In the Journals

Treatment at high-volume facilities linked to longer OS in multiple myeloma

Treatment at higher-volume facilities may result in a lower risk for death in patients with multiple myeloma, according to a study published in Journal of Clinical Oncology.

Hematologist/oncologists are estimated to see an average of only two new and six established patients with multiple myeloma each year, Ronald S. Go, MD, from the division of hematology at Mayo Clinic in Rochester, Minnesota, and colleagues wrote.

Ronald S. Go

“Multiple prior studies, mostly in surgical procedures (especially surgical oncology), have shown that higher volume of care, whether at the treatment facility or provider level, is associated with better clinical outcomes,” they added. “These results have led to an increasing focus on managing patients with rare cancers requiring surgeries at centers of excellence to optimize outcomes.”

The researchers used the National Cancer Data Base to determine if there was an association between the volume of patients with multiple myeloma treated annually and all-cause mortality.

“The study of the volume–outcome relationship in hematologic malignancies may be especially relevant, because these cancers are relatively rare and, with the advent of molecular medicine, are becoming much more complex to classify, risk stratify and treat,” they added.

The researchers classified treatment facilities according to the mean number of patients with multiple myeloma treated per year by quartiles:

  • Q1: less than 3.6 patients (5.2%);
  • Q2: 3.6 to 6.1 patients (12.6%);
  • Q3: 6.2 to 10.3 patients (21.9%); and
  • Q4: more than 10.3 patients (60.3%).

In total, 94,722 patients (median age, 67; men, 54.7%) were treated at 1,333 treatment facilities and followed for a median of 57.6 months.

The researchers identified a median annual facility volume of 6.1 patients per year; only 18 facilities treated 50 or more new patients annually.

Median OS by facility volume increased from 26.9 months in Q1, 29.1 months in Q2, 31.9 months in Q3 and 49.1 months in Q4 (P < .001).

Multivariate analysis demonstrated that a higher patient volume was independently associated with lower all-cause mortality. Patients treated at Q3 (HR = 1.12; 95% CI, 1.08-1.16), Q2 (HR = 1.17; 95% CI, 1.12-1.21) and Q1 (HR = 1.22; 95% CI, 1.17-1.28) facilities had a higher risk for death compared with patients treated at Q4 facilities.

The researchers noted the results came as “no surprise” because of the low number of multiple myeloma cases an average hematologist/oncologists sees each year, in addition to the unprecedented number of new drugs becoming available. Further, there has been a surge of published biologic and clinical information on multiple myeloma in recent years.

“Keeping up with pertinent new knowledge in multiple myeloma, which comprises only 2% of all cancers, and at the same time maintaining proficiency in its management, is becoming more difficult, especially if one also has to stay current in all the other cancers,” Go and colleagues wrote. “These facts reflecting the increasing complexity of multiple myeloma care support our findings that the volume–outcome disparity was becoming more pronounced in recent time periods.”

However, study limitations —including the exclusion of the lowest volume facilities —suggest the results may underestimate the magnitude of the volume–outcome relationship, Ethan A. Halm, MD, professor of internal medicine and clinical sciences at UT Southwestern Medical Center, and colleagues wrote in an accompanying editorial.

Halm and colleagues recommend a collaborative, virtual co-management approach in which local hematologist/oncologists and distant experts create learning cooperatives.

“It is often said that ‘geography is destiny,’” Halm and colleagues wrote. “Because most patients with complex cancers like multiple myeloma will be diagnosed and treated close to home, the challenge for oncologists, payers and policymakers is to come up with creative, feasible ways to provide expert care to patients regardless of where they live. If there was a new drug that improved OS in multiple myeloma by 22%, everyone would prescribe it. Pursuing this goal ought to be as much a priority for our field as developing the next new agent.” – by Kristie L. Kahl

Disclosure: Go reports no relevant financial disclosures. One study researcher reports research funding from Genentech. Halm reports no relevant financial disclosures. Please see the full editorial for a list of all other authors’ relevant financial disclosures.

