Black patients with multiple myeloma aren’t getting autoHCT as often as others—and the disparity has widened

Black patients are less likely than patients of other races and ethnicities to receive autologous hematopoietic cell transplants for multiple myeloma, according to a study published in the April issue of Clinical Lymphoma, Myeloma, and Leukemia.

Moreover, the analysis of nearly 30,000 patients diagnosed with MM over 26 years in California demonstrated that this disparity has increased over time.

The study also found that patients with public or no health insurance are less likely to receive the treatment than patients with private insurance, a gap that remained steady over the study period.

“This has been an issue for a very long time,” Robert A. Winn, director and Lipman Chair in Oncology at VCU Massey Comprehensive Cancer Center, said to The Cancer Letter. “When there are new innovations or new drugs, it usually results in a disparity.”

Winn was not involved in the study. 

AutoHCT is the standard of care for transplant-eligible patients, but only about 10%-40% of patients with MM receive the treatment, studies show. 

To understand the low utilization, hematologist-oncologist Naseem Esteghamat and her colleagues turned to the California Cancer Registry, the Center for International Blood and Marrow Transplant Research, and the California Patient Discharge Database. 

Linking the data allowed the researchers to examine patients diagnosed with MM from 1991 to 2016, 5,500 of whom received autoHCT and 23,609 of whom did not. 

“We wanted to look at the population in California and see if we could find any disparities in care just based on our population,” said Esteghamat, of UC Davis Comprehensive Cancer Center. “If those disparities exist, then that might give us a little bit better sense of things that we can do better as clinicians.” 

The researchers found that just 15.8% of Black patients with MM received autoHCT while 18.7% of white, 21.1% of Hispanic, and 21.2% of Asian patients utilized the treatment. But this study went a step further than many previous ones. 

“We looked at trends over time rather than as a whole only, and we wanted to see if those trends persisted through what we call time eras,” Esteghamat said. 

Breaking down the data into five-year periods revealed that autoHCT utilization increased from 5.7% to 27.4%. But looking at patient demographics showed that Black patients were less likely to receive the treatment than white patients in all time periods, and the gap widened over time, particularly after 2005. 

That’s despite a higher prevalence of MM and younger age at diagnosis in Black people, compared to non-Hispanic white people, Esteghamat said. 

Additionally, Esteghamat and her colleagues found that 28.4% of patients  with MM with private or military health insurance received autoHCT, while 25.4% of those with public government insurance and 9.8% of uninsured patients received the treatment. 

This gap remained consistent throughout the study periods.

“We are the first to report no improvements over time in the likelihood of autoHCT with Medicare or Medicaid compared to private insurance,” the study authors said.

Although medical advances have decreased cancer incidence, morbidity, and mortality overall, “the gaps in outcomes between Black and white people with cancer have generally remained the same,” Ruben Mesa, president of Atrium Health Levine Cancer, Peter Voorhees, leader of the center’s myeloma-dysproteinemia program, and Nadine Barrett, associate director of community outreach and engagement at Atrium Health Wake Forest Baptist Comprehensive Cancer Center, said in a joint statement to The Cancer Letter. 

“This important study highlights opportunities to understand the multi-level factors that contribute to these disparities impacting Black and low-income patients, and develop the multi-level interventions needed to mitigate them,” the statement said.  

Mesa, Voorhees, and Barrett were not involved in the study.

Anne Quinn Young, chief mission officer of the Multiple Myeloma Research Foundation, agrees.

“It’s very, very important to keep highlighting these differences [in treatment utilization] for the entire community—both the healthcare community and the patient caregiver community—to realize that there are still these inequities in access to care that result in worse outcomes,” said Quinn Young, who was not involved in the study. 

But when there’s equitable access to care, she said, outcomes tend to be similar. 

For instance, a 2017 study in Transplantation and Cellular Therapy found that once patients with MM were evaluated at a transplant center, there were no differences in who received treatment based on ethnicity. This suggests that access to transplant centers and referral bias play into these outcomes, Esteghamat said. 

Other factors, such as more MM diagnoses, mistrust of the healthcare system, and lack of financial and caregiver support, may also contribute to disparities in treatment utilization, she said. 

While the new study could not delve into why some people received autoHCT while others did not, Esteghamat said, “it gives us a sense that this is a persistent problem and a worsening problem.”