Real-world practitioner perceptions of CARTITUDE-4 results for patients with previously treated multiple myeloma.

INTRODUCTION

Background and significance

Multiple myeloma (MM) is a neoplastic disorder of plasma cells characterized by abnormal cells within the bone marrow producing excessive proteins and forming monoclonal immunoglobulin antibodies, both of which may lead to end‐organ compromise or damage [ 1 ]. Although the disease remains incurable, median progression‐free survival (PFS) and overall survival (OS) for patients with newly diagnosed MM can exceed well over 5 and 10 years, respectively [ 2 , 3 ]. The National Comprehensive Cancer Network (NCCN) Guidelines recommend a multitude of options for treating relapsed and/or refractory MM (RRMM), including a proteasome inhibitor (PI), an immunomodulator (IMiD), a monoclonal antibody (mAb), other agents such as selinexor, venetoclax, and more recently, bispecific antibodies (BsAbs) and chimeric antigen receptor (CAR) T‐cell therapies [ 4 ]. In terms of treatment duration—with the exception of CAR T‐cell products—these regimens are intended for continued use, are typically effective for finite periods, and have been associated with a range of adverse events (AEs) [ 5 ]. For example, neurologic toxicity is a frequent complication of CAR T‐cell therapy; AEs have been observed in more than half of the participants in some clinical trials [ 6 ]. Although immune effector cell‐associated neurotoxicity syndrome (ICANS) subsequent to CAR T‐cell therapy typically resolves on its own, it may require intensive care unit admission and can be fatal [ 6 ]. Conversely, CAR T‐cell products, which have until recently been used in the fifth‐line setting and beyond, were developed for single‐use administration (“one‐and‐done”) [ 4 ], revolutionizing single‐agent effectiveness and our ability to manage highly pretreated, multiclass‐refractory patients with MM.

Impressive results of CAR T‐cell therapy in later therapeutic lines across hematologic indications have also spurred the development of data in earlier lines, toward delivering even better results. In the lymphoma space, following landmark early‐phase clinical trials, CD19 CAR T‐cell products were approved for treating lymphoma in the third‐line (3L) setting, paving the way for second‐line (2L) studies [ 7 ]. Subsequent phase III trials in large B‐cell lymphoma conducted comparisons with 2L standard‐of‐care (SOC) treatments, and phase II studies investigated first‐line (1L) CAR T‐cell therapy in transplant‐ineligible participants [ 8 ]. Moreover, a study evaluating patient experience noted that most eligible patients receive CAR T‐cell therapy at advanced disease stages, if at all, and concluded that it should be considered at earlier stages [ 9 ]. In April 2024, an important change occurred for CAR T‐cell therapy in RRMM, when the B‐cell maturation antigen (BCMA)‐directed CAR T‐cell products idecabtagene vicleucel (ide‐cel) [ 5 , 10 , 11 ] and ciltacabtagene autoleucel (cilta‐cel) [ 12 , 13 , 14 ] were approved by the United States (US) Food and Drug Administration (FDA) for use in the 3L and 2L settings, respectively [ 12 , 15 , 16 ]. The phase III CARTITUDE‐4 trial ( NCT04181827 ) investigated the efficacy of cilta‐cel in a cohort with lenalidomide‐refractory disease who had undergone between 1 to 3 prior lines of therapy [ 14 , 17 ]. Study participants were randomized to receive either cilta‐cel or the physician's choice of SOC treatment including pomalidomide, bortezomib, and dexamethasone (PVd) or daratumumab, pomalidomide, and dexamethasone (DPd) [ 14 , 17 ]. At a median follow‐up of 15.9 months, median PFS was not reached in the cilta‐cel group and was 11.8 months in the SOC group ( p < 0.001) [ 14 , 17 ]. At 12 months, the intention‐to‐treat population had a PFS of 76% with cilta‐cel and 49% with SOC treatments [ 14 , 17 ]. Compared with SOC, the cilta‐cel group demonstrated a 74% reduction in risk of disease progression or death ( p < 0.001), with high rates of complete response and minimal residual disease negativity [ 14 , 17 ]. Other long‐term studies have also shown that patients treated with cilta‐cel have maintained deep and durable responses—even those with high‐risk features such as adverse cytogenetics, soft‐tissue plasmacytomas, and triple‐class–refractory disease—further supporting its favorable risk/benefit profile and potential as a key therapeutic option for treating early RRMM [ 16 , 18 ].

