Analysis of Healthcare Provider Practice Patterns from Individual Patient Cases Entered into an Online Treatment Decision Tool for Chronic Lymphocytic Leukemia (CLL)

Background

New agent approvals and indications in CLL have changed treatment approaches and increased the complexity of managing CLL. Healthcare providers (HCPs), particularly those practicing in community settings with limited experience in caring for patients with CLL, can be challenged to make informed treatment decisions in this evolving treatment landscape. We report on an analysis of current CLL treatment patterns of HCPs using an online treatment decision tool developed by experienced CLL physicians from leading academic institutions and cancer centers (experts) to assist HCPs in their practice.

Methods

Since 2016, CLL experts have developed and then twice updated (early 2016, late 2016, and 2017) an online treatment decision tool designed to provide specific recommendations for patient case scenarios entered by HCPs. For each iteration of the tool, 5 experts provided their treatment recommendations for hundreds of case variations based on key factors defined by the experts as those that guide treatment choices in their practice. Factors for newly diagnosed CLL included age, fitness (based on ECOG PS, CIRS, and renal function), cytogenetic abnormalities, and IGHV mutation status. Additional variables for patients with relapsed/refractory disease after first-line treatment included previous treatment, response duration, reason for switching therapy, burden of comorbidities, and disease-related symptoms. To use the tool, participating HCPs entered patient and disease factors along with their intended treatment plan for that case. When the entry of the case into the tool was completed, the 5 expert treatment recommendations for that specific patient case were shown, followed by a short survey designed to determine if the expert recommendations changed the HCPs' planned course of treatment. Our analysis includes a comparison of intended treatment of HCPs for 2198 cases entered into the tool (early 2016, n = 883; late 2016, n = 562; 2017, n = 753) with the expert recommendations for those patient cases.

Results

Although there was consensus among the experts (≥ 3 of 5 experts choosing the same treatment course) for 87% of cases included in the 2017 tool, there was substantial variation between the expert recommendations and the intended treatment of HCPs using the tool. In treatment-naive patients with del(17p) CLL in all 3 tool iterations, experts recommended ibrutinib as first-line therapy for 100% of cases regardless of any other variable, whereas only approximately 40% of HCPs planned to use ibrutinib for these patients.

For young (< 65 years of age), fit patients with non-del(17p) CLL, the addition of IGHV mutation status as a factor in the late 2016 and 2017 tools changed expert recommendations. Experts recommended FCR for 60% (vs HCPs at 68%) and ibrutinib for 40% (vs HCPs at 14%) of cases with IGHV mutations. For cases without IGHV mutations, experts recommended FCR for 0% (vs HCPs at 53%), ibrutinib for 80% (vs HCPs at 18%), and BR for 20% (vs HCPs at 21%) of the cases. Similar treatment patterns are also seen with older or unfit patients with non-del(17p) CLL, where the expert recommended use of ibrutinib increased from early 2016 to 2017 (21% to > 65% of cases), whereas HCP use of ibrutinib remained consistent (15% to 20%).

In patients with del(17p) CLL who progressed on first-line therapy, the approval of venetoclax changed treatment patterns among both experts and HCPs in the late 2016 and 2017 tools. In patient cases with del(17p) CLL who were discontinuing ibrutinib, experts consistently recommended venetoclax in 93% of cases (7% idelalisib + R for cases with intolerance to ibrutinib) vs HCPs using venetoclax for 59% and 69% of cases in late 2016 and 2017, respectively. For HCPs whose intended treatment differed from experts, 50% indicated that their treatment plan would change after using the tool (36% no/undecided and 14% reported barriers to change).

Conclusions

Practice patterns between experts and HCPs differed substantially in their use of novel therapy for routine clinical practice. Expert recommendations in this online tool changed the intended treatment plan of HCPs using the tool and suggests that online treatment decision tools developed by respected experts can help optimize the care of patients with CLL. A full analysis of all cases entered into the tool, including a detailed report of expert and HCP practice trends, will be presented.