesburg hospitals was performed to locate records for as many of these 90 patients as possible. Standard auditing techniques were used. Additional clinical trials published by Bezwoda were compared against the minutes of the University of the Witwatersrand Committee for Research on Human Subjects to verify review and approval.

RESULTS

Records for only 61 of the 90 patients could be found. Of these 61, only 27 had sufficient records to verify eligibility for the trial by the published criteria. Of these 27, 18 did not meet one or more eligibility criteria. Only 25 patients appeared to have received their assigned therapy temporally associated with their enrollment date, and all but three of these 25 received HDC. The treatment details of individual patients were at great variance from the published data. Nine other trials reported by Bezwoda were not reviewed or approved by the appropriate institutional committee despite statements to the contrary in the publications.

CONCLUSION

The multiple publications of this study do not report verifiable data, and nine other publications coauthored by the principal investigator contain at least one major untrue statement.

High-Dose Chemotherapy with Autologous Stem Cell Rescue as a Treatment Modality for Breast Cancer

Retrospective analyses of clinical trials as well as several prospective randomized clinical trials designed to evaluate dose intensity have emphasized the importance of intensive chemotherapy in determining outcomes in breast cancer treatment. One strategy that can deliver a large increment in dose intensity is high-dose chemotherapy with autologous stem cell transplantation (HDC-ASCT), since it overcomes myelosuppression, a major dose-limiting toxicity of most chemotherapy regimens. Phase II data from HDC-ASCT trials have indicated improved complete remission rates and longer remission duration when compared to historical conventional-dose chemotherapy regimens. With declining treatment-related mortality (TRM) through improvements in supportive care and innovations in stem cell collection procedures, exploration of HDC-ASCT in prospective randomized trials has been made possible. Several prospective randomized trials have completed accrual and early results are now available, while other studies are still ongoing. Unfortunately the trial designs are quite varied, the characteristics of patients differ from study to study, the early data provide conflicting results, and the follow-up is quite short, making firm conclusions impossible at present. Of note, the comparison arms in several of the studies are performing better than historical nontransplant treatments, perhaps a result of an intermediate dose intensity employed in the nontransplant arm of these trials. These data suggest that dose intensity, whether supported by stem cells or hematopoietic growth factors, may be quite important in optimizing treatment outcomes, affirming earlier concepts of the importance of dose intensity. Further follow-up of the current clinical trials and analyses of ongoing studies not yet reported are necessary before firm conclusions are possible as to the optimal strategy of using dose intensity in the management of breast cancer.

Hematopoietic stem cell transplantation activity in Europe 1999

This survey on transplantation of hematopoietic stem cells from blood or bone marrow in Europe, the 10th in a series, reports the numbers of transplants performed in 1999 and concentrates on changes in indications and donor types. Members of the European Group for Blood and Marrow Transplantation and associated teams are invited every year to report their transplant numbers by indication, donor type and stem cell source. In 1999, a total 21 430 transplants were performed by 580 teams in 35 European countries. Of these transplants 18 720 were first transplants, 5879 (31%) allogeneic, 12 841 (69%) autologous; an additional 562 allogeneic and 2148 autologous transplants were re- or multiple transplants. Ninety-five percent of the autologous transplants and 45% of the allogeneic transplants were peripheral blood stem cell transplants. A total of 103, respectively 1.8% of the allogeneic transplants, were cord blood cell transplants. Main indications in 1999 were leukemias with 6289 transplants (34%), 70% thereof allogeneic transplants; lymphomas with 8219 transplants (44%), 92% thereof autologous transplants; solid tumors with 3302 transplants (18%), 99% thereof autologous transplants; nonmalignant disorders with 715 transplants (4%), 85% thereof allogeneic transplants. Absolute numbers of allogeneic transplants continued to increase as in previous years by 10%, in contrast, there was for the first time in 10 years a decrease in autologous transplants, mainly for solid tumors. Reasons therefore are discussed. These data reflect the most recent changes in utilisation and document current status of blood and marrow transplantation in Europe.