publication date: Nov. 1, 2019

Clinical Roundup

Study finds racial disparities in treatment of multiple myeloma patients

African Americans and Hispanic people with multiple myeloma start treatment with a novel therapy significantly later than white patients, according to a study published Oct. 17 in Blood Advances.

The study found that on average it took about three months for white patients to start novel therapy after diagnosis, while it took about five months for African Americans and Hispanic patients to start novel therapy after diagnosis.

The time between diagnosis and treatment is crucial to multiple myeloma outcomes. If treatment is delayed, multiple myeloma patients can suffer organ damage, kidney dysfunction, anemia, skeletal fractures, infections and other serious conditions. Best practice is to start patients on immunomodulatory drugs such as lenalidomide and/or proteasome inhibitors such as bortezomib and carfilzomib. The use of these therapies has more than doubled survival of multiple myeloma patients within the past decade.

“We noted that minorities are not getting introduced to treatment early enough to derive adequate clinical gains,” lead author Sikander Ailawadhi, of Mayo Clinic Florida, said in a statement. “Since our analysis is based on Medicare patient data, these disparities cannot be attributed to differences in insurance coverage. Patients are not receiving treatment equally even in this ostensibly equal-access setting.”

Researchers reviewed data from the SEER–Medicare database from 2007-2013. The study included 3,504 white patients, 858 African Americans and 468 Hispanic patients. Their analysis found that the average length of time between multiple myeloma diagnosis and start of treatment for white patients was 2.7 months, compared to 4.6 months for Hispanics and 5.2 months for African Americans. Rates of autologous stem cell transplant within one year of diagnosis, considered the standard of care for eligible patients, rose among whites and African Americans but not for Hispanics.

This study found that median overall survival was similar across all groups, but comparison to previous studies suggests the survival rate for African Americans in particular has not increased as much as it could have with equal and timely access to treatment. The authors suggest the delay in treatment initiation may have inhibited African Americans’ normally better survival outcome, but this would have to be confirmed in another study.

One encouraging observation in the study was the increasing trend of beginning these therapies within the first six months of multiple myeloma diagnosis for all three race/ethnicity cohorts over the duration of the study. However, this increase was more pronounced among white and Hispanic patients compared with African Americans.

The study also found that medical costs were highest among Hispanic patients. The total monthly medical costs for whites averaged $10,143, versus $11,546 for African Americans and $12,657 for Hispanics. Researchers suggest the higher cost could be due in part to higher hospitalization costs, possibly incurred as a result of complications from delayed treatment.


Dana-Farber and UT Southwestern study finds racial disparities in culturally competent cancer care

Many non-white minority cancer survivors place importance on seeing doctors who share or understand their culture, but are less likely than non-Hispanic whites to be able to see such physicians, according to a new study from Dana-Farber Cancer Institute and University of Texas Southwestern.

The study, one of the first nationally-representative studies to examine patient-reported preference for, access to, and quality of provider cultural competency among cancer survivors, was published in JAMA Oncology.

Almost half of non-white minorities (49.6%) said it was somewhat or very important to be treated by doctors who understand their culture. However, these patients were less likely than non-Hispanic whites to receive treatment from these providers, by a difference of 65.3% to 79.9%. And 12.6% of the minority patients said they were never able to see physicians who shared or understood their culture, compared with 4% of non-Hispanic whites.

“There are data to show that oncology subspecialties, compared with other specialties in medicine, are comprised of the lowest representation of under-represented minority physicians,” co-senior author Brandon A. Mahal, of Dana-Farber, said in a statement. According to Mahal, the oncology workforce is currently made up of only 5.3% black/African American and Hispanic/Latino physicians.

Despite these disparities, minority and non-Hispanic white cancer survivors were equally positive about their encounters. Both groups reported high rates of instances where physicians frequently treat them with respect, provide easily understood health information, and ask them for their opinions or beliefs regarding care.

The researchers based their findings on a national survey that included 2,244 adult cancer survivors, of whom 1,866 were non-Hispanic white, who responded to a set of questions regarding physician cultural competency.

Racial or ethnic cultures may have different forms and norms of communication and varying levels of trust in the healthcare system. Prior research has shown that oncologists’ implicit racial bias (among racially discordant oncologist-patient relationships) is associated with poorer measures of patient confidence in treatment, patient recollection of information, length of visit, and provider supportiveness and patient-centeredness.

While the very limited diversity of the oncology workforce is one likely explanation for the mismatch between patients’ preferences and their experiences, the researchers said other factors could be involved. These include insufficient training in cultural competency, geographic variations in physician availability, insurance plan coverage networks, and the possibility that some patients may value other physician characteristics than cultural competency.

