D-dimer and sinusoidal obstructive syndrome-novel poor prognostic features of thrombotic microangiopathy in children after hematopoietic cellular therapy in a single institution prospective cohort study

Transplant-associated thrombotic microangiopathy (TA-TMA) is a common, severe complication of allogeneic hematopoietic cellular therapy (HCT). Even when treated in many studies, morbidity and mortality rates are high. This prospective single-institution cohort study serially enrolled all allogeneic HCT recipients from August 2019-August 2022. Patients were universally screened for TA-TMA and intermediate and high-risk patients were immediately treated with eculizumab. Sub-distribution cox-proportional hazards models were used to identify sub-distribution hazard ratios (sHR)  for multi-organ dysfunction (MOD) and non-relapse-related mortality (NRM). Of 136 patients, 36 (26%) were diagnosed with TA-TMA and 21/36 (58%) developed MOD, significantly more than those without TA-TMA, (p < .0001). Of those with TA-TMA, 18 (50%) had high-risk TA-TMA (HR-TA-TMA), 11 (31%) had intermediate-risk TA-TMA (IR-TA-TMA), and 8 (22%) had standard risk (SR-TA-TMA). Twenty-six were treated with eculizumab (1/8 SR, 7/11 IR, and 18/18 HR). Elevated D-dimer predicted the development of MOD (sHR 7.6, 95% confidence interval [CI] 1.8-32.3). Children with concurrent sinusoidal obstructive syndrome (SOS) and TA-TMA had an excess risk of MOD of 34% and data supported a biologic interaction. The adjusted NRM risk was significantly higher in the TA-TMA patients (sHR 10.54, 95% CI 3.8-29.2, p < .0001), despite prompt treatment with eculizumab. Significant RF for NRM in TA-TMA patients included SOS (HR 2.89, 95% 1.07-7.80) and elevated D-dimer (HR 3.82, 95% CI 1.14-12.84). An unrelated donor source and random urine protein to creatine ratio ≥2 mg/mg were significantly associated with no response to eculizumab (odds ratio 15, 95% CI 2.0-113.6 and OR 6.5, 95% CI 1.1-38.6 respectively). TA-TMA was independently associated with NRM despite early diagnosis and treatment with eculizumab in this large pediatric transplant cohort. Prognostic implications of D-dimer in TA-TMA merit further investigation as this is a readily accessible biomarker. Concurrent SOS is an exclusion criterion of many ongoing clinical trials, but these data highlight these patients could benefit from novel therapeutic approaches. Multi-institutional clinical trials are needed to understand the impact of TA-TMA-targeted therapies.

BA.5 bivalent booster vaccination enhances neutralization of XBB.1.5, XBB.1.16 and XBB.1.9 variants in patients with lung cancer

This study reports that most patients with NSCLC had a significant increase in the nAb response to the currently circulating Omicron variants after bivalent booster vaccination and had Ab titers comparable to healthy participants. Interestingly, though the durability of the nAb response persisted in most of the healthy participants, patients with NSCLC had significantly reduced nAb titers after 4-6 months of vaccination. Our data highlight the importance of COVID-19 bivalent booster vaccination as the standard of care for patients with NSCLC given the evolution of new variants of concern.

Phase 2 Trial of Anti-PD1 and 8 Gy in 1 Fraction for Relapse/Refractory Myeloma

PURPOSE/OBJECTIVE(S)

Relapsed, refractory multiple myeloma is associated with poor outcome. Role of radiotherapy is mainly for palliation. Anti-PD1 inhibitors have failed to show efficacy in relapsed refractory myeloma patients. A phase 2 trial (NCT03267888) was conducted to see if radiotherapy (8 Gy in 1 fraction) and anti-PD1 (Pembrolizumab) could provide early signals of safety and response.

MATERIALS/METHODS

A prospective single-center phase 2 trial involving patients >18 years of age with ECOG 0-1 was conducted after obtaining IRB approval. Patients had to have ISS stage I-III multiple myeloma that was either relapsed or refractory, an osseous and/or extraosseous lesion that could be radiated, and who were candidates for pembrolizumab. Patients had to have either measurable disease per the International Myeloma Working Group Criteria (IMWG) and/or had to have progressive disease on imaging. Radiotherapy was given on day 0, cycle 1 followed by pembrolizumab (200 mg/kg iv on day 2 or 3, then every 3 weeks +/- 7 days) on day 2-3 for at least 2 years or until progression. Primary endpoint was toxicity. Secondary endpoints were IMWG response, abscopal response, overall survival, and immunological changes in patient's blood. Patients were assessed at 3 months, 6 months, and 12 months IMWG criteria as well as serial PET/CT based imaging. Patients with stable disease or better were continued on the trial. Patients that progressive were removed. Standard statistical analysis was performed, and included Kaplan-Meier to estimate OS and PFS.

RESULTS

From June, 2018 until October, 2021, 32 patients were screened and 25 were enrolled. Of the enrolled patients, 76% were Caucasian, 64% had ECOG 1, and the mean age was 60 years. Prior to enrollment, the mean number of prior lines of therapy that the patients had failed was 5.20 (range: 2 - 11), suggesting a cohort with poor expected outcome. These cohort also had limited alternative options. Toxicity, as its primary endpoint, was acceptable. There were no grade 2 or higher radiation related toxicity within the irradiated volume. Only one case of grade 3 or higher pembrolizumab-related toxicity was noted amongst the 25 patients. Abscopal response was noted in 5 of 25 patients (20% patients). Several patients showed robust reductions in the paraproteins and other myeloma labs, suggesting response to radiotherapy and anti-PD1 combination. These patients were also associated to have a robust CD 8 T cell activation and an abscopal response. The secondary outcomes were better than expected for this cohort.

CONCLUSION

Combination therapy of single-fraction, low-dose radiation therapy with pembrolizumab in patients with relapsed or refractory multiple myeloma is worth assessing in future trials.

Risk Factors and Clinical Features of Fistula after Concurrent Chemoradiation and Brachytherapy for Locally Advanced Cervical Cancer

PURPOSE/OBJECTIVE(S)

The standard treatment for locally advanced cervical cancer (LACC) is concurrent chemoradiation and brachytherapy (CRT-B). Fistula formation is a serious complication of treatment; however, risk factors and clinical outcomes are not well described. We sought to identify the incidence, risk factors and prognosis of radiation-induced fistula in women who underwent CRT-B for LACC.

MATERIALS/METHODS

A single institution retrospective review of patients treated with CRT-B for LACC from July 2013 to August 2022 across 3 centers was performed. Inclusion criteria were Stage IB-IVB cervical cancer treated with definitive intent. Patients with upfront or adjuvant surgery were excluded. Cox-proportional hazards model was performed to assess factors associated with fistula. Local control and fistula-free survival were estimated using the Kaplan-Meyer method. Clinical significance was defined as p < 0.05.

RESULTS

A total of 105 patients met the inclusion criteria and were included in this analysis. Patients consisted of FIGO Stage I (n = 20, 19%), Stage II (n = 22, 21%), Stage III (n = 46, 43.8%) or Stage IV disease (n = 17, 16.2%). 12 (11.4%) patients developed fistula following CRT-B; 1/12 patients (8.3%) had fistula present at time of diagnosis. Median time to fistula development was 12 months. Fistula was characterized as vesicovaginal/urethrovaginal in 58.3% (n = 7) and rectovaginal/intestinovaginal in 83.3% (n = 10), including 8 patients (66.7%) who had more than one type of fistula. 4/12 (33.3%) of patients with fistula had concurrent local recurrence. Patients were treated with conservative management (41.7%), hyperbaric oxygen (16.7%) and/or surgery (83.3%). Complications included infection (50.0%), urinary/bowel diversion (83.3%), hospitalization (50.0%) and death (8.3%). Fistula was resolved in 7/12 patients (58.3%) at time of last follow up. Higher BMI (p = 0.04) and use of hybrid applicators (p = 0.02) were associated with decreased likelihood of fistula development. Disease extension into bladder was associated with increased likelihood of fistula development (p = 0.03). Compared to former and never smoking, current smoking was associated with a higher risk of developing fistula (p = 0.04, OR 4.42, CI:1.07-18.34). Compared to intracavitary and hybrid applicators, the use of a Syed applicator was associated with increased likelihood of fistula development (p = 0.02, OR 8.00, CI: 1.37-46.55). Two-year local control was 82.5% (CI: 64.5-91.9) for Stage I-II, 80.7% (CI: 62.8-90.6) for Stage III, and 62.2% (CI: 30.1-82.9) for Stage IV. Two-year fistula free survival was 89.9% (CI: 80.6 - 94.9).

CONCLUSION

Women who undergo definitive chemoradiation for treatment of LACC have a 11.4% risk of fistula formation overall. The risk is higher amongst patients with current smoking, disease extension into bladder and Syed applicators. Overall two-year local control was 78.7% and fistula free survival was 89.9%.

Disparities in Time to Prostate Cancer Treatment Initiation before and after the Affordable Care Act

PURPOSE/OBJECTIVE(S)

Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for men with PCa is unknown.

MATERIALS/METHODS

Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis to start of surgery, radiotherapy, or hormonal therapy. Cochran-Armitage test measured annual trends in delays, and join point regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays.

RESULTS

Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p<.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p<.001) patients had higher odds of delay. These disparities persisted when analyzing only patients treated after 2014 or for patients who had Medicare or Private insurance. Compared to uninsured patients, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = .31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p<.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p<.001) had lower odds of delay. These disparities persisted when analyzing only patients treated after 2014. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p<.001); 2014 was associated with a significant inflection for increase in rates of major delays.

