Trends in Cause of Death among Patients with Multiple Myeloma in Puerto Rico and the

United States SEER Population, 1987-2013

Maira A. Castañeda-Avila¹; Karen J. Ortiz-Ortiz²; Carlos R. Torres-Cintrón²; Brenda M.

Birmann³; Mara M. Epstein¹,⁴

¹ Department of Population and Quantitative Health Sciences, University of Massachusetts

Medical School, Worcester, MA;
² Puerto Rico Central Cancer Registry, University of Puerto Rico Comprehensive Cancer Center,
San Juan, Puerto Rico;
³ Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s
Hospital and Harvard Medical School, Boston, MA;
⁴ Meyers Primary Care Institute and the Department of Medicine, University of Massachusetts
Medical School, Worcester, MA
Short title: Cause of death in patients with multiple myeloma

Contact information:

Mara Meyer Epstein, ScD

Assistant Professor

Meyers Primary Care Institute

University of Massachusetts Medical School

365 Plantation Street

Biotech 1, Suite 100

Worcester, MA 01605

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/ijc.32232

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Email: mara.epstein@umassmed.edu

Phone: 508 856 3305

Fax: 508 856 5024

Funding: This work was funded in part by the National Cancer Institute grant R03 CA199383

(MME). MME and MACA are supported in part by the National Center for Research Resources

and the National Center for Advancing Translational Sciences, National Institutes of Health,

through Grant KL2TR001454 (MME), and TL1TR01454 (MACA).

Key words: Multiple myeloma, temporal trends, cause of death, Puerto Rico

Abbreviations: MM, multiple myeloma; PRCCR, Puerto Rico Central Cancer Registry; SEER,

Surveillance, Epidemiology, and End Results Program; APC, Annual Percent Change; MGUS,

Monoclonal Gammopathy of Undetermined Significance; US, United States.

Article Category: Research Article in Cancer Epidemiology

Novelty & Impact Statements

This study examined temporal trends in cause of death among patients with multiple

myeloma in Puerto Rico and the US SEER population over 26 years. We found that although

multiple myeloma-specific death decreased over time, it remains the predominant cause of death

for individuals diagnosed with multiple myeloma in both populations. However, as multiple

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myeloma patients live longer due to improvements in treatment, the management of other co-

morbid conditions may be of increasing importance.

Abstract

Multiple myeloma (MM) survival has improved due to recent developments in MM

treatment. As a result, other co-morbid conditions may be of increasing importance to MM

patients’ long-term survival. This study examines trends in common causes of death among

patients with MM in Puerto Rico, and in the US Surveillance, Epidemiology, and End Results

(SEER) population.

We analyzed the primary cause of death among incident MM cases recorded in the Puerto

Rico Central Cancer Registry (n=3,018) and the US SEER Program (n=67,733) between 1987-

2013. We calculated the cumulative incidence of death due to the eight most common causes and

analyzed temporal trends in mortality rates using joinpoint regression. Analyses of SEER were

also stratified by Hispanic ethnicity.

MM accounted for approximately 72% of all reported deaths among persons diagnosed

with MM in Puerto Rico and in SEER. In both populations, the proportion of patients who died

from MM decreased with increasing time since diagnosis. Age-standardized temporal trends

showed a decreased MM-specific mortality rate among US SEER (annual percent change

[APC]= -5.0) and Puerto Rican (APC=-1.8) patients during the study period, and particularly

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after 2003 in non-Hispanic SEER patients. Temporal decline in non-MM causes of death was

also observed among US SEER (APC=-2.1) and Puerto Rican (APC=-0.1) populations.

MM-specific mortality decreased, yet remained the predominant cause of death for

individuals diagnosed with MM over a 26-year period. The most pronounced decreases in MM-

specific death occurred after 2003, which suggests a possible influence of more recently

developed MM therapies.

