Background: There has been major improvement in the survival of patients with multiple myeloma (MM), mostly due to the availability of more effective drugs and increased use of autologous hematopoietic progenitor cell transplantation (AHPCT). Access to AHPCT has been linked to demographic, geographic and socioeconomic parameters. We hypothesize that the distance between the patient county of residence and a transplant center is an adequate surrogate of access to advanced care (comprising not only AHPCT, but also experimental therapies) and may affect survival of MM patients.

Methods: We conducted an analysis of patients diagnosed with MM between 2002 and 2011 reported to the Surveillance Epidemiology and End Results program (SEER-18). Cases reported from death certificate or autopsy only, and cases with missing race or county of residence were excluded (1% of total). Patients were classified according to the distance between county of residence and the nearest program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT): Cohort A (<20 miles), B (20-70 miles), C (70-200 miles) and D (>200 miles).

Results: We included 45,079 patients with median follow up of survivors of 30 months. There were substantial differences between the cohorts, particularly in race-ethnicity, income and education (Table 1). Median survival was 34, 37, 31 and 30 months for cohorts A, B, C and D respectively (Figure 1). Using Cox proportional hazards, we built two different survival models. Model 1 included demographic parameters and distance to transplant center. Compared to cohort A, risk of death was lower in cohort B and higher in cohorts C and D (Table 2). Model 2 included all parameters of model 1 plus median household income and proportion of adults in the county of residence with at least bachelor degree. Income and education were strongly associated with survival and displaced distance to transplant center from the model (Table 2). Other factors associated with worse survival were age, earlier year of diagnosis, male sex, presentation with plasma cell leukemia, and race-ethnicity.

Conclusion: Distance to transplant center, a surrogate for access to advanced care, is associated with survival in patients with MM, likely reflecting underlying differences in demographics, income and education.

Abstract 858. Table 1 –

Characteristics of the patients

 Total A B C D  
 N=45,079 N=19,476 N=15,614 N=8,262 N=1,727 P 
Female 20,419 (45.3%) 8,967 (46.0%) 7,036 (45.1%) 3,654 (44.2%) 762 (44.1%) 0.02 
Age 68.4 68.4 68.8 68.3 68.2 0.005 
Race-ethnicity      <0.001 
AIAN 211 (0.5%) 39(0.2%) 36 (0.2%) 36 (0.4%) 100 (5.8%)  
API 2282 (5.1%) 1381(7.1%) 751 (4.8%) 124 (1.5%) 26 (1.5%)  
Hispanic 4557 (10.1%) 2504 (12.9%) 1,129 (7.2%) 470 (5.7%) 454 (26.3%)  
NHB 8615 (19.1%) 4708 (24.2%) 2,236 (14.3%) 1,600 (19.4%) 71 (4.1%)  
NHW 29,414 (65.2%) 10,844 (55.7%) 11,462 (73.4%) 6,032 (73.0%) 1,076 (62.3%)  
Year of diagnosis      0.02 
2002-2006 21,076 (46.8%) 9,185 (47.2%) 7,185 (46.0%) 3,854 (46.6%) 852 (49.3%)  
2007-2011 24,003 (53.2%) 10,291 (52.8%) 8,429 (54%) 4,408 (53.4%) 875 (50.7%)  
Household income $59.157 $60,254 $66,540 $45,237 $46,633 <0.001 
Adults with at least bachelor degree 29.7% 32.8% 31.6% 19.7% 24.3% <0.001 
Disease      0.46 
Multiple Myeloma 44,749 (99.3%) 19,327 (99.3%) 15,498 (99.3%) 8,212 (99.2%) 1,712 (99.1%)  
Plasma Cell Leukemia 330 (0.7%) 149 (0.7%) 116 (0.7%) 60 (0.8%) 15 (0.9%)  
 Total A B C D  
 N=45,079 N=19,476 N=15,614 N=8,262 N=1,727 P 
Female 20,419 (45.3%) 8,967 (46.0%) 7,036 (45.1%) 3,654 (44.2%) 762 (44.1%) 0.02 
Age 68.4 68.4 68.8 68.3 68.2 0.005 
Race-ethnicity      <0.001 
AIAN 211 (0.5%) 39(0.2%) 36 (0.2%) 36 (0.4%) 100 (5.8%)  
API 2282 (5.1%) 1381(7.1%) 751 (4.8%) 124 (1.5%) 26 (1.5%)  
Hispanic 4557 (10.1%) 2504 (12.9%) 1,129 (7.2%) 470 (5.7%) 454 (26.3%)  
NHB 8615 (19.1%) 4708 (24.2%) 2,236 (14.3%) 1,600 (19.4%) 71 (4.1%)  
NHW 29,414 (65.2%) 10,844 (55.7%) 11,462 (73.4%) 6,032 (73.0%) 1,076 (62.3%)  
Year of diagnosis      0.02 
2002-2006 21,076 (46.8%) 9,185 (47.2%) 7,185 (46.0%) 3,854 (46.6%) 852 (49.3%)  
2007-2011 24,003 (53.2%) 10,291 (52.8%) 8,429 (54%) 4,408 (53.4%) 875 (50.7%)  
Household income $59.157 $60,254 $66,540 $45,237 $46,633 <0.001 
Adults with at least bachelor degree 29.7% 32.8% 31.6% 19.7% 24.3% <0.001 
Disease      0.46 
Multiple Myeloma 44,749 (99.3%) 19,327 (99.3%) 15,498 (99.3%) 8,212 (99.2%) 1,712 (99.1%)  
Plasma Cell Leukemia 330 (0.7%) 149 (0.7%) 116 (0.7%) 60 (0.8%) 15 (0.9%)  
View Large

