Even under universal healthcare, disparities in access to MM treatment persist

Inequalities exist in access to multiple myeloma (MM) care even in a universal healthcare system, especially among patients who are socioeconomically marginalized, as shown by the results of a new study conducted in Canada.

The results were published in American Journal of Hematology.

Previous research has found that low income, celibacy, lack of insurance, and living in areas with low socioeconomic status (SES) are all associated with poorer health outcomes within health care models at a private payment, explained the authors.

However, there is limited data examining the association of SES with MM-related health outcomes within a public-payer universal health care system, they said.

To better understand this link, the researchers performed a retrospective cohort study using data from Ontario, Canada, a region with a universal healthcare system that covers the costs of chemotherapy drugs and administration for provincial funding schemes.

Data were collected from the Institute for Clinical Evaluative Sciences (ICES) population-based administrative database.

All patients included in the analysis were diagnosed with MM between 2007 and 2018, while those untreated within 1 year of diagnosis were excluded. The researchers also used the Ontario Marginalization (ONMARG) index at the time of diagnosis to serve as an area-level surrogate measure of SES, they explained.

ONMARG takes into consideration several factors such as residential instability and material deprivation. Composite scores are based on census data. Participants were grouped into quintiles, with the highest quintiles representing the most marginalized areas.

Treatment was defined as administration of a proteasome inhibitor (PI; bortezomib), immunomodulatory drug (IMID; lenalidomide), alkylator (melphalan, cyclophosphamide), or autologous stem cell transplant (ASCT) as it included all prior treatments. provincially-funded line during the study period, the authors wrote.

Patients were followed up until November 2, 2022. A total of 9777 individuals were included in the analysis while 1 year after diagnosis, 2242 (23%) of patients with MM remained untreated.

The data showed:

  • Among treated patients, the median time to treatment was 35 (interquartile range [IQR]1685) days, with no significant differences in treatment time between the ONMARG groups (P = .630)
  • Compared with treated patients, untreated patients tended to be older (mean age 69 vs. 77 years), have more comorbidities (Charlson-Deyo Comorbidity Index2 in 11% vs. 18%) and live in more marginalized areas (ONMARG Q5: 18% vs 23%)
  • Patients from more marginalized areas were less likely to receive treatment within 1 year of diagnosis even after adjusting for community size, time period of diagnosis, baseline Charlson-Deyo comorbidity index, gender, and age at diagnosis (ONMARG Q5 vs. Q1: OR, 0.71 95% CI, 0.600.84 ONMARG 24 vs. Q1: OR, 0.88 95% CI, 0.771.01;P <.001)
  • Withdrawal was associated with lower odds of receiving an early autologous stem cell transplant (ONMARG Q5 vs Q1: OR 0.82, 95% CI, 0.671.01; ONMARG 24 vs Q1: OR, 0.74, 95 % CI, 0.640.85;P <.001)

The results remained consistent when the researchers studied the likelihood of receiving treatment within three months of diagnosis after adjusting for confounders.

Furthermore, the results also revealed that even after the barrier to accessing treatment was crossed, marginalization was not associated with lower survival, the authors said.

Interestingly, we found that transplant patients who lived in more marginalized areas had significantly longer lives [overall survival] compared to those who live in less marginalized areas; we speculate that this may reflect a referral bias to transplantation, where perhaps only the minority of eligible patients from marginalized patients were evaluated for [autologous stem cell transplant]they added.

The lack of patient-specific demographics and disease data marks a limitation to the study. The researchers were also unable to assess the role race or treatment in a community versus academic center might have had on health outcomes.

More studies, including qualitative studies with patients, health care providers, and health care providers, are needed to understand the patient-level and structural barriers that lead to inequitable access to health care, they concluded.


Visram A, Seow H, Fiala MA, et al. Socioeconomic marginalization and health outcomes in newly diagnosed multiple myeloma: a population-based cohort study. I’m J Hematol. Published online May 16, 2023. doi:10.1002/ajh.26957

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