Treatment at higher-volume facilities may result in a lower risk for death in patients with multiple myeloma, according to a study published in Journal of Clinical Oncology.

Hematologist/oncologists are estimated to see an average of only two new and six established patients with multiple myeloma each year, Ronald S. Go, MD, from the division of hematology at Mayo Clinic in Rochester, Minnesota, and colleagues wrote.

Ronald S. Go

“Multiple prior studies, mostly in surgical procedures (especially surgical oncology), have shown that higher volume of care, whether at the treatment facility or provider level, is associated with better clinical outcomes,” they added. “These results have led to an increasing focus on managing patients with rare cancers requiring surgeries at centers of excellence to optimize outcomes.”

The researchers used the National Cancer Data Base to determine if there was an association between the volume of patients with multiple myeloma treated annually and all-cause mortality.

“The study of the volume–outcome relationship in hematologic malignancies may be especially relevant, because these cancers are relatively rare and, with the advent of molecular medicine, are becoming much more complex to classify, risk stratify and treat,” they added.

The researchers classified treatment facilities according to the mean number of patients with multiple myeloma treated per year by quartiles:

  • Q1: less than 3.6 patients (5.2%);
  • Q2: 3.6 to 6.1 patients (12.6%);
  • Q3: 6.2 to 10.3 patients (21.9%); and
  • Q4: more than 10.3 patients (60.3%).

In total, 94,722 patients (median age, 67; men, 54.7%) were treated at 1,333 treatment facilities and followed for a median of 57.6 months.

The researchers identified a median annual facility volume of 6.1 patients per year; only 18 facilities treated 50 or more new patients annually.

Median OS by facility volume increased from 26.9 months in Q1, 29.1 months in Q2, 31.9 months in Q3 and 49.1 months in Q4 (P < .001).

Multivariate analysis demonstrated that a higher patient volume was independently associated with lower all-cause mortality. Patients treated at Q3 (HR = 1.12; 95% CI, 1.08-1.16), Q2 (HR = 1.17; 95% CI, 1.12-1.21) and Q1 (HR = 1.22; 95% CI, 1.17-1.28) facilities had a higher risk for death compared with patients treated at Q4 facilities.

The researchers noted the results came as “no surprise” because of the low number of multiple myeloma cases an average hematologist/oncologists sees each year, in addition to the unprecedented number of new drugs becoming available. Further, there has been a surge of published biologic and clinical information on multiple myeloma in recent years.

“Keeping up with pertinent new knowledge in multiple myeloma, which comprises only 2% of all cancers, and at the same time maintaining proficiency in its management, is becoming more difficult, especially if one also has to stay current in all the other cancers,” Go and colleagues wrote. “These facts reflecting the increasing complexity of multiple myeloma care support our findings that the volume–outcome disparity was becoming more pronounced in recent time periods.”

However, study limitations —including the exclusion of the lowest volume facilities —suggest the results may underestimate the magnitude of the volume–outcome relationship, Ethan A. Halm, MD, professor of internal medicine and clinical sciences at UT Southwestern Medical Center, and colleagues wrote in an accompanying editorial.

Halm and colleagues recommend a collaborative, virtual co-management approach in which local hematologist/oncologists and distant experts create learning cooperatives.

“It is often said that ‘geography is destiny,’” Halm and colleagues wrote. “Because most patients with complex cancers like multiple myeloma will be diagnosed and treated close to home, the challenge for oncologists, payers and policymakers is to come up with creative, feasible ways to provide expert care to patients regardless of where they live. If there was a new drug that improved OS in multiple myeloma by 22%, everyone would prescribe it. Pursuing this goal ought to be as much a priority for our field as developing the next new agent.” – by Kristie L. Kahl

Disclosure: Go reports no relevant financial disclosures. One study researcher reports research funding from Genentech. Halm reports no relevant financial disclosures. Please see the full editorial for a list of all other authors’ relevant financial disclosures.