Introduction

Multiple myeloma (MM) is a cancer of plasma cells in the bone marrow which is

characterized by the production of large amounts of abnormal monoclonal protein, or “M

protein”.1 MM accounts for 1% of all cancers and approximately 10% of all hematologic

malignancies diagnosed in the US each year.2 In 2018, 30,770 new cases and 12,770 deaths from

MM were expected in the US, with only 50.7% of MM patients surviving 5 years after

diagnosis.3 Few risk factors for MM are known, but men are slightly more likely to develop MM

than women, and African Americans are twice as likely to develop MM as white Americans.4

Other risk factors for MM include a history of monoclonal gammopathy of undetermined

significance (MGUS), family history of MM or related conditions, and obesity.5,6

The development of new treatments for MM over the past 10-15 years has encouragingly

extended the median survival of patients with this condition. Patients diagnosed with this

malignancy in the US had a 5-year survival rate of only 25-30% in the late 1970s,7 whereas

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expected survival has doubled to 50.7% approximately 40 years later.4 Considering that patients

are generally diagnosed with MM at older ages — e.g., on average at age 70, when other co-

morbidities are also more common8 — and that survival rates for MM patients have improved, 4

it is likely that causes of death other than MM will be increasingly more common among MM

patients in the coming years.

The Commonwealth of Puerto Rico is an unincorporated territory of the US with a

population of approximately 3.6 million, primarily of Hispanic origin (98%).9 It has been shown

that cancer trends in Puerto Rico differ strikingly from those of the continental United

States.10 Puerto Ricans also exhibited higher cancer mortality rates than other Hispanic ethnic

groups in a recent study.11 To the best of our knowledge, MM mortality has not been specifically

investigated in the Puerto Rican population. In addition, changing trends in the cause of death in

persons diagnosed with MM has not yet been examined in the US Surveillance, Epidemiology,

and End Results Program (SEER) and Puerto Rican populations. We hypothesized that, although

MM still accounts for most deaths among patients with this disease, a higher percentage of

people may be dying from other causes in recent years when compared to earlier periods. In

addition, due to varying prevalence of lifestyle risk factors and healthcare access,12 it is possible

that the specific causes of death may be different for patients diagnosed with MM in Puerto Rico

compared to Hispanic and non-Hispanic patients included in the US SEER population.

Materials and Methods

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Study population and data sources

This study involved a secondary analysis of the databases of the Puerto Rico Central

Cancer Registry (PRCCR) and the SEER Program of the National Cancer Institute. The PRCCR

is responsible for collecting, analyzing, and publishing information on all cases of cancer

diagnosed and/or treated in Puerto Rico since 1950. The PRCCR has been part of the CDC's

National Program of Cancer Registries since 1997 and has complete information available from

1987 (http://www.rcpr.org/).13 The SEER program has collected data on cancer incidence and

mortality from various locations throughout the US since 1973 (https://seer.cancer.gov/). The

present analysis includes data from the SEER 18 registries.14 PRCCR uses similar standards for

coding data to those used by SEER, making the resulting data comparable.

This analysis included all MM cases aged 40 and older reported to the PRCCR and the

SEER Program and diagnosed between 1987-2013, because less than 1% of MM cases are

diagnosed under age 40. We began the study period in 1987 since this was the first year when

complete data were available from both study populations. The study was approved by the

Institutional Review Board of the University of Massachusetts Medical School, and a written

letter of approval for this analysis was obtained from the PRCCR.

Case ascertainment

A total of 4,246 cases of MM were diagnosed in Puerto Rico between 1987 and 2013. We

excluded cases with unknown diagnostic confirmation (n=624), different histologic type (other

than ICD-O-3 morphology code 9732; n=308), cases with a secondary diagnosis of MM

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(n=233), and those who were missing age at diagnosis (n=11), leaving 3,018 cases from the

PRCCR in the analysis.

The US SEER Program data were extracted using SEER*Stat's client-server mode.15 A

total of 91,894 cases of MM were diagnosed in the US SEER population from 1987 to 2013. We

excluded cases of unknown diagnostic confirmation (n=4,056), cases with a different histologic

type (other than ICD-O-3 morphology code 9732; n= 5,700), cases with a secondary diagnosis of

MM (n=13,387), and people <40 years old (n=1,018), leaving 67,733 MM cases from SEER in

the analysis (61,138 non-Hispanic and 6,595 Hispanic).

Cause of death data

For patients with MM diagnosed in Puerto Rico, de-identified cause of death data were

provided by the Demographic Registry of Puerto Rico at the Puerto Rico Department of Health.

The Registry used the International Classification of Diseases, Ninth Edition (ICD-9) to code

deaths occurring from 1987 to 1998 and the ICD Tenth Edition (ICD-10) to code deaths

occurring between 1999 and 2013. The SEER program used the ICD-9 to classify cause of death

for people who died from 1979 through 1998 and the ICD-10 to code deaths that occurred

thereafter.

