Balancing Cost, Utilization, and Risk in CLL Treatment: Adam Kittai, MD

What does it actually cost—in dollars, in clinic visits, and in years—to treat chronic lymphocytic leukemia (CLL)? That question sits at the center of a conversation with Adam Kittai, MD, director, CLL Program, Perlmutter Cancer Center, and director, Lymphoma Program, Perlmutter Cancer Center - Long Island, at NYU Langone Health.

In the final part of his recent interview with The American Journal of Managed Care^®, Kittai opened by addressing the economics of treatment head-on. Multiple studies have confirmed that time-limited therapy is less expensive overall than continuous therapy, a finding that, on its face, seems straightforward, he explained. But he added an important nuance: most of those studies were conducted using venetoclax-obinutuzumab (VO), a regimen that includes an infused agent, and the cost picture may shift as all-oral combinations become more widely used.

For individual patients navigating out-of-pocket expenses, the math is tangible: a fixed number of cycles is simply more manageable than an indefinite monthly cost. He noted that he has adjusted treatment decisions based on a patient’s financial situation, although he emphasizes that high out-of-pocket burdens are not as common as one might expect.

Utilization is the other side of the coin. Venetoclax requires frequent clinic visits for dose ramp-up, along with labs drawn 6 to 8 and 24 hours after each escalating dose. Obinutuzumab adds infusion chair time, infusion reaction monitoring, and 8 total administrations over the disease course. By comparison, continuous Bruton tyrosine kinase inhibitors demand less monitoring and fewer visits, a real consideration when weighing regimens.

Kittai then turned to a broader framework for thinking about patients who have CLL, placing them in 3 distinct risk buckets: good-risk, normal-risk, and high-risk, each with its own unresolved questions. The roughly 25% of patients with good-risk disease may actually be overtreated today, while the approximately 20% with high-risk disease still lack a strategy that delivers durable disease control beyond a decade.

He closed with a candid look at the horizon. T-cell–directing therapies and immune-based approaches hold real promise for a future cure, but the outstanding challenge is not just efficacy; it is safety. As Kittai put it, until there is either a cure or a therapy so safe that a cure becomes unnecessary, there remains significant work ahead.