Coping Attitudes of Cancer Patients and Their Caregivers and Quality of Life of Caregivers.

BACKGROUNDS AND AIM: Cancer process is a traumatic period for both patients and their caregivers. Caregivers of the patients use various coping methods to minimize the effects of anxiety-creating negativities in their daily lives. The present study aimed to examine the coping attitudes adopted by the patients and caregivers and the effects of this process upon the quality of life (QoL) of caregivers. METHODS: The cross-sectional study was conducted on three groups of (i) 74 patients consisting of those hospitalized in the department of medical oncology in tertiary care hospital or coming to the health center for chemotherapy treatment as cancer outpatients and (ii) 46 caregivers of patients; and control group 46 healthy individuals. Face-to-face interviews were conducted with the study patients to administer a short sociodemographic questionnaire, coping attitudes assessment scale (COPE), and Short Form-36 (SF-36) QoL scale. RESULTS: Statistically significant differences were recorded among patients, caregivers, and control groups in terms of "problem-focused coping" and "dysfunctional coping" the COPE scale (P = 0.001, P = 0.017). According to scores taken from the SF-36 scale, there was a statistically significant difference between caregivers and control groups in all parameters (P < 0.05). CONCLUSION: Patients and caregivers should be encouraged to use the coping methods related to the source of the problem rather than the dysfunctional coping methods. Evaluation of the QoL indicators of not only the patients but also their caregivers enables to formulate a more integrated approach and detection of the expectations of the caregivers.

Turkish Ministry of Health, 2nd Turkish Medical General Assembly Clinical Oncology Study Group Report.

OBJECTIVE: There is an increase in the incidence of cancer, and consequently in mortality rates, both in the world and in Turkey. The increase in the incidence and mortality rate of cancer are more prominent in our country as well as in other developing countries. The aim of this workshop was to determine the current status on prevention, screening, early diagnosis and treatment of cancer in our country, to identify related shortcomings, specify solutions and to share these with health system operators, and to aid in implementation of these systems. Developments on palliative care were also evaluated. MATERIALS AND METHODS: The current situation in the practice of clinical oncology, related drawbacks, problems encountered during multidisciplinary approach and their solutions were discussed under several sub-headings during a 3-day meeting organized by the Turkish Ministry of Health (Türkiye Cumhuriyeti Saglik Bakanligi-TCSB) with participation of 16 scientists from Turkey and 6 from abroad, and the conclusions were reported. RESULTS: It is expected that the newly established Turkish Health Institutes Association (Türkiye Saglik Enstitüleri Baskanligi-TÜSEB) and the National Cancer Institute (Ulusal Kanser Enstitüsü) will provide a new framework in the field of oncology. The current positive findings include the increase in the number of scientists who carry out successful trials in oncology both in Turkey and abroad, the implementation of the national cancer registry program by the Cancer Control Department and the breast cancer registry program by the Turkish Federation of Breast Diseases Societies (Türkiye Meme Hastaliklari Dernekleri Federasyonu-TMHDF), and introduction of Cancer Early Diagnosis, Screening, and Training Centers (Kanser Erken Tani, Tarama ve Egitim Merkezi-KETEM) for the application of community-based cancer screening programs. In addition to these, obvious shortcomings related to education, implementation, management and research issues were also determined, and policy and project proposals to address these issues were presented. Collaboration with relevant organizations in the implementation of these studies was supported. CONCLUSION: Both the incidence and mortality rates of cancer are increasing in Turkey. The widespread deficiencies in population-based screening and in effective treatment lead to an increase in delay in diagnosis and mortality. Despite improvements in data recording, screening and treatment over the last 10 years, extensive, organized, population-based screening programs and fully equipped early diagnosis and treatment centers are required. Enhancement of basic cancer epidemiologic, translational, genetic and molecular research studies is essential in our country. Improvements on pain treatment and palliative care of patients with chronic and terminal cancer are also required.

Perspectives and practical applications of medical oncologists on defensive medicine (SYSIPHUS study): a study of the Palliative Care Working Committee of the Turkish Oncology Group (TOG).

Defensive medicine occasionally indulges unnecessary treatment requests to defend against lawsuits for medical errors and the use of unapproved medical applications. This study determines the attitudes and orientations of medical oncologists on defensive medicine. A cross-sectional survey was sent by e-mail to medical oncologists. The survey was designed to determine the participants' demographic characteristics and defensive medicine practices. The survey measured the attitudes about defensive medicine practices of the oncologists based on a five-point Likert scale (never, rarely, sometimes, often, and always). One hundred and forty-six of a total of 402 physicians serving in oncology were fully filled, and the rate of return invitation was 36 %. The majority of participants were male, with a duration of between 7 and 9 years of work as university hospital officials, and the mean age was 46 ± 9 (years). International guidelines were followed in the most common is NCCN, and the majority of respondents felt that the application of these guidelines improves their defensive medicine. All participants of defensive medicine who stand on the basis of the definition were found to be more afraid of complaints by patients' relatives. Physicians of 45 % was noted that applying defensive medicine. Among the participants were the most frequent checkups of positive defensive approach is defined as increasing or shortening the follow-up period, while avoiding high-risk patients were detected as described in the definition of negative defensive medicine. Both professional groups in both the positive and negative defensive medicine approach defensive medicine approach, academic tasks, work experience and job time, there was a significant correlation between the location. Made in single- and multi-variable analyses, positions were identified both positive and negative defensive medicine is an independent risk factor for direction. Improving the working conditions of young physicians to protect against medical error may require additional educational opportunities.

The Perspective of Non-oncologist Physicians on Patients with Metastatic Cancer and Palliative Care (ALONE Study): A Study of the Palliative Care Working Committee of the Turkish Oncology Group (TOG).

The aim of our study was to determine the perspective of non-oncologist physicians regarding their attitudes and beliefs associated with palliative care for patients with metastatic cancer. The study was planned as a cross-sectional survey, and non-oncologist physicians were reached via e-mail and social networking sites. The first part of the questionnaire involved demographic properties, the second part inquired as to the perspectives of participants regarding metastatic disease, and the third part was used to determine beliefs and attitudes about palliative care. All of the questions were five-point Likert-type questions. A total of 1734 physicians completed the questionnaire. The majority of participants were general surgeons or internal medicine specialists (21 and 18%, respectively), were male (61%), were younger than 50 years of age (54%), worked in the town center (67%), had more than 11 years of professional experience (57%), and worked in a hospital without an active oncology service (86%). A total of 71% of participants identified all patients with metastatic cancer as being terminal stage, 62% were unaware of palliative care techniques, 64% did not know about common supportive care options, 59% were against hospice, and 63% had no opinion on resuscitation. We determined that non-oncologist physicians believed that all patients with metastatic cancer are at the terminal stage and that palliative/supportive care is the oncologist's task. These data suggest that non-oncologist physicians would benefit from additional graduate and postgraduate courses on these topics.

Investigational tests and treatments performed in terminal stage cancer patients in two weeks before death: Turkish oncology group (TOG) study.

Although more palliative care is necessary for terminally ill cancer patients, excess investigational tests, invasive procedures, and treatments are given instead. Between November 2009 and December 2013, six hundred and twenty-four patients with end-stage cancer who were died at inpatient setting evaluated retrospectively. Patients' characteristics, sites of tumor and metastasis, tests and invasive procedures, treatments performed in the last 2 weeks before death were collected from the hospital files and analyzed. Median age of 624 patients was 58 (range 16-96) years. More than half of the patients (370, 59.3%) were men. The most frequent cancer sites were gastrointestinal (GI) system (32.2%), lung (24.0%), and breast (11.1%). Frequent metastatic sites were liver (34.8%), bone (31.5%), lung (23.3%), and/or brain (16.9%). Causes of death were respiratory failure, infections, and/or liver failure in 49.9, 23.9, and 19.4% of patients, respectively. Radiological tests performed in the last 2 weeks before death were ultrasonography, computed tomography, magnetic resonance imaging, bone scan in 25.6, 16.3, 11.4, and 3.8% of patients, respectively. Treatments received were intravenous (i.v) serum infusion, blood transfusion, total parenteral nutrition (TPN), human albumin infusion in 55.9, 44.1, 34.9, and 9.5% of patients, respectively. Invasive procedures such as invasive pain relief, terminal sedation, and chemotherapy performed in 12.6, 4.4, and 10.0% of patients, respectively. Central venous catheter application, paracentesis, thoracentesis, and GI endoscopy were applied in 41.7, 9.8, 5.6, and 3.4% of the patients, respectively. Radiological tests, invasive procedures, TPN, and human albumin transfusion were used excessively in terminal stage cancer patients in our medical oncology inpatient clinics. Invasive pain relief and terminal sedation were still underused in our cancer clinics. There is an urgent need in developing national palliative care program to improve the understanding of end-of-life care in our medical oncology clinics.

