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Variables influencing the timing of marrow transplantation in patients with
chronic myelogenous leukemia
GB Segel, W Simon and MA Lichtman
The prognosis for patients with chronic myelogenous leukemia (CML) has
improved only for patients who can receive marrow transplantation from a
histocompatible sibling. The timing of the marrow transplant is made
difficult by the high peritransplant mortality of 20% to 35% and a group of
patients with a prolonged chronic phase of CML, which can be identified on
the basis of prognostic indexes (age, percent blood myeloblasts, spleen
size, and platelet count). We have developed a mathematic model and
computer program that consider age, prognostic index, and projected
survival rate by transplantation to balance the risk of peritransplant
mortality against the risk of delaying the transplantation of patients with
Philadelphia chromosome-positive CML. The computation assesses the risk of
delaying transplantation; it does not offer the option of avoiding
transplantation, since long-term survival ultimately requires
transplantation. Three prognostic groups were considered as described by
Sokal and co-workers (Blood 63:789, 1984) (I, best; II, intermediate; III,
worst prognosis). The computation used the projected survival rates of
transplantation from the Seattle experience and from the International Bone
Marrow Transplant Registry. As an example of the model's utility, we have
determined the ratio of the calculated life expectancy to the normal life
expectancy for hypothetical patients up to 50 years of age in each of the
three prognostic categories. A value of 20% is used for patients who
successfully receive transplants after the onset of the accelerated phase.
The analysis allows assessment of the risk of delaying transplantation for
a finite time in patients with CML. The importance of the method rests in
its consideration of multiple variables, including the peritransplant
mortality, transplant projected survival before and upon entering the
accelerated phase, age, prognostic group, and other risk factors. The
program permits a change in these parameters as new information or advances
in treatment occur. This analysis does not replace the diagnostic
deliberations of the clinician. Rather, it provides a numeric framework for
prognosis based on the currently available data. The physician in
conjunction with the patient, not the algorithm, makes the decisions of
whether and when to transplant.
Volume 68,
Issue 5,
pp. 1055-1064,
11/01/1986
Copyright © 1986 by The American Society of Hematology
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