Overcoming Disparities

Studies of Asian Americans, Hispanic Americans, and African Americans

Published in Cancer Medicine in 2017, this study found that “disparities exist in patient outcomes by patient race-ethnicity.”1 However, it also found that the “majority of the reported studies of racial disparity in survival have focused on White and African-American patients.” 

The above study also noted differences in the use of immunomodulatory drug (IMiD) therapies by race. For example, Hispanics had the highest use of lenalidomide, whereas thalidomide use was higher in Hispanics and Asians. On the other hand, African Americans had the lowest use of lenalidomide. 

Another study2 showed lower use of bortezomib among African Americans, but it did not evaluate Hispanics separately.

With many of the holes in current studies, we can say that, across the board, disparities in the care of various U.S. racial and ethnic groups exist, but not enough research has been done to pinpoint the reasons for and causes of these disparities. Outlined below are some issues in myeloma care that pertain particularly to African American and Hispanics.

Disparities Specific to African Americans

Death rates are higher among black myeloma patients. A number of published studies, including the 2019 edition of the American Cancer Society’s Cancer Facts and Figures, have concluded that the disparity in black vs. white death rates from myeloma “is believed to be due to socioeconomic barriers that limit access to timely, appropriate, and high-quality medical care.”3

An article published in April 2019 in Blood confirms this hypothesis. The article, entitled “With equal access, African Americans have superior survival compared to Caucasians with multiple myeloma: A VA study,” summarizes a large study of myeloma patients seen at the Veterans Administration (VA) whose medical records are stored in the VA’s nationwide electronic health records database.4 The researchers identified 15,717 patients with symptomatic myeloma in the VA health-care system between 2000 and 2017. They compared treatments administered to African-American and Caucasian patients at VA facilities and found that they had equal access to new therapies and stem cell transplant. African-American VA patients younger than 65 years of age at diagnosis had a significantly superior median overall survival following diagnosis (7.07 years) compared to Caucasian patients (5.83 years). For patients 65 years or older at diagnosis, median overall survival was similar between African-Americans and Caucasians.

“Taken with previous research in other healthcare systems that does demonstrate disparities,” say the researchers, “our study suggests disparity to be primarily due to socioeconomic factors.” With equal access to quality care, younger black patients live longer than their white counterparts, and survival is the same for older black and white patients.

Because of these disparities, the IMF has established the African-American Initiative to assist this myeloma patient population. 

Disparities Specific to Hispanics

According to this article in Blood that surveyed multiple myeloma patient studies, “Several large population-based studies report that Hispanics have low stem cell utilization rates, limited access to novel therapeutics and clinical trials as well. Hence, outcomes for Hispanics and AA [African Americans] lag behind non-Hispanic Whites as well.”

Another study also examined Hispanic multiple myeloma [MM] patients’ lack of access to stem cell transplant. It concluded that stem cell transplant utilization rates were “low and significantly lower among Hispanic followed by non-Hispanic Blacks compared to non-Hispanic Whites. Race/ethnicity does not impact transplant outcomes. Efforts to increase transplant utilization for eligible MM patients, with emphasis on groups underutilizing transplant are warranted.” 6

The IMF supports this conclusion and hopes to widen treatment options for Hispanic patients who may face barriers to early transplant options.

People of Color and Access to Healthcare

As researcher Mark Fiala, of Washington University in St. Louis, explains, "Socioeconomic status [SES] is a construct that is commonly conceptualized as a person's social class or social standing. And typically, it's broken into low socioeconomic status, middle socioeconomic status, and upper socioeconomic status."7

We know that socioeconomic status is associated with overall survival in myeloma patients. A study of 3 groups of people divided by socioeconomic status was conducted. The group with the highest socioeconomic status had an overall survival average of 38 months. The lower groups were only 32 and 29 months respectively. African Americans were more likely to fall into the two lower socio-economic groups.7

According to a study by the Urban Institute, African Americans are less likely to see benefits from the Affordable Care Act.8 The main reason for this disparity is that African Americans disproportionately live in states that have not expanded Medicaid. The study showed that 1.4 million uninsured African Americans live in these states and constitute 23.1% of the uninsured adult population nationwide.

