Many studies have documented racial, socioeconomic, geographic, and other disparities for United States (US) patients with multiple myeloma pertaining to diagnosis and frontline management. In contrast, very little is known about disparities in the management of relapsed/refractory multiple myeloma (RRMM) despite a plethora of novel treatment options. In this review, we discuss the manifestations of disparities in RRMM and strategies to mitigate their impact. Immunomodulatory drugs can create disparities on many axes, for example inappropriately low dosing due to Duffy-null status as well as time toxicity and financial toxicity from logistical hurdles for socioeconomically vulnerable patients. Access to myeloma expertise at high-volume centers is a critical consideration given the disconnect between how drugs like carfilzomib and dexamethasone are prescribed in trials versus optimized in real-world practice to lower toxicities. Disparities in chimeric antigen receptor T-cell therapy and bispecific antibody therapy span across racial, ethnic, and socioeconomic lines in large part due to their limited availability outside of high-volume centers. Another insidious source of disparities is supportive care in RRMM, ranging from inadequate pain control in Black patients to limited primary care provider access in rural settings. We discuss the rationales and evidence base for several solutions aimed at mitigating these disparities: for example, (1) bidirectional co-management with community-based oncologists, (2) screening for risk factors based on social determinants of health, (3) strategies to build patient trust with regard to clinical trials, and (4) longitudinal access to a primary care provider. As the treatment landscape for RRMM continues to expand, these types of efforts by the field will help ensure that this landscape is equally accessible and traversable for all US patients.
多项研究已记录美国多发性骨髓瘤患者在诊断及一线治疗阶段存在的种族、社会经济、地域等方面的差异。相比之下，尽管复发/难治性多发性骨髓瘤（RRMM）的新型治疗方案层出不穷，其治疗过程中的差异性却鲜为人知。本文综述将探讨RRMM治疗差异的具体表现以及减轻其影响的应对策略。免疫调节药物可能从多个维度引发治疗差异，例如因达菲阴性血型导致的不当低剂量用药，以及社会经济脆弱患者因就医流程障碍面临的时间成本与经济负担。考虑到卡非佐米联合地塞米松等药物在临床试验中的使用方案与其在现实临床实践中为降低毒性而优化的方案存在脱节，患者能否在大型诊疗中心获得骨髓瘤专科诊疗成为关键考量因素。嵌合抗原受体T细胞疗法和双特异性抗体疗法的可及性差异跨越种族、民族和社会经济界限，主要因为这些疗法在大型诊疗中心之外的可及性有限。另一个隐性的差异来源是RRMM的支持性治疗，涵盖从黑人患者疼痛控制不足到农村地区初级医疗服务可及性有限等问题。我们探讨了若干针对性解决方案的理论依据与证据基础，例如：（1）与社区肿瘤科医生建立双向协作管理模式；（2）基于健康社会决定因素进行风险筛查；（3）建立患者对临床试验信任的策略；（4）确保患者长期获得初级医疗服务。随着RRMM治疗格局的持续拓展，该领域的此类举措将有助于确保所有美国患者都能平等获得并受益于这一不断发展的治疗体系。
肿瘤(癌症)患者之家