Site-specific patterns of early-stage cancer diagnosis during the COVID-19 pandemic

The COVID-19 pandemic caused widespread disruptions in cancer care. We hypothesized that the greatest disruptions in diagnosis occurred in screen-detected cancers. We identified patients (≥18 years of age) with newly diagnosed cancer from 2019 to 2020 in the US National Cancer Database and calculated the change in proportion of early-stage to late-stage cancers using a weighted linear regression. Disruptions in early-stage diagnosis were greater than in late-stage diagnosis (17% vs 12.5%). Melanoma demonstrated the greatest relative decrease in early-stage vs late-stage diagnosis (22.9% vs 9.2%), whereas the decrease was similar for pancreatic cancer. Compared with breast cancer, cervical, melanoma, prostate, colorectal, and lung cancers showed the greatest disruptions in early-stage diagnosis. Uninsured patients experienced greater disruptions than privately insured patients. Disruptions in cancer diagnosis in 2020 had a larger impact on early-stage disease, particularly screen-detected cancers. Our study supports emerging evidence that primary care visits may play a critical role in early melanoma detection.

Racial Disparities in 30-day Readmissions after Surgery for Head and Neck Cancer

BACKGROUND

Native Hawaiians and other Pacific Islanders (NHPI) patients with head and neck cancer are often aggregated with Asian individuals despite evidence of heterogeneous health outcomes and mortality. The aim of this study was to determine the association of race with unplanned 30-day hospital readmission rate after head and neck surgery across the five federally recognized racial categories.

METHODS

This retrospective cohort study used a national hospital-based database and included patients ≥18 years old with diagnostically confirmed, nonmetastatic head and neck cancer of any subsite treated surgically between 2004 and 2017. The primary endpoint was unplanned readmission within 30 days of discharge after primary surgery.

RESULTS

A total of 365,834 patients were included who were predominantly White (87%), treated at academic cancer centers (47%), lower income (63%), with early-stage disease (60%), and with thyroid (47%) or oral cavity (23%) cancers. Median follow-up duration was 47 months. Of the 10,717 (3%) readmissions, 5,845 (1.6%) were unplanned. Adjusted for confounders and compared with White patients, NHPI patients had the highest likelihood of unplanned (aOR 2.07, 95%CI 1.16-3.40, p = 0.008) readmissions. Within the NHPI group, patients with lower income (aOR 4.27, 95%CI 1.28-20.4, p = 0.035) and those residing in an urban or rural area (aOR 7.42, 95%CI 1.14-49.5, p = 0.034) were more likely to be readmitted.

CONCLUSIONS

NHPI patients with head and neck cancers experience significantly higher 30-day readmissions following definitive surgical treatment. These results highlight the importance of racial disaggregation in clinical studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1282-1287, 2024.

Recombination map tailored to Native Hawaiians may improve robustness of genomic scans for positive selection

Recombination events establish the patterns of haplotypic structure in a population and estimates of recombination rates are used in several downstream population and statistical genetic analyses. Using suboptimal maps from distantly related populations may reduce the efficacy of genomic analyses, particularly for underrepresented populations such as the Native Hawaiians. To overcome this challenge, we constructed recombination maps using genome-wide array data from two study samples of Native Hawaiians: one reflecting the current admixed state of Native Hawaiians (NH map) and one based on individuals of enriched Polynesian ancestries (PNS map) with the potential to be used for less admixed Polynesian populations such as the Samoans. We found the recombination landscape to be less correlated with those from other continental populations (e.g. Spearman's rho = 0.79 between PNS and CEU (Utah residents with Northern and Western European ancestry) compared to 0.92 between YRI (Yoruba in Ibadan, Nigeria) and CEU at 50 kb resolution), likely driven by the unique demographic history of the Native Hawaiians. PNS also shared the fewest recombination hotspots with other populations (e.g. 8% of hotspots shared between PNS and CEU compared to 27% of hotspots shared between YRI and CEU). We found that downstream analyses in the Native Hawaiian population, such as local ancestry inference, imputation, and IBD segment and relatedness detections, would achieve similar efficacy when using the NH map compared to an omnibus map. However, for genome scans of adaptive loci using integrated haplotype scores, we found several loci with apparent genome-wide significant signals (|Z-score|> 4) in Native Hawaiians that would not have been significant when analyzed using NH-specific maps. Population-specific recombination maps may therefore improve the robustness of haplotype-based statistics and help us better characterize the evolutionary history that may underlie Native Hawaiian-specific health conditions that persist today.

The accuracy of polygenic score models for anthropometric traits and Type II Diabetes in the Native Hawaiian Population

Polygenic scores (PGS) are promising in stratifying individuals based on the genetic susceptibility to complex diseases or traits. However, the accuracy of PGS models, typically trained in European- or East Asian-ancestry populations, tend to perform poorly in other ethnic minority populations, and their accuracies have not been evaluated for Native Hawaiians. Using body mass index, height, and type-2 diabetes as examples of highly polygenic traits, we evaluated the prediction accuracies of PGS models in a large Native Hawaiian sample from the Multiethnic Cohort with up to 5,300 individuals. We evaluated both publicly available PGS models or genome-wide PGS models trained in this study using the largest available GWAS. We found evidence of lowered prediction accuracies for the PGS models in some cases, particularly for height. We also found that using the Native Hawaiian samples as an optimization cohort during training did not consistently improve PGS performance. Moreover, even the best performing PGS models among Native Hawaiians would have lowered prediction accuracy among the subset of individuals most enriched with Polynesian ancestry. Our findings indicate that factors such as admixture histories, sample size and diversity in GWAS can influence PGS performance for complex traits among Native Hawaiian samples. This study provides an initial survey of PGS performance among Native Hawaiians and exposes the current gaps and challenges associated with improving polygenic prediction models for underrepresented minority populations.

Rising From Ruin-Revitalizing Native Hawaiian Health

This Viewpoint offers insight into the health effects of the recent fires in Hawaiʻi and what culturally conscious approaches are needed to ensure the health of Native Hawaiians going forward.

MGMT Promoter Methylation Predicts Overall Survival after Chemotherapy for 1p/19q-Codeleted Gliomas

PURPOSE

While MGMT promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy and guides treatment decisions in glioblastoma, its role in grade 2 and 3 glioma remains unclear. Recent data suggest that mMGMT is prognostic of progression-free survival in 1p/19q-codeleted oligodendrogliomas, but an effect on overall survival (OS) has not been demonstrated.

EXPERIMENTAL DESIGN

We identified patients with newly diagnosed 1p/19q-codeleted gliomas and known MGMT promoter status in the National Cancer Database from 2010 to 2019. Multivariable Cox proportional hazards regression modeling was used to assess the effect of mMGMT on OS after adjusting for age, sex, race, comorbidity, grade, extent of resection, chemotherapy, and radiotherapy.

RESULTS

We identified 1,297 eligible patients, 938 (72.3%) of whom received chemotherapy in their initial course of treatment. The MGMT promoter was methylated in 1,009 (77.8%) patients. Unmethylated MGMT (uMGMT) was associated with worse survival compared with mMGMT [70% {95% confidence interval (CI), 64%-77%} vs. 81% (95% CI, 78%-85%); P < 0.001; adjusted HR (aHR), 2.35 (95% CI, 1.77-3.14)]. uMGMT was associated with worse survival in patients who received chemotherapy [63% (95% CI, 55-73%) vs. 80% (95% CI, 76%-84%); P < 0.001; aHR, 2.61 (95% CI, 1.89-3.60)] but not in patients who did not receive chemotherapy [P = 0.38; HR, 1.31 (95% CI, 0.71-2.42)]. Similar results were observed regardless of World Health Organization grade and after single- or multiagent chemotherapy.

CONCLUSIONS

Our study demonstrates an association between mMGMT and OS in 1p/19q-codeleted gliomas. MGMT promoter status should be considered as a stratification factor in future clinical trials of 1p/19q-codeleted gliomas that use OS as an endpoint.

Diversity in Cancer Care: Current Challenges and Potential Solutions to Achieving Equity in Clinical Trial Participation

ABSTRACT

Access to and participation in cancer clinical trials determine whether such data are applicable, feasible, and generalizable among populations. The lack of inclusion of low-income and marginalized populations limits generalizability of the critical data guiding novel therapeutics and interventions used globally. Such lack of cancer clinical trial equity is troubling, considering that the populations frequently excluded from these trials are those with disproportionately higher cancer morbidity and mortality rates. There is an urgency to increase representation of marginalized populations to ensure that effective treatments are developed and equitably applied. Efforts to ameliorate these clinical trial inclusion disparities are met with a slew of multifactorial and multilevel challenges. We aim to review these challenges at the patient, clinician, system, and policy levels. We also highlight and propose solutions to inform future efforts to achieve cancer health equity.

Building a Diverse Pathway into Radiation Oncology: The Initial 12-Year Experience of the ASTRO Medical Student Fellowship Program for Underrepresented Populations

PURPOSE/OBJECTIVE(S)

Historic radiation oncology (RO) workforce trends reveal underrepresentation and lack of inclusion of racial and ethnic groups underrepresented in medicine (UIM). In 2010, ASTRO's Healthcare Access and Training Subcommittee - the predecessor of today's Committee on Health Equity, Diversity, and Inclusion - launched the Medical Student Fellowship (MSF), which provides an 8-week clinical and research experience, ASTRO mentorship, and a $5,000 stipend. Here, we premier 12-year MSF outcomes to 1) characterize the cohort, 2) identify predictors of successfully awarded applicants, and 3) determine predictors for entering RO residency.