Yet African Americans are not the only group who may have difficulty in accessing care as well as encounter risks to their financial stability because of health-care costs. According to the Kaiser Family Foundation, all people of color in the U.S. face these issues. Even though, since the implementation of the Affordable Care Act in 2014, "people of color have experienced large coverage gains that helped narrow the longstanding racial and ethnic disparities in coverage," they still are more likely to be uninsured, with American Indians and Alaska Natives, as well as Hispanics, found to be at highest risk for lacking coverage.9

It is important that health-care providers not assume that certain treatment options may be financially burdensome for some patients. Rather, patients, regardless of their socio-economic background, must be presented with all treatment options.

The IMF is committed to ensuring that all multiple myeloma patients learn how to receive the best health care possible in their state of residence. We offer a free information line to assist you to find insurance and co-pay assistance resources in your area.

Call to Action

The IMF hopes to support more investigations into the nature of disparities related to the fast-growing U.S. Hispanic and Asian populations. Furthermore, there is a great lack of research into how myeloma affects Native Americans.

We know that some of these disparities are moreover linked to socio-economic status rather than to race and ethnicity.

The 2017 study entitled “Improved survival in multiple myeloma, with a diminishing racial gap and a widening socio-economic status over three decades” determined that the survival for MM “improved each decade with a larger increment in the last two decades, with a narrowing survival gap among races and a widening gap among socioeconomic status groups.”10

Awareness of these gaps, even though they are not yet thoroughly researched, is encouraging clinicians to design better treatment protocols and advocates to press for improved health-care policy to serve people of all socioeconomic backgrounds.

a
headshot of Tiffany Williams
Tiffany Williams
Diagnosed with myeloma in 2013, Tiffany is a co-facilitator of the Charleston Area Multiple Myeloma Networking Group
Sunrise
My experiences over the years as a support group leader have been that most leaders are experiencing similar challenges, looking for ways to diversify group participation and ensure that we all live well with myeloma. Much like the health-care system, we have to better understand barriers to participation.

1.    Ailawadhi S, et al. Racial disparity in utilization of therapeutic modalities among multiple myeloma patients: a SEER-medicare analysis. Cancer Med. 2017;6(12):2876-2877.
2.    Fiala MA, Wildes TM. Racial disparities in treatment use for multiple myeloma. Cancer. 2017 May 1;123:1590–1596.
3.    American Cancer Society. Cancer Facts and Figures for African Americans 2019-2021. Atlanta: American Cancer Society, 2019. Available at: www.cancer.org. Accessed April 19, 2019.
4.    Filmore, NR, et al. With equal access, African Americans have superior survival compared to Caucasians with multiple myeloma: a VA study. Blood. 2019; Jun 13;133(24):2615-2618. 
5.    Kaur G, et al. Multiple myeloma in Hispanics is associated with better survival than non-Hispanic African Americans and Whites: analysis from a large single center minority rich cohort. Blood. 2018;132:3601.
6.    Schriber JR, et al. Hispanics have the lowest stem cell utilization rate for autologous hematopoietic cell transplantation for multiple myeloma in the United States: a CIBMTR report. Cancer. 2017 Aug15;123(16):3141-3149.
7.    Fiala MA, et al. Socioeconomic status is independently associated with overall survival in patients with multiple myeloma. Leuk Lymphoma. 2015;56(9)2643-2649.
8.    Garrett B, Gangopadhyaya A, for the Robert Wood Johnson Foundation. Who Gained Health Insurance Coverage Under the ACA, and Where Do They Live? Washington, D.C.: The Urban Institute. Dec 2016. 
9.    Artiga S, et al. Changes in Health Coverage by Race and Ethnicity since Implementation of the ACA, 2013-2017. San Francisco: Henry J. Kaiser Family Foundation. Feb 13,2019. Available at: www.kff.org. Accessed August 19, 2019.
10.    Sun T, et al. Improved survival in multiple myeloma, with a diminishing racial gap and a widening socioeconomic status gap over three decades. Leuk Lymphoma. 2018;59(1):49-58.

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