High-dose chemotherapy and autologous stem-cell transplantation for ovarian cancer: an autologous blood and marrow transplant registry report.

BACKGROUND: Autologous transplantation is increasingly used to treat epithelial ovarian cancer. However, it is not clear which patients may benefit. OBJECTIVE: To determine overall and progression-free survival and factors associated with favorable outcome after autotransplantation for ovarian cancer. DESIGN: Observational cohort study. SETTING: 57 centers reporting to the Autologous Blood and Marrow Transplant Registry (ABMTR). PATIENTS: 421 women who received transplants between 1989 and 1996. INTERVENTIONS: High-dose chemotherapy using diverse regimens with hematopoietic stem-cell rescue. MEASUREMENTS: Primary outcomes were progression-free survival and overall survival. Multivariate analyses using Cox proportional hazards regression considered the following factors: age, Karnofsky performance score, initial stage, histologic characteristics, previous therapy, remission status, extent of disease, graft source, transplant regimen, and year of transplantation. RESULTS: Most patients had extensive previous chemotherapy. Forty-one percent had platinum-resistant tumors, and 38% had tumors at least 1 cm in diameter. Only 34 patients (8%) received transplants as part of initial therapy. The probability of death within 100 days was 11% (95% CI, 8% to 14%). Two-year progression-free survival was 12% (CI, 9% to 16%), and 2-year overall survival was 35% (CI, 30% to 41%). Younger age, Karnofsky performance score of at least 90%, non-clear-cell disease, remission at transplantation, and platinum sensitivity were associated with better outcomes. Progression-free and overall survival were 22% (CI, 12% to 33%) and 55% (CI, 42% to 66%), respectively, for women with a high Karnofsky performance score and non-clear-cell, platinum-sensitive tumors. CONCLUSIONS: Some subgroups of patients with ovarian cancer seem to have good outcomes after autotransplantation, although several biases may have affected these observations. Phase III trials are needed to compare such outcomes with outcomes of conventional chemotherapy.

Effect of short-term interferon therapy on the outcome of subsequent HLA-identical sibling bone marrow transplantation for chronic myelogenous leukemia: an analysis from the international bone marrow transplant registry.

Allogeneic bone marrow transplantation (BMT) is the only curative therapy for chronic myelogenous leukemia (CML), though several studies indicate that prolonged survival can result from interferon-alpha (IFN-alpha) treatment. IFN-alpha is now often used as initial therapy for CML, before donor availability is known. Because identifying potential donors can take several weeks to months, it is important to know whether IFN-alpha adversely affects outcome of a subsequent BMT. If it does, initiation of IFN-alpha therapy might be delayed until donor availability is determined and avoided in patients for whom BMT is planned. We studied 873 patients who received HLA-identical sibling BMT for chronic-phase CML in 153 centers participating in the International Bone Marrow Transplant Registry. The object was to compare outcome in the 664 who received only hydroxyurea before BMT with outcome in the 209 who received IFN-alpha with or without hydroxyurea. The median duration of IFN-alpha therapy was 2 months (range, 1 to 39 months). Cox proportional hazards analysis was used to compare engraftment, graft-versus-host disease (GVHD), nonrelapse mortality, relapse, survival, and leukemia-free survival after adjustment for other prognostic variables. We found a higher risk of nonengraftment among patients given IFN-alpha than among those given hydroxyurea alone (2% versus 0.2%; P = 0.01). Patients who received IFN-alpha had a lower risk of relapse (relative risk, 0.17; 95% confidence interval, 0.04-0.70). Probabilities of GVHD, nonrelapse mortality, survival, and leukemia-free survival were similar in the two treatment groups. These results suggest that a short course of IFN-alpha does not adversely affect survival after a subsequent HLA-identical sibling BMT for chronic-phase CML. (Blood. 2000;95:410-415)

Influence of a statewide trauma system on location of hospitalization and outcome of injured patients.

