The review of chemical pleurodesis by Walker-Renard and colleagues [1] was informative, but their conclusion on the efficacy and cost of these agents must address efficacy, the patient-practitioner relationship, and cost.

Most of my statements here are directed toward the comparison of doxycycline with bleomycin, for which the literature for minocycline is preliminary. In their review, Walker-Renard and associates conclude that the first-dose efficacies, defined as complete responses, of doxycycline and bleomycin are 10% and 54%, respectively. For doxycycline, cumulative second-dose effectiveness is 20% and third-dose efficacy is 43%. It was not until the fourth dose of doxycycline that the efficacy resembled that of the first dose of bleomycin (53% to 54%) [1]. Robinson and colleagues [2] published the best results to date of using doxycycline for sclerotherapy. Of 21 patients initially treated, only 17 were evaluated. Two died (with chest tubes in place) because of their rapidly progressing diseases, and 2 died within the 30-day follow-up period. Patients were given 500 mg of doxycycline in sterile water with lidocaine and were monitored for 24 hours. Thirteen (62%) patients responded to one instillation, 6 to two doses (29%), and the other 2 to three instillations (10%). The authors report an overall success rate of 88% (15 of 17 patients) at 1 month. It is important to note that three patients were treated with urokinase before receiving sclerotherapy [2]. These results need to be confirmed to exclude the possibility of error because of sample size.

Several patient-care issues must also be addressed. Doxycycline requires multiple instillations (an average of four in the review by Walker-Renard and associates), usually over several days [1]. Bleomycin, requiring only one dose, allows the chest tube to be removed more rapidly, thus reducing patient discomfort and the time-related risk for infection. One could speculate that patients treated with bleomycin may be less prone to experience the emotional stress and depression or anxiety that are associated with multiple instillations [1].

Walker-Renard and associates state that the average wholesale prices are $403 for doxycycline at 2 g (500 mg for four doses) and $1104 for bleomycin at 70 mg. These are the only costs that would have to be considered if all four instillations could be done on the same day. However, in the studies cited in the review article, only one sclerosis was done per day. This requires the addition of the cost per day of hospital stay to be added to the Equation for the true cost of therapy. The average cost for a day in the hospital is $752 [3]. Adding 2 to 3 extra days of hospitalization to the cost of treatment with doxycycline increases the cost of therapy by $1500 to $2250. This suggests that bleomycin is a more cost-effective therapy.