Abstract
<h3>Background</h3> The objective of this study was to investigate if there are differences in survival for Multiple myeloma (MM) patients in Sweden depending on health care region and early use of modern therapies <h3>Method</h3> Cohorts (labelled A-F) were defined by the six healthcare regions in Sweden. Modern initial therapies were defined as bortezomib in combination with melphalan, cyclophosphamide or thalidomide or as therapy including lenalidomide, pomalidomide, carfilzomib or daratumumab. Only therapies started within a year from diagnosis were considered. Data from patients with MM in the Swedish Myeloma Register diagnosed during 2008-2017 was used. Overall, 5326 patients with MM were analyzed after 250 patients who did not receive any treatment were excluded. A one year follow up report was required to evaluate treatment. To adjust for time to treatment bias, separate analyses were performed for patients alive 6 months after diagnosis. <h3>Results</h3> In all treated MM patients, we observed a significant superior overall survival (OS) for region A compared to all other regions (p<0.01 for all respectively). After adjusting for time to treatment bias there was also a superior survival for patients with high use of modern initial therapy compared to intermediate and low use (p<0.01 for both). Initial modern therapy appeared to increase in regions over time. Age adjusted incidence for region A, B, C, D, E and F was 6.3, 6.1, 6.0, 5.9, 6.4 and 7.3 per 100 000, respectively. Coverage of one-year follow up was less frequent in region A (82.6 %) compared to other regions (95.2-99.2%). In patients treated with autologous stem cell transplantation (ASCT) a significantly superior survival was observed for region A compared to all regions besides region B. When adjusting for time to treatment bias, results were similar. In patients not treated with ASCT, 75 years or older, a superior survival was observed for region A when compared to region B, E and F (log rank p=0.02, p=0.04, p=0.02). After adjusting for time to treatment bias, a difference was noted only between region A and E (log rank p=0.04, HR 1.2, CI 1.00-1.44, p=0.06). In patients not receiving ASCT younger than 75 years of age we saw no differences in OS. When adjusting for age, ISS stage and time period of diagnosis, a difference remained in survival for patients treated with ASCT when comparing region A vs C, D, E and F (p=0.01, p<0.01, p<0.01, p=0.03). In patients not treated with ASCT, 75 years or older, no differences remained between the regions in multivariate analysis. <h3>Conclusion</h3> In conclusion we observed a superior survival in region A for patients treated with ASCT. Possible explanations may be higher usage of modern initial therapy, different number in cycles of pretreatment or regional residual confounding. In patients not receiving ASCT younger than 75 years of age no difference in survival was observed. For patients not receiving ASCT, 75 years or older the small differences in survival could be adjusted for.
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