High-dose chemotherapy and peripheral blood stem cell infusion in patients with non-Hodgkin’s lymphoma: results of outpatient treatment in community cancer centers

Abstract

Summary:Keywords: high-dose chemotherapy; non-Hodgkin's lymphoma; autologous stem cells The outcomes for patients with non-Hodgkin's lymphoma (NHL) treated with high-dose chemotherapy (HDC) and peripheral blood stem cell (PBSC) infusion by practicing oncologists in community cancer centersPatients with recurrent or refractory non-Hodgkin's lymin the United States were determined. Eighty-three phoma (NHL) may respond to further conventional treatpatients with NHL, who had failed conventional chemoment but few are cured. 1 It has been known for more than therapy, underwent mobilization of PBSC with chemoa decade that high-dose chemotherapy (HDC) or chemotherapy and a recombinant growth factor in an outradiotherapy followed by autologous stem cell infusion patient facility. At a median of 40 days (range 26-119) results in long-term event-free survival (EFS) in a signifiafter mobilization chemotherapy all received carmuscant fraction of patients with NHL who have failed chemotine (300 mg/m 2 × 1), etoposide (150 mg/m 2 twice a day therapy. 2-6 A large body of data has been accumulated over × 4 days), cytarabine (100 mg/m 2 twice a day × 4 days) the past decade that confirmed these observations. ively. The probabilities of OS and EFS for 27 patientsDespite the curative potential of HDC and autologous in untreated first relapse were 0.52 and 0.44, respectstem cell infusion, many patients with NHL who fail ively, as compared to 0.56 and 0.32, respectively, for 18 chemotherapy in the United States do not have access to patients who had reinduction attempts prior to receivthis therapy because of geographic barriers, high cost assoing mobilization chemotherapy (P = 0.81 for OS and ciated with treatment and the perception that the morbidity 0.99 for EFS). No significant risk factors for the outand mortality of treatment requires referral to a tertiary comes of TRM, relapse/progression, OS or EFS could bone marrow transplant center. 23,24 However, the developbe identified. These data demonstrate that approximent of autologous peripheral blood stem cell (PBSC) mately 40% of patients with NHL who have failed coninfusion has made the delivery of some HDC regimens a ventional chemotherapy become long-term disease-free relatively safe therapeutic procedure allowing clinical trials survivors after mobilization chemotherapy, high-dose to be carried out in community cancer centers by practicing BEAC and PBSC infusion administered in an outpatient oncologists. 6,[25][26][27][28] setting in community cancer centers, with the major The purpose of this analysis was to report the outcome cause of failure being relapse. Results obtained in this of 83 patients with NHL who had failed chemotherapy and study are comparable to published data in similar received HDC with BEAC followed by autologous PBSC patient populations receiving therapy as inpatients, suginfusion in an outpatient private practice setting. gesting that clinical trials involving well-tested HDC regimens can be carried out safely in this setting.

Autologous stem cell transplantation for non-Hodgkin's lymphoma: comparison of radiation-based and chemotherapy-only preparative regimens

“…On the other hand, the 3-5 year EFS achieved with chemotherapy-only regimens for the treatment of patients with lymphoma have ranged between 46% and 35%. [9][10][11][12] Although patients in our study had less favorable characteristics, the outcome of patients treated with highdose Bu/Mel/T regimen at the FHCRC is comparable to both the TBI-based and chemotherapy-only regimens reported in other trials. We did have somewhat more toxicity than would be expected from other regimens in the early phases of the trial.…”

“…2 Radiation-based and chemotherapy-only preparative regimens have been evaluated in patients with NHL. [2][3][4][5][6][7][8][9][10][11][12][13][14][15] However, the superiority of a specific HDC conditioning regimen for NHL has not been proven and few comparisons between regimens have been reported. [12][13][14][15] The Fred Hutchinson Cancer Research Center (FHCRC) has evaluated both radiation-based and chemotherapy-only conditioning regimens for the treatment of lymphomas.…”

Lack of caregivers limits use of outpatient hematopoietic stem cell transplant program

“…The only comparison data for these costs to caregivers are from the National Hospice Study, an evaluation of the costs and quality of care for terminally ill cancer patients. 5 This study demonstrated that 60% of caregivers reported a loss of income because of care-related time missed from work, averaging $2582. The median cost to caregivers in our study was Bone Marrow Transplantation similar to the cost of caregiving in the hospice setting and in Jagannath's outpatient stem cell transplant study.…”

“…Comparative studies including this report have demonstrated the safety of this approach and significant cost-savings, particularly among standard risk patients. [2][3][4][5][6][7][8][9] Whereas the majority of prior studies have measured direct medical costs, we also studied indirect costs to the caregiver including lost 'opportunity costs' and out-of-pocket expenses. At our institution, outpatient transplantation was associated with approximately $14 000 in savings in direct medical costs, without any decrement in quality of life.…”

“…1 A growing number of studies have demonstrated reductions in the length of hospital stay without compromising outcome. [2][3][4][5][6][7][8] A reduction in direct medical costs for outpatient HSCT has been demonstrated in some series, fueling enthusiasm for this approach. 2,4,7,9,10 There is little information, however, on the total costs of transplantation including nonmedical and out-of-pocket costs.…”