According to findings from a study published in Cancer on the utilization of specific supportive care measures in older patients with multiple myeloma, only approximately two-thirds of patients received guideline-concordant administration of a bone-modifying agent.
The course of treatment for patients with multiple myeloma is typically characterized by the administration of multiple lines of therapy associated with periods of sustained response or remission followed by eventual relapse. Hence, the quality of life in these patients can be diminished by both the cumulative adverse effects of treatment as well as manifestations of the disease, including bone lesions, skeletal-related events, and an increased risk of infection. Furthermore, older age at diagnosis of multiple myeloma is another factor likely to magnify the negative impact of treatment toxicity and disease burden, and the majority of patients with this disease are diagnosed at 65 years or older.
A number of clinical guidelines covering the diagnosis and treatment of multiple myeloma, including those from the National Comprehensive Cancer Network, recommend specific supportive-care measures for these patients. These recommendations include vaccination against influenza for all patients with multiple myeloma, use of a bone-modifying agent in all patients undergoing active treatment, and prophylactic antiviral medication for those receiving a proteasome inhibitor.
The purpose of this population-based cohort study was to evaluate the extent to which these supportive-care measures were administered to patients with multiple myeloma, and to identify factors associated with their implementation (or lack thereof).
The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was accessed to identify patients aged at least 66 years who were diagnosed with multiple myeloma between 2008 and 2013 (with no other cancer diagnoses) and who had received active treatment and survived for at least 1 year following diagnosis.
From this primary cohort of patients, which was used to assess utilization and patterns related to use of bone-modifying agents, 2 subcohorts were subsequently identified: patients surviving the first full influenza season following cancer diagnosis; and those with at least 2 claims for a proteasome inhibitor during the period flanked by 30 days prior to and 2 years following diagnosis of multiple myeloma.
Of the 1996 patients in the primary cohort, the median age was 74 years, approximately three-quarters and one-fourth of patients were non-Hispanic whites and covered by both Medicare and Medicaid, respectively, and two-thirds were treated in the office of a community physician. Regarding the 2 patient subcohorts, 1814 individuals (91%) and 1436 individuals (72%) of the primary cohort were eligible for inclusion in the assessments related to influenza vaccination and antiviral prophylaxis, respectively.
A key study finding was that bone-modifying agents (ie, pamidronate and zoledronic acid) were administered within 1 year of diagnosis to only 64% of patients in the overall primary cohort, and were given to only 48% of those with chronic kidney disease. Some of the other factors associated with a decreased likelihood of receiving a bone-modifying agent included the patient being non-Hispanic black, use of oral-only cancer therapy, older age at diagnosis, and a high comorbidity burden. Conversely, identification of bone involvement at diagnosis of multiple myeloma was associated with an increased likelihood of receiving a bone-modifying agent.
Only 52% of patients in the influenza vaccination cohort received an influenza vaccination during the study period. Notably, 58% of patients had been vaccinated against influenza during the previous season. Patients of non-Hispanic black race, living in areas represented by lower educational levels and in the Western region of the US, and having coverage with both Medicare and Medicaid were less likely to receive a flu vaccine.
Regarding antiviral prophylaxis for those receiving treatment with proteasome inhibitors, only approximately one-half of patients received guideline-concordant care.
Residing in the Southern region of the U.S., receiving treatment at a physician’s office, and a high comorbidity burden were associated with a lower likelihood of receiving antiviral prophylaxis. Conversely, those patients receiving proteasome inhibitors during the latter portion of the study period were more likely to receive prophylaxis with antiviral medications compared with those diagnosed with multiple myeloma in 2008 and 2009.
In their concluding comments, the study authors noted that the groups identified as being at risk for not receiving specific supportive care measures can “be the target for interventions such as clinical decision support tools, quality improvement projects, and clinical pathways designed to improve quality of care among patients with multiple myeloma.”
Giri S, Zhu W, Wang R, et al. Underutilization of guideline-recommended supportive care among older adults with multiple myeloma in the United States. Cancer. doi: 10.1002/cncr.32428