Alarm Sounded Over Multiple Myeloma Outcomes Versus Socioeconomics

Kamal Chamoun, MD

Higher income was associated with significantly greater probability of survival for patients with multiple myeloma (MM), according to authors of a study they performed to call attention to the need to address socioeconomic disparities that influence treatment outcomes.¹

Investigators determined that, after a median of 30.2 months of treatment, patients living in areas with a median annual income ≥$46,000 had a 16% greater chance of survival compared those living in less wealthy areas (HR, 1.16; 95% CI, 1.08-1.25; P <.0001).¹

“We can clearly see that patients living in higher income areas had a survival advantage,” lead author Kamal Chamoun, MD, a fellow in the Hematologic Malignancies and Stem Cell Transplant Program at University Hospitals Seidman Cancer Center in Cleveland, Ohio, said in a presentation at the 2019 American Society of Clinical Oncology Annual Meeting. The study was based on an analysis of demographic statistics collected by the National Cancer Database.

Those with private insurance had a 59% greater probability of survival versus those insured through Medicaid and a 62% greater probability of survival than the uninsured. In patients aged 65 years and older, those with private insurance also had superior median survival over those with Medicare (41.9 vs 30.8 months; P = .0001). However, Chamoun said that the difference was not statistically significant when accounting for factors including age, race, zip code based on median income, comorbidities, and hospital type. Neither race nor gender played a significant role in survival.

Chamoun et al wanted to highlight the presence of a survival disadvantage for people who cannot afford their treatment costs. Chamoun said that survival for patients with MM has increased greatly over the past 30 years. However, he said that “prices of oral cancer drugs have been rapidly escalating, especially for patients and survivors of [MM], and we need to take action to limit and reverse the disparity for those who cannot afford private insurance or have lower incomes.”

Lenalidomide (Revlimid), administered in combination with dexamethasone, is commonly used to treat MM. Celgene, the manufacturer of lenalidomide, raised the price of a 10 mm dose to $719.82 in January of this year. Bloomberg noted that the same dose in 2007 cost $247.28. The overall cost for a year of treatment is close to $200,000.²

Chamoun said that oral agents for MM are covered under prescription drug plans. People on Medicare may find it more difficult to pay for long-term use of these medications, he said, which can lead to higher rates of treatment interruption or discontinuation. Investigators hypothesized that limited access to expensive drugs could explain the differences in survival.

People with Medicare or Medicaid were less likely to travel more than 120 miles to treatment centers compared with those with private coverage. This lack of access to treatment may play a role in the survival disparities between these patients and those with private insurance, especially for those in rural settings who often have to travel 200 miles roundtrip to reach a primary care facility, according to the investigators.

Chamoun et al assessed data collected from 2005 to 2014 on 117,926 patients with living with MM. The median age at diagnosis was 67 years and 55% of the cohort was male. Fifty-seven percent of patients lived in areas with an annual median income of less than $46,000.

Fifty-two percent of patients were on Medicare, 35% had private insurance, 5% were on Medicaid, and 3% were uninsured.

Investigators also found that practice setting affected survival. Forty percent of patients were treated in an academic comprehensive cancer program, 39% in a comprehensive community program, 10% in an integrated network cancer program offering comprehensive services, and 9% in a community cancer program. Those treated in an academic setting had a 49% greater probability of survival (HR, 1.49; 95% CI, 1.39-1.59; P <.0001).

“Where you live and what insurance you have should not affect the length of time you survive [MM], though unfortunately it seems from Dr Chamoun’s study that it does,” said ASCO expert Catherine M. Diefenbach, MD, director of the Clinical Lymphoma Program at the Perlmutter Cancer Center, in New York, New York.

In her practice, Diefenbach treated a patient with MM whose medication would have cost $20,000 per month. Her staff got that down to about $40 per month, but she noted that not every patient has access to that kind of infrastructure. Some patients are forced to decide whether to take their medication as prescribed or to take their pills less often to stretch out the therapy.

“We’re seeing from Dr Chamoun’s study that these challenges are creating real differences in survival," she said. “As a society we should strive to ensure that every patient, no matter their location or socioeconomic status, receives equal access to high-quality cancer care.”

References

1. Chamoun K, De Lima MJG, Caimi PF, et al. Insurance status and survival of multiple myeloma (MM) patients. Presented at: 2019 ASCO Annual Meeting; Chicago, IL; May 31-June 4, 2019. Abstract LBA107.
2. Spalding R. Celgene boosted price of top cancer drug on day of mega deal. Bloomberg. January 4, 2019. www.bloomberg.com/news/articles/2019-01-04/celgene-boosted-price-of-its-top-cancer-drug-on-day-of-mega-deal. Accessed May 31, 2019.

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