Identification of genetically predicted DNA methylation markers associated with non-small cell lung cancer risk among 34,964 cases and 448,579 controls

BACKGROUND

Although the associations between genetic variations and lung cancer risk have been explored, the epigenetic consequences of DNA methylation in lung cancer development are largely unknown. Here, the genetically predicted DNA methylation markers associated with non-small cell lung cancer (NSCLC) risk by a two-stage case-control design were investigated.

METHODS

The genetic prediction models for methylation levels based on genetic and methylation data of 1595 subjects from the Framingham Heart Study were established. The prediction models were applied to a fixed-effect meta-analysis of screening data sets with 27,120 NSCLC cases and 27,355 controls to identify the methylation markers, which were then replicated in independent data sets with 7844 lung cancer cases and 421,224 controls. Also performed was a multi-omics functional annotation for the identified CpGs by integrating genomics, epigenomics, and transcriptomics and investigation of the potential regulation pathways.

RESULTS

Of the 29,894 CpG sites passing the quality control, 39 CpGs associated with NSCLC risk (Bonferroni-corrected p ≤ 1.67 × 10-6 ) were originally identified. Of these, 16 CpGs remained significant in the validation stage (Bonferroni-corrected p ≤ 1.28 × 10-3 ), including four novel CpGs. Multi-omics functional annotation showed nine of 16 CpGs were potentially functional biomarkers for NSCLC risk. Thirty-five genes within a 1-Mb window of 12 CpGs that might be involved in regulatory pathways of NSCLC risk were identified.

CONCLUSIONS

Sixteen promising DNA methylation markers associated with NSCLC were identified. Changes of the methylation level at these CpGs might influence the development of NSCLC by regulating the expression of genes nearby.

PLAIN LANGUAGE SUMMARY

The epigenetic consequences of DNA methylation in lung cancer development are still largely unknown. This study used summary data of large-scale genome-wide association studies to investigate the associations between genetically predicted levels of methylation biomarkers and non-small cell lung cancer risk at the first time. This study looked at how well larotrectinib worked in adult patients with sarcomas caused by TRK fusion proteins. These findings will provide a unique insight into the epigenetic susceptibility mechanisms of lung cancer.

Lung Cancer in Ever- and Never-Smokers: Findings from Multi-Population GWAS Studies

BACKGROUND

Clinical, molecular, and genetic epidemiology studies displayed remarkable differences between ever- and never-smoking lung cancer.

METHODS

We conducted a stratified multi-population (European, East Asian, and African descent) association study on 44,823 ever-smokers and 20,074 never-smokers to identify novel variants that were missed in the non-stratified analysis. Functional analysis including expression quantitative trait loci (eQTL) colocalization and DNA damage assays, and annotation studies were conducted to evaluate the functional roles of the variants. We further evaluated the impact of smoking quantity on lung cancer risk for the variants associated with ever-smoking lung cancer.

RESULTS

Five novel independent loci, GABRA4, intergenic region 12q24.33, LRRC4C, LINC01088, and LCNL1 were identified with the association at two or three populations (P < 5 × 10-8). Further functional analysis provided multiple lines of evidence suggesting the variants affect lung cancer risk through excessive DNA damage (GABRA4) or cis-regulation of gene expression (LCNL1). The risk of variants from 12 independent regions, including the well-known CHRNA5, associated with ever-smoking lung cancer was evaluated for never-smokers, light-smokers (packyear ≤ 20), and moderate-to-heavy-smokers (packyear > 20). Different risk patterns were observed for the variants among the different groups by smoking behavior.

CONCLUSIONS

We identified novel variants associated with lung cancer in only ever- or never-smoking groups that were missed by prior main-effect association studies.

IMPACT

Our study highlights the genetic heterogeneity between ever- and never-smoking lung cancer and provides etiologic insights into the complicated genetic architecture of this deadly cancer.

CYP2A6 Activity and Cigarette Consumption Interact in Smoking-Related Lung Cancer Susceptibility

Cigarette smoke, containing both nicotine and carcinogens, causes lung cancer. However, not all smokers develop lung cancer, highlighting the importance of the interaction between host susceptibility and environmental exposure in tumorigenesis. Here, we aimed to delineate the interaction between metabolizing ability of tobacco carcinogens and smoking intensity in mediating genetic susceptibility to smoking-related lung tumorigenesis. Single-variant and gene-based associations of 43 tobacco carcinogen-metabolizing genes with lung cancer were analyzed using summary statistics and individual-level genetic data, followed by causal inference of Mendelian randomization, mediation analysis, and structural equation modeling. Cigarette smoke-exposed cell models were used to detect gene expression patterns in relation to specific alleles. Data from the International Lung Cancer Consortium (29,266 cases and 56,450 controls) and UK Biobank (2,155 cases and 376,329 controls) indicated that the genetic variant rs56113850 C>T located in intron 4 of CYP2A6 was significantly associated with decreased lung cancer risk among smokers (OR = 0.88, 95% confidence interval = 0.85-0.91, P = 2.18 × 10-16), which might interact (Pinteraction = 0.028) with and partially be mediated (ORindirect = 0.987) by smoking status. Smoking intensity accounted for 82.3% of the effect of CYP2A6 activity on lung cancer risk but entirely mediated the genetic effect of rs56113850. Mechanistically, the rs56113850 T allele rescued the downregulation of CYP2A6 caused by cigarette smoke exposure, potentially through preferential recruitment of transcription factor helicase-like transcription factor. Together, this study provides additional insights into the interplay between host susceptibility and carcinogen exposure in smoking-related lung tumorigenesis.

SIGNIFICANCE

The causal pathway connecting CYP2A6 genetic variability and activity, cigarette consumption, and lung cancer susceptibility in smokers highlights the need for behavior modification interventions based on host susceptibility for cancer prevention.

Impact of individual level uncertainty of lung cancer polygenic risk score (PRS) on risk stratification

BACKGROUND

Although polygenic risk score (PRS) has emerged as a promising tool for predicting cancer risk from genome-wide association studies (GWAS), the individual-level accuracy of lung cancer PRS and the extent to which its impact on subsequent clinical applications remains largely unexplored.

METHODS

Lung cancer PRSs and confidence/credible interval (CI) were constructed using two statistical approaches for each individual: (1) the weighted sum of 16 GWAS-derived significant SNP loci and the CI through the bootstrapping method (PRS-16-CV) and (2) LDpred2 and the CI through posteriors sampling (PRS-Bayes), among 17,166 lung cancer cases and 12,894 controls with European ancestry from the International Lung Cancer Consortium. Individuals were classified into different genetic risk subgroups based on the relationship between their own PRS mean/PRS CI and the population level threshold.

RESULTS

Considerable variances in PRS point estimates at the individual level were observed for both methods, with an average standard deviation (s.d.) of 0.12 for PRS-16-CV and a much larger s.d. of 0.88 for PRS-Bayes. Using PRS-16-CV, only 25.0% of individuals with PRS point estimates in the lowest decile of PRS and 16.8% in the highest decile have their entire 95% CI fully contained in the lowest and highest decile, respectively, while PRS-Bayes was unable to find any eligible individuals. Only 19% of the individuals were concordantly identified as having high genetic risk (> 90th percentile) using the two PRS estimators. An increased relative risk of lung cancer comparing the highest PRS percentile to the lowest was observed when taking the CI into account (OR = 2.73, 95% CI: 2.12-3.50, P-value = 4.13 × 10-15) compared to using PRS-16-CV mean (OR = 2.23, 95% CI: 1.99-2.49, P-value = 5.70 × 10-46). Improved risk prediction performance with higher AUC was consistently observed in individuals identified by PRS-16-CV CI, and the best performance was achieved by incorporating age, gender, and detailed smoking pack-years (AUC: 0.73, 95% CI = 0.72-0.74).