CONCLUSION

The impact of race and insurance status were independently associated with longer delays to PCa treatment in the US. These disparities were unaffected by implementation of the ACA. In fact, implementation of ACA was associated with increased delays in treatment initiation for all men, regardless of race. As the epidemiology of newly diagnosed prostate cancer in the United States continues to shift due to tempered screening and the COVID pandemic, further work will be needed to increase equity in prostate cancer care.

Combined Analysis of a Phase III Randomized Trial and Phase II Prospective Trial with Blind Control Matching of Patients Receiving Whole-Lung, Low-Dose Radiation for COVID-19: Full Results and Immunologic Correlates of the RESCUE 1-19 Trial

PURPOSE/OBJECTIVE(S)

Whole-lung, low-dose radiation (LD-RT) for COVID-19 requires randomization and biologic correlates to determine causality and mechanism.

MATERIALS/METHODS

A phase III trial randomized COVID-19 patients to physician's choice of drug therapy with or without LD-RT. Primary endpoint was intubation-free survival (IFS). The trial was designed with 80% power (two-sided log rank, alpha 0.05) to detect a hazard ratio of 0.3 after 12 intubation events. Estimating a 25% event rate, the planned sample size was 84 patients plus 25 to account for declining intubation rates and screen failures. Due to hospitalization declines and other barriers, the trial closed prematurely. Available randomized data were analyzed by intention-to-treat and combined with phase II results and immunologic correlates, using one-sided significance and an alpha of 0.1 to inform future trial design.

RESULTS

From Jun 2020-Jun 2022, 14 patients were randomized on a phase III trial. From Apr 2020-Dec 2020, 42 patients were enrolled on a phase II trial and blindly matched to 40 controls from contemporaneous trials. 96 total patients and 193 blood samples were available for analysis. Mean hospital duration with LD-RT was 12.9 vs 15.4 days in controls (p = 0.12). Oxygen flow rate >15 L/min (26% vs 38%, p = .27), high-flow oxygen >30 L/min (24% vs 38%, p = 0.18), non-invasive positive-pressure >60 L/min (9% vs 27%, p = 0.03), and mechanical ventilation (9% vs 24%, p = 0.05) reduced with LD-RT. Mean supplemented oxygen volume was 171,759 vs 547,626 liters in controls, with daily means of 10 vs 23 L/min (p = 0.03). Radiographs worsened in 43% vs 71% of controls (p = 0.03). Arterial blood gas mean P/F ratios improved 22% after LD-RT vs declined 8% in controls (p = 0.12). Mean days febrile were 1.8 vs 2.9 in controls (p = 0.10). Rate of myocardial injury was 47% vs 40% in controls (p = 0.77). Flow cytometry revealed 4-fold and 30-fold larger expansions, respectively, in CD8- and CD4-positive CD3+PD1+Ki67-high proliferating cytotoxic T-cells (300% vs 75% expansion, p = 0.07) and helper T-cells (200% expansion vs 6% contraction, p = 0.03) at day 7. In the randomized cohort, mean oxygen volume fell 75% with LD-RT to 78,336 vs 316,786 liters in controls (p = 0.13), mean flow rates were 5.1 vs 18.4 L/min (p = 0.13), radiographs worsened in 50% vs 100% (p = .17), P/F ratios improved 31% vs declined 68% in controls (p = 0.03), hospital duration was 8.9 vs 11.5 days (p = 0.22), and zero LD-RT patients vs one control intubated.

CONCLUSION

Combined analysis of a phase II/III randomized trial suggests that LD-RT prevents ventilation, reduces supplemental oxygen need, improves clinical course, and enhances immune response. LD-RT may have both immediate direct effects and delayed enhanced immunity in COVID-19. Larger multi-institutional trials are justified.

Disparities in time to prostate cancer treatment initiation before and after the Affordable Care Act

BACKGROUND

Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for PCa men is unknown.

METHODS

Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis. Cochran-Armitage test measured annual trends in delays, and joinpoint regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays.

RESULTS

Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p < 0.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p < 0.001) patients had higher odds of delay. Compared to uninsured, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = 0.31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p < 0.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p < 0.001) had lower odds of delay. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p < 0.001); 2014 was associated with a significant inflection for increase in rates of major delays.

CONCLUSIONS

Non-White and Medicaid-insured men with localized PCa are at risk of treatment delays in the United States. Treatment delays have been consistently rising, particularly after implementation of the ACA.

Characterizing Outcomes in Visceral Cutaneous T-Cell Lymphoma: A Single Center Retrospective Study

INTRODUCTION

Visceral involvement of cutaneous T-cell lymphoma (vCTCL) is a rare but poorly studied complication of CTCL. We aimed to assess clinical characteristics, treatment, and outcomes, associated with vCTCL at our institution.

METHODS

We conducted a retrospective review of patients with vCTCL among patients with a confirmed histopathologic diagnosis of CTCL seen at the Winship Cancer Institute in Emory University. vCTCL was defined as a highest TNMB stage of 4B with extracutaneous metastatic disease (M1) pathologically confirmed or strongly clinically suspected based on imaging, symptoms, and the clinical judgment of the treating physician. Patients were selected from our CTCL database containing 656 patients from 1990 to 2022. Clinical characteristics were characterized. Clinical outcomes were measured as overall survival (OS) and progression-free survival (PFS) using Kaplan-Meier curve and univariable Cox regression analysis.

RESULTS

Twenty-six of 656 patients with vCTCL were identified. 42.3% of patients were black. Twenty-two patients were diagnosed with MF/SS and 4 had other CTCL subtypes including pcALCL, Gamma-Delta, and Cytotoxic T-Cell Lymphoma. The median PFS and OS were 7.3 months (3.8, 11) and 12.1 months (9.9, 18.2), respectively. Median time to metastasis from initial diagnosis was 12.1 months. The most common M1 sites were liver (19.2%) and lung (42.3%). M1 sites outside of liver or lung were associated with inferior OS (HR 8.9, 95%CI: 2.7-29.5, P-value <.001) and PFS (HR 4.3, 95%CI: 1.44-12.7, P-value = .009). No treatments or baseline factors were associated with improved survival.

CONCLUSION

Our retrospective study confirms therapy resistance and dismal outcomes among patients with vCTCL.

Impact of diagnosis to treatment interval in patients with newly diagnosed mantle cell lymphoma

The prognostic relevance of diagnosis to treatment interval (DTI) in patients with newly diagnosed mantle cell lymphoma (MCL) is unknown. Hence, we sought to evaluate the impact of DTI on outcomes in MCL using 3 large datasets (1) the University of Iowa/Mayo Clinic Specialized Program of Research Excellence Molecular Epidemiology Resource, (2) patients enrolled in the ALL Age Asthma Cohort/CALGB 50403, and (3) a multisitecohort of patients with MCL. Patients were a priori divided into 2 groups, 0 to 14 days (short DTI) and 15 to 60 days (long DTI). The patients in whom observation was deemed appropriate were excluded. One thousand ninety-seven patients newly diagnosed with MCL and available DTI were included in the study. The majority (73%) had long DTI (n=797). Patients with short DTI had worse eastern cooperative oncology group performance status (ECOG PS ≥2), higher lactate dehydrogenase, bone marrow involvement, more frequent B symptoms, higher MCL International Prognostic Index (MIPI ≥6.2), and were less likely to receive intensive induction therapy than long DTI group. The median progression-free survival (2.5 years vs 4.8 years, p<0.0001) and overall survival (7.8 years vs. 11.8 years, p<0.0001) were significantly inferior in the short DTI group than the long DTI cohort and remained significant for progression-free survival and overall survival in multivariable analysis. We show that the DTI is an important prognostic factor in patients newly diagnosed with MCL and is strongly associated with adverse clinical factors and poor outcomes. DTI should be reported in all the patients newly diagnosed with MCL who are enrolling in clinical trials and steps must be taken to ensure selection bias is avoided.

Accounting for the High Enrollment of African Americans on Winship Cancer Institute's Myeloma Clinical Trials

Background

Thirty-four percent of Multiple Myeloma (MM) clinical trial participants at Winship Cancer Institute (Winship) are African American (AA); however, AAs make up only 4.5 percent of myeloma clinical trial participants in the United States. Given our high enrollment, we aimed to measure AAs' trust in providers and identify if clinical trial enrollment barriers exist.

Methodology

A member of the ethics research team surveyed AA patients who had consented to a MM clinical trial at Winship. Three validated surveys were used: Trust in Medical Research (TMR); Human Connection (THC) which measures how much patients feel they are heard and valued by their physicians; and the Duke Intrinsic Religiosity Scale (DUREL) which measures strength of religious engagement and belief. The survey also included questions about the impact of side effects, distance to the trial center and trial related costs on the decision to participate in clinical trial.

Results

Ninety-two percent (61/67) of patients approached consented. The mean TMR score and the mean THC score were significantly higher (P-value < 0.001) than the results obtained in key national surveys (TMR 14.9 compared to 11.65; THC 57.7 compared to 54.6). These two surveys were significantly correlated, meaning trust and human connection increase or decrease in tandem. The 3 religiosity subscale results showed high religiosity (3.84, 4.36, and 4.35 with 5 being the highest score). The mean scores of the importance of the investigational agent's side effects, trial costs, and distance to trial center on the decision to enroll in a clinical trial were also high (8.5, 7.8, and 6.5, respectively, with 10 being the most important).

Conclusion

In our study population, high trust and human connection overcame other trial participation barriers: strong religious beliefs and concerns about side effects, costs, and travel distance. We present a roadmap to guide investigators to increase human connection, and hopefully trust.

