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Supportive care measures underused among older patients with multiple myeloma
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Older adults with multiple myeloma in the United States significantly underused guideline-recommended supportive care measures, and this underutilization appeared linked to both facility and patient factors, according to a study published in Cancer.
“Supportive care research is a relatively neglected part of cancer research in general; much of the focus on myeloma, or any cancer research for that matter, is on developing new therapeutics and drug combinations for improving survival,” study author Smith Giri, MD, assistant professor of medicine in the division of hematology and oncology at University of Alabama School of Medicine, said in an interview with HemOnc Today. “However, patients with myeloma are living longer than before, often more than 5 or 10 years. Now is the right time to focus on survivorship and measures to reduce morbidity and improve quality of life.”
Giri said this study is among the most recent to explore the therapeutic and palliative needs of older adults, who are especially vulnerable to cancers such as myeloma.
“Myeloma in general is a disease of aging — the median age at diagnosis is now close to 70 years and will likely get higher,” Giri said. “There is evidence of undertreatment [for] older adults with cancer, and our study suggests that. But, obviously, more research needs to happen to solve the puzzle completely and improve patient outcomes.”
SEER-Medicare data: A ‘unique resource’
Giri said underrepresentation of older patients in clinical trials is a major reason cancer incidence and outcomes in this demographic are poorly understood.
“Much of our data come from cancer clinical trials, and there has been a big push to get more older patients to participate in these trials,” Giri said. “However, there are other resources, as well. SEER-Medicare is a unique resource that allows us to study treatment patterns and outcomes among older patients.”
In their population-based cohort study, Giri and colleagues reviewed information from the SEER database to identify 1,996 adults aged 66 years and older (median age, 74 years; interquartile range, 70-80; 54% women) diagnosed with multiple myeloma as their first and only cancer between 2008 and 2013. Eligible participants had received active treatment and were alive at least 1 year after diagnosis.
Most of the patients were non-Hispanic whites (72%), followed by non-Hispanic blacks (12%). About 26% of patients were enrolled in dual-coverage Medicaid, and two-thirds (66%) received treatment in a community/physician’s office setting.
Researchers defined guideline-recommended supportive care — which served as an outcome of interest — as the use of bone-modifying drugs (BMDs) within 1 year after diagnosis; influenza vaccination in the first influenza season after diagnosis; and the simultaneous use of prophylactic antivirals and proteasome inhibitors. They used multivariate logistic regression models to assess correlations between patient- and facility-level factors and use of supportive care.
Of the patients who underwent multiple myeloma-directed therapy, 1,277 (64%) received BMDs, 946 (52%) were vaccinated against influenza and 703 (49%) were treated with prophylactic antiviral medications.
“These findings were rather surprising to all of us,” Giri told HemOnc Today. “We found that, over time, there was an improving trend toward increasing use of antiviral prophylaxis, but not for the other two measures.”
Multivariable analysis showed the following factors to be associated with lower odds of BMD use: preexisting chronic kidney disease at diagnosis (OR = 0.43; 95% CI, 0.34-0.54); non-Hispanic black race (OR vs. white race = 0.63; 95% CI, 0.46-0.88); use of only oral antimyeloma treatment (OR = 0.46; 95% CI, 0.37-0.57); older age at diagnosis (P = .05) and higher comorbidity burden (Elixhauser Comorbidity Index score of > 3; OR = 0.69; 95% CI, 0.5-0.96).
Similarly, reduced odds of receiving an influenza vaccination appeared linked to non-Hispanic black race (OR = 0.52; 95% CI, 0.37-0.73), residing in the West (OR = 0.5; 95% CI, 0.36-0.68), lower neighborhood education level (high school education < 40%; OR = 0.7; 95% CI, 0.51-0.96) and Medicaid dual coverage (OR = 0.76; 95% CI, 0.58-0.99).
Factors linked to lower odds of antiviral prophylaxis use included higher comorbidity burden (Elixhauser Comorbidity Index score of > 3; OR = 0.61; 95% CI, 0.45-0.84), treatment in the physician’s office (OR = 0.58; 95% CI, 0.46-0.72) and living in the South (OR = 0.59; 95% CI, 0.4-0.86).
