New approach to administrative medical decision-making: Evidence-based medicine using high dose chemotherapy/bone marrow transplant for breast cancer

Background. Payment for experimental treatments using medical necessity cri teria has been controversial. The process of obtaining a decision on covera ge of an experimental treatment can be distressful for the treating physici an, the patient, and family members. Method. The techniques of evidence-based medicine were used to assist with treatment/coverage decisions concerning high dose chemotherapy with autolog ous bone marrow transplants (HDC/ABMT) for invasive breast cancer. Results. We reviewed the literature, finding minimal evidence for effective ness of HDC/ABMT for invasive breast cancer; therefore, it is our opinion t hat it remains an experimental therapy. Its cost utility is likely to be lo w (approximately $100,000 per additional quality year gained). Numerous pat ients have been treated with HDC/ABMT outside of clinical trials, impeding scientific analysis of the treatment's effectiveness. Conclusion. Data-based policies and procedures for funding experimental med ical treatments need to be developed to eventually replace the medical nece ssity criteria.