Racial and Ethnic Disparities in Autologous Hematopoietic Cell Transplant Utilization in Multiple Myeloma Have Persisted Over Time even after Referral to a Transplant Center.

ABSTRACT

BACKGROUND: Despite the use of autologous hematopoietic cell transplantation (AHCT) in treatment of multiple myeloma (MM) for almost 40 years and its persistence as standard-of-care in transplant-eligible patients with MM even after the advent of novel agents, AHCT remains underutilized especially in racial and ethnic minority populations. OBJECTIVE: As part of a multi-pronged effort to quantify disparities in AHCT utilization in MM by race and ethnicity and over time in our own cancer center, we conducted an institutional review of all new patients between 2012 to 2022 who were seen at an academic transplant center for consultation for MM to calculate AHCT utilization and investigate the factors associated with AHCT utilization. STUDY DESIGN: Race and ethnicity was self-reported. Baseline characteristics were analyzed by three groups (non-Hispanic White, NHW; non-Hispanic Black, NHB; Other). Reasons for not undergoing AHCT in the EHR were recorded. Multivariate analyses evaluated the effect of group on AHCT utilization controlling for covariates related to patients not undergoing AHCT by overall cohort and consult period. RESULTS: Among 1,266 patients, 13.4% were NHB. Median age at consult was 66 (23-97), 66 (23-97), 63 (25-85), and 59.5 (31-79) years for overall, NHWs, NHBs, and Other (p<0.01), respectively. Overall AHCT utilization was 76%, 64.7% in NHBs, 76.8% in Other, and 77.8% in NHWs (p<0.01). Age, cytogenetics, stage, comorbidities, and time from diagnosis to consult were associated with AHCT receipt. From 2012-2017 to 2018-2022, NHB AHCT utilization increased from 57.5% to 69.8% (p=0.10). For those who did not receive AHCT, patient preference, older age, comorbidity, early mortality, and lack of caregiver support were the most frequently documented reasons. The NHW group had greater AHCT utilization compared to the NHB group (OR=3.32, 95% CI 2.17-5.08, p<0.0001). Absent cardiac (OR=1.88, 95% CI 1.35-2.62, p=0.0002) or renal comorbidity (OR=3.23, 95% CI 2.03-5.15, p<0.0001) was associated with AHCT receipt. Older age at consult (OR=0.89, 95% CI 0.87-0.90, p<0.0001) and longer time from diagnosis to consult (OR=0.97, 95% CI 0.95-0.98, p<0.0001) were associated with lower AHCT utilization. While AHCT utilization increased from 2012-2017 to 2018-2022 in NHB compared to NHW, it remained significantly lower. CONCLUSION: Racial and ethnic AHCT underutilization has improved over time though disparities persist. Younger age at consult, shorter time from diagnosis to consult, and lack of cardiac and renal comorbidities were also associated with AHCT utilization.