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Banerjee R, Biru Y, Cole CE, Faiman B, Midha S, Ailawadhi S. Disparities in relapsed or refractory multiple myeloma: recommendations from an interprofessional consensus panel. Blood Cancer J 2024; 14:149. [PMID: 39191731 DOI: 10.1038/s41408-024-01129-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 08/12/2024] [Accepted: 08/14/2024] [Indexed: 08/29/2024] Open
Abstract
Many studies have documented racial, socioeconomic, geographic, and other disparities for United States (US) patients with multiple myeloma pertaining to diagnosis and frontline management. In contrast, very little is known about disparities in the management of relapsed/refractory multiple myeloma (RRMM) despite a plethora of novel treatment options. In this review, we discuss the manifestations of disparities in RRMM and strategies to mitigate their impact. Immunomodulatory drugs can create disparities on many axes, for example inappropriately low dosing due to Duffy-null status as well as time toxicity and financial toxicity from logistical hurdles for socioeconomically vulnerable patients. Access to myeloma expertise at high-volume centers is a critical consideration given the disconnect between how drugs like carfilzomib and dexamethasone are prescribed in trials versus optimized in real-world practice to lower toxicities. Disparities in chimeric antigen receptor T-cell therapy and bispecific antibody therapy span across racial, ethnic, and socioeconomic lines in large part due to their limited availability outside of high-volume centers. Another insidious source of disparities is supportive care in RRMM, ranging from inadequate pain control in Black patients to limited primary care provider access in rural settings. We discuss the rationales and evidence base for several solutions aimed at mitigating these disparities: for example, (1) bidirectional co-management with community-based oncologists, (2) screening for risk factors based on social determinants of health, (3) strategies to build patient trust with regard to clinical trials, and (4) longitudinal access to a primary care provider. As the treatment landscape for RRMM continues to expand, these types of efforts by the field will help ensure that this landscape is equally accessible and traversable for all US patients.
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Affiliation(s)
- Rahul Banerjee
- Fred Hutchinson Cancer Center, Seattle, WA, USA.
- University of Washington, Seattle, WA, USA.
| | - Yelak Biru
- International Myeloma Foundation, Los Angeles, CA, USA
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Gasoyan H, Anwer F, Kovach JD, Casacchia NJ, Wang M, Valent J, Halpern MT, Rothberg MB. Disparities in time to treatment with oral antimyeloma medications. Blood Cancer J 2024; 14:142. [PMID: 39179575 PMCID: PMC11343868 DOI: 10.1038/s41408-024-01128-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 08/12/2024] [Accepted: 08/14/2024] [Indexed: 08/26/2024] Open
Abstract
This retrospective cohort study used Taussig Cancer Center's Myeloma Patient Registry to identify adults with multiple myeloma diagnosed between January 2017-December 2021. Electronic health records data captured time from diagnosis to initial prescription fill for oral antimyeloma medications and initiation of facility administered or oral antimyeloma treatment. We identified 720 patients with a mean age at diagnosis of 67 years ±11; 55% were male, 77% White, 22% Black, 1% other races, covered by private insurance (36%), traditional Medicare (29%), Medicare Advantage (25%), and Medicaid (8.3%). Over a third of patients (37%) resided in an area in the most disadvantaged area deprivation index (ADI) quartile. The median available follow-up was 765 days. Seventy-five percent of the cohort filled an oral antimyeloma medication prescription (excluding corticosteroids), with a median time to fill of 28 days (IQR, 15-61). In the multivariable Cox regression model, Black race (vs. White, adjusted hazard ratio [aHR], 0.61, 95% CI, 0.42-0.87), older age at diagnosis (aHR per 1 year, 0.97, 95% CI, 0.95-0.98), diagnosis during an inpatient admission (aHR, 0.63, 95% CI, 0.43-0.92), and estimated glomerular filtration rate ≤29 ml/min/1.73 m2 (vs. ≥60, aHR, 0.46, 95% CI, 0.29-0.73) were negatively associated with prescription fill for oral antimyeloma medication at 30 days, while insurance type and ADI were not significant predictors.
