John L. Marshall, MD; Bruce D. Cheson, MD; David Kerr, CBE, MD, DSc, FRCP, FMedSci


June 10, 2013

In This Article

The Big C Change

Dr. Marshall: There is going to be a shift, at least in the United States, from a consumption model. Right now we have an incentivized model: The more we do, the more money we make either for our institution or for ourselves. But things are evolving to where we're going to have outcomes as our primary measure and in a way be capped. So, you get so much money to take care of your lymphoma. Have fun with it. Anything more than you spend on this will come out of another budget. It will force us on an individual level to make decisions, and the value of these kinds of studies will be to say, "What do we really need to do? What is the minimum that we need to do to provide the best care?" We've been on the maximum side of that argument the whole time. It may shift.

One area that we will see shifting as well is this concept of rebiopsy and molecular profiling. Right now this is really science, but in some ways it's becoming more and more practice. In your world, molecular profiling is an everyday, routine thing. In our world, it's just emerging. People talk about the cost of a next-generation sequence or the cost of this or that. It is essentially the same cost as a single CT scan. We need to keep that in perspective as we bring in new innovations.

Dr. Kerr: We understand exactly how we are starting to select and stratify; is that going to drive costs down? I have this notion (and I haven't thought it through health economically) that if we start to segment and stratify the population, that 5% of lung cancer patients express marker X and get drug Y. That segmentation, I assume, would drive costs down, but is that correct?

Dr. Cheson: You won't be treating the other 95% with a drug that you know won't work. In that way, it will save money.

Dr. Marshall: Yes. It gets us away from treating everybody for the 20%-30% who benefit, so it should save money. But we will need very strong ammunition. It needs to be a good-enough test for us to look that patient in the eye and say, "You shouldn't have this medicine. It won't work for you."

Dr. Cheson: Good-enough tests that you would treat with a good-enough drug. Not a pancreas drug that gets you an hour and a half of prolongation of progression-free survival.


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