Easing Barriers to BTK Inhibitors in CLL: Kerry Rogers, MD

Kerry Rogers, MD, associate professor at The Ohio State University Comprehensive Cancer Center—The James, discussed financial toxicity and equitable access tied to long-term Bruton tyrosine kinase (BTK) inhibitor therapy in chronic lymphocytic leukemia (CLL), in a recent interview with The American Journal of Managed Care^®.

On cost, Rogers noted that although her institution’s Medication Assistance Office and manufacturer programs have kept therapy accessible for her patients, that isn’t the reality everywhere. She stressed that even patients with minimal out-of-pocket cost still feel the psychological weight of a drug’s price, describing patients who’ve questioned whether they’re worth the expense of therapy or worried about a destroyed pill costing hundreds of dollars.

She argued that solving financial toxicity extends well beyond what hematologists can address alone and is a health system-level problem, noting the same drugs often cost markedly less when purchased on the open market abroad. Addressing it, she said, will require coordinated action across government regulation, drug pricing negotiation, physician behavior, and how health systems reimburse and negotiate drug costs. She also pointed to the American Society of Clinical Oncology’s value framework, which, despite ibrutinib’s higher price than bendamustine/rituximab, found its efficacy and quality-of-life benefits made it the higher-value option—although she cautioned there’s no perfect way to weigh cost against benefit.

Turning to equitable access, Rogers said BTK inhibitors may improve access for patients far from CLL centers compared with infusional regimens like venetoclax and obinutuzumab, which require ramp-up visits, specialized infusion staff, and rapid lab turnaround for tumor lysis monitoring. Because BTK inhibitors are oral and can be mailed directly to patients’ homes, she said this convenience reduces geographic barriers, and manufacturer programs and Medicaid coverage have generally kept them financially accessible, sometimes more so than for patients with commercial insurance or Medicare.

On frailty and trial representativeness, Rogers said clinical trials in CLL underrepresent non-White populations relative to disease demographics, and strict eligibility criteria around organ function and performance status often exclude frail patients. She cited efforts including phase 3 studies designed to include patients with higher comorbidity scores or impaired renal function and an investigator-initiated trial of first-line pirtobrutinib in elderly patients built to limit clinic visits for less-fit enrollees. Rogers emphasized that real-world studies and dialogue among CLL specialists and community oncologists remain essential for understanding how these therapies perform in patients not reflected in trial populations.