Introduction Only 20-50% of patients with multiple myeloma (MM) who are transplant eligible (TE) undergo autologous stem cell transplantation (ASCT). Community oncologists commonly refer newly diagnosed patients with MM to specialized transplant centers. Little is known about community oncologist barriers to referring patients to transplant centers for consultation. Intermountain Health (Intermountain) introduced an MM referral protocol in April 2023 encouraging Intermountain-employed community oncologists to refer all newly diagnosed MM patients to the central Intermountain Bone Marrow Transplant Center (the Center) by the second first-line induction cycle for transplant eligibility consultation and transplant care. The aim of this study was to understand community oncology team attitudes and beliefs regarding ASCT, early consultation and use of the Center.

Methods We conducted an explanatory, sequential mixed methods study to describe the MM patient population; assess transplant eligibility per expert medical record review and measure variation in referral rates across 9 geographically disbursed community oncology sites from Jan 2018-Jun 2025. Descriptive statistics were used to characterize population demographics. Pre/post comparisons were done using hierarchical modeling adjusting for age, gender and Charlson Comorbidity Index score (CCIS), with a site-level random effect. Reasons for variation in referral patterns were determined through key informant interviews (n=25) with primary oncologists, advanced practice providers, and nurses at 5 community sites and the Center serving urban and rural patients from five states in June-July 2025. Interviews continued until thematic saturation was reached by role. Interviews were analyzed using a qualitative content analysis paradigm.

Results Nine community sites treated 269 patients with no prior cancer history newly diagnosed by an Intermountain oncologist with MM [male: 61%; mean age: 67.7 years; non-white race: 5%; Hispanic ethnicity: 10%; median CCIS: 2.0 (IQR:0-4); live>100 miles from Center: 48%]. 44% of the full patient population received a transplant. Upon expert review, 70% (n=189) of all MM patients were deemed TE with 68% of TE patients receiving a transplant.

Seventy-two percent (72%) of all patients were referred for evaluation. Referral rates increased post-implementation systemwide from 70% to 76% (adj OR 2.5 [95%CI,1.0-6.2]; TE patients: 84% to 91% (adj OR 2.7[95%CI, 0.8-8.4]) Referral rates varied significantly by site and physician. TE patients not referred tended to be older (mean age: 72 vs 62; p<.001) and live >100 miles from the Center (57% vs 43%; p=.01)

We saw an overall improvement in survival among TE patients referred to the Center for consultation vs non-referred TE patients (p<.001).

Community oncologists interviewed identified ASCT as the standard of care for first line treatment for eligible patients and could verbalize ASCT eligibility criteria. Community oncologists valued the Center's MM expertise in assessing transplant eligibility and delivery of ASCT care. When consultation occurred, the community oncology care teams perceived good alignment between sites and the Center, with few disagreements on eligibility and first line treatment, driven by strong physician-to-physician communication; use of weekly tumor boards; care coordination using specialized nurse navigators; and rapid Center response.

Consistent with quantitative findings, barriers to referral included the preference by some community oncologists to exclude from referral any patients they felt were clearly transplant-ineligible given age, fitness and/or comorbidities. For some referred patients, Center consultation was not covered by their insurance, and they sought care elsewhere. Patient treatment preferences and socio-economic concerns, including distance to the Center, were also identified barriers.

Conclusions Despite developing novel therapies, ASCT remains the reported standard of care among interviewed community oncologists in a large healthcare network. A formal MM evaluation program was associated with increases in referral rates improving informed consent regarding ASCT. Community oncology teams felt that ASCT care was best done centrally, though some evaluated transplant eligibility themselves. Persistent patient barriers remain. Future innovations that preclude the use of ASCT may require expanding local resources and expertise to support MM care.

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2025
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