The Last Resort

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What no one has ever figured out is who should foot the bill. Many HMOs wanted no part of the treatment, branding it as experimental. The problem is, the only way to change that designation is for women to undergo the treatment as part of a clinical study. And that gets pricey unless insurance companies chip in. "Insurers should be willing to pay," says Dr. John Durant, of the American Society of Clinical Oncology. "They'd probably save money with fewer relapses and more premiums."

Some insurers, however, had long dug in their heels over transplant therapy, and last week's announcement may make them dig deeper still. The five new studies looked at two types of breast cancer: high-risk cases, in which the disease has spread to 10 or more lymph nodes; and metastatic cases, in which it's migrated even further. Of the three studies that focused on high-risk cases--surveying a total of 1,462 breast-cancer patients--only one found a statistically significant advantage for transplant therapy. The two studies that focused on metastatic disease showed no real advantage in terms of survival. One of those studies did show that metastatic patients who underwent transplants had longer remission periods before relapsing--no small thing for people facing a potentially lethal disease. Moreover, the patients in all five studies must be followed for several more years before the research can be considered complete. Nonetheless, concedes Dr. Edward Stadtmauer of the University of Pennsylvania, who headed one of the trials, "it's not clear that this treatment is a major benefit."

But it's also not certain that it isn't, and that's where things get muddy. It took experimenters years to collect the volunteers they needed to give their findings any statistical oomph--in part because women didn't want to risk being in the half of the sample group that received conventional therapy instead of the transplant. Over that time, transplant methods improved, and it is thus possible that higher mortality rates from women earlier in the research are dragging down more positive results from women later on. For now, the only answer appears to be more and better studies.

How insurers will react to all this is unclear. US Healthcare (now merged with Aetna) and some Blue Cross/Blue Shield plans helped bankroll three of the recent studies, an act of good corporate citizenship that seemed to signal a willingness to keep paying for transplant treatments in breast-cancer cases. A doctor working with Kaiser-Permanente, the nation's largest HMO, offers more direct reassurance. "It will be up to the doctor and the patient," predicts oncologist Louis Fehrenbacher.

For HMOs that have been disinclined to offer coverage, however, last week's news offers little incentive to do things differently. Legislative pressure--plus the ongoing threat of more jackpot lawsuits--may yet force the hands of those holdouts. But whether that will be enough for women like Tawnya Geisbush, still awaiting an O.K. from her insurer, is unclear. "I have a fairly small window of time to work with," she says. By the time the company is persuaded, one way or the other, her window may have already closed.

--Reported by Rachele Kanigel/San Francisco and Dick Thompson/Washington