Supportive Care Utilization in Patients with Multiple Myeloma-a Single Center Retrospective Study
Authors: Chang Darryl , Robinson Myra , Bose Rupali , Ehsan Hamid , Krishnan Arunkumar , Borden Shanice , Voorhees Peter M. , Paul Barry , Bhutani Manisha , Varga Cindy , Ferreri Christopher , Atrash Shebli 
Published: December 2024

Introduction:
Patients with multiple myeloma (MM) often report distress related to physical symptoms or psychological and social factors. Disease-related complications such as skeletal-related events, risk of renal compromise and anemia, as well as toxicities secondary to therapies over time are common in MM due to the chronic nature of the disease. About 80-90% of patients with MM have osseous lesions, which can lead to pain, fractures, and debility. NCCN and ASCO guidelines recommend early utilization of supportive care services (SCS) in all cancer patients for symptom control while being treated for their primary malignancy. Still, the underutilization of SCS in MM patients has been cited in current literature. We evaluated SCS utilization, level of distress, clinical characteristics, response to therapy, emergency department (ED) visits, and hospitalizations in patients with MM.
Methods:
We performed a retrospective analysis of adult patients with newly diagnosed or relapsed/refractory MM at Levine Cancer Institute who had completed an electronic distress survey (EDS) within three months of diagnosis or relapse. The EDS contained sociodemographic questions and patient-reported outcomes (PROs): distress level, physical symptoms (scale 0-10), screening for depression (PHQ-2, scale 0-6), screening for anxiety (GAD-2, scale 0-6), and daily function. Utilizations of SCS were identified from the electronic medical record (EMR) by visit types and provider names and included encounters within 6 months after completing the EDS. ED visits and hospitalizations were identified from the EMR within 1 year after EDS date. Categorical variables were summarized using frequencies and proportions, while numerical variables were summarized with descriptive statistics. The PROs were summarized overall and compared among three distress groups [distress score (DS) &lt;4, 4-6, ≥7] with Wilcoxon rank sum tests for the EDS symptom scores and Fisher's exact tests for other categorical endpoints. Logistic regression was utilized to evaluate SCS utilization versus factors of interest.
Results:
We identified 148 patients with MM with an EDS assessment within the defined window (assessment date range 12/16/19 - 10/26/21). The mean age was 65.7 years. Of the patients, 64.2% were male; 77% were newly diagnosed with MM, while 23% of patients had relapsed/refractory disease. By self-identified race, 59.2% were White, 34.7% were Black, and 6.1% identified as other racial groups. For newly diagnosed MM, patients with high distress (DS ≥7) had higher rates of lytic bone disease compared to low distress (DS &lt;4) (69.4% vs 50.9%, p = 0.17). In relapsed MM, a greater number of prior lines of treatment (4 vs. 3, p=0.08) and higher rates of prior stem cell transplant (77.8% vs. 61.5%, p = 0.46) were associated with higher distress scores. There was no association between DS and ISS, R-ISS stage, presence of high-risk cytogenetics, neuropathy, kidney disease, or heart failure at the time of the EDS. Patients with high distress scores reported more pain (p &lt;0.001), fatigue (p &lt;0.001), nausea (p = 0.047), sleep disturbances (p &lt;0.001), diarrhea/constipation (p = 0.002), sexual concerns (p = 0.014), memory/concentration difficulties (p &lt;0.001), anxiety (p &lt;0.001), and depression (p &lt;0.001). Rates of SCS utilization increased across the increasing DS groups (DS&lt;4: 37.7%, DS 4-6: 69.6%, DS ≥7: 73.5%, p&lt;0.001), and with the presence of lytic bone lesions (OR 3.73, p &lt;0.001). On multivariable logistic regression, there was a significant association between DS and SCS utilization within 6 months after EDS, after adjusting for age and lytic bone lesions at initial assessment [OR (DS 4-6 vs &lt;4): 4.17, OR (DS ≥7 vs &lt;4): 4.26; p=0.001]. There was also no association between DS and subsequent ED visits, hospitalizations, or MM treatment response 6 months and 12 months after EDS.
Conclusion:
Certain clinical features of MM and common toxicities of MM treatments correlate strongly with distress in patients. At our cancer center, patients with higher DS resulted in a higher rate of SCS utilization, but higher DS scores were not associated with a higher rate of ED visits and hospitalizations. Further investigation is needed to evaluate whether the higher rate of outpatient SCS utilization for patients with higher levels of distress leads to a reduced rate of hospitalization and ED visits compared to patients with lower distress.