With their study published in Clinical Lymphoma, Myeloma & Leukemia, Kaur et al. highlighted key themes hidden in the data. This retrospective study evaluated 939 eligible patients with a diagnosis of MM from a single center – Montefiore Medical Center Cancer Registry. The demographics included 30% Hispanic, 52% non-Hispanic Black, and 18% non-Hispanic white patients.
Median age for all patients was comparable to the known literature (65.6 years) with an average age of 64.5 years in Hispanic and Black patients, compared with 70.6 years in white patients. It was also noted the Hispanic and Black people were diagnosed younger, such that for individuals diagnosed under 60 years of age, 35.3% were non-Hispanic Black, 28.8% were Hispanic, and 16.5% were non-Hispanic white.
Surveillance Epidemiology and End Results (SEER) data have illustrated increased incidence of MM in minorities, depicting the highest incidence in Black people.
Highlighted in the study is increased renal dysfunction at the time of diagnosis, seen more among the minority patients (61.1% in Black, 56.4% in Hispanic, and 48.8% in white patients). In addition, the lactate dehydrogenase (LDH) levels were comparatively elevated in the Hispanic and Black populations than in the white patients.
Given the International Myeloma Working Group (IMWG) Revised International Staging System (R-ISS) criteria, this should translate to Hispanic and Black groups being diagnosed with higher stage or more aggressive disease. Yet, interestingly, the white patients in this analysis more often received triple-drug induction therapy than the minority groups. Also, the Hispanic and white patients more often underwent AHCT than Black patients.
Ultimately, the study found the longest median OS among Hispanic patients, at 110 months, followed by 69 months among white patients and 65 months among Black patients.1 The latter points to inequities in health care for Black patients.
Benjamin Derman, MD, wrote a compelling perspective accompanying the summary of these findings in ASH Clinical News, highlighting cost, access, and compliance to therapies as likely inadequate reasons for fully explaining these results. He suggests that younger age and AHCT more heavily affected the superior outcomes for the Hispanic group. Lack of information on cytogenetic abnormalities and therapies received for each group were also mentioned as drawbacks to the study, as well as its inherent retrospective nature.
In comparison, Dr. Derman and colleagues published a prospective observational Multiple Myeloma Research Foundation (MMRF) CoMMpass registry study evaluating 639 eligible patients in Blood Cancer Journal earlier last year. The similarities between this and the study by Kaur et al. are of interest.
In the report from Derman et al., the demographics evaluated 113 Black patients and 526 white patients. Similar to the previous study, it was noticed that Black patients were less likely to receive triple-drug induction compared with white patients (55% vs. 73%, respectively; p<0.001) and less likely to receive AHCT (39% vs. 49%; p=0.04).
This study also included a comparison of cytogenetic abnormalities between the groups. Researchers observed that, even with evidence of zero to one high-risk cytogenetic abnormality at diagnosis, 37% of Black patients received triple-drug induction versus 50% of white patients (p=0.02). For triple-drug induction and AHCT, the difference was 31% of Black patients versus 44% of white patients (p=0.01). At the level of two or more high-risk cytogenetic abnormalities, Black and white patients had similar rates of triple-drug induction and AHCT.2 On par with the previous study, the outcomes for Black patients were inferior to those for white patients.
These two studies accentuate the inequities in care among Black, Hispanic, and white patients. Each study carries its own characteristic flaws, but the common thread noted here indicates the existence of additional gaps in health care that need to be addressed. In my opinion, more prospective and retrospective studies such as these need to be performed to highlight to the academic, physician, and patient communities the impact of inequity in clinical care outcomes.
Socioeconomic factors, cost, compliance, and their surrogates do not fully explain the differences seen. Further evaluation both in physician practice and patient communities is needed to elucidate optimal solutions to address these discrepancies.
Monique Hartley-Brown, MD
Northwell Health Cancer Institute
New Hyde Park, New York