In lesson one of the disparities course, we learned some important definition about disparities. In this lesson, we'll be discussing disparities in treatment for multiple myeloma as well as access to care. First, let's hear from Dr. Patel. What disparities exist in prescribed treatments and time to diagnosis? We know that African Americans have about a two to three times higher chance of developing myeloma as opposed to Caucasians. The problem is we're really failing this community in terms of getting access to therapy. So we know that African Americans have a lower chance of getting proteasome inhibitor induction. They have a lower chance of accessing transplant and even supportive care. Drugs like Zomato, bisphosphonates are used in lower amounts compared to Caucasians. So we're failing this entire segment of our myeloma community. We also know that many of those patients don't have access to clinical trials. When we look at diversity within trials, there's a very low number of African American patients that actually have access to those studies. And that means that all of these novel therapies that we know have been working even before approval for the last few years have just been underutilized in this segment of the community. So one thing that has been looked at through different databases is that African Americans, Hispanics are less likely to receive triplet therapy, the mainstay of induction therapy for myeloma than other ethnic groups. That they're less likely and there's a longer delay in getting those triplet therapies. We know that there's longer times of diagnosis. It takes longer for an African American myeloma patient to get diagnosed than a Caucasian patient to get diagnosed. Also it takes longer for rural patients to get diagnosed than patients that live near academic centers. And so one disparity is just built around the diagnosis and the treatment of myeloma. So when we transplant our African American patients, they have the same outcomes as Caucasians, as I said, if not better. But we have noted that there is delay in referral. So the median time to referral for a Caucasian is about six months or less. Median time to referral to a tertiary center like ours from the community is about a year. African Americans, Hispanics are less likely to get stem cell transplants. We know stem cell transplant is super important for myeloma care to extend the progression free survival, but they're less likely. And in fact, the number of African Americans engaging in stem cell transplant has actually declined over those past several years instead of rising it has for other ethnic groups. More recent studies have shown that Black patients are less likely to have maintenance therapy than patients of other ethnicities and bisphosphonates that the bone strengtheners that are just crucial for patients to have in order to help with pain or to strengthen the bones less likely in Black patients than in White patients. How can new treatments impact the prevalence of disparities in myeloma? So there's a very interesting theory called the fundamental cause theory that sort of proposes that as innovations arise in healthcare, disparities increase. Sort of to break it down kind of in a nutshell, if there are no good treatments, outcomes for all groups are uniformly not great. But once good treatments come on the market, which is the case in multiple myeloma since the year 2000, there have been 26, 27 FDA approvals and there's been new classes of drugs, treatment has really improved, it's more effective, it's also more complicated, it's also more expensive. And in that environment, you would expect that the patients that have wealth, connections, power, prestige to be able to access the better treatments more frequently than patients that are more marginalized. And so in my work that's ongoing, I'm expecting to find that over time, that disparities between the treatments that Black patients and White patients get will actually increase as the treatment for myeloma has improved. I think this is an important thing for us to document and future steps would be to better understand the mechanisms by which these treatment disparities arise. What disparities exist in myeloma outcomes? So in multiple myeloma, the disparities that exist in outcomes is mainly the survival disparities. And these survival disparities have been largely attributed to differential access to care. And so when we think about what access really entails, this is really thinking about a patient's ability to not only perceive the need for care, but they then need to seek care to reach the health care facility and then to actually be able to pay for these services. So all of these time points along this access pathway can influence the way that patients ultimately experience their disease, the types of treatments they're able to receive, which ultimately drives the differential survival outcomes that we see. In terms of the five-year survival gaps, those are pretty stark, especially for the differences between older and younger individuals with myeloma. We oftentimes quote a statistic that says that Black persons are twice as likely to die from multiple myeloma than White persons with this disease. So by and large, we do see them dying at quite a higher rate and much faster from this disease than any other demographic. If disparities in access to care were resolved, would outcomes improve? In the VA system, everyone gets treated the same because the VA tells you, you have to treat myeloma this way, so everyone gets the same treatment. If you look at the VA medical system, you look at the RVD 1000 study where they enroll a thousand patients at Emory University, and even the most recent Griffin study with the DERA RVD versus RVD, you look at those three studies, all things being equal, African Americans have equal outcomes, and the VA study said that may even have better outcomes than Caucasian patients. So all things being equal, outcomes are the same. But when you throw in the social determinants of health, it makes an inequality happen. This is often quoted, the VA study, and I think that that was really a study that shed a lot of light on these disparities. And it really showed us that when Black patients are given equal access to care, that their survival could either equate or surpass that of their White counterparts. And I think this is really telling because it really tells us that we need to be putting more efforts into making sure that our Black community or African American community has equitable access to care because it not only affects the quality of care they receive, but we have robust data not only from the VA study, but also a study that was done looking at patients enrolled in clinical trials that shows with equal access that their survival can either equate or improve when compared to White persons. We have to make sure that we have equal access to care across the board. And these are systemic issues, systemic issues that it's not just one doctor's office, it's not just one insurance company or one hospital. These are systemic areas across the board that we do need policies and procedures in place to make sure that there is equal access to care. As we always say, your zip code should not determine the type of health care that you receive. Disparities in myeloma care affects access to treatment and outcomes, especially for Black and Hispanic patients. But research shows that with equal access, survival rates can improve. Ensuring fair health care access is the key to better outcomes for everyone. If you found this video helpful, consider giving us a like and subscribing to Health Tree University. We'd like to thank our doctors, our sponsors, and of course our audience for making this video possible. See you next time on Health Tree University.