Optimizing Multiple Myeloma Assessment for Newly Diagnosed Patients at Intermountain Health: A Mixed Methods Analysis
Introduction/Background/Significance: Only 20-50% of eligible patients with multiple myeloma (MM) undergo autologous stem cell transplantation (ASCT). Community oncologists commonly refer newly diagnosed patients with MM to specialized transplant centers. Little is known about community oncologist barriers to referring patients to transplant centers for consultation.1 Intermountain Health (Intermountain) introduced a referral protocol in April 2023 encouraging Intermountain-employed community oncologists to refer all newly diagnosed MM patients by the second first-line induction cycle to the central Intermountain Bone Marrow Transplant Center (the Center) for transplant eligibility consultation and transplant care.
Materials and Methods/Case Presentation/Objective: The aim of this study was to understand community oncology team attitudes and beliefs regarding ASCT, early consultation and use of the Center. We characterized the Intermountain hub-spoke delivery model, roles and work processes; described the MM patient population; and measured variation in consultation patterns among 11 geographically disbursed community oncology sites in 2024. We conducted key informant interviews (n=25) with primary oncologists, advanced practice providers, nurses and nurse navigators at 5 of the community sites (n=17), serving urban and rural patients from five states, and the Center (n=8) in June-July 2025. Thematic saturation was reached by role. Interviews were analyzed using qualitative content analysis.
Results/Description/Main Outcome Measures: The 11 community sites had 79 patients with no prior cancer history newly diagnosed with MM in 2024 [male: 58%; mean age: 67.8 years; non-white race: 6%; Hispanic ethnicity: 11%; mean Charlson Comorbidity Index Score: 3.3 (range: 0-17); live >100 miles from Center: 33%]. Fifty-three percent (53%) of patients had a consultation note documented by the Center. All community oncologists interviewed identified ASCT as the standard of care for first line treatment for eligible patients and could identify ASCT eligibility criteria. Community oncologists, who treat a range of cancer conditions, highly valued the Center's MM expertise in assessing transplant eligibility and care delivery. When consultation occurred, community oncology care teams perceived good alignment between sites and the Center, with few disagreements on eligibility and first line treatment, driven by strong physician-to-physician communication; weekly tumor boards; care coordination using specialized nurse navigators; and rapid Center response.
Barriers to referral and consultation included the preference by some community oncologists to exclude from referral patients they felt were clearly transplant-ineligible given age, fitness and/or comorbidities. For some referred patients, Center consultation was not covered by their insurance, and they sought care elsewhere. Remaining barriers were patient treatment preferences and socio-economic concerns, including distance to the Center.
Conclusions: Despite developing novel therapies, ASCT remains the first line standard of care for newly diagnosed patients with MM among oncologists in this study. Given the specialized nature of ASCT and the lack of available local MM expertise and resources, community oncology teams felt that ASCT care was best done centrally, though some evaluated transplant eligibility locally. Future innovations that preclude the use of ASCT may require expanding local resources and expertise to support MM care and could mitigate patient barriers.
Trademarked Items
References
[1] Bashir Q, et al. Overcoming Barriers to ASCT in Multiple Myeloma: Recommendations from a Multidisciplinary Roundtable Discussion. Transplant Cell Ther. 2023;29(11):666-673.
