Clinician Approaches to Myeloma in Academia and the Community : An in-Practice Qualitative Study

Background

The growing number of treatment options for multiple myeloma has increased the complexity of clinical decision-making. Studies indicate significant variations in practice and adherence to treatment guidelines, but the root causes of this variability remain under-explored. We aimed to understand factors that influence clinician management strategies, and to assess potential differences in community vs. academic settings.

Methods

We conducted semi-structured qualitative interviews with physicians and non-physician clinicians in Southeastern U.S. academic (ACA) and community (COM) clinics. Interviews focused on contemporary management of multiple myeloma, guided by an expert panel of oncologists and qualitative researchers. De-identified audio files were transcribed, then coded and analyzed with NVivo 10 software, using an inductive and iterative constant comparative approach.

Results

Among the 20 participants, 13 were ACA and 7 were COM clinicians. We found marked variations between ACA and COM practice. All ACAs used formal risk stratification schema to inform treatment decisions, compared to just 1 COM clinician. COMs expressed uncertainty about how risk stratification models should impact practice, relying more on heuristic “rules of thumb.” COMs reported using a standardized basic set of treatment regimens across all myeloma patients; ACAs described a more nuanced, adaptive approach. COMs expressed frustration and difficulty keeping up with rapidly-evolving data from myeloma trials. In terms of transplant criteria, COMs placed more emphasis on psychosocial factors, and reported lower age cutoffs than ACA. Both ACA and COM clinicians noted challenges in determining timing of maintenance therapy initiation and in identifying relapse. Although physicians were the primary therapeutic decision-makers, non-physician clinicians influenced therapy selection and modification, and were often the first to detect toxicities.

Conclusions

Challenges to optimal management of multiple myeloma exist in both COM and ACA settings, including: the application of risk stratification and transplant eligibility criteria; the recognition of relapse and the timing of maintenance therapy initiation; and under-acknowledgement of the role of non-physician clinicians. Differences in reported practices between ACA vs. COM clinicians suggest opportunities for interventions to improve patient care and outcomes through optimal myeloma management and therapy selection.