Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis

BACKGROUND

Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population.

OBJECTIVE

To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users.

METHODS

A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates.

RESULTS

Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization.

CONCLUSION

The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.

Evaluation of Frequency of Administration of Intravenous Bisphosphonate and Recurrent Skeletal-Related Events in Patients With Multiple Myeloma

This cohort study examines the risk of skeletal-related events associated with the frequency of bisphosphonate treatment in patients with multiple myeloma.

Abstract 775: Racial and ethnic differences in the impacts of rurality on cancer-specific survival among women with de novo metastatic breast cancer

Background: The interaction of racial/ethnic and geographic disparities in determining breast cancer (BC) outcomes is not fully understood. Our purpose was to examine racial and ethnic differences in and the impact of rurality on breast cancer specific mortality among women diagnosed with metastatic BC in the U.S.

Methods: We conducted a large, population-based cohort study using the Surveillance, Epidemiology, and End Results rurality database of women ages 18+ years diagnosed with de novo metastatic BC between 2000 and 2015. Our main exposure of interest was U.S. Department of Agriculture Rural Urban Commuting Area categories, and our outcome of interest was BC-specific mortality. We collected information on demographic and clinical characteristics, including molecular subtypes, treatment, survival and cause of death. We determined associations between rurality and BC-specific mortality in Fine and Gray regression models and calculated subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) accounting for competing risks of death and with adjustment for age, year of diagnosis, hormone receptor (HR) status, treatment, marital status and insurance status. We calculated overall and race specific SHR estimates to understand racial/ethnic differences in impacts of rurality on BC mortality and performed stratified analyses by HR status.

Results: From an overall cohort of 31,991 de novo metastatic BC patients with a median age of 60 years, there were 29,069 patients in urban commuting areas vs. 2,922 in rural areas. Compared to rural areas, lower proportions of non-Hispanic white (65% vs. 81%) and Asian/Pacific islander (0.3% vs. 0.9%) patients, and higher proportions of Black (17% vs. 10%) and Hispanic (10% vs. 5%) patients lived in urban areas. Metastatic BC patients living in urban commuting areas were more likely to receive surgery compared to rural (56% vs. 48%) and have a positive joint HR status (12% vs. 9%), but were similar with respect to radiation (33% vs. 33%) and chemotherapy (53% vs. 51%). Overall, women living in rural areas had a modestly higher risk of BC-specific mortality (adjusted SHR 1.01, 95% CI 1.00-1.02); however, the impact of rurality differed by race/ethnicity and HR status. Among white women with HR-positive metastatic BC, rurality was associated with an increased risk of BC mortality (SHR 1.09, 95% CI 1.03-1.15). Among Black women with HR-negative metastatic BC, we observed the greatest increased risk of BC mortality associated with rurality (SHR 1.27, 95% CI 1.01-1.59).

Conclusion: BC-specific survival among women with de novo metastatic disease differs by race/ethnicity and geography with the greatest adverse impacts of rurality affecting Black women with HR-negative BC.

Citation Format: Mary H. Smart, Hsiao-Ching Huang, Ashwini Zolekar, Huiwen Deng, Colin C. Hubbard, Kent Hoskins, Naomi Y. Ko, Gregory S. Calip. Racial and ethnic differences in the impacts of rurality on cancer-specific survival among women with de novo metastatic breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 775.

Abstract 776: Differences in impact of socioeconomic status on cancer: Specific survival in metastatic breast cancer by race/ethnicity

Introduction: Disparities in breast cancer (BC) incidence and outcomes exist across racial/ethnic groups in the U.S. and by socioeconomic status (SES). The extent to which lower SES independently impacts breast cancer outcomes in different racial/ethnic groups is not fully described. Our purpose was to determine the impact of SES on cancer-specific mortality among women with metastatic breast cancer.

Method: We conducted a large, population-based retrospective cohort study of women ages 18+ years diagnosed with de novo metastatic breast cancer using the Surveillance, Epidemiology and End Results Census Tract-level SES and Rurality Database (2000-2015). SES was described using the Yost index, a validated time-dependent composite score that reflects SES based on several components including education and income, with the 1st quintile representing the lowest and 5th quintile being the highest SES. Information on demographic and clinical characteristics, including hormone receptor (HR) status, cancer treatment, survival and cause of death were collected from cancer registry data. We determined associations between SES and BC-specific mortality in Fine and Gray regression models. Multivariable adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were calculated accounting for competing risks of death. We determined associations between SES and BC mortality overall and calculated stratum specific SHR estimates by racial/ethnic groups and HR status.

Results: In an overall cohort of 33,976 women with de novo metastatic BC, the majority were non-Hispanic white (67%), 17% were Black, 0.4% were American Indian/Alaskan Native, 6% were Asian/Pacific Islander and 10% were Hispanic. Compared to women in the highest SES quintile, women in the lowest SES were more likely to be uninsured or on Medicaid (25% vs. 7%) and have HR-negative disease (24% vs. 18%) but were similar with respect to treatment with surgery, radiation and chemotherapy. Overall, metastatic BC patients in the lowest SES quintile had a significantly increased risk of BC mortality compared to the highest SES quintile (adjusted SHR 1.27, 95% CI 1.22-1.32); however, these impacts of SES differed across racial/ethnic groups and by HR status. Risk estimates for the association between low SES (1st quintile) and BC mortality were lower among HR-positive white women (SHR 1.19, 95% CI 1.12-1.26) and minimal among Asian/Pacific Islander women (SHR 1.05, 95% CI 0.88-1.25). The greatest increased risk was observed among HR-negative Black women (SHR 1.38, 95% CI 1.00-1.90) with metastatic BC.

Conclusion: Independent of race/ethnicity, lower SES is significantly associated with BC-specific mortality among women with de novo metastatic disease. However, when stratifying these effects by racial/ethnic groups and HR status, the impact of SES appears to be greater among Black women with HR-negative metastatic BC.

Citation Format: Hsiao- Ching Huang, Mary H. Smart, Huiwen Deng, Ashwini Zolekar, Colin C. Hubbard, Kent F. Hoskins, Naomi Y. Ko, Gregory S. Calip. Differences in impact of socioeconomic status on cancer: Specific survival in metastatic breast cancer by race/ethnicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 776.

Abstract 2628: Racial differences in the impact of socioeconomic status on cancer-specific survival in multiple myeloma

Background: Multiple myeloma (MM) incidence and outcomes differ across racial/ethnic groups in the United States. Interactions between socioeconomic status (SES) with ethnicity in MM incidence and survival outcomes are not well understood. Our objective was to evaluate disparities in cancer-specific survival of patients diagnosed with MM by race/ethnicity.

Methods: We conducted a population-based retrospective cohort study of patients ages 20+ years diagnosed with MM between 2000 and 2015 using Surveillance, Epidemiology and End Results, Census Tract-level SES and Rurality Database. SES was defined using the National Cancer Institute's time-dependent composite score developed by Yost et al. (2001). Yost index quintiles were where the 1st and 5th quintiles representing the lowest and highest SES categories respectively. Cumulative incidence functions were used to analyze cancer-specific survival across strata racial/ethnic and SES and equality of functions was determined using Gray's test. Subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were calculated using the Fine and Gray regression models adjusted for age, sex, year of diagnosis, marital status, insurance status, and treatment with chemotherapy. Race-specific risk estimates were stratified by age (<65 and 65+ years).

Results: Overall, 58,095 MM patients were included in our analysis among whom 63.0% were non-Hispanic White, 19.5% were Black, 0.3% were American Indian/Alaskan Native, 5.8% were Asian/Pacific Islander and 11.4% were Hispanic. Compared to White MM patients (median age 69 years), Black (64 years), American Indian/Alaskan Native (64 years), Asian/Pacific Islander (67 years) and Hispanic (64 years) patients were younger on average. A higher proportion of Black (42.8%) and Hispanic (27.9%) MM patients were in the lowest SES quintile compared to White (10.6%), American Indian/Alaskan Native (15.2%), and Asian/Pacific Islander (8.9%) MM patients. Cumulative incidence functions for cancer-specific survival were significantly different across SES quintiles (P < 0.0001) and racial/ethnic groups (P < 0.0001). Overall, MM patients in the lowest SES quintile had a significantly increased risk of MM-specific mortality (SHR: 1.28, 95% CI 1.21-1.36) compared to patients in the highest quintile. Risk estimates comparing the lowest to the highest quintile of SES were higher among Black (SHR 1.39, 95% CI 1.08-1.77), Hispanic (SHR: 1.78, 95% CI 1.21-2.63), and White (SHR 1.44, 95% CI 1.23-1.69) MM patients ages <65 years at diagnosis.

Conclusion: Low SES level is independently associated with poor MM-specific survival. However, the impacts of SES on MM-specific survival differ by race/ethnicity and age with the greatest increased risk observed in younger Black, Hispanic, and White patients.

Citation Format: Huiwen Deng, Ashwini Zolekar, Hsiao-Ching Huang, Mary H. Smart, Colin C. Hubbard, Brian C. Chiu, Pritesh R. Patel, Karen Sweiss, Gregory S. Calip. Racial differences in the impact of socioeconomic status on cancer-specific survival in multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2628.

Characteristics Associated With Opioid and Antibiotic Prescribing by Dentists

INTRODUCTION

The objective of this study is to identify county-level characteristics that may be high-impact targets for opioid and antibiotic interventions to improve dental prescribing.

METHODS

Prescriptions during 2012-2017 were extracted from the IQVIA Longitudinal Prescription database. Primary outcomes were yearly county-level antibiotic and opioid prescribing rates. Multivariable negative binomial regression identified associations between prescribing rates and county-level characteristics. All analyses occurred in 2020.

RESULTS

Over time, dental opioid prescribing rates decreased by 20% (from 4.02 to 3.22 per 100 people), whereas antibiotic rates increased by 5% (from 6.85 to 7.19 per 100 people). Higher number of dentists per capita, higher proportion of female residents, and higher proportion of residents aged <65 years were associated with increased opioid rates. Relative to location in the West, location in the Northeast (59%, 95% CI=52, 65) and Midwest (64%, 95% CI=60, 70) was associated with lower opioid prescribing rates. Higher clinician density, median household income, proportion female, and proportion White were all independently associated with higher antibiotic rates. Location in the Northeast (149%, 95% CI=137, 162) and Midwest (118%, 95% CI=111, 125) was associated with higher antibiotic rates. Opioid and antibiotic prescribing rates were positively associated.

