Multiple myeloma (MM) is a hematologic cancer characterized by the accumulation of malignant plasma cells in the bone marrow. Despite significant advancements in treatment options, including novel targeted therapies, chimeric antigen receptor T cells, and bispecific antibodies, MM remains incurable. While survival outcomes have improved, disparities in treatment access persist, particularly among racial and ethnic minority populations. These inequities are often linked to systemic barriers like referral bias and financial burdens, leading to undertreatment and longer times to treatment initiation (TTI).
A recent study published in the Journal of Managed Care and Specialty Pharmacy investigated the impact of social determinants of health (SDoH) on frontline treatment patterns among Medicare Advantage (MAPD) members newly diagnosed with multiple myeloma (NDMM). The retrospective study, which utilized data from Humana’s Medicare Advantage prescription drug plan enrollees between January 1, 2016, and May 31, 2023, aimed to identify SDoH factors contributing to gaps in frontline MM treatment.
Study Design and Demographics
The study included 4,483 individuals with newly diagnosed multiple myeloma. Patient characteristics, individual-level SDoH (race, dual-eligibility [DE] status for Medicare and Medicaid, low-income subsidy [LIS] status, and special needs plan [SNP] eligibility), and community-level SDoH measures were analyzed. Over half of the study participants resided in areas above the national median for receiving public assistance, having less than a high school education, lacking health insurance, and having no internet service. The cohort was predominantly located in urban areas (65.1%) and the southern United States (65.9%), with 31.9% identifying as Black.
Key Findings on Multiple Myeloma Treatment Patterns
The study revealed significant inequities in timely multiple myeloma treatment. In the overall cohort, 43.3% of patients did not receive treatment within 12 months of diagnosis. This included 18.1% with asymptomatic smoldering MM, suggesting that 25% of symptomatic patients did not initiate pharmacotherapy for at least a year. This trend was more pronounced in the DE/LIS subgroup, where one-third of symptomatic patients went without drug treatment.
Only 51.2% of patients in the overall cohort received treatment within 90 days of diagnosis. This proportion was lower for DE/LIS patients (44.9% vs. 53.1% for non-DE/LIS patients) and non-White patients (49.5% vs. 52.0% for White patients). The median TTI from diagnosis was 2.7 months overall, but it was considerably longer for DE/LIS patients (6.6 months) compared to non-DE/LIS patients (2.2 months). Similarly, TTI was longer for non-White patients (3.2 months) compared to White patients (2.4 months).
Multivariable regression analysis further demonstrated that Black patients, DE/LIS patients, and those with SNP enrollment had lower odds of initiating treatment within 90 days. Interestingly, community-level SDoH factors were generally not independently associated with TTI. However, among patients who did receive frontline treatment within 12 months of diagnosis, TTI and duration of treatment were similar across DE/LIS and non-White subgroups. This suggests that once treatment is initiated, the timeliness and duration are comparable regardless of these SDoH factors.
Implications for Managed Care Pharmacy
These findings highlight the persistent challenges in achieving equitable access to timely MM treatment. The study suggests that while individual community-level SDoH factors may not independently cause treatment delays, combinations of barriers such as higher levels of public assistance, limited English proficiency, lack of internet service, no vehicle, no health insurance, and lower education levels may collectively contribute to treatment disparities, especially within the DE/LIS subgroup. This also implies that patients in the DE/LIS subgroup are more likely to be diagnosed at a symptomatic stage rather than asymptomatically.
Addressing these inequities requires a holistic approach. The study emphasizes the need for comprehensive screening for health-related social needs and social barriers at the outset of a patient’s cancer journey. Furthermore, improving patient education, enhancing access to MM specialists, and strengthening social support systems are crucial strategies to support timely treatment initiation in managed care settings. Future research could explore the impact of specific SNP subtypes on treatment disparities and investigate the role of multidisciplinary care teams. This study, with its focus on individual-level SDoH data from a large Medicare Advantage population, provides valuable insights for developing targeted interventions to ensure more equitable care for all patients with multiple myeloma.
