European LeukemiaNet (ELN) and National Comprehensive Cancer Network (NCCN) recommendations are important resources to help guide the management of patients with chronic myeloid leukemia (CML) treated with tyrosine kinase inhibitor (TKI) therapy. However, current guidelines are sometimes difficult to apply to all patient scenarios, particularly as they do not provide definite management recommendations for patients who have suboptimal responses to first-line TKI therapy. Furthermore, in a recent survey only 58% (N=132) of community oncologists made treatment decisions in line with expert recommendations for clinical scenarios in which patients had a suboptimal response to first-line therapy with imatinib. Online tools that provide expert clinical guidance have been proposed as one adjunctive approach to help clinicians make more informed treatment decisions. We previously reported that an online tool designed to provide expert guidance on adjuvant treatment of breast cancer may positively impact treatment decisions and thus potentially improve patient care (J Clin Oncol 29: 2011 [suppl; abstr 6063]).
The goal was to determine whether an interactive online decision support tool providing expert guidance would help community practitioners make more informed therapeutic decisions for patients with CML who were receiving first-line TKI therapy. We sought to evaluate to what extent the expert recommendations changed the community practitioners' clinical approach.
An interactive decision support tool, developed with input from 5 CML experts who made treatment recommendations for 42 different patient scenarios, has been posted online at http://www.clinicaloptions.com/TreatingCML. Users of the tool enter specific factors such as patient age and duration of first-line TKI therapy, along with information on hematologic, cytogenetic, and/or molecular responses to first-line TKI therapy at 3, 6, 12 and 18 months. Before expert recommendations for that specific patient scenario are revealed, users are asked to enter their intended management approach. Once that is entered, the tool outputs a table showing the recommendations of the 5 CML experts based on the specific factors entered. Finally, the user is prompted to indicate whether the experts' recommendation confirmed or changed their intended management approach. User response data and intended treatment approaches will be tabulated and compared with the experts' recommendations.
This resource was posted online July 2012 and had 161 unique users with 219 uses of the tool in the first 40 days. Among the users to date, 15% indicated that the experts' recommendations changed their intended management approach.
A separate analysis of the in-tool recommendations showed that the experts considered not only guidelines, but also emerging data and their own clinical experience in making recommendations for specific patient scenarios. For example, ahead of similar recommendations included in the most recent update to the NCCN treatment guidelines for CML, the experts added a consideration in the tool suggesting a BCR-ABL/ABL ratio of 10% by QPCR as the threshold for guiding a therapeutic change at 3 months. Moreover, most of the experts (4 of 5) recommended a therapeutic change for patients in CCyR without MMR at 12 months if there was a concomitant increase in BCR-ABL ratio of 1 log or more and (3 of 5) also recommended a therapeutic change for patients without a MMR at 18 months regardless of whether their BCR-ABL/ABL ratio was increasing. Detailed comparisons of expert and user responses will be presented.
Preliminary data suggest that an online tool designed to provide customized, patient-specific expert advice may increase the number of clinicians who make optimal treatment decisions for patients with CML based on their response to first-line TKI therapy, and therefore, may be an important adjunct to the ELN and NCCN guidelines.
Shah:ARIAD: Consultancy, Research Funding; Bristol Myers-Squibb: Consultancy, Research Funding; Novartis: Consultancy. Smith:Bristol-Myers Squibb: Consultancy; Novartis: Consultancy. Radich:Ariad: Consultancy; Bristol-Myers Squibb: Consultancy; Pfizer: Consultancy; Novartis: Consultancy, Research Funding.
Asterisk with author names denotes non-ASH members.