CONCLUSIONS

Lung cancer PRS estimates using different methods have modest correlations at the individual level, highlighting the importance of considering individual-level uncertainty when evaluating the practical utility of PRS.

Overview of approaches to estimate real-world disease progression in lung cancer

BACKGROUND

Randomized clinical trials of novel treatments for solid tumors normally measure disease progression using the Response Evaluation Criteria in Solid Tumors. However, novel, scalable approaches to estimate disease progression using real-world data are needed to advance cancer outcomes research. The purpose of this narrative review is to summarize examples from the existing literature on approaches to estimate real-world disease progression and their relative strengths and limitations, using lung cancer as a case study.

METHODS

A narrative literature review was conducted in PubMed to identify articles that used approaches to estimate real-world disease progression in lung cancer patients. Data abstracted included data source, approach used to estimate real-world progression, and comparison to a selected gold standard (if applicable).

RESULTS

A total of 40 articles were identified from 2008 to 2022. Five approaches to estimate real-world disease progression were identified including manual abstraction of medical records, natural language processing of clinical notes and/or radiology reports, treatment-based algorithms, changes in tumor volume, and delta radiomics-based approaches. The accuracy of these progression approaches were assessed using different methods, including correlations between real-world endpoints and overall survival for manual abstraction (Spearman rank ρ = 0.61-0.84) and area under the curve for natural language processing approaches (area under the curve = 0.86-0.96).

CONCLUSIONS

Real-world disease progression has been measured in several observational studies of lung cancer. However, comparing the accuracy of methods across studies is challenging, in part, because of the lack of a gold standard and the different methods used to evaluate accuracy. Concerted efforts are needed to define a gold standard and quality metrics for real-world data.

Cancer survivors' health behaviors and outcomes: a population-based study of sexual and gender minorities

BACKGROUND

Most case-control studies compare cancer survivors with general population controls without considering sexual orientation or gender identity. This case-control analysis compared health risk behaviors and health outcomes among sexual and gender minority cancer survivors to those of matched sexual and gender minority participants without cancer (controls).

METHODS

Using data from the 2014-2021 Behavioral Risk Factor Surveillance System, a population-based sample of 4507 cancer survivors who self-identified as transgender, gay men, bisexual men, lesbian women, or bisexual women were 1:1 propensity score matched, using age at survey, race and ethnicity, marital status, education, access to health care, and US census region. Within each sexual and gender minority group, behaviors and outcomes were compared between survivors and participants without cancer, and survivors' odds ratios and 95% confidence intervals calculated.

RESULTS

Gay male survivors had higher odds of depression, poor mental health, limited usual activities, difficulty concentrating, and fair or poor health. Few differences were observed between bisexual male survivors and participants without cancer. Compared with controls, lesbian female survivors had greater odds of overweight-obese status, depression, poor physical health, and fair or poor health. Bisexual female survivors had the highest rates of current smoking, depression, poor mental health, and difficulty concentrating across all sexual and gender minority groups. Statistically significantly different from transgender controls, transgender survivors had greater odds of heavy alcohol use, physical inactivity, and fair or poor health.

CONCLUSIONS

This analysis revealed an urgent need to address the high prevalence of engaging in multiple health risk behaviors and not following guidelines to avoid second cancers, additional adverse outcomes, and cancer recurrences among sexual and gender minority cancer survivors.

Examining disparities in large-scale patient-reported data capture using digital tools among cancer patients at clinical intake

BACKGROUND

Patient-reported data can improve quality of healthcare delivery and patient outcomes. Moffitt Cancer Center ("Moffitt") administers the Electronic Patient Questionnaire (EPQ) to collect data on demographics, including sexual orientation and gender identity (SOGI), medical history, cancer risk factors, and quality of life. Here we investigated differences in EPQ completion by demographic and cancer characteristics.

METHODS

An analysis including 146,142 new adult patients at Moffitt in 2009-2020 was conducted using scheduling, EPQ and cancer registry data. EPQ completion was described by calendar year and demographics. Logistic regression was used to estimate associations between demographic/cancer characteristics and EPQ completion. More recently collected information on SOGI were described.

RESULTS

Patient portal usage (81%) and EPQ completion rates (79%) were consistently high since 2014. Among patients in the cancer registry, females were more likely to complete the EPQ than males (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.14-1.20). Patients ages 18-64 years were more likely to complete the EPQ than patients aged ≥65. Lower EPQ completion rates were observed among Black or African American patients (OR = 0.59, 95% CI = 0.56-0.63) as compared to Whites and among patients whose preferred language was Spanish (OR = 0.40, 95% CI = 0.36-0.44) or another language as compared to English. Furthermore, patients with localized (OR = 1.16, 95% CI = 1.12-1.19) or regional (OR = 1.16, 95% CI = 1.12-1.20) cancer were more likely to complete the EPQ compared to those with metastatic disease. Less than 3% of patients self-identified as being lesbian, gay, or bisexual and <0.1% self-identified as transgender, genderqueer, or other.

CONCLUSIONS

EPQ completion rates differed across demographics highlighting opportunities for targeted process improvement. Healthcare organizations should evaluate data acquisition methods to identify potential disparities in data completeness that can impact quality of clinical care and generalizability of self-reported data.

Association between duration of smoking abstinence before non-small-cell lung cancer diagnosis and survival: a retrospective, pooled analysis of cohort studies

BACKGROUND

The association between duration of smoking abstinence before non-small-cell lung cancer (NSCLC) diagnosis and subsequent survival can influence public health messaging delivered in lung-cancer screening. We aimed to assess whether the duration of smoking abstinence before diagnosis of NSCLC is associated with improved survival.

METHODS

In this retrospective, pooled analysis of cohort studies, we used 26 cohorts participating in Clinical Outcomes Studies of the International Lung Cancer Consortium (COS-ILCCO) at 23 hospitals. 16 (62%) were from North America, six (23%) were from Europe, three (12%) were from Asia, and one (4%) was from South America. Patients enrolled were diagnosed between June 1, 1983, and Dec 31, 2019. Eligible patients had smoking data before NSCLC diagnosis, epidemiological data at diagnosis (obtained largely from patient questionnaires), and clinical information (retrieved from medical records). Kaplan-Meier curves and multivariable Cox models (ie, adjusted hazard ratios [aHRs]) were generated with individual, harmonised patient data from the consortium database. We estimated overall survival for all causes, measured in years from diagnosis date until the date of the last follow-up or death due to any cause and NSCLC-specific survival.

FINDINGS

Of 42 087 patients with NSCLC in the COS-ILCCO database, 21 893 (52·0%) of whom were male and 20 194 (48·0%) of whom were female, we excluded 4474 (10·6%) with missing data. Compared with current smokers (15 036 [40·0%] of 37 613), patients with 1-3 years of smoking abstinence before NSCLC diagnosis (2890 [7·7%]) had an overall survival aHR of 0·92 (95% CI 0·87-0·97), patients with 3-5 years of smoking abstinence (1114 [3·0%]) had an overall survival aHR of 0·90 (0·83-0·97), and patients with more than 5 years of smoking abstinence (10 841 [28·8%]) had an overall survival aHR of 0·90 (0·87-0·93). Improved NSCLC-specific survival was observed in 4301 (44%) of 9727 patients who had quit cigarette smoking and was significant at abstinence durations of more than 5 years (aHR 0·87, 95% CI 0·81-0·93). Results were consistent across age, sex, histology, and disease-stage distributions.

