Building Inroads for Transplant Access: Bridging the Gap for Underserved Patients with Multiple Myeloma
Authors: Devarakonda Srinivas , Zhao Qiuhong , Benson Don , Cottini Francesca , Khan Abdullah Mohammad , Umyarova Elvira , Bumma Naresh , Islam Nowshin , Sharma Nidhi , Krok-Schoen Jessica , Fisher James L , Plascak Jesse J , Paskett Electra D , Rosko Ashley 
Published: December 2024

Introduction: Autologous Stem cell transplantation (ASCT) is the standard of care for patients (pts) newly diagnosed with Multiple Myeloma (MM). However, inequalities exist in ASCT utilization: older adults, Black pts, rural/community residing, and individuals with low socioeconomic status are among the least likely to receive a transplant for MM. Data report that older adults receive a ASCT only 9-18% of the time while Non-Hispanic Black pts receive a transplant half as often as Non-Hispanic White pts. Geographic location impacts the receipt of ASCT, and little is known about the Appalachian (central and southern sections of the Appalachian mountain region in eastern United States) population with MM, the majority of whom, live in rural areas. Differential access to transplant adversely impacts the outcomes of MM in these vulnerable populations. To increase transplant accessibility, we piloted a virtual ASCT consultative program to understand barriers and create accessibility at a center serving metropolitan, rural, and Appalachian communities, and to meet the needs of Black pt populations with MM.
Methods: We conducted a single-institution prospective pilot study to identify barriers and increase access by implementing pt navigation and a virtual health consultation with MM transplant physicians. Participants were approached who were either age 65 years or older, self-identified as Black, or residing in a rural or Appalachian community. Rural-Urban Continuum Codes (RUCC) were used to classify residing counties as metropolitan (RUCC code 1-3) or nonmetropolitan (RUCC code 4-9). Appalachian counties were coded according to the 2020 Ohio Department of Development, Office of Research. Pts demographics and disease/treatment characteristics were collated. Pts or physician could elect to see in-person, in lieu of virtual consultation, at any point. Standardized Geriatric Assessment measures and Health Related Quality of Life (HRQoL) (PROMIS Global 10) were summarized using the median and range, or frequency and percentage depending on data type, and were compared between pts living in metro vs non-metro, and Appalachian area vs non-Appalachian area, and by race using the Mann-Whitney test or Fisher's exact test.
Results: In total, 35 pts were consented, 33 were included in analysis (excluded, n=1 no access to internet, n=1 Smoldering MM). The median age was 68 (range 51-82), 23 (69%) were male and 5 (15%) pts were Black. Geo-demographically, pts were non-metropolitan n=14 (42%) and 5 (15%) were from an Appalachian area. High risk MM disease and stage were similar across groups (race, geography, rurality). In total, 24 pts were eligible for ASCT and 6 pts were ineligible. Pre-ASCT evaluation was done virtually for 18 pts and in-person for 17 pts. Seven pts declined ASCT, 2 collected and stored stem cells, and 15 pts proceeded to ASCT. Pts who underwent ASCT were younger (65 yo. vs. 71.5 yo., p=0.04), more likely to be employed (50% vs. 5.9%, p=0.01), had lower number of comorbidities (median 4 vs. 8, p=0.02) and less medications (median 9 vs. 11, p=0.04). Compared to non-metropolitan pts, more metropolitan pts received triplet regimen including bortezomib/lenalidomide/dexamethasone (VRD) (14 vs. 5, p=0.02), had higher Self-Reported KPS (90 vs. 75, p=0.007) while physician KPS and ASCT utilization were no different between the groups. Pts from Appalachian regions were more likely to be current/former smokers (p=0.025) and were less likely to receive quadruplet induction regimens (1 vs. 6, p=0.029), in this limited analysis. Among the entire cohort, Black pts with MM had younger, median age 59 (51-71), p=0.03, but there were no differences by gender, rurality, disease, treatment, ASCT receipt, performance status or comorbidities. There were no differences in HRQoL among pts by transplant status, geographical area, or race. Social support/activities, marital status, mental health, IADL, and religiousness or spirituality were also found to be similar among pt groups studied.
Conclusion: In this pilot program, the use of pt navigation and virtual consultation are potential strategies to minimize pt travel and simplify healthcare access to MM transplant expertise. Ultimately, MM care is increasingly complex and providing alternative models, via virtual consult, to improve access to underserved and vulnerable populations is an unmet area of need in the MM community.