Economics, health care systems and utilization of haematopoietic stem cell transplants in Europe

Authors


Professor A. Gratwohl, Kantonsspital Basel, Division Hematology, Department of Internal Medicine, CH-4031 Basel, Switzerland. E-mail: haematology@uhbs.ch

Abstract

Summary. Transplantation of haematopoietic stem cells from blood or bone marrow (HSCT) has seen rapid expansion. Increased costs and quality concerns present a challenge for health care providers. Information on factors influencing HSCT utilization is necessary. Data on 113 827 patients (37 761 allogeneic HSCT and 76 066 autologous HSCT), collected from 580 centres in 35 European countries between 1990 and 1999, were used. Economic factors, e.g. gross national product per capita, health care expenditure per capita and type of health care system were correlated with transplant rates (numbers of HSCT per 10 million inhabitants), team density (numbers of transplant teams per 10 million inhabitants) and increase in transplant numbers for each country. Annual numbers of HSCT increased in all European countries from 4234 in 1990 to 18 720 in 1999 irrespective of health care system. Economic strength and team density were the main determinants for transplant rate. This report reflects changes over the last decade and current status of HSCT in Europe. Economic strength, team density and hitherto unknown factors influence dissemination of the technology within Europe. These data provide a basis for health care planning, regulatory aspects and future research.

Transplantation of haematopoietic stem cells (haematopoietic stem cell transplantation, HSCT) has increased considerably over the last decade. It is established therapy for congenital or acquired severe disorders of the haematopoietic system and chemo- or radiosensitive malignancies (Forman et al, 1998; Lennard & Jackson, 2000). Autologous or allogeneic transplants of haematopoietic stem cells from bone marrow, peripheral blood or cord blood are used. Donors for allogeneic transplants include human leucocyte antigen (HLA)-identical siblings, other family members or unrelated volunteers from the remarkably expanded donor pools. Risks and benefits of the different procedures have been defined (Confer, 1997; Gluckman et al, 1997; Gratwohl et al, 1998, Fischer, 1999; Bensinger et al, 2001). Currently, one in 2000 persons per 10 years is likely to be treated with HSCT in western European countries. Most practitioners will be confronted with a patient who has received an autologous or allogeneic HSCT (Duncombe, 1997). Availability of general information on the procedure has become a necessity.

This development began with the first reports on correction of severe congenital immune deficiencies by bone marrow transplants from HLA-compatible siblings in the late 1960s (Bach et al, 1968; Gathi et al, 1968). Correction of severe aplastic anaemia and eradication of leukaemias proved the concept that bone marrow from normal healthy donors could replace failing organ function independent of the cause. These early results stimulated groups worldwide to gather together, share their experience and spread the technology. The annual numbers of HSCT in Europe increased from 18 in 1973, when the European Group for Blood and Marrow Transplantation (EBMT) was founded, to 4234 HSCT in 1990, when the EBMT activity survey was introduced (Gratwohl, 1991), and to an estimated number of more than 20 000 patients in the year 2000. Successful treatment of many patients with various diseases forms the basis of the continuing ambition and enthusiasm of the transplant community. Reduction in transplant-related mortality and standardization of procedures have fostered its expansion. Patient and donor selection and fine tuning of supportive care during the aplastic phase are part of this improvement. It has opened up new indications. With introduction of low-intensity conditioning programmes (Barrett & Childs, 2000), patient age as a limiting factor has been abandoned. Today, HSCT are part of the treatment programme in most university hospitals and larger clinics in Europe. They are integrated in the therapeutic plan for many disease categories right from diagnosis (Goldman et al, 1998).

Rapid development and the high costs associated with HSCT have put pressure on health care agencies (Jacobs et al, 2000). Temptations to restrict transplant activity parallel awareness of quality control. Recent data indicate that annual numbers of transplants performed by an institution affect outcome (Apperley et al, 2000). Such correlations between numbers of procedures and outcome have been documented for many medical or surgical interventions, including organ transplantation (Opelz et al, 1975; Hosenpud et al, 1994; Lin et al, 1998; Edwards et al, 1999; Schurman et al, 1999; Frassoni et al, 2000). As a consequence, quality assurance programmes for centres of excellence, such as the Foundation for Accreditation of Haematopoietic Cell Therapy and Graft Engineering (FAHCT) (http://www.edu/community/fahct.org) and JACIE (Joint Accreditation Committee of the International Society for Haematotherapy and Graft Engineering (ISHAGE)-Europe and EBMT) (http://www.EBMT.org), stipulate a minimum number of 10 transplants per year. Defining a minimum number of transplants for institutions might improve outcome; the optimal number still needs to be determined. Furthermore, no data are available to define optimal dissemination within a country. Focusing on outcome, quality control and economic aspects might favour a concept of concentration of the technology on a few teams and neglect aspects of availability for the population at large. The annual surveys of the EBMT on HSCT activity monitor changes in activity for individual indications and observe trends (Gratwohl, 1991; Gratwohl et al, 2001). They allow comparisons between the individual participating European countries. As such, they provide a tool for the preparation of recommendations for health care agencies.

Patients and methods

Data collection and validation.  The present report is based on the EBMT activity surveys introduced in 1990 (Gratwohl, 1991). Since then, all European centres known to the investigators to be performing transplants are requested annually to report on a survey sheet the numbers of new patients by indication, stem cell source and donor type. This survey was adopted by the General Assembly of EBMT as a mandatory self-reporting system and now forms an integral part of a prospective quality assurance programme. Details of the procedure have been published (Gratwohl, 1991). Transplants were defined as the infusion of haematopoietic stem cells following a conditioning regimen, with the intention of replacing the existing haematopoesis by injected stem cells.

Data quality is assured through cross-checking with national transplant registries and by on-site visits according to the EBMT quality assurance programme.

Participating teams.  Data are based on 610 teams in 35 European countries known to the investigators to be transplant teams. Five hundred and eighty (95% return) replied in 1999 (Gratwohl et al, 2001). This includes all 470 EBMT member teams. No major transplant team in Europe is missing from this list. One hundred and forty-two teams responded in 1990. The contacted teams are listed in the Appendix in alphabetical order according to country, city and EBMT centre code. We received personal communications that, in 1999, no blood or marrow transplants were performed in the following European countries: Albania, Andorra, Armenia, Azerbaijan, Bosnia-Herzegovina, Georgia, Latvia, Liechtenstein, Malta, Macedonia, Moldavia, Monaco, Romania, San Marino and the Vatican.

Data for 1973 and 1983 are based on a retrospective survey conducted in 1993.

Transplant rates and team density.  Transplant rates were computerized for each participating country and defined as the division of transplant numbers of a given country by its population, with adjustment to 10 million inhabitants. Transplant rates were calculated for each year for all HSCT, separately for autologous, allogeneic and unrelated HSCT, and for each main indication. Similarly, team density was defined as number of teams per 10 million inhabitants. Population data since 1996 were obtained from the US census office (http://www.census.gov/cgi-bin/ipc/idbrank.pl) and for previous years from the annual Fischer's Weltalmanach.

Economic evaluation. For each country and year, information was obtained on gross national product (GNP) per capita in US$, growth rate of GNP, health care expenditures (HCE) per capita in US$ and HCE as a percentage of GNP. Information on GNP was obtained from http://www.worldbank.org, information on HCE from the European Observatory on Health Care Systems (http://www.observatory.dk) and from literature (Hoffmeyer & McCarthy, 1994). Countries were grouped into three categories of health care systems: (a) social insurance-based health care systems or Bismarckian type (Austria, Belgium, France, Germany, the Netherlands and Switzerland) (Group 1); (b) tax-funded health care systems or Beveridge type (Denmark, Finland, Greece, Ireland, Italy, Norway, Spain, Swedena and the UK) (Group 2); and (c) centralized health care systems or Semashko-type [includes all countries from the former USSR or Council on Mutual Economic Assistance (CMEA)] (Group 3) (Majnoni d'Intignano, 1992).

Transplant efficiency was then calculated by dividing the transplant rate of each country by its HCE. Transplant efficiency was grouped by health care system.

Statistical analysis.  Mean, median and standard deviations of numerical variables were calculated on an Excel spreadsheet. Groups were compared with chi-square tests.

In order to assess trends, increases in transplant rates were computerized for donor types, stem cell source and main disease indications for each individual country and by health care system group.

Regression analyses were used to estimate the relationship of transplant rates and team density with GNP per capita, annual growth rate of GNP, HCE per capita and HCE percentage of GNP in individual countries. Analyses were performed for each year. The presented data refer to the latest that are available (1998/1999).

Results

Development of transplant activity

The evolution of HSCT in Europe from 1973 to 1999 is illustrated in Fig 1. There has been a steady increase in HSCT activity for allogeneic transplants. Autologous HSCT began later with a more rapid increase. In 1991, equal numbers were reported for both technologies. Autologous HSCT showed a marked increase after 1993, culminating in 1998 with almost 13 000 patients and a decline thereafter. In total, there were 18 720 first transplants, including 5879 (31%) allogeneic and 12 841 (69%) autologous HSCT in 1999.

Figure 1.

Evolution of HSCT in Europe from 1973 to 1999. Graphs reflect annual numbers of patients treated with autologous or allogeneic HSCT. Numbers for 1973, 1983 and 1990–1999 are derived from the EBMT activity surveys.

Increase in transplant activity during the last decade was based both on increase in teams and on increase in transplants within participating teams. Teams increased from eight in 1973 to 143 in 1990 and 610 in 1999. Of those, 580 responded and 50% perform allogeneic and autologous transplants; 48% restrict their activity to autologous and 2% to allogeneic transplants only.

There is a wide variation in activity between teams. One hundred and fifty-two (26%) teams performed less than 10 transplants, 122 (21%) teams between 10 and 20 HSCT, 180 (31%) between 20 and 50 HSCT, 99 (17%) between 50 and 100 HSCT and 27 teams (5%) more than 100 HSCT in 1999.

Indications for HSCT, donor type and stem cell source

Numbers of patients treated with HSCT over the last decade are listed in Table I, according to disease indication and donor type. Overall, there were 113 827 first transplants; 37 761 (33%) were allogeneic and 76 066 (67%) were autologous HSCT. They are grouped into four main disease categories, lymphoproliferative disorders with 43 529 patients (38·2%), leukaemias with 42 144 patients (37%), solid tumours with 21 898 patients (19·2%) and non-malignant disorders with 5216 patients (4·6%).