The causes of death of study participants were harmonized between the US SEER and

Puerto Rico registries. We focused on MM and on the eight most common categories of non-

MM cause of death: certain infectious and parasitic diseases; diseases of the circulatory system;

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diseases of the genitourinary system; diseases of the nervous system; diseases of the respiratory

system; endocrine, nutritional, and metabolic diseases; other cancers; and all other causes of

death. Cause of death categories were defined by ICD codes in the PRCCR (Supplemental Table

1) and by predetermined, descriptive categories based on ICD codes in the US SEER population

(Supplemental Table 2), as individual ICD codes were not available for the SEER population.

Statistical Analysis

Characteristics were compared between persons diagnosed with multiple myeloma by

population (Puerto Rico, Hispanic-SEER, Non-Hispanic-SEER). Chi-square tests were used to

compare categorical variables and ANOVA for continuous variables between populations. We

described the distribution of the most common causes of death among patients with MM in

Puerto Rico, and the overall SEER population, and further examined cause of death stratifying

the SEER population by Hispanic ethnicity. Cause of death was examined overall and by gender,

age at MM diagnosis, calendar year of MM diagnosis, and survival time. Survival time was

calculated from the date of MM diagnosis to the recorded date of death, loss to follow-up, or the

end of follow-up (December 31, 2013), whichever occurred first. We assessed the distribution of

causes of death among patients diagnosed with MM by calculating the percentage of total deaths

and the cumulative incidence of death from each of the selected causes using total deaths among

patients with MM as the denominator. We also examined temporal changes in cause of death by

calendar period defined by developments of new therapies for this disease.7 All analyses of the

SEER population were also stratified by Hispanic ethnicity (Hispanic versus non-Hispanic).

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 We calculated annual age-Standardized mortality rates using the 2000 US Standard

Population (10 age groups - Census P25-1130). We then used joinpoint regression to identify the

best-fit line through 26 years of annual age-standardized mortality rates, looking separately at

death from MM and from other causes. The annual percent change (APC) and 95% confidence

intervals (95% CI) were calculated using the Joinpoint Regression Program (Version 4.6.0.0)

available from the National Cancer Institute.16 The Joinpoint Regression Program identifies the

number of significant joinpoints by performing several permutation tests.17 For comparison to

the joinpoint regression findings, we calculated one-year limited duration prevalence estimates.

For the purposes of the prevalence estimates, the population at risk in 1987 was defined as all

men and women diagnosed with MM in 1987. In 1988 and subsequent years, we defined the

population at risk as people diagnosed with MM from all previous years. The age-standardized

joinpoint regression results were similar to those based on the limited-duration prevalence

estimates, and thus only the results of the joinpoint regression are presented. All other analyses

were conducted in STATA 13.18

Results

MM was diagnosed slightly more often in men than women in both populations. The

median age at diagnosis was the same among non-Hispanics in the SEER population and in

Puerto Rico at approximately 69 years old, but slightly lower among Hispanics in SEER at 65

years (p-value <0.01) (Table 1). The median survival time was longer for cases diagnosed in the

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US SEER population than in Puerto Rico (two years vs one year, respectively; p<0.01), and the

median age at death was 2 years older in the US SEER population. In both populations, patients

with MM were more likely to die from MM than from other causes during the study period.

Among all deaths occurring in the study period, approximately 72.0% were due to MM in both

populations. The second most common cause of death in MM patients in Puerto Rico was from

other cancers (11.2%) followed by diseases of the circulatory (5.3%) and respiratory (3.7%)

systems. In the US SEER population, the second most common cause of death was diseases of

the circulatory system (11.6% of non-Hispanics and 10.0% of Hispanics) followed by other

causes of death (5.7% non-Hispanics and 4.6% Hispanics) and other cancers (5.3% non-

Hispanics and 4.6% Hispanics).

A greater proportion of deaths from MM occurred in men (51.9% in Puerto Rico; and

52.5% of non-Hispanics and 51.4% of Hispanics in SEER) than in women (48.1% in Puerto

Rico; and 47.5% of non-Hispanics and 48.6% of Hispanics in SEER) in both populations during

the study period (Table 2). The mean age at death from both MM and other causes was higher

among non-Hispanics in SEER when compared to both Puerto Ricans and Hispanics in SEER (p-

value< 0.001). Furthermore, Hispanics in SEER had a younger median age at death from both

MM and other causes than Puerto Ricans.

