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Impact of Treating Facility, Provider Volume, and Patient-Sharing in the Treatment of Patients With Multiple Myeloma


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A study published by Freeman et al in JNCCN—Journal of the National Comprehensive Cancer Network found that generally, providers with more experience treating multiple myeloma have better outcomes than those with more limited experience. Providers who saw the most cases were more likely to be located at National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. However, researchers found that the very highest–volume providers at community facilities did achieve equally low mortality rates as clinicians at NCI-designated cancer centers did.

“Multiple myeloma care is complicated and nuanced, with many specific treatments and management scenarios,” said senior researcher William A. Wood, MD, MPH, of the University of North Carolina Lineberger Comprehensive Cancer Center. “Our results show that provider experience—and potentially access to resources at a comprehensive cancer center—may improve survival in patients with multiple myeloma. The reasons might have to do with familiarity with the benefits and best use of newer drugs and regimens, access to resources to help with management of toxicities or complications, or other factors. Or it might be that patients who are seen by higher-volume providers are more likely to have other unmeasured or confounding factors associated with better survival. More research is needed to help sort this out.”

"Our results show that provider experience—and potentially access to resources at a comprehensive cancer center—may improve survival in patients with multiple myeloma."
— William A. Wood, MD, MPH

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Methods

The study was based on data from 1,029 patients in the University of North Carolina Cancer Information and Population Health Resource who were diagnosed with multiple myeloma between 2006 and 2012. Patients who did not have continuous insurance enrollment for 6 months before and 12 months after diagnosis were excluded, along with those who did not receive chemotherapy within 12 months of diagnosis.

Patients ranged in age from 25 to 98 years old, with a mean age of 68 years old. Three multivariable Cox models were used to examine how the following factors impacted overall survival: evaluation at an NCI-designated Comprehensive Cancer Center; the primary oncologist’s volume of patients with multiple myeloma; and patient-sharing between multiple myeloma specialists and community oncologists.

Results

Patients who were not evaluated at an NCI-designated Comprehensive Cancer Center had an increased risk of mortality vs those who were (hazard ratio [HR] = 1.50; P < .001). Patients who were treated by both low- and high-volume community providers had a higher risk of mortality than those treated by NCI-designated Comprehensive Cancer Center multiple myeloma specialists; however, there was no difference in mortality between patients treated by the highest-volume community oncologists (those in the 9th and 10th deciles) vs those treated by an NCI-designated Comprehensive Cancer Center specialist. Patients treated by community oncologists had a higher risk of mortality vs patients treated by multiple myeloma specialists, regardless of patient-sharing.

The authors concluded, “Findings of this study add to the accumulating evidence showing that patients with multiple myeloma benefit from care at high-volume facilities and suggest that similar outcomes can be achieved by the highest-volume providers in the community.”

Commentary

Shaji K. Kumar, MD

Shaji K. Kumar, MD

“The treatment of multiple myeloma has become more complex given the increasing number of treatment options for patients with newly diagnosed as well as relapsed disease,” commented Shaji K. Kumar, MD, of the Mayo Clinic Cancer Center and Chair of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Multiple Myeloma, who was not involved with the research.

“Given the median age at diagnosis of over 65 [years old],” he continued, “it is important that patients are carefully followed for toxicity, especially with the use of multidrug combinations. In this scenario, the current study reiterates the importance of clinical experience in the management of [patients with] multiple myeloma. While the study does not completely remove the bias of sicker patients not getting to the large referral centers and being treated in the community, the findings of comparable outcome in community centers with higher volumes clearly support the importance of provider experience.”

Disclosure: For full disclosures of the study authors, visit jnccn.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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