Transcript
Announcer:
Welcome to ReachMD.
This medical industry feature, titled “Bridging the Disparity Gap in Multiple Myeloma Care: Navigating Challenges, Seizing Opportunities,” is sponsored by AbbVie US Medical Affairs.
Here’s your host, Dr. Charles Turck.
The US Medical Affairs department of AbbVie Inc. is the sole author and copyright owner of this presentation and has paid ReachMD to host this presentation. AbbVie is solely responsible for all written and oral content within this presentation. Copyright 2024 AbbVie Inc. All rights reserved.
Tiffany Hawkins Williams, DNP, CPNP-PC has received compensation from the US Medical Affairs department of AbbVie Inc. to prepare and present the following information and is speaking on behalf of AbbVie. Dr. Joseph Mikhael is presenting the following information and speaking on behalf of AbbVie. He did not receive any compensation for his services.
Dr. Turck:
Despite improved overall survival in patients with multiple myeloma due to the advent of novel therapies, health disparities in patient outcomes persist among African American, Hispanic, and Latino-American populations.1
This is ReachMD, and I’m Dr. Charles Turck. Joining me to discuss the challenges that impede timely diagnosis and intervention of multiple myeloma in African Americans, as well as explore patient-centric strategies to overcome these barriers is Dr. Joseph Mikhael. Dr. Mikhael is a Professor in the Division of Applied Cancer Research and Drug Discovery at the Translational Genomics Research Institute, which is an Affiliate of City of Hope Comprehensive Cancer Center. He also serves as the Chief Medical Officer of the International Myeloma Foundation.
Dr. Mikhael, welcome to the program.
Dr. Mikhael:
Thanks so much for having me.
Dr. Turck:
Also with us to share her unique patient perspective is Tiffany Hawkins Williams, who’s a Doctor of Nursing Practice, Certified Pediatric Nurse Practitioner, a myeloma survivor, speaker, and patient advocate.
Tiffany, thank you for joining us.
Tiffany Hawkins Williams, DNP, CPNP-PC:
I’m happy to be here with you both.
Dr. Turck:
Well, let’s start with you, Tiffany. Can you tell us more about your multiple myeloma journey and the challenges you faced while navigating the healthcare system?
Tiffany Hawkins Williams, DNP, CPNP-PC:
Sure. Let me start by giving some context. I grew up in the rural South seeing health disparities first-hand, but not knowing that's what they were. So, for me, a big challenge was being able to name what I was observing as disparities.
Another challenge that I faced occurred at the time of diagnosis. I remember when I received the diagnosis from a community healthcare provider, I was shocked and overwhelmed. And although I was a nurse at the time of diagnosis, my specialty was in pediatrics, and I had no experience with multiple myeloma before that time.
So now, I was no longer the nurse, but rather, I became the patient. And I actually found it difficult to use my voice, especially with providers who didn't welcome my voice or who rushed me through visits. And I found that I reverted back to what I had observed when I went to the doctor as a kid with my grandfather, where he was often quiet and not very active in the exchange and participating in his care. And otherwise, he was a very authoritative, prominent figure in our community.
But unlike many of the patients I advocate for, I had the benefit of having a village of support from my friends, my family, as well as the community. And my village allowed me to focus on being a patient and put my health first. I didn't have to be a nurse. I didn't have to choose between working or the treatment and the care that I received. And having these professional and personal connections not only helped me, gain access to facilities and resources, but it also helped to a timelier diagnosis and treatment options.
Dr. Turck:
Thank you for sharing your experience, Tiffany.
Turning to you now, Dr. Mikhael, are experiences like the ones Tiffany described common?
Dr. Mikhael:
Well, unfortunately, yes, they are. Many patients with multiple myeloma have a similar story to share.
And considering that myeloma is the most common hematologic malignancy in the African American population, it's critical to recognize that a number of health disparities persist, which can contribute to experiences like Tiffany's.1
For one, African American patients with multiple myeloma have a two-fold higher incidence of multiple myeloma compared with the White population. In fact, the gap widens in patients younger than 50 years, as incidence rates in African American men are 2.6 times higher than for White men, and they're 3.3 times higher in African American women than in White women.1
In terms of receiving a timely diagnosis, African American patients with multiple myeloma are also twice as likely to experience a delay. The most common causes of delay are due to non-specific clinical presentation, reduced access to primary care and specific testing, and confounding diagnoses, such as a chronic condition, like diabetes.
