Originally published as JCO Early Release 10.1200/JCO.2007.15.0169 on March 31 2008

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Individual Physician Practice Variation in Hematopoietic Cell Transplantation

Stephanie J. Lee, Steven Joffe, Andrew S. Artz, Richard E. Champlin, Stella M. Davies, Madan Jagasia, Nancy A. Kernan, Fausto R. Loberiza, Jr, Robert J. Soiffer, Mary Eapen

From the Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA; Departments of Pediatrics, Medicine, and Medical Oncology, Dana-Farber Cancer Institute, Children's Hospital, Boston, MA; Department of Medicine, University of Chicago, Chicago, IL; Department of Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, TX; Division of Hematology/Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN; Pediatric Bone Marrow Transplantation Service, Memorial Sloan-Kettering Cancer Center, New York, NY; Department of Medicine, University of Nebraska, Omaha, NE; and the Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI

Corresponding author: Stephanie Lee, MD, MPH, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D5-290, Seattle, WA 98109; e-mail: sjlee{at}fhcrc.org

Purpose: Previous studies have evaluated practice variation in hematopoietic cell transplantation (HCT) among transplant centers and countries. There are no studies investigating individual physician practice variation in HCT.

Methods: An international Internet-based survey of transplant physicians collected data on medical decisions made by adult and pediatric HCT physicians. Multivariable analyses identified practitioner and transplant center characteristics predictive of medical decision making.

Results: Analysis of 526 assessable respondents showed a wide variation in management approaches to specific clinical scenarios. Pediatric and adult transplant physicians differed significantly in their management strategies for chronic myeloid leukemia, acute and chronic graft-versus-host disease, and choice of graft source for patients with aplastic anemia. Among adult transplant physicians, there was little agreement on the patient factors favoring reduced intensity conditioning or myeloablative conditioning.

Conclusion: These results emphasize the heterogeneity of worldwide transplant practices. Local preferences or biases likely result in similar patients being offered different transplant and treatment procedures. The degree of practice variation also highlights the need for clinical trials to clarify areas of controversy. Where clinical trials are not feasible, data from observational studies may be the best available evidence to guide practice.

published online ahead of print at www.jco.org on March 31, 2008.

Presented in part at the 48th Annual Meeting of the American Society of Hematology, December 9-12, 2006, Orlando, FL.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.