Tag Archive for: ethnicity

Improving Access to Bladder Cancer Care: Impact of Insurance and Socioeconomic Factors

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How can access to bladder cancer care be improved? Expert Dr. Shaakir Hasan from Beth Israel Lahey Health discusses the impacts of health insurance and socioeconomic factors, the value of preventative care, and proactive advice for all patients to help ensure optimal health.

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“Take it upon yourself, regardless of how you feel, regardless of how good you feel to engage in preventive medicine to seek medical attention, even when you feel good, feel healthy, get routine checkups, because a lot of times you just won’t know what’s going on, you won’t feel it. But we can detect it early without you feeling it. And that could eventually save your life if we catch something early, but just when you want to catch something.”

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Can Self-Advocacy Close the Gap in Bladder Cancer Outcomes?

Transcript:

Lisa Hatfield:

Dr. Hasan, can you speak to how socioeconomic factors influence access to bladder cancer care? And what suggested strategies can help bridge these gaps for underrepresented patients and families facing bladder cancer?

Dr. Shaakir Hasan:

Sure. So the only factor that we saw that was more significant, more influential on worse prognosis, late diagnosis for bladder cancer was insurance. So even more so than ethnicity and income was the lack of insurance. And this makes sense, right? This makes sense. Again, if you do not have insurance, you probably are not getting routine checkups, you’re not getting that urinalysis, you’re not having that opportunity to mention, oh, yeah, a couple of weeks ago, I saw some blood in the urine, it went away. I don’t know if that’s a big deal or not.

You’re just not going to have that opportunity to talk about this and work this up. So that is, I think, the fundamental issue. I think that’s the most important aspect of everything is to just have initial access, preventative medicine, preventive care to look out for these symptoms that can lead you to a bladder cancer diagnosis. So, certainly I think lack of access is the number one thing, even more so than the minority groups. Of course, there is a strong correlation between the two right certain ethnicity, certain groups, underprivileged groups are going to be less likely to have health care. The question is what to do about it. That’s a lot tougher to answer.

At the end of the day, we ought to figure out how to get better access to care. I would say, please, please prioritize this, prioritize your health care. It’s easy for me to say as a physician, I know that I’m biased here, but all too often, I see people that feel great, look great, just have no complaints and therefore do not seek any care. And I understand that I actually personally, probably go by that doctors make pretty bad patients, by the way, as the saying goes, and I’m probably guilty of this as well.

But what I would tell you is that, what makes cancer so dangerous, regardless of where it is, including bladder is that you tend to not know it’s there until it’s too late. It’s very sneaky. It just hangs out with you until it wants to take over. And you’re never going to know, you know, until it’s too late, unless you kind of act on it early. And so it’s really, really important to find a way. I know it’s expensive. I know it can be difficult, but please don’t make the mistake of thinking just because you look great, you feel great, you’ve never had to see a doctor that you don’t want to take these measures to preventative care.

At the end of the day, health is all you have. You could be the richest person in the world, you can do whatever you love to do. But if you aren’t there, if you aren’t around to experience it, or you can’t be healthy while you do it, it’s kind of worthless, right? So please prioritize your health is what I’d say.

Take it upon yourself, regardless of how you feel, regardless of how good you feel to engage in preventive medicine to seek medical attention, even when you feel good, feel healthy, get routine checkups, because a lot of times you just won’t know what’s going on, you won’t feel it. But we can detect it early without you feeling it. And that could eventually save your life if we catch something early, but just when you want to catch something.

Can Race or Ethnicity Impact CAR T-Cell Therapy Response?

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Can Race or Ethnicity Impact CAR T-Cell Therapy Response? from Patient Empowerment Network on Vimeo.

Can CAR T-cell therapy response be impacted by patient race or ethnicity? Expert Dr. Sikander Ailawadhi from Mayo Clinic discusses some impacts to CAR T-cell therapy response for African Americans and some clinical methods to help reduce impacts to patients.

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“…there is a lot of work happening, research happening around how to predict and prevent side effects from CAR T so that the patients are much more informed, aware, can make an informed decision, and as clinicians, we can do whatever is within our control and is at our disposal to help prevent those side effects and make CAR T an even safer and more beneficial treatment for patients.”

