Achievements and Challenges of Evidence-Based Medicine in Hematopoietic Stem Cell Transplantation: An Analysis of Single-Center and Multicenter Trials

BV Afanasyev, IS Moiseev, NG Volkov, KV Lepik, NB Mikhailova, SN Bondarenko, LS Zubarovskaya, EV Morozova, OV Paina, PV Kozhokar, ZhZ Rakhmanova, OV Pirogova, KS Afanas’eva, AV Beinarovich, EV Semenova, OG Smykova, IV Markova, TA Bykova, AL Alyanskii, BI Smirnov, MD Vladovskaya, AG Smirnova, NE Ivanova, AD Kulagin

RM Gorbacheva Scientific Research Institute of Pediatric Oncology, Hematology and Transplantation; IP Pavlov First Saint Petersburg State Medical University, 6/8 L’va Tolstogo str., Saint Petersburg, Russian Federation, 197022

For correspondence: Ivan Sergeevich Moiseev, MD, PhD, 6/8 L’va Tolstogo str., Saint Petersburg, Russian Federation, 197022; e-mail: moisiv@mail.ru

For citation: Afanasyev BV, Moiseev IS, Volkov NG, et al. Achievements and Challenges of Evidence-Based Medicine in Hematopoietic Stem Cell Transplantation: An Analysis of Single-Center and Multicenter Trials. Clinical oncohematology. 2020;13(3):260–72. (In Russ).

DOI: 10.21320/2500-2139-2020-13-3-260-272


ABSTRACT

Randomized multicenter trials in the area of hematopoietic stem cell transplantation (HSCT) face considerable challenges, therefore, their amount is relatively small. Most clinical guidelines are based on the data of multicenter registry studies or well-controlled prospective single-center non-randomized studies. To determine the criteria of a well-controlled single-center trial the results of which can be confirmed by a multicenter analysis, the total of 44 groups of patients from 22 cooperative studies in collaboration with EBMT were analyzed. The results of these studies were compared with single-center data and the results of the planned studies of RM Gorbacheva Scientific Research Institute of Pediatric Oncology, Hematology and Transplantation. In 43 % of cases significant differences were observed, whereby result-difference probability did not decrease with a rising number of patients in the single-center groups, but became higher (odds ratio 1.037; 95% confidence interval 1.001–1.074; = 0.046), which highlights the differences in methods of single- and multicenter trials. While analyzing the reasons of significant results the following necessary criteria for high-quality single-center trials in the area of HSCT were formulated: 1) conditioning regimens and graft-versus-host disease prophylaxis (if they are not subject of the study) need to be consistent with the most frequently used practices; 2) groups of patients should be status-homogeneous; 3) the trial must not include the patients treated more than 5 years before the analysis; 4) patients should receive current antitumor therapy at pre- and post-transplantation stages; 5) each compared group should include more than 30–40 patients.

Keywords: hematopoietic stem cell transplantation, evidence-based medicine, single-center trials, multicenter trials, meta-analysis.

Received: April 1, 2020

Accepted: June 20, 2020

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REFERENCES

  1. Kuhn K. Claudii Galeni Opera Omnia. Leipzig; 1821–1833. Vol. 1.

  2. Clendening L. Source Book Of Medical History. N.Y.: Dover Pubs.; 1960.

  3. Kaplan E, Meier P. Nonparametric Estimation from Incomplete Observations. J Am Stat Assoc. 1958;53(282):457–81. doi: 10.1080/01621459.1958.10501452.

  4. Lasagna L, Meier P. Clinical Evaluation of Drugs. Annu Rev Med. 1958;9(1):347–54. doi: 10.1146/annurev.me.09.020158.002023.

  5. Doll R, Hill A. Study of the Aetiology of Carcinoma of the Lung. BMJ. 1952;2(4797):1271–86. doi: 10.1136/bmj.2.4797.1271.

  6. Bonadonna G, Zucali R, Monfardini S, de Lena M, Uslenghi C. Combination chemotherapy of Hodgkin’s disease with adriamycin, bleomycin, vinblastine, and imidazole carboxamide versus MOPP. Cancer. 1975;36(1):252–9. doi: 10.1002/1097-0142(197507)36:1<252::aid-cncr2820360128>3.0.co;2-7.

  7. Hughes A. Clinical epidemiology a basic science for clinical medicine (2nd edition). Statist Med. 1993;12(2):187–8. doi: 10.1002/sim.4780120211.

