Associations of Long-Term Financial Hardship with Autologous Transplant and Overall Survival in Patients with Multiple Myeloma

Background

Financial fragility at the time of multiple myeloma (MM) diagnosis, defined by adverse financial events such as delinquent debt or bankruptcy, is associated with delays in treatment initiation and decreased rates of autologous stem cell transplant (ASCT). Chronic MM treatment is associated with significant out-of-pocket (OOP) expenses which can further worsen patient finances and cause long-term financial hardship. Little is known about patients with MM and long-term financial hardship, including rates of ASCT and overall survival (OS). Using a novel database of linked credit reports and insurance claims, we evaluated the association of long-term financial hardship following a MM diagnosis with receipt of ASCT and OS.

Methods

A retrospective cohort analysis was conducted using linked Washington State cancer registry data, health insurance claims, and depersonalized TransUnion credit reports. The presence of financial fragility at diagnosis was assessed for patients who were diagnosed with MM from 2012 to 2020 and received treatment, using available credit reporting within 50 days from diagnosis. Additionally, patients selected for inclusion had continuous insurance enrollment for 2 years from initiation of treatment or until death. Financial fragility was defined as the presence of delinquent debt, delinquent mortgage payments, or third-party actions (collections, liens, foreclosures, repossessions, or bankruptcy). Additionally, if these attributes were present on the most recent credit report 2 years after initiation of treatment (for patients who were still alive), then those patients were considered to have long-term financial hardship. Study outcomes included receipt of ASCT (within 12 months from diagnosis) and total OOP spending (cumulative up to 2 years from initiation of treatment, derived from insurance claims). OS was calculated from the date of diagnosis to the date of death. Statistical analyses were performed using chi-squared, Wilcoxon rank-sum, and Kaplan-Meier tests.

Results

396 patients with MM who received treatment from 2012-2020 who met the eligibility criteria were identified. The overall cohort is 59% male, 88% white, and median age at diagnosis was 72 years. 59%, 25%, and 15% of patients had Medicare, commercial, and multiple types of insurance, respectively.

At diagnosis, 100 (25%) of 396 patients had financial fragility. At 2-year follow-up, 77 of 396 patients had no evaluable credit reporting, with 75 owing to mortality events. Among 319 patients with an evaluable credit report 2 years after diagnosis, 69 (22%) had long-term financial hardship. Of these patients, 53 (77%) of these patients also had financial fragility at diagnosis and 16 (23%) of these patients developed financial hardship over time.

Patients with long-term financial hardship 2 years after diagnosis (n = 69) were more likely to be non-white (25% vs. 6%, p < 0.001) and younger (68.1 vs. 71.0 years, p = 0.05) compared to those without long-term financial hardship (n = 250). Patients with long-term financial hardship paid higher mean 2-year OOP costs ($37,320 vs. $33,581, p = 0.72). They were also less likely to receive ASCT in the first 12 months after diagnosis (86% vs. 92%, p = 0.08) and mean overall survival was decreased (36.7 vs. 38.5 months, p = 0.46).

Discussion

Long-term financial hardship is present 2 years after initiation of treatment for approximately a quarter of surviving patients with MM. Over three-quarters of these patients also had financial fragility at the time of diagnosis. Patients with MM and long-term financial hardship have trends towards higher OOP costs, lower rates of ASCT, and decreased OS. Due to small sample sizes, larger populations are required to confirm these trends. Further studies are underway to investigate whether intervening on financial fragility at diagnosis improves downstream patient outcomes.