Also, many patients with multiple myeloma experience a diagnostic and treatment delay, with an average of 2.7 months between diagnosis and treatment with a novel therapy in White patients. And yet, this delay is almost doubled in African American patients who, on average, wait 5.2 months between diagnosis and a novel therapy initiation.1,2
Finally, we’ve also seen that African American patients with myeloma have mortality rates that are twice that of White Americans. African American men have a five-year adjusted mortality of 7.3 per 100,000 persons versus 3.7 in White men. And the mortality rate in African American women is five versus 2.2 in White women.1 You know, I'd like to add here that although our focus today is primarily on health disparities in African American patients with multiple myeloma—and that's where we've seen the largest disparity and where we've gathered the most data—we do recognize that there are other groups with health disparities, including Hispanic and Latino American patients with multiple myeloma.
Some known disparities that Hispanic and Latino American patients face include receiving the diagnosis at a younger age than their White peers.2 And when it comes to initiating treatment, Hispanic and Latino American patients wait 1.7 times longer to initiate a novel therapy from the time of diagnosis and are actually less likely to receive an autologous stem cell transplant than White patients.2 Additionally, when it comes to monthly medical expenditures, Hispanic and Latino American patients experience higher multiple myeloma-related costs. 2
So it's evident from the limited data that there is still much to learn about these disparities. Given all this, it's a high priority to me and many other providers that care for multiple myeloma patients to identify the barriers to equitable care so that we can implement strategies in our practice to bridge this gap.
Dr. Turck:
And as a follow-up to that, Dr. Mikhael, let’s dig deeper into these barriers to equitable care for myeloma patients. What should healthcare professionals keep in mind?
Dr. Mikhael:
Well, I like to consider these barriers in layers. So the first layer is that the systemic phenomena that affect health disparities in general, societal level challenges and issues, such as systemic racism, health care resource availability and health insurance, and the social determinants of health, including socioeconomic status.1,3The next layer of barriers for patients to receive equitable care are more specific to multiple myeloma. This includes delays in diagnosis and reduced access to treatment, as well as culturally sensitive care.1,4,5
Now, that piece of delayed diagnosis is multifaceted. On the one hand, the average lay person isn’t aware of the signs and symptoms of multiple myeloma or may not bring it up to discuss with their healthcare provider.1On the other hand, many healthcare providers may not recognize that multiple myeloma affects African American patients at a younger age and may attribute the symptoms or findings to another medical condition.1,4
Next, if we consider the access to care, it really has multiple components which I like to think of the four T's, which are: Triplets, Transplants, Trials or clinical trials, and CAR-T cell therapy.1,2,6-10 Arguably, these four things have been the most influential in improving survival in multiple myeloma over the past two decades, but sadly, we see reduced access in all four areas among certain populations including African Americans, Hispanic, and Latino American populations.2,9
In addition to the four T’s, we also need to consider the delivery of that care in a culturally sensitive manner. How we best serve our patients really may come down to our understanding of historical and cultural factors influencing their touch points with the healthcare system. So, it's really important to set the tone with culturally sensitive delivery of that care.1,11
Dr. Turck:
With all this in mind, I’d like to hear more from your perspective, Tiffany. What can health care professionals and healthcare teams do differently to improve the patient experience, during an already difficult time?
Tiffany Hawkins Williams, DNP, CPNP-PC:
Two things come to mind immediately, and they both center around the idea of community engagement.
First, I'd like providers to carry more of the burden of care. And of course, you know, patients have to be included in their care, and providers can adapt their approach and treatment plans to the needs of each patient, knowing that every patient’s journey is going to look different. Some patients might prefer an empowering approach where providers support patient autonomy and simply provide accessible and understandable health information. And other times, they may seek more of a partnership, where the provider builds rapport and demonstrates active listening by welcoming the patient’s thoughts and questions. But it's also important to remember that some patients are going to simply be unable to show up as anything more than being a passive participant in their care.
And the second thing is, I'd like to see communities and institutions undertake similar strategies, like M-Power, International Myeloma Foundation’s Initiative. That's really led by a passionate, you know, group of health equity champions, including myself and many other patients, who help address the unique needs of, each patient and, the different communities that they come from. M-Power, empowers, as its name states, it educates and it connects patients to a plethora of resources and, support groups, and these community programs simply meet patients – where they are.
It's about meeting them where they are along their journey and being an active member of the patient’s village to help provide support.
Dr. Turck:
For those just tuning in, you’re listening to ReachMD.
I’m Dr. Charles Turck, and today I’m speaking with Drs. Joseph Mikhael and Dr. Tiffany Hawkins Williams about health disparities in multiple myeloma care and strategies to overcome these barriers.
Now that we’ve explored some ways that the healthcare system and/or healthcare team could improve the patient experience with Tiffany, let’s place these concepts into context. Dr. Mikhael, can you tell us about some real-world evidence that brings clarity to the health disparities that exist in multiple myeloma care?
Dr. Mikhael:
Oh, absolutely. You know, one of the many studies that highlights the impact of racial disparities for patients with multiple myeloma is a retrospective study conducted at Veteran Affairs, or VA hospitals.1,3 So, in this study, 15,717 patients were identified over an eight-year period who met criteria for symptomatic multiple myeloma who identified as African American or White.3
The significance of this study is that all patients at the VA hospital have equal access to diagnostic and therapeutic strategies for myeloma. And this was confirmed that no racial disparity between African American and White patients were observed over the time period for the overall use of novel therapies at induction, nor in lifetime exposure to novel therapy or stem cell transplants.3 Within this setting of equal access to multiple myeloma care at the VA, the median overall survival for African American patients was 5.07 years compared to 4.52 years in White patients.3 Now the age of diagnosis had a significant impact on overall survival among all patients in the study, as those who are diagnosed in their forties had a median overall survival of 7.5 years compared to 2.6 years for those in their 80s.3
With this observation in mind, and because African Americans are diagnosed with myeloma at a younger age compared to White individuals,3 the patients were then stratified by age into two groups, those below 65 years of age versus those 65 years and older. With this distinction in place, among those younger than 65, African American patients still had a significantly longer median overall survival of 7.07 years compared to 5.83 years in White patients.3 However, no significant difference was observed between those populations in patients 65 years and older.3
So, given these findings let me explain the impact of these data on our directive for healthcare and patient outcome equity in myeloma. For one, we see that when we give equal access to diagnosis and therapy pathways, we see similar, if not superior outcomes among African American patients compared to White patients.3,4 And this should give us hope, not only that improved outcomes are possible, but also the encouragement to accept nothing less.
In addition, these data provide strong support that the disparities seen between African American and White patients aren't from a biological phenomena, despite differences in disease biology.1 Specifically, African American patients aren't exhibiting a more aggressive or high-risk form of multiple myeloma.1 In fact, we're seeing the opposite with lower risk cytogenetic factors more prevalent in patients with African ancestry.4 And younger patients, we're seeing an even greater survival benefit for African American individuals.3
Let's also keep in mind that other studies have validated this study, which again amplifies, therefore, the disparity as well as supports the need to improve barriers to equitable care.
Dr. Turck:
Given these findings, Dr. Mikhael, what are your recommendations to continue making progress toward reducing disparities and achieving equitable care for our patients?
Dr. Mikhael:
Well, that's the key question, isn't it? So I think that these challenges and barriers have to be identified, and once identified, we have to match the solution to the problem. There are some barriers that can't be fixed overnight, like systemic racism, equal access to healthcare resources, although I believe we have a responsibility within our communities to advocate for these things to improve.1 More specific to multiple myeloma, we want to overcome the delayed diagnosis. We want to improve access to novel therapies and indeed, address the social determinants of health.1
So beginning with the social determinants of health, it's really important that we recognize how much of an influence they have on patient outcomes with myeloma. This includes issues with general health, with transportation, family care, and so many others.1 So, it's important to be cognizant of what our patients are dealing with, so we can develop individual and institutional practices to overcome them.
Programs like our International Myeloma Foundation’s M-Power Program that I have the privilege of leading, has been effective model in which both medical and non-medical groups unite with the same goal to increase awareness of multiple myeloma through community engagement, through education of primary care providers, and through enhancing culturally sensitive care to ultimately overcome these health disparities within the African American community.1
Now, I'd say that in the US, our healthcare system has undergone a bit of a transformation from an institution that people only deal with when they're sick, to becoming a member of the community with the responsibility to engage locally and provide education resources for health promotion and disease prevention.1 And this is an important role because by engaging and supporting the health of the community, we begin to build a relationship that develops trust.1 We can then focus on efforts to educate primary care providers and the lay public on the presentation of multiple myeloma and help overcome that delay in diagnosis that we so prolifically see.1
All of this cannot be done without ongoing cultural competence training to optimize the care of our patients. In order to improve access to diagnostic and therapeutic strategies, well, let's consider those barriers to care for our patients so that we can overcome them. This might include facilitating better insurance coverage, resources for transportation to clinics, and robust support for these advanced novel therapies.1 It's about meeting our patients where they are in their individual journey of multiple myeloma.
Dr. Turck:
Now as our program comes to an end, I’d like to hear final thoughts from each of you. Starting with you, Tiffany, any key takeaways you’d like to leave with our audience today?
Tiffany Hawkins Williams, DNP, CPNP-PC:
Sure. As a patient, I'd like to encourage the audience to provide care as you wish for your mother, your daughter, your sister. And – because for me, that's what TRUST looks like.
If I feel that the care, you're providing me is the kind that you'd want someone you love to receive, then when you recommend the clinical trial or a change in medication regimen, I'm going to trust that it's the best thing for me.
Dr. Turck:
Thank you for those insights, Tiffany. And you have the final word, Dr. Mikhael.
Dr. Mikhael:
Well, building on what Tiffany just so beautifully said, you know, long term systemic change is needed on the regulatory or governmental level, at the industry level, at the institutional level. But also, healthcare providers and the lay public have an important role, too. And we have responsibilities if we're going to make a difference in the long run. Simply put, it took hundreds of years to get us here, but we shouldn't accept waiting hundreds more to achieve equitable care for our patients today.
Dr. Turck:
That’s a great sentiment for us reflect on as we come to the end of today’s program.
I want to thank my guests, Dr. Joseph Mikhael and Tiffany Hawkins Williams, for helping us better understand the health disparity gaps in multiple myeloma care and strategies for more equitable care to incorporate into clinical practice.
Dr. Mikhael, Tiffany, it was great speaking with you both today.
Dr. Mikhael:
Thanks so much for including me.
Tiffany Hawkins Williams, DNP, CPNP-PC:
Thanks for having me.
Announcer:
This program was sponsored by AbbVie US Medical Affairs. If you missed any part of this discussion, visit Industry Feature on ReachMD.com, where you can Be Part of the Knowledge.
References:
- Bhutani M, Blue BJ, Cole C, et al. Addressing the disparities: The approach to the African American patient with multiple myeloma. Blood Cancer J. 2023;13(1):189. doi:10.1038/s41408-023-00961-0
- Ailawadhi S, Parikh K, Abouzaid S, et al. Racial disparities in treatment patterns and outcomes among patients with multiple myeloma: A SEER-Medicare analysis. Blood Adv. 2019;3(20):2986-2994. doi:10.1182/bloodadvances.2019000308
- Fillmore NR, Yellapragada SV, Ifeorah C, et al. With equal access, African American patients have superior survival compared to White patients with multiple myeloma: A VA study. Blood. 2019;133(24):2615-2618. doi:10.1182/blood.2019000406
- Mikhael J, Bhutani M, Cole CE. Multiple myeloma for the primary care provider: A practical review to promote earlier diagnosis among diverse populations. Am J Med. 2023;136(1):33-41. doi:10.1016/j.amjmed.2022.08.030
- Ghalehsari N, Kancharla P, Nimkar NS, et al. Are we asleep at the wheel in diagnosing of myeloma. J Fam Med. 2020;7(9):1230. Accessed February 5, 2024. http://www.austinpublishinggroup.com/family-medicine/fulltext/jfm-v7-id1230.php
- Costa LJ, Huang JX, Hari PN. Disparities in utilization of autologous hematopoietic cell transplantation for treatment of multiple myeloma. Biol Blood Marrow Transplant. 2015;21(4):701-706. doi:10.1016/j.bbmt.2014.12.024
- Fiala MA, Wildes TM, Vij R. Racial disparities in the utilization of novel agents for frontline treatment of multiple myeloma. Clin Lymphoma Myeloma Leuk. 2020;20(10):647-651. doi:10.1016/j.clml.2020.04.018
- Rusli E, Diao L, Liu C, et al. Racial differences in multiple myeloma survival and treatment using pooled clinical trial and real-world electronic medical record data. Blood. 2020;136(Supplement 1):9-9. doi:10.1182/blood-2020-142960
- Kanapuru B, Fernandes LL, Fashoyin-Aje LA, et al. Analysis of racial and ethnic disparities in multiple myeloma US FDA drug approval trials. Blood Adv. 2022;6(6):1684-1691. doi:10.1182/bloodadvances.2021005482
- Duma N, Azam T, Riaz IB, Gonzalez-Velez M, Ailawadhi S, Go R. Representation of minorities and elderly patients in multiple myeloma clinical trials. Oncologist. 2018;23(9):1076-1078. doi:10.1634/theoncologist.2017-0592
- Shen MJ, Peterson EB, Costas-Muñiz R, et al. The Effects of race and racial concordance on patient-physician communication: A systematic review of the literature. J Racial Ethn Health Disparities. 2018;5(1):117-140. doi:10.1007/s40615-017-0350-4
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