Phase II study of loading-dose ibandronate treatment in patients with breast cancer and bone metastases suffering from moderate to severe pain.

BACKGROUND: The aim of this study was to determine the efficacy and safety of loading-dose intravenous (i.v.) ibandronate in women with breast cancer and bone metastases. PATIENTS AND METHODS: In this prospective, phase II, open-label study, 13 women with breast cancer, bone metastases, and moderate/severe bone pain received ibandronate 6 mg/day (i.v. loading-dose 15 min infusion over 3 consecutive days) with follow-up until day 14. Endpoints included pain response (primary), duration until pain response, analgesic use, Karnofsky index, safety (including hematologic, biochemical, and urine examinations), and adverse events. RESULTS: Pain intensity decreased on days 7 and 14 versus day 1 (mean visual analogue scale score: 3.2 ± 2.2 and 3.0 ± 2.1 versus 6.1 ± 0.9, respectively; p < 0.01 for both). Mean time to pain response was 8.2 ± 3.3 days. Mean rate of analgesic use decreased (69.2%, 16.7% and 15.4% on days 1, 7 and 14, respectively). Mean Karnofsky index score increased (80.8 ± 13.1 and 80.8 ± 13.2, on days 7 and 14 versus 77.7 ± 11.7 on day 1; p < 0.05 on both days). CONCLUSION: Bone pain and analgesic use decreased in women with breast cancer and bone metastases following loading dose i.v. ibandronate which was well-tolerated with no renal safety concerns.

Current status of palliative care in Turkey.

Patients with cancer are still suffering a lot, especially those in developing countries. The concept of palliative care has improved and disseminated slowly in Turkey since the early 1990's. It is essential that improved palliative care program should be integrated into national health-care systems to control this suffering. In this review the history of the development of palliative care, opioid availability and some ethical issues in Turkey are reported.

Factors affecting engraftment time in autologous peripheral stem cell transplantation.

BACKGROUND: Rapid hematological engraftment at autologous peripheral stem cell transplantation (APSCT) is a significant factor in reduction of early transplant-related complications and costs. For this reason, it is important to determine influences on hematological recovery. METHODS: This study was designed to evaluate factors affecting leukocyte and platelet engraftment times after high dose chemotherapy following APSCT. A total of 228 patients (131 males and 97 females) were enrolled. RESULTS: There were statistically significant differences between patients with CD34+ cell doses ≥ 2.5 x 106/kg (n=180) and < 2.5 x 106/kg (n=48), regarding leukocyte engraftment at 11 and 12 days, respectively (p<0.02), between G-CSF (n=167) and GM-CSF (n=61) posttransplant regarding median leukocyte engraftment times (p=0.005), and between with (n=75) or without (n=153) history of pretransplant radiotherapy for both leukocyte and platelet engraftment times (p<0.001). CONCLUSIONS: For leukocyte engraftment, a history of pretransplant radiotherapy, type of growth factor used and number of CD34+ cells infused, and for platelet engraftment, a history of pretransplant radiotherapy were found to be independent variables on multivariate analysis with the Cox regression method.

Modified outpatient dexamethazone, cytarabine and cisplatin regimen may lead to high response rates and low toxicity in lymphoma.

