Does "geography" mean "destiny" when it comes to multiple myeloma? It turns out that being seen by a myeloma expert matters for patients' overall survival. A recent study by the myeloma researchers at University of Texas Southwestern Medical Center in Dallas, TX was performed to identify whether being treated by a myeloma expert mattered. They noted that studies have been performed for decades to determine the impact of patient volume and clinical outcomes. The strongest associations exist for less common high-risk procedures such as pediatric cardiac surgery or esophageal cancer resection. In cancers, there is a known association between facility volume (i.e. how many patients treated annually) and long-term survival for complex cancers including acute myeloid leukemia, non-Hodgkin lymphoma, advanced melanoma and renal cell cancer. Study authors also find an association for multiple myeloma, which has had increases in complexity in diagnosis and treatment over the past 20 years.

Analyzing data from the National Cancer Database on 94,722 patients cared for at 1,333 facilities between 2003 and 2011, the authors found that patients who received their initial treatment at higher volume centers had better all-cause, long-term survival. Compared with patients initially treated by the highest volume quartile providers (10 or more patients with MM per year), those seen at the lowest quartile sites (less than four patients with MM per year) had a 22% higher risk of death. The effect appeared linear, with no obvious threshold, as has been seen in other conditions.

More than half of the patients studied were treated at non-academic centers. The volumes were averaged over 9 years to smooth out short-term fluctionas. Facility volumes were separated into quartiles and adjustments were made that impact survival (patient age, sex, race, education, income, insurance, stem cell transplant and co-morbidities). The study did not include stage, cytogenetic features or fitness status. Because all facilities were Commission on Cancer–accredited programs, they may have higher volume, be more technologically sophisticated, and have greater oncology support services than facilities not included in the study. As a result, this means that study authors probably underestimated the magnitude of the volume-outcome relationship because the lowest volume facilities were not included. Prior studies showed that specialization of the treating physician can influence cancer outcomes. The complexity of diagnosis can be a major factor in receiving better care.  In contrast to solid tumors, for which diagnosis is based on tissue biopsy, rendering a diagnosis of MM requires interpretation of numerous criteria including serum protein electrophoresis, immunofixation, light chain assays, bone marrow plasmacytosis, cytogenetics, radiographic studies, renal function, and hematologic parameters. Furthermore, diagnostic and staging criteria in MM continue to evolve. Highly specialized physicians may diagnose individuals sooner, which would lengthen survival as a result of lead-time bias.

In contrast to solid tumors, for which diagnosis is based on tissue biopsy, rendering a diagnosis of MM requires interpretation of numerous criteria including serum protein electrophoresis, immunofixation, light chain assays, bone marrow plasmacytosis, cytogenetics, radiographic studies, renal function, and hematologic parameters. Furthermore, diagnostic and staging criteria in MM continue to evolve. Highly specialized physicians may diagnose individuals sooner, which would lengthen survival as a result of lead-time bias. MM experts may also be more familiar with guideline recommendations influencing the selection, sequencing, and combination of a growing number of newer therapies. They might also have access to new therapeutics through clinical trials before they are available in the community. Consistent with this hypothesis, Go et al found that the volume-outcome effect was strongest in the most recent time period, when newer and better tolerated agents became available. In addition, MM specialists may be more familiar with disease-specific treatment-related complications, allowing them to maintain greater therapeutic dose-intensity when appropriate or modify therapy before toxicity escalates to the point of foregoing further treatment. Monitoring response to therapy in MM is nuanced, incorporating various parameters with separate response threshold determinations. Early recognition and management of rare MM complications such as amyloidosis could also impact survival. The selection and ongoing management of patients undergoing stem-cell transplantation may also drive long-term survival. Although Go et al¹¹ adjusted for receipt of initial stem-cell transplantation, they were not able to account for the downstream care needed by transplantation recipients.

High-volume centers may have more skilled teams to manage disease and treatment complications. Having highly trained providers and nurses in myeloma and in stem cell transplant could also influence outcomes. In surgical literature, high-volume hospitals can gain a short-term survival advantage because they have the ability to manager operative complications, preventing deaths in life-threatening situations.

Because one in four patients with MM dies in the first year, and half of deaths happen in the first 3 months, the stakes are high to get the early management decisions right. The current study confirms this observation, because the greatest survival benefit attributable to higher-volume sites occurred during the first year. Therefore, trying to facilitate a referral to an MM specialist during the early months of diagnosis and treatment selection would be beneficial. 

Study authors suggested that the following could be implemented to improve patient outcomes:

1. Insurer and accountable care organizations could encourage and pay for second opinions from high-volume providers.
2. Referring clinicians and patients could identify myeloma specialists in their area (Myeloma Crowd Myeloma Specialist Directory)
3. If no local or regional experts meet these criteria, an alternative would be to obtain a virtual second opinion via an electronic consult with a myeloma expert to review the diagnosis, suggest an initial treatment plan, and assess appropriateness for stem-cell transplantation and clinical trials.
4. Because the treatment of myeloma is expected to continue at a rapid pace, local hematologist-oncologists could be connected with experts through learning cooperatives. This could create increasing opportunities for  disease-specific specialization within a network, as well as facilitating virtual linkages with national experts and enrollment in appropriate clinical trials.

This is yet another confirmation that adding a myeloma specialist to your treatment team can mean added life and better outcomes. Do what you can to consult with one today!