Table I.  Numbers of patients treated in Europe from 1990 to 1999 with a first haematopoietic stem cell transplant, according to disease indication and donor type. The proportion of allogeneic transplants and the 95% confidence limits are given for all main indications and subgroups.
 Indications for HSCT in Europe 1990–1999 Percentage of allogeneic HSCT
(95% CI)
Number of patients
AllogeneicAutologousTotal
Leukaemias28856 (76·4%)13288 (17·5%)  42144 (37·0%)  68·5 (68–68·9)
 Acute myeloid leukaemia  9363 (32·4%)  7082 (53·3%)  16445 (39·0%)  56·9 (56·2–57·7)
 Acute lymphocytic leukaemia  7736 (26·8%)  3463 (26·1%)  11199 (26·6%)  69·1 (68·2–69·9)
 Chronic myeloid leukaemia  9244 (32·0%)  1819 (13·7%)  11063 (26·3%)  83·6 (82·9–84·2)
 Myelodysplastic syndromes  2226 (7·7%)    247 (1·9%)  2473 (5·9%)  90·0 (88·7–91·2)
 Chronic lymphocytic leukaemia    287 (1·0%)    677 (5·1%)  964 (2·3%)  29·8 (26·9–32·8)
Lymphoproliferative disorders  3110 (8·2%)40419 (53·1%)  43529 (38·2%)    7·1 (6·9–7·4)
 Multiple myeloma  1175 (37·8%)12818 (31·7%)  13993 (32·1%)    8·4 (7·9–8·9)
 Hodgkin's disease      252 (8·1%)  7852 (19·4%)  8104 (18·6%)    3·1 (2·7–3·5)
 Non Hodgkin's lymphoma  1683 (54·1%)19749 (48·9%)  21432 (49·2%)    7·9 (7·5–8·2)
Solid tumours      168 (0·4%)21730 (28·6%)  21898 (19·2%)    0·8 (0·7–0·9)
 Neuroblastoma        29 (17·3%)  1650 (7·6%)  1679 (7·7%)    1·7 (1·2–2·5)
 Glioma          1 (0·6%)    471 (2·2%)  472 (2·2%)    0·2 (0–1·4)
 Soft tissue sarcoma          8 (4·8%)    869 (4·0%)  877 (4·0%)    0·9 (0·4–1·9)
 Germinal tumours          7 (4·2%)  2354 (10·8%)  2361 (10·8%)    0·3 (0·1–0·6)
 Breast cancer        41 (24·4%)11817 (54·4%)    11858 (54·2%)    0·3 (0·3–0·5)
 Ewing's sarcoma        24 (14·3%)  1157 (5·3%)  1181 (5·4%)    2·0 (1·3–3·1)
 Lung cancer          1 (0·6%)    256 (1·2%)  257 (1·2%)    0·4 (0–2·5)
 Ovarian cancer          4 (2·4%)    528 (2·4%)  532 (2·4%)    0·8 (0·2–2·1)
 Other solid tumours        53 (31·5%)  2628 (12·1%)  2681 (12·2%)    2·0 (1·5–2·6)
Non malignant disorders  4995 (13·2%)    221 (0·3%)  5216 (4·6%)  95·8 (95·2–96·3)
 Aplastic anaemia + Fanconi  2196 (44·0%)        6 (2·7%)  2202 (42·2%)  99·7 (99·4–99·9)
 Thalassaemia  1202 (24·1%)        0 (0·0%)  1202 (23·0%)100 (99·6–100)
 Combined immune deficiencies      621 (12·4%)        8 (3·6%)  629 (12·1%)  98·7 (97·4–99·4)
 Inborn errors    959 (19·2%)        4 (1·8%)  963 (18·5%)  99·6 (98·9–99·9)
 Auto immune diseases        17 (0·3%)    203 (91·9%)  220 (4·2%)    7·7 (4·7–12·3)
Others    632 (1·7%)    408 (0·5%)  1040 (0·9%)  60·8 (57·7–63·7)
Total3776176066113827  33·2 (32·9–33·4)

There are distinct differences between these groups with regard to donor type. Solid tumour patients were almost exclusively treated with autologous HSCT (99·2%). In contrast, patients with aplastic anaemia, haemoglobinopathies, immunodeficiency disorders or in-born errors, in the group of non-malignant disorders, were almost exclusively treated with allogeneic HSCT (98·7–100%). The few patients with congenital disorders treated using autologous HSCT are those given genetically modified autologous HSCT. Patients with lymphoproliferative disorders were treated predominantly with autologous HSCT (92·9%). Similarly, patients with autoimmune disorders were primarily treated with autologous HSCT (92·3%). Patients with leukaemias were mainly treated with allogeneic HSCT (68·5%), even though for some subgroups, such as acute myeloid leukaemia, numbers of autologous HSCT equalled those for allogeneic procedures.

Of the 37 761 allogeneic HSCT, 27 046 (72%) recipients received cells from an HLA-identical sibling donor, 2551 (7%) recipients had other family members as a donor, 401 (1%) recipients had a syngeneic twin as donor and 7763 (21%) recipients had an unrelated volunteer donor.

Over the decade, the percentage of twin donors has remained stable; the percentage of unrelated donors has increased from less than 10% to over 30% in 1999 (see details in Gratwohl et al, 2001).

Of the 113 827 HSCT, 45 758 (40%) were bone marrow derived; 68 069 (60%) were from peripheral blood stem cells or combined bone marrow and peripheral blood stem cell transplants. There were differences between autologous and allogeneic HSCT. Of the 37 761 allogeneic HSCT, 29 820 (79%) were bone marrow and 7941 (21%) were peripheral blood stem cell transplants. Of the 76 066 autologous HSCT, 15 938 (21%) were bone marrow and 60 128 (79%) were peripheral blood stem cell transplants. The proportion of peripheral blood as stem cell source varied over time and depended on donor type. Almost all HSCT in 1990 were bone marrow derived. It has changed within the decade to 95% of cases using peripheral blood as the stem cell source for autologous HSCT, to 50% for HLA-identical sibling donor transplants, to 77% for HSCT from other family members, to 63% for twin donors and to 27% for unrelated donors in 1999.

Transplant rates and team density

There were major differences between European countries in the total number of HSCT and transplant rates, as observed previously (Gratwohl et al, 1993) (illustrated in Fig 2 and Table II and as listed in the Appendix). Total numbers ranged from none in several countries to 3637 HSCT in Germany in 1999. Transplant rates varied from 0 HSCT per 10 million in several countries to a maximum of 1050 HSCT per 10 million in small countries such as Luxemburg. Median value was 184 HSCT per 10 million inhabitants.

Figure 2.

Transplant rates in participating European countries in 1999. Shades reflect total number of HSCT (autologous and allogeneic) per 10 million inhabitants.

Table II.  Transplantation of haematopoietic stem cells and economics in European countries .*
CountryCodePopulationTeamsHSCTTRTDGNP/CGNP rateHCE CHCE %
  • *

    This table excludes Iceland and Luxemburg, and also countries with no HSCT.

  • HSCT, total number of transplants reported for 1990–99; TR, transplant rate, as number of HSCT per 10 million inhabitants in 1999; TO, team density; GNP/C, gross national product per capita in US$; GNP rate, increase/decrease in GNP in the late nineties; HCE/C, health care expenditure per capita in US$; HCE%, health care expenditure as a percentage of GNP.

AustriaA    8·1  14    195438417·3  26·8  3·21793  7·9
BelarusBY  10·4    3      190  54  1·9    2·2  10·8NA  5·7
BelgiumB  10·2  25    337848719·6  23·4  2·81747  7·6
BulgariaBG    7·9    1        20  13  1·3    1·2  5·1NA  4·7
CroatiaHR    4·3    2      588184  4·7    4·6  2·6NA  9·0
CyprusCY    0·8    1        1215012·5NANANANA
Czech RepublicCZ  10·3  10    1867405  9·7    5·2 −  2·1  904  7·0
DenmarkDK    5·3    3    1200355  5·7330  2·41848  7·7
EstoniaEST    1·4    1        68100  7·1    3·4  6·4NA  6·0
FinlandSF    5·2    6    139842511·5  24·3  6·51447  7·3
FranceF  59·1  83  2101848612·5  24·2  2·82103  9·9
GermanyDK  82·6100  1862844012·1  26·6  2·8233910·4
GreeceGR  10·6  11    109318110·4  11·7  3·1  974  7·1
HungaryHR  10·2    4      398101  3·9    4·5  4·6  602  6·5
IrelandIRL    3·8    3      468153  5·3  18·7  7·91324  7
ItalyI  57·6  95  1668750716·5  20·1  1·31589  7·6
LithuaniaLT    3·4    1          2    6  2·9    2·5  4·8NA  5·1
NetherlandsNL  15·8  14    3716380  8·9  24·8  2·7182585
NorwayN    4·5    5      67826011·1  34·3  1·71814  7·4
PolandPL  38·7  13    1466106  3·1    3·9  4·4  371  5·3
PortugalP  10·0    7    1293181  6·0  10·7  3·71125  8·2
RussiaRUS146·5  14      541    9  0·9    2·3 −  6·4    47  2·2
SlovakiaSK    5·4    4      491207  7·4    3·7  4·1NA  7·1
SloveniaSLO    1·9    1        81111  5·3    9·8  4·1  743  7·7
SpainE  40·0  761297548917·0  14·1  3·61168  7·4
SwedenS    8·9  10  294447411·2  25·6  2·81728  8·5
SwitzerlandCH    7·2  12  187738516·7  40·0  1·5254710·2
TurkeyTR  64·8  21  1113  51  3·1    3·2  2·3  232  3·5
United KingdomUK  59·4  5514723351  9·1  21·4  2·01347  6·7
YugoslaviaYU  10·7    4    274  30  3·7NANANANA

There were differences between autologous and allogeneic HSCT. Transplant rates for allogeneic HSCT varied from 0 to 263 (median 70) per 10 million inhabitants, for autologous from 0 to 1050 (median 150) per 10 million inhabitants. Differences in transplant rates for individual indications were described earlier (Gratwohl et al, 1999).

The numbers of teams and team density varied in the European countries, from none to a maximum of 100 teams in Germany. Team density varied from 0 per 10 million inhabitants to 19·6 per 10 million inhabitants in Belgium (Iceland and Luxemburg excluded). There were a median 8·8 teams per 10 million inhabitants.

Transplant rates were closely correlated with team density (R2 = 0·708; F 70·17; P < 0·0001) (excluding Iceland and Luxemburg), as an estimated increase of 28·2 HSCT per 10 million inhabitants has been suggested for each additional team per 10 million inhabitants (Fig 3). The correlation remained when countries with < 10 teams per 10 million inhabitants were analysed separately (R2 = 0·699; F 39·55; P < 0·0001). Saturation appeared when countries with team density > 10 teams per 10 million inhabitants were analysed (R2 = 0·222; F 2·85; P = 0·122).

Figure 3.

Correlation between transplant rate and team density per country in Europe (Iceland and Luxemburg are excluded from the analysis). Symbols correspond to health care systems: blue, insurance-based system; red, tax-funded system; green, centralized system.

