Impact of Racial Disparities in Myeloma | Doctors Cole and Kumar | IMS 2023

My name is Craig Cole and I'm from Michigan State University College of Human Medicine and Carmanos Cancer Institute. I'm Dr. Lalit Kumar. I'm a medical oncologist. I work at the Pallavi Institute of Medical Sciences, New Delhi in India. And today we talked about our disparities in care of myeloma. What that means is that myeloma, as we know, has tremendous strides in care. Incredible things have been talked about at this meeting. We have new drugs, new opportunities to treat this disease, potentially cure this disease. However, one thing that we know is that the delivery of care isn't equal. It's not equal in the United States. It's not equal around the world. And some of those differences about who receives the newest treatments, who receives the best diagnosis, who receives the expert care is very different because there are populations in the United States and the world that don't have access to those drugs. And that was what we really highlighted today. The incidence of multiple myeloma is quite variable. It varies from one part to another. For example, in Australia and New Zealand, incidence is very high, almost 5.6 per 100,000 people. Compared to this, North America has 5.2 and Western Europe has 4.6, while in Asia it's like 1.1 or 1.2. So there has been huge variation in the incidence of myeloma around the world. That was one of the initial points which we made. And subsequently we discussed what are the other differences in terms of clinical presentation, in terms of investigations. For example, many patients in Asia, for example, they present very linked. This could be due to many reasons. It could be the health care, availability of health care in different centers, which may be, and there are only a few centers which may have the main teaching hospitals where the patients have to travel long distance to go there. That could be one of the reasons why people come very late to these places. One thing that we know and has been discussed is that the incidence of myeloma is higher in people of African descent. So African Americans, black people, we know black people around the world have a higher incidence of myeloma, almost double that of whites. Why that is, we don't know. It's not because of a lack of trying, but it's probably something that's hidden deep inside the genome between blacks and whites that have that higher incidence of myeloma. One thing that Dr. Kumar had mentioned is when you look at the number of people diagnosed with myeloma, it's actually lowest in Africa, which is counterintuitive of what you would think. That people of African descent have a higher incidence. Why would the diagnosis be so much lower? That's because of access. And those areas that are poorer don't have access to the diagnostic modalities that we have and therefore there are people that have this disease that don't know that they have it and then of course they don't know that they have it, then they end up dying of the disease without treatment. For example, some of the new end investigations like the imaging, the PET CT scan is not available in many centers in Asia, only limited to the major teaching hospitals or major big hospitals. Similarly, the investing like FISH, chromosomal analysis is not at every place. And like serum-free light-chain NSA, again it may not be available at many places. So this is one part of this and what we suggested, how this can be raised is that we can have a government spoke model where the big major centers with these facilities are available, patients are referred to both places, this will bring down the cost and that you can have a bigger data from one center coming to this, which can really can be shared by the world community. Another point that we highlighted is how social economic status really affects myeloma survival. That underserved communities are less likely to have longer times of diagnosis like Dr. Kumar said. People with low socioeconomic status are less likely to receive modern therapy with the three drug or four drug regimens and less likely to receive stem cell transplant as this meeting has mentioned quite often that stem cell transplant is so important for myeloma survival and therefore the insurance and how much funds that you have in your social economic status really determines how long some people live with this disease and the question is how can we remedy that? In the transplant we feel like the data which is available indicate that almost 20 to 30 percent of patients are going to undergo transplant who are in easy way compared to nearly almost 50 percent or higher in the best centers in the western world. So if one can bridge this gap to bring down to 40 to 50 percent that really will help a lot and secondly in the transplant also we can find some measures which can bring down the cost. For example, in doing the non-cryopresure stem cell transplant we don't have to freeze the stem cell which will bring down the cost to nearly almost 10 to 15 percent. Similarly, like if you do the stem cell counting on day four of mobilization then you can reduce the unnecessary harvest like you can just limit to one and can bring the plerix up to four. So these are two of the points which at least can bring down the cost of transplant to many of these centers in the Asian countries. And therefore making it more accessible