Treatment Delays in Multiple Myeloma Highlight Racial and Age Disparities

Hamlet Gasoyan, MD

A new study has uncovered significant disparities in the timing of treatment initiation for patients with newly diagnosed multiple myeloma receiving oral antimyeloma medications. Black and older patients were less likely to receive these crucial treatments within the first 30 days vs other patient populations, raising concerns about access to timely care.

This research highlights a gap in the initiation of oral medications, even as other components of multidrug regimens begin. Overall, this shows the need for a deeper understanding of barriers preventing simultaneous treatment.

Identifying vulnerable groups is a key step toward addressing these delays, ensuring equitable access to guideline-recommended therapies. Moreover, the findings could inform both clinical strategies and policy changes aimed at mitigating these disparities in treatment initiation.

In an interview with Targeted Oncology^TM, Hamlet Gasoyan, MD, staff investigator at the Center for Value-Based Care Research in the Department of Internal Medicine of Cleveland Clinic’s Primary Care Institute and assistant professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, discussed the implications of the study’s findings and their potential impact on clinical practice and patient outcomes.

Multiple myeloma multiplex: © LASZLO - stock.adobe.com

Targeted Oncology: What was the rationale behind this study?

Gasoyan: There has been a considerable improvement in the treatment and survival of patients with multiple myeloma, which is very exciting. This has been documented over the past 2 decades and has led to significant improvements in patient survival and outcomes. It's essential to understand barriers, particularly modifiable barriers, to treatment access and timely access to guideline-recommended care for patients with multiple myeloma. This is why we wanted to conduct this study, as part of our research program funded by the National Cancer Institute.

What methods and designs were utilized in this study?

This is a retrospective cohort study using data from the Cleveland Clinic Health System in northeastern Ohio. We identified patients who were newly diagnosed with multiple myeloma through our cancer registry and extracted relevant clinical and sociodemographic variables from our robust electronic health record [EHR] system. We also examined the utilization of orally administered medications and facility-administered medications from our EHR data, which is linked to a service that captures prescription fills from the majority of pharmacies and prescription benefit managers.

Could you delve into the key findings from the study?

We found considerable discrepancy between the timing of oral medication fill in patients with newly diagnosed with multiple myeloma compared [with] any treatment initiation, or even treatment initiation with either orally or facility-administered treatment for multiple myeloma. In other words, patient had delayed fills for their orally administered medications, showing that there might be some administrative burden for them. We knew that then, that is pretty much why we looked at this study, that getting a prescription filled oral antimyeloma medication, particularly lenalidomide [Revlimid], is complex. Patients have to undergo a multistep process. For example, they and their providers have to complete the [risk evaluation and mitigation strategy (REMS)] survey even before a prescription could be written. And then [sometimes], lenalidomide could be only filled in specialty pharmacies. It is very expensive, so many patients would need to apply for financial assistance grants to be able to pay for their out-of-pocket costs, and also, there is an insurance authorization process which also could pose a burden.

What we found in our study was that the timing of getting any treatment for multiple myeloma, which also included cheaper corticosteroids, was much shorter than getting your prescription filled for lenalidomide, which is part of most commonly administered triplet or quadruplet regimens for patients with newly diagnosed, undiagnosed multiple myeloma and part of a standard –of care. We also found some independent predictors associated with no prescription fill for oral antimyeloma medication for 30 days. Those predictors included older age, Black race, diagnosis during an inpatient stay, and then also an EGFR, or estimated glomerular filtration rate, of less than 29 compared [with] over 60.

What are some of the common challenges that oncologists face in getting patients started on more costly oral treatments for multiple myeloma?

My colleagues treating these patients have shared the complex process of obtaining lenalidomide, which involves the mandatory REMS survey that both providers and patients must complete before a prescription can be written. There is also an insurance preauthorization process, and patients often need to navigate support programs for funding their out-of-pocket costs. Additionally, lenalidomide is a specialty medication that must be dispensed through a specialty pharmacist, as not every pharmacy can provide it. All these factors can lead to delays and challenges.

When examining social determinants of health, we did not find any disparities regarding the timing of obtaining facility-administered or oral medications. However, we identified factors associated with delayed prescription fills for oral medications, indicating that administrative burdens are posing challenges for patients and require further investigation.

How do delays in treatment impact patient outcomes? Are there any specific patients that are more vulnerable to delays?

With the significant progress in myeloma treatment, it is crucial not to delay therapy; patients should receive the best treatment as early as possible. However, specific scenarios may necessitate delays in administering oral antimyeloma medications. For instance, poor renal function might require postponing treatment until the function improves, and we accounted for that in our study. Despite this adjustment, we found that certain characteristics—such as older age, Black race, and diagnosis during an inpatient admission—were still associated with delayed prescription fills for oral antimyeloma medications, even when considering clinical factors like renal function and comorbidities.

What do you think healthcare providers can do to reduce the barriers that prevent timely access to oral medications for these patients?

Our study quantifies delays in treatment initiation and identifies patient groups that might be at higher risk for delays, specifically with oral antimyeloma medications. This information is valuable for providers, as it highlights risk factors that can direct attention to specific patient groups needing extra support to navigate this complex process. For instance, older age at diagnosis is associated with not receiving oral prescriptions filled within 30 days, suggesting a need for more resources in navigation and patient support services.

Additionally, our findings are significant for policymakers, especially given the recent policy changes aimed at addressing these disparities. It will be interesting to assess the impact of these changes on patient outcomes.

What would be the key takeaways from the study that you would want an oncologist or your colleagues to know about?

I would say the key takeaway is that specific groups of patients may [face] challenges in obtaining oral antimyeloma medications, which might not be easy for them to monitor. [While] facility administered chemo is easy to track–patients come in and receive treatment—oral medication fills may not be well documented. This highlights a discrepancy between receiving any treatment for myeloma and actually filling these expensive medications.

First, it is crucial to recognize that this problem exists. Secondly, we identified specific factors that can help healthcare providers pinpoint vulnerable groups and direct them to appropriate patient support programs. Additionally, we discuss relevant background and policy changes that could help alleviate these issues moving forward.

We try to quantify the delays and identify the patient groups that are at most risk of delayed treatment initiation, at least the oral antimyeloma part of this multidrug regimen. But what we are interested to do next is [dissecting] this complex process in each step and [seeing] which step poses the greatest barrier to patients who are at high risk of delayed treatment initiation. We would like to be able to pinpoint some actionable items that clinicians, institutions, or health policy makers could address and make sure that the patients are getting the right treatment at the earliest possible time.

REFERENCE:

Gasoyan H, Anwer F, Kovach JD, et al. Disparities in time to treatment with oral antimyeloma medications. Blood Cancer J. 2024;14(1):142. Published 2024 Aug 23. doi:10.1038/s41408-024-01128-1