Economic factors

Transplant rates and team density in part reflected the different economic situations in European countries. There was a clear correlation between transplant rates and the GNP per capita, as illustrated in Fig 4, based on data from 1999 (R2 = 0·680; F 57·45; P < 0·0001) (Fig 4A). This observation was valid for the years between 1990 and 1999 (data not shown); it was not influenced by the economic growth rate (data not shown). The calculation showed a closer correlation for allogeneic transplant rates (R2 = 0·790; F 101·82; P < 0·0001) than for autologous HSCT (R2 = 0·543; F 32·09; P < 0·0001), and a closer correlation for ‘established’ indications (34), e.g. allogeneic HSCT for chronic myeloid leukaemia (R2 = 0·68; F 61·63; P < 0·0001) than for autologous HSCT for breast cancer (R2 = 0·188; F 6·71; P < 0·015). The correlation between rate and GNP per capita remained the same when countries with a GNP per capita < 14 000 US$ were analysed separately (R2 = 0·488; F 13·7; P < 0·003); it disappeared when countries with a GNP per capita > 14 000 US$ were analysed (R2 = 0·004, F 0·05; P = 0·830). The same results were observed when HCE per capita were compared with transplant rates (R2 = 0·568; F 26·34; P < 0·0001) (Fig 4B). GNP per capita and HCE per capita show a very close correlation in Europe (data not shown in detail). Again, when countries with HCE per capita > 1400 US$ were compared separately, no correlation was found (R2 = 0·012; F 0·7115; P = 0·749). There was also a weak correlation between GNP per capita, HCE per capita and team density (data not shown in detail).

Figure 4.

Economic factors. (A) Transplant rate and GNP per capita in Europe. (B) Transplant rate and HCE per capita in Europe. Symbols correspond to health care systems: blue, insurance-based system; red, tax-funded system; green, centralized system.

In contrast to GNP per capita and HCE per capita, no correlation with transplant rate and team density was found for annual growth rate or percentage of HCE compared with GNP (data not shown in detail).

Transplant efficiency varied from 11·56 to 44·8 transplants per 10 million inhabitants for each 10 000 US$ spent on HCE per capita, with a similar distribution between insurance-based type (median 21·1; range 15·1–27·8), tax-funded type (median 26·0; 11·5–41·8) and centralized-type (32) (median 19·1; 14·9–44·8) health care systems (P = NS).

Increase in transplant rate

Transplant growth, i.e. increase of transplant rate, was observed in all European countries. Not all indications increased at the same rate, as reflected in Fig 5. Some indications appeared only recently, such as allogeneic HSCT for solid tumours or HSCT for autoimmune disorders. Concerning allogeneic HSCT, a marked increase was observed for leukaemias, and a relatively stable rate for non-malignant disorders, including aplastic anaemia (Fig 5A). In contrast, for lymphoproliferative disorders, a trend towards more allogeneic HSCT was observed for the last two years. For autologous HSCT, the pattern was different (Fig 5B). Breast cancer showed a marked increase after 1994, with a peak in 1997 and a continuous decline thereafter; other solid tumours continue to increase, as does multiple myeloma. Lymphoproliferative disorders (lymphoma) showed the most pronounced increase, with the beginning of a plateau for the last 2 years. The increase was similar within western European countries independent of health care system. There was a wide gap between eastern and western European countries, which is slowly becoming smaller.

Figure 5.

Absolute numbers of HSCT from 1990 to 1999 according to selected indications. (A) Allogeneic transplants grouped into leukaemias, lymphoproliferative disorders and non-malignant disorders. (B) Autologous transplants grouped into five groups, leukaemias, lymphomas, multiple myelomas, breast cancer and other solid tumours.

Discussion

This report provides an overview on current status of HSCT in Europe. Data on more than a 100 000 patients treated with this technology during the last decade document that HSCT has become an established therapy. There was a consistent trend towards increased use of this technology. Age is no longer considered a limiting factor. For many haematological malignancies, there is an increased incidence with increasing age. More patients in the higher-age categories will be treated for established indications (Goldman et al, 1998). New indications are being explored: the value of autologous HSCT is being examined for patients with severe autoimmune diseases (Tyndall & Gratwohl, 1997; Potter et al, 1999; Traynor et al, 2000) and the value of allogeneic HSCT for patients with certain malignancies, such as melanoma or renal cell carcinoma (Childs et al, 2000). Expansion of volunteer donor pools and cord blood banks increases the likelihood of finding a compatible unrelated allogeneic donor (Confer, 1997; Gluckman et al, 1997). Low-intensity conditioning approaches render the procedure more attractive for patients with previous exclusion criteria for an allogeneic HSCT (Barrett & Childs, 2000; Carella et al, 2000). It can be predicted that, in the immediate future, numbers of allogeneic and autologous HSCT will continue to increase.

Not all indications will increase at the same rate (Twombly, 2000). Breast cancer illustrates such an example for autologous HSCT (Gratwohl et al, 2000). Doubts about the value of HSCT have reversed the previous trend. It is difficult to predict what the numbers will be in a few years time. Results of the ongoing prospective randomized studies are awaited (Editorial, 1999). For other indications, a plateau has probably been reached. Most patients fulfilling entry criteria are already being treated with HSCT. For others, alternative treatments may improve and replace HSCT. Novel agents, such as tyrosine kinase inhibitors in chronic myeloid leukaemias or monoclonal antibodies in lymphoid malignancies, are examples that might obviate the need for HSCT (Druker & Lydon, 2000). Observational or cross-sectional studies (Liu et al, 2000), such as the EBMT activity surveys, provide a tool to capture trends early in this rapidly changing field. These rapid changes are best demonstrated by the shift from bone marrow to blood as the stem cell source within just a decade.

HSCT are a high-cost medicine. Continuing increases in utilization put a burden on health care providers and turn the focus to quality control aspects. Competent care for a specialized procedure, 24 h/d on a 7 d a week basis, can only be cost effective when a given number of procedures is performed at the same institution. There are many examples in several fields of medicine, including transplantation medicine, that experience is associated with outcome. Based on these data, quality control programmes for HSCT, by FAHCT in the US and JACIE in Europe, ask for at least 10 transplants per year to guarantee adequate quality standards. Based on considerations of simple cost-effectiveness, it may be advisable to restrict HSCT activity to a few centres in a country. Data from this report speak against this concept. This neglects the fact that additional factors influence availability of a procedure for the patient population at large.

There are major differences between European countries. Some can be explained. Transplant rates are correlated with economic factors. As presented earlier and shown in this report, GNP per capita and HCE per capita are the main determinants for transplant rates. Absolute expenditures are essential, rather than annual growth rates or percentages of GNP for HCE which are not. Still, this correlation is limited to countries with low economic strength. Above a certain GNP, more economic power no longer translates into more transplants. Economic factors are essential for initiating and promoting transplant programmes. Other factors become more important once countries have sufficient economic strength. This is exemplified by a similar transplant efficiency in different health care systems. In addition, these limited resources appear to be invested primarily in accepted indications. This is shown clearly by the correlation of transplant rates and GNP per capita with allogeneic HSCT and treatment for chronic myeloid leukaemia.

Besides GNP and HCE, team density influences transplant rates. Although weakly associated with economic factors itself, it needs to be considered separately. Optimal use of resources and experience, as well as quality concerns, might require a reduction of a technology to as few centres as possible. Optimal dissemination of a modern technology such as HSCT within a country requires expansion to several centres. It might therefore be wise to postulate that the number of teams should be expanded to allow dissemination of the technique, but be restricted to such an extent that sufficient experience at the individual centres remains. The present study gives some clues. An increase in team density above 10 teams per 10 million inhabitants is no longer associated with an increase in transplant rates.

There are some discrepancies between this study and early reports from the US on a general decline of HSCT (Twombly, 2000). Explanations remain speculative. The European survey captures almost all transplant teams in Europe. Still, some teams who previously reported or who were known to have performed transplants decided not to report or failed to answer the survey for unknown reasons, despite several attempts to reach them. Besides the usual arguments, such as an increase in workload, some participants personally communicated their reluctance to report to the bodies publishing transplant activity, for the reasons mentioned above and for fear of coercive action (Gratwohl & Baldomero, 2001). If this trend continues, novel approaches will be required to gather comprehensive transplant information.

Finally, for most of the differences between the economically strong European countries, we failed to define the factors influencing transplant rates. Differences in health care systems give inadequate explanations. Any form of grouping, such as comparing tax-funded or insurance-funded programmes, showed similar results. There are some indications that countries with strong national transplant regulations, such as France, Spain, Germany and Italy, have higher transplant rates. Financial incentives for participating institutions, as have been claimed for the rapid dissemination of HSCT for breast cancer alone, provide an inadequate explanation. Clearly, the data reveal a lack of knowledge in this field and a need for directed research.

This report highlights the current practice of HSCT in Europe during the last decade. It documents changes and trends, marking a break in the hitherto continuing rise in application. It gives some explanations about the differences in transplantation rates between the European countries and points to unanswered questions. As such, it should provide a basis for healthcare planning and interpretation of outcome data so that recommendations for the counselling of individual patients can be achieved.

Acknowledgments

The co-operation of all participating teams and their staff (listed in the Appendix), the EBMT secretariat (A. Urbano-Ispizua, A. Bauer), the European EBMT Data Office in Paris (V. Chesnel, P. Palut, N. C. Gorin), the EBMT Registry Subcommittee (P. Ljungman, C. Ruiz de Elvira), the French Registry SFGM (J. P. Vernant, M.-L. Tanguy), the Dutch Registry (T. de Witte, A. v. Biezen, N. Tazelaar), the Austrian Registry (D. Niederwieser, B. Gritsch), the Italian Registry (M. Vignetti, A. Bacigalupo, R. Oneto, C. Palazzi), the German Registry (H. Ottinger, C. Müller, B. Kubanek, N. Schmitz, U. W. Schaefer), the Swiss Registry (J. Passweg, H. Baldomero), the British Registry (A. Eades), the Belgium Registry (Y. Beguin) and the Spanish Transplantation Office (ONT) (M. Naya) is greatly appreciated. The authors also wish to thank A. Maerki for secretarial assistance, L. John and O. Baldomero for technical assistance with data management, Michael Gratwohl for statistical expertise and A. Wodnar-Filipowicz for a careful review of the manuscript.

The work was supported in part by a grant from the Swiss National Research Foundation, 32-52756·97, the Swiss Cancer League, and the Horton Foundation. EBMT is supported by grants from corporate members: Hoffmann-La Roche Ltd, Amgen Europe, Chugai Rhone-Poulenc Rorer, Baxter, Astra, Cobe International, Nextar, Liposome Co., Imtix, Octapharma, Stem Cell Technologies, ICN Pharmaceuticals and Bristol-Meyers Squibb.

