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PubMed1994

Comparison of autografting using mobilized peripheral blood stem cells with and without granulocyte colony-stimulating factor in malignant lymphomas.

Peripheral blood is becoming widely used as the only source of hematopoietic stem cells to support marrow ablative therapy in advanced lymphoma. We report data from 23 patients with high risk non-Hodgkin's (n = 19) and Hodgkin's lymphoma (n = 4) who underwent high-dose therapy with mobilized peripheral blood stem cell (PBSC) autografting. Peripheral blood progenitors were recruited using cytotoxic chemotherapy followed by administration of recombinant human G-CSF (filgrastim 5 micrograms/kg/day). Myeloablative treatment with autologous PBSC support was administrated to the 23 patients and followed by G-CSF at the same dose after cell reinjection. Hematopoietic reconstitution was compared with a control group of lymphoma patients who received chemotherapy mobilized PBSC transplantation but without G-CSF prior to leukaphereses or after high-dose therapy. The median time to neutrophil recovery > 0.5 x 10(9)/l was significantly shorter in study patients compared with the control patients (10 days and 17 days respectively) (p < 0.05). Self sustaining platelet counts of > 50 x 10(9)/l occurred at a median time of 17 days in both groups. Stable hemopoietic reconstitution was seen with a follow-up of 6 months after PBSC transplantation. In addition, a significant relationship was observed between the number of CFU-GM infused and the time to platelet recovery. We confirm the effectiveness of G-CSF given prior to PBSC harvesting in generating high numbers of progenitor cells. Hematologic recovery following high-dose therapy was improved after PBSC rescue and G-CSF.

Adolescent↗
PubMed1994

[Clinical study of recombinant human granulocyte colony stimulating factor (rhG-CSF) on leukopenia induced by chemotherapy in cancer patients].

The clinical usefulness of Recombinant Human Granulocyte Colony Stimulating Factor (rhG-CSF, Filgrastim, GRAN) was evaluated in patients with leukopenia and neutropenia following chemotherapy for non-Hodgkin's lymphoma, lung cancer and breast cancer. During chemotherapy when patients' leukocyte count (WBC) fell below 4.0 x 10(9)/L.rhG-CSF(GRAN) at a dose of 75 micrograms/body.day was given subcutaneously 48 hours after the termination of chemotherapy. The results indicated that rhG-CSF(GRAN) could elevate nadirs of WBC and significantly shortened leukopenic period with WBC below 4.0 x 10(9)/L and expedited the recovery of WBC. rhG-CSF (GRAN)'s side effects were mild.

Adult↗
PubMed1994

[Colony stimulating factors in blood formation].

The aim of this article is to review the present state of knowledge of the clinical effects of the colony-stimulating factors. Clinical experience and publications on this subject are used for this purpose. Colony-stimulating factors are being successfully used in various diseases and clinical situations, particularly in the area of hematology/oncology. However, numerous questions still remain. There are many new untested areas in which filgrastim could be employed. New indications and open questions require suitable new studies.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Blood-derived autografts collected during granulocyte colony-stimulating factor-enhanced recovery are enriched with early Thy-1+ hematopoietic progenitor cells.

