HCP Survey Outlines Challenges, Strategies for Venetoclax Initiation in CLL in the Community Setting

Within a community-based setting, different challenges could arise when initiating venetoclax (Venclexta)-based therapy for patients with chronic lymphocytic leukemia (CLL); however, several solutions have been identified, according to John M. Burke, MD.1

An online cross-sectional survey of health care providers (HCPs) including community hematologists, oncologists, and advanced practice providers (n = 103) revealed that 90% (n = 87/97) reported having best practices and/or infrastructure changes to help support initiation of venetoclax at their clinic. The survey asked providers to grade challenges to venetoclax initiation on a 1 to 5 scale, with higher scores indicating a greater challenge. Of note, the most common areas of moderate challenges included concerns about tumor lysis syndrome (TLS; mean, 2.81), patient logistics (mean, 2.81), lab turnaround time (mean, 2.46), and post-dose lab monitoring (mean, 2.46).

“An academic center is not going to have as much trouble getting a lab turned around within a couple of hours compared with a community practice with a free-standing lab,” Burke explained. “How can we overcome that problem for the community practice? Can we set up a system where patients get their blood drawn, get the [samples] transported to a facility that can do the lab, and turn the results around within about 4 hours? That’s a challenge a community practice might face in [administering venetoclax] safely.”

In an interview with OncLive®, Burke discussed the rationale of surveying challenges with venetoclax initiation in CLL, results of the survey, how challenges may differ in community- vs academic-based centers, and potential solutions to address these challenges.

Burke is a hematologist and medical oncologist at Rocky Mountain Cancer Centers in Aurora, Colorado.

OncLive: What was the rationale for examining the challenges of initiating venetoclax in patients with CLL treated in the community setting?

Burke: Patients with CLL have a couple of different options as their initial therapy. They can either receive a [covalent] BTK inhibitor or fixed-duration therapy for 1 year with a combination of venetoclax and obinutuzumab [Gazyva]. Most providers and patients choose to go with the BTK inhibitor option, which is given indefinitely, more so than the venetoclax plus obinutuzumab option. We were interested in understanding the barriers to the latter option that [community] providers [experience] and the strategies they take in their own practices to help mitigate and overcome those barriers when patients choose to go with fixed-duration venetoclax.

What were some of the results from the community-based survey in terms of barriers to initiating venetoclax in patients with CLL?

We surveyed [103 community] providers, and most of them were oncologists/hematologists. [Nine percent] were advanced practice providers. A key concern [health care providers] had [regarding barriers to venetoclax] was the issue with the [adverse] effect called TLS, which is a risk with venetoclax plus obinutuzumab. Another concern they had was regarding the logistics of having patients come in and out of the office frequently. Those were the primary, most common barriers people talked about. The third one would be getting the labs turned around in a ‘STAT fashion’ to make sure the lab tests are back because [if] labs [do not] come back in a timely fashion, you might miss TLS.

How are community practitioners overcoming these barriers to initiating venetoclax?

In terms of what [community providers] do to overcome those barriers, a lot involves education—education of the staff and education of the patients—about potential risks. There is a fair amount of use of treatment calendars for the patients, [allowing providers] to put in writing when [patients] need to be in the office. There's some work involved in making sure labs can get turned around in a timely fashion. There is involvement of social workers, [who are] relied on to do some supportive things, and financial counselors to obtain financial assistance for patients. These are a lot of the techniques that practices use to overcome some of those barriers to providing venetoclax-based treatment.

The final aspect of interest is that the majority of these experienced providers who we surveyed do discuss all the treatment options with their patients. Still, [23%] of them don't [discuss fixed-duration therapy with ventoclax]. Even in those who do discuss these options, they don't usually end up prescribing the venetoclax. It's more common for them to prescribe a BTK inhibitor.

How do these challenges in the community setting differ from the academic setting?

Academic physicians have some of the same barriers. However, there's likely a difference in patient demographics between community practice and academic centers. Academic institutions tend to be concentrated in larger cities, and they may see a lot of patients, whereas community practices are in more rural areas. I imagine that patients who are regularly going to a community doctor might have a longer drive time. Those would be the main differences, but I think there are a lot of similarities—even academic doctors face the same sort of challenges when prescribing these medicines.

The survey also highlighted logistical and system barriers. What solutions or support systems have been identified to address these barriers, especially in the community setting?

A potential solution is to reduce the burden of monitoring low-risk [AEs]. Perhaps we're monitoring [too much]; we know that the risk of TLS in treatment-naive CLL is very low. It is not very common for patients to have this [AE], so we do a lot of monitoring for not a lot of risk. There are strategies we could take to reduce the recommended burden of this monitoring that is standard now. There are studies coming out now that show that the risk is lower than we might have predicted early on when [venetoclax] first got approved [for CLL in May 2019], and maybe we can dial down on the intensity of the monitoring to make it more feasible for other people to use.2

References

1. Jacobs R, Fletcher L, Rettew A, et al. Best practices to overcoming challenges in initiating venetoclax for patients with chronic lymphocytic leukemia: results from a United States community-based healthcare practitioner survey. Blood. 2024;144(suppl 1):2268. doi:10.1182/blood-2024-198466
2. FDA approves venetoclax for CLL and SLL. FDA. May 15, 2019. Accessed March 6, 2025. https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-venetoclax-cll-and-sll