Appendix – list of participating transplant centres per country

Albania: no report

Andorra: no report

Armenia: no report

Austria

Graz, University Hospital, CIC 308, W. Linkesch

Graz, University Hospital, Onco, CIC 278, H. Samonigg, M. Schmid

Graz, Universitäts-Kinderklinik, CIC 593, Ch. Urban

Innsbruck, Universitätsspital (hem), CIC 271, G. Gastl

Innsbruck, Universitätsspital, CIC 271, D. Nachbaur

Klagenfurt, General Hospital Klagenfurt CIC 716, D. Geissler, M. Heistinger

Linz, 1. Medizinische Abteilung, AO Krankenhaus, M.A. Fridrik

Linz, AOK der Elisabethinen, CIC 594, D. Lutz

Salzburg, LKA Salzburg (Onco), CIC 356, Prof Hausmaninger

Vienna-Lainz, Krankenhaus der Stadt Wien-Lainz, 5. Medical Onko, CIC 362, G. Baumgartner, E. Ulsperger, Dr Mayer

Vienna, St. Anna Kinderspital, CIC 528, H. Gadner, C. Peters

Vienna, Donauspital, CIC 767, W. Hinterberger

Vienna, Universitätsklinik für Innere Medizin I – AKH, CIC 227, H.T Greinix, P. Kalhs

Vienna, Wilhelminerspital, CIC 828, H. Ludwig

Vienna, Hanusch-Krankenhaus, CIC 743, R. Reisner, E. Pittermann

Azerbaijan: no report

Republic of Belarus

Minsk, Belorussian Center, CIC 591, O. Aleinikova

Minsk, Hospital no. 9, CIC 801, N. Milanovitch

Minsk, Institute of Haematology, CIC 326, V. Ivanov

Belgium

Aalst, OLV Ziehenhuis, E. Wouters

Antwerpen, A.Z. Middelheim, CIC 783, R. de Bock

Antwerpen, Stuivenberg ZH, CIC 339, P. Zachée

Brugge, A.Z. St. Jan, CIC 506, D. Selleslag, A. Van Hoof

Brussels, Children's University Hospital, CIC 644, C. Devalck, E. Sariban

Brussels, Clinique Général Saint Jean, CIC 779, C. Dubois

Brussels, Hôpital Erasme, CIC 596, W. Feremans

Brussels, Clinique universitaire St. Luc (Adults), CIC 234, A. Ferrant

Brussels, Institut Jules Bordet, CIC 215, D. Bron

Brussels, University Hospital, CIC 630, B. van Camp, A. Schots

Brussels, Cliniques Universitaires St. Luc (onco), M. Symann

Brussels, Institute Edith Cavelle Marie Depage (onco), C. Vanhaelen

Brussels, Clinique Universitaire St. Luc (peds), CIC 234, C. Vermylen

Charleroi, Hôpital Notre-Dame, M. André

Edegem, University Antwerpen, CIC 648, W. Schroyens

Gent, University Hospital, CIC 744, L.A. Noens

Haine St. Paul, Hôpital de Jolimont, CIC 234, A. Delannoy, C. Ravoet

Hasselt, Virgajesse Ziekenhuis CIC 632, D. Vanstraelen, Dr Janssen

Jumet, Hôpital Civil de Jumet, A. Duvivier

Leuven, University Hospital Gasthuisberg, CIC 209, M.A. Boogaerts, H. Demuynck

Liège, University Hospital Sart-Tilman, CIC 726, Y. Béguin

Liège, CHR-Citadelle, CIC 353, B. De Prijck

Liège, Centre Hospitalier St. Joseph (hem), L. Longree

Roeselare, H. Hartziekenhuis, Van Aelst, J. Tytgat, J. Demol

Yvoir, Clinique universitaire de Mont-Godinne CIC 234, C. Doyen

Bosnia-Herzegovina: no report

Bulgaria

Sofia, Uni. Hospital ‘Queen Johanna’, CIC 346 (peds hem-onco), D. Bobev

Croatia

Zagreb, Hospital Merkur, B. Jaksic

Zagreb, Clinical Hospital Center, CIC 302, B. Labar, D. Nemet, M. Mrsic

Cyprus

Nicosia Makarious Hospital lll, N. Papaminas

Czech Republic

Brno, Masaryk University Hospital, CIC 597, J. Vorlicek

Hradec Kralové, Charles University, CIC 729, S. Filip, M. Blaha

Olomouc, University Hospital, CIC 574, K. Indràk

Pilsen, Faculty Hospital, CIC 718, V. Koza

Prague, Thomayer Memorial Hospital, CIC 375, J. Abrahamova, J. Nepomucka, L. Boublikova

Prague, University Hospital Motol (peds onco), P. Kavan

Prague, Clinical Haematology, Charles University, CIC 318, T. Kozak

Prague, University Hospital Motol (peds hem), J. Stary

Prague, Charles University, CIC 745, M. Trneny

Prague, Institute of Hematology and Blood Transfusion, CIC 656, A. Vitek, P. Kobylka

Denmark

Aarhus, Amtssygehus, CIC 634, A. Boesen

Copenhagen, Rigshospitalet, CIC 206, N. Jacobsen

Copenhagen, Herlev Hospital, University, CIC 568, H.E. Johnson

Estonia

Tartu, University Hospital, CIC 746, H. Everaus

Finland

Helsinki, University Hospital, Department Oncology, H. Joensuu, T. Wiklund

Helsinki, University Hospital, Third Department of Medicine, CIC 515, T. Ruutu

Helsinki, Children's Hospital, CIC 219, U. Pihkala, S. Vettenrarta

Kuopio, University Hospital, E. Jantunen

Tampere, University Hospital, CIC 635, M. Lehtinen

Turku, University Central Hospital, CIC 225, K. Remes

France

Amiens, CHU d'Amiens, B. Desablens

Angers, Paul Papin, Dr Gamelin

Angers, Centre Hospitalier, CIC 650, N. Ifrah

Argenteuil, Centre hospitalier, M. Urbajtel

Besançon, Hôpital Jean Minjoz & Hôpital St. Jacques (adults & peds), CIC 233, P. Hervé, J.-Y. Cahn, M.N. Cailleux, Dr Surowka

Bobigny, Hôpital Avicenne (hem), P. Casassus

Bordeaux, CHU Hôpital de Bordeaux Enfants, Y. Perely

Brest, Centre hospitalier, C. Berthou

Caen, Hôpital Cote de Nacre (peds hem onco), P. Boutard

Caen, Centre hospitalier régional, CIC 251, O. Reman

Caen, Centre régional François Baclesse, Dr Tanguy

Clermont Ferrand, Hotel Dieu (peds), CIC 589, F. Démeocq

Clermont Ferrand, Centre Jean Perrin, CIC 273, J.-O. Bay

Clichy, Hôpital Beaujon, J. Brière

Colmar, Hôpital civil, B. Audhuy

Corbeil Essonne, Hôpital Gilles de Corbeil, A. Devidas

Créteil, Hôpital H. Mondor, CIC 252, C. Cordonnier, M. Kuentz

Dijon, Hôpital d'Enfants, D. Caillot

Grenoble, Centre Hospitalier (ads, allo peds), CIC 270, J.J. Sotto, L. Molina, F. Nicolini

Grenoble, Centre Hospitalier (auto peds), D. Plantaz, M. Bost

Lille, Hôpital Claude Huriez, CIC 277, F. Bauters, J.P. Jouet

Lille, Hôpital Jeanne de Flandre, Dr Nelken

Lille, Centre Oscar Lambret (onco), Dr Depadt, Dr Defachelles

Limoges, Centre Hospitalier Dupuytren (ads.), CIC 977, D. Bordessoule, P. Turlure

Limoges, Centre Hospitalier Dupuytren (peds.), Prof De Lumley

Lyon Sud (Pierre Benite), Centre Hospitalier, B. Coiffier

Lyon, Hôpital Edouard Herriot, CIC 671, D. Fiere, E. Archimbaud, A. Belhabri, M. Michallet

Lyon, Centre Léon Bérard, CIC 241, T. Philip

Lyon, Hôpital Debrousse, CIC 806, N. Philippe, G. Souillet

Marseille, Institute Paoli-Calmettes, CIC 230, D. Blaise

Marseille, Hôpital d'Enfants de la Timone (onco), CIC 301, C. Coze

Marseille, Hôpital d'Enfants de la Timone, G. Michel

Meaux, Centre Hospitalier de Meaux, C. Soussain

Metz, Thionville Hôpital Notre-Dame de Bon-Secours (hem), V. Dorvaux

Montpellier, CHU de Montpellier Hôpital Arnaud de Villeneuve, F. Bernard

Montpellier, Centre Rég. De Lutte contre de Cancer, M. Fabbro, J-B. Dubois

Montpellier, CHR Lapeyronie, J.F. Rossi

Mulhouse, Hôpital du Hasenrain, Ph. Hénon, Dr Becker

Nantes, Hotel Dieu, CIC 253, J.L. Harousseau, N. Milpied

Nice, Hôpital de Cimiez, CIC 523, J.G. Fuzibet, J.P. Cassuto, N. Gratecos

Nice, Fondation Lenval (peds), Dr Soler, Dr De Ricaud

Nice, Centre Antoine Lacassagne, A. Thyss

Paris, Hôpital Laennec, J.M. Andrieu, C. Le Maignan

Paris, Hôpital d'Instruction des Armées Percy, Clamart, T. de Revel, G. Nedellec

Paris, Hôpital Cochin, J–P. Levy, F. Dreyfus

Paris, Hôpital Necker des enfants malades, CIC 210, A. Fischer

Paris, Hôpital St. Antoine, CIC 213, C. Gorin, L. Fouillard

Paris, Hôpital St. Louis (auto), CIC 805, G. Gisselbrecht

Paris, Hôpital St. Louis (allo), CIC 207 + (peds) CIC 748, E. Gluckman & G. Schaison

Paris, Hôpital St. Louis (auto immuno-Haem), CIC 969, J-C. Brouet, B. Royer, J-P. Fermand

Paris, Hôpital St. Louis (auto-leuk), CIC 960, H. Dombret, L. Degos, P. Rousselot

Paris, Hôpital Pitié Salpétière (onco), CIC 262, D. Khayat

Paris, Hôpital Pitié Salpétière, CIC 262, J–P. Vernant, V. Leblond

Paris, Hôpital D'enfants Armand-Trousseau, G. Leverger, A. Auvrignon

Paris, Hôpital Tenon, J.P. Lotz

Paris, Hôpital Robert Debré, P. Rohrlich, E. Vilmer

Paris, Hôpital Necker (ads), CIC 201, B. Varet, C. Bélanger, A. Veil

Paris, Hôtel Dieu (hem), CIC 222, J–P. Marie, B. Rio

Paris, Hotel Dieu (onco), Prof Bernadou, L. Chauvenet

Paris, Institut Curie (ads/onco/peds), CIC 702, P. Pouillart, J. Michon, J.M. Zucker

