Evolution in Practice Patterns and Differences Among Experts and Community Healthcare Providers in the Treatment of Patients with Chronic Lymphocytic Leukemia

Introduction Targeted therapies are dramatically changing the treatment landscape for chronic lymphocytic leukemia (CLL). Given the rapid pace of new approvals and expanded indications for targeted agents in CLL, healthcare providers (HCPs), particularly those practicing in community settings with limited experience in CLL, can be challenged to make treatment decisions that optimize outcomes for their patients. To assist HCPs in managing patients with CLL, we have developed and regularly updated an online treatment decision support tool in collaboration with CLL experts (https://www.clinicaloptions.com/CLLTool). Here we report an analysis of data from the 2 most recent CLL tool iterations capturing differences in practice patterns among HCPs compared with CLL experts over time and the impact of case-specific expert recommendations on HCP treatment decisions. Methods For each CLL tool iteration, 5 experts provided their treatment recommendations for hundreds of different case scenarios in the newly diagnosed and relapsed/refractory disease settings. These unique case scenarios were based on patient and disease factors that the experts considered important to make treatment decisions including age, fitness, cytogenetic abnormalities, IGHV mutation status, and previous treatment. To use the tool, HCPs entered specific patient and disease characteristics along with their intended treatment for that patient. Then the treatment recommendations of the 5 experts for that specific case scenario were provided, followed by a survey question on whether the expert recommendations would change their treatment plan. Results HCPs accessed the 2017 CLL tool from March to July 2017 for a total of 753 cases and the 2018 CLL tool from October 2018 to July 2019 for a total of 656 cases. We identified several differences between the intended treatment choices of HCPs and expert recommendations (Table). For previously untreated CLL with del(17p) or TP53 mutations, all 5 experts recommended ibrutinib as first-line therapy regardless of any other characteristic in both tool iterations. By contrast, HCPs chose ibrutinib for 38% and 58% of the cases in the 2017 and 2018 tool, respectively. For CLL patients with del(17p) or TP53 mutations who progressed on ibrutinib, the experts recommended venetoclax with or without rituximab for a large majority of these case scenarios (93% in 2017 and 95% in 2018). In comparison, HCPs planned to use venetoclax-based regimens for 59% and 72% of the