It was the objective of the study to characterize CD34+ hematopoietic progenitor cells from peripheral blood (PB) and bone marrow (BM) in a group of 24 cancer patients. After cytotoxic chemotherapy, R-metHu granulocyte colony-stimulating factor (R-metHuG-CSF; filgrastim, 300 micrograms daily, subcutaneously) was given to shorten the time of neutropenia as well as to increase the rebound of peripheral blood progenitor cells (PBPC) for harvesting. The proportion of CD34+ cells in the leukapheresis products (LPs) was 1.4-fold greater than in BM samples that were obtained at the same day (LP: median, 1.4% v BM: median, 1.0%, P < .01). Two- and three-color immunofluorescence showed that blood-derived CD34+ cells comprised a greater proportion of a particular early progenitor cell than CD34+ cells of bone marrow. Blood-derived progenitor cells tended to have a higher mean fluorescence intensity of CD34 and expressed significantly lower levels of HLA-DR (mean fluorescence intensity of HLA-DR: 442.6 +/- 44.9 [LP] v 661.5 +/- 64.6 [BM], mean +/- SEM, P < .01). Furthermore, the blood-derived CD34+ cells comprised a 1.7-fold greater proportion of Thy-1+ cells (LP: median, 24.4% v BM: median, 14.4%, P < .001) and expressed significantly less c-kit (LP: median, 20.5% v BM: median, 31.0%, P < .01). Three-color analysis showed that high levels of Thy-1 expression were restricted to CD34+/HLA-DRdim or CD34+/HLA-DR- cells confirming the early developmental stage of this progenitor cell subset. The proportion of CD34+/CD45RA(bright) cells representing late colony-forming unit granulocyte-macrophage (CFU-GM) was smaller in LPs compared with BM (P < .05). For an examination of BM CD34+ cells before the mobilization chemotherapy, samples of 16 patients were available. The mean proportion of c-kit expressing CD34+ cells in the bone marrow during G-CSF-stimulated reconstitution decreased 1.8-fold compared with baseline values. There was no difference in the proportion of BM-derived CD34+/Thy-1+ cells and CD34+/CD45RA+ cells between steady-state hematopoiesis and G-CSF-supported recovery. Our data suggest that during G-CSF-enhanced recovery, CD34+ cells in the PB are enriched with more primitive progenitor cells to evenly replenish the BM after the chemotherapy-related cytotoxic damage.

Adult↗
PubMed1994

Administration of granulocyte colony-stimulating factor from day 7 after autologous bone marrow transplantation: effects on neutropenia and duration of hospitalization.

G-CSF (5 mg/kg/day Filgrastim) was administered from day 7 after autologous bone marrow transplantation (ABMT) in a series of 17 patients treated for multiple myeloma or non-Hodgkin's lymphoma. In comparison with retrospective controls receiving ABMT without G-CSF and matched for age, underlying disease, disease status at ABMT, number of CFU-GM/kg reinfused, conditioning regimen and number and type of chemotherapy courses prior to ABMT, the duration of neutropenia, intravenous antibiotics and hospitalization was significantly reduced in the G-CSF group (p < 0.001). Delaying the administration of G-CSF after ABMT is an interesting possibility which merits further exploration in prospective randomized studies.

Adult↗
PubMedDate not supplied

Mobilization of circulating progenitor cells in multiple myeloma during VCAD therapy with or without rhG-CSF.

BACKGROUND: Circulating progenitor cells (CPC), when infused in large numbers, rapidly repopulate the marrow after myeloablation with high-dose therapy. In multiple myeloma (MM), as in other disorders, different chemotherapy regimens, including single-as well as multiple-agent chemotherapy, with or without hemopoietic growth factors, have been proposed to mobilize these progenitor cells into the blood. Here we report our experience with a drug combination called VCAD and compare the results to those obtained by adding rhG-CSF to the same combination. METHODS: Fourteen MM patients were given one course of VCAD, a chemotherapy association of vincristine 2 mg, cyclophosphamide 4 x 0.5 g/m2, adriamycin 2 x 50 mg/m2 and dexamethasone 4 x 40 mg, before undergoing apheresis to collect CPC for autografting. Seven also received rhG-CSF (filgrastim) 5 mcg/kg/day over the period of apheresis. These latter were allocated to rhG-CSF treatment sequentially from the time the drug became available for clinical use. RESULTS: Following VCAD-induced pancytopenia, CFU-GM peaked at a median of 853/mL (range 96-4352; 7.6 times basal level). RhG-CSF administration increased CFU-GM levels but not significantly. With rhG-CSF the CFU-GM peak was reached sooner, toxicity was reduced and granulocytopenia less protracted. Fewer aphereses were run in the rhG-CSF group, there were higher yields per single run, and patients began and completed their collection program more quickly. CONCLUSIONS: The VCAD association is able to mobilize CPC in patients with MM, and rhG-CSF is recommended as a fundamental part of the priming schedule.

Adult↗
PubMedDate not supplied

Treatment of normal donors with rhG-CSF 16 micrograms/kg for mobilization of peripheral blood stem cells and their apheretic collection for allogeneic transplantation.

