Financial Toxicity and Willingness-to-Pay for Cancer Treatment Among People With Multiple Myeloma.

PURPOSE: This study used willingness-to-pay (WTP) exercises to explore the relationships between race, financial toxicity, and treatment decision making among people with cancer. METHODS: A convenience sample of people with multiple myeloma who attended an academic medical center in 2022 was surveyed. Financial toxicity was assessed by the Comprehensive Score for financial Toxicity, with scores <26 indicating financial toxicity. WTP was assessed with (1) a discrete choice experiment (DCE), (2) fixed-choice tasks, and (3) a bidding game. RESULTS: In total, 156 people were approached, and 130 completed the survey. The majority of the sample was White (n = 99), whereas 24% (n = 31) was African American or Black. Forty-six percent (n = 60) of the sample were experiencing financial toxicity. In the DCE, the relative importance of cost was twice as high for those with financial toxicity (30% compared with 14%; P < .001). In the fixed-choice tasks, they were twice as likely to accept a treatment with shorter progression-free survival but lower costs (adjusted odds ratio [aOR], 2.47; P = .049). In the bidding game, the median monthly WTP of those with financial toxicity was half that of those without ($100 in US dollars [USD] compared with $200 USD; P < .001). Only in the bidding game was race statistically associated with WTP; after controlling for financial toxicity, African American or Black participants were three times as likely (aOR, 3.06; P = .007) to report a lower WTP. CONCLUSION: Across all three exercises, participants with financial toxicity reported lower WTP than those without. As financial toxicity disproportionally affects some segments of patients, it is possible that financial toxicity contributes to cancer disparities.

Mixed-Methods Study on the Responsiveness of the Comprehensive Score for Financial Toxicity Among People With Multiple Myeloma.

PURPOSE: Financial toxicity is a contributor to the psychosocial burden of cancer care. There is no consensus measure of financial toxicity; however, recent studies have adopted the Comprehensive Score for Financial Toxicity (COST). Despite its growing popularity, data on the responsiveness to change of the COST instrument are lacking. To address this gap in the literature, we performed a sequential mixed-methods study of people with multiple myeloma. MATERIALS AND METHODS: In the quantitative phase of the study, we collected COST scores at two time points approximately 8 weeks apart from 72 patients. In the qualitative phase, we conducted semistructured interviews with a subset of 12 patients who reported the largest changes in scores. The qualitative data were analyzed using a deductive coding scheme developed using the Framework Method in the context of a commonly cited conceptual model of financial toxicity. RESULTS: The median absolute change in COST scores was four points (IQR, 2-6). Only 13% of the sample had the same COST scores at both assessments; 38% had an improved score and 50% had a worsened score. Only, seven of the 12 patients (58%) interviewed reported changes to one or more of the constructs in the conceptual model of financial toxicity. Most commonly, changes to out-of-pocket medical costs were reported (5/12). Changes to nonmedical expenses (n = 2) and subjective financial distress without changes to objective financial burden (n = 2) were also reported. CONCLUSION: Additional research is needed to explicate changes in COST scores over time.

Disparities in Multiple Myeloma Treatment Patterns in the United States: A Systematic Review.

We performed a systematic review of the literature investigating the demographic and insurance-related factors linked to disparities in multiple myeloma (MM) care patterns in the United States from 2003 to 2021. Forty-six observational studies were included. Disparities in MM care patterns were reported based on patient race in 76% of studies (34 out of 45 that captured race as a study variable), ethnicity in 60% (12 out of 20), insurance in 77% (17 out of 22), and distance from treating facility, urbanicity, or geographic region in 62% (13 out of 21). A smaller proportion of studies identified disparities in MM care patterns based on other socioeconomic characteristics, with 36% (9 out of 25) identifying disparities based on income estimate or employment status and 43% (6 out of 14) based on language barrier or education-related factors. Sociodemographic characteristics are frequently associated with disparities in care for individuals diagnosed with MM. There is a need for further research regarding modifiable determinants to accessing care such as insurance plan design, patient out-of-pocket costs, preauthorization criteria, as well as social determinants of health. This information can be used to develop actionable strategies for reducing MM health disparities and enhancing timely and high-quality MM care.

Dynamic frailty risk assessment among older adults with multiple myeloma: A population-based cohort study.

