Ten children with recurrent metastatic (stage IV) neuroblastoma received local radiation therapy, supralethal chemotherapy, and total-body irradiation. Rescue with infusions of either allogeneic (four patients) or autologous (six patients) bone marrow followed. The drugs given to the first two patients were individualized combinations based on previous tumor responses. Both patients died with recurrent tumor three and nine months posttransplant. The eight remaining patients were treated more uniformly with local irradiation, VM-26, doxorubicin, melphalan (L-phenylalanine mustard), and 1,000-rad total-body irradiation in three fractions. Two of these patients had cardiac dysfunction and received no doxorubicin. Three children died in the immediate posttransplant period with disseminated fungal infections. A fourth relapsed and died nine months posttransplant. As of December 1, 1983, two children who received allogeneic marrow grafts have survived in complete remission for 54 and 36 months, and two children who received autologous marrow grafts have survived in complete remission for 35 and 22 months. These results suggest that relapsed metastatic neuroblastoma can be controlled by supralethal combinations of chemotherapy and irradiation coupled with bone-marrow rescue.

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was substantially less than hospital-based care. With comprehensive palliative services, we found that quality of life could be sustained and lengthy hospitalizations avoided in children, adolescents, and young adults with severe progressive chronic diseases, and that continued support for patient and family alleviated some of the distress for situations that could not be reversed. Although less expensive and cumbersome than conventional care, palliative care services require adequate reimbursement from managed care. We found that comprehensive palliation of the diseases from which children die was often more costly than traditional hospice care. In the United States, the majority of children with severe and/or progressive chronic diseases receive most of their care at tertiary-care centres or specialized children's hospitals. The cost of home care versus hospital care has been addressed for children with cancer and in hospice care (1). Studies have also reported the outcomes of specific interventions such as assessment and treatment of pain (2-5). In family-centred pediatrics, professionals share decision making and care planning with the family. This partnership is critical for the chronically ill child living at home (6-9). Most families with chronically ill children, especially those whose children are dying, prefer to provide their care at home, as opposed to in a hospital or long-term facility (3,4). Managed or capitated health care systems today rapidly return these children to home to reduce cost. Successful medical management depends upon professionals' ability to develop flexible but comprehensive care plans, to educate the family caregiver in the adaptation of those plans to the home environment, to be available to both family and

Objectives. Infusion of chemotherapy at home provides an alternative to hospitalization for children with cancer. Few programs of pediatric home chemotherapy have been described or evaluated. The purpose of this work was to compare prospectively chemotherapy in the hospital to chemotherapy at home with respect to billed medical charges, out-of-pocket expenses, and quality of life. Methods. Eligibility criteria for home therapy were defined. Parents and nurses were trained. Billed charges, loss of wages, out-of-pocket expenses, medical outcome, and quality of life of 14 patients for one course of chemotherapy in the hospital were compared with those for an identical course at home. Results. Daily charges for chemotherapy were $2329 ± 627 in the hospital and $1865 ± 833 at home; out-of-pocket costs, $68 ± 31 and $11 ± 6, respectively; and loss of income, $265 ± 233 and $67 ± 107, respectively. Patients' independence, well-being, appetite, mood, and school work were significantly better at home, and parental time at work and with the family was greater. Conclusion. Administration of selected chemotherapy at home results in lower billed charges, reduced expenses, reduced loss of income for parents, and a more satisfying lifestyle for patients and parents.

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