INTERPRETATION

In this large, pooled analysis of cohort studies across Asia, Europe, North America, and South America, overall survival was improved in patients with NSCLC whose duration of smoking abstinence before diagnosis was as short as 1 year. These findings suggest that quitting smoking can improve overall survival, even if NSCLC is diagnosed at a later lung-cancer screening visit. These findings also support the implementation of public health smoking cessation strategies at any time.

FUNDING

The Alan B Brown Chair, The Posluns Family Fund, The Lusi Wong Fund, and the Princess Margaret Cancer Foundation.

Psychosocial characteristics and quality of life among sexual and gender minority patients with cancer

BACKGROUND

Underserved and minoritized patients with cancer often experience more psychosocial concerns and inferior quality of life (QOL) compared with majority populations. This study compared patient-reported psychosocial characteristics and QOL among self-identified sexual and gender minority patients with cancer vs cisgender-heterosexual patients with cancer treated at a National Cancer Institute-designated comprehensive cancer center in the United States.

METHODS

Self-report data from 51 503 patients were obtained from an institutional standard-of-care electronic patient questionnaire that was completed prior to, or on the day of, the patient's initial visit. The electronic patient questionnaire collects demographic information, including sexual orientation and gender identity, psychosocial variables, and QOL using the validated Short Form Health Survey-12. Sexual orientation and gender identity information was used to identify self-identified sexual and gender minority and cisgender-heterosexual persons (ie, non-self-identified sexual and gender minority). Using parametric analyses, psychosocial variables and QOL measures were compared for self-identified sexual and gender minority vs non-self-identified sexual and gender minority patients with cancer.

RESULTS

Compared with non-self-identified sexual and gender minority patients (n = 50 116), self-identified sexual and gender minority patients (n = 1387, 2.7%) reported statistically significantly greater concerns regarding getting help during treatment (2.6% vs 4.3%, respectively; P = .001) and concerns with ability to seek care (16.7% vs 21.6%, respectively, P < .001). Self-identified sexual and gender minority patients reported statistically significantly elevated mental health concerns and daily emotional and pain interference (all P < .001), whereas there was no statistically significant difference in daily interference due to physical functioning.

CONCLUSION

These data reveal real-world disparities among self-identified sexual and gender minority patients with cancer, which can be used to develop psychosocial interventions tailored to address the unique psychosocial and QOL needs of this underserved and minoritized population and to ultimately improve cancer care.

Patient-Reported Outcomes as Interradiographic Predictors of Response in Non-Small Cell Lung Cancer

PURPOSE

Minimally invasive biomarkers have been used as important indicators of treatment response and progression in cancers such as prostate and ovarian. Unfortunately, all biomarkers are not prognostic in all cancer types and are often not routinely collected. Patient-reported outcomes (PRO) provide a non-obtrusive, personalized measure of a patient's quality of life and symptomatology, reported directly from the patient, and are increasingly collected as part of routine care. Previous literature has shown correlations between specific PROs (i.e., insomnia, fatigue) and overall survival. Although promising, these studies often only consider single time points and ignore patient-specific dynamic changes in individual PROs, which might be early predictors of treatment response or progression.

EXPERIMENTAL DESIGN

In this study, PRO dynamics were analyzed to determine if they could be used as interradiographic predictors of tumor volume changes among 85 patients with non-small cell lung cancer undergoing immunotherapy. PRO questionnaires and tumor volume scans were completed biweekly and monthly, respectively. Correlation and predictive analysis were conducted to identify specific PROs that could accurately predict patient response.

RESULTS

Changes in tumor volume over time were significantly correlated with dizziness (P < 0.005), insomnia (P < 0.05), and fatigue (P < 0.05). In addition, cumulative changes in insomnia could predict progressive disease with a 77% accuracy, on average 45 days prior to the next imaging scan.

CONCLUSIONS

This study presents the first time that patient-specific PRO dynamics have been considered to predict how individual patients will respond to treatment. This is an important first step in adapting treatment to improve response rates.

Mosaic Chromosomal Alterations Are Associated With Increased Lung Cancer Risk: Insight From the INTEGRAL-ILCCO Cohort Analysis

INTRODUCTION

Mosaic chromosomal alterations (mCAs) detected in white blood cells represent a type of clonal hematopoiesis (CH) that is understudied compared with CH-related somatic mutations. A few recent studies indicated their potential link with nonhematological cancers, especially lung cancer.

METHODS

In this study, we investigated the association between mCAs and lung cancer using the high-density genotyping data from the OncoArray study of INTEGRAL-ILCCO, the largest single genetic study of lung cancer with 18,221 lung cancer cases and 14,825 cancer-free controls.

RESULTS

We identified a comprehensive list of autosomal mCAs, ChrX mCAs, and mosaic ChrY (mChrY) losses from these samples. Autosomal mCAs were detected in 4.3% of subjects, in addition to ChrX mCAs in 3.6% of females and mChrY losses in 9.6% of males. Multivariable logistic regression analysis indicated that the presence of autosomal mCAs in white blood cells was associated with an increased lung cancer risk after adjusting for key confounding factors, including age, sex, smoking status, and race. This association was mainly driven by a specific type of mCAs: copy-neutral loss of heterozygosity on autosomal chromosomes. The association between autosome copy-neutral loss of heterozygosity and increased risk of lung cancer was further confirmed in two major histologic subtypes, lung adenocarcinoma and squamous cell carcinoma. In addition, we observed a significant increase of ChrX mCAs and mChrY losses in smokers compared with nonsmokers and racial differences in certain types of mCA events.

CONCLUSIONS

Our study established a link between mCAs in white blood cells and increased risk of lung cancer.

Considerations and recommendations for mHealth interventions for substance use among Sexual and Gender Minority (SGM) individuals: A narrative review of the past 5 years

Purposeof Review

The prevalence of problematic substance use is disproportionately higher among sexual and gender minority (SGM) adults compared to adults in the general population. mHealth as a treatment modality could reduce barriers to accessing substance use treatments among SGM populations. Through a qualitative literature search, the current narrative review aimed to understand the lived experiences of SGM individuals who use substances and to synthesize recommendations made in the literature to inform future mHealth interventions.

Recent Findings

Positive and negative reinforcement motives were prominent reasons for substance use, which included SGM identity expression and conformity motives. Individual- and system-level treatment barriers included a lack of safe and nonjudgmental environment, shame and stigma, and limited knowledge about treatment options. Barriers were directly linked to the reported substance use treatment needs in this population.

Summary

On-demand app features, real-time intervention and assessment, and anonymity should be considered in future mHealth trials.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-023-00497-0.

Genome-wide association study of lung adenocarcinoma in East Asia and comparison with a European population

Lung adenocarcinoma is the most common type of lung cancer. Known risk variants explain only a small fraction of lung adenocarcinoma heritability. Here, we conducted a two-stage genome-wide association study of lung adenocarcinoma of East Asian ancestry (21,658 cases and 150,676 controls; 54.5% never-smokers) and identified 12 novel susceptibility variants, bringing the total number to 28 at 25 independent loci. Transcriptome-wide association analyses together with colocalization studies using a Taiwanese lung expression quantitative trait loci dataset (n = 115) identified novel candidate genes, including FADS1 at 11q12 and ELF5 at 11p13. In a multi-ancestry meta-analysis of East Asian and European studies, four loci were identified at 2p11, 4q32, 16q23, and 18q12. At the same time, most of our findings in East Asian populations showed no evidence of association in European populations. In our studies drawn from East Asian populations, a polygenic risk score based on the 25 loci had a stronger association in never-smokers vs. individuals with a history of smoking (Pinteraction = 0.0058). These findings provide new insights into the etiology of lung adenocarcinoma in individuals from East Asian populations, which could be important in developing translational applications.