OBJECTIVE: Our purpose was to investigate the efficacy of and establish a toxicity profile for a modified regimen of dexamethasone, cytarabine and cisplatin (DHAP) for lymphoma outpatients. SUBJECTS AND METHODS: Fifty-one lymphoma patients, 26 with Hodgkin's disease and 25 with non-Hodgkin's lymphoma, were included. The patients' median age was 32 years (range: 17-61). Twenty had progressive/refractory disease and 31 relapsed disease. Twenty-five were in clinical stage I/II and 26 in clinical stage III/IV before the initiation of salvage chemotherapy. DHAP consisted of dexamethasone (40 mg i.v. on days 1-4), cytarabine (2 g/m(2) i.v. as 3-hour infusion on days 2 in the evening and 3 in the morning) and cisplatin (35 mg/m(2) as 2-hour infusion on days 1-3) were administered every 21 days. A total of 154 cycles of modified DHAP were administered, with a median of 3 cycles per patient (range: 2-4). RESULTS: The main toxicity was myelosuppression. WHO grade III-IV neutropenia and grade III-IV thrombocytopenia were observed in 27 (52.9%) and 21 (41%) patients, respectively. The overall response rate (85% for Hodgkin's disease and 95% for non-Hodgkin's lymphoma) was 88.3% (39.2% complete response and 49.1% partial response). CONCLUSION: The results showed that this outpatient schedule of DHAP was well tolerated and an effective salvage regimen.

Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy.

AIM: The purpose of this study was to investigate the effect of progressive muscle relaxation training on sleep quality and fatigue in Turkish women with breast cancer undergoing adjuvant chemotherapy. BACKGROUND: Sleep problems and fatigue are highly prevalent in patients with breast cancer. Progressive muscle relaxation training is a promising approach in ameliorating the sleep quality and reducing the fatigue associated with cancer and its treatment. DESIGN: A prospective, repeated measures, quasi-experimental design with control group. METHODS: The study sampling consisted of 27 individuals (14 individuals formed the progressive muscle relaxation group, 13 individuals formed the control group) who met the criteria for inclusion in the study. Progressive muscle relaxation training was given to the progressive muscle relaxation group, but not to the control group. The effect of the progressive muscle relaxation training was measured at different stages of the treatment. A data collection form, Pittsburgh Sleep Quality Index and Piper Fatigue Scale were used to collect the data for this study. RESULTS: The progressive muscle relaxation group experienced a greater increase in improved sleep quality and a greater decrease in fatigue than the control group. CONCLUSIONS: The findings indicated that progressive muscle relaxation training would improve sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. RELEVANCE TO CLINICAL PRACTICE: Progressive muscle relaxation training given by a nurse can improve sleep quality and fatigue in patients with breast cancer. It is important to start relaxation training just before chemotherapy to decrease the frequency and severity of sleep problems and symptoms such as fatigue during chemotherapy.

Isolated renal relapse of a case with non-Hodgkin's lymphoma.

A 29-year-old woman with left pleural effusion and a mass in anterior mediastinum was admitted. Transthoracic needle aspiration from the mass revealed findings consistent with nodular sclerosis variety of Hodgkin's disease. The patient was in remission after six cycles of ABVD followed by mediastinal radiotherapy. Ten months later CT scan showed three hypodense masses in the right kidney. Ultrasound guided renal biopsy revealed diffuse large B cell lymphoma. Retrospective re-evaluation of the archival specimens of the mediastinal mass was also consistent with diffuse large B cell lymphoma. After induction chemotherapy (four cycles of DHAP) she underwent high dose chemotherapy (BEAM) and autologous peripheral blood stem cell transplantation. She is still in remission for 7 years after transplantation. In conclusion, renal involvement during advanced lymphoma is quite common but isolated renal relapse in NHL is a rare situation. Although renal infiltration generally shows a poor prognosis, long-term survival may be achieved with high dose chemotherapy and autologous peripheral blood stem cell transplantation.

An unusual presentation of extramedullary plasmacytoma in testis and review of the literature.

Extramedullary plasmacytoma is a rare plasma cell neoplasm, and it is extremely uncommon in the testicles. We report a 73-year-old man with multiple myeloma presented with testicular plasmacytoma. He complained of left leg pain and scrotal swelling. Ultrasonography revealed testicular masses. Pathologic examination of the orchiectomy specimen showed plasmocytoma with kappa expression. Multiple lytic bone lesions were seen in bone survey scans, serum immunoelectrophoresis and bone marrow aspiration aided to the diagnosis of multiple myeloma. He received chemotherapy, melphalan and prednisolone, and palliative radiotherapy. He succumbed to disease after 8 months.

The clinical significance of tumor cells in bone marrow or apheresis product and the efficacy of CD34+ selection and high-dose chemotherapy in patients with Stage III breast cancer.

