By Nancy Cruz Sitner, DNP, ANP-BC, BMTCN®
Access to care and health equity are critical factors that affect diagnosis, treatment, and outcomes for patients with multiple myeloma, particularly among Blacks and African Americans. Although multiple myeloma is relatively rare, accounting for about 3% of all cancers, it is the second most common blood cancer in Black and African American individuals, with a statistical tie in prevalence with lymphoma and leukemia. About 24% of those cases are in Blacks and African Americans.
Race and ethnicity are social constructs, not biologic factors influencing disease. Thus, the increased health disparities and differences in disease prevalence among Black and African American individuals stem from complex and interconnected factors, such as socioeconomic status, healthcare access, environmental exposure, genetic predisposition, and lifestyle factors. Those underlying drivers are often associated with diseases that appear to align with racial or ethnic differences, such as higher rates of conditions like obesity and diabetes in Black and African American individuals, which are known risk factors for multiple myeloma.
Black and African American patients with multiple myeloma may experience delays in diagnosis. Early detection is crucial for better treatment outcomes, because delays can lead to more advanced disease at diagnosis. Although no symptoms are unique to the African American population, oncology nurses should be able to recognize general signs and symptoms that may indicate the presence of multiple myeloma:
- Anemia: Low red blood cell counts can cause weakness, shortness of breath, and pale skin.
- Bone pain: Often occurring in the back, hips, or ribs, the pain can be severe and may worsen with movement or at night.
- Fatigue: Unexplained and persistent fatigue or weakness can be an early sign of multiple myeloma.
- Frequent infections: Multiple myeloma can weaken the immune system, increasing infection susceptibility.
- Hypercalcemia: High blood calcium levels may cause excessive thirst, frequent urination, and confusion.
- Kidney damage: Patients may experience increased thirst, frequent urination, and swelling, particularly in the legs and ankles.
- Nausea and constipation: Kidney dysfunction can also lead to nausea, vomiting, and constipation.
- Unexplained weight loss: Significant and unexplained weight loss over a short period can be a symptom of multiple myeloma.
Black and African American individuals are more likely to exhibit specific biomarkers of aggressive disease, including anemia and elevated lactate dehydrogenase. They also have higher mortality rates than any other broadly defined racial or ethnic group for most cancers and other leading causes of death, including heart disease, stroke, and diabetes.
These early symptoms are not unique to multiple myeloma and can also stem from other health conditions. If you or someone you know is experiencing persistent and unexplained symptoms, consult a healthcare professional for a thorough evaluation. Early detection through blood tests, bone marrow biopsies, and imaging studies like x-rays or magnetic resonance imaging can confirm or rule out a diagnosis of multiple myeloma.
Improve Early Diagnosis Rates With Increased Access to Care
According to Healthy People 2030, decreased access to care negatively affects health outcomes, leading to increased chronicity and decreased overall survival. The literature illustrates disparities in attaining access to care for:
- Early symptom detection
- First-line treatment options
- Symptom and disease management
- Cellular therapy and stem cell transplant referrals
For example, Black and African American patients are 50% less likely than White patients to undergo a stem cell transplant for multiple myeloma. Additionally, systemic factors like financial and transportation issues, lack of requirements for specific levels of minority representation in clinical trials, and mistrust of the medical community may reduce Black and African American patients’ interest or ability to enroll in clinical trials.
Because delayed diagnosis is correlated with a higher incidence of myeloma-related complications, early identification is essential for optimal outcomes. Patients with undiagnosed multiple myeloma often initially present to emergency departments or primary care providers, sometimes requiring multiple visits before being diagnosed. Hence, primary care providers hold one of the most critical roles in early multiple myeloma diagnosis.
However, nurses can watch for specific disease indicators that may trigger suspicion. The combination of high calcium levels, kidney dysfunction, low red blood cell count, and bone damage is a classic diagnostic criterion. An elevated total serum protein can hint at multiple myeloma, but it is not specific. To establish a formal diagnosis, the medical team confirms abnormal paraproteins through serum and urine laboratory tests or bone marrow biopsies once the patient is admitted to the hospital.
When patient symptoms and primary laboratory findings suggest multiple myeloma, the primary care provider should initiate an extended laboratory workup or refer the patient to an appropriate specialist. Increasing awareness among advanced practice nurses who provide primary for high-risk populations, such as Black and African Americans, can mitigate racial disparities in the diagnostic process.
Advocate for Solutions
Reducing healthcare disparities requires a multifaceted approach that involves healthcare system reform, community outreach, patient education, and socioeconomic inequity action. Primary care and oncology providers must collaboratively advocate at the institutional level for programs and resources to improve early diagnosis and high-quality care for high-risk populations and for policies promoting diversity and inclusion for the healthcare team. Additionally, clinicians can use their voices to advocate for increased local and federal funding for nurse scientists and researchers who are evaluating cancer care disparities and building the evidence for interventions to promote equitable access to health care.
Within the local community, oncology healthcare providers can partner with trusted community or religious leaders to provide population-specific education to help patients understand their multiple myeloma risk, diagnosis, treatment options, and available resources (community support organizations and programs to reduce healthcare disparities). Providing this education directly to high-risk populations can empower them to advocate for their health and help them navigate the complex healthcare system.
Engage Cultural Competency and Educational Resources for RNs and Advanced Practice Nurses
Healthcare providers should commit to learning about racial disparities in health care and the social determinants of health that contribute to inequities. Intentional learning about cultural competence and humility, implicit bias, and health disparities allows providers to improve their understanding of their patients’ unique needs and provide care that is respectful and sensitive to their cultural backgrounds, values, and beliefs.
Oncology healthcare providers can collaborate with other healthcare specialists and the community to develop and implement strategies for reducing racial barriers and inequities, including case conferences to promote awareness and understanding, quality improvement initiatives to provide innovative care through clinical trials, and evidence-based practice to address disparities.