Abstract 1916: Cancer disparities among sexual and gender minority patients at a National Cancer Institute-Designated Comprehensive Cancer Center

Background: Over the last several decades there have been concerted efforts to reduce health disparities among intersecting underserved populations including racial and ethnic, social class, disability, and geographic location. However, there have been limited efforts to identify and address cancer disparities by sexual orientation and gender identity (SOGI). We sought to identify differences in demographics, risk factors, clinical characteristics, and outcomes between sexual and gender minority (SGM) and non-SGM cancer patients.

Methods: Analysis include over 70,000 cancer patients at the Moffitt Cancer Center (Tampa, FL) who completed our Electronic Patient Questionnaire (EPQ) at their initial appointment. Moffitt’s EPQ is a standard-of-care (SOC) questionnaire instrument used to collect self-reported demographics, prior medical history, history of cancer, utilization of cancer screening services, and lifestyle risk factors. The SOGI items in the demographics section were used to categorize persons as a SGM or non-SGM. Cancer registry data were used to obtain clinical covariates on the patients that completed the EPQ.

Results: SGM patients represented 2.3% of the patient population. The mean age of SGM patients was significantly lower (mean=56) compared to non-SGM patients (mean=62.3, p= &lt;0.001). There was a higher prevalence of racial (10.1% vs 9.4%, p= &lt;0.001) and ethnic (11.5% vs 8.8%, p= &lt;0.001) minorities among SGM vs non-SGM patients. SGM patients were significantly more likely to be single (32.8% vs 10.3%, p= &lt;0.001). For modifiable risk factors, there were significantly more current smokers among SGM vs non-SGM patients (5.4% vs 3.1%, p= &lt;0.001) and SGM patients reported higher number of pack-years smoked (mean=22.5 vs mean=22.5, p= 0.007). SGM patients reported higher rates alcohol consumption, especially significantly higher rates of more than 5 drinks per day (8.1% vs 6.2%, p= &lt;0.001). SGM patients reported significantly higher rates of depression (35.1% vs 19.8%, p= &lt;0.001). SGM patients also reported less utilization in all forms of exercise such as moderate to vigorous physical activity or walking). SGM patients reported lower utilizing of fecal occult blood test (26.6% vs 32.3%, p= 0.026) and sigmoidoscopy/colonoscopy (75.1% vs 89.8%, p= &lt;0.001) for colorectal cancer screening compared to non-SGM patients. SGM patients had slightly higher rates of cancer diagnoses for GI, Endocrine, Sarcoma, GYN and associated with overall inferior survival (p= 0.001).

Discussion: The Moffitt Cancer Center began collecting SOGI information as SOC information on all new patients since 2016. In just 5 years of data collection, our institution has identified numerous real-world disparities among SGMs patients. These findings will be critical to develop tailored interventions to improve equality care across the cancer care continuum for SGM populations.

Citation Format: Shahrzad A. Zamani, Jaileene Perez-Morales, Jarred D. Miller, Matthew B. Schabath. Cancer disparities among sexual and gender minority patients at a National Cancer Institute-Designated Comprehensive Cancer Center [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1916.

Recurrence Patterns for Regionally Metastatic Melanoma Treated in the Era of Adjuvant Therapy: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this systematic review was to examine the timing and patterns of recurrence for patients with regionally metastatic melanoma on the basis of nodal management and receipt of adjuvant therapy.

METHODS

We identified randomized controlled trials and non-randomized studies published between 2010 and 2020 that reported timing and/or patterns of recurrence. We evaluated recurrence-free survival (RFS), location of recurrence, and surveillance strategy on the basis of receipt of adjuvant systemic therapy and nodal management with observation versus completion dissection. We compared differences in patterns of recurrence across studies using RevMan. RFS was evaluated graphically using point estimates and confidence intervals.

RESULTS

Among the 19 publications, there was wide variation in study populations, imaging surveillance regimens, and format of recurrence reporting. Patterns of disease recurrence did not differ between adjuvant and placebo/observation groups. A total of 11 studies reported RFS at variable time intervals, which ranged in adjuvant therapy groups (38-88% at 1 year, 29-67% at 2 years, 33-58% at 3 years, and 34-53% at 5 years) and placebo/observation groups (47-63% at 1 year, 39-47% at 2 years, 33-68% at 3 years, and 57% at 5 years). Anti-PD-1 immune therapy and BRAF/MEK inhibitor therapy were superior to placebo at year 1.

DISCUSSION

We found that adjuvant treatment improved RFS but did not alter the patterns of disease recurrence compared with patients managed without adjuvant systemic treatment. Future studies should separately report sites of disease recurrence on the basis of specific adjuvant systemic treatment and surveillance practices to better advise patients about their patterns and risk of recurrence.

"No one size fits all" A Multi-Method Survey of Oncology Allied Health Professionals Experiences with Lesbian, Gay, Bisexual, Transgender/Queer Questioning Adolescent, and Young Adult Patients with Cancer and Reproductive and Sexual Health"

Objectives: To assess training needs for providers who care for adolescent and young adult (AYA) lesbian, gay, bisexual, transgender/queer questioning (LGBTQ) cancer patients, we conducted a mixed-method survey. During their cancer care experience, AYA cancer patients experience physical, psychosocial, and reproductive health challenges. In addition to these challenges, AYA LGBTQ individuals are a diverse and medically underserved population who experience unique challenges and disparities in medical care. Methods: Health care providers (n = 351) who participated in our reproductive health in cancer training program completed a survey with 28 quantitative items and 4 open-ended items assessing knowledge, confidence discussing reproductive health, and confidence in knowledge specific to reproductive needs and general health needs among AYA LGBTQ patients. Results: Confidence discussing and confidence in knowledge of reproductive and general health needs are lower regarding transgender and nonbinary patients. Nearly half of providers (45%) demonstrated low knowledge, while 38% and 17% demonstrated moderate and high knowledge, respectively. Open comments indicated providers desired more training around the needs of Trans and nonbinary patients, and creating welcoming environments. Conclusions: The majority of our participants demonstrate low or moderate knowledge regarding factors that can influence AYA LGBTQ patient care, suggesting that this is a key area for improvement. Furthermore, improving provider knowledge may subsequently improve confidence in general and reproductive needs of LGBTQ patients, resulting in improved patient-centered care. Improving provider knowledge and confidence may then ultimately help reduce disparities in cancer care among this patient population.

