Clinician and Patient Factors Influencing Treatment Decisions in Front-Line Chronic Lymphocytic Leukemia: A Qualitative Research Study

Background. Emerging data on novel targeted agents have been advancing the treatment landscape of front-line (1L) chronic lymphocytic leukemia (CLL) in the past decade. Despite the advances, lack of mature overall survival data for novel agents presents a challenge to treatment selection. In the absence of demonstrated long-term survival advantages, treatment selection may be subject to other factors. We hypothesize that these include physician preferences and patients’ unique evaluation of potential risks, perceived benefits, and characteristics of individual treatment modalities, such as location, time-limited (TL) vs. treat-to-progression (TPP) duration and need for monitoring. As such, there is value in understanding physician and patient preferences and the key factors that influence their goals of therapy and subsequent treatment selection.

Methods. Patients and treating physicians (hematologist oncologists) were recruited across three countries to participate in semi-structured telephone interviews lasting approximately 45 minutes in April 2022. The sample size was based on thematic data saturation principle, setting a threshold for when no new key themes emerge with each subsequent additional interview. Our sample size of 23 patients (France, n=8; Germany, n=7; UK, n=8) and 12 physicians (France, n=3; Germany, n=3; UK, n=3; Australia, n=3) considered the range where saturation is usually achieved, between 6 and 12 interviews (Guest, 2006) and the desire for diverse patient voices.

The semi-structured interview guide elicited feedback on treatment experiences, allowed spontaneous mention of attributes, and probed on a set of prespecified attributes. The key areas of focus were patient-physician interactions, treatment attributes (including efficacy, side effects, and duration of therapy), and overall treatment experiences. Thematic analysis of interview data was done using NVivo transcription coding to see the connection between emerging themes and to identify key insights.

Results. Among patients, 30% (7/23) were treatment naive, 30% (7/23) had received 1L treatment and 39% (9/23) had received 2L treatment or later. Study participants demographics are summarized in Table 1.

Efficacy was consistently reported as the top priority in selecting a new treatment for both patients (43%, 10/23) and physicians (91%, 11/12). However, only slightly over half of the patients and physicians reported discussing efficacy with each other at the point of treatment decision (patients, 56%, 13/23; physicians, 58%, 7/12).

When asked about attributes most important in treatment selection, 56% (13/23) of patients unaided mentioned a desire to avoid side effects that would impact their quality of life.

When presented with a list of treatment attributes (Table 2), patients’ top side effects to avoid were heart rhythm problems and diarrhea. Physicians similarly chose avoiding atrial fibrillation as their top concern. In contrast, physicians also prioritized avoiding infection and side effects leading to treatment discontinuation.

Patients varied in the importance they placed on TL vs. TPP (explained as "taken until the cancer worsens") duration. When selecting treatment, 22% (5/23) of patients reported treatment duration as a consideration, while 48% (11/23) reported duration as "less important” than side effects and administration mode (infusion vs. oral); and 26% (6/23) reported it "not important".

Nine patients stated a preference for TL treatment, of which two preferred TL therapy as they were looking forward to a treatment-free period. One patient preferred a TPP treatment they perceived as safer and offering better QoL. Most physicians (n=8, 75%) reported deferring to patients on preferences for TL versus TTP assuming eligibility; however, 15 out of 18 (83%) patients reported that they were offered only one treatment option.

Conclusions: This research highlights the similarities and variation in patient perspectives on treatment selection, the importance of covering key topics in shared treatment decision making and the remaining gaps in communication around treatment options. Regularly providing and discussing information on efficacy, and accounting for patient preferences, may improve the treatment selection experience for patients, particularly as novel treatment regimens become available.

Wallington:AstraZeneca: Ended employment in the past 24 months; Pfizer: Current Employment. Guillaume:AstraZeneca: Consultancy, Research Funding; Cerner Enviza: Current Employment. Mulvihill:AstraZeneca: Consultancy, Research Funding; Cerner Enviza: Current Employment. Wayser:AstraZeneca: Consultancy, Research Funding; Cerner Enviza: Ended employment in the past 24 months. Kaul:AstraZeneca: Consultancy, Research Funding; Cerner Enviza: Current Employment. Graziani-Taugeron:AstraZeneca: Consultancy, Research Funding; Cerner Enviza: Current Employment. Shahkarami:AstraZeneca: Current Employment. Ryan:AstraZeneca: Current Employment, Current equity holder in publicly-traded company.