BACKGROUND: Utilization of peripheral blood stem cells (PBSC) in allogeneic transplantation requires a method for their mobilization and collection that is not inconvenient for the donor. METHODS: We administered rhG-CSF (filgrastim) 16 micrograms/kg subcutaneously for 4 days in five normal subjects (age 18-31, M = 3, F = 2), previously selected as HLA-identical donors of siblings with leukemia. All the donors gave written informed consent. On days 4 and 5 (in one donor on day 6 too), 10:l leukapheretic collection was performed with a CS-3000 (Baxter) or an AS-104 (Fresenius) cell separator through the antecubital vein. RESULTS: The WBC count reached a median peak of 57.0 x 10(9)/L on day 5. The peripheral blood CFU-GM peaked to a median level of 8908/mL on day 5 with a median increase over baseline values of 39.1 times. The CD34+ cells peaked to (median) 147.0 x 10(6)/L on day 4 with a median increase of 65.3 times. A lesser enrichment was recorded for BFU-E (median increase 12.7 times) and CFU-GEMM (median increase 15.2 times). Even CD3+ and CD56+CD3- cells increased (median 1.7 and 1.5 times, respectively). A median of 771 x 10(8) MNC (range 672-1378), 116.4 x 10(6) CFU-GM (range 47.7-145.1) and 754 x 10(6) CD34+ cells (range 477-2599) were apheretically collected. Concerning side effects, mild to moderate back pain and general minor discomfort were reported by all donors. The platelet level regularly but transiently decreased after completion of the apheretic procedures with a median nadir of 69 x 10(9)/L (range 43-126) on (median) day 7, but in no case did thrombocytopenia cause bleeding. The thrombocytopenia was more pronounced with the CS-3000 than the AS-104 apparatus. CONCLUSIONS: rhG-CSF 16 micrograms/kg x 4 days is an efficient schedule for PBSC mobilization in healthy donors, but lower doses and even a single apheresis procedure might prove similarly adequate.

Adolescent↗
PubMed1995

Granulocyte colony-stimulating factor mobilizes primitive hematopoietic stem cells in normal individuals.

We studied the hematopoietic activity of peripheral blood stem cells (PBSC) mobilized by recombinant human granulocyte colony-stimulating factor (G-CSF) using semisolid and long-term culture systems (LTC) in 5 normal individuals. Following 2 or 3 daily subcutaneous injections of G-CSF (filgrastim; 1.5 micrograms/kg), not only committed progenitors including CFU-GM, BFU-E, and CFU-Mix, but also long-term culture initiating cells (LTC-IC) were increased in the peripheral blood. When the cells derived from CFU-GM, BFU-E and CFU-Mix colonies were replated for secondary colony formation, a minor fraction of CFU-GM and CFU-Mix colonies formed after 3 days of G-CSF stimulation in vivo could produce secondary colonies. Moreover, the replating capacity of primary colonies from 5-week-old LTC initiated after 3 days of G-CSF stimulation was increased compared to that from 5-week-old LTC initiated in a 'steady-state'. These observations indicate that G-CSF can mobilize very primitive progenitors (LTC-IC) along with committed progenitors into the circulation and suggest that some of these G-CSF-mobilized progenitors may retain self-renewal capacity.

Adult↗
PubMed1995

Circulating progenitors following high-dose sequential (HDS) chemotherapy with G-CSF: short intervals between drug courses severely impair progenitor mobilization.

Sequential administration of high-dose chemotherapy courses possibly allows extensive in vivo purging before circulating progenitor collection for autograft. To evaluate whether progenitor cell mobilization was negatively affected by repeated high-dose chemotherapy courses, we studied 23 lymphoma patients undergoing the HDS regimen. The scheme includes the sequential administration of cyclophosphamide (CY) given at 7 g/m2 and etoposide (VP16) given at 2 g/m2, each followed by G-CSF (filgrastim) at 5 micrograms/kg/day. Eleven patients received the standard HDS sequence, with a short interval between first and second myelotoxic courses of less than 45 days (median: 30 days); the remaining 12 patients received a modified HDS where the interval between first and second high-dose course was protracted over 2 months (median: 70 days); in this latter group, 2 to 4 conventional debulking courses were delivered prior to HDS. In patients receiving the standard HDS, progenitor mobilization following the first course was consistently high (median circulating CFU-GM/ml peak value: 29,022); however, significantly lower values were observed at the second course (median CFU-GM/ml peak value 3757, P = 0.002). Circulating BFU-E and CD34+ cell values paralleled those of CFU-GM. No significant difference was observed in progenitor mobilization following either course in patients receiving HDS with extended interval (median circulating CFU-GM/ml peak value: 14,363 vs 9208, at first and second course respectively, P = 0.27). Eleven patients had their progenitor cells harvested following the second delayed course and 2-4 leucaphereses allowed very satisfactory harvests in all of them (CFU-GM/kg ranging from 39-340 x 10(4)).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Viability of haemopoietic progenitors from whole blood, bone marrow and leukapheresis product: effects of storage media, temperature and time.