MATERIALS/METHODS

Demographic characteristics of MSF applicants were retrospectively analyzed. Primary endpoints were awarded MSF and RO match. Applicant data were collected from the ASTRO registry, MSF database, and online searches. Race, gender, medical school rank/region, mentor research center rank/region, application year, research type, RO residency affiliation, and award outcomes were collected. Descriptive statistics were tabulated. Univariable and multivariable logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for factors associated with MSF award receipt and matching into RO residency for those who applied via the Match.

RESULTS

Between 2010 and 2022, there were 101 MSF applicants (74 Clinical and 27 Basic Science) for a total of 39 available funded MSF awards, with an overall MSF award rate of 39%. Applicants were 62% Black, 32% Hispanic, 3% Asian, 1% American Indian or Alaska Native (AIAN), and 1% Native Hawaiian or other Pacific Islander (NHPI). Women comprised 42% of applicants and 51% of awardees. Awardees were 72% Black, 26% Hispanic, and 3% NHPI. By region, awardees were from medical schools in the South (44%), Northeast (31%), Midwest (18%), West (5%), and Caribbean (2%). Since 2010, among applicants, 63% matched into residency and 40% matched to RO. Among the 21 MSF awardees eligible for the Match, 13 (62%) pursued RO with 100% matched into RO. On adjusted analysis, no significant factors predicted a successful MSF application. However, among those who entered residency the only variable that predicted matching into RO was a successful MSF award (aOR = 4.1; 95% CI = 1.1-11.2). To date, MSF awardees who completed RO residency entered academic careers post-residency.

CONCLUSION

The first 12 years of the MSF program demonstrate an overall high rate of recruitment and retention into RO. Retention of women and recruitment of Indigenous students in the MSF are an unmet need. Future efforts and increased funding are needed to further expand the MSF program, understand student barriers, provide longitudinal engagement, train mentors, and increase recruitment and retention of UIM groups in the field.

A Large National Study on Racial Disparities among Asian American, Native Hawaiian, and Other Pacific Islander Cancer Patients Who Refuse Radiation Therapy and Surgery

PURPOSE/OBJECTIVE(S)

Asian Americans (AAs) are the only race for whom cancer is the leading cause of death in the US. Despite radiation therapy (RT) and surgery being curative treatments, prior work demonstrated AAs refuse RT/surgery at a higher rate than other races. Given AAs are often aggregated with Native Hawaiians and other Pacific Islanders (NHPIs), rates of RT/surgery refusal within this community are poorly understood. We aimed to 1) assess RT/surgery refusal on overall survival (OS) using propensity-score (PS) matched groups, 2) identify AA and NHPI populations that refuse RT/surgery and 3) determine predictors of refusing RT/surgery.

MATERIALS/METHODS

A US hospital-based retrospective cohort study of the National Cancer Database was conducted. Patients included were ≥18 years old, AA by ethnogeographic region (South AA, East AA, and Southeast AA) or NHPI race, with a confirmed diagnosis of 1 of the 10 most common US cancers during 2004-2017 who were recommended for RT/surgery. Cox proportional hazard models with adjusted Hazard Ratios (aHR) assessed propensity-score matched groups (1:10) based on age, race, cancer stage, comorbidity index, rurality, facility type, facility location, and year of diagnosis. Adjusted odds ratios (aOR) were calculated and 95% confidence intervals (95% CI) for treatment refusal using logistic regression. Population heterogeneity for treatment refusal by race was assessed with likelihood ratio tests (p-heterogeneity).

RESULTS

The cohort of 147,685 patients who met the inclusion criteria were predominantly East AA (43%), diagnosed with breast cancer (42%), and had a <2 comorbidity index (99%). Median age was 61 years. Median follow-up was 58 months. Overall, 2,888 (5%) patients refused RT, and 1,073 (1%) refused surgery. RT refusal by race was 5.7% (East AA), 7.9% (NHPI), 4.6% (South AA), and 4.6% (Southeast AA). Surgery refusal rates were 1.5% (East AA), 1.9% (NHPI), 1.1% (South AA) and 1.2% (Southeast AA). RT refusal significantly predicted poorer OS (aHR = 1.15, 95% CI = 1.06-1.25) whereas surgery refusal did not. Compared to East AA, NHPIs had a higher risk of RT refusal (aOR = 1.44, 95% CI = 1.27-1.62), whereas South AA (aOR = 0.85, 95% CI = 0.75-0.95) and Southeast AA (aOR = 0.82, 95% CI = 0.75-0.90) had a significantly lower risk (p-heterogeneity<.0001). Predictors of RT refusal were older patient age, high comorbidity index, oral cavity cancer, urban-rural residence, Midwest or West US region, and diagnosis 2011-2017.

CONCLUSION

Among AA and NHPI patients with cancers in the US, RT refusal predicted poorer OS. NHPI had the highest risk of RT refusal. Given AA and NHPI are not monolithic groups, data disaggregation is necessary to understand racial/ethnic disparities for treatment refusal. Sociocultural and historical contexts of AA and NHPI populations on treatment refusal are necessary to improve cancer outcomes among these populations.

Determining the Optimal Sequence of Immunotherapy and Lymph Node Irradiation among Patients with Cancer: A Propensity Score Matched Analysis

PURPOSE/OBJECTIVE(S)

Immunotherapy (IT) and lymph node irradiation (LNI) are essential cancer treatment modalities. In combination, the optimal sequence to enhance tumor response is poorly understood. While LNI depletes radiosensitive IT-related immune cells, LNI also provides an immunostimulatory effect by shedding tumor neoantigens in the microenvironment. Here we aim to 1) assess IT and LNI sequence patterns among patients with common cancers, 2) evaluate propensity score (PS) matched overall survival (OS) between IT first and LNI first treatments, and 3) compare OS by cancer site.

MATERIALS/METHODS

A PS matched retrospective cohort study was conducted using the National Cancer Database. The primary endpoint was OS (time from diagnosis to death). Patients age ≥18 years with breast, GI (pancreas, colorectal, liver), GU (prostate, kidney, bladder), lung, lymphoma, melanoma, and oral cavity cancers were included. All patients underwent both IT and LNI and those with incomplete treatment timing were excluded. IT followed by LNI (IT first) was compared to LNI followed by IT (LNI first). PS were performed with 1:1 matching and a standard mean difference cutoff of 0.1 for covariate balancing. PS matched age, stage, comorbidity index, facility type, and upfront lymph node surgery. Unadjusted Kaplan-Meier (KM) estimates with log-rank tests assessed OS. Multivariable Cox proportional hazard (CPH) models adjusted for patient demographics compared IT first versus LNI first with adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI). Models were stratified by cancer site.

RESULTS

A total of 23,238 patients treated with IT and LNI were included, 88% of patients underwent IT first. Median (interquartile range [IQR]) age and follow-up were 57 (48-66) years and 39 (27-53) months, respectively. Cancers included 74% breast, 8% oral cavity, 6% GI, 5% lymphoma, 4% lung, 2% GU, and 1% melanoma. Median (IQR) weeks to treatment were 7 (4-13) for IT first and 8 (4-17) for LNI first. On unadjusted analysis, OS was significantly inferior with LNI first for overall (p<.0001), breast (p<.0001), GI (p = .004), lymphoma (p = .0003), and oral cavity cancer (p = .005). There were no significant differences in OS for GU, lung, and melanoma. On PS matched adjusted CPH analysis, LNI first had significantly higher risk of death overall (aHR = 3.2, 95% CI = 3.0-3.4), compared to IT first. PS matched cancer stratified analyses found OS was significantly inferior with LNI first for breast (aHR = 1.5, 95% CI = 1.2-1.8), GI (aHR = 1.2, 95% CI = 1.1-1.4), GU (aHR = 1.3, 95% CI = 1.0-1.8), lymphoma (aHR = 1.8, 95CI = 1.3-2.6), and oral cavity cancer (aOR = 1.3, 95% CI = 1.1-1.5).

CONCLUSION

PS matched analyses revealed superior OS for patients receiving IT first then LNI for breast, GI, GU, lymphoma, and oral cavity cancers. These findings suggest the importance of an intact immune system prior to IT. Future prospective studies are warranted to validate these findings.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancers: A United States Cohort Study between 2004 and 2017

PURPOSE/OBJECTIVE(S)

Brachytherapy (BT) improves clinical outcomes among women with cervical and endometrial cancers. Recent trends found decreasing BT rates in the United States; however, racial/ethnic differences have not been investigated completely. Here we aim to analyze 1) variations in BT practice patterns, 2) racial differences of BT, and 3) predictors of BT by race among women with cervical and endometrial cancers in the United States.

MATERIALS/METHODS

A retrospective cohort of women with endometrial and cervical cancers in the US was evaluated using the National Cancer Database, between 2004 and 2017. Primary endpoint was treatment with BT. Women ≥18 years of age were included for FIGO Stage IA-IVA, non-surgically treated cervical cancers and high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers. Racial groups were in accordance with federal guidelines including Asian, American Indian and Alaska Native (AIAN), Black, Native Hawaiian and other Pacific Islander (NHPI), and White. BT practice patterns and trends over time were evaluated by race. To identify predictors of BT by race, logistic regression calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) after assessing for multicollinearity.