to so many more people. The other thing and before we talk about solutions, in fact I'm going to dovetail into solutions right now is clinical trials that this meeting is full of incredible results of clinical trials. One thing that we know is that for clinical trials that have gone to the FDA for drug approval that on average about 4.5 percent of the patients involved in those clinical trials are people of any other ethnicity other than white. Which is very difficult to apply the results of some of these clinical trials to patients who are non-white when the number involved has been so low. And the solution really is for everyone, for everyone and especially people of color to be involved in clinical trials. The clinical trials in myeloma have never been safer. They've never been more competitive. The drugs that now are involved in clinical trials are safer, better, more efficacious than they've ever been and I've ever seen in my career. So this is an opportune time to be involved in clinical trials to especially people of color so that we know that these drugs work for everyone. Because what we want to do is we want to cure myeloma but we want to cure but you can't cure myeloma by curing a fraction of the number of people in the world. We need to cure myeloma for everyone and for us to cure myeloma for everyone, everyone needs to be involved in clinical trials so we know these drugs work. Another aspect could be like if we can do the screening for people, population, especially where they have the highest population or either because of age or because of some high risk factors like obesity or family history. Those people if they're screened and found to have the positive on the serum and protein or the serum protein and lactophoresis, then they could be investigated and then you can really pick up them early and treat them early. This will definitely improve the results. So that was one aspect. Secondly, other suggestion was that if we can do the trials with the available drugs, a lot of generic drugs are available in many countries in Asia. So one can do a good trials with a large number of patients with two or three drugs or not because the direct may not be available everywhere in Asia, only to very, very few people who can afford it. So even the doing trials for the three drugs, many of these countries, if you can have larger database which can really help us to get the good data that how people do respond to these drugs. And secondly, also there may be people ethnically they have a tolerance may not be so good. I know in the northeastern part of India where the people have the difference in the tolerance of many of the drugs like vertigermin because of the genetic background is such. Some of this data has never been brought out which also can help actually to the world community to know that there are people, there's some ethnic group. Like we have some data from Japan similar to that in the northeastern part of India, they have this genetic propensity that they may have poor tolerance to some of these drugs. So that was another thing. Third thing which we thought for the relapsin refractory, many of the new end drugs like especially the antibodies, CAR T cells and then the isozoome, these drugs are not easily available for most people actually. So even going back to cytotoxic with combination of novel agents like we can use so-called metronomic therapy which could be very, very useful for many of these patients at least for some group of people which can give the equivalent results rather than jumping everything on the high end treatment. One thing that can be done to bring clinical trials to a broader population and to again increase the diversity of clinical trials, decentralized clinical trials. What does that mean? Well right now a lot of the clinical trials, a lot of the best clinical trials that are out there are centralized at major academic centers. And so of those, there's only a few that have the myeloma, the top myeloma trials. Why can't we bring those clinical trials to your backyard? I have patients that travel two, three hours to see me. I do telehealth to people around the world. Why not bring those specialists and bring those clinical trials to your local clinic? And that's the idea of decentralized clinical trials. Instead of doing it at the traditional places, they've done clinical trials for decades, bring the clinical trials to your local clinic in the inner city, to your local clinic in rural communities, to your local clinic in the suburbs where people don't have to travel as far. Because to have myeloma, to have cancer and to travel hours and hours for clinical trials is a huge barrier. And so if we can bring clinical trials and those steps have already been taken, already a lot of clinical trials and pharma and the pharma companies are looking at doing clinical trials at more local places to bring those top trials directly to your doorstep. In fact, this would be a very good idea if we can use the telemedicine for this purpose. So people living very far off who cannot come frequently and you can really monitor, you can help give them the help from your place and the help of the local physician or hematologist or oncologist and can do those kinds of trials and can compare the results. The actual real world data can come from those trials rather than doing selectively in a very, very specialized centers.