Real‐world testing and treatment patterns in chronic lymphocytic leukemia: A SEER patterns of care analysis

Abstract

Background: Laboratory testing and treatments have changed dramatically in chronic lymphocytic leukemia (CLL) within the last decade. We evaluated changes in patterns of real-world testing and treatment over time by comparing two population-based cohorts. Methods: The National Cancer Institute (NCI) sponsored Patterns of Care study was conducted among CLL patients sampled from 14 Surveillance, Epidemiology, and End Results (SEER) program registries. Demographics, testing, and treatment data were abstracted from medical records within 24 months of diagnosis. Results: 1,008 patients diagnosed in 2008 and 1,367 patients diagnosed in 2014 were included. There was a significant increase in fluorescence in situ hybridization (FISH) testing, IgVH mutation analyses, and lymph node biopsies between 2008 and 2014. FISH testing was performed in the majority of, but not all, treated patients (53% in 2008, increased to 62% in 2014). Some differences in receipt of FISH testing by age and insurance status were observed over time (older patients and Medicare patients without private insurance were less likely to be tested in 2014). There were contrasting testing patterns by practice type and year, with non-teaching hospitals more likely to perform bone marrow biopsies in 2008, and teaching hospitals more likely to perform FISH and IgVH testing in 2014. There were also differences in treatments over time, with the use of bendamustine and rituximab (BR) being more common in 2014 at the expense of fludarabine, cyclosporine, and rituximab (FCR). Conclusions: There are been rapidly changing practices of testing and treatment patterns for CLL patients in the last decade.

Treatment patterns, adverse events, and economic burden in a privately insured population of patients with chronic lymphocytic leukemia in the United States

“…The finding that nearly two‐thirds of patients did not receive a cancer‐directed therapy after CLL diagnosis suggests that observation (“watch‐and‐wait”) was the preferred initial approach during the study period. Our study identified BR, rituximab monotherapy, ibrutinib monotherapy, and FCR as the most common regimens during the study period, which is consistent with the 2017 NCCN Guidelines and other recently published reports . Recently, 2018 NCCN Guidelines suggest chemoimmunotherapy (FCR/ BR) or ibrutinib as preferred treatment choices among younger patients (<65 years) who are relatively less frail and able to tolerate purine analogues .…”

“…Our study identified BR, rituximab monotherapy, ibrutinib monotherapy, and FCR as the most common regimens during the study period, which is consistent with the 2017 NCCN Guidelines and other recently published reports. 5,21,22 Recently, 2018 NCCN Guidelines suggest chemoimmunotherapy (FCR/ BR) or ibrutinib as preferred treatment choices among younger patients (<65 years) who are relatively less frail and able to tolerate purine analogues. 23 The most common choice among LOT-1 regimens was BR, while ibrutinib was the preferred LOT-2 regimen, a finding that confirms results of another study 21 ; however, the proportion of ibrutinib users observed in our study was half of what has been reported (21% vs 42%), potentially because in our analysis ibrutinib was approved only in the later part of the study period.…”

Comparison of Time to Next Treatment, Health Care Resource Utilization, and Costs in Patients with Chronic Lymphocytic Leukemia Initiated on Front-line Ibrutinib or Chemoimmunotherapy

“…5 The date of the first claim for one of these treatments following the first CLL/SLL diagnosis is the index date. 6 End-stage renal disease was identified using ICD-9 CM code 585.6 and ICD-10 CM code N18.6. All-cause total health care costs were stratified by medical and pharmacy costs.…”

“…[1][2][3] For many patients, rituximab-based CIT, such as bendamustine plus rituximab (BR) or fludarabine cyclophosphamide plus rituximab (FCR), was, until recently, the standard of care 4,5 ; overall, these regimens are still commonly utilized in real-world clinical practice. 6 Despite this progress, BR and FCR have limited efficacy in subgroups of patients with 17p deletions (a region that contains the TP53 locus). 1,[7][8][9][10] In addition, long-term safety concerns, including a higher risk of secondary myelodysplastic syndrome, acute myeloid leukemia, and transformation to diffuse large B-cell lymphoma (ie, Richter's transformation), are other limitations associated with CIT.…”

“…29 Thus, this study was conducted to assess and compare real-world time to next treatment (TTNT), health care resource utilization (HRU), and health care costs in patients with CLL initiated on front-line treatment with ibrutinib single-agent versus CIT regimens and versus BR specifically (as this regimen is the most commonly used type of CIT in contemporary real-world clinical practice). 6,17 Materials and Methods…”