Oncology practitioners often rely on clinical trial data to make individualized treatment choices, but challenges arise when real‐world patients differ from those in clinical trials, leading to possible treatment selection bias [ 19 ]. Incorporating real‐world data (RWD) into decision‐making frameworks can help estimate treatment effectiveness and symptom burden outside of the artificially controlled clinical trial setting, facilitating more generalizable results and personalized therapeutic decisions [ 20 ]. Our previous study on the abstraction of clinical data by community oncology practitioners has demonstrated the feasibility of obtaining deep and comprehensive RWD on CAR T‐cell therapy procedures and transfers of care that are valuable for strategizing treatment [ 21 ]. Moreover, treating practitioners are open to extrapolating trial results to underrepresented patient populations—who compose only small fractions of the clinical trial participants intended to represent them [ 22 ]. However, bringing novel therapies to patients in need requires that treating practitioners are aware of the data, understand them, and are willing to prescribe the regimens.

Study aims

In this study, we aimed to determine whether reviewing recent data from CARTITUDE‐4 would impact the treatment and sequencing preferences reported by practitioners attending an in‐person summit. We further explored whether and how they would consider integrating CAR T‐cell therapies into their treatment protocols in a real‐world setting.

METHODS

Participant recruitment

In this cross‐sectional, qualitative survey‐based study, we administered an online survey to a convenience sample of US‐based hematologists and oncologists who were registered to attend the September 2023 in‐person summit in Los Angeles, California. Oncology practitioners attend these summits primarily as market research consultants; their role is to engage in discussions about various clinical topics and trends. Practitioner recruitment was limited to the Cardinal Health Oncology Provider Extended Network (OPEN), which encompasses approximately 800 oncology practices throughout the US. Eligibility criteria for participation specified that only hematologists and oncologists who had not taken part in another oncology summit within the preceding 6–9 months were eligible to participate. Registered practitioners were eligible if they had reported treating or managing patients with MM.

The study summit was focused on reviewing abstracts presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, and although the practitioners knew this, they were unaware of the survey contents prior to the summit. This measure was adopted to mitigate the risk of selection bias, which could arise if those with limited awareness of the subject matter opted out. Additionally, the practitioners were informed that survey findings would be presented in an aggregated manner and that no individual‐level data would be used or disclosed, and we compensated them at fair market value. Prior to the in‐person summit, an online premeeting survey was distributed to the registered practitioners, completion of which was mandatory for attendance. Summit objectives were to: (1) discuss and obtain feedback on oncology practitioners’ perceptions about clinical trial data,​ (2) understand how these data would impact treatment patterns and prescribing habits, and (3) gather feedback on perceptions of emerging trends and critical issues in hematology/oncology.​

Data collection

In an initial sample of 60 hematologists and oncologists, we assessed their baseline treatment preferences for patients with RRMM by administering a 2‐part survey. The online premeeting survey collected preferences about treatment regimen and sequencing and the in‐person survey gathered preferences and perceptions after viewing the CARTITUDE‐4 trial data. Demographic and practice characteristics were also collected using the premeeting survey. Data collection did not account for the responses, or lack thereof, from those who did not accept the summit invitation. The respondents’ perceptions and reactions to recent clinical trial data, including an abstract detailing the findings from CARTITUDE‐4, were captured during the in‐person summit. Responses of practitioners who reported not treating MM were excluded.

