# Patterns of Bruton’s Tyrosine Kinase Inhibitor (BTKi) Usage in B-cell Lymphomas in India: A Questionnaire-Based Study

## TL;DR

This study explores how Indian hematologists use Bruton’s tyrosine kinase inhibitors in treating B-cell lymphomas, highlighting cost and safety factors.

## Contribution

The study provides insights into BTKi usage patterns and barriers in India, emphasizing the role of cost and safety in drug selection.

## Key findings

- Generic acalabrutinib is preferred over ibrutinib due to better safety and lower cost.
- Financial constraints are the leading cause of treatment discontinuation.
- High cost is the main barrier to BTKi adoption among Indian hematologists.

## Abstract

Purpose: This cross-sectional questionnaire-based survey assessed the use of Bruton’s tyrosine kinase inhibitors (BTKis), clinical decision-making, and barriers to implementation among Indian hematologists managing B-cell lymphomas, identifying practice gaps that require policy interventions.

Materials and methods: A 28-item structured questionnaire was administered to hematologist-oncologists across India from 1 February 2025 to 31 May 2025. Of 50 invited clinicians, 38 responded (76% response rate). The survey assessed BTKi usage by disease and therapy line, molecular testing patterns, drug selection strategies, adverse event management, discontinuation reasons, and prescribing barriers. Data were analyzed using descriptive statistics with Microsoft Excel (Microsoft Corp., Redmond, WA, USA).

Results: Diffuse large B-cell lymphoma (40%) and chronic lymphocytic leukemia (CLL, 22%) were the most common. BTKis were used as first-line therapy in 92.1% of CLL cases. Generic acalabrutinib showed higher adoption (42.1%) than ibrutinib, mainly due to better safety and cost advantages. Cytogenetic markers were the most influential factor in initiating BTKi (52.63%). Molecular testing adoption exceeded 63%, with TP53, del(17p), and IgHV routinely ordered. For elderly or frail patients, 86.8% preferred BTKis over chemotherapy. Intolerance and financial constraints were the leading causes of discontinuation (36.8% and 34.2%). High cost was the significant barrier (89.47%), followed by side-effect management (42.1%) and drug availability (36.84%). Over 86% anticipate increased use of first-line BTKis within five years.

Conclusions: This survey reveals evidence-based treatment selection and appropriate risk stratification in Indian hematology practice. The predominance of generic acalabrutinib reflects superior safety compared to ibrutinib and cost considerations. Financial constraints driving treatment discontinuation underscore an urgent need for healthcare policy interventions to improve drug accessibility and affordability, ensuring equitable access and optimal outcomes.