Pessac, Hôpital Haut-Lévèque, CIC 267, J. Reiffers, Dr Fabères

Poitiers, Hôpital Jean Bernard, CIC 264, A. Sadoun

Pontoise, Hospital Renè Dubois, Dr Morvan, Y. Kernéis

Reims, Hôpital Robert Debré, J.C. Etienne

Reims, Institute Jean Godinot (onco), Dr Eymard

Rennes, Hôpital Pontchaillou, C. Dauriac

Rennes, CHRU, Clinique Médical Infantil, E. Le Gall, V. Gandemer

Rouen, Centre Henri Becquerel, H. Tilly, P. Lenain

Rouen, Hop. Charles Nicolle, P. Tron

St. Cloud, Centre René Huguenin, M. Janvier

St. Etienne, Hôpital Etienne, CIC 250, D. Guyotat, J.L. Stephan

Strasburg, Hôpital de Hautepierre, B. Lioure

Strasburg, Hospices Civils, Service de Pédiatrie 5, P. Lutz

Toulouse, Hôpital de Purpan (hem), CIC 624, M. Attal

Toulouse, Hôpital de Purpan (peds), A. Robert

Toulouse, Centre Claudius Régaud, H. Roche, C. Chevreau

Tours, Hôpital Bretonneau, CIC 272, P. Colombat

Valenciennes, Hosp. De Valenciennes, Dr M. Simon

Vandeuvre-les-Nancy, Hôpital d'Enfants, P. Bordigoni

Vandeuvre-les-Nancy, CHU Nancy-Brabois (hem auto), P. Lederlin, F. Witz

Villejuif, Institut G. Roussy (ads & peds), CIC 503, O. Hartmann; CIC 666, J.L. Pico

Villejuif, Hôpital Paul Brousse, B. Delmas-Marsalet

Georgia: no report

Germany

Aachen, Universitätsklinikum RWTH, Dr Fabry, R. Osieka

Augsburg, Zentralklinikum, G. Schlimok

Bad Saarow, Humaine Klinikum, G. Schultze

Berlin, Universitätsklinikum Charité Campus Mitte, CIC 807, R. Arnold

Berlin, University Charité der Humboldt Universität Campus (onco), CIC 518, B. Dörken

Berlin, Charité Virchow Klinikum (peds), CIC 336, W. Ebell

Berlin, Charité Virchow Klinikum (ads), CIC 293, W. Siegert

Berlin, Universitäts-Klinik Benjamin Franklin, CIC 590, W. Knauf, E. Thiel

Bielefeld, Bethel KKS Gilead, U. Krümpelmann, F.K. Lindemann

Bielefeld, Franziska Hospital, Prof Weh

Bonn, Medical Uni. Klinik Bonn, T.Sauerbruch, I. Schmidt-Wolf, R. Kleinschmidt

Bonn, Universitäts Kinderklinik, U. Bode, C. Hasan

Bremen, CIC 602, DRST 28002, C. Meier, H. Rasch

Bremen, DIAKO, DRST 28001, Dr Wolff

Chemnitz, KH Küchwald, F. Fliedler

Cottbus, Carl-Thiem Klinikum, Ch. Rudolf

Dortmund, St. Johannes Hospital, H. Pielken

Dresden, Universitätsklinikum Carl Gustav Carus, CIC 808, G. Ehninger

Duisburg, St. Johannes Hospital, CIC 519, J. Anhuf

Duisburg, Klinikum Kalkweg (onco), H. Gerhartz

Düsseldorf, Zentrum für Kinderheilkunde, CIC 651, W. Nürnberger

Düsseldorf, Medizinische Klinik (haem, onco), CIC 390, C. Aul, A. Heyll

Erlangen, Universitäts-Klinik für Kinder und Jugendliche, CIC 809, J.D. Beck, J. Greil

Erlangen, Universität Erlangen-Nuremberg, Medical Klinikum lll, CIC 809, M. Gramatzki, W. Roesler

Eschweiler, St. Antonius Hospital, Prof Fuchs

Essen, Evangelisches Krankenhaus Essen-Werden GmbH, CIC 784, W. Heit

Essen, Universitäts-Klinik (hem), U.Dührsen, R. Noppeney, J. Novotny

Essen, West German Cancer Center, S. Seeber, A. Harstrick, P. Bejko

Essen, Universitäts-Klinik (ads, peds), CIC 259, U.W. Schaefer, D.W. Beelen, B. Kremens, O. Basu

Frankfurt a. M., J.W. Goethe-Universität (ads, peds), CIC 297, D. Hoelzer, H. Martin B. Kornhuber, D. Schwabe

Frankfurt, KH Nordwest, A. Knuth

Freiburg i.Br., Medizinische Universitätsklinik (ads), CIC 810, J. Finke, W. Lange

Freiburg i.Br., Medizinische Universitätsklinik (peds), CIC 810, C. Niemeyer, M. Brandis, U. Duffiser, B. Bächle

Göttingen, Georg-August Universität, B. Wörmann

Greifswald, Ernst-Moritz-Arndt Universität (ads + peds), CIC530, G. Dölken

Gütersloh, Städtkrankenhaus, C. Gropp

Hagen, Kath. Krankenkaus, H. Eimermacher

Halle, Martin Luther Universität, CIC 338 + CIC 654, H-J. Schmoll, Dr Wolf, S. Burdach

Hamburg, Allgemeines Krankenhaus, Dr Braumann, K. Hümmel

Hamburg, Eppendorf-Krankenhaus (hem, onco), Prof Hossfeld

Hamburg, Eppendorf-Krankenhaus (KMT) CIC 614, A.R. Zander

Hamburg, KH St. George, Dr Lamersdorf, R. Kuse

Hameln, KreiskrNKENHAUS Hameln, H. Schmidt

Hannover, Medizinische Hochschule, CIC 295, A. Ganser, B. Hertenstein

Hannover, Medizinische Hochschule, Abt. Kinderheilkunde, CIC 295, A. Reiter, K. Welte

Hannover, KH Siloah, H. Kirchner

Heidelberg, Universitäts-Poliklinik, CIC 524, R. Haas

Homburg/Saar, Universität des Saarlandes, CIC 785, L. Trümper, M. Pfreudschuh

Idar-Oberstein, Klinik für Hämato-/Onkologie, CIC 592, A.A. Fauser

Jena, Klinik fur Innere Medizin ll, CIC 533, H.G. Sayer, K. Hoeffken

Jena, Universitäts-Kinderklinik, CIC 750, F. Zintl, D. Fuchs

Kaiserslautern, Westpfalzklinikum, F.-G. Hagmann, H. Link

Karlsruhe, Städtisches Klinik, J. Fischer

Kassel, Städtische Kliniken, W.D. Hirschmann, K. Schultes

Kiel, Christian-Albrechts-Universität (ads, peds), CIC 256, N. Schmitz, J. Schaub, M. Suttorp

Köln, Kinderonkologie der Universitäts-Klinik, F. Berthold

Köln, Universitäts-Klinik, CIC 534, V. Diehl, D. Söhngen, Ch. Scheid

Krefeld, Klinikum Krefeld, Medical Klinik lll, R. Peceny, M. Planker

Leipzig, Universitäts-Klinik, W. Helbig, R. Krahl

Lemgo, Klinikum Lippe, H.P. Lohrmann

Lübeck, Städt. KH Sud, M. Thalheimer, H. Bartels

Lübeck, Medical Universität, T. Wagner

Lübeck, Kinderklinik Universität, Dr Schultz, Dr Bucsky

Magdeburg, Otto-von-Guericke Universität, H.-G. Höffkes, A. Franke

Mainz, Medizinische Klinik der Universität, CIC 786, C. Huber, K. Kolbe

Mannheim, II. Medical Klinik, R. Hehlmann

Marburg, Medical Universitätsklinik der Philipps Universität, CIC 645, R. Weide, U. Kaiser

Minden/Westfallen, Medical Klinik, H. Bodenstein

Mönchengladbach, KH Maria Hilf ll, G. Trenu, D. Kohl, H-E. Reis

Munich, Städt Krankenhaus Schwabing (peds), L. Stengel-Rutkowski

Munich, Klinikum Innenstadt, B. Emmerich, C. Straka

Munich, Klinikum Grosshadern (ads) CIC 513, H.-J. Kolb

Munich, Klinikum Grosshadern (peds), CIC 513, C. Bender-Götze

Munich, Dr v Haunersches Kinderspital (hem & onco) R.J. Haas, D. Stachel, Dr Schmid

Munich, SKH München-Harlaching, R. Hartenstein, N. Brack

München, Städtisches Krankenhaus, Ch. Nerl, N. Fischer

München, Klinikum rechts der Isar, M. Sandherr

Münster, Uni. Klinik, CIC 680, W. Berdel, J. Kienast, Th. Büchner, H. Ostermann

Münster, Klinik fur Kinderheilkunde (hem + onco), CIC 505, H. Jürgens, M. Paulussen, J. Vormoor

Neuss, Lukaskrankenhaus, T. Wieberding, P. Czygan

Nürnberg, Klinikum, CIC 625, H. Wandt, K. Schäfer-Eckart

Oldenburg, Städtische Kliniken, CIC 749, B. Metzner

Offenburg, Klinikum Offenburg, Medical Klinik lll, B. Weber, F. Hirsch

Osnabrück, Paracelsus Klinik, O.M. Koch, G. Innig

Potsdam, Klinikum Potsdam, A. Haas

Regensburg, Universitäts Klinikum, CIC 787, E. Holler, R. Andreesen, A. Reichle

Rostock, Universitäts Klinikum, CIC 585, M. Freund, J. Casper

Stuttgart, Bürgerhospital, H. Benöhr, W. Grimminger, D. Hahn

Stuttgart, Olgahospital, Pädiatrisches Zentrum, CIC 701, U. Gross, J. Treuner, E. Koscielniak

Stuttgart, Diakonissen Krankenhaus, E. Heldemann

Stuttgart, Robert-Bosch-Krankenhaus, S. Kleiner, S. Martin, W. Aulitzky

Stuttgart, Katharinenhospital, U. Rüther, H. Fiechtner, J. Schleicher, H-G. Mergenthaler

Tübingen, Medizinische Universitäts-Klinik, CIC 223, L. Kanz, W. Brugger, C. Faul

Tübingen, Medizinische Universitäts-Klinik, Abteilung Pädiatrie, CIC 535, D. Niethammer, T. Klingebiel

Ulm, Medizinische Universitäts-Klinik, CIC 204, D. Bunjes

Ulm, Kinderklinik der Universität, CIC 204, W. Friedrich

Wiesbaden, Deutsche Klinik für Diagnostik, CIC 311, R. Schwerdtfeger

Wiesbaden, Dr Horst-Schmidt Klinikum, CIC 586, N. Frickhofen

Wuppertal, Klinikum Wuppertal (St. Antonius), S. Oehl, Dr Raghavachar

Würzburg, Universitätsklinikum, Würzburg, M. Wilhelm, K. Wilms, M. Braun

Greece

Alexandroupolis, Thrace University Medical School (Haem), G. Bourikas

Athens, Hellenic Cancer Institute St. Savas, CIC 751, A. Efremedis

Athens, ‘Aghia Sophia’ Children's Hospital, CIC 752, S. Graphakos

Athens, Evanghelismos Hospital, CIC 622, D. Karakasis, A. Skandalis, N. Harhalakis, E. Nikiforakis

