EARLY DISCONTINUATION (ED) OF THERAPY AND TREATMENT PATTERNS AMONG

CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) PATIENTS: FINDINGS FROM A LINKED CLAIMS

AND ELECTRONIC HEALTH RECORD (EHR) DATASET

Seth Kuranz1, Sierra Luciano1, Jennifer Stacey1

1TriNetX, Inc., Cambridge, MA, United States

INTRODUCTIONThe Bruton’s tyrosine kinase (BTK) inhibitor ibrutinib is used as first line of

therapy (LOT) and salvage therapy in chronic lymphocytic leukemia (CLL)

patients and in combination with chemotherapy, anti-CD20 biologics, and

venetoclax among other drugs. Several studies have shown that 10-20% of

patients receiving ibrutinib discontinue due to intolerance, disease progression,

transformation, or other causes. Those who discontinue due to disease

transformation or early disease progression are reported to have increased

mortality risk. This study was conducted to provide much-needed real-world

data (RWD) on CLL treatment patterns and treatment-related adverse effects.

METHODSCLL patients first diagnosed between 2012-2019 were identified in a 200 million

patient claims/EHR dataset. All patients were aged 18+, had two claims for CLL

submitted at least 1 week apart, and were treated with an antineoplastic

medication following diagnosis. All patient characteristics were defined using

ICD-9/10, CPT, RxNorm, and LOINC codes.

To examine treatment patterns, the start date of the first LOT was defined as

the time of the first treatment following the CLL diagnosis. All medications taken

within 28 days of the start date were grouped into a combination LOT. The

second and subsequent LOTs started when a new medication was identified in

a patient’s record or when 365 days passed without any record of a medication.

Time on treatment was defined as the number of months between the first and

most recent record of an ingredient in a patient’s EHR.

Early discontinuation (ED) was defined as any patients who discontinued their

first antineoplastic within the first month after the initial CLL diagnosis. The

frequency of diagnoses in the month before discontinuation were used to

examine potential reasons for discontinuation among the two largest treated

populations: patients treated with ibrutinib and patients treated with rituximab

and bendamustine (rit+bend). Patients who discontinued therapy were

compared to patients who continued with therapy (continuers), using the first

treatment recorded in the month after diagnosis as the index date in both

groups, and adjusting for demographics using a 1:1 matched propensity score

model. Following the index event, a Kaplan-Meier analysis measured the

event-free survival probability for anemia, transfusions, and all-cause mortality.

Figure 1. Proportion of patients treated with each ingredient

during the first LOT

RESULTSThe mean age at diagnosis of the 38,653 CLL patients identified in the dataset

was 70.4 (+10.7). In the first LOT, 67 unique ingredients were identified. The

most common medications included ibrutinib (21%), rituximab (20%),

bendamustine (9%), fluorouracil (6%), cyclophosphamide (5%), chlorambucil

(5%), and fludarabine (3%) (Figure 1). Most patients were treated with a single

LOT and did not progress to other medications. Among patients who

progressed from ibrutinib in the first LOT, other antineoplastics made up the

most common second LOT. Patients with an antineoplastic recorded in the first

LOT were more likely to switch to ibrutinib than any other therapy. Patients

treated with a combination of rit+bend most often switched to ibrutinib or other

antineoplastics as a second LOT.

Patients treated with ibrutinib remain on treatment for longer than patients

treated with rituximab and bendamustine. Among patients treated with ibrutinib,

the length of treatment decreased monotonically over two years (Figure 3). The

proportion of patients treated with rituximab dropped off substantially after 6

months (Figure 3).

In the month before the index treatment, ED patients treated with ibrutinib had a

higher prevalence of anemia, pain, and malaise/fatigue as compared to

continuers. Among rit+bend patients, characteristics were similar between

continuers and ED patients (Table 1). Among both ibrutinib and rit+bend treated

patients, continuers had a higher survival probability than ED patients (p<0.05)

(Figures 4 and 5). Continuers treated with ibrutinib were less likely to develop

anemia and receive a transfusion (p<0.05) (Figures 6 and 8).

Table 1. Patients characteristics among ED and continuer

patients treated with ibrutinib and rit+bend

CONCLUSIONSThe treatment landscape in CLL includes many off-label therapies including

monoclonal antibodies and other chemotherapies. However, most patients

remain on either ibrutinib or rit+bend for the length of care. Patients who do not

discontinue a therapy within the first month are less likely to develop

complications and have a lower probability of all-cause mortality. Further

research is needed to understand the dynamics of more complex treatment

pathways.

REFERENCESJain P, Thompson PA, Keating M, et al. Long-term outcomes for patients with

chronic lymphocytic leukemia who discontinue ibrutinib. Cancer.

2017;123(12):2268–2273. doi:10.1002/cncr.30596

DISCLOSURESAll authors are employed by TriNetX, Inc.

Figure 2. Month of most recent treatment of bendamustine

following the first treatment

Figure 3. Month of most recent treatment of ibrutinib and

rituximab following the first treatment

Figure 4. All-cause mortality among continuers and ED patients

treated with ibrutinib

Figure 5. All-cause mortality among continuers and ED patients

treated with rit+bend

Figure 6. Occurrence of anemia among continuers and ED

patients treated with ibrutinib

Figure 7. Occurrence of anemia among continuers and ED

patients treated with rit+bend

Figure 8. Occurrence of transfusions among continuers and ED

patients treated with ibrutinib

Figure 9. Occurrence of transfusions among continuers and ED

patients treated with rit+bend

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Ibrutinib Rituximab

ASH Annual Meeting 2019 | Orlando, FL United States

Ibrutinib Rit+bend

ED Continuers ED Continuers

n /

mean% / SD

n /

mean% / SD

n /

mean% / SD

n /

mean% / SD

Age at Index (mean / SD) 72.7 10.0 70.6 10.2 67.9 9.5 70.4 9.9

White (n / %) 753 30.7 2,208 28.4 653 21.8 249 23.0

Female (n / %) 895 36.5 2,909 37.4 993 33.1 392 36.2

Hemolytic anemias (n / %) 44 1.8 101 1.3 83 2.8 32 3.0

Aplastic and other anemias and other bone marrow

failure syndromes (n / %)320 13.1 705 9.1 525 17.5 205 18.9

Other anemias (n / %) 244 10.0 537 6.9 417 13.9 163 15.0

Anemia due to antineoplastic chemotherapy (n / %) 11 0.4 30 0.4 42 1.4 31 2.9

Anemia, unspecified (n / %) 232 9.5 491 6.3 377 12.6 138 12.7

Purpura and other hemorrhagic conditions (n / %) 166 6.8 480 6.2 334 11.1 118 10.9

Pain in joint (n / %) 64 2.6 145 1.9 57 1.9 12 1.1

Nausea and vomiting (n / %) 41 1.7 69 0.9 555 18.5 185 17.1

Malaise and fatigue (n / %) 144 5.9 314 4.0 259 8.6 100 9.2

Poisoning by, adverse effect of and underdosing of

antineoplastic and immunosuppressive drugs (n / %)14 0.6 43 0.6 144 4.8 65 6.00

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