Back Back
Reducing Health Disparities in Multiple Myeloma
Recommendations to Reduce Health Disparities in the Treatment of Patients With Multiple Myeloma

Released: October 24, 2022

Expiration: October 23, 2023

Joseph Mikhael
Joseph Mikhael, MD, MEd, FRCPC, FACP
Activity Information

Activity

Progress
1
Course Completed
Continue

Key Takeaways:

  • Results of an online survey on treatment preferences revealed that efficacy is the most important factor for patients with multiple myeloma when selecting therapy.
  • Several steps can be incorporated into daily practice to aid in reducing the health disparities that are present in the care of patients with multiple myeloma.

It is important to recognize that health disparities are present throughout healthcare—particularly in the care of patients with multiple myeloma. To gain a better understanding of patients’ preferences regarding treatment selection, factors influencing their decision-making, and challenges that may impact their access to care, an online survey was conducted in partnership with the patient advocacy group Smart Patients.

In total, 80 patients with multiple myeloma responded to the online survey. These types of surveys are particularly important because they can objectively give us a patient’s view that is not filtered through a healthcare professional. At the end of this commentary, 7 simple steps that can be implemented in daily practice are recommended to address health disparities.  

Patient Survey Results
Patients across the spectrum of multiple myeloma, from earlier to later in their disease course, participated in this online survey. The majority of respondents were suburban, with an age distribution that matches what we typically see in clinical practice. However, one disparity within these results highlighted what often is seen in clinical trials: 93% of the respondents were White or Caucasian, whereas only 2% were Black or African American. Black or African American patients comprise 20% of all patients with multiple myeloma, so the data were roughly one tenth of what we would expect to see. This underscores the importance of considering health disparities throughout the continuum of patient care. Instead of detracting from the power of the survey, these data help us appreciate that we have more work to do to ensure a more equitable distribution. 

This survey included a question describing 3 types of BCMA-targeted therapies—CAR T-cell therapy, bispecific antibodies, and antibody–drug conjugates—without identifying which therapy was which. The question had general information on efficacy, potential toxicities, and requirements for administration for each class of therapy and asked patients to rank their choice. Although not surprising, it was fascinating that patients selected CAR T-cell therapy as their first choice, as it had the greatest efficacy with a 1-time administration, albeit coming with the significant challenges of necessary hospitalization, cell collection, and potentially serious adverse events. The bispecific class was ranked second, and the antibody–drug conjugate was ranked third.

Patients then were asked to rank the specific factors that influence their preference and decision-making for treatments. Efficacy or highest likelihood of response was the top choice, followed by preference for a therapy with the lowest risk of recurrence, and then therapy with the fewest side effects or based on physician recommendations. Of interest, there was less concern about the cost of therapy, the convenience of therapy, or the number of required office visits. These questions emphasize that depth of response seemed to make the most difference to patients in their choice of treatment. However, when considering the inherent disparity of the survey based on the participants, a more diverse population may impact these responses, as there may be greater concerns about cost and frequency of visits among people with more varied socioeconomic backgrounds. 

To understand more about preferences regarding potential toxicities of various therapies for multiple myeloma, a few questions were asked about the potential for ocular toxicities (associated with belantamab mafodotin) and gastrointestinal upset (associated with selinexor). The challenge of having routine eye exams and having to administer eye drops regularly had a moderate or major effect for 60% of patients when asked how this would influence their choice of starting a new cancer therapy. Of interest, the need to take concurrent antinausea and antidiarrheal medications for the first few months of therapy was less impactful, with only 30% of patients indicating a moderate or major effect on selection of therapy. When discussing these options with healthcare professionals, they tend to think patients would be less likely to prefer treatments associated with nausea and may recommend the therapy that has potential ocular toxicity over one that is more emetogenic. Yet, here our patients are saying the opposite, which highlights the need to have these discussions with patients to understand their concerns and preferences.  

It was quite encouraging to see that 66% of people responded that they were very confident in their healthcare team, and another 17% were moderately confident. This underscores a very important principle in medicine, particularly oncology—that building trust and confidence between the healthcare professional and patient is fundamental. This result may be quite variable in different populations where, historically, there have been reasons for a lack of trust in the medical community, but it does emphasize the importance of developing trust as we care for our patients. When asked if their healthcare team explained available treatment options clearly and in a manner that was easy to understand, 86% of people responded yes. Again, this could vary with different populations, but it underscores culturally sensitive care, which is ensuring that we speak and present information in a way that a patient can understand very clearly.

When asked, 79% of people noted that cost had no to minimal influence in their treatment decisions, and 86% reported no or minimal effect of transportation impacting their ability to get to appointments for their multiple myeloma. Although the overwhelming majority of respondents in this survey indicated that cost and transportation were not a large factor in their treatment decisions, some patients (approximately 10%) said these issues had a major effect—and it is important for us not to lose the minority in the majority. Part of understanding and reacting appropriately to health disparities is to not always focus on the majority, but to appreciate the challenge of the minority. Although we can appreciate that a large fraction of our patients may not have challenges with financial or transportation issues, some patients do have these challenges, and we should pay particularly close attention to that.