The purpose of this study is to determine the presence of disseminated tumor cells in bone marrow or apheresis product, and also to evaluate the clinical significance of contaminated products and the efficacy of CD34(+) selection and high-dose chemotherapy in patients with Stage III breast cancer. Fifty-five patients were enrolled in this prospective cohort study. Whereas CD34(+) positive selection was not carried out in the first group (unselected group, n:31), CD34(+) positive selection was performed in the second group (CD34 selected group, n:24). Tumor cells were detected with anticytokeratin monoclonal antibody in the bone marrow, apheresis product and positive fraction. Tumor cells were found in six (19.3%) patients in unselected group and four patients (16.6%) in CD34 selected group (P = 0.76). The percentages of distant metastases were found higher in unselected group (51.6% vs. 25%, P < 0.01). Although there were no differences between the two groups for disease free survival (DFS; 44% vs. 74%, P = 0.24) or overall survival (54% vs. 68%, P = 0.84), DFS was significantly lower in patients with tumor cells than in patients without tumor cells (21% vs. 62%, P = 0.02). In conclusion, the presence of tumor cells in bone marrow or apheresis product decreases DFS in patients with Stage III breast cancer who underwent high-dose chemotherapy. CD34(+) selection does not change survivals, but it may decrease the distant metastases.

Analysis of patient-related barriers in cancer pain management in Turkish patients.

The purpose of this study was to evaluate the validity and reliability of the Barriers Questionnaire II (BQ-II) for Turkish patients and to define the patient-related barriers to cancer pain management in Turkey. For this, 170 patients with cancer who used or were still using analgesic medication for pain related to cancer participated in the study. It was found that patients have beliefs that may be barriers to optimal pain management, mostly in relation to addiction, and to a small extent, physical side effects. It was ascertained that male, unmarried patients, patients with cancer who also have another chronic disease, patients whose "average pain" intensity is more than 5 for the past 24 hours, and patients who use an inadequate analgesic have more beliefs that may be barriers to optimal pain management. It was concluded that the BQ-II is a valid and reliable scale in Turkey for defining patient-related barriers to cancer pain management.

Self-reported experience of mucositis in cancer patients who underwent conditioning regimen and stem cell transplantation.

PURPOSE: This study was done to evaluate the frequency and severity of mucositis in the early period of stem cell transplantation (SCT) and the relation of conditioning regimens with mucositis. PATIENTS AND METHODS: Patients with hematologic or solid tumors who underwent conditioning regimen were asked to score mucositis severity daily from the first day to the tenth day of reinfusion. Patient-reported scoring was performed according to a five-grade scale (0: no symptom; 1: mild; 2: moderate; 3: severe; 4: very severe). Total mucositis score (TMS) was defined as the addition of daily mucositis scores for 10 days. A total of 68 SCT (58 autologous and 10 allogeneic) patients, 48 men (71%) and 20 women (29%) were included to the study. Median age of patients was 32.5 (range 15-78) years. The most frequent three diagnosis were non-Hodgkin's lymphoma (37%, n = 25), Hodgkin's lymphoma (12%, n = 8), and multiple myeloma (12%, n = 8). BEAM (n = 27), ICE (n = 17), melphelan 200 mg/m(2) (M200)(n = 8), and TBI+C (total body irradiation + cyclophosphamide) (n = 16) were used as conditioning regimens. RESULTS: All of the patients experienced mucositis at any grade. TMS in the sixth day was higher than TMS in the first day (p < 0.05). TMS was not related to the diagnosis or gender (p > 0.05). TMS at ICE regimen in the first 5 days after transplantation was more severe than BEAM regimen. TMS at TBI+C regimen was higher than TMS at BEAM regimen from day 4 to day 10 (p < 0.05). The mean percentages of patients who scored severe or very severe mucositis in 10 days was 7.4% in BEAM, 8.9% in ICE, 12.5% in M200, and 31.2% in TBI+C groups. CONCLUSION: Patients experience mucositis frequently following conditioning regimen and SCT. The necessity and the timing of prophylaxis for mucositis change due to the type of conditioning regimens.

Long-lasting multiagent chemotherapy in adult high-risk Ewing's sarcoma of bone.