CONCLUSIONS

Dental prescribing of opioids is decreasing, whereas dental antibiotic prescribing is increasing. High prescribing of antibiotics is associated with high prescribing of opioids. Strategies focused on optimizing dental antibiotics and opioids are needed given their impact on population health.

Racial Disparities in Intravenous Bisphosphonate Use Among Older Patients With Multiple Myeloma Enrolled in Medicare

PURPOSE

Intravenous (IV) bisphosphonates reduce the risk of skeletal-related events in patients with multiple myeloma (MM). However, data describing racial differences in IV bisphosphonate utilization outside of clinical trial settings are limited. We evaluated population-level IV bisphosphonate initiation and discontinuation among patients of age ≥ 65 years with MM.

METHODS

We conducted a retrospective cohort study of patients of age ≥ 65 years diagnosed with first primary MM between 2001 and 2011. Patients were identified using the SEER-Medicare linked database and followed through December 2013. Cumulative incidences of IV bisphosphonate initiation and time to discontinuation among users were compared between racial and ethnic groups. In Fine and Gray competing risk models, we estimated subdistribution hazard ratios (SHRs) and 95% CIs for initiation and discontinuation.

RESULTS

We included 14,231 eligible patients with MM (median age, 76 years; 52% male). Over a median follow-up of 23.1 months, 54% of patients received at least one IV bisphosphonate dose. Our final analytical sample included 10,456 non-Hispanic (NH) Whites, 2,267 NH Blacks, 548 Asian and Pacific islanders, and 815 Hispanic and Latino patients. A higher proportion of White patients (56.1%) newly received IV bisphosphonates after MM diagnosis compared with NH Blacks (45.4%). Compared with White patients, NH Black patients were less likely to initiate IV bisphosphonates (SHR, 0.74; 95% CI, 0.70 to 0.79) and slightly more likely to discontinue treatment (SHR, 1.10; 95% CI, 1.01 to 1.19).

CONCLUSION

Approximately half of the patients with MM of age ≥ 65 years did not receive IV bisphosphonates, with significant delay among racial minority groups. These findings highlight the need for improvement of IV bisphosphonate uptake in patients with MM of age ≥ 65 years.

Association of Race/Ethnicity and the 21-Gene Recurrence Score With Breast Cancer-Specific Mortality Among US Women

Importance

Given the widespread use of the 21-gene recurrence score for identifying candidates for adjuvant chemotherapy, it is important to examine the performance of the Oncotype DX Breast Recurrence Score test in diverse patient populations to validate this approach for tailoring treatment in women in racial/ethnic minority groups.

Objective

To examine whether breast cancer-specific mortality for women with hormone-dependent breast cancer differs by race/ethnicity across risk categories defined by the Oncotype DX Breast Recurrence Score test and whether the prognostic accuracy of the 21-gene recurrence score differs by race/ethnicity.

Design, Setting, and Participants

This retrospective, population-based cohort study used the Surveillance, Epidemiology, and End Results Oncotype DX 2004-2015 database to obtain breast cancer-specific survival data on US women 18 years and older who were diagnosed with first primary stage I to III, estrogen receptor-positive breast cancer between January 1, 2004, and December 31, 2015, and had tumor testing through the Genomic Health Clinical Laboratory. Data were analyzed from April 20 to September 27, 2020.

Main Outcomes and Measures

The primary outcome was breast cancer-specific mortality among women from different racial/ethnic groups stratified by the 21-gene recurrence score risk categories. Secondary analyses compared the prognostic accuracy of the recurrence score among the different racial/ethnic groups.

Results

A total of 86 033 patients with breast cancer (mean [SD] age, 57.6 [10.6] years) with Oncotype DX Breast Recurrence Score test information were available for the analysis, including 64 069 non-Hispanic White women (74.4%), 6719 non-Hispanic Black women (7.8%), 7944 Hispanic women (9.2%), 6950 Asian/Pacific Islander women (8.0%), and 351 American Indian/Alaska Native women (0.4%). Black women were significantly more likely than non-Hispanic White women to have a recurrence score greater than 25 (17.7% vs 13.7%; P < .001). Among women with axillary node-negative tumors, competing risk models adjusted for age, tumor characteristics, and treatment found higher breast cancer-specific mortality for Black compared with non-Hispanic White women within each recurrence score risk stratum, with subdistribution hazard ratios of 2.54 (95% CI, 1.44-4.50) for Black women with recurrence scores of 0 to 10, 1.64 (95% CI, 1.23-2.18) for Black women with recurrence scores of 11 to 25, and 1.48 (95% CI, 1.10-1.98) for Black women with scores greater than 25. The prognostic accuracy of the recurrence score was significantly lower for Black women, with a C index of 0.656 (95% CI, 0.592-0.720) compared with 0.700 (95% CI, 0.677-0.722) (P = .002) for non-Hispanic Whites.

Conclusions and Relevance

In this cohort study, Black women in the US were more likely to have a high-risk recurrence score and to die of axillary node-negative breast cancer compared with non-Hispanic White women with comparable recurrence scores. The Oncotype DX Breast Recurrence Score test has lower prognostic accuracy in Black women, suggesting that genomic assays used to identify candidates for adjuvant chemotherapy may require model calibration in populations with greater racial/ethnic diversity.

Factors influencing antibiotic duration in culture-negative neonatal early-onset sepsis

STUDY OBJECTIVE

Little guidance exists on the treatment duration of culture-negative early-onset sepsis (CN-EOS) in neonates, which may lead to prolonged antimicrobial therapy and adverse outcomes. Our objective was to identify risk factors associated with prolonged antibiotic therapy in CN-EOS in neonates.

DESIGN

This was a retrospective, matched cohort study of neonates treated with empiric antibiotic therapy for EOS. Infants were sampled with matching of gestational age (GA) into short (≤3 days) and prolonged (>3 days) antibiotic course. Primary outcomes were to identify predictive factors that may be associated with prolonged therapy and compare rates of late-onset sepsis (LOS) and mortality. Secondary outcomes included necrotizing enterocolitis, feeding intolerance, and early development assessment. Predictors associated with prolonged antibiotic therapy were identified using multivariable-adjusted logistic regression.

MEASUREMENTS AND MAIN RESULTS

Three hundred infants were included with 150 infants in each group. Mean GA and birthweights were 34.2 ± 4.7 weeks and 2293 ± 991 g, respectively. Male gender, 5-min Apgar <7, immature-to-total neutrophil ratio ≥0.2, C-reactive protein (CRP) ≥10 mg/L, need for vasopressors, and mechanical ventilation were identified as significant predictors for prolonged antibiotics in all infants. Independent of GA, elevated CRP (OR 40.84, 95% CI 15.28-109.15, p < 0.001), need for vasopressors (OR 13.48, 95% CI 3.86-47.15, p < 0.001), and mechanical ventilation (OR 12.98, 95% CI 4.91-34.35, p < 0.001) remained significant predictors of prolonged antibiotic use. Infants in the prolonged courses experienced significant delays in achieving independent oral feeding compared with infants receiving short-course antibiotics (median 17.5 vs. 8 days, p = 0.002, respectively). There were no significant differences in LOS, mortality, or other neonatal comorbidities.

CONCLUSIONS

Elevated CRP levels, need for vasopressors, and mechanical ventilation were associated with prolonged antibiotic use in neonates presumptively treated for CN-EOS. Further research is warranted in identifying selective biomarkers for EOS and evaluating whether early antibiotic discontinuation for CN-EOS, despite abnormal laboratory tests/illness severity, is safe and justified.

Abstract PS7-13: Associations between frailty and cancer-specific mortality among older women with breast cancer

PURPOSE Frailty is assessed when making treatment decisions among older women with breast cancer (BC), which in turn impacts survival. We evaluated associations between frailty and risks of BC-specific and all-cause mortality in older women.

METHODS We conducted a retrospective cohort study of Medicare beneficiaries ages ≥65 years with stage I-III BC using the Surveillance, Epidemiology and End Results Medicare Health Outcome Survey Data Resource. Frailty was measured using the deficit-accumulation frailty index, categorized as robust, pre-frail or frail, at baseline and during follow-up. Fine and Gray competing risk and Cox proportional hazards models were used to estimate sub-distribution hazard ratios (SHR) and hazard ratios (HR) with 95% confidence intervals (CI) for BC-specific and all-cause mortality, respectively.

RESULTS Among 2,411 women with a median age of 75 years at BC diagnosis, 50% were categorized as robust, 29% were pre-frail and 21% were frail. Compared to robust women, fewer frail women received breast-conserving surgery (52% vs. 63%) and radiation (44% vs. 52%). In multivariable analyses, frail women had higher risks of all-cause mortality compared to robust women (HR 2.16, 95% CI 1.80-2.60).

CONCLUSION Frail women in our study had a higher cumulative hazard of BC-specific death, but this observed higher risk was not significant after accounting for differences in treatment and competing risks of other-cause death. Measuring frailty may help determine overall life expectancy but not BC-specific death.

Table. Risk of Breast Cancer-Specific and All-cause Mortality, using time-varying DAFI measureEventsCrude SHRRobust 95%CIP-valueMinimally Adjusted SHRaRobust 95%CIP-valueFully Adjusted SHRbRobust 95%CIP-valueBreast Cancer-Specific MortalityDAFI CategoriesRobust891.001.001.00Pre-frail691.250.91 – 1.700.161.150.84 – 1.590.381.060.77 – 1.480.72Frail621.531.11 – 2.110.011.371.00 – 1.900.051.190.85 – 1.660.31All-Cause MortalityDAFI CategoriesRobust2721.001.001.00Pre-frail2241.551.30 – 1.84&lt;0.00011.411.19 – 1.68&lt;0.00011.371.15 – 1.63&lt;0.0001Frail2362.32.12 – 3.02&lt;0.00012.331.96 – 2.78&lt;0.00012.161.80 – 2.60&lt;0.0001DAFI = deficit-accumulation frailty index; HR = hazard ratio; SHR = subdistribution hazard ratios; CI = confidence intervalsa adjusted for age categories and breast cancer staging b adjusted for age categories, breast cancer staging, surgery type, radiation, Estrogen/Progestin Receptor, race/ethnicity, marital status, and education

Citation Format: Connie H Yan, Chandler Coleman, Nadia A Nabulsi, Brian Chiu, Naomi Y Ko, Kent Hoskins, Gregory S Calip. Associations between frailty and cancer-specific mortality among older women with breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-13.

Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer

Importance

Compared with non-Hispanic white women, racial/ethnic minority women receive a diagnosis of breast cancer at a more advanced stage and have higher morbidity and mortality with breast cancer diagnosis. Access to care with adequate insurance may be associated with earlier diagnosis, expedited treatment, and improved prognosis.

Objective

To examine the extent to which insurance is associated with access to timely breast cancer diagnosis and breast cancer stage differences among a large, diverse population of US patients with breast cancer.

Design, Setting, and Participants

This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results Program on 177 075 women aged 40 to 64 years who received a diagnosis of stage I to III breast cancer between January 1, 2010, and December 31, 2016. Statistical analysis was performed from August 1, 2017, to October 1, 2019.

Main Outcomes and Measures

The primary outcome was the risk of having a more advanced stage of breast cancer at diagnosis (ie, stage III vs stages I and II). Mediation analyses were conducted to determine associations of race/ethnicity and proportion of observed differences mediated by health insurance status with earlier stage of diagnosis.

Results

A total of 177 075 women (mean [SD] age, 53.5 [6.8] years; 148 124 insured and 28 951 uninsured or receiving Medicaid) were included in the study. A higher proportion of women either receiving Medicaid or who were uninsured received a diagnosis of locally advanced breast cancer (stage III) compared with women with health insurance (20% vs 11%). In multivariable models, non-Hispanic black (odds ratio [OR], 1.46 [95% CI, 1.40-1.53]), American Indian or Alaskan Native (OR, 1.31 [95% CI, 1.07-1.61]) and Hispanic (OR, 1.35 [95% CI, 1.30-1.42]) women had higher odds of receiving a diagnosis of locally advanced disease (stage III) compared with non-Hispanic white women. When adjusting for health insurance and other socioeconomic factors, associations between race/ethnicity and risk of locally advanced breast cancer were attenuated (non-Hispanic black: OR, 1.29 [95% CI, 1.23-1.35]; American Indian or Alaskan Native: OR, 1.11 [95% CI, 0.91-1.35]; Hispanic: OR, 1.17 [95% CI, 1.12-1.22]). Nearly half (45%-47%) of racial differences in the risk of locally advanced disease were mediated by health insurance.

Conclusions and Relevance

This study's findings suggest that nearly half of the observed racial/ethnic disparities in higher stage at breast cancer diagnosis are mediated by health insurance coverage.

Abstract PO-102: Racial disparities in outcomes following neoadjuvant chemotherapy by breast cancer subtype: Analyses from the National Cancer Database, 2010- 2016

Introduction: Pathologic complete response (pCR) following neoadjuvant chemotherapy for breast cancer is associated with improved prognosis in patients with aggressive subtypes. Our purpose was to describe racial disparities in pCR rate and overall survival among breast cancer patients treated with neoadjuvant chemotherapy. Methods: We conducted a retrospective cohort study of women with stages I-III breast cancer in the National Cancer Database who received neoadjuvant chemotherapy between 2010 and 2016. We collected demographic information, clinical characteristics, county-level socioeconomic factors, insurance status, type of treatment facility and overall survival. Breast cancer subtypes were categorized according to joint hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status. Response to neoadjuvant therapy was categorized as (i) pathologic complete response (absence of invasive carcinoma in the breast and ipsilateral axillary lymph nodes) and (ii) partial or no response. Associations between race/ethnicity and rates of pCR by subtype were determined using modified Poisson regression models to estimate rate ratios (RR) and 95% confidence intervals (CI) with robust standard errors adjusted for age, T and N status, grade, histology, county- level education and median income, comorbidity score, facility type, geographic region and insurance status. Racial differences in overall survival by pCR status were determined using Kaplan-Meier survivor functions and multivariable Cox proportional hazards models to estimate adjusted hazard ratios and 95% CI. Results: A cohort of 73,950 breast cancer patients with a median follow up of 36 months included 70% non-Hispanic white, 16% non-Hispanic black, 8% Hispanic and 4% non- Hispanic Asian/Pacific Islander. Overall, 35% of women had pCR, which differed according to subtype (luminal A, HR+/HER2- 17%; luminal B, HR+/HER2+ 44%; triple negative, HR-/HER2- 44%; HER2-enriched, HR-/HER2+ 64%). Compared to whites, black women with aggressive subtypes had significantly lower rates of pCR (triple- negative, RR 0.92, 95% CI 0.88-0.96; HER2-enriched, RR 0.87, 95% CI 0.82-0.92), but no significant differences in pCR rate for luminal A (RR 1.07, 95% CI 0.99-1.16) and B (RR 0.95, 95% CI 0.89-1.02) tumors. Racial disparities in overall mortality were observed among black women without a pCR following neoadjuvant chemotherapy (hazard ratio 1.17, 95% CI 1.09-1.25) but there were no differences among those who achieved a pCR (hazard ratio 1.00, 95% CI 0.86-1.18). Conclusions: Racial disparities in pCR rate are limited to aggressive breast cancer subtypes. Independent of subtype, black women who do not experience pCR following neoadjuvant chemotherapy are at greater risk for all-cause mortality. These results should inform risk-stratified treatment decisions following neoadjuvant chemotherapy, and future clinical studies of neoadjuvant therapy should investigate potential racial differences in chemoresistance.

Citation Format: Gregory S. Calip, Kent F. Hoskins, Naomi Y. Ko. Racial disparities in outcomes following neoadjuvant chemotherapy by breast cancer subtype: Analyses from the National Cancer Database, 2010- 2016 [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-102.

Risks of Second Primary Gynecologic Cancers following Ovarian Cancer Treatment in Asian Ethnic Subgroups in the United States, 2000-2016

BACKGROUND

The differential occurrence of second primary cancers by race following ovarian cancer is poorly understood. Our objective was to determine the incidence of second primary gynecologic cancers (SPGC) following definitive therapy for ovarian cancer. Specifically, we aimed to determine differences in SPGC incidence by Asian ethnic subgroups.

METHODS

We identified 27,602 women ages 20 years and older and diagnosed with first primary epithelial ovarian cancer between 2000 and 2016 who received surgery and chemotherapy in 18 population-based Surveillance, Epidemiology and End Results Program registries. We compared the incidence of SPGC with expected incidence rates in the general population of women using estimated standardized incidence ratios (SIR) and 95% confidence intervals (CI).

RESULTS

The incidence of SPGC was lower among White women (SIR = 0.73; 95% CI, 0.59-0.89), and higher among Black (SIR = 1.80; 95% CI, 0.96-3.08) and Asian/Pacific Islander (API) women (SIR = 1.83; 95% CI, 1.07-2.93). Increased risk of vaginal cancers was observed among all women, although risk estimates were highest among API women (SIR = 26.76; 95% CI, 5.52-78.2) and were also significant for risk of uterine cancers (SIR = 2.53; 95% CI, 1.35-4.33). Among API women, only Filipinas had significantly increased incidence of SPGC overall including both uterine and vaginal cancers.

CONCLUSIONS

Risk of SPGC following treatment of ovarian cancer differs by race and ethnicity, with Filipina women having the highest rates of second gynecologic cancers among Asian women.

IMPACT

Ensuring access and adherence to surveillance may mitigate ethnic differences in the early detection and incidence of second gynecologic cancers.

Potentially Inappropriate Medication Combination with Opioids among Older Dental Patients: A Retrospective Review of Insurance Claims Data

BACKGROUND

Opioid prescribing by dentists for older patients receiving medications with potential contraindications and the subsequent impact on acute care outcomes is not well described.

OBJECTIVES

Our objective of this paper was to evaluate the use of potentially inappropriate medication combinations (PIMCs) involving opioids prescribed by dentists according to the Beers Criteria and risks of 30-day emergency department (ED) visits and all-cause hospitalization among commercially insured dental patients ages 65 years and older.

METHODS

We conducted a retrospective cohort study of 40,800 older dental patient visits in which opioids were prescribed between 2011 and 2015 using the IBM MarketScan databases. Data collection from dental, medical, and pharmacy claims included information on the concurrent use of PIMCs and outcomes of all-cause acute care utilization over the 30-day period after dental encounters.

RESULTS

For the overall cohort, the median age was 69 years, and 45% were women. The prevalence of PIMCs per Beers Criteria was 10.4%. A total of 947 all-cause acute care events were observed in the 30 days post-dental visit. Patients with PIMCs involving opioids prescribed by dentists according to the Beers Criteria had higher rates of acute care use (3.3% vs 2.2%, p<0.001), which were associated with an increased risk of all-cause acute care utilization (adjusted risk ratio [RR] 1.23, 95% confidence interval [CI] 1.02-1.48). A dose-response relationship was seen with increasing oral morphine equivalents prescribed and increased acute care utilization (p<0.001).

CONCLUSION

A significant proportion of older patients receiving opioids at dental visits use psychotropic medications that in combination should be avoided according to the American Geriatric Society Beers Criteria.

Family history of breast cancer in men with non-BRCA male breast cancer: implications for cancer risk counseling

PURPOSE

The role of genetic predisposition in male breast cancer (MBC) patients who test negative for a BRCA mutation is unclear. The aim of this study is to define the association between MBC and family history of breast cancer in patients without mutations in BRCA1 or BRCA2.

METHODS

We conducted an unmatched case-control study with men who received commercial testing for germline mutations in cancer susceptibility genes, including 3,647 MBC cases who tested negative for deleterious mutations in BRCA1/BRCA2, and 4,269 men with a personal history of colorectal cancer who tested negative for mutations in DNA mismatch repair genes to serve as controls. Associations between family history of breast cancer and MBC were estimated using unconditional multivariable logistic regression with adjustment for age, race/ethnicity and year of testing.

RESULTS

Breast cancer in a first- or second-degree relative was associated with a four-fold increased odds of MBC (OR 4.7; 95% CI 4.1, 5.3). Associations with MBC were strongest for family history of breast cancer in 2 or more first-degree relatives (FDR) (OR 7.8; 95% CI 5.2, 11.6), for probands and FDR diagnosed at age < 45 years (OR 6.9; 95% CI 3.9, 12.4), and for family history of MBC (OR 17.9; 95% CI 7.6, 42.1). Findings were confirmed in a sensitivity analysis of MBC cases who tested negative on a 25-gene pan-cancer panel.

