Resident Physician UT Southwestern Medical Center, United States
Introduction: Multiple myeloma (MM) typically affects older adults, with a median age of diagnosis of 70 years, but 10-15% of MM patients are diagnosed at 55 years or younger. Stem cell transplant (SCT) is generally considered the standard of care for young patients with good functional status. However, little is known about the outcomes for young and fit MM patients who are unable to receive transplant due to financial status or insurance coverage. This study assesses the clinical characteristics of young transplant-eligible (TE) MM patients and compares outcomes between those who are transplant accessible (TE/TA) and transplant inaccessible (TE/TI).
Methods: This retrospective study includes 186 patients diagnosed with MM between 18-55 years from 1997-2022 at a safety net hospital in Dallas, TX. A total of 450 patients of all ages were diagnosed with MM during this period. Patients with smoldering MM, MGUS and solitary plasmacytoma were excluded. Demographics, baseline myeloma markers, comorbidities and treatments were collected from the EHR. Outcomes were analyzed by transplant status and overall survival (OS).
Results: Our cohort showed a high percentage of young multiple myeloma patients (41.3%) diagnosed at 55 years or younger. The median age of diagnosis was 49 years. This population consisted of 48.4% Hispanics and 33.9% African Americans as well 24.2% undocumented immigrants. There were 22 patients with ISS/R-ISS stage I disease at diagnosis (11.8%), 37 with stage II (19.9%) and 55 with stage III (29.6%). Approximately 72% of the cohort had lytic lesions. The most common first line therapies were VD (21.5%), VRD (19.4%), and CyBorD (9.7%). Other regimens such as RD, TD, and DRD made up the remainder. There was a total of 46 patients who received SCT (24.7%) (TE/TA). Both TE/TA and TE/TI relied on taxpayer funded charity assistance programs, with 75.0% and 62.5% respectively who cited this as their primary insurance coverage. Median OS, including TE/TA and TE/TI, was 7.83 years. There was a significant association with SCT access and OS (HR 0.24, 95% CI 0.11 to 0.50, p< 0.001). The mOS for TE/TA was 18.5 years with a 5-year OS rate of 94.4% (CI 86.7% to 100%), while the mOS for TE/TI was 6.60 years with a 5-year OS rate of 55.8% (CI 45.7% to 65.9%). In stage 3 disease, mOS for TE/TA and TE/TI was 7.82 versus 3.80 (HR 0.27, CI 0.10 to 0.73, p=0.002). Of the entire cohort, 36.6% were deceased at the time of data collection and 21.5% were lost to follow up at the time of data analysis.
Conclusions: Accessibility to stem cell transplant remains a significant barrier in patients with hematologic malignancies who face financial and healthcare disparities. Our results show that MM patients who are transplant eligible but inaccessible (TE/TI) have worse OS compared to transplant accessible (TE/TA) patients.