  8. Oxman A. Users’ Guides to the Medical Literature. JAMA. 1993;270(17):2093. doi: 10.1001/jama.1993.03510170083036.

  9. Greenhalgh T. How to read a paper. BMJ Books; 2014.

  10. Hill G. Archie Cochrane and his legacy. J Clin Epidemiol. 2000;53(12):1189–92. doi: 10.1016/s0895-4356(00)00253-5.

  11. Петров В.И. Базисные принципы и методология доказательной медицины. Вестник ВолгГМУ. 2011;2(38):3–8.[Petrov VI. Basic principles and methodology in evidence-based medicine. Vestnik VolgGMU. 2011;2(38):3–8. (In Russ)]

  12. Liesegang TJ. Evidence-based medicine: principles for applying the users’ guides to patient care. Am J Ophthalmol. 2001;1:153. doi: 10.1016/s0002-9394(00)00911-9.

  13. Bondarenko, SN, Moiseev IS, Slesarchuk, OA, et al. Allogeneic hematopoietic stem cell transplantation in children and adults with acute lymphoblastic leukemia. Cell Ther Transplant. 2016;5(2):12–20. doi: 10.18620/1866-8836-2016-5-2-12-20.

  14. Sadowska-Klasa A, Piekarska A, Prejzner W, et al. Colonization with multidrug-resistant bacteria increases the risk of complications and a fatal outcome after allogeneic hematopoietic cell transplantation. Ann Hematol. 2017;97(3):509–17. doi: 10.1007/s00277-017-3205-5.

  15. Alessandrino EP, Della Porta MG, Bacigalupo A, et al. Prognostic impact of pre-transplantation transfusion history and secondary iron overload in patients with myelodysplastic syndrome undergoing allogeneic stem cell transplantation: a GITMO study. Haematologica. 2019;95(3):476–84. doi: 10.3324/haematol.2009.011429.

  16. Schmidt-Hieber M, Tridello G, Ljungman P, et al. The prognostic impact of the cytomegalovirus serostatus in patients with chronic hematological malignancies after allogeneic hematopoietic stem cell transplantation: a report from the Infectious Diseases Working Party of EBMT. Ann Hematol. 2019;98(7):1755–63. doi: 10.1007/s00277-019-03669-z.

  17. Ayuk F, Beelen DW, Bornhauser M, et al. Relative Impact of HLA Matching and Non-HLA Donor Characteristics on Outcomes of Allogeneic Stem Cell Transplantation for Acute Myeloid Leukemia and Myelodysplastic Syndrome. Biol Blood Marrow Transplant. 2018;24(12):2558–67. doi: 10.1016/j.bbmt.2018.06.026.

  18. Zheng C, Dai R, Gale RP, Zhang MJ. Causal inference in randomized clinical trials. Bone Marrow Transplant. 2019;55(1):4–8. doi: 10.1038/s41409-018-0424-x.

  19. Bazarbachi AH, Hamed RA, Labopin M, et al. Allogeneic stem-cell transplantation with sequential conditioning in adult patients with refractory or relapsed acute lymphoblastic leukemia: a report from the EBMT Acute Leukemia Working Party. Bone Marrow Transplant. 2020;55(3):595–602. doi: 10.1038/s41409-019-0702-2.

  20. Shem-Tov N, Peczynski C, Labopin M, et al. Haploidentical vs. unrelated allogeneic stem cell transplantation for acute lymphoblastic leukemia in first complete remission: on behalf of the ALWP of the EBMT. Leukemia. 2020;34(1):283–92. doi: 10.1038/s41375-019-0544-3.

  21. Battipaglia G, Labopin M, Kroger N, et al. Posttransplant cyclophosphamide vs antithymocyte globulin in HLA-mismatched unrelated donor transplantation. Blood. 2019;134(11):892–9. doi: 10.1182/blood.2019000487.

  22. Brissot E, Labopin M, Ehninger G, et al. Haploidentical versus unrelated allogeneic stem cell transplantation for relapsed/refractory acute myeloid leukemia: a report on 1578 patients from the Acute Leukemia Working Party of the EBMT. Haematologica. 2019;104(3):524–32. doi: 10.3324/haematol.2017.187450.

