Racial and insurance disparities in multiple myeloma management in a referral center.

e18140 Background: Multiple Myeloma (MM) management has significantly improved disease-free and overall (OS) survival but disparities among racial groups still exist. After the Affordable Care Act, the extent to which induction, autologous stem cell transplant (ASCT), and maintenance therapies are used are uncertain. We sought to describe underuse of induction, ASCT and maintenance in a large referral center. Methods: Between 2010 and 2014, 3101 patients were diagnosed with MM via ICD-9 code from the Data Warehouse and certified hospital tumor registry. NCCN 2014 and CMS guidelines were used to define the categories of treatment underuse, and define transplant eligibility. Demographics including insurance, Charlson Comorbidity Index and treatments received were determined via chart abstraction. To date, 393 confirmed MM from 697 charts were abstracted. Comparison by groups used Chi-square for categorical variables, t-test and ANOVA for continuous variables. Multivariate logistic regression models were applied to predict underuse of induction, harvest, ASCT, and maintenance. Results: Patients were 62 ±11.3 years-old, with no racial differences in age and insurance coverage. More minorities had Medicaid (Black [B] 13%, White [W] 7%, Hispanic [H] 25%; p = 0.001). Almost all patients (97%) received induction (B 99%, W 96%, H 100%; p = 0.3), with no difference by insurance. Among transplant eligible patients, 93% underwent harvest, 87% underwent ASCT, with no racial differences. Patients with Medicare or self-pay were less likely to undergo harvest compared to patients with Medicaid or private insurance (p = 0.01). No difference in ASCT rates by insurance were noted. B patients were less likely to receive maintenance than non-B (73% vs 86%; p = 0.03), with no difference by insurance. OS was 73%, with no racial differences. In multivariate model, older age predicted induction underuse (aOR = 1.15, 95% CI: 1.06-1.25) (c = 0.9, p = 0.005), and B patients experienced more maintenance underuse (aOR = 2.22, 95% CI: 1.09-4.54) (c = 0.61, p = 0.1), controlling for age and comorbidity. Conclusions: While there were no racial or insurance differences in access to induction therapy, fewer Black patients received maintenance therapy. Interviews are underway to understand reasons for observed differences.

Download Full-text

Characteristics of Multiple Myeloma Patients with Multiple Lines of Therapy Using Real-World US Claims Data

Blood ◽

10.1182/blood.v126.23.4519.4519 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4519-4519

Author(s):

Eric Maiese ◽

Brian Macomson ◽

Chris Kozma ◽

Terra Slaton ◽

Mekre Senbetta

Keyword(s):

Multiple Myeloma ◽

Stem Cell ◽

Stem Cell Transplant ◽

Treated Group ◽

Initial Therapy ◽

Categorical Variables ◽

Administrative Claims ◽

Cell Transplant ◽

Continuous Variables ◽

Hiv Diagnosis

Abstract Background: Multiple myeloma is an incurable disease with poor survival rate. Recently, novel treatments have focused on addressing unmet needs among heavily pre-treated patients who have failed prior therapies. The purpose of this analysis was to describe the characteristics of patients who are heavily pre-treated vs patients who were not, within 2 years of initiating MM therapy. Results of this analysis will help to understand the characteristics, including treatment patterns and burden, of MM patients who progress through lines of therapy over a relatively short time period. Methods: Using a US administrative claims database (Truven Health MarketScan® Database), adult patients (age ≥18) were included in the analysis if they had 1) ≥2 MM diagnoses codes (ICD-9 203.0x) on different dates between Jan 1, 2005-Mar 31, 2014 (study period); 2) MM treatment between Jan 1, 2007-Mar 31, 2012 and within 90 days of an MM diagnosis code (date of the first MM treatment set as the index date); and 3) continuous eligibility for medical insurance 24 months pre/postindex. Patients were excluded if they had 1) MM treatment during 24 months preindex; or during 24 month pre/post index had 2) moved from commercial insurance to Medicare; 3) non-MM chemotherapy; 4) pregnancy-related or stem cell transplant codes; or 5) HIV diagnosis during study period. An algorithm using dispensing dates and days supply was developed to define line of therapy (LOT) and double refractory. A new LOT was identified where there was a ≥60 day gap with no treatment, a ≥60 day gap followed by retreatment with the same drug, or where there was a change in therapy based on 30 day windows and the summed days supply of medication was >60 days. Refractory events were defined when a PI or IMiD had days supply for <60 days, was discontinued for ≥60 days, a different PI or IMiD was initiated and the initial drug did not appear in the next LOT. Heavily pre-treated was defined as starting an LOT after having received ≥3 prior LOT that included a PI and IMiD or double refractory to both PI and IMiD. Chi-square test was used to test for differences in categorical variables and Mann Whitney U test for continuous variables. Results: A total of 1109 patients were included in the analysis. The percent of patients with 1, 2, 3, 4 or >4 LOT were 39.8%, 33.0%, 15.4% and 6.1% and 5.7%, respectively. A single refractory event occurred in 66 (6.0%) patients and 2 (0.2%) patients were identified as double refractory. There were 80 (7.2%) patients who were heavily pre-treated. The heavily pre-treated group had a similar percent of males (56.3%) as the non-heavily pre-treated group (54.9%; p=0.82). The heavily pre-treated group was slightly younger (66.1 vs 70.9 years; p=0.0008) and had a lower percent with Medicare coverage (55.0% vs 71.1%; p=0.0024). The heavily pre-treated group had a substantially higher percent of regimens that included both PI and IMiD in the 1st LOT (28.8% vs 7.4%; p<0.0001). The most common 1st LOT drug regimens for the heavily pre-treated group were bortezomib (BOR) (21.31%), thalidomide (THAL) (21.3%), lenalidomide/bortezomib (LEN/BOR) (20.0%), and lenalidomide (LEN) (18.8%). In the non-heavily pre-treated group the most common 1st LOT regimens were LEN (36.7%), BOR (20.4%), THAL (14.4%), and melphalan (10.1%). Patients who were heavily pre-treated reached their 2nd LOT in fewer days than non-heavily pre-treated (152.5 vs 279.9 days; p<0.0001). There was a much higher percent of patients using BOR/LEN in the 2nd LOT in the heavily pre-treated than non-heavily pre-treated (20.0% vs. 4.1%). Conclusions: In this analysis, 7.2% of non-stem cell transplant patients were heavily pre-treated at 2 years after initiating MM therapy. Heavily pre-treated patients had a faster time to initiation of 2nd LOT. They also tended to be younger. Moreover, heavily pre-treated patients were more likely to have had both a PI and IMiD as their initial therapy. Patients who were heavily pre-treated in this analysis may have had faster disease progression, which may have led to becoming heavily pre-treated within the follow-up time of the study. Additional research should further explore the disease and economic burden of these patients. Disclosures Maiese: Janssen Scientific Affairs, LLC: Employment. Macomson:Janssen Scientific Affairs, LLC: Employment. Kozma:Janssen Scientific Affairs, LLC: Consultancy. Slaton:Janssen Scientific Affairs, LLC: Consultancy. Senbetta:Janssen Scientific Affairs, LLC: Employment.