RESULTS

A total of 13,857 women with cervical cancer and 140,942 women with endometrial cancer were included. Median follow-up was 69 months. Median (IQR) age was 53 (43-63) years for cervical cancer and 64 (57-72) years for endometrial cancer. Most cervical cancers were Stage III (44%), squamous cell carcinoma (88%), and lymphovascular space invasion (LVSI) positive (49%). Most endometrial cancers were Stage IB (45%), endometrioid histology (82%), and LVSI-positive (50%). Between 2004 and 2017, endometrial cancer BT increased (34% to 57%). BT rates for cervical cancer ranged from 65% NHPI, 63% Asian, 62% White, 59% AIAN, and 57% Black. BT rates for endometrial cancer ranged from 26% Black, 25% White, 25% Asian, 21% AIAN, and 20% NHPI. By race, only Black women with cervical cancer were significantly less likely to receive BT (aOR = 0.8; 95% CI = 0.7-0.9), compared to White women. Only NHPI women with endometrial cancer were less likely to receive BT (aOR = 0.7; 95% CI = 0.5-1.0), compared to White women. Community cancer center treatment was the only factor associated with a decreased odds of BT for both Black women with cervical cancer (aOR = 0.7; 95% CI = 0.6-0.9) and NHPI women with endometrial cancer (aOR = 0.3; 95% CI = 0.1-0.8), compared to academic centers.

CONCLUSION

In this study of women diagnosed with endometrial and cervical cancers with stages known to benefit from BT, NHPI women with endometrial cancer and Black women with cervical cancer were less likely to receive brachytherapy compared to White women. Community engagement is needed to increase BT access for patients treated at community cancer centers to ensure equitable gynecologic cancer care.

Recombination map tailored to Native Hawaiians improves robustness of genomic scans for positive selection

Recombination events establish the patterns of haplotypic structure in a population and estimates of recombination rates are used in several downstream population and statistical genetic analyses. Using suboptimal maps from distantly related populations may reduce the efficacy of genomic analyses, particularly for underrepresented populations such as the Native Hawaiians. To overcome this challenge, we constructed recombination maps using genome-wide array data from two study samples of Native Hawaiians: one reflecting the current admixed state of Native Hawaiians (NH map), and one based on individuals of enriched Polynesian ancestries (PNS map) with the potential to be used for less admixed Polynesian populations such as the Samoans. We found the recombination landscape to be less correlated with those from other continental populations (e.g. Spearman's rho = 0.79 between PNS and CEU (Utah residents with Northern and Western European ancestry) compared to 0.92 between YRI (Yoruba in Ibadan, Nigeria) and CEU at 50 kb resolution), likely driven by the unique demographic history of the Native Hawaiians. PNS also shared the fewest recombination hotspots with other populations (e.g. 8% of hotspots shared between PNS and CEU compared to 27% of hotspots shared between YRI and CEU). We found that downstream analyses in the Native Hawaiian population, such as local ancestry inference, imputation, and IBD segment and relatedness detections, would achieve similar efficacy when using the NH map compared to an omnibus map. However, for genome scans of adaptive loci using integrated haplotype scores, we found several loci with apparent genome-wide significant signals (|Z-score| > 4) in Native Hawaiians that would not have been significant when analyzed using NH-specific maps. Population-specific recombination maps may therefore improve the robustness of haplotype-based statistics and help us better characterize the evolutionary history that may underlie Native Hawaiian-specific health conditions that persist today.

Definitive Treatment of Brain Metastases From a Neuroendocrine Tumor With Peptide Receptor Radionuclide Therapy With 177Lutetium DOTATATE: A Case Report

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare malignancies that arise from secretory endocrine cells of the gastroenteropancreatic system. Clinical outcomes have improved for patients with GEP-NETs due to the development and recent FDA approval of 177Lutetium DOTATATE. However, the response of brain metastases from GEP-NETs from 177Lutetium DOTATATE is unreported. We present the case of an 81-year-old man with low-grade small bowel GEP-NET with liver and brain metastases treated with a total of six cycles of 177Lutetium DOTATATE. With over three years of follow-up from his initial treatment, his brain metastases have had complete or partial responses, with no need for brain radiotherapy or radiosurgery.

Association of MGMT Promoter Methylation With Survival in Low-grade and Anaplastic Gliomas After Alkylating Chemotherapy

Importance

O6-methylguanine-DNA methyltransferase (MGMT [OMIM 156569]) promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy for glioblastomas and is routinely used to guide treatment decisions. However, the utility of MGMT promoter status for low-grade and anaplastic gliomas remains unclear due to molecular heterogeneity and the lack of sufficiently large data sets.

Objective

To evaluate the association of mMGMT for low-grade and anaplastic gliomas with chemotherapy response.

Design, Setting, and Participants

This cohort study aggregated grade II and III primary glioma data from 3 prospective cohort studies with patient data collected from August 13, 1995, to August 3, 2022, comprising 411 patients: MSK-IMPACT, EORTC (European Organization of Research and Treatment of Cancer) 26951, and Columbia University. Statistical analysis was performed from April 2022 to January 2023.

Exposure

MGMT promoter methylation status.

Main Outcomes and Measures

Multivariable Cox proportional hazards regression modeling was used to assess the association of mMGMT status with progression-free survival (PFS) and overall survival (OS) after adjusting for age, sex, molecular class, grade, chemotherapy, and radiotherapy. Subgroups were stratified by treatment status and World Health Organization 2016 molecular classification.

Results

A total of 411 patients (mean [SD] age, 44.1 [14.5] years; 283 men [58%]) met the inclusion criteria, 288 of whom received alkylating chemotherapy. MGMT promoter methylation was observed in 42% of isocitrate dehydrogenase (IDH)-wild-type gliomas (56 of 135), 53% of IDH-mutant and non-codeleted gliomas (79 of 149), and 74% of IDH-mutant and 1p/19q-codeleted gliomas (94 of 127). Among patients who received chemotherapy, mMGMT was associated with improved PFS (median, 68 months [95% CI, 54-132 months] vs 30 months [95% CI, 15-54 months]; log-rank P < .001; adjusted hazard ratio [aHR] for unmethylated MGMT, 1.95 [95% CI, 1.39-2.75]; P < .001) and OS (median, 137 months [95% CI, 104 months to not reached] vs 61 months [95% CI, 47-97 months]; log-rank P < .001; aHR, 1.65 [95% CI, 1.11-2.46]; P = .01). After adjusting for clinical factors, MGMT promoter status was associated with chemotherapy response in IDH-wild-type gliomas (aHR for PFS, 2.15 [95% CI, 1.26-3.66]; P = .005; aHR for OS, 1.69 [95% CI, 0.98-2.91]; P = .06) and IDH-mutant and codeleted gliomas (aHR for PFS, 2.99 [95% CI, 1.44-6.21]; P = .003; aHR for OS, 4.21 [95% CI, 1.25-14.2]; P = .02), but not IDH-mutant and non-codeleted gliomas (aHR for PFS, 1.19 [95% CI, 0.67-2.12]; P = .56; aHR for OS, 1.07 [95% CI, 0.54-2.12]; P = .85). Among patients who did not receive chemotherapy, mMGMT status was not associated with PFS or OS.

Conclusions and Relevance

This study suggests that mMGMT is associated with response to alkylating chemotherapy for low-grade and anaplastic gliomas and may be considered as a stratification factor in future clinical trials of patients with IDH-wild-type and IDH-mutant and codeleted tumors.

Racial Disparities among Asian American, Native Hawaiian, and Other Pacific Islander Patients with Cancer Who Refuse Recommended Radiation Therapy or Surgery

Despite radiation therapy (RT) and surgery being the curative treatments, prior work demonstrated that the aggregated Asian American (AA) and Native Hawaiian and Other Pacific Islanders (NHPI) population refuse RT and surgery at a higher rates than other races. Given that AA and NHPI are distinct groups, data disaggregation is necessary to understand racial and ethnic disparities for treatment refusal. We aimed to (1) compare RT and surgery refusal rates between AA and NHPI populations, (2) assess RT and surgery refusal on overall mortality, and (3) determine predictors of refusing RT and surgery using the United States (U.S.) National Cancer Database. Adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for treatment refusal were calculated using logistic regression. Adjusted hazard ratios (aHR) were calculated for overall survival using Cox proportional hazard models among propensity score-matched groups. The overall rate of RT refusal was 4.8% and surgery refusal was 0.8%. Compared to East AA patients, NHPI patients had the highest risk of both RT refusal (aOR = 1.38, 95%CI = 1.21-1.61) and surgery refusal (aOR = 1.28, 95%CI = 1.00-1.61). RT refusal significantly predicted higher mortality (aHR = 1.17, 95%CI = 1.08-1.27), whereas surgery refusal did not. Predictors of RT and surgery refusal were older patient age, high comorbidity index, and cancer diagnosis between 2011-2017. The results show heterogenous treatment refusal patterns among AA and NHPI populations, suggesting areas for targeted intervention.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancer in the United States

Brachytherapy improves clinical outcomes among women diagnosed with cervical and endometrial cancers. Recent evidence demonstrates that declining brachytherapy boosts for women with cervical cancer were associated with higher mortality. In this retrospective cohort study, women diagnosed with endometrial or cervical cancer in the United States between 2004 and 2017 were selected from the National Cancer Database for evaluation. Women ≥18 years of age were included for high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers and FIGO Stage IA-IVA-non-surgically treated cervical cancers. The aims were to (1) evaluate brachytherapy treatment practice patterns for cervical and endometrial cancers in the United States; (2) calculate rates of brachytherapy treatment by race; and (3) determine factors associated with not receiving brachytherapy. Treatment practice patterns were evaluated over time and by race. Multivariable logistic regression assessed predictors of brachytherapy. The data show increasing rates of brachytherapy for endometrial cancers. Compared to non-Hispanic White women; Native Hawaiian and other Pacific Islander (NHPI) women with endometrial cancer and Black women with cervical cancer were significantly less likely to receive brachytherapy. For both NHPI and Black women, treatment at community cancer centers was associated with a decreased likelihood of brachytherapy. The data suggest racial disparities among Black women with cervical cancer and NHPI women with endometrial cancer and emphasize an unmet need for brachytherapy access within community hospitals.

