Delphi-panel analysis of appropriateness of high-dose chemotherapy and blood cell or bone marrow autotransplants in diffuse large-cell lymphoma

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 apropriateness 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.