Transplant Still Relevant Even in the Era of Novel Treatments for Multiple Myeloma — National Cancer Database Analysis

Background: Survival of patients with multiple myeloma has significantly improved over the last decade. Several new treatments have been approved for the treatment of myeloma in the last few years that have changed its landscape. Newer drugs with deeper and durable responses have challenged the role of autologous stem cell transplant (auto SCT) in the management of myeloma.

Aim: We aimed to study the impact of auto SCT and several other demographic and treatment related factors on the outcome of myeloma by analyzing the data from National Cancer Database (NCDB).

Materials and Methods: Data was analyzed from 9218 patients (both men and women aged >18 years) who were diagnosed with multiple myeloma and registered in NCDB between 2010 and 2013 with follow up to the end of 2014. Factors such as age, race, gender, income, education, Charlson comorbidity index (CCI), distance traveled to get cancer care, treatment facility, health insurance and type of treatment (chemotherapy only versus chemotherapy followed by auto SCT) were investigated and the primary outcome was overall survival.

Results: The median age of the patients was 66 years. Fifty five percent of patients were male. Around 56% of the patients were older than 65 years. Among the patients reviewed, 73% were Caucasian and 24% African American. As assessed by Charlson comorbidity index, 75% of patients had no major medical comorbidities. Forty six percent of patients received treatment at a facility different from where they were diagnosed with myeloma. Around one third of the patients were treated at an academic facility and the rest at either a community cancer program or comprehensive community cancer program. Treatment was initiated within 2 weeks of diagnosis in 36% of the patients whereas 21% of patients could not start treatment until after 6 weeks from diagnosis. Approximately 53% of patients had health care funding by Medicare, 35% had private insurance, 7% had Medicaid and around 5% of the patients were uninsured. Around 11% of the patients received auto SCT as part of treatment. In a multivariate analysis, after adjusting for other variables, receiving auto SCT was a statistically significant predictor of overall survival. A 71% improvement in survival was observed in patients who received auto SCT for myeloma compared to those who did not. Male gender, age older than 65 years, African American race, major comorbidities as determined by CCI, change of facility for treatment were other significant predictors of survival in the multivariate analysis. Females were 11% less likely to die of myeloma compared to males. Patients older than 65 years had 59% increased risk of dying compared to patients younger than 40 years. African Americans had 17% reduced risk of death compared to Caucasians. Myeloma patients with 1 and 2 medical comorbidities had 31% and 75% increased risk of death respectively compared to those with no comorbidities. Receiving treatment at a facility different from that of diagnosis had a very small survival advantage. Patients with Medicaid, Medicare and no health insurance had 16%, 29% and 19% increased risk of death compared to those with private insurance respectively. Level of education of patients, annual income and distance traveled to the treatment facility did not have any significant impact on the overall survival in multivariate analysis.

Conclusions: Even in the era of novel drugs for the treatment of myeloma, auto SCT still has a significant role and offers overall survival benefit according to our NCDB analysis. Male gender, elderly age, 1 or more medical comorbidities, lack of private health insurance were shown to be predictors of poor overall survival.