  23. Kharfan-Dabaja MA, Labopin M, Polge E, et al. Association of Second Allogeneic Hematopoietic Cell Transplant vs Donor Lymphocyte Infusion With Overall Survival in Patients With Acute Myeloid Leukemia Relapse. JAMA Oncol. 2018;4(9):1245–53. doi: 10.1001/jamaoncol.2018.2091.

  24. Giebel S, Labopin M, Potter M, et al. Comparable results of autologous and allogeneic haematopoietic stem cell transplantation for adults with Philadelphia-positive acute lymphoblastic leukaemia in first complete molecular remission: An analysis by the Acute Leukemia Working Party of the EBMT. Eur J Cancer. 2018;96:73–81. doi: 10.1016/j.ejca.2018.03.018.

  25. Bazarbachi A, Boumendil A, Finel H, et al. Brentuximab vedotin prior to allogeneic stem cell transplantation in Hodgkin lymphoma: a report from the EBMT Lymphoma Working Party. Br J Haematol. 2018;181(1):86–96. doi: 10.1111/bjh.15152.

  26. van Gelder M, Ziagkos D, de Wreede L, et al. Baseline Characteristics Predicting Very Good Outcome of Allogeneic Hematopoietic Cell Transplantation in Young Patients With High Cytogenetic Risk Chronic Lymphocytic Leukemia – A Retrospective Analysis From the Chronic Malignancies Working Party of the EBMT. Clin Lymphoma Myel Leuk. 2017;17(10):667–75.e2. doi: 10.1016/j.clml.2017.06.007.

  27. Santoro N, Ruggeri A, Labopin M, et al. Unmanipulated haploidentical stem cell transplantation in adults with acute lymphoblastic leukemia: a study on behalf of the Acute Leukemia Working Party of the EBMT. J Hematol Oncol. 2017;10(1):113. doi: 10.1186/s13045-017-0480-5.

  28. Lucchini G, Labopin M, Beohou E, et al. Impact of Conditioning Regimen on Outcomes for Children with Acute Myeloid Leukemia Undergoing Transplantation in First Complete Remission. An Analysis on Behalf of the Pediatric Disease Working Party of the European Group for Blood and Marrow Transplantation. Biol Blood Marrow Transplant. 2017;23(3):467–74. doi: 10.1016/j.bbmt.2016.11.022.

  29. Savani BN, Labopin M, Blaise D, et al. Peripheral blood stem cell graft compared to bone marrow after reduced intensity conditioning regimens for acute leukemia: a report from the ALWP of the EBMT. Haematologica. 2016;101(2):256–62. doi: 10.3324/haematol.2015.135699.

  30. Ecsedi M, Lengline E, Knol-Bout C, et al. Use of eltrombopag in aplastic anemia in Europe. Ann Hematol. 2019;98(6):1341–50. doi: 10.1007/s00277-019-03652-8.

  31. Battipaglia G, Boumendil A, Labopin M, et al. Unmanipulated haploidentical versus HLA-matched sibling allogeneic hematopoietic stem cell transplantation in relapsed/refractory acute myeloid leukemia: a retrospective study on behalf of the ALWP of the EBMT. Bone Marrow Transplant. 2019;54(9):1499–510. doi: 10.1038/s41409-019-0459-7.

  32. Yaniv I, Krauss AC, Beohou E, et al. Second Hematopoietic Stem Cell Transplantation for Post-Transplantation Relapsed Acute Leukemia in Children: A Retrospective EBMT-PDWP Study. Biol Blood Marrow Transplant. 2018;24(8):1629–42. doi: 10.1016/j.bbmt.2018.03.002.

  33. Ruggeri A, Labopin M, Bacigalupo A, et al. Post-transplant cyclophosphamide for graft-versus-host disease prophylaxis in HLA matched sibling or matched unrelated donor transplant for patients with acute leukemia, on behalf of ALWP-EBMT. J Hematol Oncol. 2018;11(1):40. doi: 10.1186/s13045-018-0586-4.

  34. Avivi I, Boumendil A, Finel H, et al. Autologous stem cell transplantation for primary mediastinal B-cell lymphoma: long-term outcome and role of post-transplant radiotherapy. A report of the European Society for Blood and Marrow Transplantation. Bone Marrow Transplant. 2018;53(8):1001–9. doi: 10.1038/s41409-017-0063-7.