Multiple myeloma (MM) is a cancer of older adults and those who are more frail are at high risk of poor outcomes. Current tools for identifying and categorizing frail patients are often static and measured only at the time of diagnosis. The concept of dynamic frailty (i.e. frailty changing over time) is largely unexplored in MM. In our study, adults with newly-diagnosed MM who received novel drugs between the years 2007-2014 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases. Using a previously published cumulative deficit approach, a frailty index score was calculated at diagnosis and each landmark interval (1-yr, 2-yr, 3-yr post diagnosis). The association of frailty with overall survival (OS) both at baseline and at each landmark interval as well as factors associated with worsening frailty status over time were evaluated. Overall, 4617 patients were included. At baseline, 39% of the patients were categorized as moderately frail or severely frail. Among those who had 3 years of follow-up, frailty categorization changed post diagnosis in 93% of the cohort (78% improved and 72% deteriorated at least at one time point during the follow up period). In a landmark analysis, the predictive ability of frailty at the time of diagnosis decreased over time for OS (Harrell's C Statistic 0.65 at diagnosis, 0.63 at 1-yr, 0.62 at 2-yr, and 0.60 at 3-yr) and was inferior compared to current frailty status at each landmark interval. Our study is one of the first to demonstrate the dynamic nature of frailty among older adults with MM. Frailty may improve or deteriorate over time. Current frailty status is a better predictor of outcomes than frailty status at time of diagnosis, indicating the need for re-measurement in this high-risk patient population.

The Dynamics of Financial Toxicity in Multiple Myeloma.

INTRODUCTION/BACKGROUND: People with multiple myeloma are at risk for financial toxicity due to the high cost of treatment and prolonged treatment duration. However, little data exist regarding financial toxicity among people with myeloma. PATIENTS AND METHODS: In this study, a cohort of 135 patients were recruited from an ongoing observational trial to complete the Comprehensive Score for financial Toxicity (COST). Participants were sent follow-up surveys at 3, 6, and 12 months. RESULTS: The median age was 68 years; the majority were non-Hispanic whites (88%), male (63%), held a college degree (61%), and had left the workforce (70%). The median time from myeloma diagnosis was 28 months. The median COST score was 27; 48% of participants had a score below 27 and considered to have financial toxicity. The only characteristic associated with financial toxicity was a college degree. After controlling for other covariates, those with a college education were 69% less likely to have financial toxicity. Of the 108 participants who completed a follow-up survey, 34% reported changes in their financial toxicity status at a subsequent time point. Transitioning from not having financial toxicity to having financial toxicity was more common than the reverse. CONCLUSION: Because financial toxicity is a dynamic process, which patients are experiencing it at any given time is difficult to predict. Focusing the research agenda on improved detection and intervention may be warranted.

Disparities in health care affordability among childhood cancer survivors persist following the Affordable Care Act.

BACKGROUND: The Affordable Care Act (ACA) included many provisions that may have improved access to care for childhood cancer survivors (CCS). In this study, we sought to compare health insurance coverage and the affordability of health care among adult childhood CCS before and after the implementation of the ACA. PROCEDURE: Using data from the National Health Interview Survey (NHIS), two cohorts of CCS age 21-65 years old and matched (1:3) controls without a history of cancer were identified. A difference-in-differences analysis was used to compare insurance coverage and health care affordability pre- (2011-2013) and post-ACA (2015-2017). RESULTS: There were 309 CCS identified in the pre-ACA cohort and 324 in the post-ACA cohort. The two cohorts were similar in demographic composition. Prior to the ACA, CCS were 39% more likely to be uninsured than their peers (p = .046). Post, there was no difference in the odds of being uninsured between CCS and their peers. Following implementation of the ACA, the proportion of CCS who reported having difficulty with the affordability of health care decreased (p = .013) as did the proportion reporting skipping needed care due to cost (p < .001). However, 13% of CCS still reported being uninsured, 36% reported difficulty paying for health care, and 13% reported foregoing needed care due to cost. Relative to their peers, CCS saw improvement in foregoing needed care due to cost, but disparities still remain. CONCLUSIONS: Although improvements were observed, health care affordability, and medical nonadherence remains a problem for CCS. IMPLICATIONS FOR CANCER SURVIVORS: Additional efforts are needed to improve health care affordability among CCS.

Bortezomib in first-line therapy is associated with falls in older adults with multiple myeloma.