Together-Equitable-Accessible-Meaningful (TEAM) Training to Improve Cancer Care for Sexual and Gender Minorities (SGM): Outcomes from a Pilot Study

To alleviate health disparities experienced by sexual and gender minority (SGM) patients, cancer care professionals need further education on the needs of SGM cancer patients and their loved ones and caregivers. The Together-Equitable-Accessible-Meaningful (TEAM) Training to Improve Cancer Care for SGM Patients (TEAM SGM) was developed and piloted to address this need. This study reports healthcare professional learner outcomes from the TEAM SGM pilot intervention. The TEAM SGM Training pilot consisted of 2.5 h of content from the original online self-paced TEAM Training plus 12 1-h Zoom sessions on specialized topics in addition to readings and activities. Participants (n = 28), representing seven cancer service organizations from six states in the USA, were recruited through newsletter listservs and social media. All participants (n = 28) completed the pre-test and twenty-two participants completed the post-test. Using five factors confirmed in a separate Confirmatory Factor Analysis, paired t-tests of TEAM SGM participant pre- and post-test data were conducted. Statistically significant improvements were found in four of five factors: Environmental Cues (t(21) = 2.56, p = .018), Knowledge (t(21) = 2.15, p = .043), Clinical Preparedness (t(7) = 3.89, p = .006), Clinical Behaviors (t(21) = 2.48, p = .022). The Attitudes factor was not significantly improved from pre-intervention to post-intervention likely due to strong affirming attitudes toward SGM patients at baseline. TEAM SGM is a feasible, effective training to build capacity in SGM-affirming care for cancer care providers.

Respiratory and Cardiometabolic Comorbidities and Stages I to III NSCLC Survival: A Pooled Analysis From the International Lung Cancer Consortium

INTRODUCTION

We explored the association of respiratory and cardiometabolic comorbidities with NSCLC overall survival (OS) and lung cancer-specific survival (LCSS), by stage, in a large, multicontinent NSCLC pooled data set.

METHODS

On the basis of patients pooled from 11 International Lung Cancer Consortium studies with available respiratory and cardiometabolic comorbidity data, adjusted hazard ratios (aHRs) were estimated using Cox models for OS. LCSS was evaluated using competing risk Grey and Fine models and cumulative incidence functions. Logistic regression (adjusted OR [aOR]) was applied to assess factors associated with surgical resection.

RESULTS

OS analyses used patients with NSCLC with respiratory health or cardiometabolic health data (N = 16,354); a subset (n = 11,614) contributed to LCSS analyses. In stages I to IIIA NSCLC, patients with respiratory comorbidities had worse LCCS (stage IA aHR = 1.51, confidence interval [CI]: 1.17-1.95; stages IB-IIIA aHR = 1.20, CI: 1.06-1.036). In contrast, patients with stages I to IIIA NSCLC with cardiometabolic comorbidities had a higher risk of death from competing (non-NSCLC) causes (stage IA aHR = 1.34, CI: 1.12-1.69). The presence of respiratory comorbidities was inversely associated with having surgical resection (stage IA aOR = 0.54, CI: 0.35-0.83; stages IB-IIIA aOR = 0.57, CI: 0.46-0.70).

CONCLUSIONS

The presence of either cardiometabolic or respiratory comorbidities is associated with worse OS in stages I to III NSCLC. Patients with respiratory comorbidities were less likely to undergo surgery and had worse LCSS, whereas patients with cardiometabolic comorbidities had a higher risk of death from competing causes. As more treatment options for stages I to III NSCLC are introduced into the practice, accounting for cardiometabolic and respiratory comorbidities becomes essential in trial interpretation and clinical management.

Cancer in Transgender and Gender-Diverse Persons: A Review

Importance

Transgender and gender-diverse individuals face unique challenges, including barriers to health care access and inequities in treatment, that may influence cancer risk and outcomes.

Observations

In this narrative review, a scoping review was conducted focusing on primary and secondary prevention and epidemiology of cancer, barriers to health care services, and health care practitioners' knowledge about specific issues pertaining to transgender and gender-diverse individuals. PubMed, the Cochrane Library, and Embase, were reviewed for citations from their inception to December 31, 2021. This review revealed that transgender and gender-diverse people had a high prevalence of tobacco consumption and alcohol use and high rates of infection with human papillomavirus (HPV) and HIV. Transgender and gender-diverse individuals were less likely to adhere to cancer screening programs and had a higher incidence of HIV- and HPV-associated cancers. Social and economic determinants seemed to drive these disparities in risk factors and outcomes. A lack of knowledge about gender minorities' health needs among health care practitioners was evidenced, and it represented a major hurdle to cancer prevention, care, and survivorship for transgender and gender-diverse individuals. Discrimination, discomfort caused by gender-labeled oncological services, stigma, and lack of cultural sensitivity of health care practitioners were other barriers met by transgender and gender-diverse persons in the oncology setting.

Conclusions and Relevance

The findings suggest that transgender and gender-diverse peoples' needs in the cancer care continuum are not optimally addressed. Effective solutions are needed to offer the best care to every patient in a person-centric and gender diversity-sensitive environment.

Assessing Medical Students' Attitudes and Knowledge Regarding LGBTQ Health Needs Across the United States

BACKGROUND

The lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community experiences health disparities. It is thus imperative that medical trainees receive training in the care of LGBTQ community. The objective of this study was to identify gaps in knowledge and comfort among medical school students in providing care for the LGBTQ community.

METHODS

An online survey was administered to medical students at 3 institutions in the United States from December 2020 to March 2021. Using a Likert scale, the survey assessed attitudes, comfort, and knowledge in providing care for the LGBTQ community. The survey included questions for each specific LGBTQ population. Results were quantified using descriptive and stratified analyses, and an exploratory factor analysis was used to calculate attitude summary measure (ASM) scores. A total knowledge score was calculated, with higher values indicating greater knowledge.

RESULTS

Among the 300 medical students who completed the survey, the majority were female (55.7%), White (54.7%), and heterosexual (64.3%). The majority of medical students felt comfortable (strongly agree/agree) participating in the care of lesbian (94.3%), gay (96.0%), and bisexual (96.3%) patients; this percentage dropped to 82.3% for non-binary and 71.3% for transgender patients. Only 27.0% of medical students reported confidence in their knowledge of health needs of transgender patients. LGBTQ self-identification, percent of core rotations completed in school, region of country, and friends and/or family who are part of the LGBTQ community were significantly associated with various ASM scores. Knowledge questions yielded high percentages of "neutral" responses, and medical students who identified as LGBTQ had significantly higher total knowledge scores.

CONCLUSIONS

Overall, the surveyed medical students feel comfortable and willing to provide care for LGBTQ persons. But, there is limited knowledge about specific LGBTQ health needs. More education and training in the needs of transgender and non-binary patients, in particular, is indicated.

Qualitative Findings From a Survey on Patient Experiences and Satisfaction with Lung Cancer Screening

BACKGROUND

To reveal successes and potential limitations of the lung cancer screening program, we conducted a survey that included both quantitative and open-ended questions to measure patient experiences and satisfaction with screening.

METHODS

We report on the five open-ended items related to barriers to returning for screening, experience with other cancer prevention screenings, positive and negative experiences, and suggestions for improving future appointments. The open-ended responses were analyzed using constant comparison method and inductive content analysis.

RESULTS

Respondents (182 patients, 86% response rate for open-ended questions) provided generally positive comments about their lung cancer screening experience. Negative comments were related to desire for more information about results, long wait times for results, and billing issues. Suggestions for improvements included: scheduling on-line appointments and text or email reminders, lower costs, and responding to uncertainty about eligibility criteria.

CONCLUSION

Findings provide insights about patient experiences and satisfaction with lung cancer screening which is important given low uptake. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates.

