Influence of Treatment Modality on Outcomes in CLL

Steven Peskin, MD, MBA, FACP: A stem cell transplant is certainly a major commitment by the patient. It’s a major commitment of financial resources and human resources. [When] there are approaches and therapies that can obviate the need for stem cell transplant, that’s a better solution. Clearly, there are patients who fail other therapies and stem cell transplantation can be truly lifesaving and life-prolonging. So, that’s an area where we’re, again, working at the medical policy level and working with our clinical organizations to determine what alternatives there are before stem cell transplantation.

Then, there’s the issue of not wanting to go down the pathway of salvage chemotherapies or even salvage immunotherapies that have no value. The patient is getting sicker and stem cell transplantation becomes more difficult and more problematic, with a higher probability of infection or bad outcomes. So, weighing those [options] is very much a delicate balance.

[In regard to coverage for chronic lymphocytic leukemia (CLL) treatment], we have explicit medical polices that are publicly available. If any of our listeners, viewers, would want to review those, they are a matter of public record.

I can’t, today, comment on, specifically, our coverage policy for particular infused therapies for CLL versus oral therapies. Again, that information is available. We do mostly rely on our clinical organizations to make informed and evidence-based decisions about which pathway to follow, or which alternative to use.

We really see those [very important kinds of decisions] in the domain and the province of clinicians, medical oncologists, surgical oncologists (where surgeons are involved), radiation oncologists, and really, the true care team—comprehensive cancer care. Again, we provide a certain framework around medical policy. If there’s insufficient evidence to support the use of something, we may have a medical policy that states that. In this group of competing therapies that were mentioned in the area of CLL—infused therapies versus oral therapies—again, with those all being in the armamentarium, we’re really going to look to our clinical partners to make those decisions.

[In regard to considerations for use of infused therapies versus oral therapies], oral therapies are available, and equally, or more efficacious. They offer certain advantages in terms of the ability of the patient to control his or her taking of the medicine as opposed to having to have an appointment at an infusion center. So, there are certain obvious advantages to oral therapies.

On the other hand, if the infused therapy offers advantages in survival, or other advantages around knowing that the patient is getting the precise therapy that is needed in a particular dosing scheme, then that might trump the oral therapy.

As far as cost, I really can’t comment because that gets into a lot of different considerations about what the patient cost burden might be. In one particular plan design versus another, more often, you are going to have a somewhat higher patient out-of-pocket cost when you go to a facility than if you’re picking up a medicine. But, if the medicine is considered a specialty pharmacy product, and might have a higher co-payment or even a coinsurance, then it’s possible that it could be less expensive for the patient to get an infused product. So, I can’t give you a one-size-fits-all answer to that.