Challenges in Initiating Venetoclax-Based Treatment for Patients With CLL

In this interview, John M. Burke, MD, Rocky Mountain Cancer Centers, provides an overview of his study entitled "Best Practices to Overcoming Challenges in Initiating Venetoclax for Patients with Chronic Lymphocytic Leukemia: Results from a United States Community-Based Healthcare Practitioner Survey.” The results were presented at the 2024 American Society of Hematology Annual Meeting.

Please introduce yourself by stating your name, title, organization, and relevant professional experience.

My name is John Burke, and I am a hematologist and medical oncologist at Rocky Mountain Cancer Centers. I am also a member of the executive committee for lymphoma research at Sarah Cannon Research Institute.

What are the most significant barriers that influence a health care providers' decision to initiate venetoclax-based treatment as an initial therapy for chronic lymphocytic leukemia (CLL), and how can these barriers be mitigated in a community-based setting?

We did a study where we surveyed 100 providers—mostly oncologists, hematologists, and some advanced practice providers—about the barriers they experience in starting venetoclax as initial therapy for CLL, and what strategies they are using to mitigate those barriers. The key concerns they identified were the risk of tumor lysis syndrome with initiation of therapy, the logistics that are required for getting patients in and getting things done properly, and the details of getting the labs done in a rapid turnaround time, which is required for safe initiation of venetoclax  therapy.

The study found that most health care providers reported having best practices or resources in place to facilitate the initiation of venetoclax. Can you provide an example of a specific best practice or resource that can help ensure a smooth treatment initiation for CLL patients?

The physicians we surveyed identified several ways of mitigating these barriers. The most important component of initiating venetoclax treatment properly is education. This includes both the education of the providers and staff involved, and patient education about what is involved in the initiation of venetoclax and what are the risks. Other methods include helping patients by providing them treatment calendars, explaining exactly where they need to be and when, and having all that in writing because it is complex. Having a menu or calendar that a patient can follow can follow is helpful.

A third strategy is ensuring that there is an available laboratory that has the ability to turn the labs around in a “stat” fashion, so that any tumor license syndrome that occurs can be identified quickly. Financial assistance programs and social support can also help patients get through the treatment initiation.

Despite the relatively low level of reported challenges in the survey, the study found that a significant portion of providers (24%) did not discuss fixed-duration therapy (FDT) with most of their patients. What factors contributed to this, and how can health care providers better facilitate shared decision-making regarding FDT in CLL treatment?

The providers that we surveyed were experienced CLL doctors by definition. They had to have some experience with venetoclax and with administering it in their clinic. Despite this, a quarter of them were not discussing it as a treatment option with the majority of their patients. In addition, even those who had discussed it as an option with the majority of their patients, were not administering it to the majority of their patients. We did not really investigate why not.

A main factor that contributed to this decision is the relative ease of administering BTK inhibitors (eg, patients not having to come in for the tumor license, monitoring frequent labs, doctors not having to get the labs turned around in a stat fashion, and lack of an intravenous (IV) requirement. Whereas, the initiation of venetoclax is given with an IV medicine of veltuzumab, so I suspect that all those are factors that contribute to the reticence of many physicians to use venetoclax-based therapy as their initial treatment for CLL.

Shared decision making is extremely important. Providers should be offering patients their options and patients should be educated about and aware of all treatment options. Although, barriers such as travel time to the clinic are going to be hard to overcome, efforts should be made to ensure drugs are covered properly by insurers and other services should be provided to ensure that patients are being offered all of their options.