CONCLUSIONS

MBC patients without mutations in BRCA1/2 have significantly higher odds of a family history of breast cancer, suggesting the existence of unidentified MBC susceptibility alleles.

Comparison of Cardiac Events Associated With Azithromycin vs Amoxicillin

IMPORTANCE

Conflicting evidence exists on the association between azithromycin use and cardiac events.

OBJECTIVE

To compare the odds of cardiac events among new users of azithromycin relative to new users of amoxicillin using real-world data.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from Truven Health Analytics MarketScan database from January 1, 2009, to June 30, 2015. Patients receiving either amoxicillin or azithromycin and enrolled in a health care plan 365 days before (baseline period) the dispensing date (index date) were included in the study. Patients were matched 1:1 on high-dimensional propensity scores. Data were analyzed from October 1, 2018, to December 31, 2019.

EXPOSURES

New use of azithromycin compared with new use of amoxicillin.

MAIN OUTCOMES AND MEASURES

The primary outcome consisted of cardiac events, including syncope, palpitations, ventricular arrhythmias, cardiac arrest, or death as a primary diagnosis for hospitalization at 5, 10, and 30 days from the index date. Logistic regression models were used to estimate odds ratios (ORs) with 95% CIs.

RESULTS

After matching, the final cohort included 2 141 285 episodes of each index therapy (N = 4 282 570) (mean [SD] age of patients, 35.7 [22.3] years; 52.6% female). Within 5 days after therapy initiation, 1474 cardiac events (0.03%) occurred (708 in the amoxicillin cohort and 766 in the azithromycin cohort). The 2 most frequent events were syncope (1032 [70.0%]) and palpitations (331 [22.5%]). The odds of cardiac events with azithromycin compared with amoxicillin were not significantly higher at 5 days (OR, 1.08; 95% CI, 0.98-1.20), 10 days (OR, 1.05; 95% CI, 0.97-1.15), and 30 days (OR, 0.98; 95% CI, 0.92-1.04). Among patients receiving any concurrent QT-prolonging drug, the odds of cardiac events with azithromycin were 1.40 (95% CI, 1.04-1.87) greater compared with amoxicillin. Among patients 65 years or older and those with a history of cardiovascular disease and other risk factors, no increased risk of cardiac events with azithromycin was noted.

CONCLUSIONS AND RELEVANCE

This study found no association of cardiac events with azithromycin compared with amoxicillin except among patients using other QT-prolonging drugs concurrently. Although azithromycin is a safe therapy, clinicians should carefully consider its use among patients concurrently using other QT-prolonging drugs.

Targets of biologic disease-modifying antirheumatic drugs and risk of multiple myeloma

Several commonly used immune-suppressing biologic drugs target proteins and cytokines involved in myeloma pathogenesis. Our objective was to determine whether targeted biologic disease-modifying antirheumatic drugs (DMARDs) are associated with risk of multiple myeloma (MM). We conducted a nested case-control study within a retrospective cohort of 56,886 commercially insured adults undergoing treatment for rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis between 2009 and 2015 using the Truven Health MarketScan Databases. MM cases (n = 287) were matched to up to 10 controls (n = 2,760) on age, sex and rheumatologic indication using incidence density sampling without replacement. Our exposures of interest were biologic DMARDs targeting tumor necrosis factor-alpha, interleukin 6, cytotoxic t-lymphocyte-associated protein-4 and depletion of B cells. Relative risks were estimated as adjusted odds ratios (OR) and 95% confidence intervals (CI) using conditional logistic regression models. Cases and controls were similar with respect to use of prescription NSAIDs and concurrent conventional-synthetic DMARDs. Cases had slightly fewer etanercept users (4% vs. 7%) and slightly more tocilizumab users (1.4% vs. 0.4%). Compared to patients treated with only conventional-synthetic DMARDs, those receiving concomitant conventional-synthetic plus biologic DMARDs had lower risk of developing MM (OR = 0.48; 95% CI 0.30-0.88; p = 0.02). Risks differed by drug target with an inverse association observed with use of etanercept inhibiting tumor necrosis factor-alpha (OR = 0.55; 95% CI 0.30-1.02; p = 0.06) and a positive association with tocilizumab inhibiting interleukin-6 (OR = 4.33; 95% CI 1.33-14.19; p = 0.02) compared to biologic DMARD-naïve patients. Further investigation is warranted to understand the roles of drugs suppressing tumor necrosis factor-alpha and interleukin-6 in myeloma pathogenesis.

Abstract 5749: The association between physical health-related quality of life, physical functioning and risk of contralateral breast cancer

Background: Physical limitations and disability among older cancer patients can lead to suboptimal treatment and surveillance for secondary cancers. Our objective was to evaluate the effects of poor physical health-related quality of life (PQOL) and physical functioning (PF) on contralateral breast cancer (CBC) risk among older women diagnosed with unilateral breast cancer (UBC).

Methods: We performed a nested case-control study within a cohort from the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey (MHOS) database. Women were required to have first primary UBC without prophylactic contralateral mastectomy. Among 2,938 women ages 65 years and older with stages I-III UBC between 1997 and 2011, we identified 100 subsequent CBC cases and 915 controls using incidence density sampling without replacement matched on age, race, and quarter-year of diagnosis. PQOL and PF were determined from survey responses to the Medical Outcomes Trust Short Form 36 component scores. Conditional logistic regression models were used to estimate relative risks (RR) and 95% confidence intervals (CI) for metachronous CBC.

Results: Cases and controls were similar with respect to comorbidities, stage, surgery and radiation treatments but differed by hormone receptor status (ER/PR-negative, cases 23% and controls 11%). Cases had lower mean PQOL (-1.8; 95% CI -4.3, 0.7) and PF (-2.2, 95% CI -4.9, 0.5) component scores, but these differences were not statistically significant. In multivariable models, estimates suggest increased CBC risk for women in the lowest quartile of PQOL compared to those in the upper quartile (RR=1.8; 95% CI 0.8, 4.3). Compared to women in the upper quartile of physical functioning scores, women in the lower three quartiles had a 2.6-fold (95% CI 1.2, 5.9) increased risk of CBC.

Conclusions: Our findings indicate that low physical health-related quality of life is common among older women diagnosed with breast cancer, and poor physical functioning is related to risk of CBC. Efforts to understand and minimize declines in physical functioning post-breast cancer diagnosis may help optimize treatment strategies to reduce the risk of this adverse outcome.

Citation Format: Nita Mukand, Nadia Nabulsi, Ali Alobaidi, Alemseged Asfaw, Brian C. Chiu, Naomi Y. Ko, Gregory S. Calip. The association between physical health-related quality of life, physical functioning and risk of contralateral breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5749.

Abstract 5748: Declines in health-related quality of life among older patients diagnosed with hematologic malignancies

Background: The diagnosis of cancer and its treatment have meaningful impacts on health-related quality of life (HRQOL). Although advances in novel therapy and stem cell transplantation have increased survival in patients with hematologic malignancies (HM), less evidence exists on the subsequent impacts of HM on HRQOL. The objective of this study was to evaluate changes in HRQOL following diagnosis of HM in a cohort of older Medicare beneficiaries.

Methods: This was a retrospective study utilizing the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey Data Resource, a linkage of longitudinal surveys and cancer registry data. We included patients ages ≥65 years diagnosed with first primary leukemia, lymphoma or multiple myeloma between 1998 and 2014 who completed at least one survey within two years pre- and post-diagnosis. HRQOL was measured using the Short Form Health Survey (SF-36) composite scores with a minimum clinically important difference of 2 points. We also measured self-reported general health, depressive symptoms, and the deficit-accumulation frailty index before and after HM diagnosis. Patients with HM were compared to up to four patients without cancer with exact matching on age, sex, race, marital status, smoking status, education, comorbid conditions, proxy response and calendar time of HM diagnosis. Comparisons of means were performed between groups using ANOVA with adjustment for survey type.

Results: Among 401 patients with HM included in our analysis, mean (SD) age of diagnosis was 75.98 (6.2) years and 26% were diagnosed with leukemia, 57% with lymphoma, and 17% with multiple myeloma. No significant differences in HRQOL, self-reported health, depressive symptoms, or frailty were observed between patients with HM and their non-cancer matches (n=1578) before diagnosis. Substantial declines in HRQOL were observed across all types of HM after cancer diagnosis. Mean decreases in composite SF-36 scores among patients with HM (physical component score [PCS] -7.1, 95% CI -8.8, -5.5; mental component score [MCS] -3.4, 95% CI -4.9, -1.8) were greater in magnitude compared to declines in matched non-cancer patients (PCS -1.6, 95% CI -2.4, -0.7; MCS -0.6, 95% CI -1.3, 0.1). During follow-up, patients with HM also had higher rates of low self-reported health (46% vs. 27%), depressive symptoms (34% vs. 25%) and frailty (56% vs. 43%).

Conclusion: Our study found decreases in HRQOL measures among older patients with HM that were more than three-fold higher than the minimum clinically important differences in the general population and twice that reported in older patients with common solid tumors. Prospective studies and clinical trials in patients with leukemia, lymphoma, and multiple myeloma should include measures that assess whether life-prolonging, novel therapies are also effective in preserving HRQOL.

Citation Format: Ashwini Zolekar, Nadia A. Nabulsi, Alemseged A. Asfaw, Jifang Zhou, Karen Sweiss, Pritesh R. Patel, Brian C.-H. Chiu, Edith A. Nutescu, Gregory S. Calip. Declines in health-related quality of life among older patients diagnosed with hematologic malignancies [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5748.

A multi-institutional comparison of mitoxantrone, etoposide, and cytarabine vs high-dose cytarabine and mitoxantrone therapy for patients with relapsed or refractory acute myeloid leukemia

Relapsed or refractory acute myeloid leukemia (R/R AML) has a poor prognosis and is best treated with salvage chemotherapy as a bridge to allogeneic stem cell transplant (alloSCT). However, the optimal salvage therapy remains unknown. Here we compared two salvage regimens; mitoxantrone, etoposide, and cytarabine (MEC) and mitoxantrone and high-dose Ara-C (Ara-C couplets). We analyzed 155 patients treated at three academic institutions between 1998 and 2017; 87 patients received MEC and 68 received Ara-C couplets. The primary endpoint was overall response (OR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), duration of hospitalization, hematologic and nonhematologic toxicities, and success in proceeding to alloSCT. Baseline characteristics of the cohorts were well matched, though patients receiving Ara-C couplets had more co-morbidities (48.5% vs 33%; P = .07). OR was achieved in 43.7% of MEC and 54.4% of Ara-C couplets patients (P = .10). Ara-C couplets patients also trended towards a longer OS and PFS, more frequently proceeded to alloSCT (31% vs 54.4%; P = .003), and experienced less febrile neutropenia (94% vs 72%; P < .001) and grade 3/4 gastrointestinal toxicities (17.2% vs 2.94%; P = .005). No significant differences in other toxicities or median duration of hospitalization were noted. This is the first multi-institutional study directly comparing these regimens in a racially diverse population of R/R AML patients. Although these regimens have equivalent efficacy in terms of achieving OR, Ara-C couplets use is associated with significant reductions in toxicities, suggesting it should be used more frequently in these patients.