Table 2 –

Multivariate analysis of factors associated with survival in MM

Factor Reference HR 95% C.I. P 
Model 1     
     
Year of diagnosis Per year 0.963 0.959-0.968 <0.001 
Age at diagnosis Per year 1.042 1.041-1.044 <0.001 
Female Male 0.90 0.89-0.93 <0.001 
Plasma Cell Leukemia Multiple Myeloma 2.94 2.60-3.31 <0.001 
Race-ethnicity    <0.001 
AIAN NHW 1.04 0.87-1.26 0.65 
API NHW 1.03 0.97-1.09 0.32 
Hispanic NHW 1.14 1.09-1.19 <0.001 
NHB NHW 1.11 1.07-1.15 <0.001 
Distance to advanced care    <0.001 
20 - 70 miles <20 miles 0.96 0.93-0.99 0.005 
70-200 miles <20 miles 1.10 1.06-1.14 <0.001 
>200 miles <20 miles 1.10 1.03-1.17 0.004 
     
Model 2     
     
Year of diagnosis Per year 0.963 0.959-0.968 <0.001 
Age at diagnosis Per year 1.042 1.041-1.044 <0.001 
Female Male 0.91 0.89-0.93 <0.001 
Plasma Cell Leukemia Multiple Myeloma 2.94 2.60-3.31 <0.001 
Race-ethnicity    <0.001 
AIAN NHW 1.04 0.86-1.25 0.68 
API NHW 1.06 1.00-1.12 0.04 
Hispanic NHW 1.15 1.10-1.20 <0.001 
NHB NHW 1.08 1.05-1.12 <0.001 
Household income Per $10,000 0.98 0.96-0.99 0.001 
% adults with bachelor degree Per % point 0.994 0.992-0.996 <0.001 
Factor Reference HR 95% C.I. P 
Model 1     
     
Year of diagnosis Per year 0.963 0.959-0.968 <0.001 
Age at diagnosis Per year 1.042 1.041-1.044 <0.001 
Female Male 0.90 0.89-0.93 <0.001 
Plasma Cell Leukemia Multiple Myeloma 2.94 2.60-3.31 <0.001 
Race-ethnicity    <0.001 
AIAN NHW 1.04 0.87-1.26 0.65 
API NHW 1.03 0.97-1.09 0.32 
Hispanic NHW 1.14 1.09-1.19 <0.001 
NHB NHW 1.11 1.07-1.15 <0.001 
Distance to advanced care    <0.001 
20 - 70 miles <20 miles 0.96 0.93-0.99 0.005 
70-200 miles <20 miles 1.10 1.06-1.14 <0.001 
>200 miles <20 miles 1.10 1.03-1.17 0.004 
     
Model 2     
     
Year of diagnosis Per year 0.963 0.959-0.968 <0.001 
Age at diagnosis Per year 1.042 1.041-1.044 <0.001 
Female Male 0.91 0.89-0.93 <0.001 
Plasma Cell Leukemia Multiple Myeloma 2.94 2.60-3.31 <0.001 
Race-ethnicity    <0.001 
AIAN NHW 1.04 0.86-1.25 0.68 
API NHW 1.06 1.00-1.12 0.04 
Hispanic NHW 1.15 1.10-1.20 <0.001 
NHB NHW 1.08 1.05-1.12 <0.001 
Household income Per $10,000 0.98 0.96-0.99 0.001 
% adults with bachelor degree Per % point 0.994 0.992-0.996 <0.001 
View Large

Figure 1
Figure 1.
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Disclosures

No relevant conflicts of interest to declare.

Topics:
multiple myeloma, leukemia, plasma cell, transplantation, cell therapy, experimental treatment, follow-up, hematopoietic stem cell transplantation, survivors

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2014 by The American Society of Hematology
2014
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