BACKGROUND: Bortezomib is a common multiple myeloma therapy that can cause treatment-related peripheral neuropathy, a risk factor for falls. The relationship between bortezomib and falls in older patients with multiple myeloma is unknown. METHODS: We analyzed the SEER-Medicare database for patients aged 65 or older diagnosed with multiple myeloma between 2007 and 2013. Claims were analyzed for myeloma treatments, falls, and covariates of interest. We evaluated accidental falls occurring within 12 months after starting first-line multiple myeloma treatment with bortezomib. RESULTS: Bortezomib was used in first-line therapy for 2052 older adults with new diagnoses of multiple myeloma. Claims for falls were reported in 157 (8%) patients within 12 months after starting bortezomib, compared to 102 (5%) patients not receiving bortezomib (p < 0.001). Bortezomib was associated with a 36% increased risk of falls after controlling for covariates (aHR 1.36; 95% CI 1.05-1.75; p = 0.018). In a landmark analysis of those who survived 12 months after starting treatment, the median overall survival of those with a fall was 35.7 months compared to 49.1 months for those without (p < 0.0001). A fall in the first year after diagnosis was associated with a 26% increased risk in hazard for death (aHR 1.26; 95% CI 1.02-1.56; p = 0.033). CONCLUSION: In older adults with multiple myeloma, bortezomib was associated with an increased risk of having a diagnostic code for falls. Decreased overall survival was seen in those who fell within the year of starting therapy. Prospective trials involving fall assessments and fall-prevention interventions are needed in this population.

A deficit-accumulation frailty index predicts survival outcomes in patients with gynecologic malignancy.

OBJECTIVE: To determine the association between scores from a 25-item patient-reported Rockwood Accumulation of Deficits Frailty Index (DAFI) and survival outcomes in gynecologic cancer patients. METHODS: A frailty index was constructed from the SEER-MHOS database. The DAFI was applied to women age ≥ 65 diagnosed with all types of gynecologic cancers between 1998 and 2015. The impact of frailty status at cancer diagnosis on overall survival (OS) was analyzed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS: In this cohort (n = 1336) the median age at diagnosis was 74 (range 65-97). Nine hundred sixty-two (72%) women were Caucasian and 132 (10%) were African-American. Overall, 651(49%) of patients were considered frail. On multivariate analysis, frail patients had a 48% increased risk for death (aHR 1.48; 95% CI 1.29-1.69; P < 0.0001). Each 10% increase in frailty index was associated with a 16% increased risk of death (aHR, 1.16; 95% CI, 1.11 to 1.21; P < 0.0001). In subgroup analyses of the varying cancer types, the association of frailty status with prognosis was fairly consistent (aHR 1.15-2.24). The DAFI was more prognostic in endometrial (aHR 1.76; 95% CI 1.41-2.18, P < 0.0001) and vaginal/vulvar (aHR 1.94; 95% CI 1.34-2.81, P = 0.0005) cancers as well as patients with loco-regional disease (aHR 1.94; 95% CI 1.62-2.33, P < 0.0001). CONCLUSIONS: Frailty appears to be a significant predictor of mortality in gynecologic cancer patients regardless of chronological age. This measure of functional age may be of particular utility in women with loco-regional disease only who otherwise would have a favorable prognosis.

Burden of Treatment Among Older Adults With Newly Diagnosed Multiple Myeloma.

BACKGROUND: Multiple myeloma is an incurable hematologic malignancy with significant recent treatment advances; however, the magnitude of treatment burden among patients in the first year after diagnosis has yet to be fully researched and reported. PATIENTS AND METHODS: Patients with multiple myeloma newly diagnosed between 2007 and 2013 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases. Treatment burden was captured as the number of total days with a health care encounter (including acute care and outpatient visits), oncology and nononcology physician visits, and the number of new prescriptions within the first year after diagnosis. Logistic regression was used to identify factors associated with high treatment burden. RESULTS: A total of 3065 patients were included in the analysis. There was a substantial burden of treatment within the first year after diagnosis (median, 77 days; interquartile range, 55-105 days), which was highest during the first 3 months. Patients with high comorbidities (adjusted odds ratio [aOR] 1.27 per 1-point increase in Charlson comorbidity index, P < .001), poor performance status (aOR 1.85, P < .001), myeloma-related end organ damage, particularly bone disease (aOR 2.28, P < .001), and those who underwent autologous stem-cell transplantation (aOR 2.41, P < .001) were more likely to have a higher treatment burden. CONCLUSION: There is considerable burden of treatment in patients with newly diagnosed multiple myeloma within the first year after diagnosis, particularly within the first 3 months. Future tailored interventions aimed at optimizing this treatment burden when possible while simultaneously providing support to manage it may improve patient-centered care.

Geriatric assessment and quality of life changes in older adults with newly diagnosed multiple myeloma undergoing treatment.

