Barriers to optimal care and educational opportunities for european physicians treating patients with relapsed/refractory (R/R) CLL Free

Background: Healthcare professionals (HCPs) who manage patients with CLL are challenged to provide optimal care as treatment paradigms rapidly evolve. In addition, differential availability of novel agents globally can complicate treatment selection and educational initiatives. To this end, we created a multimodal continuing medical education (CME) program centered around small-group collaborative workshops tailored specifically toward hematology/oncology physicians who treat CLL in 5 European countries. Here, we report specific concerns and educational opportunities as identified in this educational initiative.

Methods: From September to October 2024, small-group (≤15 participants) workshops were conducted in which physicians who actively treated patients with CLL in France, Germany, Italy, Spain, or Greece were paired with an expert in CLL treatment from their respective country. Prior to each workshop, participants completed a presurvey that included questions focused on how they would manage 7 patient case scenarios with R/R CLL. Each workshop included an open-format discussion of these cases to facilitate experience sharing and qualitative data collection. Immediately following the workshop, participants were given a postsurvey asking if their thoughts on treatment had changed. A selection of participants were interviewed to further explore the perspectives of physicians across Europe on managing patients with R/R CLL. Data from the surveys, workshops, and interviews were assessed for treatment trends and barriers to care.

Results: 51 physicians participated in the CME program; 88% reported that they cared for more than 10 patients with CLL per month. As determined by discussions during workshops and interviews, the following barriers were identified in managing R/R CLL: 1) national guidelines can be outdated and may not be fully reflective of the nuances of patient fitness beyond age; 2) restrictions on compassionate use programs and regulatory and reimbursement delays in accessing new treatments.

Participants reported multiple areas of ongoing educational need. First, interpreting complex mutation data can be challenging, often requiring expert laboratory support. Second, selecting between the BTK inhibitors acalabrutinib and zanubrutinib in the R/R setting can be difficult due to the absence of direct comparative trial data; of note, a small number of physicians chose ibrutinib as a first BTK inhibitor option in patient cases progressing after first-line chemoimmunotherapy or venetoclax-based therapy. Third, managing patients with CLL that has progressed on both a BTK inhibitor and venetoclax-based therapy is a significant challenge, with most HCPs considering pirtobrutinib (where available); for example, for a case patient with CLL with progression after acalabrutinib and venetoclax plus obinutuzumab with a BTK C481 mutation, 78% of presurvey respondents recommended pirtobrutinib. Fourth, managing cardiovascular side effects associated with BTK inhibitors, including atrial fibrillation and hypertension, can be significant challenge, particularly in older patients with comorbidities. Notably, testing for BTK and PLCG2 mutations was considered for patients with progressive disease on BTK inhibitors, but routine monitoring for BTK resistance was not common practice.

Regarding the educational value of the workshops, HCPs noted that the workshops reinforced their existing clinical practices, fostered discussions that broadened perspectives, and encouraged “thinking outside the box” regarding CLL management. Participants also highlighted the value of sharing best practices and learning about newer agents like pirtobrutinib.

Conclusions: Data from this educational initiative with a foundational collaborative workshop revealed barriers to optimal treatment of R/R CLL in European countries, most notably administrative challenges. Physicians participating in this program also reported numerous areas of educational need, including biomarker testing, treatment of “double refractory” CLL, and management of AEs. This educational initiative suggests that community-informed education can strengthen clinical expertise, potentially improving patient outcomes.