Cancer mortality rates by racial/ethnic groups in the United States, 2018-2020

BACKGROUND

Starting in 2018, national death certificates included a new racial classification system that accounts for multiple-race decedents and separates Native Hawaiian and Pacific Islander (NHPI) individuals from Asian individuals. We estimated cancer death rates across updated racial/ethnic categories, sex, and age.

METHODS

Age-standardized U.S. cancer mortality rates and rate ratios from 2018-2020 among ≥20-year-olds were estimated with national death certificate data by race/ethnicity, sex, age, and cancer site.

RESULTS

In 2018, there were approximately 597,000 cancer deaths, 598,000 in 2019, and 601,000 in 2020. Among men, cancer death rates were highest in Black men (298.2/100,000; n = 105,632), followed by White (250.8; n = 736,319), American Indian/Alaska Native (AI/AN) (249.2; n = 3,376), NHPI (205.6; n = 1,080), Latino (177.2; n = 66,167), and Asian (147.9; n = 26,591) men. Among women, Black women had the highest cancer death rates (206.5/100,000; n = 104,437), followed by NHPI (192.1; n = 1,141), AI/AN (189.9; n = 3,239), White (183.0; n = 646,865), Latina (128.4; n = 61,579), and Asian women (111.4; n = 26,396). The highest death rates by age group occurred among NHPI individuals aged 20-49 years, and Black individuals aged 50-69 and ≥70 years. Asian individuals had the lowest cancer death rates across age groups. Compared to Asian individuals, total cancer death rates were 39% higher in NHPI men and 73% higher in NHPI women.

CONCLUSIONS

There were striking racial/ethnic disparities in cancer death rates during 2018-2020. Separating NHPI and Asian individuals revealed large differences in cancer mortality between two groups that were previously combined in vital statistics data.

Griseofulvin Radiosensitizes Non-Small Cell Lung Cancer Cells and Activates cGAS

Extra copies of centrosomes are frequently observed in cancer cells. To survive and proliferate, cancer cells have developed strategies to cluster extra-centrosomes to form bipolar mitotic spindles. The aim of this study was to investigate whether centrosome clustering (CC) inhibition (CCi) would preferentially radiosensitize non-small cell lung cancer (NSCLC). Griseofulvin (GF; FDA-approved treatment) inhibits CC, and combined with radiation treatment (RT), resulted in a significant increase in the number of NSCLC cells with multipolar spindles, and decreased cell viability and colony formation ability in vitro. In vivo, GF treatment was well tolerated by mice, and the combined therapy of GF and radiation treatment resulted in a significant tumor growth delay. Both GF and radiation treatment also induced the generation of micronuclei (MN) in vitro and in vivo and activated cyclic GMP-AMP synthase (cGAS) in NSCLC cells. A significant increase in downstream cGAS-STING pathway activation was seen after combination treatment in A549 radioresistant cells that was dependent on cGAS. In conclusion, GF increased radiation treatment efficacy in lung cancer preclinical models in vitro and in vivo. This effect may be associated with the generation of MN and the activation of cGAS. These data suggest that the combination therapy of CCi, radiation treatment, and immunotherapy could be a promising strategy to treat NSCLC.

Human papillomavirus-associated cancer incidence by disaggregated Asian American, Native Hawaiian, and other Pacific Islander ethnicity

BACKGROUND

Asian Americans and Native Hawaiians and other Pacific Islanders have suboptimal human papillomavirus (HPV) vaccination and cancer screening rates. Asian Americans and NHPIs are often aggregated, masking disparities characterized by varying colonization and immigration patterns and cultural and religious beliefs between populations and ethnicities. We examined the incidence of HPV-associated cancers across disaggregated Asian American and NHPI ethnicities.

METHODS

Using the Surveillance, Epidemiology, and End Results Detailed Asian/Pacific Islander database, we calculated 1990 to 2014 sex-specific, age-standardized HPV-associated cancer incidence of cervical carcinoma, oropharyngeal squamous cell carcinoma (SCC), vulvar SCC, vaginal SCC, anal SCC, and penile SCC by ethnicity: Asian Indian and Pakistani, Chinese, Filipino, Japanese, Kampuchean, Korean, Laotian, Native Hawaiian, other Pacific Islander, and Vietnamese. Trends by calendar period (1990 to 1996, 1997 to 2002, 2003 to 2008, 2009 to 2014) were estimated using Joinpoint regression.

RESULTS

The most common HPV-associated cancer was cervical carcinoma in women and oropharyngeal SCC in men. During 1990 to 2014, cervical carcinoma incidence per 100 000 ranged from 4.5 (Asian Indian and Pakistani) to 20.7 (Laotian). Cervical carcinoma incidence only statistically significantly declined for Asian Indian and Pakistani, Filipino, Korean, Laotian, and Vietnamese women (range = 19.9% to 44.1% decline per period). Among men, oropharyngeal SCC incidence per 100 000 ranged from 1.1 (Chinese) to 5.1 (Native Hawaiian). Oropharyngeal SCC incidence only statistically significantly increased (31.0% increase per period) for Japanese men. Heterogeneity across ethnicities were observed for other cancer sites.

CONCLUSIONS

HPV-associated cancer incidence varied widely between Asian Americans and NHPIs and by ethnicity, underscoring the need for improved data capture of ethnic groups in research and more tailored interventions to better address health disparities between Asian American and NHPI populations.

SUPPORT: SUrvey of Parental Leave POlicies of RadiaTion Oncology Programs and Residency Applicants

Purpose

Recruitment to radiation oncology training programs has recently declined, and gender inequities persist in radiation oncology. Policies that promote inclusivity, such as the updated American College of Graduate Medical Education parental leave policy establishing minimum parental leave requirements, may support recruitment to radiation oncology.

Methods and Materials

We surveyed 2021-2022 radiation oncology residency applicants and program directors (PDs) about program-specific parental leave policies, transparency of parental leave information during the residency application and interview process, and perceptions of the effect of parenthood on residency training, career advancement, and well-being.

Results

Of 89 radiation oncology PDs, 29 (33%) completed the survey. Of 154 residency applicants (current fourth-year medical students, international applicants, or postdoctoral fellows) surveyed, 62 (40%) completed the survey. Most applicants planned to start a family during residency (53%) and reported perceived flexibility to start a family influenced their decision to pursue radiation oncology over other career specialties (55%). Many applicants viewed time in residency (nonresearch, 22%), in research (33%), and as early career faculty (24%) as the best time to start a family. A small number of applicants used program-specific parental leave policy information in determining their rank list (11%), and many applicants sought information regarding fertility health care benefits (55%). Many applicants obtained parental leave information verbally, despite expressing a preference for objective means (slide deck, 63%; website, 50%; or handout, 42%) of information sharing. PDs were all supportive of a 6-week maternity leave policy (100% agree or strongly agree with the policy) and did not feel parental leave would negatively affect a resident's ability to pursue an academic (100%) or private practice career (100%).

Conclusions

Many radiation oncology residency applicants plan to start families during training, seek and value program-specific parental leave information and health benefits, and prefer objective means of information sharing. These findings likely reflect those who have strong views of parental leave policies.

Tailored Mentorship for the Underrepresented and Allies in Radiation Oncology: The Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee Mentorship Experience

PURPOSE

There are limited opportunities for mentorship for underrepresented in medicine (URM) trainees and physicians in radiation oncology (RO). The purpose of this study was to create and evaluate a formal mentorship program open to URMs and allies with interests in diversity, equity, and inclusion.

METHODS AND MATERIALS

A mentorship program incorporating a virtual platform was designed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee. It was structured to include 6 sessions over 6 months with matched mentor-mentee pairs based on responses to a publicized online interest form. A compilation of evidence-based guidelines was provided to optimize the mentorship relationship. Linked pre- and postprogram surveys were administered to collect demographic data, define baseline goals and level of support, and evaluate program satisfaction.

RESULTS

Thirty-five mentor-mentee pairs were matched; 31 mentees completed the preprogram survey and 17 completed the postprogram survey. Preprogram, only 3 mentees (9.7%) reported satisfaction with current mentorship and 5 (16%) reported mechanisms or mentorship in place at their program to support URMs. On the postprogram survey, mentees reported high satisfaction with areas of mentorship, mentor attributes, and the program overall. Opportunities for improvement include implementation of mechanisms to enhance communication with mentor-mentee pairs and maintain longitudinal engagement.

CONCLUSIONS

In the first tailored mentorship program in RO for URMs and those with diversity, equity, and inclusion interests, our results demonstrate that there is self-reported interest for better mentorship for URMs in RO, and that a nationwide structured mentorship program can address participants' goals with high satisfaction. Program expansion could provide URMs and allies in RO more opportunities for career development and promote a greater sense of community and inclusion within the field.

A National Cancer Disparities Analysis of Predictors for Radiation Therapy Refusal by Race

PURPOSE

Radiation therapy (RT) refusal by patients with cancer is infrequent but is significant because it portends poor outcomes. No prior study has evaluated all five federally defined racial categories with respects to RT refusal. Here we use a large nationally representative population with cancer to determine: 1) which race of patients refuse RT the most and 2) predictive factors for RT refusal by race.

