Bone marrow transplantation

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However, the demise of mutilating surgery did not spell the end of the ‘more is better’ mindset – far from it. During the last two decades of the 20th century, a new treatment approach, involving high-dose chemotherapy followed by bone marrow transplantation or ‘stem cell rescue’, was introduced. A report in the New York Times in 1999 summed up the reasoning behind this approach:

‘Doctors remove some bone marrow or red blood cells from the patient, then load her with huge amounts of toxic drugs, quantities that destroy the bone marrow. The hope is that the high doses will eliminate the cancer and that the saved bone marrow, when returned to the body, will grow back quickly enough so that the patient does not die from infection. A version of the procedure, using donations of bone marrow, had long been established as effective for blood cancer, but solely because the cancer was in the marrow that was being replaced. The use of the treatment for breast cancer involved a completely different – and untested – reasoning.’ [9]

In the USA especially, thousands of desperate women pressed for this very unpleasant treatment from doctors and hospitals, even though as many as five out of 100 patients died from the treatment. Many thousands of dollars were spent, including some from the patients’ own pockets. Eventually, some patients were reimbursed by their health insurance companies, who caved in to pressure to do so, despite the lack of evidence that the treatment was useful.

Many hospitals and clinics became rich on the proceeds. In 1998, one hospital corporation made $128 million, largely from its cancer centres providing bone marrow transplants. For US doctors it was a lucrative source of income and prestige and it provided a rich field for producing publications. Insistent patient demand fuelled the market.

Competition from private US hospitals to provide the treatments was intense, with cut-price offers advertised. In the 1990s, even US academic medical centres trying to recruit patients for clinical trials were offering this treatment. These questionable programmes had become a ‘cash cow’ for the cancer services.

The struggle for unbiased evidence

Researchers expected it would take about three years to enrol about 1,000 women in the two studies. Instead it took seven years . . . That is not so surprising…

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Unrestricted access to such unproven treatments had another serious downside: there were not enough patients available to take part in trials comparing these treatments with standard therapies. As a result it took far longer than anticipated to get reliable answers.

But despite the difficulties of obtaining unbiased evidence in the face of such pressures, some clinical trials were carried out and other evidence reviewed critically. And by 2004, a systematic review of the accumulated results of conventional chemotherapy compared with high-dose chemotherapy followed by bone marrow transplantation, as a general treatment for breast cancer, failed to reveal any convincing evidence that it was useful. [10, 11]

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