Advent of novel anti-myeloma agents and broader use of stem cell transplant has led to significant improvement in survival of patients (pts) with Multiple Myeloma (MM). However, there are well-described issues with affordability of novel drugs and rapidly escalating price of these agents (Shih et al. JCO 2017), leading to significant disparity among different sociodemographic groups. Hereby, we interrogated the National Cancer Database (NCDB) (which covers 70% of MM patient diagnosed nationwide) to assess impact of insurance type on survival. We also sought to investigate if autologous transplant may overcome socioeconomic effects on survival, by potentially minimizing the need for chronic use of expensive drugs.

Methods: Data from 117,926 MM pts diagnosed with MM (ICD-O 9732) between 2005 and 2014 were analyzed.

Results: Median age at diagnosis was 67 (19-90); 55% were males. 57% of pts lived in areas where the median income was < $46k/year (individual income data was not available); Primary insurance was Medicare (52%), private insurance (35%) or Medicaid (5%), and 3% were uninsured. 40% were treated in academic institutions. Median follow up was 30.2 (range, 0-145.2) months. By univariate analysis, better OS was observed in pts with primary MM, lower Charlson Comorbidity Index (CCI), treatment in academic institutions, higher median regional income, or private insurance (p<0.001 for all) (Table-1). 96% of pts were treated in facilities located ≤ 120 miles from area of residence. Amongst pts younger than 65 years, 33% of pts with private insurance received transplant compared to 20% of those on Medicare (p<0.001). For those 65 years and older, 11% of privately insured pts were transplanted compared to only 6 % for those on Medicare (p<0.001). Median age of pts on Medicare and private insurance, was 74 and 57 years old, respectively. When restricting the analysis to pts ≥ 65 years old, pts with private insurance had longer OS compared to Medicare pts (p<0.001). Table-2 shows the results of multivariate analysis. There was a statistically significant difference in survival between patients with private insurance and those with Medicare in favor of the private insurance among pts older than 65 years old (41.9 vs. 30.8 months, p<0.001 (Fig-1)). Similarly insurance type was a significant predictor of survival among pts who received therapies other than transplant among pts younger or older than 65 (Fig-2), however when considering pts who received transplant, there was no difference in survival between privately insured pts and Medicare in both age group (Fig-3).

Conclusions: Although insurance type and regional income are associated with MM survival among pts who relied on non-transplant modalities, there was no significant impact of these socioeconomic factors on survival of pts that received an autologous transplant in this large database. This finding merits further investigation.

新型抗骨髓瘤药物的出现和干细胞移植的广泛应用已导致多发性骨髓瘤（MM）患者（pts）的生存率显着提高。然而，关于新药的可负担性以及这些药物的价格迅速上涨存在众所周知的问题（Shih等人，JCO，2017年），导致不同社会人口学群体之间存在巨大差异。因此，我们询问了国家癌症数据库（NCDB）（该数据库覆盖了全国70％确诊的MM患者），以评估保险类型对生存的影响。我们还试图通过潜在地减少长期使用昂贵药物的需求来研究自体移植能否克服对生存的社会经济影响。

方法：分析了2005年至2014年间诊断为MM（ICD-O 9732）的117926例MM患者的数据。

结果：诊断中位年龄为67岁（19-90）；55％是男性。57％的人口居住在中位数收入<$ 46k /年的地区（无法获得个人收入数据）；基本保险为Medicare（52％），私人保险（35％）或Medicaid（5％），而3％未投保。40％在学术机构中接受治疗。中位随访时间为30.2（范围：0-145.2）个月。通过单因素分析，在原发性MM，较低的查尔森合并症指数（CCI），学术机构的治疗，较高的区域收入中位数或私人保险的患者中观察到更好的OS（p均<0.001）（表1）。96％的患者在距居住区≤120英里的设施中接受治疗。在65岁以下的患者中，有私人保险的患者中有33％接受了移植，而在Medicare中则为20％（p <0.001）。在65岁及65岁以上的人群中，有11％的私人保险患者进行了移植，而在Medicare中只有6％（p <0.001）。医疗保险和私人保险的中位年龄分别为74岁和57岁。将分析限制在≥65岁的患者时，与Medicare患者相比，有私人保险的患者的OS更长（p <0.001）。表2显示了多元分析的结果。在65岁以上的人群中，有私人保险的患者和赞成医疗保险的患者之间的生存率存在统计学差异（41。p <0.001（图1））。同样，保险类型是65岁以下或未接受移植的患者中接受移植以外治疗的患者生存率的重要预测指标（图2），但是，考虑接受移植的患者，私人保险患者和Medicare的生存率没有差异在两个年龄段（图3）。

结论：尽管保险类型和区域收入与依赖非移植方式的患者的MM生存率相关，但是在这些大型数据库中，这些社会经济因素对接受自体移植的患者的生存率没有显着影响。这一发现值得进一步调查。