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Transcript:

Lisa Hatfield:

Dr. Ailawadhi, is there data around ethnicity and response to CAR T-cell therapy and whether genetic factors may affect treatment outcomes? And can the side effects of CAR T-cell therapy be predicted or prevented?

Dr. Sikander Ailawadhi:

So Lisa, a very important question of whether there are racial ethnic factors that can affect CAR T-cell therapy benefit or side effects, and what are we doing to prevent some of these side effects? We know side effects can happen, what can we do to actually prevent them? So I’ll take this question in two different subgroups. The first one of talking about racial ethnic groups or differences. So we know patients who are African Americans. This is one study reported that African Americans are more likely to have side effects from CAR T-cell therapy.

So while it’s not a specific “genetic factor,” but race ethnicity can sometimes be associated with more side effects, and that is just because these are very inflammatory delivered or inflammatory mediated side effects like CRS. It’s also important to know that there are certain other factors, disease or treatment-related factors, that can help predict potentially more side effects with CAR T. For example, patients who are very heavily pre-treated, patients who have a very high disease burden, patients who did not respond to bridging therapy that was given to them prior to the CAR T.

These are all factors where we know that side effects are going to be more, and the success of the treatment might be lesser. What we are trying to do to mitigate some of these side effects, there are now studies which are giving either some low doses of steroids as a prophylaxis before, right around the time of CAR T, so that side effects may not happen. Studies that are giving a low dose or even standard dose of what’s called tocilizumab (Actemra), toci, or tocilizumab.

This toci drug is an antidote for CRS or cytokine release syndrome. The thought is, well, why wait for the toci to be given after the side effect happens? Why not give it beforehand and prevent the CRS? Historically, there was a concern that steroids or toci given early on could affect the CAR T-cell viability or activity, but that’s not the case. For example, in lymphomas, there are clinical trials that have shown very clearly given prophylactic or preventative steroids could help. Using steroids or toci in a preventative manner is helping mitigate some of the side effects. 

Well, by preventing the side effects, we are being able to give the treatment in a way that the patients may have lesser side effects and can get it done closer to home or at home sometimes, and their time to stay in the hospital is lesser. You can imagine that some of these barriers are being further mitigated.

My activation tip for this question is that there is a lot of work happening, research happening around how to predict and prevent side effects from CAR T so that the patients are much more informed, aware, can make an informed decision, and as clinicians, we can do whatever is within our control and is at our disposal to help prevent those side effects and make CAR T an even safer and more beneficial treatment for patients.

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How Do Race and Ethnicity Impact CAR T Side Effects?

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How Do Race and Ethnicity Impact CAR T Side Effects? from Patient Empowerment Network on Vimeo.

How are CAR T side effects impacted by race and ethnicity? Expert Dr. Sikander Ailawadhi from Mayo Clinic shares some research study results about CAR T response rates and disease progression in African American and Hispanic patients and solutions for clinicians.

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“…there are some differences by race, ethnicity, specifically for the side-effect profile, patients should be aware of it, and clinicians who are the CAR T specialists should be aware of it so that they can manage the side effects well in their patients.”

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 How Can Information Disparities on Emerging Therapies Be Addressed?

How Can Information Disparities on Emerging Therapies Be Addressed?

 Can Race or Ethnicity Impact CAR T-Cell Therapy Response?

Can Race or Ethnicity Impact CAR T-Cell Therapy Response?

Transcript:

Lisa Hatfield:

Dr. Ailawadhi, real-world data from one of the available CAR-T-cell therapies, ide-cel (Abecma), has shown some differences in the side effect profile and benefit by patient race and ethnicity. What is your take on this, and how do you utilize this in your clinical practice? And also, what do you think researchers should do next to learn more about how CAR T therapies affect different people?

Dr. Sikander Ailawadhi:

This is an extremely important question, looking at what is the data currently on the risks and benefits of CAR T-cell therapy in patients from different racial ethnic groups, and then how are we using that in the clinic today and where should the field go about research in this area. So, Lisa, you’ve correctly pointed out that this study that was published recently is based on some real world data from one of the CAR T cells available, ide-cel.