In general, MM patients were more likely to die from MM than from other causes across

all time periods in all populations (Figure 1); nonetheless, the proportion of deaths due to MM

decreased somewhat for patients who lived three or more years after diagnosis in Puerto Rico

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and those living two or more years after diagnosis in the SEER population (in both non-

Hispanics and Hispanics). The decrease in the proportion of MM-specific deaths coincided with

a slight increase in the proportion of deaths from causes other than MM for patients who lived

longer. In these patients, we observed increasing proportions of deaths due to other cancers and

diseases of the circulatory and respiratory systems in Puerto Rican patients, and due to

circulatory system diseases, other cancers and other causes of death in SEER patients.

The results of the joinpoint regression suggest that while MM-specific mortality declined

in all populations over the study period, trends in non-MM causes varied by population. In the

non-Hispanic SEER population between 1987 and 2003, we observed an annual percent decrease

of 2.1% per year in deaths from MM, which grew to an annual percent decrease of 5.2% per year

from 2003 to 2013 in age-standardized temporal trends models (Figure 2 and Table 3). In the

Hispanic SEER population between 1987 and 2013, we observed an annual percent decrease of

3.0%, with no distinction over the time period. In Puerto Rico, an annual percent decrease of

only 1.8% per year was observed between 1987 and 2013 (Table 3). We observed fairly steady

mortality rates from all non-MM causes in the SEER population through 2003. From the

joinpoint regression, we also observed an annual percent decrease of 2.0% per year in death from

all non-MM causes from 2003 to 2013 among non-Hispanics, while the Hispanic US SEER

population had an annual percent decrease in non-MM causes of 2.3% from 1987 to 2013. In

contrast, in Puerto Rico, an annual decrease in non-MM death of just 0.1% per year was

observed (Table 3).

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Discussion

We examined temporal trends in causes of death among patients with MM over 26 years

in two well-defined populations. Despite recent improvements in the treatment and long-term

survival of patients with MM, people diagnosed with MM in Puerto Rico and the US SEER

population, including Hispanics and non-Hispanics, remain more likely to die from MM.

However, in the most recent years, a decrease in the overall number of deaths from MM was

evident. We observed a slight increase in the proportion of deaths resulting from non-MM causes

with increasing survival time since diagnosis, which may be due to more effective treatments

prolonging the lives of MM patients.19 We also observed a decrease in both MM and non-MM

causes of death, particularly among non-Hispanics in the SEER population since 2003; this could

reflect patients living longer after their MM diagnosis, or a decrease in overall mortality in the

SEER population, as a decline in the age-standardized death rate in the United States has been

reported.20 However, it should also be noted that the Hispanic SEER population and the Puerto

Rican population were much smaller, and may have lacked the statistical power to detect such a

trend.

The results of the joinpoint regression analysis suggested that, in Puerto Rico overall,

deaths from MM have decreased over the study period, while deaths from other causes have also

decreased slightly as patients survive longer past diagnosis. Similarly, in the SEER population,

we observed a decrease in the proportion of deaths from both MM and other causes over the

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study period, although the decrease in deaths from MM was greater in magnitude than the

decrease in deaths from non-MM causes. The more striking decline in both MM and other causes

of death among the SEER population could be explained in part by improvements in MM

treatment options.21 However, this may differ in Puerto Rico where the decrease in the

proportion of deaths was lower than in the SEER population. Puerto Ricans are known to be

vulnerable to cancer disparities and may have less access to new treatments due to higher cost,22

potentially due to socioeconomic inequalities. Approximately 44% of the population of Puerto

Rico lives in poverty,23 although the percentage of individuals in Puerto Rico without health

insurance was lower (6%) compared with mainland US (9%) in a 2015 survey.24

We also observed different distributions of non-MM causes of death between

populations. In Puerto Rico, other cancers, diseases of the circulatory system, and diseases of the

respiratory system were the three most common non-MM causes of death among MM patients,

while in the SEER population including both non-Hispanics and Hispanics, diseases of the

circulatory system, other causes of deaths, and other cancers were the most common. Cause of

death among Hispanics in the SEER population appeared more similar to non-Hispanics in