Statistical methods

To investigate whether the respondents’ treatment regimen or sequencing preferences for fourth‐line (4L) therapy in a hypothetical patient with triple‐class–refractory MM would change after seeing the trial data, we asked the same question with the same answer options before and after presenting the data and analyzed the differences. We hypothesized that there would be preference changes after presenting the data in either direction (2‐tailed test) from their selected treatment preference established prior to viewing the data based on a level of significance (α) of less than .05. Using the base statistics package in R version 4.4.1, we tested our hypothesis with the McNemar chi‐squared test. This test evaluates changes in each respondent's paired pre‐ and post‐trial data presentation 4L treatment preferences for the hypothetical patient with triple‐class–refractory MM. Specifically, the test was chosen because it is suitable for evaluating changes in the paired nominal data. We converted the aggregated paired nominal data responses collected for each before‐and‐after hypothetical MM patient treatment preference numerically to facilitate the hypothesis testing. All responses from the practitioners in attendance were included for hypothesis testing to ensure a complete dataset. Additionally, we ran a secondary analysis using the same methodology described above to discern changes in the practitioners’ perceptions of the use of CAR T‐cell therapy in earlier lines for patients with triple‐class–refractory MM.

RESULTS

Responses from 50 hematology/oncology practitioners were included (Table 1 ). Of them, 64% specified hematology/oncology as their primary specialty and 36% selected medical oncology. Most (86%) were in community practice (52% privately owned) and were located mainly in the Southern (28%) and Western (28%) US regions (24% Midwest, 20% Northeast). The top 3 malignancies they most often treated or managed were chronic lymphocytic leukemia (80%), active MM (72%), and diffuse large B‐cell lymphoma (48%). Additionally, they estimated treating a mean (standard deviation [SD]) of 20.4 (8.2) patients per day (range, 4–50) and had a median of 13 years in practice (range, 2–44). Regarding the top 3 services and capabilities available at their practices, 86% listed clinical research, 80% cancer survivorship programs, and 70% imaging and radiation oncology. Also, most practitioners (80%) spent between 76% and 100% of their time in direct patient care, 48% spent no time teaching, 36% spent no time in research, and 42% spent nearly a third of their time (26%‐30%) performing administrative duties. Of the respondents who participated in the research, the top 3 types of studies reported were phase III clinical trials (80%), phase II clinical trials (62%), and observational/noninterventional studies (52%).

Pre‐CARTITUDE trial presentation results

Before being presented with CARTITUDE‐4 data, practitioners were asked about their baseline treatment practices. They identified the top 3 factors influencing decisions to refer or prescribe CAR T‐cell therapy for MM, which included slot availability at CAR T‐cell therapy centers (58%), comorbidities (52%), and center locations (34%) (Figure 1 ). The remaining factors included patient fitness (32%), age (24%), prior therapies (22%), and AE profiles of CAR T‐cell regimens and disease burden (each 16%), among others (2%). To gauge 4L treatment preferences prior to viewing CARTITUDE‐4, we presented a hypothetical case of a 66‐year‐old man with triple‐class–refractory disease (i.e., progression through regimens containing a PI, an IMiD, and a CD38 mAb) who had relapsed from 3L treatment and asked them to choose their next therapeutic intervention. Among 46 respondents, cilta‐cel was chosen by 48%, followed by ide‐cel at 22% and teclistamab at 15% (Figure 2 ). Additionally, we assessed preferences for earlier‐line CAR T‐cell therapy by asking them to assume FDA approval in the 2L and 3L settings and select up to 2 statements that best summarized their perceptions of earlier CAR T‐cell therapy. As practitioners were allowed to select up to 2 responses (pre‐ and post‐trial presentation), results included all possible response options (not only those preferring 2L/3L CAR T‐cell therapy). Among 47 respondents, 40% wanted more real‐world and long‐term CAR T‐cell outcomes in any line, 38% wanted more 2L data, and 34% favored CAR T‐cell regimens in the 2L and 3L settings (Figure 3 ).