Understanding the predictors
According to Saad Z. Usmani, MD, FACP, division chief of plasma cell disorders at Levine Cancer Institute at Atrium Health and a HemOnc Today Editorial Board Member, geographic and socioeconomic factors play a significant role in access to supportive care treatments for elderly patients with multiple myeloma.
“One big issue that we see when it comes to disparities in care is that not every geographic area in the U.S. has the same resources; there are places in the Midwest where the closest cancer center may be 50 or 60 miles away from the patient,” Usmani told HemOnc Today. “There also are urban areas where, even though the nearest cancer center may be 10 or even 5 miles away, it takes the patient 45 to 50 minutes to get there. So, this partly has to do with some of these logistical issues, where the patients may think of this as an optional part of their care and don’t actually seek these treatments.”
Usmani added that similar nuances may contribute to a low uptake of influenza vaccines among this patient population.
“Maybe the patient has had a bad experience with getting the flu vaccine; maybe they have gotten symptoms from it in the past and have said, ‘This vaccine gives me symptoms; I’m not going to get it,’ or maybe they did get the vaccine and still ended up getting the flu,” Usmani said. “It can be hit-or-miss depending on what kind of strain becomes prevalent in a particular season. Some of these factors play a role in patients not following through with influenza vaccinations.”
According to Giri, the low vaccination rates among older patients with multiple myeloma were perplexing to his research team but may reflect an overall trend among patients with cancer.
“We did not have the data to look at reasons for nonuse; however, we believe both patients and providers are to blame,” he said. “There is a lot of skepticism, even within oncology, as to whether vaccination truly benefits patients with cancer. However, I think we have enough evidence to support that flu vaccines work and that they are safe, although efficacy may be a little lower than in normal, healthy adults.”
Giri noted that patient-level barriers likely also played a role in the lack of vaccination.
“There are reservations among patients in general,” he said. “We’ve all seen patients who have strong reservations about vaccination. That needs to change.”
Addressing survivorship
Usmani emphasized that, as the population ages, the need to focus on quality of life among older patients with cancer will become increasingly important. He said he would like to see facility-level systems put into place that will prioritize and organize supportive care treatments.
“This is where cancer centers could benefit from having more of a pathway-based approach, where there is a checklist that needs to be marked off on antimyeloma therapy, bone health, immune dysfunction and infection risk, etc,” he said. “You’ll find that kind of approach may already exist in larger centers that have disease-specific teams. But, out in the community, we have good physicians who are trying to deal with every kind of cancer, and perhaps this is why some of these lapses may happen.”
The current study has provided valuable insight into the use of these essential supportive care treatments, which are particularly relevant for older patients with myeloma, Usmani said.
“This is a good baseline, and it can inform us about the true implementation of these guidelines in clinical practice,” he said. “One of the key things we want to do now, because we have so many effective yet tolerable drugs for older patients with myeloma, is to start paying more attention to these important supportive care measures. The core of care for these patients is not just providing longevity, but also to improve their quality of life.”
Usmani said ideally, this study will prompt the implementation of quality improvement projects at cancer centers.
“It would be a really nice follow-up to this study if centers — not just large centers but centers across the U.S. — undertook quality improvement projects to increase the follow-through and compliance with these guidelines,” he said. “In the end, these efforts can improve patients’ quality of life and outcomes.” – by Jennifer Byrne
Reference:
Giri S, et al. Cancer. 2019;doi:10.1002/cncr.32428.
For more information:
Smith Giri, MD, can be reached at 2000 Sixth Ave. South, Floor 5; Birmingham, AL 35233; email: smithgiri@uabmc.edu.
Saad Z. Usmani, MD, FACP, can be reached at 1021 Morehead Medical Drive, Building II, Suite 60200, Charlotte, NC 28204; email: saad.usmani@atriumhealth.org.
Disclosures: Giri reports no relevant disclosures. Please see the study for all other authors’ relevant disclosures. Usmani reports no relevant financial disclosures.