Economic Factors, Treatment Facility Type Produce Notable Survival Impact in Multiple Myeloma

Contemporary Concepts | <b>Contemporary Concepts in Hematologic Oncology</b>

Survival among patients with multiple myeloma appears to be influenced by factors such as socioeconomic status and treatment facility type.

Both socioeconomic factors and treatment facility type appeared to have an important impact on survival among patients with multiple myeloma, according to findings from a study published in Cancers.

Patients who were 65 years or older with private insurance were more likely to live longer, at 42 months vs 31 months for patients with Medicare (P <.0001). Additionally, treatment at an academic institution was also associated with better survival compared with other hospital types (HR, 1.49; 95% CI, 1.39-1.59). Other factors that were significantly associated with an improvement in survival were younger age, fewer comorbidities, and residence in a higher income area.

The trial included 117,926 patients who had Medicare (53%), private insurance (35%), Medicaid (5.4%), other government insurance (1%), or were otherwise uninsured (3.2%). The median patient age at diagnosis was 67 years and most patients were male (55%) and White (77%) with a smaller population of Black patients (20%).

A higher proportion of patients with Medicaid or who were uninsured lived in areas where the median annual income was less than $46,000 per year. In the Medicare arm, 33% of patients underwent treatment at an academic institution compared with 48% of patients with private insurance and 50% of patients with Medicaid (P <.001). Nine percent and 20% of patients with Medicare and private insurance, respectively, received treatment at large facilities, defined as those with over 50 cases annually.

Although survival for patients with Medicare was like those with private insurance after adjusting for confounders, the hazard of death remained higher for the population vs private insurance (HR, 1.59; 95% CI, 1.36-1.87), as well as for those without insurance (HR, 1.62; 95% CI, 1.32-1.99).

A total of 96% of patients received treatment at institutions that were 120 miles or less away from where they lived. Patients with private insurance (5.7%) were more likely to travel over 120 miles to undergo treatment for their disease compared with patients who had Medicare (3%; P <.0001). In the population of patients who were less than 65 years of age, 33% with private insurance and 20% with Medicare received autologous hematopoietic stem cell transplantation (HSCT; P <.0001). HSCT was also reported in 11% and 6% of patients 65 years and older in both respective groups (P <.0001).

The study had a median follow up of 30.2 months. Patients with private insurance had a median overall survival (OS) of 41.9 months (95% CI, 40.1-43.6) compared with 30.8 months (95% CI, 30.3-31.2) in the Medicare arm (P <.0001). No differences in survival were observed between those with private insurance and Medicare among patients who underwent HSCT regardless of age, although a survival benefit was observed for those who did not receive the treatment in both arms, respectively.

“We assume that autologous transplant recipients are less likely to rely on continuous or intermittent intensive medical therapy than patients who did not receive HSCT. As previously shown, patients treated in academic institutions were found to survive significantly longer than those treated in community-based institutions,” the authors wrote.

Patients with private insurance who were treated at academic institutions had better survival vs patients with Medicare regardless of age group. Patients residing in areas with a higher median income has the longest OS compared with other groups, particularly among those with private insurance.

Investigators also observed a difference in insurance coverage based on race, with lower proportions of Black patients having Medicare (47%) and private insurance (33%) compared with White patients (55%; P <.0001; 35%; P <.0008). Additionally, a higher proportion of Black patients had Medicaid (10%) or were uninsured (6%) vs White patient (4%; P <.0001; 2%; P <.0001). Black patients also had higher Charlson scores of 1 or higher compared with White patients (28.7 vs 22.9; P <.0001) and were more likely to live in low-income regions (76.1% vs 56.4%; P <.0001). Notably, Black patients had a longer unadjusted OS vs White patients and were more likely to receive treatment at an academic medical center and live close to their treatment facility.

Reference

Chamoun K, Firoozmand A, Caimi P, et al. Socioeconomic factors and survival of multiple myeloma patients. Cancers (Basel). 2021;13(4):590. doi:10.3390/cancers13040590