Immigration Status and Disparities in the Treatment of Cardiovascular Disease Risk Factors in the Hispanic Community Health Study/Study of Latinos (Visit 2, 2014-2017)

Objectives. To estimate treatment rates of high cholesterol, hypertension, and diabetes among Hispanic/Latino immigrants by immigration status (i.e., naturalized citizens, documented immigrants, or undocumented immigrants).Methods. We performed a cross-sectional analyses of the Hispanic Community Health Study/Study of Latinos (visit 2, 2014-2017). We restricted our analysis to Hispanic/Latino immigrants with high cholesterol (n = 3974), hypertension (n = 3353), or diabetes (n = 2406); treatment was defined as use of statins, antihypertensives, and antidiabetics, respectively.Results. When compared with naturalized citizens, undocumented and documented immigrants were less likely to receive treatment for high cholesterol (38.4% vs 14.1%; prevalence ratio [PR] = 0.37 [95% confidence interval [CI] = 0.27, 0.51] and 25.7%; PR = 0.67 [95% CI = 0.58, 0.76]), hypertension (77.7% vs 57.7%; PR = 0.74 [95% CI = 0.62, 0.89] and 68.1%; PR = 0.88 [95% CI = 0.82, 0.94]), and diabetes (60.3% vs. 50.4%; PR = 0.84 [95% CI = 0.68, 1.02] and 55.8%; PR = 0.93 [95% CI = 0.83, 1.03]); the latter did not reach statistical significance. Undocumented and documented immigrants had less access to health care, including insurance coverage or a usual health care provider, than naturalized citizens. Therefore, adjusting for health care access largely explained treatment disparities across immigration status.Conclusions. Preventing cardiovascular disease among Hispanic/Latino immigrants should focus on undertreatment of high cholesterol, hypertension, and diabetes by increasing health care access, especially among undocumented immigrants.

Impact of adverse event reports from marketing authorization holder-sponsored patient support programs on the performance of signal detection in pharmacovigilance

OBJECTIVES

Marketing authorization holder (MAH)-sponsored patient support programs (PSPs) are a major source of adverse event (AE) reports. The impact of reports from PSPs on the ability to detect AE signals is unclear. We compared signal detection performance using data from PSPs vs. non-PSP sources, and between PSPs providing clinical services vs. PSPs not providing clinical services.

METHODS

Data were obtained from an internal safety database for a global pharmaceutical company 2015-2017. We assessed whether signals were detected for the reference drug-AE pairs using data from PSPs vs. non-PSP sources, and among different PSP services. The performance was evaluated by four measures including area under the receiver operating characteristic curve (AUC) and time-to-signal detection.

RESULTS

While the majority of reports were from PSPs, non-PSP sources were better and faster at detecting signals (AUC 0.63 vs. 0.41, p = 0.035; HR 3.52, p = 0.014) compared to PSPs. Within PSPs, PSPs providing clinical services were marginally better at detecting signals (AUC 0.60 vs. 0.41, p = 0.053) but not faster compared to PSPs not providing clinical services.

CONCLUSION

Reports of AEs from PSPs had worse signal detection performance compared to non-PSP sources. Pharmacovigilance experts should be mindful when using databases that contain reports from PSPs for signal detection.

Abstract C020: Racial differences in the risks of second primary gynecologic cancers following chemotherapy for malignant ovarian tumors: Asian subgroups in the United States, 2000-2016

Objective: The incidence of ovarian cancer in the United States varies by race with the highest rates among white women but lower survival observed among black women and other racial and ethnic groups. These disparities in outcomes among women with ovarian cancer are not well understood, including the differential occurrence of second primary cancers according to race. Our objective was to measure racial differences in incidence of second primary gynecologic cancers (SPGC) among women with malignant ovarian tumors following treatment with chemotherapy. Specifically, we aimed to determine differences in SPGC incidence by Asian ethnic subgroups in the United States. Methods: We conducted a retrospective cohort study of women ages 20 years and older diagnosed with first primary malignant ovarian tumors treated with definitive surgery and chemotherapy between 2000 and 2016 from 18 population-based registries in the Surveillance, Epidemiology and End Results (SEER) Program. We collected demographic and clinical information on ovarian histologic subtypes, laterality, tumor grade, type of surgery and treatment with radiotherapy. Census tract-level sociodemographic characteristics of women were also described. The incidence of SPGC in our cohort was compared to expected incidence rates in the general population using age-and region-standardized incidence ratios (SIRs) and 95% confidence intervals (CI) for individual racial/ethnic groups. Results: Among 34,081 women with ovarian cancer, 74% were white, 6% were black, 8% were Asian/Pacific Islander (API) and 11% were Hispanic. Median age at diagnosis was lower among API and Hispanic women (54 years) compared to white (60 years) and black women (58 years). Most ovarian tumors were serous or endometrioid, although API women had a higher proportion of clear cell ovarian tumors (15%) compared to white (6%), black (5%) and Hispanic women (6%). Subgroups of API women also differed in distribution of ovarian tumor histology, grade, and age at diagnosis. Whereas incidence of SPGC was observed to be lower than expected among white women (SIR 0.72 CI 0.59-0.87), estimates were suggestive of higher than expected incidence among black (SIR 1.61, CI 0.88-2.71) and API women (SIR 1.64, CI 0.96-2.63), although confidence intervals included 1.0. Increased risk of vaginal cancers was observed among all women, although risk estimates were highest among API women (SIR 23.90, CI 4.93-69.84) and were also significant for risk of uterine cancers (SIR 2.28 CI 1.21-3.90). Among API women, only Filipinas had significantly increased incidence of SPGC overall including both uterine and vaginal cancers. Conclusions: Risk of SPGC following treatment of ovarian cancer differs by race. The increased incidence of secondary gynecological cancers observed in Asian women is driven largely by increased rates of uterine and vaginal cancers among Filipina women. Further research is warranted to understand the possible mechanism(s) underlying this observed disparity.

Citation Format: Nita H Mukand, Ashwini N Zolekar, Naomi Y Ko, Gregory S Calip. Racial differences in the risks of second primary gynecologic cancers following chemotherapy for malignant ovarian tumors: Asian subgroups in the United States, 2000-2016 [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C020.

Abstract PR09: Racial disparities in health insurance status of U.S. adults with hematologic malignancies in states with and without Medicaid expansion: Analyses from the National Cancer Database, 2007-2016

Introduction: Lack of health insurance is an important determinant of cancer health disparities in the United States. For patients with hematologic malignancies, breakthroughs in novel chemotherapeutics, targeted therapies, and stem cell transplantation are counterbalanced with concerns for financial toxicity and lack of access without adequate health coverage. Our objective was to measure racial differences in uninsured rates among patients with hematologic malignancies in states with and without Medicaid expansion under the Affordable Care Act.

Methods: We conducted a hospital-based retrospective cohort study of adults aged 40-64 years diagnosed with hematologic malignancies (lymphoma, multiple myeloma, leukemia, and Waldenstrom macroglobulinemia) between 2007 and 2016 using the National Cancer Database (NCDB). We collected information on demographics, clinical characteristics, insurance coverage, socioeconomic factors, and state Medicaid expansion status. We grouped Medicaid expansion states as: (i) non-expansion states, (ii) early expansion states (2010-2013), and (iii) late expansion states (2014-2016). Covariate adjusted difference-in-differences (DID) analyses were performed to determine changes in the percentage of uninsured hematologic malignancy patients over time. In modified Poisson regression models, we calculated adjusted rate ratios (RR) and 95% confidence intervals to identify disparities in uninsured rates among black, Hispanic, and Asian/Pacific Islander (API) patients compared to white patients by time period and Medicaid expansion.

Results: An overall cohort of 338,353 hematologic malignancy patients (median age: 56 years; 43% female) residing in Medicaid non-expansion (n=124,875), early expansion (n=60,305) and late expansion (n=153,173) states were included. Compared to 2007-2009, the proportion of uninsured patients was lower in 2014-2016 across all states; however, more substantial decreases in percentage uninsured occurred in states with Medicaid expansion (4.9% to 2.5%, diff 2.4%) versus states without expansion (9.4% to 8.3%, diff 1.1%; DID -1.3, P&lt;0.01). These reductions were consistent among white (DID -1.1, P&lt;0.01) and Hispanic (DID -4.3, P&lt;0.01) patients; however, decreases in uninsured rates among black (DID -0.3, P=0.67) and API (DID 1.9, P=0.41) patients were not statistically significant. Regardless of expansion status, racial disparities persisted over time with racial and ethnic minority patients having a 1.5- to 3.0-fold higher likelihood of being uninsured compared to white patients.

Conclusions: Our study found that the proportion of uninsured hematologic malignancy patients in the NCDB decreased between 2007 and 2016, but this reduction was significantly greater in states with Medicaid expansion. We also identified racial disparities where black and API patients experienced minimal decreases attributed to Medicaid expansion and black, Hispanic, and API patients were consistently more likely to be uninsured over time.

This abstract is also being presented as Poster A115.

Citation Format: Gregory S. Calip, Naomi Y Ko, Karen I. Sweiss, Pritesh R. Patel, Brian C.-H. Chiu. Racial disparities in health insurance status of U.S. adults with hematologic malignancies in states with and without Medicaid expansion: Analyses from the National Cancer Database, 2007-2016 [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr PR09.

