Survival Data is a Forefront Consideration in Choosing Third-Line DLBCL Treatment

In an interview with Targeted Oncology, Patrick Connor Johnson, MD, discussed the top considerations taken into account by physicians when choosing a third-line therapy for diffuse large B-cell lymphoma.

In recent years there has been a number of new treatments for diffuse large B-cell lymphoma (DLBCL), especially in the third-line setting. However, there is still a lack of understanding about what factors go into physician decision making when picking a third-line treatment.

According to Patrick Connor Johnson, MD, background is still needed on what physicians see as key treatment attributes. In order to gather more information, he and other investigators administered a survey to physicians who treat patients with DLBCL across Western Europe and the United States. 

The survey found that the biggest considerations taken into account by physicians when choosing a third-line treatment were data on survival and toxicities. On the other land, the factors taken into account the least were logistical, such as frequency of administration and whether hospitalization was required.

In an interview with Targeted Oncology™, Johnson, an instructor in Medicine at the Dana-Farber Cancer Institute, discussed the top considerations taken into account by physicians when choosing a third-line therapy for DLBCL.

TARGETED ONCOLOGY™: Can you give a brief overview of your survey on physician considered treatments and attributes for third-line diffuse large B-cell lymphoma treatment decision making?

JOHNSON: Diffuse large B-cell lymphomas is the most common non-Hodgkin lymphoma, and there's been a number of different new treatment options, particularly in the third line or later setting that have been FDA approved and an overall EMA approved in recent years. I'm including the advent of CAR T-cell therapy. And so, therapy selection has become much more complex. Despite this, we don't have a lot of data to understand what physician perspectives are in respect to making treatment selection in this setting. And so that was really the background for why we wanted to assess physician perspectives and respect to key treatment attributes.

This study was conducted as a single point in time survey. It did cross multiple countries, France, Germany, Italy, Spain, the UK, and the United States, of practicing hematologist, hematology oncologist, and medical oncologist who'd seen diffuse large B cell lymphoma patients a minimum of five per month. And we asked them to rank their top 7 treatment attributes from a preselected list. This was almost 240 physicians. A third of these surveyed physicians worked in the academic setting. Most of these physicians referred to CAR T-cell therapy centers for that specific treatment. And the highlights in terms of what physicians ranked are, they really favored progression-free survival, overall survival, duration of response, adverse events, including severe adverse events, the chance of a complete response and patient quality of life as the high attributes. And conversely, frequency of administration, hospitalization requirements, so the logistics of therapy, were uncommonly cited as important treatment attributes, both from a physician perspective, and from their perspective of the patient's acceptability of these. And this was really true across countries that were really minor variations by country. So, there's pretty general agreement on the top attributes when selecting these treatments.

My important takeaways from this are, I think it's important to gather data about physician treatment selection in a number of different settings because important information for the healthcare system at large. And what this emphasizes to me are the efficacy, safety and quality of life are really the key attributes for physicians. And conversely, administration, logistics, and our perception of sort of patient logistics in terms of administration, including hospitalization requirements are really much less important treatment attributes for selection. I think those inform the healthcare system at large as well as physicians and patients.

Did you notice if physicians took anything else into account when selecting a third-line treatments, such as age, degree of illness, or comorbidities? How did factors like that play into treatment decisions?

Certainly, for an individual patient in front of the physician, that's not necessarily fully captured on a broad survey. But in terms of broad standpoint, those are all factors that were amongst the different treatment choice selections when physicians weigh that. So, in terms of acceptability for age, acceptability for comorbidities, those are broadly amongst the series of various attributes that were listed on this survey. And so those are weighed, of course, but the point being that these other attributes are more important for physicians.

What were some of the key insights that were provided by your survey?

I think my two major takeaways from the survey overall are probably not unexpectedly, but it is interesting to see that really across the board in a number of different countries, efficacy data in terms of those parameters, and adverse events, tolerability data, as well as quality of life, those are really the 3 key attributes. With the advent of a number of different therapies, in terms of CAR T-cell therapy, and other targeted therapies, and antibody therapies, and bio specifics, so how these are logistically administered, whether hospitalization was acquired, those were really not major considerations for physicians. And I think that's important because it is an open question about some of these things from a logistic standpoint, how much that factors into decision making for physicians, and how much that factors into patient decision making, though this is not a survey of patients.

How can clinicians further incorporate and utilize data collected from your survey in their own practice?

I think it's a great question. I think what this can be helpful for is this provides a broad swath of what a number of different physicians across countries are doing. And so, I think that lends support to the idea that this is a fairly broad country comparison of these attributes. And it really gives a perspective for physicians about what are the top attributes across a number of different physicians, across a number of different countries. Obviously, for a given patient, you have to integrate all kinds of things to make this decision making. But I think this provides a little bit of data to help inform physicians across the board about what different physicians around a number of different countries weigh in terms of their own decision making. I will note that there's always a limitation that there's a chance that these decisions could not be representative of all physicians across all these countries. It's a limited sample size per country. But this still does survey physicians across a number of different countries and provides an overview of what the most common treatment attributes in terms of decision making are.

I think it is important to make sure that we have data about physician perspectives on how treatment selection occurs to help understand from the healthcare system at large how physicians are making treatment selections. And so, I think it is helpful data. Hopefully, this will lead to larger studies across multiple different countries and larger sample sizes to really continue to gain information about how physicians make treatment selection decisions. And that will have additional information about how patients perceive physician’s selection or how patients like to think about what's important to them in terms of treatment selection.

Johnson P, Queck R, Bailey A, et al. Physician considered treatment attributes for third-line diffuse-large B-cell lymphoma treatment decision-making: Physician perspectives from a survey across Western Europe and US. Annal. Oncol. 2021;32(5):778. DOI: