Evaluation of Socioeconomic Barriers Impacting Patients with Newly Diagnosed Multiple Myeloma
Authors: Srinivasan Maya D. , Culnan John , Hora Mehar , Lazzaro Alexander , Bell Britney , Bodanapu Geethika , Yildirim Cenk , Corrigan June , Do Nhan V. , Brophy Mary T. , Munshi Nikhil C. , Szalat Raphael E. , Fillmore Nathanael R. , Edwards Camille V. 
Published: December 2024

Background:

Despite major advances in the treatment of multiple myeloma (MM), significant treatment disparities for racial, ethnic, and linguistic minorities continue to impact patient outcomes in the United States. Additionally, several studies have shown that socioeconomic barriers limit access to triplet and quadruplet therapies, autologous stem cell transplantation, and cellular therapies and may explain, in part, differences in MM care and outcomes. Consistently, a study from our safety-net hospital serving a diverse population in which 60% of MM patients have 2 or more socioeconomic barriers further highlighted these disparities. Racial/ethnic minorities were more likely to have socioeconomic barriers to healthcare than non-Hispanic White patients. Standardized patient navigation (PN) programs have been found to reduce treatment delays and to improve access to treatment for patients with cancer by addressing common barriers. However, despite implementation of cancer-specific PN programs, disparities in MM care persist, possibly due to lack of a MM-specific standard PN model. Identifying socioeconomic risk factors for poor outcomes is an integral step to standardizing PN services and providing equitable MM care. To accurately characterize socioeconomic risk factors, we evaluated (1) barriers among patients with newly diagnosed MM identified by the cancer care team assessment or a validated self-report of social determinants of health (SDoH) screening tool (THRIVE) and (2) longitudinal utilization of PN services during care for MM at the largest safety-net hospital in New England, MA, USA.

Methods:

We retrospectively evaluated 203 patients diagnosed with MM since the cancer center PN program was established in January 2005 until July 2024 at Boston Medical Center (BMC). We included information on demographics, MM disease characteristics, and SDoH. Referrals to PN by the care team were assessed at diagnosis and longitudinally in conjunction with barriers identified and addressed by PN.

Results:

In this cohort, 66.2% were male and 32.4% were female. Median age was 65 (interquartile range [IQR] 57-73). Our population was racially and ethnically diverse, with 43.0% Non-Hispanic Black, 34.3% non-Hispanic White, 14.0% Hispanic/Latino, 1.0% Alaskan Native or Native American, 1.5% Asian, and 0.5% Hawaiian/Pacific Islander. Additionally, 22.3% of patients were non-native English speakers, and 7.7% of patients lacked stable housing. Domiciled patients lived a median of 7.6 kilometers from the hospital (IQR 4.2-40.6). 57.8% (n =108) had public insurance, and 14.4% (n = 27) were uninsured. Upon initial provider visit, 24.6% (n = 50) of patients diagnosed with MM were recommended for PN services.

THRIVE screening completion rate was 28.1% (n = 57), with infrequent self-reported barriers (n = 7) including food insecurity (n = 2) and housing insecurity (n = 3). The most common referring provider was MD (44%), followed by advanced practitioners (27.8%), nurses (16.7%), and social workers (11.1%). At initial diagnosis, provider identified barriers leading to PN referral were transportation needs (78.9%), financial constraints (11.7%), and limited social support (9.1%). At subsequent visits following diagnosis, however, PN addressed more complex needs including food and housing insecurity (22.5%, n=11).

Conclusions:

In this retrospective study of an underserved and diverse MM patient cohort, transportation and financial constraints were identified as the most common socioeconomic barriers to MM care at diagnosis. Housing insecurity and food insecurity were only identified and addressed at subsequent visits, perhaps, once needs related to immediate access to care were addressed. We also note infrequent self-reporting of socioeconomic barriers using the standardized THRIVE survey and non-standardized provider assessments causing variability in the identification of socioeconomic barriers and potentially leading to limited utilization of PN services. Comprehensively identifying patient needs throughout MM diagnosis and treatment is key to providing appropriately targeted interventions to promote equitable MM care and outcomes. Thus, our study lends support to the development of a standardized PN model for MM incorporating the longitudinal assessment of socioeconomic barriers to guide effective utilization of PN services for patients at risk of poor outcomes.