Racial Disparities in the Management Outcomes and the Care of Patients with Multiple Myeloma

FAQ Library published on February 4, 2020
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Sikander Ailawadhi, MD
Associate Professor
Division of Hematology-Oncology
Mayo Clinic
Jacksonville, Florida

Hello, everybody, and welcome to Managing Myeloma. I am Sikander Ailawadhi. I’m one of the hematologists with the Mayo Clinic in Jacksonville, Florida and I focus primarily on the care of multiple myeloma patients.

I want to discuss with you today on a topic that is not very frequently brought up or discussed - and I should mention that there is a lot of research that is happening in this area - and that is exploring racial disparities in the management, outcomes, and the care of patients with multiple myeloma. All of us who are focused on treating multiple myeloma know that while it is not a very common diagnosis, as compared to let's say the more common diagnoses of breast cancer, lung cancer, prostate, or colon cancer for example, but myeloma treatment is a little complex, and is also very fast evolving with availability of several new drugs regimens, very large clinical trials. But one thing that has been missing is trying to understand, does all of that clinical data, does all of that outcomes data apply equally to patients of different racial backgrounds? Or is it that the outcomes, etc., are different for patients who belong to different racial categories?

As I’ve mentioned, there is a lot of research coming out and it happens to be an area where I'm very focused on. The data that exists today tells us that there are quite a few disparities that exist in myeloma care between patients who are Caucasians or whites, African Americans or blacks, and the fast-growing group of Hispanics. I should tell you, first of all, that the outcomes or survival is different and that will help put it in context and perspective.

There is data to show that Hispanics have worse survival than whites, and African Americans have superior survival than whites, but it has also been shown that the drug utilization and how these patients are treated is very different. Now, we may say, “Well, why is it that the survival is better in African Americans?” And there is some data to suggest that there may be a biological background for that, that patients who are African Americans may have a less aggressive disease. So, for example, lower incidence of the very high risk (17p) deletion mutation, for example. So, African Americans should have a superior outcome if they are treated appropriately. But after this data, there were several manuscripts and several large studies that showed that the outcomes were in fact not different when longer follow-up or large databases were used. So that brought up the idea, “Well is it possible that the African Americans may not be getting access to the right drugs, and is that possibly affecting their outcomes?” And quite truly, that was the case that was shown in a lot of studies evaluating large databases like SEER, Medicare, some claims-based databases, etc. It has been shown that African Americans and, for that matter, Hispanics get access to novel drugs much later in their treatment course. Also, there is some thought, although not much data to support it yet, that the combination regimens with, for example, three-drug combinations that are now the cornerstone of myeloma care or transplant, which is also a very important treatment modality, that patients who are minorities, racial ethnic minorities, do not get access to these very effective regimens and transplant like whites. Also, it's important to note that there are studies that have shown that racial ethnic minorities actually bear a higher cost of care when it comes to myeloma. So, it seems that it's getting disadvantaged from a lot of different levels, getting later access to drugs and higher cost of care that they may have to incur.

But there's also encouraging data, encouraging data to show that when clinical trials have been utilized and have been studied, the outcomes of myeloma patients are very similar. In fact, in the VA setting, there was a study recently done which showed that when equal access to care was given, for example, the VA system, that African Americans actually did have superior outcomes. So, it is important to keep in mind that if we are to utilize this similar appropriate evidence-based treatment approaches for racial ethnic minorities, their outcomes can even be much better.

Another very important aspect that is gaining a lot of attention from the FDA, from AACR, from ASCO, and American Society of Hematology is that when clinical trials are done, unfortunately, majority of the patients enrolled, in fact very frequently even in excess of 90%, are whites. So, we do not have a lot of clinical trial data in, let's say, African Americans or Hispanics. So, there is a focus and an effort to try and understand why that may be happening. In fact, we have a study going on in which we are trying to understand why patients who are belonging to racial ethnic minorities may not be accruing to or getting on to clinical trials, therapeutic clinical trials. There are a lot of factors that we think maybe at play, but I think getting the opinion of the patients and trying to understand why they may not be enrolling into clinical trials is extremely important.

If I was to summarize, what I can say is that racial ethnic minorities do not get access to myeloma care timely, fast enough, and in quite a few cases, they do not get access to the right care at all, and they tend to bear a higher cost of care. So, I think it is important for all of us who treat myeloma patients and focus on their care is to figure out how to get the right patient to the right treatment at the right time, so that we can get them the most optimal benefit from everything that you and I do for their care. Thanks a lot for viewing this activity.

Last modified: February 4, 2020