The LOvE ECHO Training: Developing a Web-Based LGBTQ Cultural Competency Training Module for Oncology Allied Health Professionals

Purpose: This article describes the development of the LGBTQ Oncofertility Education (LOvE-ECHO). The Enriching Communication skills for Health professionals in Oncofertility (ECHO) team created this new education module in response to the needs of oncology allied health professionals to provide inclusive and affirming care to lesbian, gay, bisexual, transgender, and queer (LGBTQ) AYA patients with cancer. The new module is part of the ECHO, a web-based educational training program for oncology allied health professionals to improve communication with AYA about reproductive health. Methods: The development of LOvE-ECHO includes five phases-learner needs assessment, content development and revision, piloting, and finalizing. Results from a survey of past ECHO learners and a comprehensive literature review provided the basis of need for this module and identified the most prominent gaps in knowledge and training. Content development and revision were iterative, including input, feedback, and voices from LQBTA youth and survivors, researchers, reproductive health experts, oncology clinicians, and web developer. Results: The complete LOvE-ECHO module consists of both didactic and interactive lessons. A glossary of terms and narrated PowerPoint establishes a knowledge base and shared vocabulary. Three interactive cases and a plan for action provide learners opportunities to test their new knowledge and transfer it to their practice. Conclusion: The module has received positive feedback to date. It is currently being piloted with new learners who complete a pre-test and post-test, as well as a feedback survey. Analysis of these results will inform revisions to the module.

Genome-wide interaction analysis identified low-frequency variants with sex disparity in lung cancer risk

Differences by sex in lung cancer incidence and mortality have been reported which cannot be fully explained by sex differences in smoking behavior, implying existence of genetic and molecular basis for sex disparity in lung cancer development. However, the information about sex dimorphism in lung cancer risk is quite limited despite the great success in lung cancer association studies. By adopting a stringent two-stage analysis strategy, we performed a genome-wide gene-sex interaction analysis using genotypes from a lung cancer cohort including ~ 47 000 individuals with European ancestry. Three low-frequency variants (minor allele frequency < 0.05), rs17662871 [odds ratio (OR) = 0.71, P = 4.29×10-8); rs79942605 (OR = 2.17, P = 2.81×10-8) and rs208908 (OR = 0.70, P = 4.54×10-8) were identified with different risk effect of lung cancer between men and women. Further expression quantitative trait loci and functional annotation analysis suggested rs208908 affects lung cancer risk through differential regulation of Coxsackie virus and adenovirus receptor gene expression in lung tissues between men and women. Our study is one of the first studies to provide novel insights about the genetic and molecular basis for sex disparity in lung cancer development.

“I need more knowledge”: Qualitative analysis of oncology providers’ experiences with sexual and gender minority patients

Background

While societal acceptance for sexual and gender minority (SGM) individuals is increasing, this group continues to face barriers to quality healthcare. Little is known about clinicians’ experiences with SGM patients in the oncology setting. To address this, a mixed method survey was administered to members of the ECOG-ACRIN Cancer Research Group.

Materials and methods

We report results from the open-ended portion of the survey. Four questions asked clinicians to describe experiences with SGM patients, reservations in caring for them, suggestions for improvement in SGM cancer care, and additional comments. Data were analyzed using content analysis and the constant comparison method.

Results

The majority of respondents noted they had no or little familiarity with SGM patients. A minority of respondents noted experience with gay and lesbian patients, but not transgender patients; many who reported experience with transgender patients also noted difficulty navigating the correct use of pronouns. Many respondents also highlighted positive experiences with SGM patients. Suggestions for improvement in SGM cancer care included providing widespread training, attending to unique end-of-life care issues among SGM patients, and engaging in efforts to build trust.

Conclusion

Clinicians have minimal experiences with SGM patients with cancer but desire training. Training the entire workforce may improve trust with, outreach efforts to, and cancer care delivery to the SGM community.

The Association between Smoking and Anal Human Papillomavirus in the HPV Infection in Men Study

BACKGROUND

Previous studies show an association between smoking and anal cancer. The objective of this study was to assess the association between smoking and anal HPV (human papillomavirus) prevalence, incidence, and persistence in men.

METHODS

The HPV Infection in Men (HIM) Study is a multinational study that enrolled HIV-negative men. At baseline and follow-up visits, anal specimens were collected. HPV genotyping was assessed by linear array. Prevalence ratios (PR) were used to assess the association between smoking and anal HPV prevalence. Odds ratios (OR) were used to assess the association between smoking and anal HPV incidence and ≥12-months persistence.

RESULTS

Current smokers have a higher prevalence [adjusted PR (aPR), 1.36; 95% confidence interval (CI), 1.06-1.73) and incidence [adjusted OR (aOR), 1.74; 95% CI, 1.26-2.39] and ≥12-months persistence (aOR, 1.67; 95% CI, 1.19-2.33) of any anal HPV compared with never smokers. There were no differences in the prevalence, incidence, or persistence of anal HPV between former and never smokers. Smoking status was not associated with the prevalence or persistence of anal HPV among men who have sex with men but was associated with higher incidence of HR-HPV. Among men that have sex with women (MSW), current smokers had an increased prevalence and incidence of LR-HPV compared with never smokers.

CONCLUSIONS

Current smokers had a higher prevalence, persistence, and incidence of HPV compared with never smokers. Further research is needed to assess the role smoking in anal HPV persistence and progression to disease.

IMPACT

Prevention initiatives should raise awareness about smoking and the risk factor of anal HPV infection and anal cancer.

Cross-ancestry genome-wide meta-analysis of 61,047 cases and 947,237 controls identifies new susceptibility loci contributing to lung cancer

To identify new susceptibility loci to lung cancer among diverse populations, we performed cross-ancestry genome-wide association studies in European, East Asian and African populations and discovered five loci that have not been previously reported. We replicated 26 signals and identified 10 new lead associations from previously reported loci. Rare-variant associations tended to be specific to populations, but even common-variant associations influencing smoking behavior, such as those with CHRNA5 and CYP2A6, showed population specificity. Fine-mapping and expression quantitative trait locus colocalization nominated several candidate variants and susceptibility genes such as IRF4 and FUBP1. DNA damage assays of prioritized genes in lung fibroblasts indicated that a subset of these genes, including the pleiotropic gene IRF4, potentially exert effects by promoting endogenous DNA damage.

Sexual Orientation and Gender Identity Data Collection in Oncology Practice: Findings of an ASCO Survey

PURPOSE

Lack of collection of sexual orientation and gender identity (SOGI) data in oncology practices limits assessment of sexual and gender minority (SGM) cancer patients' experiences and restricts opportunities to improve health outcomes of SGM patients. Despite national calls for routine SOGI data collection, individual-level and institutional barriers hinder progress. This study aimed to identify these barriers in oncology.

METHODS

An online survey of ASCO members and others assessed SOGI data collection in oncology practices, institutional characteristics related to SOGI data collection, respondents' attitudes about SOGI data and SGM patients, and respondent demographics. Logistic regression calculated adjusted odds ratios (ORs) and 95% CIs for factors associated with sexual orientation (SO) and gender identity (GI) data collection.

RESULTS

Less than half of 257 respondents reported institutional SO and GI data collection (40% and 46%, respectively), whereas over a third reported no institutional data collection (34% and 32%, respectively) and the remainder were unsure (21% and 17%, respectively). Most respondents felt that knowing both SO and GI was important for quality care (77% and 85%, respectively). Collection of SO and GI was significantly associated in separate models with leadership support (ORs = 8.01 and 6.02, respectively), having resources for SOGI data collection (ORs = 10.6 and 18.7, respectively), and respondents' belief that knowing patient SO and GI is important (ORs = 4.28 and 2.76, respectively). Themes from qualitative comments mirrored the key factors identified in our quantitative analysis.