MATERIALS/METHODS

A retrospective study included patients ≥18 years old with diagnostically confirmed cancer between 2004-2017, using the National Cancer Database. All patients included were offered RT for first course treatment. Multivariable logistic regression assessed RT refusal (adjusted odds ratio [aOR]) with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, rurality, income, education, and comorbidities) and cancer characteristics (stage, cancer type, facility type, year of diagnosis, and region). Median overall survival was calculated using the Kaplan-Meier method.

RESULTS

Of 11,609,044 patients, 2,759,753 patients were included and recommended for RT by the treating physician. Median follow-up was 50 months. RT was refused by 139,383 patients (5.0%), varying by race: 416 NHPI (7.2%), 489 AIAN (5.8%), 118,186 Non-Hispanic White (5.0%), 17,427 Black (4.8%), and 2,865 Asian (4.8%) patients. The rates of annual RT refusal were increasing, especially among NHPI patients. The populations with the highest likelihood of refusing RT were NHPI (aOR=1.53, 95%CI=1.36-1.71), AIAN (aOR=1.24, 95%CI=1.12-1.37), and Black (aOR=1.11, 95%CI=1.09-1.14) patients, compared to Non-Hispanic White patients. Older age and higher comorbidity burden predicted RT refusal across all races. Median overall survival was 81 months and 144 months for patients who refused RT and received RT, respectively.

CONCLUSIONS

Indigenous and Black patients are more likely to refuse RT, which may contribute to inferior cancer outcomes. Understanding NHPI and AIAN patient perspectives and perceptions may elucidate interventions to mitigate these disparities.

Disparities in Survival and Comorbidity Burden Between Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer

IMPORTANCE

Improper aggregation of Native Hawaiian and other Pacific Islander individuals with Asian individuals can mask Native Hawaiian and other Pacific Islander patient outcomes. A comprehensive assessment of cancer disparities comparing Asian with Native Hawaiian and other Pacific Islander populations is lacking.

OBJECTIVE

To compare comorbidity burden and survival among East Asian, Native Hawaiian and other Pacific Islander, South Asian, and Southeast Asian individuals with non-Hispanic White individuals with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a national hospital-based oncology database enriched with Native Hawaiian and other Pacific Islander and Asian populations. Asian, Native Hawaiian and other Pacific Islander, and White individuals diagnosed with the most common cancers who received treatment from January 1, 2004, to December 31, 2017, were included. Patients younger than 18 years, without pathologic confirmation of cancer, or with metastatic disease were excluded. Data were analyzed from January to May 2022.

MAIN OUTCOMES AND MEASURES

The primary end points were comorbidity burden by Charlson-Deyo Comorbidity Index and overall survival (OS).

RESULTS

In total, 5 955 550 patients were assessed, including 60 047 East Asian, 11 512 Native Hawaiian and other Pacific Islander, 25 966 South Asian, 42 815 Southeast Asian, and 5 815 210 White patients. The median (IQR) age was 65 (56-74) years, median (IQR) follow-up was 58 (30-96) months, and 3 384 960 (57%) were women. Patients were predominantly from metropolitan areas (4 834 457 patients [84%]) and the Southern United States (1 987 506 patients [34%]), with above median education (3 576 460 patients [65%]), and without comorbidities (4 603 386 patients [77%]). Cancers included breast (1 895 351 patients [32%]), prostate (948 583 patients [16%]), kidney or bladder (689 187 patients [12%]), lung (665 622 patients [11%]), colorectal (659 165 patients [11%]), melanoma (459 904 patients [8%]), endometrial (307 401 patients [5%]), lymphoma (245 003 patients [4%]), and oral cavity (85 334 patients [1%]) malignant neoplasms. Native Hawaiian and other Pacific Islander patients had the highest comorbidity burden (adjusted odds ratio [aOR], 1.70; 95% CI, 1.47-1.94) compared with Asian and White groups. Asian patients had superior OS compared with White patients for most cancers; only Southeast Asian patients with lymphoma had inferior survival (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.16-1.37). In contrast, Native Hawaiian and other Pacific Islander patients demonstrated inferior OS compared with Asian and White patients for oral cavity cancer (aHR, 1.56; 95% CI, 1.14-2.13), lymphoma (aHR, 1.35; 95% CI, 1.11-1.63), endometrial cancer (aHR, 1.30; 95% CI, 1.12-1.50), prostate cancer (aHR, 1.29; 95% CI, 1.14-1.46), and breast cancer (aHR, 1.09; 95% CI, 1.00-1.18). No cancers among Native Hawaiian and other Pacific Islander patients had superior OS compared with White patients.

CONCLUSIONS AND RELEVANCE

In this cohort study, compared with White patients with the most common cancers, Asian patients had superior survival outcomes while Native Hawaiian and other Pacific Islander patients had inferior survival outcomes. Native Hawaiian and other Pacific Islander patients had significantly greater comorbidity burden compared with Asian and White patients, but this alone did not explain the poor survival outcomes. These results support the disaggregation of these groups in cancer studies.

Disaggregation of Asian American and Pacific Islander Women With Stage 0-II Breast Cancer Unmasks Disparities in Survival and Surgery-to-Radiation Intervals: A National Cancer Database Analysis From 2004 to 2017

PURPOSE

Aggregation of Asian Americans (AAs) with Native Hawaiians and Other Pacific Islanders (NHPIs) masks significant health disparities. We evaluated overall survival (OS) and surgery-to-radiation intervals (STRIs) among AA and NHPI women with early-stage breast cancer.

METHODS

This National Cancer Database study included women with stage 0-II breast cancer diagnosed between 2004 and 2017. STRI was defined as days from surgery to radiation. Patients were stratified by adjuvant treatment. AAs were disaggregated into geographically relevant subpopulations: East, South, and Southeast Asians. Kaplan-Meier estimates and log-rank tests assessed survival. Cox proportional hazard and linear regression were adjusted for clinical and sociodemographic factors.

RESULTS

In total, 578,927 women were included (median age 61 years, median follow-up 65 months, and 10-year OS 83%). AA and NHPI 10-year OS was 91% overall; subpopulation 10-year OS was 92% for East Asian, 90% for South Asian, 90% for Southeast Asian, and 83% for NHPI. On multivariable analysis, compared with non-Hispanic White, NHPI women had worse survival (adjusted hazard ratio [aHR] = 1.38; 95% CI, 1.09 to 1.77); all AA subpopulations had improved survival: East Asian (aHR = 0.57; 95% CI, 0.48 to 0.69), South Asian (aHR = 0.66; 95% CI, 0.51 to 0.84), and Southeast Asian (aHR = 0.78; 95% CI, 0.65 to 0.94). The AA and NHPI median STRI for was 73 days overall; the disaggregated median STRI was 68 days for East Asian, 80 days for South Asian, 77 days for Southeast Asians, and 81 days for NHPI. On adjusted analysis, compared with non-Hispanic White, Southeast Asians and NHPI had longer STRI by 6.6 (95% CI, 4.3 to 8.9) and 10.0 (95% CI, 5.8 to 14) days, respectively.

CONCLUSION

Breast cancer disparities exist among disaggregated AA and NHPI subpopulations. Data disaggregation insights may lead to interventions to overcome these disparities, such as optimizing time-to-treatment for select populations.

Ancestral Stem Cell Reprogramming Genes Active in Hemichordate Regeneration

Hemichordate enteropneust worms regenerate extensively in a manner that resembles the regeneration for which planaria and hydra are well known. Although hemichordates are often classified as an extant phylogenetic group that may hold ancestral deuterostome body plans at the base of the deuterostome evolutionary line leading to chordates, mammals, and humans, extensive regeneration is not known in any of these more advanced groups. Here we investigated whether hemichordates deploy functional homologs of canonical Yamanaka stem cell reprogramming factors, Oct4, Sox2, Nanog, and Klf4, as they regenerate. These reprogramming factors are not expressed during regeneration of limbs, fins, eyes or other structures that represent the best examples of regeneration in chordates. We first examined Ptychodera flava EST libraries and identified Pf-Pou3, Pf-SoxB1, Pf-Msxlx, and Pf-Klf1/2/4 as most closely related to the Yamanaka factors, respectively. In situ hybridization analyses revealed that all these homologs are expressed in a distinct manner during head regeneration. Furthermore, Pf-Pou3 partially rescued the loss of endogenous Oct4 in mouse embryonic stem cells in maintaining the pluripotency gene expression program. Based on these results, we propose that hemichordates may have co-opted these reprogramming factors for their extensive regeneration or that chordates may have lost the ability to mobilize these factors in response to damage. The robustness of these pluripotency gene circuits in the inner cell mass and in formation of induced pluripotent stem cells from mammalian somatic cells shows that these programs are intact in humans and other mammals and that these circuits may respond to as yet unknown gene regulatory signals, mobilizing full regeneration in hemichordates.

Prostate Cancer Disparities in Risk Group at Presentation and Access to Treatment for Asian Americans, Native Hawaiians, and Pacific Islanders: A Study With Disaggregated Ethnic Groups

PURPOSE

We identified (1) differences in localized prostate cancer (PCa) risk group at presentation and (2) disparities in access to initial treatment for Asian American, Native Hawaiian, and Pacific Islander (AANHPI) men with PCa after controlling for sociodemographic factors.

METHODS

We assessed all patients in the National Cancer Database with localized PCa with low-, intermediate-, and high-risk disease who identified as Thai, White, Asian Indian, Chinese, Vietnamese, Korean, Japanese, Filipino, Hawaiian, Pacific Islander, Laotian, Pakistani, Kampuchean, and Hmong. Multivariable logistic regression defined adjusted odds ratios (AORs) with 95% CI of (1) presenting at progressively higher risk group and (2) receiving treatment or active surveillance with intermediate- or high-risk disease, adjusting for sociodemographic and clinical factors.

