The introduction of effective, novel, targeted therapies with differing mechanisms of action, toxicity profiles, and routes and frequencies of administration has provided clinicians and patients with more choices for frontline CLL therapy. An increasing value is being placed on patient preference, given the greater number of options.

For older patients who are not candidates for fludarabine, cyclophosphamide, and rituximab (FCR), there are not quite as many factors to consider as there might be with younger patients. My most extensive discussions of treatment options have been with IGHV-mutated patients who are relatively young and fit, and the choice was between FCR and a novel agent such as ibrutinib. Some patients choose FCR because they like the idea of being in remission and off of therapy in 6 months. They prefer to just be done with it. Finances may also be an issue for some of these patients, depending on insurance coverage. However, the factor that is going to be the most important to an individual is variable. Now, with the availability of venetoclax plus obinutuzumab and ibrutinib plus obinutuzumab as newly approved frontline regimens, these conversations are likely to become more complicated once these regimens become integrated into routine clinical practice.

If you look at the literature, some studies have tried to examine the relative importance of various attributes of treatment to patients. In general, in these studies, patients placed the highest relative importance on efficacy (ie, longer progression-free survival or overall survival), but the risk of adverse events was also important. Mansfield et al found that a significant gain in progression-free survival was needed to offset patients’ acceptance of worsening adverse events. Patients were also sensitive to cost, with even small increases in out-of-pocket expenses resulting in changes in the choice of hypothetical treatments. That is something that I have seen in my own practice as well. For instance, I have had patients decide to go on chemotherapy to avoid paying out-of-pocket expenses. Similarly, Landfeldt and colleagues found that overall survival was the most important attribute to patients with CLL. They also reported that route of administration, with oral preferred to intravenous, was more important to patients than to physicians. But, again, the factor that is going to be the most important to an individual is going to be determined by that individual.