Authored by Ann Liu, PhD
Medically Reviewed by Brian Koffman, MDCM (retired), MSEd
The Bottom Line:
While time-limited treatment for CLL / SLL with venetoclax sounds appealing, its use remains low because it is more complicated to start than a BTK inhibitor. However, several best practices can be implemented by healthcare providers to support the initiation of venetoclax therapy.
Who Performed the Research and Where Was it Presented:
Dr. Ryan Jacobs from Atrium Health Levine Cancer Institute and colleagues presented the results at the American Society for Hematology (ASH) Annual Meeting 2024.
Background:
When patients with chronic lymphocytic leukemia (CLL) / small lymphocytic lymphoma (SLL) need to start their first treatment, they generally have two options. One option is continuous, indefinite treatment with a BTK inhibitor (ibrutinib, acalabrutinib, zanubrutinib). BTK inhibitors are very easy to initiate because they are pills that are taken by mouth, and they require minimal monitoring.
The other option is time-limited therapy, where there is a known end date (usually one year later for frontline therapy). This type of therapy usually involves the BCL2 inhibitor venetoclax, and while it sounds more appealing, it is more complicated to initiate. Venetoclax is an oral medication usually combined with an anti-CD20 monoclonal antibody (rituximab or obinutuzumab), an IV infusion that starts with weekly infusions for three weeks. Additionally, venetoclax has to be initiated with a five-week ramp-up with frequent lab checks and even potentially an inpatient stay for high-risk patients because of concerns about tumor lysis syndrome (TLS). When starting a venetoclax regimen, the first eight weeks are very busy for patients.
For this study, researchers wanted to understand what community healthcare providers felt were the barriers to initiating venetoclax therapy in patients with CLL / SLL.
Methods and Participants:
This study was an online survey of US hematologists, oncologists, and advanced practice providers. Healthcare providers were eligible if they practiced in a community setting, treated ≥10 patients with CLL in the past year, and used venetoclax at least once.
Results:
- 103 community healthcare providers responded to the survey, and 91% were physicians.
- 23% of respondents did not discuss fixed-duration therapies as a first-line option with patients.
- Among respondents who discussed continuous and fixed-duration therapies, 65% decided to use continuous therapies.
- Practices that were helpful for providers when initiating venetoclax included:
- Having a written protocol for monitoring and managing TLS and for scheduling labs
- Timing patient visits in relation to lab tests
- Training lab staff to monitor for TLS so that the physician doesn’t necessarily need to be at every visit
- Being able to get stat labs back within a few hours rather than having to send samples to an outside lab
- Creating patient calendars
- Arranging transportation/lodging for patients who have a hard time getting to the clinic
- Challenges to initiating venetoclax therapy included:
- Concern about TLS
- Patient logistics
- Issues with lab monitoring and lab turnaround time
- Patients wanting to avoid the infusion center
Conclusions:
While time-limited treatment with venetoclax sounds appealing and can be very effective, its use remains low because it is more complicated to start than a BTK inhibitor. However, implementing best practices, infrastructure changes, quick turnaround times for lab results 24/7, and educational resources in community clinics can help support the successful initiation of venetoclax. Healthcare providers don’t need to reinvent the wheel, as other clinics have developed protocols that work and help support patients starting venetoclax therapy.
Links and Resources:
Watch the interview on the abstract here:
You can read the actual ASH abstract here: Best Practices to Overcoming Challenges in Initiating Venetoclax for Patients with Chronic Lymphocytic Leukemia: Results from a United States Community-Based Healthcare Practitioner Survey
