Real-world utilization patterns of bone-modifying agents for multiple myeloma in the era of novel therapies

Abstract Background Little is known about the utilization patterns of bone modifying agents (BMA) among patients with newly diagnosed multiple myeloma (NDMM) in the era of triplet and quadruplet regimens. Methods This retrospective cohort study used electronic health records from a large, integrated health system in Ohio and Florida to identify adults with NDMM between January 1, 2017-December 31, 2023 who received triplet or quadruplet regimen within a year of diagnosis. Main outcomes were receipt of BMA within +/- 90 days of systemic treatment initiation and type of initial BMA received. Results A total of 706 patients were identified. Mean [SD] age at diagnosis was 66.3 [10.1] years; 321 [45.5%] were female; 593 received triplet and 113 quadruplet regimen. In terms of race and ethnicity, 165 patients [23.4%] were Black, 515 [72.9%] were White, and 39 [5.5%] had Hispanic ethnicity. The majority of patients (497 [70.4%]) had Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, and 399 [56.5%] had estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2. During the study period, 502 patients (71.1%) received BMA and 372 (52.7%) received it within +/- 90 days of systemic therapy initiation. Among those diagnosed between 2018 and 2023 and with BMA during the study period (n=422), the initial BMA was a bisphosphonate for 339 (80.3%) and denosumab for 83 (19.7%). The median patient who had 1- or 2-year follow-up since initiation of systemic therapy and also received BMA during that time (n=494 for year 1 and n=315 for year 2), had BMA administered 6 times in the first year (IQR, 3.0-9.0) and 5 times in the second year (IQR, 3.0-8.0). In the multivariable models, baseline eGFR <60 (vs. ≥60) was negatively associated with BMA receipt within +/- 90 days (AOR, 0.56, 95% CI, 0.40-0.77), while micropolitan area (vs. metropolitan, AOR, 2.41, 95% CI, 1.28-4.75) and Ohio regional hospitals (vs. Taussig cancer center, AOR, 1.65, 95% CI, 1.08-2.53) were positively associated. Sex, age at diagnosis, race, ethnicity, year of diagnosis, Area Deprivation Index quartile, insurance type, Charlson comorbidity index, and ECOG performance status were not associated with BMA receipt within +/- 90 days of systemic therapy Patients with a baseline eGFR <60 (vs. ≥60) had higher odds of receiving denosumab (vs. bisphosphonates, AOR, 3.48, 95% CI, 2.03-6.06). Other variables were not significant predictors in the model. Conclusion Delays and underuse of BMAs in patients with NDMM have not markedly improved in the era of novel therapies. Future studies should examine the barriers to the timely initiation of BMAs.