Abstract PD1-03: Neighborhood deprivation and breast cancer mortality among Black and White women

Background: Neighborhood deprivation is hypothesized as a potential driver of racial disparities in breast cancer mortality. However, research shows that neighborhood deprivation is associated with increased breast cancer mortality among White women, but has little to no association among Black women. No study has previously considered the intersections of race, social cohesion, or urban/rural status in the association between neighborhood deprivation and breast cancer mortality. Methods: Neighborhood deprivation was examined in relation to breast cancer mortality among 31,358 non-Hispanic Black and non-Hispanic White women diagnosed with invasive breast cancer (stage I-IIIA) between 2010-2017, followed through 2019, and identified by the Georgia Cancer Registry. Two composite scores, the Area Deprivation Index (ADI) and neighborhood deprivation index (NDI), were used to characterize neighborhood deprivation. A third composite score, the Yost index, was assessed as a measure of neighborhood socioeconomic status (SES). Each composite score was composed of factors representing six domains: poverty, income, occupation, housing, employment, and education. Data on ADI were obtained from the Neighborhood Atlas and was assessed in deciles. American Community Survey data from 2011-2015 and principal components analysis were used to derive the NDI and Yost index. Both measures were assessed in quartiles. Each composite variable was measured at the block group level and linked to patient data. Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between each composite variable and breast cancer mortality, overall and by race/ethnicity. Intersectionality will be examined by considering the joint effects of race/ethnicity, social cohesion, and urban/rural status. Results: During the 9-year follow-up period, 2,353 (1,347 non-Hispanic White, 1,006 non-Hispanic Black) women died from breast cancer. Regardless of which composite score was assessed, living in the most deprived or lowest SES neighborhoods was associated with an increased risk of breast cancer mortality in models adjusted for age and race (ADI decile 10 vs. 1: HR=1.57, 95% CI 1.26-1.96; NDI quartile 4 vs. 1: HR=1.43, 95% CI 1.26-1.63; Yost index quartile 1 vs 4: HR= 1.34, 95% CI 1.18-1.51). Stratification by race/ethnicity showed associations were slightly stronger among non-Hispanic White women but null among non-Hispanic Black women. Results from analyses examining the joint effects of race/ethnicity, social cohesion, and urban/rural status are forthcoming and will be presented in December. Conclusions: Consistent with previous studies, our study found that living in a deprived neighborhood may increase breast cancer mortality among non-Hispanic White women, but not non-Hispanic Black women. Investigating the association with an intersectionality framework may help identify subgroups of women who are particularly susceptible to the adverse impact of neighborhood deprivation on breast cancer mortality.

Citation Format: Lauren E. Barber, Jasmine M. Miller-Kleinhenz, Maret L. Maliniak, Leah Moubadder, Jeffrey Switchenko, Lauren E. McCullough. Neighborhood deprivation and breast cancer mortality among Black and White women [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-03.

Abstract OT2-10-03: HCRN BRE 19-433: A Multi-institutional Phase II Study to Evaluate Efficacy and Safety of TAlazoparib, Radiotherapy and Atezolizumab in gBRCA 1/2 negative Patients with PD-L1+ Metastatic Triple Negative Breast Cancer (TARA)

Background Although immunotherapy (IO) in combination with chemotherapy has improved progression free and overall survival in patients with PD-L1+ metastatic triple negative breast cancer (mTNBC), prognosis remains poor. A potential therapeutic strategy to restore sensitivity to IO in patients with progressive disease is to introduce agents that re-sensitize the immune system to IO leading to a more tumor-specific and less toxic treatment in the second-line setting or beyond. Both talazoparib, a PARP inhibitor, and radiation (XRT) independently increase PD-L1 expression on the tumor cell surface resulting in heightened sensitivity to IO agents like atezolizumab, a PD-L1 inhibitor. Although a local treatment, XRT has the ability to produce an abscopal effect resulting in systemic shrinkage of non-irradiated tumors outside/distant to the XRT field, a phenomenon observed in patients receiving concurrent IO. While talazoparib is standard treatment in patients with gBRCA1 and 2 mutations, it is also a potent radiosensitizing agent that suppresses homologous recombination and PARP-1-dependent nonhomologous end joining (NHEJ) repair while promoting error-prone alt-NHEJ. When combined with IO, talazoparib can amplify immune responses by generating immunogenic neo-antigens independent of gBRCA1/2 status. We, therefore, hypothesize that the combination of talazoparib, XRT, and atezolizumab will re-sensitize mTNBC tumors to IO and promote a durable tumor-specific response that spares patients from toxicities associated with traditional chemotherapy regimens. Methods This is a Phase II multi-institutional study designed to assess efficacy and safety of talazoparib, high dose XRT, and atezolizumab given in the second-, third-, or fourth-line settings to patients with mTNBC that is PD-L1 positive. A total of 23 patients with mTNBC who do not carry gBRCA pathogenic variants will be enrolled. All patients will be treated with induction talazoparib of 1mg PO daily starting Day 1 of a 28-day cycle. Patients will then receive 8 Gy x 3 fractions to 1-4 metastatic lesions QOD beginning Day 12, 13, or 14. Atezolizumab will be given intravenously (840 mg)) on Day 15 of the 1st cycle and then on Day 1 and Day 15 of the subsequent cycles. Talazoparib and atezolizumab treatment will continue until progression or severe toxicity. The primary endpoint is objective response rate (ORR) in non-irradiated lesions 8 weeks after the first dose of atezolizumab. Key inclusion criteria include biopsy proven mTNBC (ER&lt; 10%, PR&lt; 10%, Her2-) with at least 2 extracranial metastatic lesions. Patients must have at least 1 extracranial metastatic lesion amenable to high dose radiotherapy and at least one additional extracranial lesion of measurable disease by Response Evaluation Criteria in Solid Tumors (RECIST v1.1) that will not receive radiotherapy. Tumors must be PD-L1 positive as defined as &gt;1% on IHC using the SP142 Ventana Assay. Key exclusion criteria include patients with germline BRCA pathogenic variants, more than three previous lines of chemotherapy treatment in the advanced setting with or without IO, and breast cancer progression within the first 3 months of previous IO treatment for non-metastatic or metastatic breast cancer. Sample size was determined using Simon’s 2-stage Minimax design to detect a 20% increase in ORR. The null hypothesis that the true response rate among gBRCA1/2 negative patients of 10% will be tested against a one-sided alternative. Inflammatory cytokines, circulating B cells, and ctDNA will be collected for correlative analysis. Enrollment began in April 2021. The study is managed by the Hoosier Cancer Research Network and is open to accrual at Emory University and University of Alabama at Birmingham. Clinical trial information: NCT04690855

Citation Format: Mylin A. Torres, Kevin Kalinsky, Erica Stringer-Reasor, Ahmed Elkhanany, Jolinta Lin, David M. Schuster, Sarah Friend, Jeffrey Switchenko, Manali Bhave. HCRN BRE 19-433: A Multi-institutional Phase II Study to Evaluate Efficacy and Safety of TAlazoparib, Radiotherapy and Atezolizumab in gBRCA 1/2 negative Patients with PD-L1+ Metastatic Triple Negative Breast Cancer (TARA) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT2-10-03.

Abstract P1-04-14: Predicting the likelihood of response in PDL-1 positive metastatic triple negative breast cancer treated with an immune checkpoint inhibitor

Background: Patients with metastatic triple negative breast cancer (mTNBC) have a poor prognosis with median survival of 18 months or less. While the combination of immune checkpoint inhibitors (ICIs) and chemotherapy has shown promise in mTNBC, biomarkers beyond PDL-1 are needed to better predict which individuals will benefit from this treatment approach. In this study, we assessed the ability of spatial characteristics in predicting clinical best response in patients with PDL-1 positive mTNBC treated with an ICI and chemotherapy. Methods: Women with advanced unresectable or mTNBC treated with an ICI plus chemotherapy at Emory University between 2019 and 2021 with available biopsy specimens were retrospectively evaluated. Different cell types (tumor, stroma, immune cells) were identified by morphology on H&E staining. A cellular network was created by connecting each cell centroid to its adjacent centroids within a 30-μm distance. The resulting spatial neighborhood network was used to assess tumor density and quantify immune infiltration. The immune infiltration score was defined as the number of immune to tumor cell neighbors divided by the total number of immune cell neighbors in a region of 75-μm. A final immunoscore was calculated for each patient by averaging the immune infiltration scores in regions with high tumor cell density. Tumor infiltrating lymphocytes (TILs) were manually quantified. Responders were defined as those with a complete response (CR), partial response (PR), or stable disease (SD), while those with progressive disease (PD) were categorized as non-responders. A continuous response score was developed from tumor measurements of a target lesion on serial imaging. Pearson’s correlation coefficients were used to assess the relationship between continuous response scores and tumor characteristics. Responders and non-responders were compared using Mann-Whitney U tests. Results: Fifteen women with PDL-1 positive mTNBC treated with ICI plus chemotherapy and available tissue were included. All patients had relapsed disease, and 10 patients (67%) received an ICI and chemotherapy as first line treatment for mTNBC. Eight patients (53%) received atezolizumab and nab-paclitaxel while the remaining 7 (47%) patients received pembrolizumab with an approved chemotherapeutic agent. Seven patients (47%) experienced a PR, 3 (20%) with a CR, and 1 (7%) had SD. Four patients (27%) had PD with no clinical benefit. Higher immunoscores (-0.17, p=0.6) and TILs (-0.21, p=0.5) were numerically associated with continuous response scores. However, there were no significant differences in immunoscores (0.28 vs 0.26, p=0.6) or TIL counts (2 vs 5, p=0.6) between responders (N=11) and non-responders (N=4). Interestingly, patients with response to treatment had lower tumor densities compared to non-responders (7.5 vs 17.3, p=0.02). Conclusions: Spatial analysis of tumor density and immune infiltration, including immunoscore shows evidence of correlation with response. Tumor density was the only parameter significantly associated with response. The study identified novel tumor characteristics that need to be considered in the prediction of response to ICIs plus chemotherapy in mTNBC. The current findings are hypothesis generating and need validation in additional tissue samples to determine the role of tumor density as a predictor of response to ICI.