Abstract D092: Racial disparities in HIV-associated lymphoma

Introduction: Human immunodeficiency virus (HIV)-related lymphomas are more frequently diagnosed at advanced stages and HIV is associated with lower survival in Hodgkin and non-Hodgkin lymphoma. Less is documented on how the impacts of HIV on lymphoma outcomes differ between racial groups in the United States. Methods: We conducted a hospital-based retrospective cohort study of adults ages 18 years and older diagnosed with Hodgkin and non-Hodgkin lymphoma between 2004 and 2016 using the National Cancer Database. Information on demographic, socioeconomic and clinical characteristics were collected including histologic subtype, stage, initial treatments and whether lymphoma diagnoses were HIV-associated and/or patients were HIV positive. For the three most frequent HIV-associated lymphoma subtypes – Hodgkin lymphoma (HL), diffuse large B-cell lymphoma (DLBCL) and Burkitt lymphoma (BL) – modified Poisson regression models were used to estimate adjusted rate ratios (RR) and 95% confidence intervals (CI) for the race-specific impacts of HIV on risk of advanced stages, B-symptoms at diagnosis, and receipt of chemo-immunotherapy. We measured Kaplan Meier survivor functions and estimated adjusted hazard ratios (HR) and 95% CI for the impact of HIV on overall survival by race in Cox proportional hazards models. Results: From an overall cohort of 579,123 lymphoma patients, 18,826 (3.3%) were HIV-associated. Compared to patients with non-HIV-associated lymphoma, HIV positive patients were younger (median 47 vs. 64 years) and more likely to be male (77% vs. 54%), black (34% vs. 8%), Hispanic (15% vs. 6%), have Medicaid or be uninsured (35% vs. 10%) and live in zip codes with the lowest quartile of median income (30% vs. 16%) and lowest quartile of attained education (34% vs. 19%). Among patients with HIV-associated lymphomas, black and Hispanic patients were diagnosed at lower median ages (45 and 44 years, respectively) compared to white patients (49 years). Rates of chemo-immunotherapy treatment for HIV-associated lymphoma were lower among black (68%) and Asian/Pacific Islander patients (63%) compared to white patients (73%). Black patients with HIV-associated lymphomas had consistently lower five-year survival across subtypes, a trend not seen with non-HIV-associated lymphomas. In multivariable models accounting for differences in stage and treatment, HIV was associated with a 33% increase (95% CI 10% to 61%) in risk of all-cause mortality among black patients with HL. Among white, Hispanic and Asian/Pacific Islander patients with HL, HIV was not associated with a statistically significant increase in overall mortality. Conclusions: Among HIV-associated lymphoma patients, we observed racial differences in outcomes with black patients experiencing the lowest five-year survival, a trend not seen in non-HIV-associated lymphomas. In adjusted analyses, HIV was associated with significantly increased overall mortality among black patients with HL but not in other racial groups.

Citation Format: Gregory S Calip, Jifang Zhou, Karen I Sweiss, Pritesh R Patel, Sina Ith, Colin C Hubbard, Naomi Y Ko, Brian C-H Chiu. Racial disparities in HIV-associated lymphoma [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D092.

Maximizing Breast Cancer Therapy with Awareness of Potential Treatment-Related Blood Disorders

In this review we summarize the impact of the various modalities of breast cancer therapy coupled with intrinsic patient factors on incidence of subsequent treatment-induced myelodysplasia and acute myelogenous leukemia (t-MDS/AML). It is clear that risk is increased for patients treated with radiation and chemotherapy at younger ages. Radiation is associated with modest risk, whereas chemotherapy, particularly the combination of an alkylating agent and an anthracycline, carries higher risk and radiation and chemotherapy combined increase the risk markedly. Recently, treatment with granulocyte colony-stimulating factor (G-CSF), but not pegylated G-CSF, has been identified as a factor associated with increased t-MDS/AML risk. Two newly identified associations may link homologous DNA repair gene deficiency and poly (ADP-ribose) polymerase inhibitor treatment to increased t-MDS/AML risk. When predisposing factors, such as young age, are combined with an increasing number of potentially leukemogenic treatments that may not confer large risk singly, the risk of t-MDS/AML appears to increase. Patient and treatment factors combine to form a biological cascade that can trigger a myelodysplastic event. Patients with breast cancer are often exposed to many of these risk factors in the course of their treatment, and triple-negative patients, who are often younger and/or BRCA positive, are often exposed to all of them. It is important going forward to identify effective therapies without these adverse associated effects and choose existing therapies that minimize the risk of t-MDS/AML without sacrificing therapeutic gain. IMPLICATIONS FOR PRACTICE: Breast cancer is far more curable than in the past but requires multimodality treatment. Great care must be taken to use the least leukemogenic treatment programs that do not sacrifice efficacy. Elimination of radiation and anthracycline/alkylating agent regimens will be helpful where possible, particularly in younger patients and possibly those with homologous repair deficiency (HRD). Use of colony-stimulating factors should be limited to those who truly require them for safe chemotherapy administration. Further study of a possible leukemogenic association with HRD and the various forms of colony-stimulating factors is badly needed.

Self-reported health and survival in older patients diagnosed with multiple myeloma

PURPOSE

Patient-reported outcomes such as self-reported health (SRH) are important in understanding quality cancer care, yet little is known about links between SRH and outcomes in older patients with multiple myeloma (MM). We evaluated associations between SRH and mortality among older patients with MM.

METHODS

We analyzed a retrospective cohort of patients ages ≥ 65 years diagnosed with first primary MM using the Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) data resource. Pre-diagnosis SRH was grouped as high (excellent/very good/good) or low (fair/poor). We used Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for associations between SRH and all-cause and MM-specific mortality.

RESULTS

Of 521 MM patients with mean (SD) age at diagnosis of 76.8 (6.1) years, 32% reported low SRH. In multivariable analyses, low SRH was suggestive of modest increased risks of all-cause mortality (HR 1.32, 95% CI 1.02-1.71) and MM-specific mortality (HR 1.22, 95% CI 0.87-1.70) compared to high SRH.

CONCLUSION

Findings suggest that low pre-diagnosis SRH is highly prevalent among older patients with MM and is associated with modestly increased all-cause mortality. Additional research is needed to address quality of life and modifiable factors that may accompany poor SRH in older patients with MM.

First trimester use of artemisinin-based combination therapy and the risk of low birth weight and small for gestational age

Background

While there is increasing evidence on the safety of artemisinin-based combination therapy (ACT) for the case management of malaria in early pregnancy, little is known about the association between exposure to ACT during the first trimester and the effect on fetal growth.

Methods

Data were analysed from prospective studies of pregnant women enrolled in Mozambique, Burkina Faso and Kenya designed to determine the association between anti-malarial drug exposure in the first trimester and pregnancy outcomes, including low birth weight (LBW) and small for gestational age (SGA). Exposure to anti-malarial drugs was ascertained retrospectively by record linkage using a combination of data collected from antenatal and adult outpatient clinic registries, prescription records and self-reported medication usage by the women. Site-level data synthesis (fixed effects and random effects) was conducted as well as individual-level analysis (fixed effects by site).

Results

Overall, 1915 newborns were included with 92 and 26 exposed to ACT (artemether–lumefantrine) and quinine, respectively. In Burkina Faso, Mozambique and Kenya at recruitment, the mean age (standard deviation) was 27.1 (6.6), 24.2 (6.2) and 25.7 (6.5) years, and the mean gestational age was 24.0 (6.2), 21.2 (5.7) and 17.9 (10.2) weeks, respectively. The LBW prevalence among newborns born to women exposed to ACT and quinine (QNN) during the first trimester was 10/92 (10.9%) and 7/26 (26.9%), respectively, compared to 9.5% (171/1797) among women unexposed to any anti-malarials during pregnancy. Compared to those unexposed to anti-malarials, ACT and QNN exposed women had the pooled LBW prevalence ratio (PR) of 1.13 (95% confidence interval (CI) 0.62–2.05, p-value 0.700) and 2.03 (95% CI 1.09–3.78, p-value 0.027), respectively. Compared to those unexposed to anti-malarials ACT and QNN-exposed women had the pooled SGA PR of 0.85 (95% CI 0.50–1.44, p-value 0.543) and 1.41 (95% CI 0.71–2.77, p-value 0.322), respectively. Whereas compared to ACT-exposed, the QNN-exposed had a PR of 2.14 (95% CI 0.78–5.89, p-value 0.142) for LBW and 8.60 (95% CI 1.29–57.6, p-value 0.027) for SGA. The level of between sites heterogeneity was moderate to high.

Conclusion

ACT exposure during the first trimester was not associated with an increased occurrence of LBW or SGA. However, the data suggest a higher prevalence of LBW and SGA for children born to QNN-exposed pregnancies. The findings support the use of ACT (artemether–lumefantrine) for the treatment of uncomplicated malaria during the first trimester of pregnancy.

Clinical trajectories, healthcare resource use, and costs of long-term hematopoietic stem cell transplantation survivors: a latent class analysis

PURPOSE

To identify patterns of healthcare utilization in allogeneic and autologous hematopoietic stem cell transplantation (HSCT) recipients and evaluate factors associated with high-need and high-cost post-transplantation care.

METHODS

Latent class analysis of a retrospective cohort of long-term allogeneic (n = 436) and autologous (n = 888) HSCT survivors within the Truven MarketScan database (2009-2014). We assessed factors associated with the latent classes by comparing post-transplantation healthcare utilization including inpatient admissions and length of stay, emergency room visits, specialist visits, and primary care provider visits.

RESULTS

Four utilization classes were identified in allogeneic and autologous HSCT recipients: (i) outpatient specialist care dominant (51.8% and 57.3%), (ii) outpatient primary care dominant (10.3% and 25.7%), (iii) outpatient/inpatient balanced (20.6% and 13.5%), and (iv) inpatient dominant (17.2% and 3.5%). Mean monthly healthcare expenditures in the inpatient dominant utilization class were $41,097 and $25,556 for allogeneic and autologous survivors, respectively, which were two to five times higher compared with other classes during the 2-year post-transplantation period. Factors associated with the high utilization class were transfusion (OR = 1.87, 95% CI 1.06-3.30) and 100-day post-transplant graft-versus-host-disease (OR = 1.76, 95% CI 1.05-2.94) in allogeneic HSCT; higher baseline Charlson comorbidity index (OR = 1.45, 95% CI 1.19-1.76) in autologous HSCT.

CONCLUSION

Based on distinct patterns of healthcare utilization following HSCT, we identified factors associated with higher resource utilization and greater healthcare related expenditures.