OBJECTIVE: Evaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death. DESIGN: Retrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture. MATERIALS AND METHODS: Risk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning. MEASUREMENTS AND MAIN RESULTS: After trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92). CONCLUSIONS: The Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.

An analysis of Hospital Discharge Index as a trauma data base.

STUDY OBJECTIVE: To document the validity of a Hospital Discharge Index (HDI) as a data base on injured patients. DESIGN: Patient information in trauma registries was compared with information in HDI. POPULATION: Injured patients admitted to trauma centers. METHODS: Patients in HDI were crossmatched with individuals in one or two trauma registries using deterministic matching techniques. Agreement regarding the presence and severity of injury was assessed. RESULTS: A comprehensive trauma registry from a level I trauma center and HDI agreed on the presence of an injury in each of 6 body regions over a range of kappa values from 0.17 to 0.71. The severity of injury score assigned by the two data bases demonstrated agreement over a range of intraclass correlation values from 0.12 to 0.82. CONCLUSION: HDI provides adequate information concerning injury for the majority of hospitalized patients, but was primarily limited by incomplete information. Efforts to improve HDI should focus on guidelines for data abstraction.

Outcome of hospitalized injured patients after institution of a trauma system in an urban area.

OBJECTIVE: To determine if risk of death for hospitalized injured patients changes when an urban trauma system is implemented. DESIGN: An analysis of the risk of death in hospitalized injured patients in 1984 and 1985 (pretrauma system), 1986 and 1987 (early trauma system), and 1990 and 1991 (established trauma system) using hospital discharge abstract data. SETTING: A total of 18 acute care hospitals in the four-county area encompassing Portland, Ore. PATIENTS: A cohort of 70,350 hospitalized patients with at least one discharge diagnosis indicating injury. MAIN OUTCOME MEASURE: Death during hospitalization. RESULTS: After the trauma system was established, 77% of patients in the region with an Injury Severity Score (ISS) of 16 or greater were admitted to level I trauma centers. More than 72% of patients with an ISS less than 16 were hospitalized in nontrauma centers. Risk of death for injured patients hospitalized at level I trauma centers declined after the trauma system was established (odds ratio, 0.65; 95% confidence interval, 0.51 to 0.81). Patients who died in trauma centers after institution of the trauma system were younger and had more severe injuries, and the majority died within 1 day of admission, whereas patients who died in nontrauma centers died a median of 5 days after admission. CONCLUSION: Establishment of a trauma system shifted the more seriously injured patients to level I trauma centers, where there was a significant reduction in the adjusted death rate.

Outcome after allogeneic bone marrow transplant for leukemia in older adults.

OBJECTIVE: To determine whether age over 40 years is associated with adverse outcome after allogeneic bone marrow transplantation for leukemia. DESIGN: A retrospective analysis of outcome after bone marrow transplants for leukemia reported to the International Bone Marrow Transplant Registry (IBMTR) among recipients 30 through 39 years, 40 through 44 years, 45 through 49 years, and 50 years of age and older. SETTING: Transplantations performed in 138 institutions worldwide and reported to the IBMTR. PATIENTS: A total of 2180 recipients of HLA-identical sibling bone marrow transplants for leukemia, divided into four cohorts based on age: 30 through 39 years (n = 1282), 40 through 44 years (n = 527), 45 through 49 years (n = 291), and 50 years and older (n = 80). MAIN OUTCOME MEASURES AND RESULTS: Incidence of leukemia-free survival, graft-vs-host disease, and relapse was comparable among the four age cohorts. Patients with advanced leukemia aged 45 years or older had a slightly higher risk of treatment-related mortality, and the 45- through 49-year-old cohort had a higher risk of interstitial pneumonia. CONCLUSIONS: These data indicate that among leukemia patients over 30 years of age at the time of allogeneic bone marrow transplantation, increasing age into the fifth decade does not adversely affect outcome after transplants from HLA-identical siblings.