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Race colors transplantation utilization for multiple myeloma

These are exciting times for multiple myeloma. The abundance of new approved therapeutic options makes it the envy of other hematologic malignances. There are several novel targeted and immunotherapeutic treatments in the pipeline. We can better prognosticate patients and are moving toward personalizing therapy based on cytogenetic and molecular risk factors and minimal residual disease. Amid these advances, high-dose melphalan followed by autologous hematopoietic cell transplantation (AHCT), the time-tested old workhorse for treating myeloma, remains the standard of care as part of upfront therapy and augments the depth of remission, progression-free survival, and overall survival achieved with contemporary induction regimens. AHCT is a common and safe procedure, with treatment-related mortality rates of 1% to 2% and survival improvements in transplant recipients mirror the overall improvement in outcomes for myeloma. Patients with multiple myeloma in the United States who are candidates for AHCT are susceptible to health care disparities, especially by race/ethnicity. The literature has largely focused on black-white disparities and indicates that: 1) racial minorities with myeloma have a lower probability of receiving AHCT compared with whites, and 2) black patients who undergo AHCT have outcomes that are comparable to those of white patients. The study by Schriber et al in this issue of Cancer adds to this conversation. By using data on 28,450 AHCT recipients reported by US centers to the Center for International Blood and Marrow Transplant Research from 2008 through 2014 and incidence of myeloma estimated from the Surveillance, Epidemiology, and End Results database, the authors validate previously reported findings of racial disparities in access to transplantation. They report that transplantation utilization rates were overall low during this era, increased over time, and lagged among blacks and Hispanics compared with whites. This was most prominent in Hispanic patients; the transplantation utilization rate increased from 22.6% to 37.8% in non-Hispanic whites, from 12.2% to 20.5% in non-Hispanic blacks, and from 8.6% to 16.9% in Hispanics. Patient age, performance status, comorbidities, and myeloma response status before AHCT did not explain the very low rate of transplantation receipt among Hispanics. Again, race had no impact on survival after transplantation, highlighting that, if access barriers can be removed and racial minority patients can get to a transplantation, they enjoy the same survival as that expected in white patients. Notwithstanding the limitations of a registry-based analysis, this study highlights some important issues around access to transplantation for myeloma. The most prominent finding is the very low utilization of AHCT in the United States. For the whole cohort, less than one-third of patients received a transplantation, which is woefully low in the current era, in which AHCT can be safely performed, including in older patients. However, this is not an isolated finding, and several recent studies have highlighted this pattern of low AHCT rates ranging from 12% to 30%. The etiology of low AHCT use is complex and poorly understood. It can be broadly considered from a patient, physician, and health system perspective. Factors other than race/ethnicity, such as socioeconomic status, place of residence, and type of medical insurance, can limit access to transplantation. Some patients with myeloma are not considered suitable candidates for transplantation because of their functional status or comorbidities. Furthermore, after considering their options, patients may choose not to pursue transplantation. However, access barriers, eligibility for transplantation, clinical trial participation, and patient preference do not completely explain the very low rate of AHCT utilization. Low referral rates by hematologist-oncologists for transplantation likely contribute to and are impacted by physician knowledge and their perceptions about the role, timing, efficacy, and toxicity of AHCT. Structural health system factors, like accessibility of transplantation centers and the challenges around care coordination, also have a role to play. In addition, Schriber and colleagues demonstrate that black and Hispanic patients with myeloma get a double whammy—in addition to the general low transplantation utilization rates, they must navigate the disparities that ail the US health care system. The findings are striking, because only 1 in 5 black patients and 1 in 6 Hispanic patients received AHCT. Previous studies have not been able to describe disparities in transplantation utilization among Hispanics