SEER than to MM patients in Puerto Rico. Due to existing evidence for an increased risk of

certain types of secondary cancers like bone and other lymphoid cancers in survivors of MM, it

is not surprising that other cancers would comprise one of the major non-MM causes of death in

MM patients; however we were unable to assess the contribution of specific cancer types.25,26

Circulatory disease, which includes ischemic heart disease and cerebrovascular disease, was

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among the top non-MM causes of death in both populations. It is known that MM pathogenesis

and treatment may increase the risk of cardiovascular events; pre-existing cardiovascular risk

factors could increase an MM patient’s risk of dying from this secondary cause.27 In addition,

respiratory disease was a common cause of death in Puerto Rico, but not among the top causes in

the SEER population. The respiratory tract is a common site of infection in MM patients.28 In

addition, in Puerto Rico, there is a high incidence of respiratory diseases likely due to

environmental factors like fungal spores,29 which may partially explain the elevated rate of death

from respiratory causes in this population specifically. Future studies could investigate the

influence of these co-morbid conditions on prognosis and cause of death in MM patients.

In this study, we used reliable population-level data collected over 26 years by the

PRCCR and the US SEER program. The comparison of data from Puerto Rico with the Hispanic

and non-Hispanic SEER populations is of interest because of the sociocultural relationship

between Puerto Rico and the US, and to evaluate the similarities and differences between these

populations with regards to MM outcomes. The lengthy study period allowed us to describe

subtle variations in the rates of death from MM and non-MM causes over nearly three decades.

Our analysis investigated time trends for MM-specific and non-MM deaths, which to our

knowledge has not previously been reported in these populations. We also were able to assess

whether recent declines in MM mortality already documented in some US population samples7

and in other countries30 were apparent in Puerto Rico.

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 There are also some limitations to our analysis, including the relatively small number of

MM patients in the Puerto Rico database, which may have limited the power to detect temporal

changes in less common causes of death. In addition, since data were only available through

2013, our findings may only partially reflect the influence of more recently approved therapies

for MM.31 We also lacked individual-level information on variables such as smoking, alcohol,

medication use, and obesity, which may contribute to risk of death from both MM and non-MM

causes. We limited the analyses to the primary cause of death and ignored contributing causes,

which may have over- or underestimated the number of deaths from MM, as patient deaths may

have been incorrectly attributed to their MM. Differences in the approach to coding cause of

death between populations may have resulted in misclassification of some less common causes

of death, although we expect any impact on study results to be minimal.

Conclusions

Our data illustrate that people diagnosed with MM are still more likely to die from MM

than from non-MM causes despite improvements in patient survival and treatment options during

the study period. Furthermore, the decreases in MM-specific death in Puerto Rico have occurred

at a lesser rate than in the SEER population, among both Hispanics and non-Hispanics, between

1987 and 2013 for reasons that are not immediately clear from this analysis. Nonetheless, death

rates from MM do appear to have decreased in both Puerto Rico and in the SEER population. It

is to be expected that as MM patients continue to survive longer, the management of other co-

morbid conditions will be of increasing importance in this patient population, and that the

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distribution of such conditions will vary across different patient populations. Future studies are

warranted to further clarify trends in co-morbidity and cause of death, to elucidate potential areas

for improvement in care, and enhance the survival of patients with MM. Multi-center studies

with detailed individual-level data are needed to further investigate the underlying explanations

for our observed results, including examining associations between temporal changes to

individual risk factors and treatment patterns with survival time and cause of death in MM

patients.

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 Table 1. Population characteristics of persons diagnosed with multiple myeloma in the Puerto Rico Central Cancer Registry and the

United States Surveillance, Epidemiology, and End Results Program (SEER) 1987–2013

