Distance From a Tertiary Care Center Is Not a Barrier to Transplant for Patients with Myeloma.

Abstract 4366

Autologous hematopoietic stem cell transplantation (HSCT) may improve overall survival for patients with myeloma. In rural communities, access to care limits the availability of HSCT and questions its safety for patients travelling long distances. In rural settings, therapies independent of tertiary care centers assume increased relevance. For example, novel agents (bortezomib, lenalidomide), alone or in combination, offer high response rates, near rates observed with HSCT. As an NCI-designated Comprehensive Cancer Center located in rural New Hampshire, we evaluated the impact of transplant patients' distance from the center on survival following transplant for myeloma.

We performed a retrospective analysis of 77 myeloma patients who received a HSCT at Dartmouth between 1996 and 2009. All patients received high dose melphalan followed by a HSCT. Using linear regression and univariate analysis, we examined the impact of distance from the transplant center and the use of novel agents prior to transplant on survival. Kaplan-Meier curves identified overall and event free survival. The median distance for the 77 patients was 48 miles (range 6 to 2225 miles). Patients living further away were 55 yrs of age (median; range 43-73 yrs) compared with 59 yrs (median; range 45-71 yrs) for patients living closer. There was no difference in response rates at the time of transplant between patients living close or traveling distances: PR (n = 60), CR (n=7), MR (n=5), or PD (n=3). For the total patient cohort, overall survival was 75 months (median; range 0.5 – 142 mos) and the relapse free survival was 22 months (median; range 2.5- 142 mos). Distance from the transplant center correlated with improved overall survival (p=0.004), but had no impact on disease-free survival (p = 0.26). Due to these findings, we examined the effect of novel agents on survival in patients travelling long distances. Sixty-nine percent of patients living more than 48 miles away received novel agents compared to 60% of patients of patients living within 48 miles (p value not significant). There was no impact on overall survival (p = 0.9), but a trend toward earlier relapse was observed with the use of novel agents (p=0.06). Although patients traveling farther tended to be younger, age did not correlate with differences in overall or disease-free survival (p= 0.32 and 0.19 respectively).

Although distance from the transplant center may affect patient's care, these results indicate an improved survival with increasing distance from the transplant center. This improvement is not related to the use of novel agents prior to transplant, but is likely due to a referral bias, with only the healthiest patients living long distances away being referred. Additionally, cohort sizes, early initiation of novel agents after transplant in patients not receiving a PR or the low number of patients in CR entering transplant may impact results. These results indicate that distance from a transplant center should not be a barrier to HSCT for eligible patients with multiple myeloma.