Delphi-panel analysis of appropriateness of high-dose chemotherapy and blood cell or bone marrow autotransplants in women with breast cancer

Background: Them is controversy whether high-dose chemotherapy and a blood cell or bone marrow autotransplant is a better treatment than conventional- dose chemotherapy for women with local/regional or metastatic breast cancer . Subject selection and time-to-treatment biases make definitive comparison impossible. Recent results of randomized trials are contradictory. Objective: Determine appropriateness of high-dose chemotherapy and a blood cell or bone marrow autotransplant in women with breast cancer. Panelists: Nine breast cancer experts from diverse geographic sites and practice setti ngs. Evidence: Boolean MEDLINE searches of 'breast cancer' and 'chemotherapy' an d/or 'blood cell' or 'bone marrow transplants'. Process: We used a modified Delphi-panel group judgement process. Clinical variables were permuted to define 2058 clinical settings. Each panelist rated appropriateness of high- dose therapy and an autotransplant versus conventional therapy on a 9-point ordinal scale (1: most inappropriate, 9: most appropriate). An appropriate ness index was developed based on median rating and amount of disagreement. The relationship of appropriateness indices to the permuted clinical varia bles was considered by analysis of variance and recursive partitioning. Conclusions: In women with local/regional breast cancer autotransplants wer e rated: 1) appropriate in those with greater than or equal to 10 cancer-in volved lymph nodes; 2) uncertain in those with 4-9 cancer-involved nodes; a nd 3) inappropriate in women with less than or equal to 3 cancer-involved l ymph nodes. In women with metastatic breast cancer autotransplants were rat ed: 1) appropriate in those with metastases to 'favorable' sites (skin, lym ph node, pleural and a complete or partial response to chemotherapy; 2) unc ertain in women with metastases to 'unfavorable' sites (lung, liver, or cen tral nervous system) and a complete response to chemotherapy or those with bone metastases and a complete or partial response or stable disease after chemotherapy; and 3) inappropriate in other settings.