Ways to Address Health Disparities
We touched on health disparities in multiple myeloma in the results of the patient survey, and there are some key take-home messages around providing care in the clinic that can help reduce these. This is a complex problem that takes a complex solution, but the following are 7 simple but important steps that a healthcare professional can take to help reduce disparities in their daily practice.

  1. Be aware of health disparities. It is important to understand the facts about health disparities, which are striking—in the United States, multiple myeloma is twice as common in the Black population vs the White population, and the age of diagnosis is 5 years younger in the Black population vs the White population. The age of diagnosis also is 6 years younger in the Hispanic/Latinx population vs the White population. In addition, population-based studies have shown that the overall survival rate of Black Americans is one half that of White Americans. As we learn about the biology or pathophysiology of multiple myeloma, we also should understand the health disparities of the disease.
  2. Understand the causes of the health disparities. We know that in multiple myeloma, they are not just biological. Black patients are less likely to have high-risk disease but more likely to die from their disease. This is a multifold problem that stems from systemic and historical issues—including systemic racism—in the way the healthcare and insurance systems are built, as well as a lack of trust within the system. Understanding the social determinants of health and the causes of these disparities is our responsibility.
  3. Improve early and accurate diagnosis. Studies have suggested that delayed diagnosis in some patients is a large part of these health disparities. This is particularly true for patients within the Black and Hispanic/Latinx communities, where there is a greater likelihood of delayed diagnosis because of overlapping conditions such as diabetes and a lack of access to diagnostic testing and trust within the system. It is our responsibility to help educate our colleagues in primary care and other fields about the importance of early and accurate diagnosis of multiple myeloma. Healthcare professionals should be able to identify the signs and symptoms and order the right tests, including serum protein electrophoresis and free light chain measurement.
  4. Enhance access. We need to learn to advocate for our patients to get access to the optimal treatment for their disease by leveraging the entire healthcare team to seek out available resources. Various organizations—government, nongovernment, foundations, and societies—also can help patients find the financial and support resources necessary to access therapy for multiple myeloma. In underserved populations, including Black patients in the United States, there is reduced access to some of our most effective treatments for multiple myeloma, including stem cell transplantation, triplet combinations, CAR T-cell therapy, and clinical trials, which may drive the dramatic decrease in survival in Black Americans vs White Americans. In the Veterans Affairs system, where there is theoretically similar access to all therapies for all patients, Black Americans actually have a superior outcome, so access to therapy is critical.
  5. Engage the community. Our community engagement is important. As healthcare professionals, we must be responsible citizens, understand the community in which we live, and engage with people in that community so we can gain trust over time. If you understand your community better, you can provide better care. The relationship a patient builds with their healthcare team is very important, and it is our responsibility to honor that. There are great opportunities to be engaged as a healthcare professional and simply as a person in the community you serve.
  6. Practice culturally sensitive care. Understand the principles of listening to each patient and that each patient comes with a different perspective. Appreciate that each patient’s view of health may be different from our own view, and understand that a patient may want someone else there to help make their healthcare decisions. For example, without understanding or asking questions, I may not appreciate a patient’s hesitancy to begin therapy without a chance to discuss their options with their family. There are many aspects of practicing culturally sensitive care, but just understanding the principle and the concept will take us part of the way there.
  7. Empower our patients. As healthcare professionals, it is our responsibility to give patients the appropriate education, support, and resources that they deserve and need to undergo this journey with multiple myeloma. Being able to provide places where they can seek that support is essential. For example, one great resource is through the International Myeloma Foundation at myeloma.org, where patients can find resources and a support group near them.

Health disparities are a major issue in our community and our society, and they are particularly important in multiple myeloma. Multiple myeloma may be the most disparate malignancy within the Black community, and the solution is not going to be fast or easy, but it is important that all of us—every stakeholder at the government level, industry level, healthcare level, and community level—work together to reduce those health disparities. I hope we’ve demonstrated that, as practitioners in the clinic, we have a significant role in that. 

Final Thoughts
To learn about health disparities and improving outcomes for patients with multiple myeloma, check back on the full program page, titled “Smarter. Stronger. Together. Optimizing Multiple Myeloma Care and Addressing Health Disparities Through Education,” as we add a downloadable slideset; CME-certified, expert-authored text module; podcast episode; and updated Interactive Decision Support Tool that will provide expert guidance on treatment decisions for individual patients with multiple myeloma.

To hear more information on optimizing the treatment of patients with multiple myeloma, sign up here to attend a satellite symposium with a panel of experts at the 2022 American Society of Hematology annual meeting, either in person or via live stream, on Friday, December 9, 2022.

Your Thoughts?
What challenges have you encountered in treating patients with multiple myeloma? Please answer the polling question and join the conversation by posting a comment in the discussion section below.

Continue

Poll

1.
What are you most interested in learning about regarding multiple myeloma?
Submit