Now, I shouldn’t say that this is specifically to ide-cel, but basically, ide-cel has been around a little bit longer than cilta-cel (Carvykti), and so the real-world data on ide-cel was to the point that this racial ethnic analysis could be done, and it was reported. That said, we don’t know how cilta-cel would be. That data just does not exist. So, I’m not saying that this is applicable to cilta-cel or not, because at least this study was specifically for ide-cel because that data was mature enough to be reported. That was just a qualifier of this particular question.

Now, what that study showed was that some of the side effects, including CRS, the cytokine release syndrome, and certain markers that can be an accompaniment of CRS, like the ferritin or what’s called CRP, C-reactive protein, which are inflammatory markers. So, inflammatory markers were higher in African Americans, and the CRS was also higher in African Americans from that real-world data.

The other thing that it showed was that the response rates were lower in Hispanics, but the progression-free survival, meaning time it took for the disease to progress and require more treatment, was lower in African Americans or overall survival was same across the racial ethnic groups. So, side effects a little bit more in African Americans, and the immediate response, a little bit less in Hispanics, but overall outcome, similar across races. Now, this is important for us to know because African Americans tend to have certain inflammatory disorders more frequently, like even asthma is seen more frequently in African Americans.

So, CRS, which is an immune system mediated inflammatory response, I can imagine that some of it might be higher in African Americans. So, in our clinics, what we are doing is when we are monitoring the patients, every patient is getting monitored the same way, but when it’s an African American patient, we are putting a little bit more focus on those inflammatory markers that can sometimes start showing up even before the CRS happens. I don’t think the response rate portion of Hispanics that we’re really taking into account much because the overall outcome or the long-term outcome was not really different between races and ethnicities.

Of course, there needs to be much more research, so I think we need longer-term follow-up data, we need larger number of patient data, and what I alluded to in the very beginning, we do need data on cilta-cel also, which has not yet been presented, but we are hoping that it will come out very soon. So, my activation tip for this question is, that there are some differences by race, ethnicity, specifically for the side-effect profile, patients should be aware of it, and clinicians who are the CAR T specialists should be aware of it so that they can manage the side effects well in their patients.

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AML Clinical Trial Participation Disparities | Impact on Access, Outcomes, and Inclusion Strategies

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AML Clinical Trial Participation Disparities | Impact on Access, Outcomes, and Inclusion Strategies from Patient Empowerment Network on Vimeo.

What are AML clinical trial disparities, outcomes, and solutions for inclusion? Expert Dr. Sara Taveras Alam from UTHealth Houston discusses patient factors that impact access, underrepresented patient groups, and patient advice for improving clinical trial access. 

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“…inquire if there are clinical trials available at the institution where you’re being cared for, not all institutions do have clinical trials available, and that is okay, but you should be informed and given the opportunity to look into other facilities if clinical trials are available and have the ability to do so.”

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Transcript: 

Lisa Hatfield:

Dr. Taveras, so this is kind of a three-part question regarding disparities in acute myeloid leukemia. So what are the disparities in clinical trial participation among AML patients, and how do these disparities affect access to innovative treatments and outcomes, and then kind of a third part to this question, how can efforts be made to increase diversity and inclusion and clinical trials for AML? 

Dr. Sara Taveras Alam:

Thank you. This is a very important question. Unfortunately, disparities exist in the outcome of AML patients based on different factors, social-economic factors, racial factors, ethnicity, and unfortunately, it has been proven that in clinical trials, the non-Hispanic white population is the predominant population study, so unfortunately, our African Americans or Black patients and our Hispanic patients are underrepresented, and this may impact whether or not the treatments that are getting put, being studied and being utilized in AML patients are appropriate for these patients who were not included on the clinical trials.

I do see that there is an intentional effort to recruit patients from minority groups in institutions where trials are available; however, one caveat is that unfortunately, some of those underrepresented populations don’t necessarily have access to the institutions that are leading the clinical trials. I’m in Houston, and we actually have a county system here in Houston, where leukemia trials are available, and that is really a blessing, because it’s not something that is very common. So throughout my training, when I did go to a county hospital, I was able to see Hispanic patients and African American patients being given the opportunity to participate in clinical trials that may impact the long-term treatment of other patients and those treatments being studied in the population that was using them.

My activation tip for this question is to inquire if there are clinical trials available at the institution where you’re being cared for, not all institutions do have clinical trials available, and that is okay, but you should be informed and given the opportunity to look into other facilities if clinical trials are available and have the ability to do so.