RESULTS

Among 980,889 men (median age 66 years), all AANHPI subgroups with the exception of Thai (AOR = 0.84 [95% CI, 0.58 to 1.21], P > .05), Asian Indian (AOR = 1.12 [95% CI, 1.00 to 1.25], P > .05), and Pakistani (AOR = 1.34 [95% CI, 0.98 to 1.83], P > .05) men had greater odds of presenting at a progressively higher PCa risk group compared with White patients (Chinese AOR = 1.18 [95% CI, 1.11 to 1.25], P < .001; Japanese AOR = 1.36 [95% CI, 1.26 to 1.47], P < .001; Filipino AOR = 1.37 [95% CI, 1.29 to 1.46], P < .001; Korean AOR = 1.32 [95% CI, 1.18 to 1.48], P < .001; Vietnamese AOR = 1.20 [95% CI, 1.07 to 1.35], P = .002; Laotian AOR = 1.60 [95% CI, 1.08 to 2.36], P = .018; Hmong AOR = 4.07 [95% CI, 1.54 to 10.81], P = .005; Kampuchean AOR = 1.55 [95% CI, 1.03 to 2.34], P = .036; Asian Indian or Pakistani AOR = 1.15 [95% CI, 1.07 to 1.24], P < .001; Native Hawaiians AOR = 1.58 [95% CI, 1.38 to 1.80], P < .001; and Pacific Islanders AOR = 1.58 [95% CI, 1.37 to 1.82], P < .001). Additionally, Japanese Americans (AOR = 1.46 [95% CI, 1.09 to 1.97], P = .013) were more likely to receive treatment compared with White patients.

CONCLUSION

Our findings suggest that there are differences in PCa risk group at presentation by race or ethnicity among Asian American, Native Hawaiian, and Pacific Islander subgroups and that there exist disparities in treatment patterns. Although AANHPI are often studied as a homogenous group, heterogeneity upon subgroup disaggregation underscores the importance of further study to assess and address barriers to PCa care.

Abstract PR-15: Disaggregating Asian American and Pacific Islanders unmasks disparities in survival, time-to-surgery, and surgery-to-radiation intervals among women with Stage I-III breast cancer: An NCDB analysis from 2004-2016

INTRODUCTION The aggregation of Asian Americans (AA) with Native Hawaiian and other Pacific Islanders (NHPI) masks health disparities. Few studies have appropriately disaggregated AA & NHPI patients with breast cancer. The purpose of this study was to evaluate 1) survival outcomes, 2) times-to-surgery (TTS), & 3) surgery-to-radiation intervals (STRI) among AA & NHPI women with non-metastatic breast cancer. Methods This was an IRB exempt, retrospective cohort study using the National Cancer Database of women diagnosed with stage I-III breast cancer in 2004-2016 with AA & NHPI were compared to Non-Hispanic White (NHW). TTS (diagnosis date to surgery date) & STRI (surgery date to radiation date) were calculated. STRI was stratified by adjuvant radiotherapy (STRI-R) or adjuvant chemotherapy-followed-by-radiotherapy (STRI-CR). AA was separated geographically: East Asian (EA; Chinese, Japanese, Korean), South Asian (SA; Indian, Pakistani), & Southeast Asian (SEA; Filipino, Vietnamese, Laotian, Hmong, Cambodian). Log-rank tests assessed survival. Linear regressions assessed adjusted coefficients (β) with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, urban/rural, income, education, comorbidities) & cancer characteristics (stage, pathology, diagnosis year). P&lt;.05 was used for significance & multivariable co-variable selection. Results 1,407,523 women were included: 1,361,215 NHW, 3,579 NHPI, 19,422 EA, 8,569 SA, & 14,738 SEA. Median follow-up was 69 months (IQR=41-106). 15-year survival (95%CI) was 60% (60-61%) for NHW, 66% (55-78%) for NHPI, 77% (72-82%) for SEA, 77% (73-81%) for EA, & 84% (82-87%) for SA, p&lt;.001. On adjusted analysis, compared to NHW, all AA subgroups had improved survival (EA HR=0.63, 95%CI=0.57-0.70; SA HR=0.74, 95%CI=0.64-0.87; SEA HR=0.67, 95%CI=0.59-0.75). NHPI was not significantly different (HR=1.06, 95%CI=0.88-1.27). Median TTS was 25 days (IQR=13-40 days). On adjusted analysis compared to NHW, TTS was significantly longer for NHPI (β=3.4 days; 95%CI=1.9-4.9 days) & SEA (β=5.0 days; 95%CI=4.3-5.8 days), with no differences in TTS for EA & SA. Median STRI-R was 49 days (IQR=38-67 days). On adjusted analysis compared to NHW, STRI-R was significantly longer for NHPI (β=6.8 days, 95%CI=3.6-9.9 days), SEA (β=6.3 days, 95%CI=4.5-8.0 days), & EA (β=2.1 days, 95%CI=0.65-3.5 days), with no difference in STRI-R for SA. Median STRI-CR was 181 days (IQR=152-216 days). On adjusted analysis compared to NHW, STRI-CR was significantly longer for NHPI (β=11 days, 95%CI=6.1-17 days) & SEA (β=4.1 days, 95%CI=1.3-6.9 days). No difference in STRI-CR were seen for EA & SA. Conclusions The data reveal disparities among women with breast cancer for survival, time-to-surgery, & surgery-to-radiation intervals among NHPI & three major AA subgroups. Improper aggregation, particularly for NHPI & SEA, masks these disparities. Through proper disaggregation, solutions may be identified to abrogate overlooked racial disparities among minority women with breast cancer, such as longer times to treatment.

Citation Format: Kekoa Taparra, Edward Christopher Dee, Dyda Dao, Rohan Patel, Patricia Santos, Fumiko Chino. Disaggregating Asian American and Pacific Islanders unmasks disparities in survival, time-to-surgery, and surgery-to-radiation intervals among women with Stage I-III breast cancer: An NCDB analysis from 2004-2016 [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 PR-15.

The Impact of COVID-19 on Radiation Oncology Residency Applicant Away Rotations, Interviews, and Rank Lists: A Comparison Between the 2020 Match and 2021 Match

Purpose

The COVID-19 pandemic modified the Residency Match process for fourth-year medical students. In-person away rotations were discouraged, interviews were virtual, and traditional factors used to rank programs were absent. Here, we compare survey results administered to both the 2020 and 2021 Match applicants to assess the influence of the pandemic on the radiation oncology (RO) Match process.

Methods

An institutional review board-approved prospective cross-sectional study was conducted. The 2020 and 2021 RO Match applicants at a large RO program were invited to participate. Descriptive summary statistics were assessed.

Results

The 2020 and 2021 Matches each had 76 applicants complete the survey with response rates of 54% and 57%, respectively. The 2 groups were predominantly white, cisgender male, single, and without children. Whereas 11% of 2020 applicants did not complete away rotations, 45% of 2021 applicants did not. For 2021 Match applicants, 65% of away rotations were performed virtually, whereas 51% were not for medical school credit. Of the applicants, 84% were satisfied with virtual interviews and 72% felt cost savings were worth not having in-person interviews. Whereas 49% of Match 2020 applicants spent >$5000 in interview costs, 0% of the Match 2021 applicants did so, with 45% spending <$100. Postinterview communications from programs increased during the pandemic from 36% to 42% in 2020 Match and 2021 Match, respectively. Although program culture was the most common factor influencing 2021 Match applicants program rankings, half of applicants did not gain a sense of program culture during virtual interviews.

Conclusions

We found 2021 Match applicants completed fewer away rotations, were satisfied with virtual interviews/reduced costs, and did not gain a sense of program culture through virtual rotations/interviews despite it being the most important ranking factor reported. This study supports further exploration of virtual away rotations and virtual interviews moving forward beyond the pandemic.

Racial and Ethnic Disparities in Rates of Invasive Second Breast Cancer Among Women With Ductal Carcinoma In Situ in Hawai'i

Importance

Women with ductal carcinoma in situ (DCIS) may develop a subsequent invasive second breast cancer (SBC). Understanding the association of racial and ethnic factors with the development of invasive SBC may help reduce overtreatment and undertreatment of women from minority groups.

Objective

To evaluate risk factors associated with developing invasive ipsilateral SBC (iiSBC) and invasive contralateral SBC (icSBC) among women with an initial diagnosis of DCIS who are from racial and ethnic minority populations.

Design, Setting, and Participants

This retrospective cohort study used deidentified data from the Hawai'i Tumor Registry of 6221 female Hawai'i residents aged 20 years or older who received a diagnosis of DCIS between January 1, 1973, and December 31, 2017. The 5 most populous ethnic groups were compared (Chinese, Filipino, Japanese, Native Hawaiian, and White). Data analysis was performed from 2020 to 2021.

Exposures

Patient demographic and clinical characteristics and the first course of treatment.

Main Outcome and Measures

The a priori study outcome was the development of invasive SBC. Logistic regression was used to identify factors associated with invasive SBC. Factors that were significant on unadjusted analyses were included in the adjusted models (ie, age, race and ethnicity, diagnosis year, DCIS histologic characteristics, laterality, hormone status, and treatment).