“Our findings highlight a persistent shortcoming of longitudinal cancer care for minority patients and the critical need for culturally competent providers,” first author Santino S. Butler, of Dana-Farber/Brigham and Women’s Cancer Center, said in a statement.

Butler said the survey’s results reinforce policy initiatives set forth by major cancer organizations, including the American Society of Clinical Oncology, which recently highlighted the association between racial/ethnic disparities in cancer outcomes and a “lack of access to high-quality care that is understanding and representative of diverse traditions and cultures.”

The investigators added that “institutions should emphasize the need for, and offer opportunities for their workforce to pursue continuing medical education in cultural competency in order to improve care for their diverse patient populations.”


NCCN publishes guidelines on managing complications and improve readiness for stem cell transplants

The National Comprehensive Cancer Network published guidelines that provide step-by-step information on best practices in evaluating patients for hematopoietic cell transplantation and managing complications afterwards.

This type of specialized treatment is increasingly common, occurring approximately 22,000 times a year in the United States in people with various malignancies, most commonly for blood-related cancers.

“The current version of the guidelines addresses both pre-transplant evaluation and the management of a common complication: graft versus host disease,” NCCN Guidelines panel chair for HCT, Ayman A. Saad, professor of clinical medicine at The Ohio State University Comprehensive Cancer Center—James Cancer Hospital and Solove Research Institute, said in a statement.

“Given the diversity of practice and expertise, we believe these guidelines will provide a pivotal tool for learning about the continuously updated therapy landscape in HCT. We hope this will help streamline clinical practices and educate new generations of physicians-in-training,” Saad said.

The NCCN Clinical Practice Guidelines in Oncology for hematopoietic cell transplantation provide recommendations on how to evaluate a potential transplant recipient to

determine if the patient is an appropriate candidate for the procedure, and how to best manage different manifestations of post-transplant GVHD. They reflect the latest evidence and consensus from foremost experts across the 28 leading academic cancer centers that comprise NCCN, including hematologists/oncologists, transplant-specific practitioners, and infectious disease specialists.

The NCCN Guidelines for Hematopoietic Cell Transplantation are available free-of-charge for non-commercial use at and via the Virtual Library of NCCN Guidelines app. NCCN will continue expanding blood cancer resources through continuous updates to the HCT guidelines, along with upcoming new NCCN Guidelines for Histiocytosis, Myeloid/Lymphoid Neoplasms, Pediatric B-Cell Lymphomas, and Pediatric Hodgkin Lymphoma.


Acute lymphoblastic leukemia relapses reduced by 31%, St. Jude study shows

St. Jude Children’s Research Hospital’s Total Therapy Study 16 showed a reduced rate of central nervous system relapse in acute lymphoblastic leukemia, according to results published online Oct. 28 in the Journal of Clinical Oncology.

Despite modern therapies, 10% of patients with ALL treated in the United States relapse, which dramatically reduces their chance of survival.

The study evaluated interventions aimed at preventing relapse by improving systemic and CNS disease control. Researchers found that adding doses of chemotherapy in the cerebrospinal fluid earlier in care improved CNS control without adding toxicity for high-risk patients.

On the predecessor clinical trial (Total 15), the rate of CNS relapse for high-risk patients was 5.7%. Under Total 16, the rate of CNS relapse for a similar group of patients was reduced to 1.8%, the lowest among reported studies. As in Total 15, no patient received prophylactic cranial radiation. These results further supported the conclusion of Total 15 that all children with acute lymphoblastic leukemia can be safely spared prophylactic cranial radiation.

Total 16 enrolled 598 patients age 18 and younger from 2007-2017. This study included all subtypes of ALL, including B-ALL and T-ALL, those with Philadelphia chromosome rearrangements, and infant leukemia, among others.

The next St. Jude clinical trial for ALL, Total 17, continues to stratify patients based on their risk of relapse and introduces novel molecular targeted and immunotherapies, including CAR T-cells.

The study’s authors are Sima Jeha, Ching-Hon Pui, Dequing Pei, John Choi, Chang Cheng, John Sandlund, Hiroto Inaba, Jeffrey Rubnitz, Raul Ribeiro, Tanja Gruber, Susana Raimondi, Raja Khan, Jun J. Yang, Charles Mullighan, James Downing, William Evans, Mary Relling and Ching-Hon Pui. Elaine Coustan-Smith and Dario Campana of the National University of Singapore also contributed to the study.

The research at St. Jude was funded by grants from the National Cancer Institute (CA21765, CA36401, CA176063 and P50 GM115279), and ALSAC, the fundraising and awareness organization of St. Jude.

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