Download Full-text

Racial and Socioeconomic Disparities in the Utilization of Autologous Stem Cell Transplant for Treatment of Multiple Myeloma in the Era of Novel Agents

Blood ◽

10.1182/blood-2019-130859 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 423-423 ◽

Cited By ~ 1

Author(s):

Victoria A. Vardell ◽

Daniel Ermann ◽

Maryam Gbadamosi-Akindele ◽

Funmi Badejo ◽

Peter T. Silberstein ◽

...

Keyword(s):

Multiple Myeloma ◽

Stem Cell ◽

Stem Cell Transplant ◽

Private Insurance ◽

Autologous Stem Cell Transplant ◽

Rate Of Change ◽

Socioeconomic Disparities ◽

Novel Agents ◽

Cell Transplant ◽

To Receive

INTRODUCTION: The prognosis of multiple myeloma (MM) has improved drastically in the last 20 years with the advent of novel agents, specifically with the introduction of bortezomib in late 2003. Novel agents in combination with autologous stem cell transplant (ASCT), have led to the achievement of high response rates in many patients. ASCT is now considered standard of care for all eligible patients, and previous studies have found increasing rates of ASCT in all age groups since the introduction of novel agents. Studies have also revealed disparities with decreased ASCT utilization in racial and socioeconomic minorities. This study utilizes the National Cancer Database (NCDB) to determine how the use of ASCT has changed for MM in the bortezomib era. METHODS:The NCDB was used to identify 157,443 patients diagnosed between 2004-2016 with Multiple Myeloma. Only patients with information on ASCT were included, and demographic characteristics between those patients that received and did not receive ASCT were compared. Race, insurance type, facility type, average income, education, and Charleson-Deyo comorbidity score, among other factors, were included in this analysis (Table 1). To determine the trends in ASCT over the era of novel agents, the proportion of patients receiving ASCT within these groups was trended over each year, and linear models to determine the rate of change in each group was compared. Bivariate and Multivariate regression analysis for each characteristic was used to determines odds ratios (OR) for receiving ASCT by demographic factors. RESULTS: Between 2004 to 2016 the proportion of all patients receiving ASCT as part of initial therapy more than doubled from 10.1% to 22.0%; increasing by approximately 1.06% per year on a linear regression model (R20.98) (Table 2). The greatest proportional increases were seen in Blacks, Hispanics, patients over 65 years of age, patients with higher comorbidity scores, Medicare, and patients treated at community centers. On multivariate analysis the patients that were most likely to receive ASCT (p<0.05) had private insurance (OR 5.4), were treated at academic centers (OR 7.3) and were highly educated (OR 1.7) (Table 3). For each increased year of diagnosis patients were significantly more likely (OR 1.1) to receive ASCT. Patients with a decreased chance of receiving transplant (p<0.05) were black (OR 0.6) or other non-white race (OR 0.7), Hispanic (OR 0.8), or had increased comorbidities (OR 0.4 for Charleson-Deyo score of 3 or greater). For every year of increased age, the likelihood of ASCT decreased (OR 0.92) (Table 3). DISCUSSION: In the era of novel agents, the rate of ASCT has rapidly increased each year, with the greatest increases seen in elderly patients, those with higher comorbidity indexes, and in patients who are racially and socioeconomically disadvantaged. However, significant racial and socioeconomic disparities still exist in the treatment of MM, and must be considered as treatment continues to advance. Disclosures No relevant conflicts of interest to declare.

Download Full-text