Results

The racial and ethnic distribution of patients with DCIS across the state's most populous groups were 2270 Japanese women (37%), 1411 White women (23%), 840 Filipino women (14%), 821 Native Hawaiian women (13%), and 491 Chinese women (8%). Women of other minority race and ethnicity collectively comprised 6% of cases (n = 388). A total of 6221 women (age range, 20 to ≥80 years) were included in the study; 4817 (77%) were 50 years of age or older, 4452 (72%) received a diagnosis between 2000 and 2017, 2581 (42%) had well or moderately differentiated histologic characteristics, 2383 (38%) had noninfiltrating intraductal DCIS, and 2011 (32%) were treated with mastectomy only. Of these 6221 women, 444 (7%) developed invasive SBC; 190 developed iiSBC (median time to SBC diagnosis, 7.8 years [range, 0.5-30 years]) and 254 developed icSBC (median time to SBC diagnosis, 5.9 years [range, 0.5-28.8 years]). On adjusted analysis, women who developed iiSBC were more likely to be younger than 50 years (adjusted odds ratio [aOR], 1.49; 95% CI, 1.08-2.06), Native Hawaiian (aOR, 3.28; 95% CI, 2.01-5.35), Filipino (aOR, 1.94; 95% CI, 1.11-3.42), Japanese (aOR, 1.58; 95% CI, 1.01-2.48), and untreated (aOR, 2.29; 95% CI, 1.09-4.80). Compared with breast-conserving surgery (BCS) alone, there was a decreased likelihood of iiSBC among women receiving BCS and radiotherapy (aOR, 0.45; 95% CI, 0.27-0.75), BCS and systemic treatment with or without radiotherapy (aOR, 0.40; 95% CI, 0.23-0.69), mastectomy only (aOR, 0.23; 95% CI, 0.13-0.39), and mastectomy and systemic treatment (aOR, 0.57; 95% CI, 0.33-0.96). Women who developed an icSBC were more likely to be Native Hawaiian (aOR, 1.69; 95% CI, 1.10-2.61) or Filipino (aOR, 1.70; 95% CI, 1.10-2.63). Risk of both iiSBC and icSBC decreased in the later years of diagnosis (2000-2017) compared with the earlier years (1973-1999).

Conclusions and Relevance

This study suggests that Native Hawaiian and Filipino women who initially received a diagnosis of DCIS were more likely to subsequently develop both iiSBC and icSBC. Japanese women and younger women were more likely to develop iiSBC. Subpopulation disaggregation may help guide clinical treatment and screening decisions for at-risk subpopulations.

Disaggregating Pacific Islanders and major Asian subpopulations to reveal hidden breast cancer disparities

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Background: The Asian American, Native Hawaiian, and Other Pacific Islander (AA/NHPI) population is the fastest growing and most socioeconomically heterogeneous racial/ethnic group in the US. AA/NHPI breast cancer outcomes are often reported as superior to Non-Hispanic Whites (NHW) however evidence suggests aggregating AA/NHPI masks disparities among subpopulations. As NHPI is often ignored as one of five official US races, this study aims to disaggregate AA and NHPI to unmask breast cancer disparities. Methods: An IRB exempt, retrospective cohort study using the National Cancer Database was conducted for women diagnosed with breast cancer in 2004-2016. AA and NHPI patients were compared with the majority NHW group. AA was separated into pertinent geographical origins: East Asian (EA; Chinese, Japanese, Korean), South Asian (SA; Indian, Pakistani), and Southeast Asian (SEA; Filipino, Vietnamese, Laotian, Hmong, Cambodian). Descriptive statistics were used. Logistic and Cox proportional hazard regressions assessed adjusted Odds Ratios (aORs) and adjusted Hazards Ratios (aHR), respectively, with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, insurance, income, rural/urban, education, hospital region, hospital distance, Deyo comorbidity score) and cancer characteristics (grade, stage, metastases, diagnosis year, hormone status). Results: Of 2,073,822 women there were 28,311 EA, 13,259 SA, 21,645 SEA, 5,375 NHPI, and 2,005,232 NHW. The median age was 62 years with median 66 month follow-up. Compared to NHW (9.6%), presentation with late-stage disease (Stage III/IV) was higher in NHPI (12%), SA (12%), and SEA (11%), but not EA (7.5%). On adjusted analysis (Table), EA was the only group with a statistical difference from NHW with aOR=0.85 (95%CI=0.76-0.94). Kaplan-Meier test for overall survival (OS) showed differences between ethnic/racial groups with NHPI having worse OS than AA subpopulations (p<0.0001). On adjusted analysis (Table), all AA subpopulations had lower risk of death compared to NHW: EA (aHR=0.69; 95%CI=0.64-0.74), SA (aHR=0.65; 95CI=0.59-0.71), and SEA (aHR=0.78; 95%CI=0.73-0.84) however the NHPI group had a greater risk of death (aHR=1.14; 95%CI=1.02-1.28). Conclusions: NHPI women with breast cancer have worse outcomes compared to NHW. This is masked by superior AA outcomes when aggregated. The continual improper aggregation of AA with NHPI downplays NHPI cancer disparities. Proper disaggregation of NHPI from AA warrants greater attention.[Table: see text]

Health care costs for adolescents and young adults with cancer: a Wisconsin community-based hospital study between 2005 and 2020

INTRODUCTION

Adolescents and young adults (AYA) with cancer are at risk of high cumulative healthcare system costs potentially associated with poor health and financial outcomes. Although this has been studied at academic centers, little data on AYA costs at community-based practices exist. The goals of this study were to understand direct health care costs for AYA patients, identify factors for high costs, and assess how total health care costs may relate to survival.

METHODS

AYA patients (15-39 years) treated at a community hospital in Wisconsin (USA) between 2005 and 2020 were identified. Patient demographics, cancer characteristics, therapies, support services, and all direct health care charges (including up to 1 year prior to diagnosis to capture any diagnostic workup) were collected. Logistic and Cox proportional hazard regression models identified factors associated with high costs and survival, respectively.

RESULTS

The 388 AYA patients had a median follow-up of 9 years (97% survival). Most were 30-39 years (62%), female (61%), white (95%), diagnosed early-stage (85%), and underwent surgery (83%). Complete health care costs were available for 233 patients (60%). Median total costs per patient were $123 K (range, $73-$215 K). On adjusted analysis, higher direct health care costs (> $125 K) were associated with greater odds of hospital admissions (odds ratio [OR] = 1.7, 95% CI = 1.35-2.27), chemotherapy (OR = 4.1, 95% CI = 1.44-12.70), and breast cancer diagnosis (OR = 3.8, 95% CI = 1.07-14.70). Living farther from the hospital (OR = 0.1, 95% CI = 0.02-0.50), later year of diagnosis (OR = 0.7, 95% CI = 0.55-0.77), and uninsured/unknown insurance status (OR = 0.1, 95% CI = 0.01-0.57) were associated with decreased odds of having higher health care costs. On adjusted analysis, death was associated with greater odds of higher direct health care costs per $125 K (hazards ratio [HR] = 7.9, 95% CI = 2.22-27.80) and radiation (HR = 31.8, 95% CI = 3.15-321) but lower odds of hormone therapy (HR = 0.1, 95% CI = 0.01-0.72) and later year of diagnosis (HR = 0.3, 95% CI = 0.12-0.60).

CONCLUSION

High direct health care costs among AYA patients are associated with hospital admissions, chemotherapy, breast cancer diagnosis, hospital proximity, and earlier year of diagnosis. Death was associated with high direct health care costs, earlier years of diagnosis, and radiation therapy. Total health care costs in community-based hospitals should be considered in the context of AYA patients with cancer.

Why an Increasing Number of Unmatched Residency Positions in Radiation Oncology? A Survey of Fourth-Year Medical Students

Purpose

The number of US fourth-year medical students applying to radiation oncology has decreased during the past few years. We conducted a survey of fourth-year medical students to examine factors that may be influencing the decision to pursue radiation oncology.

Methods and Materials

An anonymous online survey was sent to medical students at 9 participating US medical schools.

Results

A total of 232 medical students completed the survey. Of the 153 students who stated they were never interested in radiation oncology, 77 (50%) reported never having been exposed to the specialty as their reason for not pursuing radiation oncology. The job market was the most commonly cited factor among students who said they were once interested in but ultimately chose not to pursue radiation oncology. Conversely, the recent low pass rates for board examinations and a perception of a lack of diversity within radiation oncology had the least influence.

Conclusions

Despite discussion of potential measures to address this disquieting trend, there have been minimal formal attempts to characterize and address potential causes of a decreasing interest in radiation oncology. This study's data are consistent with previous research regarding the trend of decreased medical student interest in radiation oncology and may be used as part of ongoing introspective assessment to inform future change within radiation oncology.

Health care costs among adolescent young adults with cancer at a community-based hospital

e18857

Background: Adolescent Young Adults (AYAs) are likely to live for decades after a cancer diagnosis and thus have the potential to accumulate high healthcare costs. Prior research has shown high costs can be associated with increased risk of morbidity and mortality. However, there is limited understanding of how costs impact AYAs, especially in a community hospital. The purpose of this study is to 1) understand total community hospital healthcare costs for AYA patients with cancer, 2) identify risk factors for high costs, and 3) assess the impact of costs on survival. Methods: AYA patients (ages 15-29) treated at a community hospital were identified. Data collected included patient demographics, cancer characteristics, treatments (chemotherapy, radiation, surgery, immunotherapy, hormone therapy), support services (financial counseling, social work, survivorship), hospital admissions, miles from the hospital (great-circle distance), and all healthcare charges from one year prior to cancer diagnosis until last follow-up between 2000-2020. Multivariate logistic regression analyses were used to identify patients with costs greater than the median ($125K). Cox Proportional Hazard (CPH) regression models were used to identify factors associated with the risk of all-cause mortality. Results: A total of 388 AYA patients were identified with a median follow-up of 9 years and 97% survival. Most patients were age 30-39 years (62%), female (61%), white (95%), married (63%), non-smoker (59%), had insurance (78%), had early-stage cancer (85%), and were treated with surgery (83%). The most common cancers were melanoma (17%), breast cancer (14%), and thyroid cancer (14%). Median distance from treatment site was 23 miles. Median number of admissions was one. About a third of patients received chemotherapy (37%), radiation (28%), or hormone therapy (30%). Two-hundred thirty-three patients (60%) had complete healthcare cost data with a median total costs per patient of $123K (range, $73K-$215K). In adjusted analysis, patients with higher than median healthcare cost ( > $125K) had greater odds of hospital admission (odds ratio [OR] = 1.5, p < .001) and chemotherapy treatment (OR = 3.4, p = .005) as well as lower odds of living further from the hospital per one mile (OR = 0.3, p = .049) and being uninsured/unknown insurance (OR = 0.1, p = .047). In adjusted analysis, increased risk of death was associated with receiving radiation therapy (HR = 7.8, p = .02) and higher healthcare costs per $125K (HR = 3.8, p = .001). Conclusions: High costs of healthcare among AYA patients with cancer are related to chemotherapy, hospital admissions, and hospital proximity. High healthcare costs and radiation therapy may be associated with increased risk of death in the AYA population. This data may guide physician decision making for AYA patients ensuring mindfulness of high costs of care and how it relates to poor survival outcomes in community hospitals.

