Socioeconomics/Demographic Disparities Influence Myeloma Treatment and Survival Outcomes

Value-Based Care in Myeloma - Multiple Myeloma
Caroline Helwick

In the treatment of patients with multiple myeloma, disparities in care based on socioeconomic and demographic parameters affect survival outcomes, according to studies presented at the 2014 American Society of Hematology meeting.

Age, Socioeconomic Status Influence Survival

Mark A. Fiala, BS, CCRN, of Washington University School of Medicine, St Louis, MO, led an analysis of the SEER-18 database that extracted 85,115 patients who were diagnosed with myeloma from 1973 through 2010. As previously reported, his analysis showed that improvements in overall survival after stem-cell transplant disproportionally benefit patients who are younger at diagnosis and/or white. In addition, a novel finding from his study was that patients with myeloma of higher socioeconomic status benefit more than those of lower socioeconomic status, Mr Fiala said at the meeting.

Compared with patients younger than age 65 years, the risk for patients aged 65 to 69 years was increased 48%, and the risk for those aged ≥70 years was increased more than 200%. Black patients had a 5% increased risk of death versus whites, and patients of low socioeconomic status had a 13% increased risk of death versus patients with a high socioeconomic status.

Racial/Ethnic Disparities Reduce Transplant Volume

Autologous hematopoietic progenitor cell transplant (AHPCT) can reduce the risk for disease progression or death from myeloma by approximately 40% to 60%. Although the use of AHPCT is increasing in myeloma—and myeloma is the most common disease for which transplant is performed—this treatment is still underutilized. Researchers at the University of Alabama at Birmingham sought to identify the obstacles to receiving transplant.

Although nearly 50% of patients aged <50 years undergo transplant, its use drops to 39% among patients aged 50 to 64 years and to only 7% among older patients, even though age is no longer an established contraindication to AHPCT, according to Luciano J. Costa, MD, PhD, of the University of Alabama at Birmingham, who led an evaluation of disparities among transplant recipients by age, racial/ethnic group, and sex.

“Individuals from different age-groups and different ethnicities appear to derive similar benefit from AHPCT,” Dr Costa noted. “But the presence of age, gender, and race/ethnicity disparities in AHPCT utilization is poorly understood.”

He led a retrospective analysis of the SEER-18 database for the years 2005-2009 and determined the relative utilization ratio. This is determined by the apparent utilization for the group of interest divided by the apparent utilization for the entire population. The analysis revealed 22,462 cases of myeloma and 13,311 cases of AHPCT.

“We found that there are substantial racial and ethnic disparities in the utilization of AHPCT,” Dr Costa said.

The age-adjusted relative utilization ratio was 1.17 for non-Hispanic whites, which was significantly higher than for non-Hispanic blacks, Hispanics, and Asians. There was also higher utilization of transplant in men than in women among the Hispanic population, and age disparity was pronounced in all racial/ethnic categories “and not justified by the data,” he noted.

“The current trend to increase AHPCT use in older patients will continue to substantially increase transplant activity,” Dr Costa added.

He and his colleagues determined that by correcting the racial and ethnic disparities in the use of transplant, the volume of AHPCT would increase by approximately 15%. The increase would be most pronounced among non-Hispanic blacks, Hispanics, and Asians.

“These disparities may be a surrogate for utilization of advanced care and partially explain the outcome disparities seen in population studies,” Dr Costa suggested.

Distance to Transplant Center Affects Survival

Racquel D. Innis-Shelton, MD, also of the University of Alabama at Birmingham, led a study that evaluated access to AHPCT with regard to demographic, geographic, and socioeconomic parameters.

“We hypothesized that the distance between the patient’s county of residence and a transplant center is an adequate surrogate of access to advanced care, comprising not only AHPCT but also experimental therapies, and may affect the survival of multiple myeloma patients,” she noted.

Dr Innis-Shelton and colleagues analyzed patients diagnosed with myeloma between 2002 and 2001 in the SEER-18 database. The patients were classified into 3 cohorts according to the distance between their county of residence and the nearest program accredited by the Foundation for the Accreditation of Cellular Therapy: Cohort A (<20 miles), Cohort B (20-70 miles), Cohort C (70-200 miles), and Cohort D (>200 miles). The researchers found 45,079 patients with a median follow-up for survivors of 30 months.

“There were substantial differences among the cohorts, particularly in race or ethnicity, income, and education,” she reported.

The median survival duration was 34 months for Cohort A, 37 months for Cohort B, 31 months for Cohort C, and 30 months for Cohort D.

Using Cox proportional hazards modeling, Dr Innis-Shelton and colleagues built 2 survival models that included demographic parameters, distance to the center, median household income, and proportion of household with at least a bachelor’s degree.

The models showed that compared with patients who lived within 20 miles of the transplant center, those who lived 70 to 200 miles away or more than 200 miles away had a significant 10% increased risk for death. Interestingly, those who lived 20 to 70 miles away had a significant 4% lower risk of death. The models also showed that increasing the household income and the educational level were associated with a small (<2%), although significant, difference in mortality risk.

Other factors related to worse survival were older age, earlier year of diagnosis, male sex, presentation with plasma-cell leukemia, and Hispanic or non-Hispanic black race or ethnicity.

“Distance to the transplant center, a surrogate for access to advanced care, is associated with survival in patients with multiple myeloma,” Dr Innis-Shelton concluded, “likely reflecting underlying differences in demographics, income, and education.”

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