  35. Cesaro S, Crocchiolo R, Tridello G, et al. Comparable survival using a CMV-matched or a mismatched donor for CMV+ patients undergoing T-replete haplo-HSCT with PT-Cy for acute leukemia: a study of behalf of the infectious diseases and acute leukemia working parties of the EBMT. Bone Marrow Transplant. 2018;53(4):422–30. doi: 10.1038/s41409-017-0016-1.

  36. Martinez C, Gayoso J, Canals C, et al. Post-Transplantation Cyclophosphamide-Based Haploidentical Transplantation as Alternative to Matched Sibling or Unrelated Donor Transplantation for Hodgkin Lymphoma: A Registry Study of the Lymphoma Working Party of the European Society for Blood and Marrow Transplantation. J Clin Oncol. 2017;35(30):3425–32. doi: 10.1200/JCO.2017.72.6869.

  37. Kroger N, Iacobelli S, Franke GN, et al. Dose-Reduced Versus Standard Conditioning Followed by Allogeneic Stem-Cell Transplantation for Patients With Myelodysplastic Syndrome: A Prospective Randomized Phase III Study of the EBMT (RICMAC Trial). J Clin Oncol. 2017;35(19):2157–64. doi: 10.1200/JCO.2016.70.7349.

  38. Pavlu J, Labopin M, Zoellner AK, et al. Allogeneic hematopoietic cell transplantation for primary refractory acute lymphoblastic leukemia: A report from the Acute Leukemia Working Party of the EBMT. Cancer. 2017;123(11):1965–70. doi: 10.1002/cncr.30604.

  39. Rubio MT, Savani BN, Labopin M, et al. Impact of conditioning intensity in T-replete haplo-identical stem cell transplantation for acute leukemia: a report from the acute leukemia working party of the EBMT. J Hematol Oncol. 2016;9(1):25. doi: 10.1186/s13045-016-0248-3.

  40. Baron F, Labopin M, Peniket A, et al. Reduced-intensity conditioning with fludarabine and busulfan versus fludarabine and melphalan for patients with acute myeloid leukemia: a report from the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Cancer. 2015;121(7):1048–55. doi: 10.1002/cncr.29163.

  41. Verneris MR, Eapen M, Duerst R, et al. Reduced-intensity conditioning regimens for allogeneic transplantation in children with acute lymphoblastic leukemia. Biol Blood Marrow Transplant. 2010;16(9):1237–44. doi: 10.1016/j.bbmt.2010.03.009.

  42. Gilleece MH, Labopin M, Yakoub-Agha I, et al. Measurable residual disease, conditioning regimen intensity, and age predict outcome of allogeneic hematopoietic cell transplantation for acute myeloid leukemia in first remission: A registry analysis of 2292 patients by the Acute Leukemia Working Party European Society of Blood and Marrow Transplantation. Am J Hematol. 2018;93(9):1142–52. doi: 10.1002/ajh.25211.

  43. Moiseev IS, Pirogova OV, Alyanski AL, et al. Graft-versus-Host Disease Prophylaxis in Unrelated Peripheral Blood Stem Cell Transplantation with Post-Transplantation Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil. Biol Blood Marrow Transplant. 2016;22(6):1037–42. doi: 10.1016/j.bbmt.2016.03.004.

  44. Бондаренко С.Н. Роль аллогенной трансплантации гемопоэтических стволовых клеток в программной терапии острого миелоидного лейкоза у взрослых: Дис. … д-ра мед. наук. СПб., 2020. 277 с.[Bondarenko SN. Rol’ allogennoi transplantatsii gemopoeticheskikh stvolovykh kletok v programmnoi terapii ostrogo mieloidnogo leikoza u vzroslykh. (The role of allogeneic hematopoietic stem cell transplantation in the programmed treatment of acute myeloid ) [dissertation] Saint Petersburg; 2020. 227 p. (In Russ)]

  45. Afanasyev B, Borzenkova E, Lepik K, et al. Improving the outcome in patients with relapsed/refractory classical Hodgkin lymphoma undergoing allogeneic stem cells transplantation. Bone Marrow Transplant. 2019;53(S1):P622. doi: 10.1038/s41409-018-0354-

  46. Kalashnikova OB, Ivanova MO, Shmidt DI, et al. Allogeneic hematopoietic stem cell transplantation for relapsed and refractory chronic lymphocytic leukemia: single-center experience. Cell Ther Transplant. 2019;8(3):56–7.