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Affiliation(s)
- Hamlet Gasoyan
- Center for Value-Based Care Research, Department of Internal Medicine and Geriatrics, Primary Care Institute, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
| | - Faiz Anwer
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey D Kovach
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas J Casacchia
- Center for Value-Based Care Research, Department of Internal Medicine and Geriatrics, Primary Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ming Wang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jason Valent
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Michael T Halpern
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Department of Internal Medicine and Geriatrics, Primary Care Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Fiala MA, Ji M, Shih YH, Huber J, Wang M, Johnson KJ, Gasoyan H, Wang R, Colditz GA, Wang SY, Chang SH. Treatment Access among Younger Medicaid Beneficiaries with Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00286-6. [PMID: 39209567 DOI: 10.1016/j.clml.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 07/15/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Continuous Medicaid coverage prior to a cancer diagnosis has been associated with earlier detection and better outcomes, for patients with solid tumors. In this study, we aimed to determine if this was observed among patients with multiple myeloma, a hematologic cancer where there are no routine screening tests and most are diagnosed through acute medical events. MATERIALS AND METHODS This is an analysis of the Merative MarketScan Multistate Medicaid Database, a claims-based dataset. In total, 1105 patients < 65 years old were included in the analyses. Among them, 66% had continuous enrollment (at least 6 months enrollment prior to myeloma), and 34% had discontinuous enrollment (2-6 months enrollment prior to myeloma). Multivariable Cox regression was used to estimate the association between continuous enrollment status and receipt of myeloma treatment within 1 year of index date. RESULTS Only 54% of all Medicaid enrollees received myeloma therapy and only 12% received stem cell transplant within the 1st year. Those with continuous enrollment were less likely to receive any treatment (adjusted hazard ratio [aHR] 0.59; 95% confidence interval [CI] 0.59-0.70; P < .001) and to receive stem cell transplant (aHR 0.51; 95% CI 0.32-0.81; P = .005). CONCLUSION Patients with continuous Medicaid coverage prior to diagnosis were less likely to receive myeloma therapy. Future studies should examine whether myeloma patients with continuous Medicaid enrollment have more chronic financial instability and/or higher medical needs and, thus, have higher barriers to care.
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Affiliation(s)
- Mark A Fiala
- Division of Oncology, Washington University School of Medicine, St Louis MO.
| | - Mengmeng Ji
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis MO
| | - Yi-Hsuan Shih
- Department of Electrical & Systems Engineering, Washington University School of Medicine, St Louis MO
| | - John Huber
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis MO
| | - Mei Wang
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis MO
| | - Kimberly J Johnson
- Brown School of Social Work, Washington University School of Medicine, St Louis MO
| | - Hamlet Gasoyan
- Department of Internal Medicine and Geriatrics, Center for Value-Based Care Research, Primary Care Institute, Cleveland Clinic, Cleveland OH
| | - Rong Wang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven CT
| | - Graham A Colditz
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis MO
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven CT
| | - Su-Hsin Chang
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis MO
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Gasoyan H, Anwer F, Casacchia NJ, Kovach JD, Valent J, Wang M, Halpern MT, Rothberg MB. Role of Patient Characteristics and Insurance Type in Newly Diagnosed Multiple Myeloma Care Disparities. JCO Oncol Pract 2024; 20:699-707. [PMID: 38354331 DOI: 10.1200/op.23.00672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/12/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Little is known about the role of social determinants of health (SDOH) in the utilization of novel treatments among patients with newly diagnosed multiple myeloma (NDMM). METHODS This retrospective cohort study used Taussig Cancer Center's Myeloma Patient Registry to identify adults with NDMM between January 1, 2017, and December 31, 2021. Electronic health records data captured treatment with (1) triplet or quadruplet regimen and (2) lenalidomide during the first year after NDMM, and (3) stem-cell transplant (SCT) through December 31, 2022. Multivariable logistic regression models examined associations of demographic/clinical characteristics and SDOH with care patterns. RESULTS We identified 569 patients with median age at diagnosis of 66 years (IQR, 59-73); 55% were male, 76% White, 23% Black, 1.1% other races, insured by Medicare (51%), private payer (38%), Medicaid (8.3%), and self-pay/other (1.8%). In the multivariable models, self-pay/other payers (adjusted odds ratio [AOR], 0.15 [95% CI, 0.03 to 0.54]) was associated with lower odds of triplet or quadruplet regimen, compared with Medicare. Private insurance (AOR, 0.48 [95% CI, 0.27 to 0.86]) and self-pay/other payers (AOR, 0.16 [95% CI, 0.04 to 0.74]) had lower odds of lenalidomide. Black patients (v White; AOR, 0.47 [95% CI, 0.26 to 0.85]) and patients treated at regional hospitals (v Taussig Cancer Center; AOR, 0.27 [95% CI, 0.12 to 0.57]) had lower odds of SCT. The odds of receiving triplet or quadruplet regimen, lenalidomide, and SCT also varied by the year of NDMM. CONCLUSION Care for NDMM varied based on race, insurance type, year of diagnosis, and treatment facility. It may be useful to examine the impact of insurance-related characteristics and recent policy initiatives on care disparities.
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Affiliation(s)
- Hamlet Gasoyan
- Department of Internal Medicine and Geriatrics, Center for Value-Based Care Research, Primary Care Institute, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Faiz Anwer
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Nicholas J Casacchia
- Department of Internal Medicine and Geriatrics, Center for Value-Based Care Research, Primary Care Institute, Cleveland Clinic, Cleveland, OH
| | - Jeffrey D Kovach
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Jason Valent
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Ming Wang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Michael T Halpern
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, MD
| | - Michael B Rothberg
- Department of Internal Medicine and Geriatrics, Center for Value-Based Care Research, Primary Care Institute, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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