Reduced intensity conditioning (RIC) regimens have allowed older patients and those with comorbidities to receive hematopoietic cell transplantation (HCT). We analyzed medical costs from the beginning of conditioning to 100 days after HCT for 484 patients and up to 2 years for 311 patients who underwent a RIC HCT at two institutions from January 2008 to December 2010. Multiple linear regression was used to analyze the association between clinical variables, center effect, and costs. Patient and transplant characteristics were comparable between the sites, although differences were seen in pretransplant performance scores. Significant predictors for lower costs for the first 100 days included a diagnosis of lymphoma/myeloma and use of human leukocyte antigen-matched related donors. Grade II-IV acute graftversus-host disease (GVHD) was associated with higher costs. The overall short-term costs between the two institutions were comparable when adjusted for clinical variables (p 5 .43). Late costs between 100 days and 2 years after HCT were available for one cohort (n 5 311); median costs during this period were $39,000 and accounted for 39% of costs during the first 2 years. Late costs were not associated with any pretransplant variables, but were higher with extensive chronic GVHD and death. After adjustment for clinical characteristics, the overall costs of the RIC transplants were similar between the two institutions despite different management approaches (inpatient vs. outpatient conditioning) and accounting methodologies. Use of unrelated/ alternative donors, transplant for diseases other than lymphoma or myeloma, and acute GVHD were predictors for higher early costs, and extensive chronic GVHD and death were associated with higher late costs. The Oncologist 2014; 19:639-644Implications for Practice: This study from two large centers describes the profile and predictors of costs of reduced intensity conditioning (RIC) hematopoietic cell transplantation. Results indicate comparable costs between two centers with different practice patterns. Identification of optimum donors with favorable cost-benefit ratio and interventions to prevent complications such as graft-versus-host disease may yield clinical and financial benefits. A commitment to lowering costs while preserving quality of care is essential in the current environment, especially for RIC transplants. These transplants are done mainly for the older population, a majority of whom may be prone to insufficient coverage and declining reimbursements by Medicare.The study also underscores the need for collection of resource utilization data in a prospective fashion with clinical studies.

7034 Background: Reduced intensity (RIC) conditioning regimens have allowed older patients and those with comorbidities to receive hematopoietic cell transplantation (HCT). Methods: We analyzed medical costs from the beginning of conditioning to 100 days after HCT for 484 patients who underwent a RIC allogeneic HCT at Fred Hutchinson Cancer Research Center (FHCRC; n=147) and Dana Farber Cancer Institute (DFCI; n=337) from 1/2008 to 12/2010. Costs up to 2 years after HCT were analyzed for DFCI (n=311) as most patients receive their post-transplant care there. Multiple linear regression was used to analyze the association between clinical variables and costs. Results: Disease distribution and transplant characteristics were comparable between the two sites, though significant differences were seen in age distribution (88% FHCRC patients ≥ 50 years vs. 80% at DFCI, p=0.04) and pre-transplant performance scores (63% patients with Karnofsky score≥ 90 at FHCRC vs. 47% at DFCI; p=0.006). Median costs for first 100 days in 2010 $ at FHCRC and DFCI were $129 000 (range 31,000-352,000) and $96,000 (3,000-614,000) respectively, p=0.0002, but differences were not significant in multivariate analysis. Inpatient costs accounted for 42% of early costs at FHCRC and 87% at DFCI.Significant predictors for early costs included a diagnosis of lymphoma/ myeloma (17% decrease in costs; p=0.01), donors other than matched related (50 -100% increase; p<0.001), relapse (17% increase, p=0.04) and ≥ grade II acute GVHD (37% increase; p<0.001). Median costs between d100 and 2 years were $39,000 (0-976,000) at DFCI. 39% of the 2 year costs occurred after first 100 days. There was no association of late costs with pre-transplant variables, and only death was associated with higher costs (138% increase; p=0.005). Conclusions: After adjustment for pre and post HCT variables, the overall costs of the RIC allogeneic transplants were similar between the two institutions despite different management approaches (inpatient vs. outpatient conditioning) and accounting methodologies. Use of unrelated/ alternative donors, relapse and acute GVHD were predictors for higher early costs while only death was associated with higher late costs.

The search for more effective and less toxic therapies for cancer has occupied scientists for decades. Recently approved treatments involving the genetic modification of a patient's own T cells to better target cancer cells are an important advance in cancer treatment, thereby sparing patients less effective therapies while offering a meaningful chance at remission. Chimeric antigen receptor (CAR) T cells involve the ex vivo transduction of T cells so they express a receptor on their surface that both is specific for a tumor antigen and contains T-cell activation domains such that engagement of the receptor by tumor antigen results in activation of the T cell against the tumor cell. The 2 approved CAR T-cell products include axicabtagene ciloleucel, manufactured by Kite Pharma, and tisagenlecleucel, a Novartis product. Both therapies target CD19 on the surface of B lymphocytes and are approved as single infusions for the treatment of relapsed and refractory B-cell malignancies, including B-cell acute lymphoblastic leukemia (B-ALL) in children and young adults (tisagenlecleucel) and aggressive B-cell non-Hodgkin lymphoma (B-NHL) (both tisagenlecleucel and axicabtagene ciloleucel). Even though these cell therapies produce durable remissions in some patients with no existing effective options, they are priced at a 1-time cost of $475 000 for B-ALL and $373 000 for B-NHL. Countries around the world are grappling with the cost of these treatments.CAR T-cell therapy is not the first treatment to present health care payers and policy makers with difficult choices about coverage and reimbursement; however, this treatment represents a significant escalation in these challenges. Ensuring equitable and affordable access to CAR T-cell therapy is an important policy goal; development of appropriate policies that anticipate and encourage similar innovations in the future is critical. As the largest payer for cancer care, Medicare is at the center of this discussion. CAR T-cell therapy can be used as a lens through which to examine the larger health policy challenges that high-cost innovation will bring to Medicare and, by extension, other payers.

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