Management of Bone Marrow Transplants in Incarcerated Patients with Plasma Cell Dyscrasias: A Case Series

Background

The U.S.' incarcerated population aged 55 years or older is expected to increase to 400,000 by 2030. This aging population faces intensifying health issues, including an increase in cancer diagnosis rates without adequate healthcare infrastructure and access. Studies show that individuals who received a cancer diagnosis while incarcerated, or within one year of release, had higher rates of cancer-related and all-cause mortality, compared to the general population. Our research seeks to assess how a cohort of patients with plasma cell dyscrasias (myeloma, amyloidosis, plasma cell leukemia) were treated and managed while incarcerated.

Methods

We performed a retrospective chart review of three patients with plasma cell dyscrasias in the incarcerated population who have undergone bone marrow transplants. Patients' disease characteristics, treatment sequences and details, and clinical outcomes were described qualitatively.

Results

Case 1: a 48-year-old Black man diagnosed with multiple myeloma in 2019. He was treated with 5 cycles of CyBorD at an outside hospital and had a favorable response. Stem cells were collected but never transplanted and patient was lost to follow-up due to incarceration. In April 2021, he presented to us with bilateral lower extremity paralysis and difficulty walking while in prison. He received emergent radiation to spine, then underwent both DCEP and VDPAC. The patient was discharged for physical rehabilitation in prison with ixazomib maintenance and monthly lab work. 6 months later, he was sent to another outside hospital with acute renal failure and then transferred to us. He demonstrated relapsed myeloma, received DV-AC, and was discharged back to prison while we awaited banked stem cells from 2019. He was admitted a month later for melphalan and auto-SCT, which was well-tolerated. We were ultimately able to arrange lenalidomide maintenance with prison.

Case 2: a 65-year-old Black man with abnormal cardiac imaging and lymph node biopsy concerning for amyloid in 2020 while in prison. No treatment was given at the time. In 2021, an outside hospital conducted a bone marrow biopsy showing monoclonal plasma cells consistent with primary amyloidosis. 3 months later, the patient began CyBorD but completed subsequent cycles at another outside hospital. Correctional authorities indicated transplant would ultimately need to occur at our facility. Patient began stem cell mobilization and was admitted to us for melphalan and auto-SCT in March 2022. Patient was discharged back to corrections but there was a delay in acquiring lenalidomide for maintenance therapy, which was not started until August 2022.

Case 3: a 44-year-old Black man was diagnosed with plasma cell leukemia in 2009. That year, he received an auto-SCT and then an allo-SCT from his HLA-matched sister at an outside hospital. In 2016, he received radiation for a large mass in his brain, as well as lenalidomide and dexamethasone. Since then, records indicate limited follow-up until he presented to us in 2022 with leg pain and imaging showing progressing myeloma while in prison. He was given 1 cycle of DCEP, was discharged back to a correctional facility, and subsequently refused 2 ^nd cycle. He sought a second opinion from an outside hospital for CAR-T therapy but was told eligibility required failure of daratumumab. In January 2023, he was offered Dara-Pom-Dex-Carfilzomib though declined the pomalidomide portion. He has responded well and is continuing maintenance. The CAR-T center offered to see him for treatment if he progresses on this regimen.

Discussion

Our research suggests that incarcerated patients face multiple obstacles that delay or hinder treatment, including siloed care, poor record-keeping, lack of follow-up, and difficulty obtaining appropriate medications. All three patients were frequently transferred between correctional facilities, outside hospitals, and our institution, which led to incomplete records. Additionally, patients went months or even years without follow-up monitoring after initial treatment and would often re-enter the healthcare system only upon presenting with severe symptoms from relapsed disease. Correctional facilities faced issues procuring expensive medications only available through restricted distribution programs. Further analysis is warranted to understand the generalizability of our results and identify solutions to support this population.