Citation Format: Jeffrey Aldrich, Thomas Hu, Jeffrey Switchenko, Ahmet Coskun, Yesim Gokmen-Polar, Sunil Badve, Manali Bhave. Predicting the likelihood of response in PDL-1 positive metastatic triple negative breast cancer treated with an immune checkpoint inhibitor [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-04-14.

Mitigation strategies among cutaneous T-cell lymphoma patients with positive Staphylococcus aureus skin and soft tissue cultures have unclear impacts on the risk of subsequent bacteremia

Infections originating in the skin/soft tissue are a major cause of mortality in cutaneous T-cell lymphoma (CTCL). We performed a retrospective analysis to characterize cutaneous cultures and assess risk factors for bacteremia among 69 patients with CTCL. Cutaneous infections and antimicrobial resistance were common. Black race and lymph node involvement were associated with bacteremia. Mitigating strategies for invasive infections in CTCL remain unclear. HighlightsSkin/soft tissue infections are common in cutaneous T-cell lymphoma (CTCL).Black race, lymph node involvement, and positive cultures for S. aureus, Gram-negative bacteria, or multiple organisms were associated with an increased rate of bacteremia.The role of antimicrobial prophylaxis and staphylococcus decolonization is unclear.

The impact of poorly differentiated histology on immunotherapy in advanced gastrointestinal cancers

Introduction Checkpoint inhibitors (CPI) have significantly improved survival among patients with various cancer types. Prior studies have shown a correlation between immune cell infiltration and poorly differentiated cancers. This study evaluated the impact of poorly differentiated histology on survival in patients with advanced gastrointestinal cancers treated with immunotherapy. Methods This study was a retrospective, single-center analysis of patients with gastrointestinal cancers treated with checkpoint inhibitors between 2016 and 2021. Univariate (UVA) and multivariable analyses (MVA) were performed to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used to assess the association between tumor and patient characteristics, progression free survival, and overall survival. Results A total of 123 patients were eligible and included in the analysis. Median age was 66 years (23-88 years). Majority had stage IV disease (89%), were white (65.5%), and were male (64.5%). Most common diagnoses were hepatocellular carcinoma (30.5%), gastric adenocarcinoma (16.5%) ,esophageal adenocarcinoma (17%) and colorectal cancer (19.8%). About 32% of the tumors were microsatellite instability-high (MSI-HIGH/DMMR), with BRAF V600E mutation rate of 10%. About 25% of the patients received checkpoint inhibitors as initial treatment while 35.5% had received two or more prior lines of therapy. Compared with well and moderately differentiated histology, patients with poorly differentiated tumors had a shorter median overall survival (mOS) (not reached [NR] vs. NR vs. 9.3 months, p=0.0264). There was no statistically significant difference in median progression free survival between histology types (2.5 vs.4.2 vs. 2 months, p=0.1314). On univariate survival analysis, moderately differentiated tumors correlated with a significantly longer mOS (HR: 0.48, CI: 0.24-0.93, p=0.030) and mPFS (HR: 0.62, 95%CI: 0.38-1.00, p=0.048) compared to poorly differentiated histology. Female patients (HR: 0.55, 95%CI: 0.34-0.90, p=0.018) and Eastern Cooperative Oncology Group (ECOG) of 1 (vs. ≥2) had significantly longer mPFS (HR: 0.58, 95%CI: 0.35-0.97, p=0.036). ECOG of 1 also correlated with longer mOS (HR: 0.47, 95%CI: 0.23-0.94, p=0.034). Microsatellite stable (MSS) tumors had significantly shorter mPFS (HR: 5.74, 95%CI: 2.41-13.63, p<0.001) and mOS (HR: 5.45, 95%CI: 1.64-18.12, p=0.006). The number of prior systemic therapies was also associated with shorter mPFS (HR: 1.19, 95%CI: 1.03-1.39, p=0.022) and mOS (HR: 1.23, 95%CI: 1.01-1.50, p=0.045). On multivariable analyses, ECOG status of 0/1 vs. ≥2 and MSI-HIGH/DMMR vs. MSS remained significantly associated with longer mPFS and mOS. There was no correlation with histologic differentiation status, race or mutations such as BRAF V600E or KRAS.

Factors Affecting Clinical Outcomes Among Patients Infected With HIV and Anal Cancer Treated With Modern Definitive Chemotherapy and Radiation Therapy

Purpose

Anal cancer affects a disproportionate percentage of persons infected with human immunodeficiency virus (HIV). We analyzed a cohort of patients with HIV and anal cancer who received modern radiation therapy (RT) and concurrent chemotherapy to assess whether certain factors are associated with poor oncologic outcomes.

Patients and Methods

We performed a retrospective chart review of 75 consecutive patients with HIV infection and anal cancer who received definitive chemotherapy and RT from 2008 to 2018 at a single academic institution. Local recurrence, overall survival, changes in CD4 counts, and toxicities were investigated.

Results

Most patients were male (92%) with large representation from Black patients (77%). The median pretreatment CD4 count was 280 cells/mm³, which was persistently lower at 6 and 12 months' posttreatment, 87 cells/mm³ and 182 cells/mm³, respectively (P < .001). Most (92%) patients received intensity modulated RT; median dose was 54 Gy (Range, 46.8-59.4 Gy). At a median follow-up 5.4 years (Range, 4.37-6.21 years), 20 (27%) patients had disease recurrence and 10 (13%) had isolated local failures. Nine patients died due to progressive disease. In multivariable analysis, clinically node negative involvement was significantly associated with better overall survival (hazard ratio, 0.39; 95% confidence interval, 0.16-1.00, P = .049). Acute grade 2 and 3 skin toxicities were common, at 83% and 19%, respectively. Acute grade 2 and 3 gastrointestinal toxicities were 9% and 3%, respectively. Acute grade 3 hematologic toxicity was 20%, and one grade 5 toxicity was reported. Several late grade 3 toxicities persisted: gastrointestinal (24%), skin (17%), and hematologic (6%). Two late grade 5 toxicities were noted.

Conclusions

Most patients with HIV and anal cancer did not experience local recurrence; however, acute and late toxicities were common. CD4 counts at 6 and 12 months' posttreatment remained lower than pretreatment CD4 counts. Further attention to treatment of the HIV-infected population is needed.

Antibody Response to COVID-19 mRNA Vaccine in Patients With Lung Cancer After Primary Immunization and Booster: Reactivity to the SARS-CoV-2 WT Virus and Omicron Variant

PURPOSE

To examine COVID-19 mRNA vaccine-induced binding and neutralizing antibody responses in patients with non-small-cell lung cancer (NSCLC) to SARS-CoV-2 614D (wild type [WT]) strain and variants of concern after the primary 2-dose and booster vaccination.

METHODS

Eighty-two patients with NSCLC and 53 healthy volunteers who received SARS-CoV-2 mRNA vaccines were included in the study. Blood was collected longitudinally, and SARS-CoV-2-specific binding and neutralizing antibody responses were evaluated by Meso Scale Discovery assay and live virus Focus Reduction Neutralization Assay, respectively.

RESULTS

A majority of patients with NSCLC generated binding and neutralizing antibody titers comparable with the healthy vaccinees after mRNA vaccination, but a subset of patients with NSCLC (25%) made poor responses, resulting in overall lower (six- to seven-fold) titers compared with the healthy cohort (P = < .0001). Although patients age > 70 years had lower immunoglobulin G titers (P = < .01), patients receiving programmed death-1 monotherapy, chemotherapy, or a combination of both did not have a significant impact on the antibody response. Neutralizing antibody titers to the B.1.617.2 (Delta), B.1.351 (Beta), and in particular, B.1.1.529 (Omicron) variants were significantly lower (P = < .0001) compared with the 614D (WT) strain. Booster vaccination led to a significant increase (P = .0001) in the binding and neutralizing antibody titers to the WT and Omicron variant. However, 2-4 months after the booster, we observed a five- to seven-fold decrease in neutralizing titers to WT and Omicron viruses.

CONCLUSION

A subset of patients with NSCLC responded poorly to the SARS-CoV-2 mRNA vaccination and had low neutralizing antibodies to the B.1.1.529 Omicron variant. Booster vaccination increased binding and neutralizing antibody titers to Omicron, but antibody titers declined after 3 months. These data highlight the concern for patients with cancer given the rapid spread of SARS-CoV-2 Omicron variant.

Study Protocol: Efficacy and Safety of Radioembolization (REM) as an Early Modality (EM) Therapy for Metastatic Breast Cancer (BR) to the Liver with Y90 (REMEMBR Y90)

PURPOSE

The primary objective of the REMEMBR Y90 study is to evaluate the efficacy of Yttrium-90 (Y90) radioembolization in patients with breast cancer metastases to the liver as a 2nd or 3rd line treatment option with systemic therapy by assessing liver-specific and overall progression-free survival. Secondary objectives include quality of life, overall survival benefit, and toxicity in relation to patients' tumor biology.