  47. Beynarovich AV, Babenko EV, Moiseev IS, et al. Haploidentical stem cell transplantation in adults for the treatment of hematologic diseases: results of a single center (CIC725). Cell Ther Transplant. 2019;8(1):26–35. doi: 10.18620/ctt-1866-8836-2019-8-1-26-35.

  48. Paina OV, Rakhmanova ZZ, Kozhokar PV, et al. Comparison of Allogeneic Transplant Outcomes Using Conditioning with Different Dose of Busulfan for Children with Acute Myeloid Leukemia. Blood. 2019;134(Suppl_1): doi: 10.1182/blood-2019-128155.

  49. Кучер М.А. Роль и оптимизация трансфузиологической тактики при трансплантации гемопоэтических стволовых клеток у онкологических и гематологических больных: Дис. … д-ра мед. наук. СПб., 2018. 246 с.[Kucher MA. Rol’ i optimizatsiya transfuziologicheskoi taktiki pri transplantatsii gemopoeticheskikh stvolovykh kletok u onkologicheskikh i gematologicheskikh bol’nykh. (The role and optimization of transfusion approach in hematopoietic stem cell transplantation in oncological and hematological patients.) [dissertation] Saint Petersburg; 2018. 246 p. (In Russ)]

  50. Кожокарь П.В., Паина О.В., Боровкова А.С. и др. Повторная аллогенная трансплантация гемопоэтических стволовых клеток как метод терапии у детей с рефрактерным течением онкогематологических заболеваний. Российский журнал детской гематологии и онкологии. 2019;6(S1):162–3.[Kozhokar PV, Paina OV, Borovkova AV, et al. Repeated allogeneic hematopoietic stem cell transplantation as therapy for children with refractory oncohematological diseases. Rossiiskii zhurnal detskoi gematologii i onkologii. 2019;6(S1):162–3. (In Russ)]

  51. Моисеев И.С. Совершенствование методов профилактики и лечения реакции «трансплантат против хозяина»: Дис. … д-ра мед. наук. СПб., 2019. 300 с.[Moiseev IS. Sovershenstvovanie metodov profilaktiki i lecheniya reaktsii “transplantat protiv khozyaina”. (Improvement of methods for prevention and treatment of graft-versus-host disease.) [dissertation] Saint Petersburg; 2019. 300 p. (In Russ)]

  52. Morozova EV, Barabanshikova MV, Tcvetkov NY, et al. Application of standard and novel prognostic systems in patients with myelodysplastic syndrome undergoing allogeneic hematopoietic stem cell transplantation. Cell Ther Transplant. 2019;8(1):36–45. doi: 18620/ctt-1866-8836-2019-8-1-36-45.

  53. Бондаренко С.Н., Разумова С.В., Станчева Н.В. и др. Эффективность аллогенной трансплантации гемопоэтических стволовых клеток с миелоаблативными режимами и режимами кондиционирования со сниженной интенсивностью у детей и подростков с острым миелобластным лейкозом. Онкопедиатрия. 2015;2(4):396–403. doi: 10.15690/onco.v2.i4.1466.[Bondarenko SN, Razumova SV, Stancheva NV, et al. Efficacy of Allogeneic Stem Cell Transplantation for Children and Adolescents with Acute Myeloid Leukemia After Myeloablative and Reduced-Intensity Conditioning. Onkopediatria. 2015;2(4):396–403. doi: 10.15690/onco.v2.i4.1466. (In Russ)]

  54. Giralt S, Ballen K, Rizzo D, et al. Reduced-intensity conditioning regimen workshop: defining the dose spectrum. Report of a workshop convened by the center for international blood and marrow transplant research. Biol Blood Marrow Transplant. 2009;15(3):367–9. doi: 10.1016/j.bbmt.2008.12.497.

  55. Gavaghan DJ, Moore AR, McQay HJ. An evaluation of homogeneity tests in meta-analysis in pain using simulations of patient data. Pain. 2000;85(3):415–24. doi: 10.1016/s0304-3959(99)00302-4.

  56. Volpp KG, Troxel AB, Pauly MV, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360(7):699–709. doi: 10.1056/NEJMsa0806819.

  57. Fredman LS. Tables of the number of patients required in clinical trials using the logrank test. Statist Med. 1982;1(2):121–9. doi: 10.1002/sim.4780010204.

