The Veterans Health Administration Provides Equal Access to Autologous Hematopoietic Stem Cell Transplantation for Patients with Multiple Myeloma
Authors: Freytes Cesar O. , Callander Natalie S , Goodman Stacey A , Luo Suhong , Toro Juan J. , Carson Kenneth R 
Published: November 2019

Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) remains an integral part of multiple myeloma (MM) therapy. Previous studies have documented disparities in the utilization of AHSCT, with black MM patients receiving AHSCT less frequently than white patients. Among the factors that may influence AHSCT utilization is the availability and quality of health insurance. A previous analysis of black and white MM patients who underwent AHSCT in an equal access health care system, demonstrated comparable survival between black and white patients following AHSCT in MM. Unfortunately, this study did not provide information regarding potential race-based differences in AHSCT utilization. In an effort to understand the relationship between race and AHSCT utilization in an equal access healthcare system, we evaluated AHSCT utilization in a cohort of MM patients from the Veterans Health Administration (VHA) central cancer registry.
Patients diagnosed with MM at any VHA medical center between September 1, 1999 and September 30, 2009 using International Classification of Diseases for Oncology, third revision, code 9732/3. Patients who did not receive treatment within 6 months of diagnosis were excluded in order to remove patients with monoclonal gammopathy or smoldering myeloma miscoded as MM (n=1,002). This resulted in a cohort of 2,968 patients. AHSCT was identified by ICD-9 procedure codes (410.4, 410.7, 410.0, 410.1, 410.9) or use of high-dose melphalan. Household income was estimated based upon zip code of residence, linked to census data on median household income by zip code.
Of the 2,968 patients, 2,040 (68.7%) were white, 850 (28.6%) were black, 40 (0.1%) from other racial groups, and 38 (0.1%) were from unknown racial groups. The proportion of patients who underwent AHSCT was similar: 270 of 2118 white/other MM patients underwent AHSCT compared to 94 black patients (12.8% vs. 11%, respectively, p = 0.2). Demographics of the patients who received AHSCT are presented in table 1. Comparison of socioeconomic status demonstrated that across the entire cohort of 2,698 patients, black patients were significantly more likely to be from the lowest income quartile compared to white/other patients (38.2% vs. 18.4%, p < 0.001). Among the patients who received transplant, black patients again were more likely to come from the lowest income quartile (29.8% vs. 18.2%, p = 0.07).
We conclude that the proportion of white and black patients who undergo AHSCT for MM is similar in the VHA, a finding that was present despite significant differences in estimated household income. Our finding is in contrast to previous registry studies that have shown limited access to transplantation for black MM patients. This suggests that in the VHA, utilization of high-cost interventions such as AHSCT is equal, despite differences in race and socioeconomic status.
Table- Demographic and clinical characteristics by race among transplanted MM patients diagnosed 1999 to 2009 Demographic clinical characteristics Overall (N=364) White or other (n=270) Black (n=94) p-value Age (mean / range) 57.5 (27-73) 58 (27-73) 56.1 (30 - 71) 0.02 Sex (Male %) 96.7 97.4 94.7 0.2 Comorbidities (mean Charlson score) 1.4 1.3 1.6 0.09 BMI (%) <18.5 1.1 0.7 2.1 18.5-<25 22 22.2 21.3 25-<30 44.8 41.5 54.3 >=30 32.1 35.6 22.3 0.1 Estimated Household Income (%) Quartile 1 21.2 18.2 29.8 Quartile 2 23.4 23.7 22.3 Quartile 3 25.6 27 21.3 Quartile 4 27.5 28.2 25.5 Unknown 2.5 3 1.1 0.07 Hemoglobin (mean) 11 11.2 10.3 < 0.001 Creatinine (mean) 1.8 1.9 1.5 0.03 Albumin (mean) 3.3 3.4 3.3 0.3 Time(months) between Dx and transplant (mean/range) 12.8 (3.4-87.7) 12.3 (3.4-55.5) 14.1 (3.6-87.7) 0.15

Disclosures
Freytes: Merck: Research Funding; Otsuka: Consultancy, Research Funding; Sanofi: Speakers Bureau. Carson:Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; Millennium: Consultancy, Research Funding.