High-dose cytotoxic chemotherapy can be supported with autologous haemopoietic cells. Cryopreserved bone marrow has conventionally been used for this but blood stem cells are now in common use. We have examined different storage conditions for haemopoietic cells from bone marrow, leukapheresis product and whole blood primed with chemotherapy and filgrastim. The mean number of GM-CFC surviving cryopreservation was 80% in leukapheresis product (95% CI 66-96). At 4 degrees C, GM-CFC viability in all three sources of haemopoietic progenitors declined at the same rate, with mean recovery at 24 h of 90% (95% CI 82-98), at 48 h of 68% (95% CI 61-75) and at 72 h of 47% (95% CI 40-53). Progenitors remained viable for longer in autologous serum and citrate phosphate dextrose or Iscove's medium than in phosphate buffered saline. There was no significant difference in GM-CFC recovery from whole blood or whole blood buffy layer at 4 degrees C. The capacity to generate and sustain haemopoiesis in long-term culture is a feature of the more primitive progenitor cells. This capacity was similar in cryopreserved bone marrow and leukapheresis product, cryopreserved or stored for up to 5 days at 4 degrees C, suggesting that long-term culture-initiating cells are more resilient than colony-forming cells when cryopreserved or stored at 4 degrees C. These data indicate that primed whole blood, in addition to leukapheresis product and bone marrow, could be stored at 4 degrees C and used to support multicyclic high-dose chemotherapy.

Blood Cells↗
PubMed1994

A phase I-II study of high-dose thiotepa, busulfan and cyclophosphamide as a preparative regimen for allogeneic marrow transplantation.

Thirty adults with hematologic malignancies at high-risk for relapse were treated on a phase I-II study of high-dose thiotepa, busulfan (BU) and cyclophosphamide (CY) as the preparative regimen for allogeneic marrow transplantation. Cyclosporine and methylprednisolone or anti-CD5 ricin A chain immunoconjugate were used as graft-versus-host disease prophylaxis. Filgrastim was given from day 1 to enhance engraftment. Median follow-up time is 16 months (range 9-29 months). Grades III-IV regimen-related toxicity occurred in 5 (26%) of 19 patients treated with thiotepa 250 mg/m2 x 3, BU 1 mg/kg x 12 and CY 60 mg/kg x 2 and this was considered the maximal tolerated dose-schedule. Stomatitis and hepatoxicity were dose-limiting. All patients engrafted and had complete donor chimerism. The actuarial rate of acute graft-versus-host disease was 71% (95% CI 62-80%). The relapse rate at 1 year was 38% (95% CI 25-50%) and the actuarial survival at 1 year was 30% (95% CI 22-38%). The combination of thiotepa, BU and CY is tolerable as a preparative regimen for allogeneic marrow transplantation.

Adolescent↗
PubMed1993

Reimbursement and pharmacoeconomic perspectives in biotechnology.

Problems associated with reimbursement for biotechnology agents and strategies for solving these problems are reviewed. Because of the many different insurers in the U.S. health care system, a variety of reimbursement strategies have been developed for the biotechnology drugs that are now reaching the market. These strategies can vary by insurer, contract, treatment setting, and patient condition. With the advent of high-cost biotechnology drugs, pharmacists have taken on the additional roles of institutional educators and reimbursement specialists. Case studies involving three biotechnology agents illustrate how insurers deal with reimbursement for these drugs. Thrombolytic agents are reimbursed under Medicare, but the diagnosis-related-group (DRG) payment for myocardial infarction was not changed until two years after alteplase was marketed. Septic shock therapies potentially face similar reimbursement problems, which are compounded because the drugs can be lifesaving--leading to longer hospital stays. When filgrastim is administered, the amount reimbursed depends on the treatment setting. When claims for biotechnology agents are denied, the institution or provider should contact the payer to provide the needed information (in the case of missing information) or to discuss payer policies that may need review. Through proper case management, pharmacists and other institutional personnel can ensure reimbursement for these lifesaving biotechnology therapies.

