Provider Perspectives on Clinical and Non-Clinical Considerations in BTKi Selection

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Prepared by Mohit Narang, MD, and NCODA for BeOne | December 2025

Bruton tyrosine kinase inhibitors (BTKis) have become foundational therapies in the management of B-cell malignancies such as chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL). As treatment options have expanded beyond first-generation agents, oncology providers are increasingly navigating a complex decision-making landscape that extends beyond clinical trial data alone.

This NCODA white paper examines how oncology physicians and pharmacists select and manage BTKi therapy in real-world practice, drawing on insights from a national survey of 96 providers working in community-based and medically integrated oncology settings. The findings highlight how efficacy, tolerability, patient experience, operational workflow, payer policies, and emerging federal pricing reforms collectively shape BTKi treatment decisions.

White Paper Overview

The survey explored both clinical and non-clinical considerations influencing BTKi selection, including comorbidity risk, adverse event management, patient hesitancy, counseling demands, administrative burden, and access challenges. Responses were analyzed by role to capture the complementary perspectives of physicians, who drive treatment initiation and switching decisions, and pharmacists, who support access, adherence, toxicity management, and patient education.

Results demonstrate that while efficacy remains the primary driver of BTKi choice, tolerability and cardiovascular risk strongly influence real-world prescribing patterns. The survey also underscores the growing impact of payer restrictions, prior authorization requirements, and anticipated policy changes—such as those associated with the Inflation Reduction Act—on therapeutic flexibility and workflow efficiency.

Key Insights from the White Paper

• Efficacy remains the leading driver of BTKi selection, followed by tolerability and safety considerations.
• Comorbidity risk, particularly cardiovascular-related concerns, plays a central role in agent choice and switching decisions.
• Patient hesitancy and anxiety about switching therapies are common and require substantial education and multidisciplinary reinforcement.
• Operational and access barriers, including prior authorizations and payer steering, significantly affect treatment initiation and continuity of care.
• Awareness of federal pricing reforms varies by role, with providers anticipating increased administrative burden and potential access restrictions in the future.

Why This Matters for Oncology Practice

BTKi therapy selection increasingly occurs at the intersection of clinical evidence, patient experience, and healthcare system constraints. Understanding how providers navigate these competing demands can inform better patient education, workflow optimization, and advocacy efforts to preserve access to appropriate therapy. Medically integrated oncology practices are uniquely positioned to address these challenges through coordinated, multidisciplinary care models.

References

Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Advances. 2024;8(9):2300–2309.

Tapay N. The Inflation Reduction Act’s potential impact on oncology care: patient costs and provider reimbursement implications. Oncology Issues. 2025;40(2):76–77.

Alston & Bird. Health Care Week in Review: November 26, 2025. November 26, 2025.

Centers for Medicare & Medicaid Services. Medicare Program; Inflation Reduction Act (IRA) Medicare Drug Price Negotiation Program Final Guidance. Federal Register. November 28, 2025;90(228):82245–82264.

Komorny KM, Burkett JM, Mensing T, Whaley BA, Robb K, Chen D. Payer site-of-care mandates with oncology medications: It’s time to demand payer accountability on behalf of patients. American Journal of Health-System Pharmacy. 2023;80(14):939–943.