Athens, Diagnosis & Therapy Centre ‘Hygeia’, Maroussi, CIC 643, G. Karianakis

Athens, Medical Center, CIC 603, A. Pigadito

Athens, University of Athens, CIC 604, I. Dervenoulas

Thessaloniki, The George Papanicolaou General Hospital, CIC 561, A.S. Fassas

Athens, Laikon General Hospital, CIC 328, Y. Rombos

Patras, University Medical School, N. C. Zoumbos, M. Tiniakou

Hungary

Budapest, National Institute of Hematology, CIC 504, K. Palocz, R. Denes

Budapest, Szent Laszlo Hospital, CIC 739, T. Masszi, P. Reményl, G. Kriván

Miskolc, Postgraduate Medical School (peds), CIC 599, N. Kalman, K. Kiss, G. Marton

Pécs, University of Pécs, CIC 682, H. Losonczy

Iceland

Reykjavik, National University Hospital, CIC 605, S. Reykdal (starting in 2000)

Iran

Teheran, Shariati Hospital (Hem-Onco), CIC 633, A. Ghavamzadeh

Ireland

Dublin, St. James's Hospital, CIC 257, S.R. McCann

Dublin, St. Vincent's Hospital, CIC 541, J. Crown

Dublin, Our Lady's Hospital of Sick Children, Crumlin, CIC 774, A. O'Meara

Israel

Haifa, Rambam Medical Center, J. Rowe

Jerusalem, Hadassah University Hospital, CIC 258, R. Or, S. Slavin

Petach-Tikva, Children's Medical Center, CIC 755, J. Stein

Revohot, Kaplan Hospital, CIC 327, A. Berribi

Tel Aviv, University, Chaim Sheba Medical Center (hem) CIC 754, I. Ben-Bassat

Italy

Alessandria, S.S. Antonio e Biagio e C. Arrigo, CIC 825, A. Levis, A. Allione, M. Pnin, F. Salvi

Ancona, Ospedale Toarette, CIC 788, P. Leoni, A. Olivieri

Ancona, Ospedale Toarette, CIC 229, Prof Cellarino

Avellino, Giovanni di Guglielmo, CIC 789, E. Volpe

Avezzano, Ospedale Civile di Avezzano, CIC 921, F. Recchia

Bari, Policlinico, CIC 649, V. Pavone, V. Liso

Bergamo, Ospedale Riuniti, CIC 658, T. Barbui

Bologna, St. Orsola-Malpighi (haem), CIC 240, G. Bandini, G. Rosti, S. Rizzi

Bologna, St. Orsola-Malpighi, Oncologia Medica, CIC 657, A. Martoni, C. Zamagni

Bologna, Clinica paediatrica III, CIC 790, A. Pession

Bolzano, Ospedale S. Maurizio, CIC 299, P. Coser

Brescia, Ospedali Civili, CIC 288, T. Izzi

Brescia, Università, CIC 741, F. Porta

Brindisi, Perrino Hospital, CIC 920, G. Quarta, S. Pinna

Cagliari, Ospe dale Oncologica, CIC 791, G. Broccia, P. Dessalvi

Cagliari, II. Clinica Pediatrica, CIC 812, F. Argiolu, A. Cao

Cagliari, Cattedra di Genetica, University of Cagliari CIC 811, L. Contu, G. La Nasa

Catania, Università, CIC 792, R. Ginstolisi, G. Milone

Cremona, Medicina II, CIC 226, S. Morandi

Cuneo, Hospital S. Croce E Carle (hem), CIC 606, A. Gallamini

Cuneo, Hospital S. Croce E Carle (onco), CIC 355, P. Laciura

Ferrara, St. Anna Hospital, CIC 330, F. Lanza, G. Castoldi

Firenze, Policlinico di Careggi, CIC 304, A. Bosi

Firenze, Azienda Ospedale, ‘A.Meyer’, CIC 600, L. Faulkner

Forli, Morgagni-Pierantoni Hospital, CIC 298, G. L. Frassineti, D. Amadori

Genova, Ospedale S. Martino, CIC 217, A. Bacigalupo, A. Carella, G. Santini

Genova, Istituto Giannina Gaslini, CIC 274, G. Dini

Genova, Università, CIC 139, F. Patrone

Genova, 1st Nat. per la Ricerca s. Cancro, CIC 340, M. Venturini

Latina, Ospedale S. Maria Goretti, S. Nardelli

Lodi, Ospedale Maggiore Lodi, G. Nalli, V. Fregoni

Milano, Istituto Scientifico H.S. Raffaele, CIC 813, C. Bordignon

Milano, Istituto Nazionale Tumori, CIC 616, A. Gianni

Milano, Università, CIC 265, G. Lambertenghi Deliliers

Milano, Ist. Nat. del Tumore, CIC 381, R. Luksch

Milano, Ospedale di Niguarda, CIC 294, P. Marenco, R. Cairoli

Milano, Ospedale di Niguarda (hem/oncoST), CIC 294/2, P. Pedrazzoli, S. Siena, R. Schiavo

Milano, Istituto Europeo di Oncologia, CIC 331, G. Martinelli

Milano, Ospedale Fatebenefratelli e Oftalmico (onco), CIC 269, A. Scanni, C. Bianchi, D. Pedretti

Milano, 1st. Clinico Humanitas (hem-onco), CIC 354, A. Santoro, L. Castagna

Milano, S. Carlo Borromeo Hospital (onco), L. Tedeschi

Modena, University of Modena, CIC 543, F. Narni, A. Donelli, R. Sabbatini

Monza, Ospedale S. Gerardo, CIC 279, C. Uderzo

Monza, Institute Di Scienze Biomediche, CIC 544, P. Pioltelli, E. Pogliani

Napoli, Division Di Oncologia, CIC 313, C. Battista, G. Pacilio, B. Chiurazzi, G. Iodice

Napoli, Università, CIC 766, B. Rotoli, C. Selleri, G. De Rosa

Napoli, Hospital ‘Pausilipon’ (hem peds), CIC 341, V. Poggi, M. Ripaldi

Napoli, Cardarelli Hospital (hem), CIC 607, F. Ferrara

Nuoro, Ospedale San Francesco, CIC 793, A. Gabbas, A. Palmas

Orbassano, Ospedale San Luigi Gonzaga, G. Saglio

Padova, Centro Leucemie Infantili, CIC 285, L. Zanesco, C. Messina

Padova, Centro Oncologia Regionale, CIC 319, S. Aversa, S. Monfardini

Palermo Policlinico (hem), CIC 814, M. Mariani

Palermo, Ospedale V. Cervello, CIC 392, I. Majolino, R. Scimè, A. Cavallaro

Palermo, ospedale ‘La Maddalena’, M. Musso, F. Porretto, A. Crescinanno

Parma, Ospedaliera Di Parma (onco), CIC 364, G. Cocconi, V. Franciosi, G. Vasini

Parma, Università degli studi, CIC 245, V. Rizzoli

Pavia, Policlinico S. Matteo (hem), CIC 286, C. Bernasconi

Pavia, Policlinico St. Matteo peds), CIC 557, F. Locatelli

Pavia, Policlinico St. Matteo (onco), CIC 562, E. Ascari, M. Danova

Pavia, Fondazione Clinica del Lavoro, CIC 771, A. Zambelli, G. Robustelli della Cuna

Perugia, Silvestrini Hospital, CIC 815, A. Amici

Perugia, Policlinico Monteluce, Università, CIC 794, M.F. Martelli, F. Aversa

Perugia, Policlinico Monteluce, CIC 573, F. Grignani

Pesaro, Ospedale, CIC 529, G. Lucarelli

Pescara, Ospedale Civile, CIC 248, P. di Bartolomeo

Pisa, University of Pisa (Ads hem, peds hem + onco), CIC 795, P. Macchia, M. Petrini

Pisa, St. Chirara Hospital (ads onco) CIC 320, P.F. Conte, C. Bengala

Ravenna, Ospedale Civile, CIC 306, G. Rosti

Reggio di Calabria, Azienda Ospedale ‘Riuniti e Morelli’, CIC 587, P. Iacopino

Roma, Università S. Eugenio, CIC 756, S. Amadori, L. Cudillo

Roma, Università‘La Sapienza’, CIC 232, W. Arcese, F. Mandelli, G. Meloni

Roma, Università Cattolica, CIC 307, S. Cuore, S. Sica, G. Leone

Roma, Ospedale Bambino Gesu, CIC 796, G. Deb

Roma, Ospedale S. Camillo, CIC 287, I. Majolino, A. Locascivlli

Roma, Ospedale Bambino Gesu, G. De Rossi

San Giovanni Rotondo, Hospital Casa Sollievo Sofferenza (onco), CIC 314, G. Lelli

San Giovanni Rotondo, Hospital Casa Sollievo Sofferenza (hem), CIC 526, M.M. Greco

San Giovanni Rotondo, Hospital Casa Sollievo Sofferenza (peds), CIC 350, P. Paolucci

Siena, Ospedale Sclavo, CIC 321, F. Lauria

Taranto, Ospedale Nord, CIC 332, P. Mazza, G. Palazzo, B. Amurri

Taranto, Ospedale SS. Annunziata, Dr Pezzella

Torino, S. Giovanni Antica Sede Hospital, CIC 322, M. Airoldi

Torino, Ospedale Mauriziano Umberto 1, CIC 377, M. Aglietta, A. Capaldi; G. Garetto

Torino, University Hospital of Turin, San Giovanni Battista, CIC 231, M. Falda, F. Locatelli

Torino, Department of Pediatrics, University, CIC 305, E. Madon, F. Fagioli

Trieste, Istituto per I'Infanzia, Clinical Pediatrica, M. Andolina, A. de Manzini

Udine, Policlinico Universitario, CIC 705, M. Baccarani, R. Fanin, A. Geromin

Venezia, Ospedale Civile Riuniti di Venezia, CIC 502, T. Chisesi, M. Vespignani, M. Chinello

Venice, Civic Hospital (onco), CIC 563, O. Vinante, G. Azzarello

Verbania Pallanza, Ospedale di Verbania, M. Bersi

Verona Ospedale Civile Maggiore (onco), G.L. Cetto

Verona, Policlinico di Borgo Roma, CIC 623, G. Perona

Vicenza, Ospedale S. Bortolo (hem), CIC 797, R. Raimondi, F. Rodeghiero

Vicenza, Ospedale S. Bortolo (onco), CIC 347, V. Fosser, P. Morandi, P. Ruffini

Latvia: no report

Liechtenstein: no report

Lithuania

Vilnuis, University Hospital (hem), I. Trociukas

Luxemburg

Centre Hospitalier, M. Dicato

Esch-Alrette, Hôpital de la Ville Esch/Alzette, CIC 545, F. Le Moine

Macedonia: Skopje, T. Stojcevski, no report

Malta: no report

Moldova: no report

Monaco: no report

Netherlands

Amsterdam, Free University Hospital (Haem), CIC 588, G.M. Ossenkoppele

Amsterdam, Free University Hospital (onco), CIC 380, E. van der Wall

Amsterdam, Academic Medical Center (ads.), CIC 247, J. van der Lelie, H. van den Berg (peds)

