Cost Studies Help Determine Best BMT Use

HACKENSACK, NJ--The use of high-dose chemotherapy followed bybone marrow or stem cell transplantation (BMT) for metastaticbreast cancer continues to be controversial, partially becauseof concerns that it is not cost effective, Christopher E. Desch,MD, said at a conference sponsored by the Northern New JerseyCancer Center, Hackensack Medical Center.

In the absence of phase III trials, cost-effectiveness analyseshave to be done with limited information, said Dr. Desch, associateprofessor of medicine and health administration, and director,Cancer Outreach and Control, Massey Cancer Center, Virginia CommonwealthUniversity, Richmond. Dr. Desch uses data from phase II trials,incorporating the results of standard chemotherapy, morbidity,and relapse costs into the equation.

Computer models of cost-effectiveness ratios can be created, butcritics argue that this "takes the art out of medicine,"Dr. Desch said. He pointed out that this technology simply makesthe medical facts explicit and does not substitute for clinicaljudgment.

He noted that the data are likely to be limited for a long timebecause both patients and their referring physicians refuse toparticipate in the clinical trials that would provide the informationneeded to show whether or not the treatment is beneficial.

BMT or any procedure is not cost effective when it is inappropriatelyperformed on patients who do not qualify medically, and insurerstend to scrutinize every BMT case to avoid such inappropriateuse.

In his role as consulting physician for Medical Care ManagementCorp., Bethesda, Md, an or-ganization that ex- amines contestedmedical cases for insurance companies for a fee, and pro bonofor patients, Dr. Desch reviewed about 40 BMT cases last year.

"Of the first 36 cases I reviewed, 10 had resistant disease,five were chemosensitive, and I could not definitely determinethe status of the others," he said.

Eight patients had greater than six sites of metastatic disease.Eight patients had liver metastases, and five had metastases tothe brain. None of the patients had been recommended to participatein a national protocol, although 24 had been placed in local phaseII studies. Altogether, about one third of the cases were notappropriate, using the best data about prognostic factors.

As to how BMT is best used in terms of the overall health-caresystem, Dr. Desch commented: "We can have a very uncontrolleddelivery system of BMT or a very regulated system providing thistreatment only for those on clinical research protocols. Neitherchoice at this moment is affordable or practical; therefore doctorsneed to use the most current data and their best clinical judgment,and only offer this treatment to those who are most likely tobenefit."