Dose-Intensive Chemotherapy with Growth Factor or Autologous Bone Marrow or Stem-Cell Transplant Support in First-Line Treatment of Advanced or Metastatic Adult Soft Tissue Sarcoma: A Clinical Practice Guideline

Questions: (1) In patients with inoperable locally advanced or metastatic soft tissue sarcoma, does first-line doseintensive chemotherapy supported by growth factor or autologous bone marrow or stem-cell transplantation improve response rate, time to disease progression, or survival as compared with standarddose chemotherapy? (2) What are the effects of first-line dose-intensive chemotherapy supported by growth factor or autologous bone marrow or stem-cell transplantation on toxicity and quality of life? Perspectives: Because therapeutic options for adult patients with advanced or metastatic soft tissue sarcoma are scarce and the possibility of cure for these patients is extremely limited, the Sarcoma Disease Site Group (DSG) felt that a review of the available literature on doseintensive chemotherapy for adult patients with locally advanced or metastatic soft tissue sarcoma and subsequent development of a clinical practice guideline based on the evidence were important. Methodology: A systematic review was developed and clinical recommendations relevant to patients in Ontario were drafted. The practice guideline report was reviewed and approved by the Sarcoma DSG, which comprises medical oncologists, radiation oncologists, surgeons, a pathologist, a methodologist, and community representatives. External review by Ontario practitioners was obtained through a mailed survey, the results of which were incorporated into the practice guideline. Final review and approval of the practice guideline was obtained from the Report Approval Panel. Practice Guideline: Based on the systematic review, consensus, and external review, the Sarcoma DSG makes these recommendations: (1) Dose-intensive chemotherapy with growth factor support is not recommended in the first-line treatment of patients with inoperable locally advanced or metastatic soft tissue sarcoma. (2) The data are insufficient to support the use of highdose chemotherapy with autologous bone marrow or stem-cell transplantation as first-line treatment in this group of patients. (3) Eligible patients should be encouraged to enter clinical trials assessing novel approaches or compounds. Qualifying Statements: High-dose chemotherapy with growth factor or autologous bone marrow or stem-cell transplantation has adverse effects similar to those seen with standard-dose chemotherapy. With high-dose regimens, the incidence of grades 3 and 4 thrombocytopenia is significantly higher, and neutropenic fever and febrile neutropenia occur more frequently. Compared with standard treatment, the rate of treatment-related death is also higher with highdose regimens.