Post‐CARTITUDE trial presentation results

After being presented with the CARTITUDE‐4 trial data, there was a noticeable shift in treatment preferences. Among respondents (46 prior to trial presentation and 50 afterward), this shift resulted in a 100% increase in the percentage considering cilta‐cel, from 48% to 88% ( p < 0.001) (Figure 2 ). After reviewing the trial presentation, respondents' preference for ide‐cel decreased by 80% (22% before, 4% after [ p = 0.01]). Additionally, teclistamab was preferred by 15% of respondents and subsequently decreased to 6% (57% reduction; p = 0.06). We also noted that viewing trial data influenced a rise in the number of respondents who favored CAR T‐cell therapy in earlier lines, specifically 2L or 3L (assuming FDA approval). Among 47 respondents who answered the question prior to the trial presentation and 49 who answered afterward, this change led to a 69% increase (from 34% to 55%) in those favoring 2L or 3L CAR T‐cell therapy ( p = 0.001) (Figure 3 ). After the trial presentation, the percentage who wanted more data on 2L CAR T‐cell therapy decreased by 6% (from 38% to 35% [ p = 0.80]), and those wanting more data on 3L CAR T‐cell therapy decreased by 21% (from 30% to 23% [ p = 0.44]). Additionally, the percentage who wanted more data on real‐world and long‐term outcomes of CAR T‐cell therapy in any line also decreased by 21% (from 40% to 31% [ p = 0.29]). For determining the most suitable treatment sequencing, the majority (55%) of 49 respondents preferred BCMA‐directed CAR T‐cell therapies prior to BsAbs, whereas 39% preferred the inverse (Figure 4 ). The R coding script we used for the analysis is included as a Supplement; it shows the numeric identifiers that were assigned to track each participant's responses before viewing the trial data, which were matched to her/his responses after viewing the trial data.

DISCUSSION

With the April 2024 FDA approvals of ide‐cel and cilta‐cel, CAR T‐cell therapy is being used in earlier lines of therapy for previously treated MM. Although our data were collected prior to the approvals, we have shown that making oncology practitioners aware of the CARTITUDE‐4 trial updates from ASCO 2023 precipitated their critical treatment decision‐making factors—which the survey elucidated—and led to some notable statistically significant shifts in their perceptions surrounding CAR T‐cell therapy as well as their treatment preferences in the real‐world setting. Before being presented with the trial data, the top 3 factors influencing the respondents’ decision‐making processes when referring or prescribing CAR T‐cell therapy were the availability of slots at a CAR T‐cell therapy center, patient comorbidities, and the locations of the CAR T‐cell therapy centers. Additionally, we observed a shift in treatment preferences when posing the scenario involving a hypothetical patient with triple‐class–refractory status being treated in the 4L setting. After viewing the trial data, the percentage of respondents considering using cilta‐cel doubled. Moreover, the preference for ide‐cel decreased by 80% and the preference for teclistamab decreased by 57%.

Presenting the CARTITUDE‐4 data also engendered a rise in the number of practitioners who favored CAR T‐cell therapy in earlier lines for patients with RRMM, specifically in the 2L or 3L settings—assuming FDA approval. This change led to a 69% increase in respondents supporting 2L or 3L CAR T‐cell therapy. Notably, their need for additional data also changed; the respondents who wanted more data on CAR T‐cell therapy in earlier lines decreased by 6% and 21%, respectively. In keeping with that trend, the respondents who wanted more data on CAR T‐cell therapy in any line decreased by 21%. Along with changing the respondents’ intended treatment approaches for patients with triple‐class–refractory RRMM, presenting the CARTITUDE‐4 data also contributed to an uptick in the number of respondents who were inclined toward CAR T‐cell therapy in earlier lines and prior to BsAbs. Approximately 55% of respondents preferred sequencing BCMA‐directed CAR T‐cell therapies prior to BsAbs, whereas nearly 40% preferred the inverse.