IMPLICATIONS FOR CANCER SURVIVORS

Earlier identification of high-cost and high-need HSCT long-term survivors could pave the way for clinicians to offer more continuous engagement in survivorship care delivery.

Evaluation of the Risk Factors for Acute Kidney Injury in Neonates Exposed to Antenatal Indomethacin

OBJECTIVE

Evidence is limited about important maternal and neonatal risk factors that affect neonatal renal function. The incidence of acute kidney injury (AKI) and identification of associated risk factors in neonates exposed to antenatal indomethacin was studied.

METHODS

A retrospective cohort of neonates exposed to antenatal indomethacin within 1 week of delivery was analyzed for development of AKI up to 15 days of life. Adjusted hazard ratios (HRs) and 95% CIs for AKI risk were calculated in time-dependent Cox proportional hazards models.

RESULTS

Among 143 neonates with mean gestational age of 28.3 ± 2.4 weeks, AKI occurred in 62 (43.3%), lasting a median duration of 144 hours (IQR, 72-216 hours). Neonates with AKI had greater exposure to postnatal NSAIDs (48.4% vs 9.9%, p < 0.001) and inotropes (37.1% vs 3.7%, p < 0.001) compared with neonates without AKI. In multivariable-adjusted models, increased AKI risk was observed with antenatal indomethacin doses received within 24 to 48 hours (HR, 1.6; 95% CI, 1.28-1.94; p = 0.036) and <24 hours (HR, 2.33; 95% CI, 1.17-4.64; p = 0.016) prior to delivery. Further, postnatal NSAIDs (HR, 2.8; 95% CI, 1.03-7.61; p = 0.044), patent ductus arteriosus (HR, 4.04; 95% CI, 1.27-12.89; p = 0.018), and bloodstream infection (HR, 3.01; 95% CI, 1.37-6.60; p = 0.006) were associated significantly with increased risk of AKI following antenatal indomethacin. Neonates with AKI experienced more bloodstream infection, severe intraventricular hemorrhage, patent ductus arteriosus, respiratory distress syndrome, and longer hospitalization.

CONCLUSIONS

Extended risk of AKI with antenatal indomethacin deserves clinical attention among this population at an already increased AKI risk.

Survey of drug information centers in the United States—2018

Purpose

To provide a current directory of drug information centers (DICs) in the United States and present information about their characteristics, activities and services, and networking activities.

Methods

In February 2018, an electronic 23-question survey was delivered to 118 contacts on a distribution list compiled from previous directories of DICs, responses to listserv messages, and an Internet search. DICs, defined as formal centers dedicated to providing drug information services, including but not limited to responding to drug information requests, were asked questions about their characteristics, activities and services, drug information requests, and networking activities.

Results

The response rate was 79% (93 of 118 DICs). Of the 93 respondents, 82 (88%) met the definition of a DIC and were included in the directory. Of the 82 included DICs, 37 (45%) belonged to a university or college, while 36 (44%) belonged to a medical center or hospital. Seventy percent of the DICs (n = 57) had been in existence for more than 20 years. Of the 81 respondents reporting activities performed at the DICs, precepting pharmacy students (n = 79, 98%) and training pharmacy residents and/or fellows (n = 68, 84%) were most commonly reported. Nearly 90% reported that answering drug information questions was central to the DIC operations. Most DICs (n = 52, 65%) indicated receiving an average of 50 requests or less on a monthly basis. DICs reported a variety of electronic means of communicating with the DIC community, although 16 (21%) of the 77 respondents reported no need to do so.

Conclusion

The survey identified 82 DICs that collectively provide a variety of services to their clienteles. The DIC directory published herein should facilitate networking among DICs.

Mediation analyses of socioeconomic factors determining racial differences in the treatment of diffuse large B-cell lymphoma in a cohort of older adults

Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.

Sodium-glucose co-transporter 2 inhibitors and the risk of fractures: A propensity score-matched cohort study

PURPOSE

To determine the risk of fractures associated with sodium-glucose co-transporter 2 inhibitors (SGLT2i) compared with dipeptidyl peptidase-4 inhibitors (DPP4i).

METHODS

We conducted a retrospective cohort study using data from the Truven Health MarketScan (2009-2015) databases. Our cohort included patients newly initiating treatment with SGLT2i or DPP-4i between 1 April 2013 and 31 March 2015 that were matched 1:1 using high dimensional propensity scores. Patients were followed up in an as-treated approach starting from initiation of treatment until the earliest of any fracture, treatment discontinuation, disenrollment, or end of data (31 December 2015). Risk of fractures was determined at any time during the follow-up, early in therapy (1-14 days of the follow-up), and later in therapy (15 days and beyond). Cox proportional hazards models were used to determine hazard ratios and robust 95% confidence intervals (95% CI).

RESULTS

After matching, our cohort included 30 549 patients in each treatment group. Over a median follow-up of 219 days, there were 745 fractures overall. The most common site for fractures was the foot (32.7%). The effect estimates for fracture risk occurring at any time during follow-up, early in therapy, and later in therapy were HR 1.11 [95% CI 0.96-1.28], HR 1.82 [95% CI 0.99-3.32], and HR 1.07 [95% CI 0.92-1.24], respectively.

CONCLUSION

There is a possible increase in risk for fractures early in therapy with SGLT2i. Beyond this initial period, SGLT2is had no apparent effect on the incidence of fractures.

Metastatic breast cancer survival improvement restricted by regional disparity: Surveillance, Epidemiology, and End Results and institutional analysis: 1990 to 2011

Background

The extent of breast cancer outcome disparity can be measured by comparing Surveillance, Epidemiology, and End Results (SEER) breast cancer‐specific survival (BCSS) by region and with institutional cohort (IC) rates.

Methods

Patients who were diagnosed with a first primary, de novo, stage IV breast cancer at ages 25 to 84 years from 1990 to 2011 were studied. The change in 5‐year BCSS over time from 1990 to 2011 was compared using the SEER 9 registries (SEER 9) without the Seattle‐Puget Sound (S‐PS) region (n = 12,121), the S‐PS region alone (n = 1931), and the S‐PS region IC (n = 261). The IC BCSS endpoint was breast cancer death confirmed from chart and/or death certificate and cause‐specific survival for SEER registries. BCSS was estimated using the Kaplan‐Meier method. Hazard ratios (HzR) were calculated using Cox proportional‐hazards models.

Results

For SEER 9 without the S‐PS region, 5‐year BCSS improved 7% (from 19% to 26%) over time, it improved 14% for the S‐PS region (21% to 35%), and it improved 27% for the S‐PS IC (29% to 56%). In the IC Cox proportional‐hazards model, recent diagnosis year, chemotherapy, surgery, and age <70 years were associated with better survival. For SEER 9, additional significant factors were white race and positive hormone receptor status and S‐PS region was associated with better survival (HzR, 0.87; 95% CI, 0.84‐0.90). In an adjusted model, hazard of BC death decreased in the most recent time period (2005‐2011) by 28% in SEER 9 without S‐PS, 43% in the S‐PS region and 45% in the IC (HzR, 0.72 [95% CI, 0.67‐0.76], 0.57 [95% CI, 0.49‐0.66], and 0.55 [95% CI, 0.39‐0.78], respectively).

Conclusions

Over 2 decades, the survival of patients with metastatic breast cancer improved nationally, but with regional survival disparity and differential improvement. To achieve equitable outcomes, access and treatment approaches will need to be identified and adopted.

The observation of a greater improvement in survival with metastatic breast cancer by region indicates progress in treatment and a possible statistical cure, in that patients may be able to live long enough with disease to die of other causes. The direct identification of specific factors related to differential survival rates, such as access to care and molecular subtype‐appropriate treatment, is warranted.

Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission

BACKGROUND

The use of medications not relieving symptoms or maximizing quality of life should be minimized following hospice enrollment.

OBJECTIVE

To evaluate the frequency of and predictive factors for continuation of medications with limited benefit after hospice admission among those admitted for cancer- and non-cancer-related causes.

DESIGN

Cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database.

PATIENTS

Medicare Part D-enrolled beneficiaries 66 years and older who were admitted to and died under hospice care between January 1, 2008, and December 31, 2013 (N = 70,035).

MAIN MEASURES

Patients were followed from hospice enrollment through death for Part D dispensing of limited benefit medications (LBMs) they had used in the 6 months prior to hospice admission, including anti-hyperlipidemics, anti-hypertensives, oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors. The proportion of patients continuing an LBM after hospice admission was evaluated. Adjusted relative risks (RRs) were estimated for factors associated with LBM continuation.

KEY RESULTS

Overall, 29.8% and 30.5% of patients admitted to hospice for a cancer- and non-cancer-related cause, respectively, continued at least one LBM after hospice admission. Anti-dementia medications were continued most frequently (29.3%) while anti-osteoporotic medications were continued least often (14.1%). Compared to home hospice, LBM continuation was greater in hospice patients residing in skilled nursing (RR 1.25, 95% CI 1.20-1.29), non-skilled nursing (RR 1.29, 95% CI 1.25-1.32), and assisted living facilities (RR 1.28, 95% CI 1.24-1.32). Patients with hospice stays ≥ 180 days were more likely to continue at least one LBM compared to those with stays of 1 week or less (RR 13.11, 95% CI 12.25-14.02).

CONCLUSIONS

A substantial proportion of Medicare hospice beneficiaries continued to receive LBMs following hospice enrollment. Providers should evaluate the necessity of continuing non-palliative medications at the end of life through a careful, patient-centric consideration of their potential risks and benefits.

Bevacizumab Use and the Risk of Arterial and Venous Thromboembolism in Patients with High-Grade Gliomas: A Nested Case-Control Study

STUDY OBJECTIVE

Bevacizumab is used in the treatment of recurrent glioblastoma, but evidence is limited on the incidence of thromboembolic complications regarding the use of this drug in real-world settings. We evaluated the risk of arterial thromboembolism (ATE) and venous thromboembolism (VTE) associated with the use of bevacizumab among adults diagnosed with high-grade gliomas in a commercially insured U.S.

POPULATION

DESIGN

Nested case-control study.

DATA SOURCE

Truven Health MarketScan Commercial and Medicare Supplemental health claims databases (2009-2015).