Biotechnology↗
PubMed1993

Strategic management of biotechnology agents.

The use of biologic response modifiers to demonstrate a value-driven approach to strategic management by pharmacists is described. To participate in decisions on the use of technology in their institutions, pharmacists must practice strategic management. This process includes environmental scanning, analysis of clinical and pharmacoeconomic data, and development of clinical management approaches. It is ideal for analyzing biologic response modifiers such as filgrastim and sargramostim. Emphasis must be placed on maximizing the fit among the products, the institution, and the health care environment. Pharmacists will find plentiful opportunities for clinical management with biotechnology agents. Practitioners who specialize in determining the total cost of care by using pharmacoeconomic methods are needed, as are practitioners trained to monitor the complicated biotechnology agents. Also, the institution needs to forecast accurately the impact of emerging biotechnology agents. If pharmacists can develop and control clinical, pharmacoeconomic, and reimbursement information databases for biotechnology agents, the pharmacy profession will be in a strong position to meet the challenges of biotechnology and realize the inherent opportunities.

Biotechnology↗
PubMed1995

[Agranulocytosis caused by clozapine: the importance of leukocyte monitoring and efficacy of hematopoietic growth factors].

In four patients, a woman aged 85 and three men aged 33, 42 and 70 years, clozapine-induced agranulocytosis was diagnosed. In three patients the white cell counts were not performed as they should have been. Two patients were treated for their agranulocytosis with granulocyte colony-stimulating factor (G-CSF; filgrastim). Two patients were not treated. The literature concerning clozapine-induced agranulocytosis and its treatment with growth factors consists of only a few case reports. Therefore a definite conclusion about the efficacy of the treatment for this particular indication is not yet possible.

Adult↗
PubMed1995

Engraftment characteristics of peripheral blood stem cells mobilised with cyclophosphamide and the delayed addition of G-CSF.

The optimal protocol for the mobilisation of PBSC remains unknown. We present data on 42 patients mobilised with cyclophosphamide (3 or 4 g/m2) and the delayed addition of a standard 300 micrograms dose of G-CSF (Filgrastim) from day +5. The patients had received a median of 2 previous chemotherapy regimes, 38% had received prior radiotherapy and 38/42 had active disease at the time of mobilisation. The protocol was well tolerated and 38 patients proceeded to transplantation. The median number of CD34+ cells reinfused was 4.3 x 10(6)/kg (range 0.5-30) and CFU-GM 15.8 x 10(4)/kg (range 0-148). The total number of CD34+ cells harvested correlated with the total number of CFU-GM available for reinfusion (P = 0.008). Overall engraftment occurred within median days to neutrophils > 0.5 x 10(9)f/l or platelets > 20 x 10(9)/l of 14 and 13 days, respectively. Patients receiving more than 2.5 x 10(6)/kg CD34+ cells had even more rapid haemopoietic reconstitution with significant reductions in hospital stay and transfusion requirements. Those below this threshold had significantly delayed platelet engraftment. The mobilising dose of cyclophosphamide did not influence the achievement of the threshold CD34+ cell yield for optimal engraftment. The delayed addition of a standard 300 micrograms G-CSF dose after priming chemotherapy resulted in the use of a median 9 days hence 9 vials of G-CSF. This protocol presents the potential for cost saving without compromising the quality or success of PBSC mobilisation.

Adult↗
PubMed1996

[Successful syngeneic transplantation using G-CSF-stimulated peripheral hematopoietic progenitor cells combined with post-transplant administration of G-CSF in a patient with acute lymphatic leukemia].

