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

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.

From Theory to Practice: Implementation of Strategies to Reduce Acute Care Visits in Patients With Cancer.

Patients with cancer frequently seek acute care as a result of complications of their disease and adverse effects of treatment. This acute care comes at high cost to the health care system and often results in suboptimal outcomes for patients and their caregivers. The Department of Health and Human Services has identified this as a gap in our care of patients with cancer and has called for quality-improvement efforts to reduce this acute care. We highlight the efforts of three centers-a community practice, an academic practice, and a cancer center-to reduce acute care for their patients. We describe the foundational principles, the practice innovation and implementation strategy, the initial results, and the lessons learned from these interventions. Each of the described interventions sought to integrate evidence-based best practices for reducing unplanned acute care. The first, a telephone triage system, led to 82% of calls being managed at home and only 2% being directed to an emergency department (ED) or hospital. The second, a 24-hour continuity clinic, led to a 26% reduction in ED utilization for patients with cancer. The third, a digital symptom monitoring and management program for high-risk patients on active treatment, led to a 17% reduction in ED presentations. There is a need for innovative care delivery models to improve the management of symptoms for patients with cancer. Future research is needed to determine the elements of these models with the greatest impact and how successful models can be scaled to other institutions.

Chronic Myeloid Leukemia-the Promise of Tyrosine Kinase Inhibitor Discontinuation.

Some believe that tyrosine kinase inhibitor (TKI) therapy is as close to perfect as it gets in oncologic therapy. Patients diagnosed with chronic myeloid leukemia (CML) are treated with a daily oral therapy, through which most achieve remission. TKI therapy is not associated with classic chemotherapy side effects, and most patients are able to resume their normal activities of daily living. Moreover, recent data has demonstrated that CML does not affect the life expectancy of patients whose disease is well controlled with a TKI. However, TKI therapy is actually not that perfect. Patients need to stay on therapy forever. They have to remember to take their medications daily. TKIs are expensive, and the financial burden to patient and society cannot be overstated. Most patients' health-related quality of life is affected; common side effects include fatigue, muscle cramps, pain, edema, skin problems, and gastrointestinal symptoms. In addition, concerns about long-term side effects remain. Recently several studies have shown the feasibility and safety of discontinuation in a select group of patients. Herein, we will review the currently available data on stopping TKIs in CML.