Previous studies have also demonstrated that oncology practitioners’ treatment decisions to employ CAR T‐cell therapy could be influenced by a myriad of factors including efficacy, adherence to clinical guidelines, extent of patient health insurance coverage and ease of obtaining approval, existing relationships with CAR T‐cell therapy facilities, familiarity with CAR T‐cell therapies, and the impact on patient quality of life [ 23 , 24 , 25 , 26 ]. Further, the availability of CAR T‐cell product manufacturing, proximity to treatment centers, financial implications, caregiver availability, and socioeconomic factors all contributed to the decision‐making process [ 25 ]. Practitioners must navigate these complex challenges related to their own knowledge, care coordination logistics, payor issues, and patient preferences in order to secure timely treatment for those with limited remaining options. Our finding of the availability of slots at a CAR T‐cell therapy center as the top determining factor in treatment decision‐making (selected by 58% of respondents) corroborates previous evidence suggesting that this is an unmet resource‐related need [ 27 , 28 ]. The capacity of CAR T‐cell therapy centers is instrumental for practitioners prescribing and patients undergoing the procedure [ 29 ]. As CAR T‐cell products are patient‐specific, have a complicated manufacturing process, and are typically administered off‐site, their availability varies widely. Moreover, cilta‐cel is currently only available at a limited number of hospitals that are risk evaluation and mitigation strategy (REMS)‐certified to offer it, and the approximately 30‐day wait time may be too long for patients with highly aggressive disease [ 15 ].

More than half (52%) of the respondents selected patient comorbidities as the second most important factor in strategizing treatment. Other health conditions impact a patient's ability to tolerate CAR T‐cell therapy and its treatment‐related risks [ 30 ]. Younger and fitter patients may be more resilient to the intensive nature of CAR T‐cell therapy and its AEs, as different CAR T‐cell therapies have varying safety profiles [ 30 , 31 ]. Additionally, the treatments that a patient has previously undergone can influence the effectiveness of CAR T‐cell therapy [ 32 ]. Practitioners must therefore carefully assess the patient's overall health status, likelihood of complications, and treatment history and weigh the purported benefits against the risks to determine the best course of treatment. They must also consider the extent of the patient's disease burden, which can dictate the urgency and suitability of CAR T‐cell therapy; a higher disease burden may warrant more aggressive treatment approaches with faster delivery timelines [ 32 ]. The last of the top 3 factors concerned the relative distance to the CAR T‐cell therapy center. Travel can be especially burdensome for patients with severe symptoms or limited mobility [ 32 ], and as CAR T‐cell therapy also carries unique toxicity risks, the patient's proximity to the treatment center and treating practitioner is key to obtaining and effectively managing AEs related to CAR T‐cell therapy. Interestingly, among the practitioners who participated in our study, only 12 (24%) indicated that their practice has the capacity to administer CAR T‐cell therapy. Previous programs conducted by Cardinal Health have revealed through qualitative data that few patients referred out for CAR T‐cell therapy return to their original practices. Assuming that most practitioners refer their patients out for CAR T‐cell therapy, it is likely that many are unaware of the actual treatment‐related effects on their patients. This suggests a potential gap in the continuity of care between community oncologists and their patients receiving CAR T‐cell therapy.