A 45-year-old male with acute lymphoblastic leukemia in first remission was successfully transplanted with G-CSF (filgrastim)-mobilized syngeneic PBPC (peripheral blood progenitor cells). Conditioning regimen consisted of high-dose etoposide, cyclophosphamide and total body irradiation. For PBPC mobilization the patient's healthy syngeneic brother was subcutaneously stimulated with 16 micrograms/kg/day G-CSF for 5 consecutive days. Only mild adverse effects (myalgia, transient changes of laboratory test) were observed. PBPC-apheresis was performed three times without complications on days 4, 5 and 6 after the start of G-CSF application. The unmanipulated PBPC (total 5.75 x 10(8)/kg mononucleated cells) were transfused immediately after each collection. Engraftment under administration of G-CSF (5 micrograms/kg/day subcutaneously) from day 0 to +12 was very rapid. Neutrophils exceeded 1.0 x 10(9)/l on day +9, platelet counts reached 50 x 10(9)/l on day +13. On day +27 the patient was discharged from the hospital with normal blood counts except mild anemia (Hb 9.5 g%). Bone marrow aspiration was repeatedly normocellular with normal differential count and no leukemia. We demonstrate that G-CSF-mobilized syngeneic PBPC transplantation after myeloblative chemoradiotherapy results in rapid and so far stable hematologic reconstitution with an actual follow-up of more than 15 months. This experience may be of relevance for future allogeneic G-CSF-mobilized PBPC transplantation.

Antineoplastic Combined Chemotherapy Protocols↗
PubMedDate not supplied

The emergence of peripheral blood progenitor cells to support intensive chemotherapy for patients with breast cancer.

Increasing evidence supports the hypothesis that "dose" is critical to the clinical outcomes of cytotoxic chemotherapy for patients with breast cancer. Clinical trials continue to investigate whether higher doses of chemotherapy lead to proportionate improvements in the outcomes of patients. Delivery of dose-intensive chemotherapy has been facilitated by technological advancements in supportive care. Improved antiemetics have led to increased patient tolerance of the most acute symptoms of aggressive chemotherapeutic dosing. Chemotherapy-induced myelosuppression may be minimized in a lineage-specific manner by appropriate use of hematopoietic cytokines such as filgrastim (granulocyte colony-stimulating factor), sargramostim (granulocyte-macrophage colony-stimulating factor), and/or epoetin alfa (erythropoietin). However, cumulative myelotoxicity occurs with dose-intensive chemotherapy over multiple cycles despite adjunctive cytokine support. Additionally, no cytokine has yet been demonstrated to support platelet production to any clinically significant degree although several regulators of platelet production (such as thrombopoietin, IL-6, and IL-11) are in clinical trials. Many cytokines can induce the mobilization of hematopoietic progenitor and stem cells from the bone marrow into the circulating blood pool, where these cells may be harvested. Clinical use of these cytokine-mobilized peripheral blood progenitor cells (also known as PBPCs or, commonly, as blood stem cells) has documented the effectiveness of these cells to reconstitute multilineage blood production following very high-dose chemotherapy. The ease with which PBPCs can be collected and their reproducible clinical effectiveness to support patients through intensive treatment protocols have led to a virtual elimination of bone marrow as the source of cellular support for myeloablative chemotherapy in many transplant centers. Novel investigative approaches are also possible with PBPCs. In this review, the historical background of PBPCs is summarized, and the potential benefits (including economic advantages) of PBPCs to support dose-intensive chemotherapy for treating breast cancer are discussed. While dose intensification of breast cancer chemotherapy to the degree requiring PBPC support remains controversial and, in most centers, investigational, there is no doubt that PBPCs are an effective adjunct to the hematopoietic support of patients undergoing transplant-level cytotoxic treatments. Further study will undoubtedly lead to increased use of PBPCs in novel treatments for patients with breast cancer and other solid tumors.

Bone Marrow Transplantation↗
PubMedDate not supplied

Peripheral blood progenitor cell transplantation for breast cancer: pharmacoeconomic considerations.

The recent observation that mobilized peripheral blood progenitor cells (PBPCs) can be used as a source of hematopoietic support has had a major effect on the cost and morbidity associated with bone marrow transplantation in patients with breast cancer. The pharmacoeconomic impact of this new technology is especially evident when secondary costs are analyzed. We see a reduction in hospital stay, decreased use of resources such as platelet transfusions and antibiotics, and long-term quality life-years gained for those patients benefiting from this therapy. Experienced transplant centers have found that the direct cost of high-dose chemotherapy using filgrastim and PBPC support is reduced as much as 50% to the patient or their insurance company. Pharmacists will play a key role in optimizing the benefits of PBPC transplantation, particularly because this therapy is moving to the outpatient arena. This article will review the pharmacoeconomic impact of PBPC transplantation primarily in terms of secondary cost measures and quality of life and discuss the limited direct cost data available and the impact of this therapy on pharmacy practice.

Antineoplastic Combined Chemotherapy Protocols↗