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Are There Disparities in Stem Cell Transplant Outcomes?

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Are There Disparities in Stem Cell Transplant Outcomes? from Patient Empowerment Network on Vimeo.

What do myeloproliferative neoplasm (MPN) patients need to know about disparities in stem cell transplant outcomes? Expert Dr. Idoroenyi Amanam from City of Hope explains key factors that impact the outcomes of stem cell transplants and the importance of finding fully matched donors.

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Emerging MPN Therapies in the Research Pipeline

Transcript:

Lisa Hatfield:

Dr. Amanam, does race or ethnicity play a role in outcomes of stem cell transplantation?

Dr. Indoroenyi Amanam:

Yes. There have been some really great studies looking at this. And I think in general, we know that health disparities are a major issue for racial, ethnic, and socioeconomic disadvantaged groups. Stem cell transplant is a curative therapy for blood disorders. And we’ve looked at a variety of different, there have been multiple approaches to assess like where these disparities come from or if there are disparities from specific groups. And I think the Affordable Care Act was great in allowing expansion and insurance coverage to multiple groups and increased access to care. But that hasn’t solved the problem.

And so, one of the issues we’ve seen is that providers themselves do not refer patients proportionately. So from proportion if you’re African American, Hispanic, if you are coming from a ZIP code that your meaning income is lower, that there are some instances where referrals for transplant don’t occur in equal rates.

And we’ve also seen that even if you’re insured and you’re African American or Hispanic, referral rates are still lower. And so that’s something that, it’s something that we have to work to improve. And you know, one big thing for transplant is that you have to have donors. You have to have donors who are matches for these patients who have these disorders who need a transplant. And we do know that African Americans, Hispanics, and Asians have lower chances of finding a fully matched donor compared to white Americans. And so, why that’s really important is that when you look at rates of complications after transplant, we do know that the level of match of the donor does play a part in that. Namely the chances of the patient relapsing after the bone marrow transplant and the rates of graft-versus-host disease are significantly higher.

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Expert Advice | Shining a Light on Equitable AML Care

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Expert Advice | Shining a Light on Equitable AML Care from Patient Empowerment Network on Vimeo.

While treatment options are improving, there are still many factors impacting equitable care for AML patients. Dr. Ann-Kathrin Eisfeld shares advice for improving research and clinical trials for underserved AML populations.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

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How Does the Presence of Molecular Testing Affect AML Care?

Transcript:

Katherine Banwell:

Dr. Eisfeld, we’ve covered a lot of information related to AML care. As a researcher, what other topics are currently top of mind for you in the field of AML? What are you passionate about? 

Dr. Eisfeld:

Again, so many parts. I think there are probably three main things that I’d like to name. And I think about it as a little bit outside the box. Most of what we know about AML, we have become so much better. It’s because we have been studying patients who were treated over the past decades on clinical trials and very often here in the U.S. or in Europe.  

But all clinical trials have a bias in that most of them have been done A) on patients who are younger than the age of 60. And B) fewer patients of other races and ethnicities included. And had patients not included that have AML, for example, not only in the bone marrow but on extramedullary sites – how we call it – up to 10 percent of their patients. And also, very often have not been done on very old patients where the AML is very common. So, all the patients – patients from other race, ethnicities, or underrepresented minorities, and patients who present with extramedullary disease are currently in my – underserved.  

And these are exciting areas and opportunities of research and of active clinical practice. Because those are the patients we need to include if it’s possible now to include them in clinical trials. 

If there are no trials available, then make sure any other additional molecular testing it done to understand them better and to advance our disease knowledge that we make sure that we can give the best possible care.  

I think that the most important part is to get the molecular testing, and to enroll into clinical trials, and then to very often biobanking.  

Why am I saying that is because our knowledge AML comes from patients who donated some tissue so that we could learn – researchers decades ago could learn about the genes. We know that leukemias differ so much in between patients.  

So, I am worried that we are yet missing out on potentially important genes that need to be discovered and where we could develop docs for. This will only be possible with these additional testing. 

 The second part is to really consider going to larger treatment and larger treatment cancer center. And there are support systems in case that can help in here.  

And the third part is to get involved even as early as possible even if you’re not personally affected, with Be The Match – with bone marrow transplant because there’s a paucity of donors, of people of color that makes it harder for these patients to get a potentially curative treatment in here.  

