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Opinion | Is Multiple Myeloma a Greater Threat to Black Patients?

Colin Powell’s death from COVID-19 shined a light on the danger for patients with weakened immune systems. Hematologic cancers (Powell had multiple myeloma), their treatment, and advancing age all make patients more vulnerable to breakthrough COVID-19 infection, complications, and death.

Far from being the indictment of vaccine efficacy that some believe it to be, the former secretary of state’s death is a stark reminder of why we need a robust COVID-19 vaccine strategy. Policies that help more people get vaccinated will help protect the most vulnerable among us — including cancer patients, cancer survivors, and many others who are immunocompromised.

But General Powell’s death also underscored another important health gap. Multiple myeloma, a blood cancer that like many others suppresses the immune system, disproportionately affects Black Americans both in terms of incidence and outcomes.

Black Americans have a twofold increased risk of multiple myeloma and are diagnosed with the disease at younger ages. However, the incidence gap starts well before malignancy. In individuals younger than age 50, the prevalence of the myeloma precursor state monoclonal gammopathy of undetermined significance (MGUS) is significantly higher in the Black population compared to the white population, with up to a 10-year earlier age of onset.

The reasons for increased incidence and earlier onset of MGUS in the Black population are not fully understood, but potential genetic and environmental factors are being studied. A population-based sample of Black men in Ghana showed a twofold higher prevalence of MGUS compared to a white reference population, suggesting genetics may play a role.

While only a percentage of people with MGUS go on to develop multiple myeloma, MGUS and smoldering multiple myeloma always precede multiple myeloma. The younger age of MGUS onset should be an opportunity for earlier identification of those at risk, and an opportunity for early intervention. In reality, misdiagnosis is likely because practitioners are used to seeing MGUS in older patients and may not consider the diagnosis in someone who is in their 30s or 40s.

While overall it is true that earlier diagnosis is linked to better outcomes, older Black multiple myeloma patients ages 65 to 74 have not experienced the same recent survival gains associated with newer therapies as their white counterparts. Social and socioeconomic disparities have likely contributed to lesser survival gains, but evidence of unequal access to the newest therapies is also a part of the problem.

This is particularly troubling since there is evidence that with the newest treatments Black patients may actually fare better than white patients with multiple myeloma. This would seem to indicate that it may not be that the disease is worse, but that Black patients are not getting the right treatment in the timeliest fashion.

These disparities have only become more problematic in light of pandemic-related health gaps: racial disparities in COVID-19 outcomes and vaccination rates.

According to the CDC, Black and non-Hispanic white populations have a similar risk of COVID-19 infection. However, the risk of COVID-related death is two times higher and the risk of hospitalization is nearly three times higher in Black individuals compared to whites.

While Powell had received two COVID-19 vaccine doses and was scheduled to receive his third dose before becoming ill, his experience is not mirrored in the U.S. Black population. Over the course of the vaccination rollout, Black individuals have been less likely than their white counterparts to have been vaccinated. There is promising evidence that COVID-19 vaccination rates are picking up in Black communities, however. The recent share of vaccinations reaching the U.S. Black population is 12%, the same as their share of the total population.

All eligible blood cancer patients should get vaccinated against COVID-19. This means a three-dose primary series (if using one of the mRNA vaccines), plus a booster dose 6 months later, or one dose of the Johnson & Johnson vaccine plus a booster 2 months later.

Because of diminished immune response in certain blood cancer patients, including those with multiple myeloma, breakthrough infections are more likely even after vaccination when compared to the general population. But several studies show that COVID-19 vaccines provide some protection to the majority of blood cancer patients. We need to consider our friends and neighbors whose immune system puts them at risk, when deciding on vaccination.

Disparities in COVID-19’s impact on Black people, as well as the disparities in COVID-19 vaccination rates and multiple myeloma among the Black population represent a triple threat that patients and practitioners need to be aware of. Advocacy, resources, and education can help enhance access to care and support better outcomes among Black Americans.

Gwen Nichols, MD, is the chief medical officer of the Leukemia & Lymphoma Society.

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