Amsterdam, the Netherlands Cancer Institute, CIC 976, S. Rodenhuis J. Baars

Groningen, University Hospital (onco), CIC 395, E. de Vries

Groningen, University Hospital (hem), CIC 546, E. Vellenga

The Hague, Leyenburg Hospital, CIC 547, P.W. Wijermans

Leiden, University Medical Centre (ads, peds), CIC 203, J. Vossen, R. Willemze

Maastricht, University Hospital (haem, onco), CIC 565, H.C. Schouten, J. Wagstaff

Nijmegen, University Hospital (ads, peds, onco), CIC 237, A. Schattenberg, L. Beex, P. Hoogerbrugge

Rotterdam, Dr Daniel den Hoed Cancer Center, CIC 246, J.J. Cornelissen

Utrecht, University Hospital (ads + peds), CIC 239, L.F. Verdonck, N.M. Wulffraat, D. Biesma

Zwolle, Isala Klinieken/Sophia Ziekenhuis, CIC 548, M. von Marwijk Kooy

Enschede, The Medisch Spectrum Twente, CIC 360, Dr Schaafsma

Norway

Bergen, Haukelands Sjukhus, P. Ernst

Oslo, Rikshospitalet, CIC 235, D. Albrechtsen, L. Brinch

Oslo, The Norwegian Radium Hospital, CIC 782, S. Kvaloy

Oslo, Ullevals Sjukhus, F. Wisslöf

Trondheim, Regionsjukhuset, A. Waage

Poland

Gdansk, Medical University, CIC 799, A. Hellmann

Katowice, Silesian Medical Academy, CIC 677, J. Holowiecki

Krakow, CMUJ, CIC 553, A. Skotnicki

Lublin, Ped Hem Onco, CIC 678, J. Kowalczyk

Poznan, Medical Academy, CIC 730, J. Hansz

Poznan, Institute of Pediatrics, CIC 641, J. Wachowiak

Warsaw, Central Clinical Hospital, Military Medical Academy, CIC 816, K. Sulek

Warsaw, Maria Sklodowska-Curie, Centre of Oncology, CIC 800, J. Walewski

Warsaw, Institute of Haematology and Blood Transfusion, CIC 693,B. Marianska, L. Konopka

Warsaw, Central Clinical Hospital, CIC 954, W. Wiktor-Jedrzejczak

Wroclaw, University of Medicine, Department of Children, CIC 817, J. Boguslawska-Jaworska

Wroclaw, K. Diuske Hospital, CIC 538, A. Lange

Portugal

Coimbra, University Hospital, N. Costa

Lisbon, Instituto Portugues de Oncologia, CIC 300, M. Abecasis, F. Campilli

Lisbon, Hospital de Santa Maria, CIC 636, J. Alves do Carmo, F. de Lacerda

Lisboa, Hospital dos Capuchos, J.P. Fernandes

Porto, Instituto Portugues de Oncologia, CIC 291, P. Pimentel, F. Campilho

Porto, Hospital S. Joao (hem), CIC 329, F. Principe

Porto, Faculty of Medicine of Porto, Hospital S. Joao (Onco), CIC 572, J.E. Guimaraes

Romania: no report

Russia

Ekaterinburg, City Hospital no. 7, L.B. Filatov

Ekaterinburg, Regional Hospital no. 1, T.S. Konstaninova, V.A. Shalaev

Moscow, Institute of Biophysics, A.E. Baranov

Moscow, Cancer Research Center, CIC 757, V. Ptuschkin

Moscow, Cancer Research Center peds Hem/onco, G. Mentrevich

Moscow, Research Hematology Center of RAS, V.G. Savtchenko

Novosibirsk, Insitute of Clinical Immunology, CIC 376, I. Lisukov

Samara, Regional Hospital, V.A. Rossiev

St. Petersburg, Research Institute of Hematology, CIC 724, K.M. Abdulkadirov

St. Petersburg, Military Medical Academy, CIC 520, A. Novik

St. Petersburg, Clinical Center for Advanced Medical Tech, CIC 370, E. Podoltseva

St. Petersburg, State Pavlov Medical University, CIC 725, B.V. Afanassiev, L. Zubarovskaya

Yaroslavl, City Hospital no. 8, V.A. Lapin

San Marino: no report

Slovakia

Bansra Bystrica, Roosevelt Hospital, CIC 333, K. Mocikova

Bratislava, 2nd Children's Clinic, University Hospital, J. Lukac

Bratislava, University Hospital, CIC 610, M. Mistrik

Bratislava, National Cancer Institute, CIC 560, J. Lakota

Slovenia

Ljubljana, University Medical Centre, CIC 640, J. Pretnar

Spain

Alicante, Hospital General, C. Rivas-Gonzales

Barcelona, Instituto de Oncologia Corachan, D. Alfonso-Modolell

Barcelona, Santa Creu I Sant Pau (adults), CIC 260, J. Sierra, S. Brunet

Barcelona, Santa Creu I San Pau (peds), CIC 260, I. Badell Serra, J. Cubells -Riero

Barcelona, Santa Creu I Sant Pau (onco), CIC 260, Dr J.J. Lopez, C. Solà

Barcelona, Hospital Sant Joan de Deu, CIC 668, J. Estella Aguado

Barcelona, Hospital Duran i Reynals (Hem), Institut Catala d'Oncologia, CIC 759, A. Granena, C. Ferra, J. Berlanga

Barcelona, Hospital de Llobregat (onco), A. Granena

Barcelona, Hospital General ‘Vall d’Hebron', CIC 583, A. Julia Font

Barcelona, Hospital Mutua de Terrasa (hem-onco), J. Marti

Barcelona, Hospital Universitario Germans Trias i Pujol, CIC 613, J. Ribera (starting in 2000)

Barcelona, Hospital M. Infantil, CIC 527, J. Ortega

Barcelona, Hospital Clinic, CIC 214, E. Montserrat, E. Carreras

Barcelona, Clinica Corachan, CIC 758, P. Vivancos

Barcelona, Instituto Dexeus, CIC 334, M. Ribas-Mundo, A. Domingo Albos

Cadiz, Hospital del SAS de Jérez, A. Leon

Cadiz, Hospital Universitario ‘Puerta del Mar’, CIC 679, J. Gil

Canary Isles, Hospital Insular Las Palmas, CIC 335, F. Fernandez-Fuentes, J. Gonzalez-San Miguel

Canary Isles, Hop. Materno-Infantil Las Palmas (peds), J. Lodos Rojas, A. Molinés

Canary Isles, Hospital Universitario de Canarias, Santa Cruz de Teneriffe, L. Hernandez Nieto, M.T. Hernandez Garcia

Canary Isles, Hospital Nostra Senora del Pino, Las Palmas, J.J. Malcorra, R. Mataix, C. Campo

Castellon de La Plana, Hospital general de castellon (haem), R. Garcia-Boyero

Cordoba, Hospital de la Cruz Roja de Cordoba (haem), J-M. Garcia-Castellano

Cordoba, Hospital Reina Sofia, CIC 238, A. Torres Gomez

Cruces-Barakaldo, Hospital de Cruces, I. Zuazua-Verde

Galdakao, Hospital de Galdakao, Hem, J. Ojanguren, K. Atucha

Granada, Hospital Virgen de la Nieves, J.M. de Pablos

Jaen, Hospital Cuidad de Jaen (haem)

La Coruna, Complexo Hospitalario Juan Canalejo, F.J. Batlle, C. Ramirez, P. Torres, R. Varela

Lérida, Hospital Arnan de Villanova, J. Macia

Lugo, Hospital Xeral-Calde, M. Gonzales-Lopez

Madrid, Clinica La Luz, H. Cortés-Funes, J. Hornedo

Madrid, Clinica Moncloa (hem), J. M. Fernandez, Q. Escudero

Madrid, Hospital Universitario de Getafe (hem), O. Compan, C. Monteserin, J. Vels, N. Somolinos, I. Delgado

Madrid, Hospital Universitario San Carlos, CIC 733, J. Diaz Mediavilla, L. Llorente

Madrid, Hospital University San Carlos, CIC 733, M. Martin, E. Diaz-Rubio, A. Casado, J.A. Lopez-Martin

Madrid, Hospital Ruber Internacional, J. Diaz Mediavilla

Madrid, Unidad de TMO-ONC 4, Hospital Gregorio Maranon, CIC 819, J.L. Diez Martin

Madrid, Clinica Ruber, J.M. Fernandez-Ranada, Q. Escudero

Madrid, Hospital de la Princesa, CIC 236, J.M. Fernández Rañada, A. Figuera, A. Alegre

Madrid, Clinica Puerta de Hierro, CIC 728, M.N. Fernandez

Madrid, Hospital General La Paz (ads), F. Hernandez Navarro, E. Ojeda

Madrid, Hospital Doce de Octubre, J.J. Lahuerta (hem), H. Cortés Funes (onco), J. Lopez Perez (peds)

Madrid, Hospital Nino Jesus, CIC 732, L.M. Madero

Madrid, Clinica San Camillo, M. Martin-Jimenez

Madrid, Hospital La Paz Infantil, CIC 734, A. Martinez-Rubio, A. Sastre, P. Garcia-Miguel

Madrid, Hospital Ramon y Cajal (peds) A. Munoz Villa, E. Otheo, M.S. Maldonado

Madrid, Hospital Ramon y Cajal (ads), CIC 615, J. Odriozola, J. Pérez de Oteyza, J. Lopez, J. Garcia Larana

Madrid, Fundacion Jimenez Diaz, J. Tomas, C. Paniagua, F. Lobo

Madrid, Hospital Militar Gomez Ulla, F. Sancho-Cuesta, S. Enrech-Frances

Malaga, Hospital Regional, CIC 576, J. Maldonado

Murcia, Hospital Virgen de la Arrivxaca, CIC 323, R. Candel Parra

Murcia, Hospital General, CIC 735, J.M. Moraleda, V. Vicente-Garcia, I. Heras

Orense, Hospital Cristal-Pinor (hem), Dra. Vazquez

Oviedo, Hospital Covadonga, CIC 642, D. Carrera Fernandez, C. Rodriguez Pinto

Palma de Mallorca, Hospital Son Dureta, CIC 722, J. Besalduch, H.S. Dureta

Palma de Mallorca, Policlinica Miramar, J. Besalduch, A. Sampol

Pamplona, Hospital Provincial de Navarra, CIC 577, E. Pérez Equiza, M.J. Uriz Pascual, J. Gastearena

