We Need More Black Patients In Multiple Myeloma Clinical Trials

By Craig Cole, MD

Multiple myeloma is a disease that is about twice as likely to affect Black people as white people. The good news is Black patients tend to have an earlier age of diagnosis and are likely to have a lower-risk genetic profile than other races — both are important factors that should result in promising treatment outcomes. Unfortunately, a recent study suggests Black people have not experienced similar survival benefits from recent treatment advancements because of the underutilization of new effective treatments in both real-world settings and clinical trials, poor access to care, and delays in diagnosis and treatment. I have observed this as a malignant hematologist in practice and my own research. The medical and research community can do more to prevent this, and the solution isn’t complex — we need to raise awareness about the impact of innovative treatments recently developed through clinical trials and the availability of promising new clinical trials currently underway that can offer a better chance at a cure.

Achieving equitable outcomes in multiple myeloma depends on a multitude of factors. Even though we have achieved rapid advances in treatment in the past decade, we fail to ensure this critical knowledge filters down to the primary care community. Primary care physicians are most often on the frontlines of diagnosis and in a position to recommend cutting-edge treatments and clinical trials for their patients with this disease, but they must possess the knowledge to move the needle on outcomes.

There are biological reasons for the unique disparities in outcomes for multiple myeloma. Still, many outcomes would be vastly improved in the Black population if we could improve our outreach to the primary care physician community to encourage more Black patients to enter clinical trials. The standard of care for multiple myeloma has changed significantly in recent years, and by improving education and access to potentially lifesaving clinical trials, I am convinced we can quickly make a noticeable impact on multiple myeloma disparities.

Higher Incidence And Worse Outcomes

Treatment options for multiple myeloma have increased rapidly, meaning if a patient has access to a doctor who can appropriately diagnose them and is educated on the latest treatment options, their outcomes are likely to be better. The reverse is also true. In addition to being twice as common in Black people as in white people, Black people are about twice as likely to die from the disease as whites.

Early intervention is critical in combating disparities. Thanks to clinical trials, we now know that as people develop myeloma, the disease evolves and gathers strength. Essentially, over time, the T cells become exhausted trying to control the disease, in the same way I would if I were herding cats. When they give up, the cancer explodes. That’s why early detection, which is so easy, is so important.

But that’s more difficult than it seems. Experts call multiple myeloma the “great masquerader” because some of its primary symptoms are fatigue and back pain — easily mistakable by primary care physicians as the result of aging and our busy culture. But those symptoms often signal anemia from low kidney function, a key indicator of multiple myeloma that is often missed. That is why we have delays in diagnosis, especially in people of color. For Black patients who have anemia or low kidney function, physicians need to make sure it is not myeloma because it is treatable — and reversible. And myeloma is extremely easy to rule out — three blood tests will find 99% of myelomas.

Rapid Treatment Advances

Clinical trials are the reason a revolutionary therapy — genetically engineered cancer-fighting T cells — is now mainstream for the treatment of multiple myeloma. Known as CAR T cell therapy, the process retrains a patient’s immune cells to attack cancerous cells and has been the most significant treatment advance in multiple myeloma. Additionally, trials investigating off-the-shelf CAR T cells can eliminate the disease and are immediately available to patients. This treatment is relatively new, so we don’t know how long these therapies last. However, it is so transformative that you can use the T cells of one person to attack the cancer in someone else, which is an evolutionary advance to the original CAR T cell therapy.

We are also finding new ways to treat this disease via biology by poisoning the myeloma cells. We initially did that 25 years ago with thalidomide, which evolved into cell modulator therapies (CeMODs), also in clinical trials. We have engineered pills to find the Achilles’ heel of myeloma and its self-signaling proteins. Sometimes, we can combine this therapy and others for even more success. By combining therapies where appropriate, we see response rates in the 80%-90% range, which I never thought I would see in my career. Survival rates now exceed 13 years on average because of all the innovation over the past decade. And, eventually, I am confident we will find a cure for this disease because technology is moving quickly. So many new drugs, clinical trial opportunities, and treatments continue evolving rapidly — all good signs for patients and providers who care for them.

Developing innovative treatments isn’t the issue; the challenge is ensuring that those opportunities for modern treatment are equitable so that people in downtown Detroit or Michigan’s rural Upper Peninsula have equal access to therapy and survival as those in the suburbs.

Improving Disparities Through Clinical Trials

Part of the Barbara Ann Karmanos Cancer Institute’s mission deals with addressing disparities both socially in terms of myeloma awareness and diagnosis and equity of treatment through clinical trials. I have worked with disparities in myeloma for a decade and learned it’s especially important to attract and recruit diverse people to enroll in clinical trials for multiple myeloma because effective treatment is more dependent on racial and ethnic differences than in many other cancers.

Increasing clinical trial participation among Black patients has the potential to rapidly equalize treatment and outcomes, which is why I devote many nights and weekends to speaking to primary care physicians about the importance of staying up to date on the most modern diagnostics and treatments for this disease. Because it is relatively rare, most community doctors don’t treat it very often, unlike more commonly diagnosed cancers like lung and breast. They may have only one or two patients with blood cancers like multiple myeloma. Because technology is rapidly changing, the oncology community must do its part to help educate them on the newest and best treatments.

Awareness And Motivation

To achieve better outcomes, we need community doctors to be informed about the rapid advancements in treating this disease and aware that clinical trial opportunities exist for their patients. These opportunities will allow them to receive a high standard of care and the potential benefits of cutting-edge treatments.

I often ask primary care physicians to send their patients to me for a second opinion to ensure they have the opportunity to learn about the vast resources available to treat this disease. This includes everything from financial assistance to pathology and radiology to our multidisciplinary meeting, where multiple experts review the case.

There is also a need for professionals at biotech and pharma companies, which often lead and fund these trials, to design them to improve minority participation through a variety of tactics, potentially including:¹

• developing a diversity plan with specific patient enrollment goals based on disease incidence early in the trial design
• broadening eligibility criteria to be more inclusive for diverse populations and recognizing that laboratory criteria and the number of lines of prior therapy can unintentionally exclude patients
• selecting study sites with racially and ethnically diverse populations
• requiring implicit bias training among researchers and staff
• designing trials that reduce the burden on trial participants by establishing research sites closer to patients, decreasing the number of on-site study visits, utilizing telemedicine, and providing financial and travel support
• working to increase the diversity of healthcare providers, trial support staff, and researchers.

We can’t do anything about the genetic and environmental history that makes Black people more susceptible to multiple myeloma than other races, but with better education, better trial design, and greater awareness about the availability of clinical trials, we will begin to eradicate the tragic disparities that so often mean Black people with multiple myeloma die earlier than others with the disease.

References:

1. Hartley-Brown M, Cole CE, Price P, Andreini M, Mulligan G, Young AQ, Cho HJ. Creating Equitable and Inclusive Clinical Trials for Multiple Myeloma. Clin Lymphoma Myeloma Leuk. 2024 Jan;24(1):32-39. doi: 10.1016/j.clml.2023.09.004. Epub 2023 Sep 15. PMID: 37783639.

About The Author:

Craig Emmitt Cole, MD, is a member of the Multiple Myeloma and Amyloidosis Multidisciplinary Program at Karmanos Cancer Institute in Detroit and Lansing. As a member of the American Society of Hematology, International Myeloma Society, and International Myeloma Working Group, Dr. Cole has led multiple clinical trials in multiple myeloma and worked extensively with patient advocacy groups to discover new therapies for multiple myeloma and empower, educate, and bring equitable care to everyone.