The precision of cell and gene therapy has the power to improve treatment effectiveness while minimizing AEs for all patients; by considering individual patient variations in response, the therapy is shifting treatment paradigms and impacting CAR‐T cell product manufacturing and logistics. Manufacturing involves leukapheresis, cell enhancement or reduction (e.g., lymphodepletion), T‐cell activation, gene delivery, CAR T‐cell expansion and formulation, and cryopreservation prior to infusion—with variations in techniques and technologies used across different procedures [ 33 ]. Over the past few years, key changes in CAR T‐cell product manufacturing have included the shift toward point‐of‐care production or decentralized in‐house manufacturing to enhance patient access and outcomes while maintaining quality, despite the lack of standardization for CAR T‐cell products manufactured in‐house for administration at physician offices [ 34 ]. Notably, modifications in manufacturing have led to improved product performance, resulting in prolonged persistence, enhanced disease‐free survival, and improved B‐cell aplasia in patients with relapsed or refractory B‐cell acute lymphoblastic leukemia, reflecting ongoing efforts to increase availability and reduce health care costs by standardizing and automating CAR T‐cell production [ 35 ]. The April 2024 FDA approvals of ide‐cel and cilta‐cel for earlier therapeutic lines have revolutionized the therapeutic landscape for RRMM, emphasizing the importance of standardized manufacturing techniques and ex vivo culture conditions to enhance CAR T‐cell functionality—which is often overlooked in clinical translation—and necessitating adjustments in manufacturing times and logistics to meet the demand for earlier‐line CAR T‐cell therapy [ 34 , 36 ]. They have also spurred biotech and pharmaceutical companies to innovate production methods [ 34 ].

As with other treatments, the real‐world translation of clinical trial results will be influenced by a variety of factors; these include patient selection, fitness, and heterogeneity; treatment accessibility and setting; practitioner awareness and willingness to prescribe CAR T‐cell therapy; and patient preference and willingness to receive CAR T‐cell therapy [ 14 ]. Cost is another limiting factor; a single infusion of cilta‐cel lists at $465,000—although the final cost to the patient depends on insurance coverage [ 15 ]. On the practice management front, the limited geographic spread of CAR T‐cell therapy centers may lead to a lack of payor reimbursement, injecting uncertainty into accessing CAR T‐cell regimens in earlier lines of therapy. Importantly, most CAR T‐cell therapy is usually reimbursed in indications with unmet needs —such as non‐Hodgkin lymphoma and acute lymphocytic/lymphoblastic leukemia—as opposed to MM, which has several therapeutic alternatives [ 37 ]. Notably, 21 practitioners (42%) reported spending 30% or more of their time on administrative tasks. It is well known that obtaining payor approval for oncologic therapies imposes a significant burden on providers, hindering their ability to effectively treat patients. Although we did not specifically inquire about the nature of the administrative work, it is likely that the cost and complexity of securing coverage for CAR T‐cell therapy for their patients with MM contributes significantly to the high proportion of time these practitioners spend on administrative duties. Nevertheless, the strong PFS benefit and rapid, deep response with cilta‐cel emphasize its therapeutic potential for patients with previously treated MM as early as after the first relapse [ 14 ].

Strengths and limitations

Our study methodology had several notable strengths. Survey studies can gather insights into the choice architecture of oncology practitioners’ treatment decisions. By collecting data directly from the practitioners, we gained a better understanding of the factors driving their choices. Additionally, our survey produced quantitative data that allowed us to identify trends, patterns, and associations related to their treatment preferences.

The major limitations of our study were its reliance on self‐reported data and possible biases in practitioner selection and responses. Moreover, the practitioners’ responses to hypothetical patient scenarios (rather than actual care evaluation) may have been influenced by how they thought we would want them to answer—instead of expressing their true views. Additionally, our inability to analyze nonresponders limited our sample to practitioners who may not have been representative of the larger population; however, our sample was geographically distributed across the US. Finally, although our September 2023 survey data are less relevant following the April 2024 FDA approvals of ide‐cel and cilta‐cel for earlier therapeutic lines, they can serve as a baseline from which to evaluate changes in the treatment regimen and sequencing perceptions and preferences surrounding CAR T‐cell therapy as a 1L or 2L treatment option in future research, as well as the need for bridging therapy.

CONCLUSIONS

Oncology practitioners’ perspectives, patient preferences, and the evolving landscape of treatment options all contribute to the decision‐making process surrounding CAR T‐cell therapy for patients with RRMM. We have shown that making oncology practitioners aware of clinical trial data can precipitate decision‐making factors and lead to notable, significant shifts in future intended practice patterns.