MATERIALS AND METHODS

This trial is a multi-center, prospective, Phase 2, open-label, IRB-approved, randomized control trial in the final phases of activation. Eligible patients include those over 18 years of age with metastatic breast cancer to the liver with liver-only or liver-dominant disease, and history of tumor progression on 1-2 lines of chemotherapy. 60 patients will be randomized to radioembolization with chemotherapy versus chemotherapy alone. Permissible regimens include capecitabine, eribulin, vinorelbine, and gemcitabine within 2 weeks of enrollment for every patient. Patients receiving radioembolization will receive lobar or segmental treatment within 1-6 weeks of enrollment depending on their lesion. After final radioembolization, patients will receive clinical and imaging follow-up every 12-16 weeks for two years, including contrast-enhanced computed tomography or magnetic resonance imaging of the abdomen and whole-body positron emission tomography/computed tomography.

DISCUSSION

This study seeks to elucidate the clinical benefit and toxicity of Y90 in patients with metastatic breast cancer to the liver who are receiving minimal chemotherapy. Given previous data, it is anticipated that the use of Y90 and chemotherapy earlier in the metastatic disease course would improve survival outcomes and reduce toxicity.

LEVEL OF EVIDENCE

Level 1b, Randomized Controlled Trial.

TRIAL REGISTRATION NUMBER

NCT05315687 on clinicaltrials.gov.

Abstract 3678: Drivers of racial, regional, and socioeconomic disparities in metastatic breast cancer mortality

Despite an overall decline in breast cancer (BC) mortality due to advancements in cancer therapy, mortality disparities by race, rurality, and socioeconomic status (SES) persist among women diagnosed with metastatic disease in the US. Women residing in high-poverty or rural areas or who are non-Hispanic Black (NHB) experience higher rates of BC mortality relative to their counterparts. Although mortality disparities among late-stage BC patients are well-documented, few studies have examined the drivers of these disparities, which are likely multifactorial. We sought to identify tumor, treatment, and patient characteristics that may contribute to differences in BC mortality by race, rurality, and SES among women diagnosed with a first primary stage IIIB - IV BC in Georgia.Using the Georgia Cancer Registry, we identified 3085 patients with an initial diagnosis of stage IIIB-IV primary BC between January 2013 and December 2017. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) to compare NHB vs. non-Hispanic White (NHW), rural vs. urban residents, and residents of low- vs. high-SES neighborhoods by tumor (stage, grade, ER status, and molecular subtype), treatment (surgery type, receipt of chemotherapy, radiation, hormonal, neoadjuvant, and immunotherapy), and patient (race, insurance, age group, marital status, region, SES) characteristics. Using an extension of the counterfactual framework, we estimated the mediating effects of subtype, stage, SES, rurality, and insurance on the association between race and BC mortality. Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. Overall, we observed mortality disparities by race (HR=1.27, 95% CI: 1.13, 1.41) and rurality (HR=1.14, 95% CI: 1.00, 1.30), but not by SES (HR=1.04, 95% CI: 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR=2.30, 95% CI: 1.53, 3.45). Residing in a rural neighborhood was associated with increased mortality among uninsured women (HR=2.25, 95% CI: 1.31, 3.86) or receipt of breast-conserving surgery (HR=2.21, 95 CI%: 1.32, 3.71). The most pronounced socioeconomic disparities were among younger women (&lt;40 years: HR=1.46, 95% CI: 0.88, 2.42) and patients who received neoadjuvant therapy (HR=1.44, 95% CI: 1.01, 2.05). The mediation analysis demonstrated that 48% of the effect between race and BC mortality was mediated by subtype.There is considerable variation in racial, regional, and socioeconomic disparities in metastatic BC mortality by tumor, treatment, and patient characteristics. For each, we’ve identified patient groups where disparities are most pronounced. Understanding specific barriers within these patient groups will inform future interventions aimed at reducing disparities in metastatic BC mortality.

Citation Format: Leah Moubadder, Lindsay J. Collin, Rebecca Nash, Jeffrey Switchenko, Jasmine Miller-Kleinhenz, Keerthi Gogineni, Kevin C. Ward, Lauren E. McCullough. Drivers of racial, regional, and socioeconomic disparities in metastatic breast cancer mortality [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3678.

Abstract 3672: Area-level drivers of the breast cancer mortality race disparity in Georgia

In the US, breast cancer mortality is 40% greater among Black than White women. The mortality disparity varies geographically and has persisted despite improvements in survival. Georgia is one of six states where breast cancer recently surpassed lung cancer as the leading cause of cancer death among Black but not White women, is a large and diverse state, and thus, an ideal setting to study race disparities. Our work in the Atlanta Metro area has shown that the mortality disparity is pronounced among patients with clinically favorable subtypes, low Oncotype DX® recurrence scores, guideline-concordant care, and similar access to surgical facilities. The disparity also persists among patients with private insurance and those living in areas of low poverty, suggesting clinical and sociodemographic differences do not fully account for the observed disparity. Recent evidence suggests area-level factors may contribute to the disparity. Our group reported that neighborhood-level redlining (i.e., mortgage denial based on place) is associated with an increase in breast cancer mortality while neighborhood-level lending bias (i.e., mortgage denial based on race) is associated with a decrease in breast cancer mortality. In Atlanta, Black patients are more likely to live in redlined areas and less likely to live in areas with lending bias, than White patients, further suggesting place is an important driver of disparities. We investigated the role of other area-level factors on race-specific mortality in Georgia. Race-specific standardized mortality ratios were computed for each county in Georgia. Observed breast cancer deaths among non-Hispanic White (NHW) and non-Hispanic Black (NHB) women within 5 years of a stage I-III breast cancer diagnosis (2005-2013) were obtained from the Georgia Cancer Registry. County-level characteristics were derived from the American Community Survey and Georgia Department of Public Health. A Bayesian model-based approach was used to stabilize local estimates and estimate associations with area-level factors. Smoothed estimates of relative disparity ranged from 1.2 to 1.7, with pronounced disparity for counties surrounding the Atlanta and Savannah metropolitan areas and least pronounced disparity in Metro Albany counties. Among NHB women, living in a rural (versus non-rural) county was associated with a nearly 20% increase in breast cancer mortality (RR=1.19, 95% credible interval (CI): 0.96, 1.48); an association not observed in NHW patients (RR=0.93, 95% CI: 0.79, 1.07). In contrast, a 10-point increase in the percent of adults with ≤high school education was associated with a 10% increase (95% CI: 1.05, 1.17) in mortality for NHW patients only. The race disparity in Georgia is not evenly distributed across counties. We identified area-level characteristics associated with race-specific mortality. Identifying other area-level drivers of breast cancer mortality is an important area of inquiry.

Citation Format: Rebecca Nash, Lindsay J. Collin, Jeffrey Switchenko, Lauren E. McCullough. Area-level drivers of the breast cancer mortality race disparity in Georgia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3672.

Therapeutic Misconception about Research Procedures: Does a Simple Information Chart Improve Understanding?

In phase I trials, some biospecimens are used both for research and patient care and some for research only. Some research participants have therapeutic misconception, assuming all biospecimens are for patient care. This study's aim was to test if a simple information chart would improve understanding of nontherapeutic research procedures. A two-arm study was conducted. Participants in the control group (C) were asked whether biospecimens were for their care, for research only, or for both. The experimental group (E) was asked the same questions but provided with a study-specific information chart labeling the purpose of each biospecimen. One hundred one patients were interviewed. In both arms, understanding that pretreatment blood draws were for patient care and research was moderate (49% for C and 62% for E). Understanding that posttreatment blood draws were for research only was significantly higher in the experimental arm (16% for C and 44% for E; p = 0.002). Providing a simple information chart may help alleviate this aspect of therapeutic misconception.

Postoperative Surgical Site Infection Rate in Patients with Diabetes following Mohs Micrographic Surgery: A Retrospective Analysis

BACKGROUND

Incidence of surgical site infection (SSI) following Mohs micrographic surgery (MMS) among patients with diabetes is largely unknown.

OBJECTIVE

Evaluate diabetes as a potential SSI risk factor in MMS by comparing SSI incidence in a cohort of patients with and without diabetes.

METHODS

5-year retrospective review to determine SSI rate in patients with diabetes compared to patients without diabetes. SSI incidence in patients with diabetes was further compared by A1c, and the impact of antibiotics on SSI rate was also examined.

RESULTS

Overall rate of SSI was 1.47% (53/3,597 cases). SSI rate among patients with diabetes was 1.95% (14/719 cases) compared to 1.35% (39/2,878 cases) in patients without diabetes, with a non-significant odds ratio for SSI of 1.45 (95% CI = 0.78-2.68, p = 0.241). Multivariable logistic regression analysis revealed no difference in SSI. Stratification of diabetic patients by A1c into ≥7.0 and <7.0 compared to patients without diabetes yielded no statistically significant difference in SSI among all groups (p = 0.815). Whether an antibiotic was prescribed did not significantly impact SSI rate between groups.

CONCLUSION

No significant difference in postoperative SSI was found in patients with diabetes compared to patients without diabetes following MMS regardless of degree of glycemic control.

Antibody response to SARS-CoV-2 mRNA vaccine in lung cancer patients: Reactivity to vaccine antigen and variants of concern

PURPOSE

We investigated SARS-CoV-2 mRNA vaccine-induced binding and live-virus neutralizing antibody response in NSCLC patients to the SARS-CoV-2 wild type strain and the emerging Delta and Omicron variants.