CONCLUSION

Three self-reinforcing factors emerged as critical drivers for collecting SOGI data: leadership support, dedicated resources, and individual respondents' attitudes. Policy mandates, implementation science, and clinical reimbursement are strategies to advance meaningful data collection and use in clinical practice.

Sexual Orientation and Gender Identity Data Collection in Oncology Practice: Findings of an ASCO Survey

PURPOSE

Lack of collection of sexual orientation and gender identity (SOGI) data in oncology practices limits assessment of sexual and gender minority (SGM) cancer patients' experiences and restricts opportunities to improve health outcomes of SGM patients. Despite national calls for routine SOGI data collection, individual-level and institutional barriers hinder progress. This study aimed to identify these barriers in oncology.

METHODS

An online survey of ASCO members and others assessed SOGI data collection in oncology practices, institutional characteristics related to SOGI data collection, respondents' attitudes about SOGI data and SGM patients, and respondent demographics. Logistic regression calculated adjusted odds ratios (ORs) and 95% CIs for factors associated with sexual orientation (SO) and gender identity (GI) data collection.

RESULTS

Less than half of 257 respondents reported institutional SO and GI data collection (40% and 46%, respectively), whereas over a third reported no institutional data collection (34% and 32%, respectively) and the remainder were unsure (21% and 17%, respectively). Most respondents felt that knowing both SO and GI was important for quality care (77% and 85%, respectively). Collection of SO and GI was significantly associated in separate models with leadership support (ORs = 8.01 and 6.02, respectively), having resources for SOGI data collection (ORs = 10.6 and 18.7, respectively), and respondents' belief that knowing patient SO and GI is important (ORs = 4.28 and 2.76, respectively). Themes from qualitative comments mirrored the key factors identified in our quantitative analysis.

CONCLUSION

Three self-reinforcing factors emerged as critical drivers for collecting SOGI data: leadership support, dedicated resources, and individual respondents' attitudes. Policy mandates, implementation science, and clinical reimbursement are strategies to advance meaningful data collection and use in clinical practice.

A Large-Scale Genome-Wide Gene-Gene Interaction Study of Lung Cancer Susceptibility in Europeans With a Trans-Ethnic Validation in Asians

INTRODUCTION

Although genome-wide association studies have been conducted to investigate genetic variation of lung tumorigenesis, little is known about gene-gene (G × G) interactions that may influence the risk of non-small cell lung cancer (NSCLC).

METHODS

Leveraging a total of 445,221 European-descent participants from the International Lung Cancer Consortium OncoArray project, Transdisciplinary Research in Cancer of the Lung and UK Biobank, we performed a large-scale genome-wide G × G interaction study on European NSCLC risk by a series of analyses. First, we used BiForce to evaluate and rank more than 58 billion G × G interactions from 340,958 single-nucleotide polymorphisms (SNPs). Then, the top interactions were further tested by demographically adjusted logistic regression models. Finally, we used the selected interactions to build lung cancer screening models of NSCLC, separately, for never and ever smokers.

RESULTS

With the Bonferroni correction, we identified eight statistically significant pairs of SNPs, which predominantly appeared in the 6p21.32 and 5p15.33 regions (e.g., rs521828C6orf10 and rs204999PRRT1, ORinteraction = 1.17, p = 6.57 × 10-13; rs3135369BTNL2 and rs2858859HLA-DQA1, ORinteraction = 1.17, p = 2.43 × 10-13; rs2858859HLA-DQA1 and rs9275572HLA-DQA2, ORinteraction = 1.15, p = 2.84 × 10-13; rs2853668TERT and rs62329694CLPTM1L, ORinteraction = 0.73, p = 2.70 × 10-13). Notably, even with much genetic heterogeneity across ethnicities, three pairs of SNPs in the 6p21.32 region identified from the European-ancestry population remained significant among an Asian population from the Nanjing Medical University Global Screening Array project (rs521828C6orf10 and rs204999PRRT1, ORinteraction = 1.13, p = 0.008; rs3135369BTNL2 and rs2858859HLA-DQA1, ORinteraction = 1.11, p = 5.23 × 10-4; rs3135369BTNL2 and rs9271300HLA-DQA1, ORinteraction = 0.89, p = 0.006). The interaction-empowered polygenetic risk score that integrated classical polygenetic risk score and G × G information score was remarkable in lung cancer risk stratification.

CONCLUSIONS

Important G × G interactions were identified and enriched in the 5p15.33 and 6p21.32 regions, which may enhance lung cancer screening models.

Quality of Life in Underrepresented Cancer Populations

This series of six articles (five original articles and one review) is presented by international leaders in health disparities research [...]

NCCN Guidelines® Insights: Lung Cancer Screening, Version 1.2022

The NCCN Guidelines for Lung Cancer Screening recommend criteria for selecting individuals for screening and provide recommendations for evaluation and follow-up of lung nodules found during initial and subsequent screening. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for Lung Cancer Screening.

Abstract 22: Sexual and gender minority patients report psychosocial concerns and low quality of life entering cancer treatment

Background: Prior studies have suggested that underserved and minority populations experience psychosocial concerns and low quality of life (QoL) regarding their cancer care experience; however, presently there are limited data regarding psychosocial concerns and QoL among sexual and gender minority (SGM) populations (i.e., LGBTQ). Given the significantly higher emotional difficulties among SGM cancer patients and adverse impact of psychosocial vulnerabilities on patient outcomes, understanding of unique concerns related to physical/emotional health and QoL among SGM cancer patients is an unmet need. The current study analyzed the association between psychosocial concerns and QoL by SGM status.

Methods: Participants (N=70,312) were cancer patients who completed a standard-of-care electronic patient questionnaire (EPQ) during their initial visits at the Moffitt Cancer Center. The EPQ captures patient-reported information on demographics (including sexual orientation and gender identity [SOGI]), medical history, family cancer history, lifestyle factors, use of complementary and alternative medicine, and QoL. The SOGI questions were used to identify SGM and non-SGM patients. The outcome variables were concerns in (1) having someone who can help the patient during treatment, (2) interference with ability to seek care (e.g., transportation, financial), (3) problems with work or other regular activities due to physical/emotional health and pain over the past 4 weeks, and (4) perceived general health. Pearson’s Chi-Square test and ANOVA were utilized; significance was determined by p&lt;0.05.

Results: Approximately 2.3% of the population self-identified as an SGM. SGM vs. non-SGM patients reported significantly greater concerns in having someone who can help the patient (4.4% vs 2.7%; p&lt;.001), interference with ability to seek care (21.8% vs 16.6%; p&lt;.001), and reported having accomplished less than one would like (36.6% vs 27.8%; p&lt;.001), and engaged in activities less carefully than usual (23.1% vs 18.2%; p&lt;.001) as a result of emotional problems. Further, SGM vs. non-SGM patients reported significantly greater interference due to pain and overall physical/emotional problems (p&lt;.001) and marginally significant worse perceived general health (p=.060). Daily interference due to physical health did not differ between SGM and non-SGM patients.

Discussion: These data suggest that SGM cancer patients compared to non-SGM cancer patients are reporting less psychosocial resources and lower QoL. These results add to the existing literature by elucidating potential difficulties in cancer treatment and preexisting interference due to emotional difficulties and pain among SGM cancer patients with heterogeneous cancer types. Further research is warranted in the short- and long-term impact of such concerns on cancer outcomes and potential need for early intervention.

Citation Format: Min-Jeong Yang, Jaileene Pérez-Morales, Jarred D. Miller, Vani N. Simmons, Matthew B. Schabath. Sexual and gender minority patients report psychosocial concerns and low quality of life entering cancer treatment [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 22.

