Gale R P, Park R E, Dubois R, Bierman P J, Fisher R I, Loh K K, Peterson B A, Phillips G L, Portlock C S, Rosenblum D, Armitage J O
Salick Health Care, Inc., Los Angeles, CA 90048, USA.
Leuk Lymphoma. 1998 Dec;32(1-2):139-49. doi: 10.3109/10428199809059254.
Although high-dose chemotherapy and a blood cell or bone marrow autotransplant are commonly used to treat people with diffuse large-cell lymphoma, there is controversy whether this is better than conventional-dose chemotherapy. Subject-selection and time-to-treatment biases preclude comparison of data from uncontrolled trials and there are few date from randomized trials. We used a Delphi-panel group judgment process to determine appropriateness of high-dose chemotherapy and a blood cell or bone marrow transplant. Results were compared to those of randomized trials. Nine lymphoma experts from diverse geographic sites and practice settings were panelists. Boolean MEDLINE searches of lymphoma and chemotherapy and an autotransplant formed the dataset. Panelists were asked to rate appropriateness of high-dose chemotherapy and an autotransplant compared to conventional-dose chemotherapy. Clinical variables were permuted to define 80 clinical settings rated by the panelists on a 9-point ordinal scale. Results were used to determine an appropriateness index reflecting the mean and distribution of ratings. The relationship of appropriateness indices to permuted clinical variables was considered by analysis of variance and recursive partitioning. In people with initial diffuse large-cell lymphoma, autotransplants were never rated appropriate. They were rated uncertain in all settings except in people never receiving chemotherapy and in those with a complete response to chemotherapy and an international prognostic index < 3, where they were rated inappropriate. In people with recurrent lymphoma, autotransplants were rated appropriate in those with a complete or partial response to chemotherapy, uncertain in those with a less than partial response and in those not receiving re-induction chemotherapy and inappropriate in people with CNS lymphoma. These conclusions agree with results of randomized trials.
尽管高剂量化疗以及血细胞或骨髓自体移植常用于治疗弥漫性大细胞淋巴瘤患者，但对于其是否优于传统剂量化疗仍存在争议。受试者选择和治疗时间偏差妨碍了对非对照试验数据的比较，且随机试验的数据很少。我们采用德尔菲专家小组判断程序来确定高剂量化疗以及血细胞或骨髓移植的适用性。将结果与随机试验的结果进行比较。来自不同地理位置和实践环境的9名淋巴瘤专家作为小组成员。通过布尔检索MEDLINE数据库获取淋巴瘤、化疗及自体移植方面的数据，形成数据集。要求小组成员对高剂量化疗及自体移植相对于传统剂量化疗的适用性进行评分。对临床变量进行排列组合，定义80种临床情况，由小组成员按照9分制序数尺度进行评分。结果用于确定反映评分均值和分布的适用性指数。通过方差分析和递归划分来考虑适用性指数与排列后的临床变量之间的关系。对于初发弥漫性大细胞淋巴瘤患者，自体移植从未被评为适用。在所有情况下，除了从未接受过化疗的患者以及对化疗完全缓解且国际预后指数＜3的患者（在这些情况下自体移植被评为不适用），自体移植被评为不确定。对于复发性淋巴瘤患者，自体移植在对化疗有完全或部分缓解的患者中被评为适用，在对化疗缓解程度不足以及未接受再诱导化疗的患者中被评为不确定，而在中枢神经系统淋巴瘤患者中被评为不适用。这些结论与随机试验的结果一致。