METHODS

82 NSCLC patients and 53 healthy adult volunteers who received SARS-CoV-2 mRNA vaccines were included in the study. Blood was collected longitudinally, and SARS-CoV-2-specific binding and live-virus neutralization response to 614D (WT), B.1.617.2 (Delta), B.1.351 (Beta) and B.1.1.529 (Omicron) variants were evaluated by Meso Scale Discovery (MSD) assay and Focus Reduction Neutralization Assay (FRNT) respectively. We determined the longevity and persistence of vaccine-induced antibody response in NSCLC patients. The effect of vaccine-type, age, gender, race and cancer therapy on the antibody response was evaluated.

RESULTS

Binding antibody titer to the mRNA vaccines were lower in the NSCLC patients compared to the healthy volunteers (P=<0.0001). More importantly, NSCLC patients had reduced live-virus neutralizing activity compared to the healthy vaccinees (P=<0.0001). Spike and RBD-specific binding IgG titers peaked after a week following the second vaccine dose and declined after six months (P=<0.001). While patients >70 years had lower IgG titers (P=<0.01), patients receiving either PD-1 monotherapy, chemotherapy or a combination of both did not have a significant impact on the antibody response. Binding antibody titers to the Delta and Beta variants were lower compared to the WT strain (P=<0.0001). Importantly, we observed significantly lower FRNT50 titers to Delta (6-fold), and Omicron (79-fold) variants (P=<0.0001) in NSCLC patients.

CONCLUSIONS

Binding and live-virus neutralizing antibody titers to SARS-CoV-2 mRNA vaccines in NSCLC patients were lower than the healthy vaccinees, with significantly lower live-virus neutralization of B.1.617.2 (Delta), and more importantly, the B.1.1.529 (Omicron) variant compared to the wild-type strain. These data highlight the concern for cancer patients given the rapid spread of SARS-CoV-2 Omicron variant.

Single-route CNS prophylaxis for aggressive non-Hodgkin lymphomas: real-world outcomes from 21 US academic institutions

Prophylaxis is commonly used to prevent central nervous sy stem (CNS) relapse in diffuse large B-cell lymphoma (DLBCL), with no clear standard of care. We retrospectively evaluated 1162 adult patients across 21 US academic centers with DLBCL or similar histologies who received single-route CNS prophylaxis as part of frontline therapy between 2013 and 2019. Prophylaxis was administered intrathecally(IT) in 894 (77%) and using systemic high-dose methotrexate (HD-MTX) in 236 (20%); 32 patients (3%) switched route due to toxicity and were assessed separately. By CNS-International Prognostic Index (IPI), 18% were considered low-risk, 51% moderate, and 30% high. Double-hit lymphoma (DHL) was confirmed in 243 of 866 evaluable patients (21%). Sixty-four patients (5.7%) had CNS relapse after median 7.1 months from diagnosis, including 15 of 64 (23%) within the first 6 months. There was no significant difference in CNS relapse between IT and HD-MTX recipients (5.4% vs 6.8%, P = .4), including after propensity score matching to account for differences between respective recipient groups. Weighting by CNS-IPI, expected vs observed CNS relapse rates were nearly identical (5.8% vs 5.7%). Testicular involvement was associated with high risk of CNS relapse (11.3%) despite most having lower CNS-IPI scores. DHL did not significantly predict for CNS relapse after single-route prophylaxis, including with adjustment for treatment regimen and other factors. This large study of CNS prophylaxis recipients with DLBCL found no significant difference in CNS relapse rates between routes of administration. Relapse rates among high-risk subgroups remain elevated, and reconsideration of prophylaxis strategies in DLBCL is of critical need.

Abstract PO-173: Spatial heterogeneity and rural-urban differences in the Black-White breast cancer mortality disparity in Georgia

Introduction: Breast cancer mortality in the US is 40% higher among Black than White women. Even among patients with prognostically favorable tumors, disparities persist, suggesting clinical features do not fully account for mortality differences. Area-level factors (e.g., rurality) influence health outcomes and may explain spatial variation in mortality disparities. Rurality can impact access to and quality of care, and socioeconomic status. Georgia is an ideal place to study spatial heterogeneity in race disparities because of the diverse population (&gt;30% Black), large number of counties (159), and pronounced disparities in breast cancer mortality in the Atlanta area. Methods: Race-specific standardized mortality ratios (SMRs) were calculated for each county in Georgia to account for sparsely populated areas and areas with high residential segregation. Observed deaths among women diagnosed with localized or regional breast cancer between 2005 and 2013 were obtained from the Georgia Cancer Registry. To ensure equal follow-up, only deaths within five years of diagnosis were included. Expected deaths were estimated using race-specific population counts, race-specific breast cancer incidence rates, and the pooled (Black and White) mortality rate among Georgia women, with indirect age adjustment (20–44, 45–54, 55+ years). Spatial smoothing methods, including adding neighboring data to meet a threshold and Bayesian models with conditionally autoregressive priors, were used to stabilize local estimates. Counties were classified by 2013 RUC codes (urban: 1–3, rural: 4–9). Results: A total of 3,235 breast cancer deaths were observed during the study period, with 42% among Black women. The median SMR was lower for White (0.8, IQR: 0.7, 1.1) than Black women (1.4, IQR: 1.1, 2.0). Among Black women only, median SMR was greater in rural (1.7, IQR: 1.1, 2.5) than urban counties (1.3, IQR: 1.1, 1.6). After sequentially adding neighboring data to meet a race-specific threshold of 30 observed deaths, smoothed median SMRs were 0.9 (IQR: 0.8, 0.9) and 1.4 (IQR: 1.2, 1.6) for White and Black women, respectively. For Black women, median SMR was attenuated in rural counties (1.4, IQR: 1.2, 1.7) but unchanged in urban counties (1.3, IQR: 1.2, 1.5). The greatest SMRs for Black women were observed in urban counties comprising the Atlanta area and rural southeast Georgia. For example, Fulton County SMRs were 1.6 and 0.7, for Black and White women, respectively. Highest SMRs for White women were observed in southwest Georgia, but were similar to SMRs among Black women in this region. The spatial distribution of SMRs using same neighbor smoothing and Bayesian models were similar. Conclusion: Breast cancer mortality race disparities vary widely across Georgia. These results highlight specific areas for public health intervention, especially among Black women. This work presents a potential mechanism to monitor trends in small area cancer mortality race disparities over time. Future work will model the impact of area-level factors on the disparity magnitude.

Citation Format: Rebecca J. Nash, Lauren E. McCullough, T.J. Pierce, Lindsay J. Collin, Anne H. Gaglioti, Kevin C. Ward, Michael Kramer, Jeffrey Switchenko. Spatial heterogeneity and rural-urban differences in the Black-White breast cancer mortality disparity in Georgia [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-173.

COVID-19 Pandemic-Associated Changes in the Acuity of Brain MRI Findings: A Secondary Analysis of Reports Using Natural Language Processing

Rationale and Objectives

We aimed to assess early COVID-19 pandemic-associated changes in brain MRI examination frequency and acuity of imaging findings acuity.

Methods

Using a natural language processing model, we retrospectively categorized reported findings of 12,346 brain MRI examinations performed during 6-month pre-pandemic and early pandemic time periods across a large metropolitan health system into 3 acuity levels: (1) normal or near normal; (2) incidental or chronic findings not requiring a management change; and (3) new or progressive findings requiring a management change. Brain MRI frequency and imaging finding acuity level were compared over time.

Results

Between March and August of 2019 (pre-pandemic) and 2020 (early pandemic), our health system brain MRI examination volumes decreased 17.0% (6745 vs 5601). Comparing calendar-matched 6-month periods, the proportion of higher acuity findings increased significantly (P< 0.001) from pre-pandemic (22.5%, 43.6% and 34.0% in acuity level 1, 2, and 3, respectively) to early pandemic periods (19.1%, 40.9%, and 40.1%). During the second 3 months of the early pandemic period, as MRI volumes recovered to near baseline, the proportion of higher acuity findings remained high (42.6% vs 34.1%) compared with a similar pre-pandemic period. In a multivariable analysis, Black (B coefficient, 0.16) and underinsured population (B coefficient, 0.33) presented with higher acuity findings (P< 0.05).

Conclusions

As the volume of brain MRI examinations decreased during the early COVID-19 pandemic, the relative proportion of examinations with higher acuity findings increased significantly. Pandemic-related changes in patient outcomes related to reduced imaging access merits further attention.

RADT-31. TREATMENT TRENDS AND SURVIVAL OUTCOMES IN ATYPICAL MENINGIOMA

BACKGROUND

WHO grade II (atypical) meningiomas are treated with surgical resection, often followed by adjuvant fractionated radiation therapy (FRT). The increased availability of frameless stereotactic radiosurgery (SRS) presents an opportunity to offer patients a high biological effective dose over fewer fractions. Here we study the patterns of care and outcomes of these two forms of adjuvant RT.

METHODS

Patients with atypical meningioma were abstracted from the National Cancer Database (NCDB). Descriptive statistics were reported, and differences between treatment groups were assessed using either a chi-square test or ANOVA. Patients were grouped by treatment type and Kaplan Meier (KM) analysis was performed to compare overall survival (OS) using a log rank test. Univariable (UVA) and multivariable (MVA) cox regression analyses were completed.

RESULTS

Of 10,015 cases diagnosed from 2004-2016, 7,153 received surgery alone, 2,059 received surgery and adjuvant FRT (S+RT), and 362 received adjuvant SRS (S+SRS). The use of adjuvant RT increased by 71.8% for S+RT and 97.8% for S+SRS. In 2004, 15.1% of 443 registered patients received S+RT and 2.26% received S+SRS, while in 2016 these figures were 26.0% and 4.47%, respectively, for the 1051 registered patients (p&lt; 0.001 and 0.022, respectively). For the 8,636 patients with survival data there was no significant difference in median OS between S+RT and S+SRS (130 months vs. 125 months, log rank p=0.935). On UVA, S+RT conferred better survival compared to surgery alone (HR 0.81 [0.72-0.91], p&lt; 0.001) while S+SRS trended towards better survival (HR 0.82 [0.64-1.06], p=0.124). On MVA, no significant OS benefit was seen with S+RT (HR 0.96 [0.85-1.08], p=0.491) or S+SRS (HR 0.90 [0.69-1.16], p=0.413) versus surgery alone.

