John L. Fox, MD, MHA: I think there is no area in cancer that hasn’t been affected by the advances in our diagnostic capabilities. Before, we simply had a histologic diagnosis or a cytologic diagnosis, and now we have the ability to do a whole host of more things. We still do karyotypes, we do still do cytogenetics, but our ability to look at the molecular mutations in CLL…for example, you can look at immune globulin, heavy chain variability in the DNA sequencing to predict risk, and you can look at a number of molecular markers, as well, to predict risk. So, the cost of the diagnostics themselves are really not an issue. Those are the up-front costs in trying to establish what the most appropriate therapy is for that particular patient.
One question is: how are managed care companies influencing, directing, or framing the diagnostic evaluation of patients with any type of cancer, including CLL? From our vantage point, it’s the upfront costs of establishing what appropriate therapy is. I really think that purview of overseeing what’s appropriate, diagnostically, is really in the hands of the professional societies, whether or not that be the NCCN or ASCO or other agencies. We really view that as their domain. I think we’re interested in the costs of these therapies; if they’re unproven, for example, next-generation sequencing. But outside of that, we’re really going to leave that to the providers to decide what the optimal diagnostic strategies are.
Stem cell transplants are certainly viable therapeutic options in many patients with hematologic malignancies. It used to be that the cost of a stem cell transplant was the most expensive part of therapy. A stem cell transplant, an autologous stem cell transplant, $125,000; an allogeneic stem cell transplant, $180,000. And we used to manage those very carefully and ensure that patients were appropriate. We still do, but what’s changed in the last decade has been the cost of the chemotherapy or the targeted therapies that are used. So, while I used to be very concerned about the cost of stem cell transplant, right now, I think it’s a bargain in many circumstances, depending on what patients get post-transplant. Today in multiple myeloma, for example, patients get maintenance therapy after they get their stem cell transplant. But the cost of the transplant is not the largest cost overall, given the lifetime costs of inducing and maintaining people in remission who have CLL.