VIDEO: Exploring health equity in multiple myeloma

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The essence is to realize what I call real-world practices’ needs. Hospitalization for many of my patients, it’s not attractive to them. And as often single parents, breadwinners, being hospitalized for a week to 2 weeks to 3 weeks is a major challenge. We have tools, we have therapies that are strictly outpatient — be they oral, infusional — that we can use and really meaningfully benefit patients. And I think that when we talk about off the shelf that, to my mind, means you can use it in the clinic, that you can have it in the outpatient setting. Obviously bispecifics, technically speaking, are indeed off the shelf, but they do in fact require hospitalization. And that from a patient’s perspective is important to realize. So, I think that whilst these platforms are very exciting, I think at the same time, we have to realize their limitations, because obviously that opens the doors to the other treatment options we have for patients, which I think really matter. And I think for the elderly, the frail, for community practices to the very large communities of patients who are in the rural setting where access to a tertiary or top center that offers state-of-the-art cellular therapy, may be quite daunting or actually unattainable. You really need to think about how we can offer those patients good treatment options. So, I think there are sort of several aspects to your question you asked.

On the one hand, there’s the availability of all treatments that make sense are safe, effective, active. And, at the same time, there’s also this ability to recognize that multiple myeloma is many different diseases under one tent. Our patients are, therefore, highly varied and in that context, we need to try and provide options for all our patients in every way possible. And when you talk of health equity and how we can do that, I would pivot back to one particular study that we published last year and the importance of why it matters. This is the Determination trial that it was a privilege to be part of and to lead in which over 56 centers participated. And we looked at the role of early versus delayed transplant and the use of novel therapies in relapse. And we made a very deliberate effort to reach out to community practices and to offer access to patients in whom, traditionally, a transplant-based approach might be difficult. What was so important is that we had the highest representation of African Americans in our trial, at over 18% — who actually approached 19% overall. And that’s the largest representation in a phase 3 trial of this nature to date.

Why this was so important is because, for obvious reasons, we offered equal access for therapy. So, outcomes were excellent in all patients treated in this study. But what’s really important to recognize is that medications were provided at no charge — in particular the lenalidomide. And at the same time with that equal access provided to patients, we were able to find some astonishing conclusions. One of the most important that we have presented on at ASCO last year, also at International Myeloma Society in Los Angeles in the fall of last year, most importantly by my colleague Dr. Hani Hassoun at EBMT as an oral session this year in Paris. What Hani showed was that there are subgroups of patients who derive more benefit from actually non-transplant-based approaches than those who benefit from an early transplant. And, remarkably, we have a signal that in the African-American community and, in particular, in women of color, that actually transplant early, may not be as beneficial as we had hoped and in fact may be very reasonably kept in reserve, particularly when one looks at covariates such as body mass index. And that’s a very important observation, because it helps inform practice. So I think, this concept of health equity goes beyond the obvious, which is of course we should have it. But above all, to realize that in myeloma, more and more as I think of the disease, truly one size does not fit all. And we need to have that ability to tailor therapy for each of our patients.