Non-Hispanics US
Overall US SEER Hispanics US SEER Puerto Rico*
SEER
Characteristics (n=67,733) (n=61,138) (n=6,595) (n=3,018)
n % n % n % n %
Male 36,177 53.4 32,691 53.5 3,486 52.9 1,537 50.9
Median age at diagnosis, years 69 69 65 69
Age at diagnosis in years
40-59 17,410 25.7 15,190 24.9 2,220 33.7 686 22.7
60-69 18,401 27.2 16,503 27.0 1,898 28.8 889 29.5
70-79 19,460 28.7 17,812 29.1 1,648 25.0 947 31.4
≥80 12,462 18.4 11,633 19.0 829 12.6 496 16.4
Year of diagnosis
1987-1997 13,226 19.5 12,375 20.2 851 12.9 999 33.1
1998-2002 12,670 18.7 11,500 18.8 1,170 17.7 388 12.8
2003-2007 17,227 25.4 15,446 25.3 1,781 27.0 577 19.1
2008-2013 24,610 36.3 21,817 35.7 2,793 42.4 1,054 34.9
Median survival time, years (±SD) 2 2 2 1
Median age at death, years1 74 74 71 72
Died from all causes 46,746 69 42,648 69.8 4,098 62.1 2,293 76
Died from multiple myeloma 33,336 49.2 30,280 49.5 3,056 46.3 1,628 54
Died from other cause 13,410 19.8 12,368 20.2 1,042 15.8 665 22
Censored2 20,987 31 18,490 30.2 2,497 37.9 725 24
Cause-specific death
Myeloma 33,336 71.3 30,280 71 3,056 74.6 1,628 71.7

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Certain infectious and parasitic diseases 644 1.4 596 1.4 48 1.2 34 1.5
Diseases of the circulatory system 5,360 11.5 4,948 11.6 412 10.0 121 5.3
Diseases of the genitourinary system 692 1.5 642 1.5 50 1.2 42 1.8
Diseases of the nervous system 141 0.3 134 0.3 7 0.2 13 0.6
Diseases of the respiratory system 1,142 2.4 1,057 2.5 85 2.1 85 3.7
Endocrine, nutritional and metabolic
382 0.8 320 0.7 62 1.5 40 1.8
diseases
Other cancer3 2,443 5.2 2,255 5.3 188 4.6 254 11.2
Other causes of death4 2,606 5.6 2,416 5.7 190 4.6 54 2.4

SEER = Surveillance, Epidemiology, and End Results.

1
Includes those who died or were lost to follow-up.
2
Alive as of December 2013 or lost to follow-up.
3
US SEER included malignant neoplasms, stated or presumed to be primary, of lymphoid, hematopoietic and related tissue (n=611, 25%) and malignant
neoplasms of independent (primary) multiple sites (n=448, 18%); Puerto Rico include malignant neoplasm of ill-defined, secondary and unspecified sites (n=61,
24%) and malignant neoplasms, stated or presumed to be primary, of lymphoid, hematopoietic and related tissue (n=60, 23%).
4
US SEER included unspecified other causes of death (n=1,953, 74%) and accidents/adverse events (n=298, 11.4%); Puerto Rico include diseases of digestive
system (n=19, 35%) and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (n=18, 33%), and accidents/adverse events
(n=12, 22%).
5
All p-values for the comparisons between non-Hispanic SEER, Hispanic SEER and Puerto Rico populations were <0.02

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 Table 2. Distribution of causes of death for people diagnosed with multiple myeloma in the Puerto Rico Central Cancer Registry,

1987–2013 and the United States Surveillance, Epidemiology, and End Results Program (SEER), 1987–2013*

Overall US SEER Non-Hispanics-SEER

Population characteristics Died from Died from
Died from Died from
multiple Censored1 multiple Censored1
other cause other cause
myeloma myeloma
All patients, N 33,336 13,410 20,987 30,280 12,368 18,490
Gender, N (%)
Male 17,468 (52.4) 7,426 (55.4) 11,283 (53.8) 15,897(52.5) 6,845 (55.3) 9,949 (53.8)
Female 15,868 (47.6) 5,984 (44.6) 9,704 (46.2) 14,383 (47.5) 5,523 (44.7) 8,541 (46.2)
Median age at diagnosis, years 70 73 63 70 73 63
Age at diagnosis in years, N (%)
40-59 7,335 (22.0) 2,101 (15.7) 7,974 (38.0) 6,447 (21.3) 1,877 (15.2) 6,866 (37.1)
60-69 8,691 (26.1) 3,014 (22.5) 6,696 (31.9) 7,807 (25.8) 2,745 (22.2) 5,951 (32.2)
70-79 10,370 (31.1) 4,561 (34.0) 4,529 (21.6) 9,553 (31.5) 4,219 (34.1) 4,040 (21.8)
≥80 6,940 (20.8) 3,734 (27.8) 1,788 (8.5) 6,473 (21.4) 3,527 (28.5) 1,633 (8.8)
Year of diagnosis, N (%)
1987-1997 9,212 (27.6) 3,550 (26.5) 464 (2.2) 8,608 (28.4) 3,364 (27.2) 403 (2.2)
1998-2002 8,150 (24.4) 3,204 (23.9) 1,316 (6.3) 7,424 (24.5) 2,945 (23.8) 1,131 (6.1)
2003-2007 9,318 (27.9) 3,769 (28.1) 4,140 (19.7) 8,347 (27.6) 3,437 (27.8) 3,662 (19.8)
2008-2013 6,656 (20.0) 2,887 (21.5) 15,067 (71.8) 5,901 (19.5) 2,622 (21.2) 13,294 (71.9)
Median age at death, years 73 76 _ 73 76 _