OBJECTIVE: Multiple myeloma (MM) is a cancer of older adults with a median age at diagnosis of 70 years. Our study aimed to understand the changes that occurred in geriatric domains and quality of life parameters as older adults underwent treatment for MM over 6-months following initial diagnosis. METHODS: This was a secondary analysis of a prospective cohort study of 40 adults aged ≥65 with newly-diagnosed MM who completed the Cancer and Aging Research Group geriatric assessment and the Functional Assessment of Cancer Therapy (General and subscale Gynecologic Oncology Group-Neurotoxicity) quality of life tool at baseline and at 6 months following treatment initiation. RESULTS: Thirty-six participants completed 6-months of follow-up. There was no significant change in geriatric domains, including dependence in instrumental activities of daily living (IADLs). Compared to baseline, mental health improved at 6-months of follow-up (Mental Health Inventory-17 score, median 77.1 versus 84.3 at baseline and 6-months respectively, p < .001). Objective physical performance as measured by the Timed Up and Go test showed a trend towards improvement (12.3 versus 11.0 s, p = .057) and remained stable or improved in almost all (30/32, 93.8%) of the adults using the minimum clinically important difference threshold. CONCLUSION: From baseline to 6-months of follow-up, older adults with MM showed improvement in mental health but otherwise remained stable with regards to function and overall quality of life. Timed Up and Go Test may provide a dynamic indicator of functional status and needs to be further evaluated in future studies.

The characteristics, treatment patterns, and outcomes of older adults aged 80 and over with multiple myeloma.

OBJECTIVES: Tremendous progress has been made in the treatment of multiple myeloma; however, the majority of this success has been demonstrated in younger patients. With 36% of patients >80 years-old at diagnosis, it is important to understand if older patients are receiving similar benefits. MATERIALS AND METHODS: We identified 2155 patients diagnosed with myeloma at age 80 or older in the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare database from 2007 to 2013. A cohort of 2933 similar patients diagnosed with myeloma at age 70-79 was used for comparison using a difference-in-differences design. RESULTS: Only 51% of patients >80 years-old at diagnosis received systemic anti-myeloma treatment. Treatment was associated with a 26% decrease in hazard for death, independent of age, race, gender, poverty, comorbidities, and proxy measures of performance status. In the 70-79 cohort, treatment was associated with a 22% decrease in hazard for death. Based on the difference-in-differences design, there is no statistically significant difference in treatment benefit based on age cohort (p = .610). CONCLUSIONS: Anti-myeloma treatment produces a similar survival benefit among the oldest patients. The population over 80, when myeloma incidence peaks, is projected to triple over the next few decades. It is imperative that we continue to advance our understanding of the needs of this vulnerable subgroup of patients with myeloma.

Cost differential associated with hospice use among older patients with multiple myeloma.

BACKGROUND: Hospice is an effective end-of-life care approach for patients with incurable illnesses such as multiple myeloma; however, it has been historically underutilized. In addition to improving quality of life, hospice enrollment reduces healthcare spending in many incurable illnesses but this has been unstudied in the myeloma population to date. MATERIAL AND METHODS: Retrospective analysis of myeloma cases diagnosed from 2007 to 2013 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset. Included patients were: diagnosed at age 65 or older, received myeloma-directed therapy, had an overall survival >3 months, and were enrolled in Medicare the month preceding death. Costs included those paid by Medicare and patient copays during the 30 days preceding death. RESULTS: 2075 patients were included in the analysis. 56% were enrolled in hospice at end of life. Increasing age and female gender were associated with greater odds of hospice enrollment. Non-white race, Medicaid enrollment, and increasing comorbidities were associated with decreased odds. Hospice enrollment was associated with a $13,574 (p < .0001) decrease in costs; however, the maximal savings were observed by those enrolled >14 days prior to death. CONCLUSION: While improving quality of life should be the ultimate reason for increasing hospice utilization among patients with myeloma, there seems to be considerable cost implications as well.

Measuring cardiopulmonary complications of carfilzomib treatment and associated risk factors using the SEER-Medicare database.

