The demise of bone marrow transplants for breast cancer
The July 3 (2003) issue of New England Journal of Medicine (NEJM) includes two new studies and an editorial on the use of autologous bone marrow transplantation (AMBT) to treat late-stage breast cancer. In the 1990’s, ABMT for late stage breast cancer came into widespread use without evidence that it works better than conventional chemotherapy. This happened as a result of government mandates, court rulings, aggressive promotion by special interest groups, and reporting from certain news media. The message was conveyed that this is an effective treatment; often the side-effects of the highly toxic treatment were understated.
Several large studies were delayed because women declined to enroll in clinical trials, thinking ABMT was already the proven, gold standard. Of five studies finally reported in l999, four had negative findings with respect to ABMT, and the one that had positive findings was later determined to be bogus.
Subsequently, demand for this treatment apparently declined dramatically because the treatment has been discredited. ABMT for late-stage breast cancer continued to be used on a case-by-case basis mainly because there are mandates to cover it in effect in about a dozen states, and under some tax funded benefits plans. It is important to note ABMT is used to treat other specific conditions for which there is evidence it works better than conventional therapy.
The two studies in Thursday’s NEJM show conflicting results:
· One by Tallman et al. concludes "The addition of high-dose chemotherapy and autologous hematopoietic stem-call transplantation to six cycles of adjuvant chemotherapy with CAF [this stands for the names of three therapies] may reduce the risk of relapse but does not improve the outcome among patients with primary breast cancer and at least 10 involved axillary lymph nodes. Conventional-dose adjuvant chemotherapy remains the standard of care for such patients."
· One by Rodenhuis et al. concludes "High-dose alkylating therapy improves relapse-free survival among patients with stage II or III breast cancer and 10 or more positive axillary lymph nodes. This benefit may be confined to patients with HER-2/neu-negative tumors."
Thus, one study confirms conventional chemotherapy as the standard of care for patients with late stage breast cancer, while the other suggests some benefit for ABMT in terms of time to relapse but not mortality in a highly targeted group of women. The accompanying editorial appears to a number of readers to tilt more to the second study.
Observers make the point that these studies were done comparing ABMT to outmoded therapy. Others observe that there is nothing in the new studies to outweigh the large body of evidence arguing against it, and nothing in the new studies to outweigh the toxicity of ABMT.
The studies are available at www.nejm.org.
Several large studies were delayed because women declined to enroll in clinical trials, thinking ABMT was already the proven, gold standard. Of five studies finally reported in l999, four had negative findings with respect to ABMT, and the one that had positive findings was later determined to be bogus.
Subsequently, demand for this treatment apparently declined dramatically because the treatment has been discredited. ABMT for late-stage breast cancer continued to be used on a case-by-case basis mainly because there are mandates to cover it in effect in about a dozen states, and under some tax funded benefits plans. It is important to note ABMT is used to treat other specific conditions for which there is evidence it works better than conventional therapy.
The two studies in Thursday’s NEJM show conflicting results:
· One by Tallman et al. concludes "The addition of high-dose chemotherapy and autologous hematopoietic stem-call transplantation to six cycles of adjuvant chemotherapy with CAF [this stands for the names of three therapies] may reduce the risk of relapse but does not improve the outcome among patients with primary breast cancer and at least 10 involved axillary lymph nodes. Conventional-dose adjuvant chemotherapy remains the standard of care for such patients."
· One by Rodenhuis et al. concludes "High-dose alkylating therapy improves relapse-free survival among patients with stage II or III breast cancer and 10 or more positive axillary lymph nodes. This benefit may be confined to patients with HER-2/neu-negative tumors."
Thus, one study confirms conventional chemotherapy as the standard of care for patients with late stage breast cancer, while the other suggests some benefit for ABMT in terms of time to relapse but not mortality in a highly targeted group of women. The accompanying editorial appears to a number of readers to tilt more to the second study.
Observers make the point that these studies were done comparing ABMT to outmoded therapy. Others observe that there is nothing in the new studies to outweigh the large body of evidence arguing against it, and nothing in the new studies to outweigh the toxicity of ABMT.
The studies are available at www.nejm.org.
posted by nawledge at
8:54 PM
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