Demographic and socioeconomic determinants to the access to hematopoietic stem cell transplantation (HSCT) in multiple myeloma (MM): A National Cancer Database (NCDB) analysis of years 2004-2017.
Authors: Saba Ludovic , Liang Hong , Dominguez Barbara , Fu Chieh Lin , Chaulagain Chakra Pani 
Published: June 2023

e20013

Background: Despite the advent of novel chemo-immunotherapies in multiple myeloma (MM), hematopoietic stem cell transplantation (HSCT) remains a crucial aspect of therapy in eligible patients. However, disparities in access to HSCT have been well documented. In this IRB approved retrospective analysis, the NCDB was used to evaluate the determinants of access to HSCT among MM patients who were treated in Commission on Cancer (CoC) accredited facilities across the USA. Methods: Using the NCDB, we identified N = 171,261 patients diagnosed and treated for MM from 2004 to 2017. Multivariable logistic regression analysis was conducted to identify the predictors for receiving HSCT, using significance level of p < 0.05. SAS version 9.4 was used to analyze the data. Results: Multivariable logistic regression analysis showed that there were 12 significant factors associated with HSCT: age, sex, race, ethnicity, facility, insurance, median income, education level, year of diagnosis, distance to facility, Charlson score, and type of treatment regimen. Patients of age 65-75 (OR = 0.65, p < 0.0001) and age ≥ 75 (OR = 0.04, p < 0.0001) were less likely to receive HSCT compared to patients of age < 55. Male patients were more likely to be treated with HSCT compared to female patients (OR = 1.08, p = 0.005). Black patients were predicted to have less access to HSCT compared to White patients (OR = 0.69, p < 0.0001). Patients of non-Hispanic ethnicity were predicted to have better access to HSCT compared to Hispanic patients (OR = 1.25, p = 0.0007). Furthermore, subjects who were treated in non-academic facilities were less likely to receive HSCT compared to the ones who received care in academic or research centers (OR = 0.51, p < 0.0001). Patients with Medicare (OR = 0.79, p < 0.0001), Medicaid (OR = 0.77, p < 0.0001), and no insurance (OR = 0.38, p < 0.0001) were less likely to receive HSCT compared to patients with private insurance. Interestingly, the lower median income < $38,000 was associated with increased frequency of HSCT in comparison with higher median income ≥ $63,000 (OR = 1.17, p < 0.0001). This may be due to reduced access to novel agents by lower income patients who typically cannot afford high co-payment associated with novel agents. In contrast, subjects with a lower level of education (no high school diploma in 21% or more) were predicted to have less access to HSCT in comparison with subjects who had a higher level of education (no high school diploma in less than 7%) (OR = 0.57, p < 0.0001). Detailed analysis will be presented. Conclusions: Our study shows that Black and Hispanic patients as well as those with non-private insurance were less likely to receive HSCT in this large cohort of real world data set from across the USA. These results further corroborate the need to improve equitable access to care to all myeloma patients to ameliorate outcomes.