Contemporary Fixed-Duration Treatment Options in the First-Line Setting of Chronic Lymphocytic Leukemia: Perspectives from a Publicly Funded Healthcare System

TL;DR

Canadian experts discuss benefits and challenges of fixed-duration treatments for chronic lymphocytic leukemia in a publicly funded healthcare system.

Contribution

Highlights perspectives on integrating fixed-duration therapies into clinical practice while emphasizing patient-centered decision-making.

Findings

Fixed-duration therapies offer benefits like treatment-free periods and improved quality of life.

All-oral combinations are seen as convenient and equitable for rural Canadian populations.

Shared decision-making is emphasized to align treatment with patient preferences and system constraints.

Abstract

Contemporary drug combinations are or will soon be available for the first-line treatment of chronic lymphocytic leukemia that are provided to patients within a fixed duration. Hematologists from across Canada met to discuss the attributes of these options and share considerations for their use in clinical practice. The hematologists identified many benefits related to these therapies (e.g., time off treatment, improved patient quality of life and safety, reduced cost burden), though noted that a need likely remains for continuously administered options for certain patient subgroups. They stated that new all-oral fixed-duration combinations may be particularly appealing to Canadian patients and clinicians, flagging their associated convenience and treatment equity. The hematologists also emphasized the need for shared decision-making between patients, caregivers, and clinicians to ensure informed and optimal treatment selection that acknowledges patient characteristics and goals and drug availability within a publicly funded healthcare system.

First-line options for chronic lymphocytic leukemia (CLL) are evolving, recently returning to a fixed-duration (FD) approach incorporating regimens such as venetoclax + obinutuzumab, ibrutinib + venetoclax, and soon acalabrutinib + venetoclax ± obinutuzumab. Five Canadian hematologists convened to share perspectives regarding the attributes of these options and considerations for clinically appropriate integration within Canada’s publicly funded healthcare system. The hematologists underscored the importance of shared decision-making with patients, family members, and caregivers involving careful consideration of disease profile and patient characteristics, preferences, and values. They indicated that although a role persists for continuous therapy with approved covalent Bruton’s tyrosine kinase inhibitors (typically in high-risk disease), newer FD regimens offer multiple benefits related to the treatment-free period, quality of life, safety, re-treatment, healthcare resource utilization, and costs. The hematologists highlighted the appeal of all-oral FD combinations given their convenience and impact on treatment equity, factors especially compelling given Canada’s vast geography and large segment of rural populations. In closing, they emphasized the quickly evolving therapeutic setting of CLL in the 1L and beyond, underscoring the need for ongoing patient involvement in decision-making to support optimal treatment selection based on patient goals and within the confines of provincial funding.