As interest in incorporating CAR T‐cell therapy in the context of early relapse continues to gain momentum in the real‐world setting, the strategies for sequencing CAR T‐cell products (such as cilta‐cel) alongside established therapeutic modalities (like BsAbs) are emerging focal points of research. Clinical trials provide a controlled interventional environment, and RWD from the community oncology setting—where most patients with cancer are treated, including for MM—serve to valuably complement these findings. Practitioners' awareness of clinical trial data could impact their ability to make informed treatment decisions, offer the most current and effective therapies, and successfully manage treatment‐related AEs. Knowledge of clinical trial outcomes also guides them in the CAR T‐cell therapy referral process and is useful for navigating complex collaborations with infusion centers.

In summary, our study has shown that informing oncology practitioners about the CARTITUDE‐4 clinical trial influenced real‐world decision‐making within a hypothetical scenario and changed perceptions surrounding CAR T‐cell therapy, particularly for 4L cilta‐cel use (100% increase). Practitioners should be aware of clinical trials evaluating CAR T‐cell therapy because these data provide critical insights into the safety, efficacy, and potential treatment outcomes for patients. Being aware of trial data enables them to make more informed treatment decisions, tailor therapies to individual patient needs, and ultimately improve patient outcomes.

AUTHOR CONTRIBUTIONS

All authors have made substantial contributions to the conception or design of the work; acquisition; analysis; or interpretation of data; drafting or revising critically for important intellectual content; have agreed to final approval of the version to be published; and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

All authors confirm that they had access to all the data in the study and accept responsibility to submit it for publication.

Specific contributions were :

Alexandrina Balanean : Investigation; methodology; project administration; validation; visualization; writing—original draft; writing—review and editing. Samuel Baird : Data curation; formal analysis; investigation; methodology; software; validation; visualization; writing—review and editing. Brooke Dulka : Data curation; formal analysis; investigation; methodology; project administration; software; supervision; validation; writing—review and editing. Luke Jennings‐Zhang : Investigation; writing—review and editing. Robert N. Bone : Investigation; supervision; writing—review and editing. Yolaine Jeune‐Smith : Investigation; supervision; writing—review and editing. Bruce Feinberg : Clinical expertise; investigation; writing—review and editing. Muhamed Baljevic : Project conception; clinical expertise; investigation; validation; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

All authors have made substantial contributions to the conception or design of the work, acquisition, analysis, or interpretation of data; drafting or revising critically for important intellectual content; have agreed to final approval of the version to be published; and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ms. Alexandrina Balanean, Mr. Samuel Baird, Dr. Brooke Dulka, Dr. Luke Jennings‐Zhang, and Dr. Robert N. Bone are employees of Cardinal Health.

Dr. Yolaine Jeune‐Smith and Dr. Bruce Feinberg are employees of and own stock in Cardinal Health.

Dr. Muhamed Baljevic has been a consultant for Cardinal Health, AbbVie, and Pfizer. He has also been on the advisory boards of Janssen Biotech, BMS/Celgene, and Sanofi‐Genzyme and on the independent review committee for Parexel.

FUNDING INFORMATION

We conducted this study per our employment; no external funding applies.

ETHICS STATEMENT

As we used only deidentified data and did not collect protected health information (PHI) for this study, it was not subject to institutional review board (IRB) approval. This study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

PATIENT CONSENT STATEMENT

The authors have confirmed patient consent statement is not needed for this submission

CLINICAL TRIAL REGISTRATION

The authors have confirmed clinical trial registration is not needed for this submission.

Supporting information

Supporting Information

ACKNOWLEDGMENTS

Diana Kubitz, BS, Consultant, Research Operations at Cardinal Health, performed data collection and assisted with data collection and preliminary data analyses.

DATA AVAILABILITY STATEMENT

The deidentified survey data that support the findings of this study are available from the corresponding author upon reasonable request.

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