CONCLUSIONS

While the use of adjuvant RT for atypical meningioma has increased substantially since 2004, OS is comparable between FRT and SRS. The data presented here support further prospective investigation of adjuvant SRS.

Physician Communication and Patient Understanding of Molecular Testing Terminology

BACKGROUND

The use of molecular testing in oncology is rapidly expanding. The aim of this study was to determine how oncologists describe molecular testing and whether patients understand the terminology being used.

MATERIALS AND METHODS

Sixty conversations between oncologists and patients about molecular testing were observed, and the used technical terms were noted by the researcher. Patients were interviewed post-conversation to assess their understanding of the noted technical terms. A patient understanding score was calculated for each participant. Comparisons of the terms were conducted using χ² tests, Fisher's exact tests, or ANOVA when appropriate.

RESULTS

Sixty-one unique technical terms were used by oncologists, to describe seven topics. "Mutation" was a challenging term for patients to understand with 48.8% (21/43 mentions) of participants correctly defining the term. "Genetic testing" and "Gene" were understood a little more than half the time (53.3%; 8/15 and 56.4%; 22/39 respectively). "DNA" was well understood (80%; 12/15). There was no correlation between the terms being defined by the oncologist in the conversation, and the likelihood of the patient providing a correct definition. White participants were significantly more likely to understand both "mutation" and "genetic testing" than non-White participants. Forty-two percent (n = 25) of participants had an understanding score below 50%, and a higher family income was significantly correlated with a higher score.

CONCLUSION

Our results show that oncologists use variable terminology to describe molecular testing, which is often not understood. Because oncologists defining the terms did not correlate with understanding, it is imperative to develop new, improved methods to explain molecular testing.

IMPLICATIONS FOR PRACTICE

The use of molecular testing is expanding in oncology, yet little is known about how effectively clinicians are communicating information about molecular testing and whether patients understand the terminology used. The results of this study indicate that patients do not understand some of the terminology used by their clinicians and that clinicians tend to use highly variable terminology to describe molecular testing. These results highlight the need to develop and implement effective methods to explain molecular testing terminology to patients to ensure that patients have the tools to make autonomous and informed decisions about their treatment.

Improved Progression-Free Survival for Bulky and Non-Bulky Advanced Stage Diffuse Large B-Cell Lymphoma With Consolidative Radiation Therapy: A Bi-Institutional Analysis

Background The role of consolidative radiation therapy (RT) for advanced-stage diffuse large B-cell lymphoma (DLBCL) is not fully established. A growing body of data suggests a role for consolidative RT in select stage III-IV DLBCL patients and emerging data from randomized studies further address the role of RT in advanced-stage patients initially presenting with bulky disease. Methods Patients with treatment-naive stage III-IV DLBCL treated at two institutions who achieved a clinically complete response to systemic therapy were included. Patients with either bulky or non-bulky disease were included, but those with the relapsed or refractory disease were excluded. Kaplan-Meier analysis was performed to determine the impact of consolidative RT. Univariate and multivariable analyses were performed using a Cox proportional hazards model. Results One hundred eighty-eight patients received systemic therapy consisting of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; 79%), another rituximab-based regimen (9%), or chemotherapy alone (12%). Clinical response was assessed using conventional CT or PET-CT. Sixty-eight patients (36%) received consolidative RT (median dose 30 Gy). Consolidative RT conferred a 36.7% absolute benefit in five-year progression-free survival (PFS; 85.9% vs. 49.2%, log rank p < 0.0001), a 14.5% absolute benefit in five-year overall survival (OS; 87.4% vs. 72.9%, log rank p = 0.0134), and a 37.0% absolute benefit in five-year LC (91.9% vs. 54.9%, log rank p < 0.0001). On multivariable analysis, consolidative RT was associated with improved PFS (HR 0.23, 95% CI 0.10-0.52, p < 0.001) and LC (HR 0.20, 95% CI 0.07-0.59, p = 0.003). Patients receiving consolidative RT demonstrated significantly improved PFS for tumors measuring both <5 cm (log rank p = 0.0454) and ≥5 cm (log rank p = 0.0003). Conclusions For patients with stage III-IV DLBCL who achieve clinical complete response after systemic therapy, consolidative RT improves PFS for all patients, including those with the non-bulky disease. This benefit persists in the setting of rituximab-based systemic therapy.

Impact of Metastasectomy and Aggressive Local Therapy in Newly Diagnosed Metastatic Soft Tissue Sarcoma: An Analysis of the NCDB

BACKGROUND

The optimal management of patients with stage IV soft tissue sarcoma of the extremity (STSE) with distant metastases at diagnosis is unclear due to limited evidence and heterogeneity of current practice patterns. National guidelines have recommended surgical management of the primary site (SP) with or without radiotherapy (R), chemotherapy (C), and metastasectomy (M).

METHODS

In the National Cancer Database (NCDB), patients with initially metastatic STSE who received definitive SP from 2004 to 2014 were identified. Survival distributions were estimated and compared using the Kaplan-Meier method and log-rank tests, and covariates were compared using Chi-square tests or analysis of variance (ANOVA). Propensity score analysis using inverse probability of treatment weighting was used.

RESULTS

Overall, 1124 patients were included, with a median age of 55 years (range 18-90). Utilization of SP+M increased over time from 18.8% in 2004-2006, to 33.3% in 2007-2009, to 47.9% in 2010-2014 (p = 0.024). The addition of M to SP was associated with superior 5-year overall survival (OS) at 30.8% (SP+M+/-C+/-R) compared with 18.2% for those treated with non-surgical adjuvant therapies (SP+/-C+/-R) and 12.6% for SP alone (p < 0.0001). Positive surgical margins were noted in 24.1% of patients and was associated with worse OS (hazard ratio 1.44, p < 0.001) on multivariable analysis.

CONCLUSIONS

This is the first known study utilizing a large database to explore practice patterns and outcomes for patients with metastatic STSE receiving definitive SP. Utilization of metastasectomy increased in the study period and was associated with longer survival compared with SP alone. These hypothesis-generating data warrant additional study.

Correlates of financial toxicity in adult cancer patients and their informal caregivers

BACKGROUND

Financial toxicity is commonly reported by cancer patients, but few studies have assessed caregiver perceptions. We aimed to validate the modified Comprehensive Score for Financial Toxicity (COST) in cancer caregivers, identify factors associated with financial toxicity in both patients and caregivers, and assess the association of caregiver financial toxicity with patient and caregiver outcomes.

METHODS

Using a convenience sampling method, 100 dyads of adult cancer patients and a primary caregiver visiting outpatient oncology clinics (Jan-Sep 2019) were recruited. We assessed the internal consistency and convergent and divergent validity of the modified COST. Multivariable analyses identified correlates of financial toxicity. Association of financial toxicity with care non-adherence, lifestyle-altering behaviors (e.g., home refinance/sale, retirement/saving account withdrawal), and quality of life (QOL) was investigated.

RESULTS

Recruited patient vs. caregiver characteristics were as follows: mean age: 60.6 vs. 56.5; 34% vs. 46.4% female; 79% vs. 81.4% white. The caregiver COST measure demonstrated high internal consistency (Cronbach α = 0.91). In patients, older age (B, 0.3 [95% CI, 0.1-0.4]) and higher annual household income (B, 14.3 [95% CI, 9.3-19.4]) correlated with lower financial toxicity (P < 0.05). In caregivers, lower patient financial toxicity (B, 0.4 [95% CI, 0.2-0.6]) and cancer stages 1-3 (compared to stage 4) (B, 4.6 [95% CI, 0.4-8.8]) correlated with lower financial toxicity (P < 0.05). Increased caregiver financial toxicity correlated with higher care non-adherence in patients, increased lifestyle-altering behaviors, and lower QOL in patients and caregivers (P < 0.05).

CONCLUSION

The COST measure can also be used to assess caregiver financial toxicity. Caregivers' financial toxicity was associated with negative outcomes for both dyad members.

Evaluating the impact of the Patient Preference Assessment Tool on clinicians' recommendations for phase I oncology clinical trials

OBJECTIVE

Many groups recommend assessment of patient preferences particularly for patients with advanced, incurable cancer. We, therefore, developed the Patient Preference Assessment Tool (PPAT) to ascertain patient preferences in order to inform clinician recommendations and improve shared decision-making. The aim of this study is to assess the PPAT's impact on clinicians' strength of recommendations for phase I oncology clinical trials.

METHODS

Clinicians recorded the strength of their recommendation on a Likert scale before viewing the patient's PPAT. After viewing the PPAT, the clinician discussed the clinical trial with the patient and then recorded the strength of recommendation again. If there was a change, the clinician noted the reason for the change: clinical findings or patient preference. Clinicians were interviewed about the acceptability of the tool. Our threshold for determining if a change in recommendation due to the PPAT was significant was 20%, given the multiple factors influencing a clinician's recommendation. We also noted the type of phase I conversation observed based on classifications defined in prior work-priming, treatment-options, trial logistics, consent.