PATIENTS

A total of 2157 patients with high-grade gliomas who underwent incident (first-time) craniotomy, radiation, and concurrent temozolomide treatment between 2009 and 2015 were identified. Overall, 25 cases of ATE and 99 cases of VTE were each identified in this cohort, and each case was matched to up to 10 controls (170 for ATE and 819 for VTE) based on sex, age, quarter year of index time, and follow-up duration by using incidence density sampling without replacement from the overall cohort. Controls were at risk for the outcome of interest (ATE or VTE) at the time of case occurrence and survived at least as long as their referent case.

MEASUREMENTS AND MAIN RESULTS

Exposure to bevacizumab was determined during inpatient or outpatient encounters between the index date (date of the incident craniotomy) and the ATE or VTE event or corresponding matched control date. Multivariable conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of ATE and VTE separately. A higher proportion of patients with ATE received bevacizumab compared with controls (28% vs 17%; adjusted OR 1.51, 95% CI 0.54-4.24), but this excess in odds was not statistically significant. Similarly, bevacizumab was not significantly associated with VTE (13% vs 9%; adjusted OR 1.40, 95% CI 0.71-2.75).

CONCLUSION

We found no significant association between the use of bevacizumab and the occurrence of thromboembolic events in patients with high-grade gliomas, although our study was limited by the small number of ATE events. Because the potential for complications from arterial thrombosis cannot be completely ruled out, further research is needed to confirm the thromboembolic safety of bevacizumab in a larger sample of patients with high-grade gliomas.

Pretransplant hemoglobin and creatinine clearance correlate with treatment-free survival after autologous stem cell transplantation for multiple myeloma

Melphalan is given at a dose of 200 mg/m² (Mel200) prior to ASCT for multiple myeloma (MM). Pharmacokinetic (PK) studies show a high degree of interpatient variability. We aimed to test the impact of clinical factors previously shown to affect melphalan PK such as hemoglobin (Hgb), fat-free mass (FFM), and creatinine clearance (CrCl) on outcomes. Median Hgb (from day -2 to -1) and FFM were grouped as low or high relative to their sample medians, and CrCl was divided into ≥60 or <60 ml/min. In 133 MM patients, median TFS (defined as time from ASCT to initiation of next subsequent line of therapy or death) was longer in patients with lower Hgb (35 vs. 16 months, p = 0.02). Patients with both lower Hgb and CrCl experienced longer TFS compared to those with higher Hgb and CrCl (35 vs. 13 months, p = 0.03). In multivariate analysis, lower hemoglobin, lower CrCl, and a combined low hemoglobin and CrCl were strongly associated with improved TFS. Patients with a lower hemoglobin or creatinine clearance experienced significantly more toxicity. We show for the first time that Hgb and CrCl are important predictors of outcomes after Mel200. PK-directed melphalan dosing may be beneficial in achieving optimal outcomes.

Superior Survival in African American Patients Who Underwent Autologous Stem Cell Transplantation for Multiple Myeloma

INTRODUCTION/BACKGROUND

African American (AA) individuals have a twofold higher incidence of multiple myeloma (MM) compared with other racial groups. Outcomes are affected by factors such as disparate access to care as well as differences in disease biology.

PATIENTS AND METHODS

We conducted a single-institution analysis to evaluate the effect of AA race on outcomes of MM patients who underwent autologous stem cell transplantation (ASCT) in the pre-novel and novel agent era.

RESULTS

Sixty-one (47%) patients were AA and 69 (53%) were non-AA. Overall, 78 (60%) patients received any novel agent before transplantation and 52 (40%) received only chemotherapy. More non-AA patients received initial induction with a proteasome inhibitor (40 [60%] vs. 17 [28%]; P = .0007), and were treated with post-ASCT maintenance therapy (28 [41%] vs. 14 [23%]; P = .04). Time from diagnosis to ASCT in AA patients was 10 (range, 4-144) versus 8 (range, 3-54) months in non-AA patients (P = .01). Despite this, treatment-free survival (TFS) was equivalent between the 2 groups (x vs. y). Furthermore, AA patients had greater median overall survival (OS) compared with non-AA patients (not reached vs. 108 months; P = .03) and significantly improved OS in multivariable Cox proportional hazards models (adjusted hazard ratio, 0.30; 95% confidence interval, 0.11-0.81; P = .017). Median OS, landmarked at the time of relapse, was improved in AA patients (not reached vs. 68 months for P = .05).

CONCLUSION

Our study showed with long follow-up, equivalent TFS after ASCT in AA and non-AA patients yet improved OS. Post relapse survival is improved in AA patients suggesting a better response to salvage therapy.

Polypharmacy and potentially inappropriate medication use is highly prevalent in multiple myeloma patients and is improved by a collaborative physician–pharmacist clinic

Objective

To compare polypharmacy and potentially inappropriate medication use in multiple myeloma patients receiving care under a traditional, physician-managed, or collaborative physician–pharmacist clinic.

Design

Retrospective chart review.

Setting

Urban academic cancer center.

Data source

Computerized electronic record.

Patients

Forty-four patients in the traditional physician-managed clinic and 57 patients in the collaborative physician-pharmacist clinic.

Measurements and main results

Patients in the collaborative clinic took fewer medications on average (9 vs. 7, p = 0.045). Although the median number of myeloma-related medications was higher (2 vs. 4, p < 0.0001), the number of non-myeloma-related medications was lower (7 vs. 3, p < 0.0001) in the collaborative clinic. Polypharmacy rates were high in both clinics (93% vs. 84%, p = 0.22). However, the collaborative clinic had a lower rate of polypharmacy of non-myeloma medications (71 vs. 33%, p = 0.0003), including both minor (five to nine medications, 48 vs. 28%, p = 0.06) and major (≥10 medications, 23 vs. 5%, p = 0.02) polypharmacy. Minor polypharmacy of myeloma-related medications was higher in the collaborative clinic (32 vs. 2%; p = 0.0002). Multivariate analysis showed a reduced risk of having a higher number of medications (Relative risk (RR) 0.79, 95% confidence interval 0.67–0.93; p = 0.004), a lower risk of having any polypharmacy of non-myeloma-related medications (RR 0.41, 95% confidence interval 0.25–0.67; p < 0.001) and a lower risk of receiving potentially inappropriate medication (RR 0.62, 95% confidence interval 0.41–0.95; p = 0.029) in the collaborative clinic.

Conclusions

Multiple myeloma patients have a high rate of polypharmacy but comanagement with a pharmacist reduced the number of all medications, but in particular the number of non-myeloma-related medications.

Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015

Importance

Antibiotics are recommended before certain dental procedures in patients with select comorbidities to prevent serious distant site infections.

Objective

To assess the appropriateness of antibiotic prophylaxis before dental procedures using Truven, a national integrated health claims database.

Design, Setting, and Participants

Retrospective cohort study. Dental visits from 2011 to 2015 were linked to medical and prescription claims from 2009 to 2015. The dates of analysis were August 2018 to January 2019. Participants were US patients with commercial dental insurance without a hospitalization or extraoral infection 14 days before antibiotic prophylaxis (defined as a prescription with ≤2 days' supply dispensed within 7 days before a dental visit).

Exposures

Presence or absence of cardiac diagnoses and dental procedures that manipulated the gingiva or tooth periapex.

Main Outcomes and Measures

Appropriate antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. To assess associations between patient or dental visit characteristics and appropriate antibiotic prophylaxis, multivariable logistic regression was used. A priori hypothesis tests were performed with an α level of .05.

Results

From 2011 to 2015, antibiotic prophylaxis was prescribed for 168 420 dental visits for 91 438 patients (median age, 63 years; interquartile range, 55-72 years; 57.2% female). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most dental visits were classified as diagnostic (70.2%) and/or preventive (58.8%). In 90.7% of dental visits, a procedure was performed that would necessitate antibiotic prophylaxis in high-risk cardiac patients. Prevalent comorbidities include prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Per guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were unnecessary. Clindamycin was more likely to be unnecessary relative to amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were associated with unnecessary antibiotic prophylaxis.

Conclusion and Relevance

More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. Implementation of antimicrobial stewardship in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.

Comparison of Opioid Prescribing by Dentists in the United States and England

IMPORTANCE

The United States consumes most of the opioids worldwide despite representing a small portion of the world's population. Dentists are one of the most frequent US prescribers of opioids despite data suggesting that nonopioid analgesics are similarly effective for oral pain. While oral health and dentist use are generally similar between the United States and England, it is unclear how opioid prescribing by dentists varies between the 2 countries.

OBJECTIVE

To compare opioid prescribing by dentists in the United States and England.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of prescriptions for opioids dispensed from outpatient pharmacies and health care settings between January 1 and December 31, 2016, by dentists in the United States and England. Data were analyzed from October 2018 to January 2019.

EXPOSURES

Opioids prescribed by dentists.

MAIN OUTCOMES AND MEASURES

Proportion and prescribing rates of opioid prescriptions.

RESULTS

In 2016, the proportion of prescriptions written by US dentists that were for opioids was 37 times greater than the proportion written by English dentists. In all, 22.3% of US dental prescriptions were opioids (11.4 million prescriptions) compared with 0.6% of English dental prescriptions (28 082 prescriptions) (difference, 21.7%; 95% CI, 13.8%-32.1%; P < .001). Dentists in the United States also had a higher number of opioid prescriptions per 1000 population (35.4 per 1000 US population [95% CI, 25.2-48.7 per 1000 population] vs 0.5 per 1000 England population [95% CI, 0.03-3.7 per 1000 population]) and number of opioid prescriptions per dentist (58.2 prescriptions per dentist [95% CI, 44.9-75.0 prescriptions per dentist] vs 1.2 prescriptions per dentist [95% CI, 0.2-5.6 prescriptions per dentist]). While the codeine derivative dihydrocodeine was the sole opioid prescribed by English dentists, US dentists prescribed a range of opioids containing hydrocodone (62.3%), codeine (23.2%), oxycodone (9.1%), and tramadol (4.8%). Dentists in the United States also prescribed long-acting opioids (0.06% of opioids prescribed by US dentists [6425 prescriptions]). Long-acting opioids were not prescribed by English dentists.

CONCLUSIONS AND RELEVANCE

This study found that in 2016, dentists in the United States prescribed opioids with significantly greater frequency than their English counterparts. Opioids with a high potential for abuse, such as oxycodone, were frequently prescribed by US dentists but not prescribed in England. These results illustrate how 1 source of opioids differs substantially in the United States vs England. To reduce dental opioid prescribing in the United States, dentists could adopt measures similar to those used in England, including national guidelines for treating dental pain that emphasize prescribing opioids conservatively.