What are the main discrepancies between MM treating centers in Brazil?

Over the last 20 years, there have been significant advances in multiple myeloma (MM) treatment, yet there remain significant inequalities in access to treatment and survival.¹ Patient outcomes in clinical trials do not necessarily reflect the real-world effectiveness of these interventions.¹

The MMyBRave trial was set with the aim to establish the clinical and demographic characteristics, as well as care pathways and outcomes for patients with MM in Brazil.¹ The Multiple Myeloma Hub was pleased to speak to Vania Tietsche de Moraes Hungria, Clínica São Germano, São Paolo, BR, about her takeaways on the findings of this study, which are summarized below.

Study design¹

A total of 943 patients were recruited from 17 institutions with a diagnosis of MM based on the latest International Myeloma Working Group (IMWG) criteria. The MMyBRave trial reported the patient outcomes, including overall survival (OS) and predictors of OS. The analysis presented at the 64th American Society of Hematology (ASH) Annual Meeting and Exposition focused on the comparison of OS by baseline characteristics (Table 1), eligibility for transplant, and whether treatment was received in private or public institutions. Of note, a higher proportion of patients treated in public institutions presented with Durie-Salmon Stage III and International Staging System Stage III than in private institutions.

Table 1. Baseline characteristics by type of center*

ISS, International Staging System; IQR, interquartile range. *Adapted from Hungria.1
Characteristic, % (unless otherwise stated)	Public (n = 519)	Private (n = 424)	p value
Median age (IQR), years	68 (60–76.8)	69 (61–78)	0.273
Sex
Female	48.6	(43.6	0.149
Male	51.4	56.4
Race
White	61.8	60.1	0.640
Other or unknown	38.2	39.9
Durie-Salmon stage
I	5.4	8.1	0.001
II	16.2	15.8
III	(66.9)	56.8
Not performed/unavailable	11.5	19.3
ISS stage
I	13.3	26.7	<0.001
II	20.2	22.6
III	27.4	25.7
Not performed/unavailable	39.1	25.0

Results¹

OS was associated with multiple factors, including center type (Figure 1), age, and Durie-Salmon stage. Each of these factors resulted in a significant difference in OS. The type of center (public or private) was identified as an important factor in disparity despite the fact the number of patients undergoing transplant or eligible for transplant was not significantly different between centers. Transplant eligibility did independently have an impact on median OS, with patients who are transplant-eligible having a median OS of 93 months vs 49 months in the transplant-ineligible group. This difference was maintained regardless of the type of center these patients attended.

*Adapted from Hungria.¹

In addition to OS, there was also a difference in the frontline treatment patients received depending on whether they were treated in a public or private institution. Patients treated in private institutions were more likely to receive bortezomib as a frontline therapy compared with primarily thalidomide and melphalan-based treatments in public centers.

Conclusion

The treatment of MM in Brazil is improving over time, but disparities in therapeutic options and patient outcomes still exist. The MMyBRave trial identified the type of treating center (private or public) as one source of disparity. The cause of difference in outcomes across centers is not yet fully understood; however, access to novel therapies may be a key factor.