  58. Wakamatsu M, Terakura S, Ohashi K, et al. Impacts of thymoglobulin in patients with acute leukemia in remission undergoing allogeneic HSCT from different donors. Blood Adv. 2019;3(2):105–15. doi: 10.1182/bloodadvances.2018025643.

  59. Залялов Ю.Р. Роль поликлональных антитимоцитарных глобулинов в повышении эффективности трансплантаций аллогенных гемопоэтических стволовых клеток в клинике: Автореф. дис. … канд. мед. наук. СПб., 2012. 21 с.[Zalyalov YuR. Rol’ poliklonal’nykh antitimotsitarnykh globulinov v povyshenii effektivnosti transplantatsii allogennykh gemopoeticheskikh stvolovykh kletok v klinike. (The role of polyclonal antithymocyte globulins in improving the efficacy of allogeneic hematopoietic stem cell transplantation in clinical practice.) [dissertation] Saint Petersburg; 2012. 21 р. (In Russ)]

  60. Кистенева Л.Б. Клинико-лабораторные особенности цитомегаловирусной и HC-вирусной инфекции у беременных и новорожденных. Разработка системы лечебно-профилактических мер: Дис. … д-ра мед. наук. М., 2011. 322 с.[Kisteneva LB. Kliniko-laboratornye osobennosti tsitomegalovirusnoi i HC-virusnoi infektsii u beremennykh i novorozhdennykh. Razrabotka sistemy lechebno-profilakticheskikh mer. (Clinical and laboratory features of cytomegalovirus and HC-virus infection in pregnancy and neonates. Development of therapeutic and prophylactic measures.) [dissertation] Moscow; 2011. 322 p. (In Russ)]

  61. Ciurea SO, Al Malki MM, Kongtim P, et al. The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic cell transplantation. Bone Marrow Transplant. 2020;55(1):12–24. doi: 10.1038/s41409-019-0499-z.

  62. Armand P, Kim HT, Cutler CS, et al. A prognostic score for patients with acute leukemia or myelodysplastic syndromes undergoing allogeneic stem cell transplantation. Biol Blood Marrow Transplant. 2008;14(1):28–35. doi: 10.1016/j.bbmt.2007.07.016.

  63. Schroeder T, Wegener N, Lauseker M, et al. Comparison between upfront transplantation and different pretransplant cytoreductive treatment approaches in patients with high-risk myelodysplastic syndrome and secondary acute myelogenous leukemia Biol Blood Marrow Transplant. 2019;25(8):1550–9. doi: 10.1016/j.bbmt.2019.03.011.

  64. Shaheen M, Moiseev IS, Ivanova MO, et al. Prognosis of Elevated Serum Ferritin in Allogeneic-HCT. Global J Hematol Blood Transf. 2015;2(2):1–10. doi: 10.15379/2408-9877.2015.02.02.01.

  65. Lepik KV, Mikhailova NB, Moiseev IS, et al. Nivolumab for the treatment of relapsed and refractory classical Hodgkin lymphoma after ASCT and in ASCT-naive patients. Leuk Lymphoma. 2019;60(9):2316–9. doi: 10.1080/10428194.2019.1573368.

  66. Паина О.В. Аллогенная трансплантация стволовых гемопоэтических клеток от гаплоидентичного донора в лечении первичной химиорезистентности и рецидивов острых лейкозов у детей и подростков: Дис. … д-ра мед. наук. СПб., 2017.[Paina OV. Allogennaya transplantatsiya stvolovykh gemopoeticheskikh kletok ot gaploidentichnogo donora v lechenii pervichnoi khimiorezistentnosti i retsidivov ostrykh leikozov u detei i podrostkov. (Allogeneic hematopoietic stem cell transplantation from haploidentical donor for the treatment of primary chemoresistant or relapsed acute leukemias in children and adolescents.) [dissertation] Saint Petersburg; 2017. (In Russ)]

  67. Connors JM, Jurczak W, Straus DJ, et al. Brentuximab Vedotin with Chemotherapy for Stage III or IV Hodgkin’s Lymphoma. N Engl J Med. 2018;378(9):878. doi: 10.1056/nejmx180007.

  68. Sertkaya A, Birkenbach A, Berlind A, Eyraud J. Examination of Clinical Trial Costs and Barriers for Drug Development. Available from: https://aspe.hhs.gov/report/examination-clinical-trial-costs-and-barriers-drug-development (accessed 4.05.2020).