BACKGROUND: Carfilzomib improves survival in patients with recurrent myeloma. Given the strict eligibility criteria in clinical trials, the actual frequency of cardiac adverse events (CAEs) and pulmonary adverse events (PAEs) and the risk factors associated with these AEs in the general population need to be established. METHODS: The authors extracted myeloma cases in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database from 2000 through 2013 and corresponding claims through 2014. They then identified patients who received carfilzomib during their disease course. Subsequently, the International Classification of Diseases, Ninth Revision (ICD-9) was used to identify all the codes for CAEs, PAEs, and respiratory infections associated with carfilzomib use. Preexisting diagnoses corresponding to the CAEs and PAEs of interest were excluded to distinguish toxicity from comorbidity. Multivariate Cox regression was performed to determine those variables independently associated with the development of CAEs and PAEs. RESULTS: Of the 635 patients analyzed, the median age was 72 years (range, 36-94 years); 55% of the patients were male and 79% were white. The median duration of carfilzomib treatment was 58 days (range, 1-716 days). Overall, approximately 66% of the patients had codes for either CAEs or PAEs. In terms of CAEs, approximately 22% of patients developed hypertension, 15% developed peripheral edema, and 14% experienced heart failure. With regard to PAEs, approximately 28% of patients developed dyspnea, 15% developed cough, and 15% developed pneumonia. Only chronic obstructive pulmonary disease (COPD) was found to be independently associated with the development of CAEs. Patients with preexisting COPD were found to have a 40% increase in their hazard of developing CAEs (adjusted hazard ratio, 1.40; 95% CI, 1.03-1.90). CONCLUSIONS: In older adults with myeloma who are undergoing treatment with carfilzomib, new cardiac and pulmonary diagnoses were common. Patients with preexisting COPD were found to be at an increased risk of developing CAEs.

Development of a Medicare Health Outcomes Survey Deficit-Accumulation Frailty Index and Its Application to Older Patients With Newly Diagnosed Multiple Myeloma.

Purpose: To develop a frailty index using the Rockwood Accumulation of Deficits approach for the Medicare Health Outcomes Survey (MHOS) and apply it in a subset of older patients with newly diagnosed multiple myeloma. Methods: Data from 2,692,361 patients without cancer, > 66 years of age, in SEER-MHOS linked databases between 1998 and 2009 were analyzed. A frailty index was constructed, resulting in a 25-item scale; cutoff values were created for individuals classified as frail. This frailty index was then applied to 305 patients with newly diagnosed myeloma in the database to predict overall survival. Results: In the derivation cohort of patients without cancer, the median age was 74 years and the mean frailty index was 0.23 (standard deviation, 0.17). Among patients without cancer, each 10% increase in frailty index (approximately three to four more deficits) was associated with a 40% increased risk for death (adjusted hazard ratio, 1.397; 95% CI, 1.396 to 1.399; P < .001). In the cohort of patients with newly diagnosed myeloma, the median age was 76 years an d the mean frailty index was 0.28 (standard deviation, 0.17). Each 10% increase in frailty index was associated with a 16% increased risk for death (adjusted hazard ratio, 1.159; 95% CI, 1.080 to 1.244; P < .001). Fifty-three percent of patients with multiple myeloma were considered frail. The estimated median overall survival of patients considered frail was 26.8 months, compared with 43.7 months (P = .015) for those who were not. Conclusion: The MHOS-based frailty index was prognostic for patients with multiple myeloma in predicting overall survival.

Racial disparities in treatment use for multiple myeloma.

BACKGROUND: Recent treatment advances have greatly improved the prognosis of patients with multiple myeloma. However, some of these newer, more effective treatments are intensive and expensive and their use remains low, particularly among black patients. METHODS: In the current study, the authors reviewed the use patterns of stem cell transplantation and bortezomib using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. RESULTS: After controlling for overall health and potential access barriers, black patients were found to be 37% (P<.0001) less likely to undergo stem cell transplantation, and 21% (P<.0001) less likely to be treated with bortezomib. Moreover, the authors found that the underuse of these treatments was associated with a 12% increase in the hazard ratio for death among black patients (P = 0.0007). CONCLUSIONS: Eliminating health disparities, a current focus of US public policy, is highly complex, as illustrated by the results of the current study. In patients with multiple myeloma, treatment disparities are not completely explained by potential access barriers. Additional factors, such as structural barriers in the health care system and individual decision making among black and white patients, must be explored to fully explain the disparity. Cancer 2017;123:1590-1596. © 2017 American Cancer Society.

Socioeconomic status is independently associated with overall survival in patients with multiple myeloma.

Population-based studies suggest that black patients with multiple myeloma (MM) have a higher mortality rate than white patients. However, other studies suggest that this disparity is related to socioeconomic status (SES) rather than race. To provide clarity on this topic, we reviewed 562 patients diagnosed with MM at our institution. Patients with high SES had a median overall survival (OS) of 62.8 months (95% confidence interval [CI] 43.1-82.6 months), compared to 53.7 months (45.2-62.3 months) and 48.6 months (40.4-56.8 months) for middle and low SES, respectively (p = 0.015). After controlling for race, age, year of diagnosis, severity of comorbidities, stem cell transplant utilization and insurance provider, patients with low SES had a 54% increase in mortality rate relative to patients with high SES. To support our findings, we performed a similar analysis of 45,505 patients with MM from the Surveillance, Epidemiology and End Results-18 (SEER) database. Low SES is independently associated with poorer OS in MM.