Pamplona, Clinica Universitario de Navarra, CIC 737, J. Rifon

Pontevedra, Hospital Montecelo, CIC 549, M. Constela

Salamanca, Complejo Hospital, CIC 727, D. Caballero

San Sebastian, Hospital Nostra Senora de Aranzazu, CIC 598, J. Marin, D. Martinez

Santander, Hospital Universitario M. de Valdecilla, CIC 242, A. Iriondo, E. Conde, E. Bureo, A. Zubizarreta-Pina

Sant Cugat del Vallés, Hospital General de Cataluna, M. Sureda-Gonzales

Santiago de Compostela, Hospital Xeral de Galicia, CIC 570, J.L. Bello

Sevilla, Hospital Universitario Virgen del Rocio, CIC 769, J.M. Rodriguez Fernandez

Sevilla, Clinica Del Sagrado Corazon, M. Rodriguez

Tarragona, Hospital de Tarragona Joan XXlll (hem), C. Alonso y Macia

Valencia, Hospital Universitario La Fe (peds), CIC 653, V. Castel, A. Verdeguer

Valencia, Hospital Clinico Universitario, CIC 282, J. Garcia-Conde, C. Solano

Valencia, Instituto Valenciano de Oncologia, V. Guillen, J. Palau

Valencia, Hospital Universitario La Fe, CIC 663, M.A. Sanz, G.F. Sanz

Valencia, Clinica Virgen del Consuelo (hem), M. A. Sanz

Valencia, Hospital Doctor Peset (hem), P. Ribas Garcia

Valladolid, Hospital Rio Hortega, J. Garcia Frade

Vigo, Hospital Xeral-Cies, A. Martinez-Dalmau

Zaragoza, Hospital Miguel Servet (hem + onco) M. Giralt, G. Pérez-Lugmus, D. Rubio-Félix, A. Anton

Zaragoza, Clinico Universitario Lozano Blesa (Haem, onco), A. Tres, L.Palomera, M. Gutierrez, J. Mayordomo

Sweden

Goteborg, Medical Clinic, CIC 715, M. Brune

Goteborg, East Hospital, CIC 289, A. Fasth, S. Rodjer

Huddinge, Hospital, CIC 212, P. Ljungman

Linköping, University Hospital, CIC 740, G. Juliusson

Lund, University Hospital, CIC 283, A.N. Bekassy

Malmö, University Hospital, I. Turesson

Örebro, Medical Center Hospital, CIC 738, U. Tidefelt

Stockholm, Karolinska Hospital, CIC 626, M. Björkholm

Umea, Norrland University Hospital, CIC 731, E. Löfvenberg

Uppsala, University Hospital, CIC 266, B. Simonsson, K. Carlson, H. Hagberg

Switzerland

Aarau, Kantonsspital, CIC 316, M. Wernli

Basel, Kantonsspital, CIC 202, A. Gratwohl, T. Kühne, R. Herrmann

Bellinzona, Ospedale San Giovanni, CIC 829, F. Cavalli, M. Ghielmini

Berne, Inselspital, CIC 221, A. Tobler, K. Leibundgut

Geneva, Hôpital cantonal universitaire, CIC 261, B. Chapuis, J.Humbert

Geneva, Clinique La Tour, C. Irlé

Lausanne, CHUV, CIC 820 + CIC 579, M. Schapira, T. Kovacsovics, N. Nenadov-Beck, S. Leyvraz, N. Ketterer

Neuchatel, Hôpital des Cadolles, D. Piguet

Pully, Clinic de la Source, W. von Fliedner

St. Gallen, Kantonsspital, CIC 324, U. Hess

Zurich, University Hospital, CIC 208, J. Gmür, R. Stahel, L. Jost, R. Seger

Zurich, Klinik Hirslanden, A. von Rohr, J. Gmür, U. Breitenstein

Turkey

Ankara, Numune Education and Research Hospital, CIC 691, T. Demirer

Ankara, Ibn-1 Sina Hospital, CIC 617, H. Koc

Ankara, Hacettepe University, CIC 292, E. Kansu

Ankara, Childrens Hospital Hacettepe University, CIC 509, A. Tuncer, D. Uckan

Ankara, University of Ankara (peds), CIC 620, E. Unal

Ankara-Etlik, GATA BMT Center, CIC 372, A. Yalcin, F. Arpaci, A. Özet, C. Beyan, A. Ural

Ankara-Etlik, GATA Haydarpasa Egitim Hst, CIC 687, N. Uskent

Antalya, Akdeniz University hospital, CIC 618, M.A. Yesilipek, V. Hazar, O. Yegin

Antalya, Akdeniz University hospital, CIC 685, L. Undar

Balcali, Hospital, CIC 821, A. Tanyeli

Eskisehir, Osmangazi University, CIC 686, Z. Güblas

Istanbul, Marmara University, Altunizade, CIC 714, S. Ratip, T. Akoglu

Istanbul, Maltepe Medical Faculty, CIC 210, K. Ozerkan, A. Tamkan (new team for 2000)

Istanbul, Cerrahpasa Medical School, CIC 761, B. Ferhanoglu, T. Soysal, Z. Baslar

Istanbul, Tip Fakultesi, CIC 762, G. Gedikoglu

Istanbul, Medical Faculty, CIC 760, Y. Tangün

Istanbul, Institute of Oncology, CIC 689, H. Onat

Izmir, Ege University Medical Faculty (ads), CIC 628, S. Cagirgan

Izmir, Ege University Medical Faculty (peds), CIC 621, S. Kansoy

Izmir, Dokuz Eylul University, CIC 688, U. Yilmaz

Kayseri, Erciyes University Hospital, CIC 627, A. Unal, M. Cetin

Ukraine: no report

United Kingdom

Aberdeen, The Royal Infirmary, CIC 344, D.J. Culligan

Bangor, Gwynedd Hospital, CIC 736, H. Parry

Bath, Royal United Hospital, CIC 619, J.G. Smith

Belfast, Belvoir Park Hospital, P. Abram

Belfast, Royal Victoria Hospital, CIC 268, F. Jones, M.F. McMullin, P. Burnside

Belfast, City Hospital, CIC 753, T.C.M. Morris, L. Ranaghan

Birmingham, The Birmingham Childrens Hospital, CIC 781, P.J. Darbyshire, M.W. Williams

Birmingham, Queen Elizabeth Hospital, CIC 387, P. Mahendra, C. Craddock

Birmingham, Heartlands Hospital, CIC 284, D.W. Milligan

Bournemouth, Royal Bournemouth Hospital, CIC 765, H. Myint

Bristol, Royal Hospital for Sick Children, CIC 386, J.M. Cornish & Southmead Hospital, J. Hows, M.G. Rainey

Cambridge, Addenbrooke's Hospital and Norwich Hospital, CIC 566 + 391, R.E. Marcus, M. Deane

Cardiff, University of Wales, CIC 303, C.H. Poynton

Coventry, Walsgrave Hospital, R. Harris

Dundee, Ninewells Hospital, CIC 719, D. Bowen

Edinburgh, Western General Hospital (hem) CIC 228, P.S. Ganly, M.J. Mackie, P.R.E. Johnson

Edinburgh, Western General Hospital (onco) CIC 228, R. Leonard (new team for 2000)

Exeter, Royal Devon and Exeter Hospital, CIC 571, M. Joyner

Glasgow, Royal Infirmary, CIC 244, A. Parker, I.G. McQuaker

Glasgow, The Western Infirmary, CIC 325, T. Fitzsimons

Glasgow, Royal Hospital for Sick Children, CIC 707, Dr Gibson

Leeds, St. James's University Hospital & The General Infirmary, D. Barnard, S. Kinsey, J.A.Child, CIC 254

Leicester, Royal Infirmary, CIC 713, A.E. Hunter

Liverpool, Royal Liverpool University Hospital, CIC 501, R.E. Clark

Liverpool, Alder Hay

London, Hammersmith & Charing Cross Hospital, CIC 205 & CIC 510, J.M. Goldman, D. Samson, E. Kanfer

London, University College Hospital, CIC 224, A.H. Goldstone

London Oncology Marrow Transplantation Group, CIC 263, P.J. Gravett

London, St. George's Hospital, CIC 539, J. Marsh, S. Ball, E.C. Gordon-Smith

London, King's College, CIC 763, A. Pagliuca, G.J. Mufti

London, Royal Marsden Hospital, CIC 218, R. Powles, J. Mehta

London, Royal Free Hospital, CIC 216, H.G. Prentice, M. Potter

London, St. Bartholomew's, CIC 768 and the Royal London Hospital, CIC 269, A. Rohatiner, A.C. Newland

London, Guy's Hospital, CIC 721, S. Schey

London, Institute of Child Health, CIC 243, P. Veys, I.M. Hann

Manchester, Christie Hospital, G. Morgenstern

Manchester, Royal Children's Hospital, CIC 521, A.M. Will

Manchester, The Royal Infirmary, J.A. Yin

Manchester, Trafford General Hospital, P.A. Carrington

Manchester, Hope Hospital, P.A. Carrington

Newcastle upon Tyne, Royal Victoria Infirmary, CIC 276, S.J. Proctor, P. Taylor, A. Cant, A.D.J. Pearson

Norwich, Norfolk and Norwich Hospital (hem), CIC 391, M. Deane (reported with CIC 566 Addenbrookes, Cambridge)

Nottingham, City Hospital, CIC 717, N. Russell

Oxford, John Radcliffe Hospital, Headington, CIC 255, D. Smith, C. Hatton, T.J. Littlewood, J. Wainscoar

Plymouth, Derriford Hospital, CIC 823, M.D. Hamon

Poole, Dorset Cancer Centre, CIC 580, A. Bell

Rotherham, General Hospital, CIC 647, H. Barker

Sheffield, The Royal Hallamshire Hospital (ads) CIC 778, E. Vandenberghe, A. Vora, R. Hincliffe

Sheffield, The Roald Dahl Paediatric Haematology Centre

Sheffield Weston Park Hospital, CIC 930, P. Lorigan

Somerset, Taunton and Somerset Hospital, S.A. Johnson, S. Rule

CRC Wessex, Southampton, CIC 704, A. Smith, A. Duncombe, J. Sweetenham, J. Kohler

Stoke-on-Trent, North Staffordshire Royal Infirmary, R. Chasty

Sunderland, The Sunderland Royal, P.J. Carey

Swansea, Singleton Hospital, Sketty, S. Al Ismail

Swindon, Princess Margaret Hospital (Hem), CIC608, N.E. Blesing, A. Gray, S. Green, A. Koster

Wakefield, Pinderfield's General Hospital, CIC 764, C. Galvin, D. Wright

Yugoslavia (Serbia and Montenegro)

Belgrade, Clinical Centre of Serbia, CIC 373, M. Colovic, A. Bogdanovic

Belgrade, Mother and Child Health Institute, D. Makic

Belgrade, Military Medical Academy, CIC 582, M. Malesevic

Novi Sad, Institute of Internal Diseases, CIC 655, D. Pejin

Ancillary