“Many studies have documented racial, socioeconomic, geographic, and other disparities for US patients with multiple myeloma pertaining to diagnosis and frontline management,” researchers wrote in Blood Cancer Journal. “In contrast, very little is known about disparities in the management of relapsed/refractory multiple myeloma (RRMM) despite a plethora of novel treatment options.”

To address the role that treatment disparities have in RRM, Rahul Banerjee, MD, and colleagues convened an interprofessional task force. Dr. Banerjee and colleagues aimed to develop a position statement with expert recommendations for US patients with RRMM.

Dr. Banerjee spoke with Physician’s Weekly (PW) about the results.

PW: What prompted the development of this panel?

Dr. Banerjee: Multiple myeloma is an incurable blood cancer, albeit one where patients can live for years, if not over a decade, if treated optimally. Unfortunately, care is not always optimal. Many disparities along racial, ethnic, geographic, and socioeconomic lines can prevent patients from receiving the best possible treatments and supportive care. Many prior publications have (appropriately) focused on disparities in the diagnosis and frontline management of multiple myeloma, given that these are real issues. However, most patients with myeloma (even if treated optimally) will have a relapse, and there were no prior publications to guide clinicians about best practices. That was the impetus for our panel.

What are the most critical recommendations?

One of the biggest issues that can emerge with myeloma treatment is that the doses of drugs used by myeloma specialists are often much lower— with fewer toxicities but equally effective—than the original doses studied in trials. These are often followed verbatim by oncologists who don’t specialize in myeloma, but, of course, optimal care for cancer should not depend on whether a patient has access to a myeloma specialist. This is a multifaceted problem, and the long-term solution will require fixing how trials are designed.

In the interim, however, we listed several practical recommendations about optimal drug dosing. We hope oncologists can use this as a reference to change their practices and convince pharmacists, nurses, and other team members who may be skeptical about deviating from a trial-studied regimen to improve patients’ outcomes.

How can physicians incorporate the recommendations in clinical settings?

Oncologists can implement some of our recommendations immediately, such as using certain agents once per week or discontinuing dexamethasone once patients have responded. Our open-access manuscript lists phone numbers at several myeloma advocacy organizations for patients. These trained personnel, many of whom are patients with myeloma, can advocate for patients and help identify what tweaks can be made to their treatment plans to optimize care.

Many of the recommendations are based on real-world evidence, which means large data sets of patients treated in community settings. For example, much of our data supports the once-weekly use of certain agents in myeloma.

How can mitigating disparities improve multiple myeloma care?

We include several examples of how small disparities in treatment can snowball into bigger problems. For example, Black patients can be disproportionately affected by drug-induced peripheral neuropathy; however, the initial trials used these agents twice a week, compared with once a week, which has equal efficacy but a much lower risk for neuropathy. Patients who receive treatment twice per week because they didn’t have access to a myeloma specialist may develop more neuropathy and be deemed less fit for cellular immunotherapies. Similarly, pain is often undertreated in Black patients with myeloma, which can limit functional status and prevent access to optimal therapy. We hope that mitigating disparities from the beginning can have beneficial outcomes (Sidebar).

What makes this issue particularly urgent?

CAR-T therapy was approved in the United States for relapsed/refractory myeloma in April 2024. CAR-T recipients were shown to have more prolonged remissions, better quality of life, and, in one case, even longer overall survival. We need to ensure that every patient with relapsed myeloma is informed about and ideally evaluated for CAR-T therapy. Unfortunately, the disparities we describe can prevent such discussions.

What should future research focus on?

An issue I alluded to earlier is that myeloma regimens in clinical trials do not match what I would recommend for my patients. This leads to a double standard and a bizarre situation where we are regularly encouraging physicians to underdose medications to improve outcomes. I’m working with many other stakeholders, including the International Myeloma Working Group, to change this perception with published, evidence-based recommendations that they can cite to modernize treatment regimens.