The outcome of Ewing's sarcoma depends on the anatomical site of the tumor. Studies conducted in high-risk patients are limited. We evaluated the outcome of high-risk Ewing's sarcoma patients that received long-term treatment protocol. Twenty-five patients (22 males, 3 females) with poor prognostic features were treated according to long-term Ewing's sarcoma protocol. Central-axis localization, inadequacy or unavailability of surgical resection, older than 15 years of age, are accepted as high-risk factors. The median age of patients was 23 years (range, 18-55). The tumor localization was pelvis (9), femur (1), tibia (1), fibula (1), maxilla (1), clavicle (1), vertebrae (5), metatarse (1), and ribs (5). Neoadjuvant chemotherapy was applied between weeks 0 and 6, local therapy on week 9, and adjuvant maintenance chemotherapy between weeks 11 and 41. All patients received neoadjuvant and adjuvant maintenance chemotherapy. Local therapy consisted of radiotherapy (32%), surgery alone (12%), or surgery and radiotherapy (56%). The median total treatment period was 10 months. The median follow-up was 25 months (range, 7-89). Three-year cumulative OS and DFS rates were 43% (95% CI, 28.5-57.85) and 40% (95% CI 23.63-52.19), respectively. The most common grade III/IV toxicities observed during the treatment protocol were neutropenia (16%) and gastrointestinal toxicities (16%). Our study indicated that long-term multiagent combination chemotherapy may result in better outcome in adult high-risk patients undergoing adequate surgical resection of the tumor and local radiotherapy. Further randomized studies are needed to assess the efficacy of this treatment protocol in patients with adequate surgical margins.

Reduced dose of lenograstim is as efficacious as standard dose of filgrastim for peripheral blood stem cell mobilization and transplantation: a randomized study in patients undergoing autologous peripheral stem cell transplantation.

In vitro studies have demonstrated a 27% increased efficacy of lenograstim over filgrastim. However, equal doses of 10 microg/kg/day of filgrastim and lenograstim have been recommended for mobilization of CD34+ cells without associated chemotherapy. In this study, we investigated whether a 25% reduced dose of lenograstim at 7.5 microg/kg/day is equavalent to 10 microg/kg/day filgrastim for autologous peripheral blood stem cell (PBSC) mobilization and transplantation. A total of 40 consecutive patients were randomized to either filgrastim (n = 20) or lenograstim (n = 20). The two cohorts were similar in regard to disease, sex, body weight, body surface area, conditioning regimens, previous chemotherapy cycles and radiotherapy. Each growth factor was administered for 4 consecutive days. The first PBSC apheresis was done on the 5th day. In the posttransplant period, the same G-CSF was given at 5 microg/kg/day until leukocyte engraftment. Successful mobilization was achieved in 95% of patients. Successful mobilization with the first apheresis, was achieved in 10/20 (50%) patients in the filgrastim group versus 9/20 (46%) patients in the lenograstim group. No significant difference was seen in the median number of CD34+cells mobilized, as well as the median number of apheresis, median volume of apheresis, percentage of CD34+ cells, and CD34+ cell number. Leukocyte and platelet engraftments, the number of days requiring G-CSF and parenteral antibiotics, the number of transfusions were similar in both groups in the posttransplant period. Lenograstim 7.5 microg/kg/day is as efficious as filgrastim 10 microg/kg/day for autologous PBSC mobilization and transplantation.

Impact of c-erb2 status on survival after high dose chemotherapy in high-risk breast cancer patients.

OBJECTIVE: To investigate the impact of c-erb2 status on survival after high-dose chemotherapy. METHODS: Between March 1997 and June 2004, a total of 54 women with breast cancer who has at least 8 metastatic lymph nodes underwent high-dose chemotherapy with hematopoietic stem cell transplantation in Gulhane Military Medical School, Ankara, Turkey. Archival specimens were analyzed by fluorescent in situ hybridization to determine the impact of c-erb2 status after peripheral blood stem cell transplantation on survival. The patients were divided into c-erb2 negative (n=20) and positive (n=11) groups. RESULTS: No statistically significant differences were detected between c-erb2 negative and positive groups regarding 5-year disease-free survival (41 and 27%, log rank p=0.11), and overall survival (60 and 45%, p=0.33). Transplant related mortality did not differ between groups. CONCLUSION: We found no differences between c-erb2 negative and positive groups regarding disease-free and overall survival. To clarify the value of the c-erb2 status in predicting outcome after high-dose chemotherapy, prospective randomized studies are needed.