Hispanic SEER Puerto Rico

Population characteristics Died from Died from
Died from 1 Died from
multiple Censored multiple Censored1
other cause other cause
myeloma myeloma

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All patients, N 3,056 1,042 2,497 1,628 665 725
Gender, N (%)
Male 1,571 (51.4) 581 (55.8) 1,334 (53.4) 845 (51.9) 359 (54.0) 333 (45.9)
Female 1,485 (48.6) 461 (44.2) 1,163 (46.6) 783 (48.1) 306 (46.0) 392 (54.1)
Median age at diagnosis, years 67 70 61 69 71 66
Age at diagnosis in years, N (%)
40-59 888 (29.1) 224 (21.5) 1,108 (44.4) 353 (21.7) 108 (16.2) 225 (31.0)
60-69 884 (28.9) 269 (25.8) 745 (29.8) 481 (29.6) 190 (28.6) 218 (30.1)
70-79 817 (26.7) 342 (32.8) 489 (19.6) 508 (31.2) 239 (35.9) 200 (27.6)
≥80 467 (15.3) 207 (19.9) 155 (6.2) 286 (17.6) 128 (19.3) 82 (11.3)
Year of diagnosis, N (%)
1987-1997 604 (19.8) 186 (17.8) 61 (2.4) 671 (41.2) 251 (37.7) 77 (10.6)
1998-2002 726 (23.8) 259 (24.9) 185 (7.4) 235 (14.4) 101 (15.2) 52 (7.2)
2003-2007 971 (31.8) 332 (31.9) 478 (19.1) 322 (19.8) 148 (22.3) 107 (14.8)
2008-2013 755 (24.7) 265 (25.4) 1,773 (71.0) 400 (24.6) 165 (24.8) 489 (67.4)
Median age at death, years 69 73 _ 71 74 _
– = not applicable.
1
Alive as of December 2013 or lost to follow-up.

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 Table 3. The estimated annual percentage change (APC) and 95% confidence intervals (CI) of mortality rates from multiple myeloma

and other causes of death by calendar period using joinpoint regression, and age-standardized to the United States population in 2000.

Death from multiple myeloma Other cause of death1

n Calendar period APC (95% CI) n Calendar period APC (95% CI)
Overall US 33,336 1987-2003 -2.0 (-2.8, -5.2) 13,410 1987-2002 0.1 (-1.1, 1.2)
SEER2 2003-2013 -5.0 (-5.8, -4.3) 2002-2013 -2.1 (-2.8, -1.4)
Non-Hispanics 30,280 1987-2003 -2.1 (-2.9, -1.3) 12,368 1987-2003 -0.1 (-1.2,1)
SEER 2003-2013 -5.2 (-6, -4.4) 2003-2013 -2.2 (-3.2, -1.3)
Hispanics 3,056 1,042
1987-2013 -3.0 (-3.7, -2.2) 1987-2013 -2.3 (-3.9, -0.7)
SEER
Puerto Rico 1,628 1987-2013 -1.8 (-3.1, -0.5) 665 1987-2013 -0.1 (-1.8, 1.6)
1
The non-MM category includes all causes of deaths (certain infectious and parasitic diseases; circulatory system; genitourinary system; nervous system;
respiratory system; endocrine, nutritional and metabolic; other cancers; other causes of death).
2
Overall US SEER population includes both non-Hispanics and Hispanics.

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This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.