Abstract
Autologous Hematopoietic stem cell transplant (autoHSCT) has remained the cornerstone in the management of multiple myeloma (MM), with numerous studies demonstrating its efficacy in deepening response and prolonging progression-free survival (PFS). However, its benefit in improving overall survival (OS) is less apparent, particularly among patients with high-risk MM. In addition, access remains limited for many patients, especially those receiving care at institutions without on-site transplant capabilities.
This study aims to evaluate outcomes of newly diagnosed patients with high-risk MM who underwent autoHSCT compared to those who did not, within a cohort characterized by a high proportion of minorities to reflect real-world clinical practice in a small metropolitan area. Socioeconomic factors, including race, insurance type, and area of residence, were also analyzed, given their potential to influence access to transplantation and associated outcomes.
We conducted a retrospective chart review at a single academic institution in Mobile, Alabama, that does not have on-site autoHSCT capabilities. Investigators assessed electronic medical system records to obtain necessary information. High risk was defined as per the mSMART 4.0 classification and included del(17p), biallelic del(1p), t(4;14), t(14;16), or t(14;20) plus either gain/amplification 1q or del(1p), gain/amplification 1q plus del(1p) by fluorescence in situ hybridization.
The analysis includes data for 57 patients with newly diagnosed high-risk MM between 2009 and 2025. The median age of diagnosis for the 29 patients who had undergone autoHSCT was 60.5 years (range: 40.1 to 78.6 years). Whereas, of the 28 patients who did not undergo autoHSCT, the median age of diagnosis was 70.3 years (range: 41.5 to 83.3 years). 51% (n=29) were minorities (27 Black, 2 Asian, and 1 biracial), and 49% (n=28) were white. The majority were female 32 (56%). Insurance coverage comprised of Medicare (n=36), Medicaid (n=4), commercial (n=10), Veterans Affairs (n=4), and unspecified (n=3). Patients resided in Mobile County (n=14), Baldwin County (n=14), and other counties (n=10).
In unadjusted analyses, patients who underwent autoHSCT had a significantly longer time from diagnosis to last follow-up (median: 80.8 months; range: 12.2 to 193.9) compared to those who did not (21.8 months; range: 1.5 to 166.9), p = 0.03. PFS, defined as time from diagnosis to relapse, was longer among the autoHSCT group (median: 50 months; range: 8.6 to 188), compared to the non-transplanted group (median: 20.5 months; range: 5.4 to 138.6), although this difference was not statistically significant, p = 0.25. Both the white and minority patients underwent autoHSCT at similar rates, 57% and 45%, respectively. Despite this, the OS, defined as time from diagnosis to death, was significantly longer among white patients (median: 79.3 months; range: 12.2 to 137.7), compared to minority patients (23.6 months; range: 3.6 to 57.1 months), p = 0.04. The median follow-up duration was 56.4 months (range: 3.5 to 165.5) for white patients and 45.8 months (range: 1.5 to 193.9) for minority patients. Of the 10 patients with commercial insurance, 80% (n=8) underwent autoHSCT, whereas only 45% (n=21) of the 47 patients with non-commercial insurance underwent autoHSCT. Although 93% of patients residing in Baldwin County were white and 73% of patients in Mobile County were minorities, there was no significant difference between county of residence and those who underwent autoHSCT.
The results from this retrospective study further reinforce the role of autoHSCT in the high-risk MM population despite the availability of novel therapeutic agents. Nonetheless, access to autoHSCT remains inequitable due to patient resources, insurance coverage, and socioeconomic support. MM with high-risk cytogenetic features continue to confer unfavorable outcomes despite autoHSCT and effective salvage therapies, especially among minorities. These findings highlight the urgent need for novel, innovative strategies to improve equitable access in this vulnerable patient population.