RESULTS

N = 29. The strength of the clinicians' recommendations changed due to patient preferences in 7 of 29 (24%) of the conversations. The seven changes due to preferences were all in the 23 treatment-options conversations, for an impact rate of 30% in this type of conversation. 82% of clinicians found the PPAT useful.

CONCLUSION

The PPAT was impactful in an academic setting, exceeding our 20% impact threshold. This tool helps achieve the important goal of incorporating patient preferences into shared decision-making about clinical trials.

Longitudinal changes of financial hardship in patients with multiple sclerosis

OBJECTIVE

To measure the longitudinal changes in three domains of financial hardship (i.e., financial worry, cost-related care non-adherence, material hardship) in patients with MS.

METHODS

A convenience sample of 559 adult patients with a known diagnosis of MS visiting a single outpatient neurology clinic between July 2018 to February 2020 were approached. Patients completed surveys at baseline and 3, 6, 9, and 12 months post-enrollment. Outcomes included financial worry (using Comprehensive Score for Financial Toxicity Patient-Reported Outcome (COST)), cumulative cost-related care non-adherence, and cumulative financial hardship as adopted by Medical Expenditure Panel Survey (MEPS). Associations of financial worry with care non-adherence and material hardship were assessed using ANOVA.

RESULTS

A total of 242 (43.3%) participated at baseline. Mean age was 43.6 ± 13.6 years (76.9% female; 46.4% White); median months from diagnosis was 63 (IQR, 28-120). The mean COST score at enrollment was 17.43 (± 10.15) and increased to 19.41 (± 11.12) at 12 months (p = 0.09). Cumulative cost-related MS care non-adherence increased from 32.6% at baseline to 53.3% at 12 months (20.7% increase; p <0.001). Cumulative material hardship increased from 61.6% at baseline to 76.0% at 12 months (14.4% increase; p<0.001). Changes in COST score from baseline to 12 months were significantly associated with changes in non-adherence and material hardship (p<0.01).

CONCLUSION AND RELEVANCE

Cost-related care non-adherence and material hardship accumulate progressively over time and correlates with financial worry. Clinical practices should focus on screening those at risk and intervene with the goal of mitigating costs of care and improving patient outcomes.

Platelet-derived growth factor beta is a potent inflammatory driver in paediatric high-grade glioma

Paediatric high-grade gliomas (HGGs) account for the most brain tumour-related deaths in children and have a median survival of 12-15 months. One promising avenue of research is the development of novel therapies targeting the properties of non-neoplastic cell-types within the tumour such as tumour associated macrophages (TAMs). TAMs are immunosuppressive and promote tumour malignancy in adult HGG; however, in paediatric medulloblastoma, TAMs exhibit anti-tumour properties. Much is known about TAMs in adult HGG, yet little is known about them in the paediatric setting. This raises the question of whether paediatric HGGs possess a distinct constituency of TAMs because of their unique genetic landscapes. Using human paediatric HGG tissue samples and murine models of paediatric HGG, we demonstrate diffuse midline gliomas possess a greater inflammatory gene expression profile compared to hemispheric paediatric HGGs. We also show despite possessing sparse T-cell infiltration, human paediatric HGGs possess high infiltration of IBA1+ TAMs. CD31, PDGFRβ, and PDGFB all strongly correlate with IBA1+ TAM infiltration. To investigate the TAM population, we used the RCAS/tv-a system to recapitulate paediatric HGG in newborn immunocompetent mice. Tumours are induced in Nestin-positive brain cells by PDGFA or PDGFB overexpression with Cdkn2a or Tp53 co-mutations. Tumours driven by PDGFB have a significantly lower median survival compared to PDGFA-driven tumours and have increased TAM infiltration. NanoString and quantitative PCR analysis indicates PDGFB-driven tumours have a highly inflammatory microenvironment characterized by high chemokine expression. In vitro bone marrow-derived monocyte and microglial cultures demonstrate bone marrow-derived monocytes are most responsible for the production of inflammatory signals in the tumour microenvironment in response to PDGFB stimulation. Lastly, using knockout mice deficient for individual chemokines, we demonstrate the feasibility of reducing TAM infiltration and prolonging survival in both PDGFA and PDGFB-driven tumours. We identify CCL3 as a potential key chemokine in these processes in both humans and mice. Together, these studies provide evidence for the potent inflammatory effects PDGFB has in paediatric HGGs.

The Impact of Genetic Counseling Educational Tools on Patients' Knowledge of Molecular Testing Terminology

Molecular testing is increasingly being integrated into cancer management. Despite rapid advancements, little work has been done to explore strategies for communicating with patients undergoing molecular tumor testing. This study evaluated the impact of genetic counseling educational tools on improving patients' understanding of key terms related to molecular testing. A genetic counseling intern designed a picture book to explain six words found in prior research to be difficult to understand (mutation, germline mutation, somatic mutation, biomarker, molecular testing, and targeted therapy). Participants who had previously discussed molecular testing with their oncologist were asked to define the terms. The same participants then received an explanation of each term either from the intern using the picture book in person or from a video presentation of the picture book. They were then asked to redefine each term afterward. The difference between the number of terms defined correctly pre- and post-intervention was compared between presentations. Sixty-three patients with melanoma, colon, lung, or breast cancer were recruited. After both interventions, correct understanding rates improved for all six terms, with significant improvement for germline mutation (p < 0.001), somatic mutation (p < 0.001), biomarker (p < 0.001), and molecular testing (p < 0.001). Understanding of targeted therapy improved significantly (p = 0.011) for the video presentation only. Mean change in knowledge scores did not differ between the two interventions (intern presentation 3.2 vs. video 2.9, p = 0.428). Our data suggest that genetic counseling educational tools can increase patient understanding of terms used to describe molecular testing.

Patient-reported financial toxicity in multiple sclerosis: Predictors and association with care non-adherence

BACKGROUND

Multiple sclerosis (MS) results in considerable financial burdens due to expensive treatment and high rates of disability, which could both impact care non-adherence.

OBJECTIVE

To measure financial toxicity in MS patients, identify its predictors and association with care non-adherence.

METHODS

Adult MS patients visiting neurology clinic (June 2018 to February 2019) were consented to complete a survey. Financial toxicity was measured using Comprehensive Score for Financial Toxicity (COST) (range: 0-44, the lower the score, the worse the financial toxicity). Independent predictors of financial toxicity were identified using linear regression. Associations of COST score with patient outcomes were assessed.

RESULTS

The mean COST score in 243 recruited patients was 17.4 ± 10.2. In response to financial burdens, 66.7% and 34.7% reported life-style altering behaviors or care non-adherence, respectively. Higher financial self-efficacy was associated with less financial toxicity (coefficient, 1.33 (95% confidence interval (CI), 1.02-1.64); p < 0.001). At least one relapse in the last 3 months was associated with greater financial toxicity (coefficient, -3.34 (95% CI, -6.66 to -0.01); p = 0.049). Greater financial toxicity correlated with life-style-altering coping strategy use (p < 0.001), care non-adherence (p = 0.001), and worse health-related quality of life (HRQOL) (p = 0.03).

CONCLUSION

MS patients with lower financial self-efficacy and prior relapse history are at higher risk for financial toxicity, with associated care non-adherence and lower HRQOL.

Risk of bacteremia in patients with cutaneous T-cell lymphoma (CTCL)

Patients with CTCL are at increased risk for bacteremia which is a leading cause of morbidity and mortality. We assessed risk factors for and the impact of bacteremia on survival in a retrospective cohort of 188 CTCL patients at a single US academic institution treated between 1990 and 2018. With a median follow up of 6.2 years, 20% of patients (n = 36) developed 79 bacteremia events. Risk factors for bacteremia included advanced stage, female gender, African American (AA) race, invasive lines, and chemotherapy. Bacteremia was associated with an increased risk of death on univariate and multivariable models. Bacteremia is associated with an increased risk of death in patients with CTCL. The greatest avoidable risk factors included chemotherapy treatment and presence of an invasive line. Key points 20% of patients developed bacteremia at any point in time in this analysis. Bacteremia is associated with an increased risk of death in patients with CTCL Risk factors for bacteremia include advanced stage, female gender, AA race, invasive line, and chemotherapy.

Genomic copy number variation correlates with survival outcomes in WHO grade IV glioma

Allele-specific copy number analysis of tumors (ASCAT) assesses copy number variations (CNV) while accounting for aberrant cell fraction and tumor ploidy. We evaluated if ASCAT-assessed CNV are associated with survival outcomes in 56 patients with WHO grade IV gliomas. Tumor data analyzed by Affymetrix OncoScan FFPE Assay yielded the log ratio (R) and B-allele frequency (BAF). Input into ASCAT quantified CNV using the segmentation function to measure copy number inflection points throughout the genome. Quantified CNV was reported as log R and BAF segment counts. Results were confirmed on The Cancer Genome Atlas (TCGA) glioblastoma dataset. 25 (44.6%) patients had MGMT hyper-methylated tumors, 6 (10.7%) were IDH1 mutated. Median follow-up was 36.4 months. Higher log R segment counts were associate with longer progression-free survival (PFS) [hazard ratio (HR) 0.32, p < 0.001], and overall survival (OS) [HR 0.45, p = 0.01], and was an independent predictor of PFS and OS on multivariable analysis. Higher BAF segment counts were linked to longer PFS (HR 0.49, p = 0.022) and OS (HR 0.49, p = 0.052). In the TCGA confirmation cohort, longer 12-month OS was seen in patients with higher BAF segment counts (62.3% vs. 51.9%, p = 0.0129) and higher log R (63.6% vs. 55.2%, p = 0.0696). Genomic CNV may be a novel prognostic biomarker for WHO grade IV glioma patient outcomes.