We have other options now in bone marrow transplant where one can use only half-matching donors and or other availabilities. But again, that doesn’t outweigh that the bone marrow and donor registry that we need to get better at.  

And I can – there are just so many factors – such a high degree of structural racism that affects people from every corner. And I think we as physicians, as society, and everybody need to acknowledge that. And we have to make sure that we get better to, again, give every patient the best care and keep the patient in mind and see what’s right for them at the right moment.    

Katherine Banwell:

Where can patients or people who are interested find out about being a donor? 

Dr. Eisfeld:

There is the website called “Be the Match” that one can put in. This is probably the best way to get first information.  

And usually, at all the cancer sites. And sometimes, there is information at lab donation places, universities, either or the American Red Cross. Usually those places have information laid out there as well. 

Noted Racial, Ethnic, and Socioeconomic Disparities In Breast Cancer Outcomes

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Noted Racial, Ethnic, and Socioeconomic Disparities In Breast Cancer Outcomes from Patient Empowerment Network on Vimeo.

What are breast cancer disparities? Expert Dr. Demetria Smith-Graziani explains notable disparities seen in breast cancer risks, treatments, and outcomes – and questions for patients to ask their doctor to help ensure their best care. 

Demetria Smith-Graziani, MD, MPH is an Assistant Professor in the Department of Hematology and Medical Oncology at Emory University School of Medicine. Learn more about Dr. Smith-Graziani.

[ACT]IVATION TIP

“…have an open and honest discussion with your physicians about the, your particular breast cancer risk and about the specific treatment recommendations that you receive, why you’re receiving those recommendations, and how people who get those treatments usually do.”

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Transcript:

Lisa Hatfield:

Dr. Smith, what are the noted racial, ethnic, and socioeconomic disparities seen in breast cancer risk, treatment, and outcomes?

Dr. Demetria Smith-Graziani:

So a lot of work has been done over the years to really understand more about disparities in breast cancer. When it comes to breast cancer risk, we know that while white women are more likely in United States to be diagnosed with breast cancer, Black women are more likely to die from breast cancer. Black women also have a higher risk of triple-negative breast cancer, which is known to be a more aggressive form of breast cancer, and Black women are diagnosed on average at a younger age compared to white women.

When it comes to disparities in treatment and outcomes, we can see that a lot of what affects the type of treatment that you receive and how you end up doing after that treatment are related to not only your race or ethnicity, but also your income, your insurance status, what zip code you live in, and other social factors and structural factors in our country, it’s really important that both patients and providers are aware of the disparities and the causes, because it’s up to all of us, but especially those in the healthcare system, to think about the ways that we can address them.

So, my activation tip for patients is to be aware of the fact that these disparities exist and to have an open and honest discussion with your physicians about the, your particular breast cancer risk and about the specific treatment recommendations that you receive, why you’re receiving those recommendations, and how people who get those treatments usually do. 

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How Can Myeloma Patients Advocate for the Best Care?

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How Can Myeloma Patients Advocate for the Best Care? from Patient Empowerment Network on Vimeo.

Dr. Peter Forsberg shares advice for myeloma patients on why it’s important to speak up about symptoms and side effects, how to become a better partner in their care, and the role of a second opinion.

Dr. Peter Forsberg is assistant professor of medicine at the University of Colorado School of Medicine and is a specialist in multiple myeloma. More about Dr. Forsberg here.

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What Should You Know About Myeloma Treatment Options?

Transcript:

Katherine:                  

What is some key advice that you give patients when they’re considering their treatment options?

Dr. Forsberg:             

Well, I think one important one is to always feel comfortable communicating with your provider. I think that there no by the book questions, list of questions, that’re the right questions to ask. I think the more important thing is trying to establish a good working relationship with your treatment team. Myeloma is much more of a marathon than it is a sprint. So, getting comfortable with your team, getting comfortable with a relationship and a partnership that can be often many years in duration, are really critical steps.

So, I think laying that foundation, feeling comfortable asking questions, trying to understand why. Understand how and what are tools to monitor what the myeloma will be and what indicates success or a need for something else. Those would all be critical pieces that I would encourage patients to feel empowered to be part of.