Racial disparities among women who develop invasive secondary breast cancer

e18523

Background: Noninvasive breast cancers ( e.g. ductal and lobular carcinoma in situ) are highly treatable nonobligate precursors to invasive breast cancers. However, even after treatment, some women develop second breast cancers (SBCs), increasing their mortality risk. Prognosticators may inform treatment recommendations for women at higher risk of SBC. In this study, risk factors for SBC were evaluated using deidentified data from the Hawaiʻi Tumor Registry (HTR), an NCI SEER registry. The HTR covers a uniquely multiethnic, statewide population allowing for elucidation of disparities in understudied U.S. populations. Methods: Women initially diagnosed between 1973-2017 with noninvasive (ductal and lobular) breast cancer were identified. Patient demographics, cancer characteristics, and treatment information were collected. Univariate (UVA) and multivariate (MVA) logistic regression analyses were used to identify factors associated with SBC, defined as a breast cancer diagnosis > 6 months after their prior cancer. Results: Of 7,057 women diagnosed with a first noninvasive breast cancer, 696 (10%) developed SBC. Invasive ipsilateral (iiSBC) and invasive contralateral (icSBC) disease represented 9% and 20% of patients who developed SBC, respectively. The five most prevalent ethnic groups were Chinese, Filipino, Japanese, Native Hawaiian, and White. When adjusting for confounders, women who developed iiSBC were more likely to be Native Hawaiian (odds ratio [OR] = 3.20, 95% CI = 2.07-4.94) or Filipino (OR = 1.72, 95%CI = 1.02-2.91) when compared to Whites; diagnosed between 1990-1999 (OR = 2.06, 95%CI = 1.27-3.34); and not have undergone surgical treatment (OR = 2.93, 95%CI = 1.42-6.04). Women who developed iiSBC were less likely to be > 50 years old (OR = 0.67, 95%CI = 0.49-0.90); diagnosed between 2010-2017 (OR = 0.18, 95%CI = 0.09-0.35); received lumpectomy with radiation therapy (OR = 0.54, 95%CI = 0.35-0.72); and undergone mastectomy (OR = 0.48, 95%CI = 0.32-0.72). Women who developed an icSBC were more likely to be Native Hawaiian (OR = 1.58, 95%CI = 1.06-2.35) or Filipino (OR = 1.60, 95%CI = 1.06-2.42). These women were also less likely to have been diagnosed between 2010-2017 (OR = 0.30, 95%CI = 0.17-0.53). On a subset analysis separating all patients with SBC by first course treatment type, there were no statistically significant differences for treatment type based on race/ethnicity. Conclusions: Overall, in this observational study, Native Hawaiian women, Filipino women, and younger women had increased odds of developing invasive SBC. This study highlights racial disparities in SBC development risk that was not previously appreciated among disaggregated groups of Pacific Islanders and Asian women when compared to White women. This may help oncologists understand the risk of developing SBC in these understudied populations.

Abstract PO-067: The transactivation domain of TWIST1 is required for TWIST1-induced aggressiveness in non-small cell lung cancer

Non-small cell lung carcinoma (NSCLC) is the most common cause of cancer mortality. Although therapeutic advances have been made, resistance to treatments remain high and the overall survival is still dismal. The high expression of the transcription factor TWIST1 strongly correlates with invasive and metastatic cancers, and is generally attributed to the epithelial-to-mesenchymal transition phenotype. We have demonstrated that TWIST1 can antagonize the induction of fail-safe programs as oncogene (KrasG12D)-induced senescence (OIS) in primary NSCLC tumor. OIS suppression by TWIST1 required increased global O-GlcNAcylation, which perhaps can also impact DNA repair and radiation response. As TWIST1 is essential for development, deciphering the critical domains and downstream transcriptional targets required for pro-tumorigenicity and radioresistance may allow the identification of new therapeutic strategies by targeting TWIST1. We created a transactivation-null TWIST1 mutant, by mutation of phenylalanine 191 to glycine, genetically engineered mouse model (GEMM) utilizing the tetracycline-inducible gene expression system. In these GEMMs, doxycycline treatment allows a concomitant induction of KrasG12D oncogene (R) with TWIST1 (T) or with TWIST1F191G mutant (F) expression, specifically in the lung epithelium directed by CCSP promoter-rtTA (C) transgene. CRT mice presented a more aggressive tumor progression and a shorter survival (median= 15.6 weeks) compared to CR (31 weeks). TWIST1F191G expression in CRF abrogates these effects (26.7 weeks) suggesting that the TWIST1 transactivation domain is required for TWIST1-dependent accelerated tumorigenesis. CRT mice, HBEC, and H460 cells overexpressing TWIST1 showed radiation resistance. A second KrasG12D lung tumor GEMM with induction of TWIST1 prior to 15Gy lung tumor irradiation showed lung tumor stasis compared to regression without TWIST1 expression. Histological analysis showed a strong expression of TWIST1 in CRT lungs while CRF showed a progressive loss over time suggesting that TWIST1F191G was non-functional and conferred no selective advantage. CRT mice also had lung tumors with higher proliferation (by Ki67), reduced apoptosis (by cleaved caspase3) and a decreased cell cycle arrest (by p16) compared to CR lung tumors. In comparison, CRF mice lung tumors did not show any change in cell death but showed increased p16 cell cycle arrest marker suggesting that the transactivation domain of TWIST1 is important for the suppression of OIS. We are exploring similar in vitro phenotypes using a primary immortalized HBEC cell lines co-transfected with HRasG12V oncogene and TWIST1 versus TWIST1 transactivation mutant. In future work, we are investigating the role of the TWIST1 transactivation domain in the induction of O-GlcNAcylation and the stabilization and/or activation of critical targets for OIS suppression and radiation resistance, with the goal of identifying new therapeutic targets and radiosensitizers.

Citation Format: Audrey Lafargue, Hailun Wang, Sivarajan T. Chettiar, Rajendra P. Gajula, Caleb Smack, Ismaeel Siddiqui, Kekoa Taparra, Christine Lam, Francesca Carrieri, Katriana Nugent, Natasha Zachara, Phuoc T. Tran. The transactivation domain of TWIST1 is required for TWIST1-induced aggressiveness in non-small cell lung cancer [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr PO-067.

Away Rotations, Interviews, and Rank Lists: Radiation Oncology Residency Applicant Perspectives on the 2020 Match Process

Purpose

Using 2020 match applicants, the purpose of this study was to identify baseline applicant perspectives on the match process surveying (1) away rotations, (2) interview/postinterview communications, and (3) factors influencing applicant rank order lists.

Methods and Materials

Applicants in the 2020 match cycle at a large radiation oncology (RO) residency program received a questionnaire covering demographics and the match process: away rotations, interview/postinterview communications, and ranking. Univariable and multivariable logistic regression analyses were used to identify factors associated with completing fewer away rotations.

Results

Of 141 surveys sent, 76 were completed, for a response rate of 54%. Most applicants were White, male, and matched into RO. One in 3 applicants did not have a home RO program. Most applicants completed 2 RO rotations (ie, a home rotation and an additional away rotation; range, 0-4 total rotations); RO rotations influenced the applicant rank order lists and the ultimate match result for 94% and 79% of applicants, respectively. Forty-seven percent of applicants reported being asked inappropriate questions during the interview (eg, parental or marital status). Applicants did not perceive a consistent message regarding postinterview communications from program directors. Most applicants were contacted postinterview. Interviews cost most applicants more than $5000. Thirty-seven percent of respondents reported submitting a letter of interest after the interview, hoping to improve their rank. When applying to programs, general reputation and location were the most common influential factors mentioned. When ranking programs, informal conversations with residents and program culture observations were the most common influential factors mentioned. Based on multivariable analysis, applicants who completed fewer RO rotations (including away rotations) had greater odds of matching to their home program (odds ratio [OR], 12.05; 95% CI, 1.27-206.69), lower odds of program location influencing where to apply (OR, 0.04; 95% CI, 0.003-0.37), and lower odds of the program's general reputation affecting their rank list (OR, 0.04; 95% CI, 0.001-0.47).

Conclusions

The results suggest that medical students perceive away rotations as an important influencer of their match process. Although applicants and program directors both participate in postinterview communications, interactions with residents influence rank order lists. These data may serve as an up-to-date baseline to evaluate the influence of the COVID-19 pandemic on the RO match process.