Katherine:                  

Patients can sometimes feel like they’re bothering their healthcare team with the comments and the questions. So, why is it important for patients to speak up when it comes to their symptoms and side effects?

Dr. Forsberg:             

Well, I think feeling comfortable being vocal about what’s going on is one of the key issues to navigating myeloma successfully. Being aware of issues, even if they may seem minor or insignificant, they may be an indicator for something that is emerging in terms of a treatment related side effect that we wanna be aware of. There are treatment side effects that we are willing to work through. But it can be very broad in terms of the spectrum of how we maneuver through different side effects.

And additionally, we always want to be aware of any issues that may be going on that could be a sign for what’s happening with the myeloma. So, trying to be vocal. Not only to understand what’s going on, what our treatments are, how successful are we at any given point in time, where things stand. But also, to make sure that you are putting things on your provider’s radar are key. So, lots of folks want to be good and compliant patients and we certainly appreciate that hope. But being assertive in terms of issues that may be coming up or questions that you may have, can really make for a much more successful long-term relationship in terms of how we manage the myeloma.

Katherine:                  

Well, do you have suggestions on how a patient could feel more confident in speaking up and becoming a partner in their care?

Dr. Forsberg:             

Well, certainly using tools like, if you found your way to this material, I think is a great first step.

Becoming a little bit more versed in the myeloma, in the language of the myeloma, what these tests that we use are. What their results might be. Using a number of great patient specific organizations are great first steps. So, being proactive about learning, to some degree about the myeloma. And then feeling comfortable asking that first questions. Once you begin the process of unlocking the myeloma and demystifying what it is and what these tests mean and where we stand, then that can really build on itself and allow folks to feel more in control of their myeloma and their myeloma journey.

Katherine:                  

And if a patient isn’t feeling confident with their treatment plan or their care, do you recommend that they seek a second opinion or consult a specialist?

Dr. Forsberg:             

Well, I never think it’s a bad idea to think about a second opinion or seeing a myeloma specialist. Even if you feel very comfortable with your treatment plan. Myeloma’s a unique disease and our approaches for it may be somewhat different, person to person.

And your needs as a myeloma patient my change and they may change somewhat abruptly. So, having seen someone who specializes in myeloma as part of your care team, and usually it is a care team. And there’s different models we sometimes work with in terms of both local or primary oncologists, as well as more specialized academic oncologists. We’re used to working through all sorts of models to provide the best possible care for patients. So, I never think it’s a bad idea to ask about that. Because having that more robust team is usually mostly benefit without adding a lot of headache. 

Debunking Common Myeloma Misconceptions

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Debunking Common Myeloma Misconceptions from Patient Empowerment Network on Vimeo.

Myeloma expert Dr. Peter Forsberg discusses common misconceptions about the disease and explains who may have an increased risk for developing myeloma.

Dr. Peter Forsberg is assistant professor of medicine at the University of Colorado School of Medicine and is a specialist in multiple myeloma. More about Dr. Forsberg here.

See More From The Pro-Active Myeloma Patient Toolkit

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What Is the Patient’s Role in Myeloma Treatment Decisions?

Transcript:

Katherine:                  

Are there common misconceptions you hear when you see a new myeloma patient for the first time?

Dr. Forsberg:             

Yeah, I think some of the more common questions that come up involve those questions like I mentioned about things like stage and understanding this unique characteristic to myeloma. Myeloma unfortunately remains an incurable disease in the year 2020. So, some of the questions come up regarding what prognosis or treatment approaches may entail. Certainly, going to not up-to-date sources can lead to a lot of misconceptions about what our options are and what our outlook might be for myeloma.

And certainly at times, patients wonder where the myeloma came from. Is there something that I did or that I was exposed to that was a real driver for me to develop this? That’s a really common question that comes up. And unfortunately, or fortunately, the answer is not really any that we know well about. So, let me rephrase. So, one question that comes up a lot is what may have caused the myeloma.

Is there something that someone did or was exposed to that drove the myeloma? And truthfully, at this point there aren’t a lot of drivers for myeloma that we know about. So, usually that’s something that can be a little hard to understand or to reconcile. But it is a type of disease that can, unfortunately, can affect anyone. It does get more common as people get older. But aside from some potential genetic impact or mild increased risk in family members and with certain ethnic groups. Not a lot of historical things that were done might drive the development of myeloma.