Abstract 3218: Radiomic biomarkers to optimize treatment decision and predict patient outcomes in serous ovarian carcinoma

Background: There are two first-line treatment recommendations for advanced ovarian cancer: i) upfront cytoreductive debulking followed by chemotherapy and ii) neoadjuvant chemotherapy prior to surgical debulking. The choice between these two treatment strategies is controversial as there are no standardized guidelines for clinical decision support. As such, there remains a critical unmet need to identity biomarkers to personalize the most effective treatment strategies. The primary objective of this study is to identify and validate radiomic biomarkers that predict treatment response among patients with high-grade serous ovarian cancer treated with upfront surgical debulking.

Methods: Intratumoral radiomic features (n=308) were extracted from pre-treatment contrast-enhanced CT images; analyses were conducted to remove correlated, non-stable, and non-reproducible features. Patients treated with upfront surgery (N=182) were split into training (N=91) and test (N=91) cohorts and a cohort of patients treated with upfront neoadjuvant (N=116) was used to determine if the radiomic features were prognostic or predictive. Overall (OS) and progression-free survival (PFS) were the main endpoints. Classification and Regression Tree analysis was used to identity the most informative radiomic features in the training cohort, which were then analyzed in the test cohort and the upfront neoadjuvant cohort.

Results: Decision tree analysis identified a volumetric feature, ROI volume center of mass (CoM) in X direction, as the most informative radiomic feature which stratified upfront surgery patients into high- and low-risk. In the training cohort, high-risk patients were associated with significantly worse OS versus low-risk patients (HR=2.01; 95% CI 1.07-3.77 vs. 1.00 and 5-year OS=39.9% vs. 56.1%, respectively; log-rank p-value=0.03). In the test cohort, the high- vs. low-risk patients were also associated with poor OS (HR=2.23; 95% CI 1.19-4.17 vs. 1.00 and 5-year OS=23.3% vs. 51.3%, respectively; log-rank p-value=0.01). This radiomic feature was not associated with OS among patients with upfront neoadjuvant (HR=1.23; 95% CI 0.73-2.07 vs. 1.00 and 5-year OS=23.9% vs. 36.6%, respectively; log-rank p-value=0.44). Similar findings were observed for PFS.

Conclusion: Utilizing standard-of-care imaging, we identified and validated a predictive radiomic feature associated with outcomes among patients with high-grade serous ovarian cancer treated with upfront surgical debulking but not among patients treated with neoadjuvant chemotherapy. This radiomic biomarker, which describes the location of center of mass inside the tumor in pixels in the x-direction, could be potentially utilized as clinical decision support to guide first-line treatment options. This study was generously funded by a Miles for Moffitt pilot grant.

Citation Format: Jaileene Perez-Morales, Christelle M. Colin Leitzinger, Sweta K. Sinha, Melissa J. McGettigan, Daniel K. Jeong, Olya Stringfield, Mahmoud Abdala, Natarajan Raghunand, Robert J. Gillies, Jing-Yi Chern, Lauren C. Peres, Matthew B. Schabath. Radiomic biomarkers to optimize treatment decision and predict patient outcomes in serous ovarian carcinoma [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 3218.

Abstract 3635: A randomized trial to examine the effectiveness of an LGBT cultural sensitivity training for oncologists: The COLORS trial

Background: Our group developed and piloted the Curriculum for Oncologists on LGBT populations to Optimize Relevance and Skills (COLORS), an interactive web-based LGBT cultural sensitivity training for oncologists. Building on our formative pilot work, in February 2021 we launched a randomized trial to compare the effectiveness of the oncology-specific COLORS training to a general LGBT healthcare cultural sensitivity training. We report here on pre- and post-assessments of this trial.

Methods: From the AMA Masterfile we obtained names and mailing addresses for 5,000 practicing oncologists that were randomly selected for equal distributions across the 9 U.S. Census Divisions. From February to May 2021, we mailed FedEx envelopes to these oncologists that included a invitation letter and information to register for the trial. Using REDCap, oncologists registered, completed a pre-training assessment, were randomized and emailed instructions on how to complete their assigned training (COLORS training or a publicly available web-based LGBT comparison training), and then completed a post-training assessment. The pre- and post-training assessments include measures for knowledge, attitudes (Modern Homonegativity Scale [MHS] and Modified Attitudes Toward LGBT Patients Scale [ATLPS-M], and practice behaviors (Gay Affirmative Practice [GAP] Scale)

Results: As of October 2021, 224 oncologists were enrolled, 201 completed the pre-training and were randomized, and 138 completed the post-training assessment. Among those randomized to COLORS, there were significant decreases from pre- to post-training (median: 24 [IQR 19-30] vs. 22.5 [16-28.5]; p&lt;0.01), indicating a shift toward more positive attitudes, and no significant difference from pre- to post-training for LGBT comparison training (median: 22.5 [IQR 16-29] vs. 22 [14-27]; p=0.98). Both trainings yielded significant (p&lt;0.01) increases from pre- to post-training for the GAP scale, indicating an increase in LGBT-affirming practice behaviors. However, the delta was higher for COLORS vs. LGBT comparison training (Δ 4 vs. Δ 2, respectively). Likewise, both trainings yielded significant (p&lt;0.01) improvements in knowledge from pre- to post-training. Neither training yielded trainings yielded significant differences from pre- to post-training for ATLPS-M.

Conclusion: Results from two prior single-arm trials and now this RCT demonstrate that the COLORS training is effective in improving knowledge, attitudes, and affirming clinical practices related to the care of LGBT patients. This work is generously funded by the Bristol Myers Squibb (BMS) Foundation and BMS Company.

Citation Format: Matthew B. Schabath, Jaileene Perez-Morales, Eryk N. Hernandez, Jarred D. Miller, Gwendolyn P. Quinn, Julia Seay. A randomized trial to examine the effectiveness of an LGBT cultural sensitivity training for oncologists: The COLORS trial [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 3635.

Gender- and Sexual Orientation- Based Inequities: Promoting Inclusion, Visibility, and Data Accuracy in Oncology

Sexual and gender minority (SGM) people, including agender, asexual, bisexual, gay, gender diverse, genderqueer, genderfluid, intersex, lesbian, nonbinary, pansexual, queer, and transgender people, comprise approximately 10% or more of the U.S. population. Thus, most oncologists see SGM patients whether they know it or not. SGM people experience stigma and structural discrimination that lead to cancer disparities. Because of the lack of systematic and comprehensive data collection, data regarding SGM cancer incidence, outcomes, and treatment responses are limited. Collection of data regarding sexual orientation, gender identity, transgender identity and/or experience, anatomy, and serum hormone concentrations in oncology settings would drastically increase collective knowledge about the impact of stigma and biologic markers on cancer outcomes. Increasing the safety of oncology settings for SGM people will require individual, institutional, and systems changes that will likely improve oncologic care for all patients.

Images Are Data: Challenges and Opportunities in the Clinical Translation of Radiomics

Radiomics provides an opportunity to uncover image-based biomarkers through the conversion and analysis of standard-of-care medical images into high-dimensional mineable data. In the last decade, thousands of studies have been published on different clinical applications, novel analysis algorithms, and the stability and reproducibility of radiomics. Despite this, interstudy comparisons are challenging because there is not a generally accepted analytic and reporting standard. The ability to compare and combine results from multiple studies using interoperative platforms is an essential component on the path toward clinical application. The NCI supported study from van Griethuysen and colleagues published in Cancer Research in 2017 proposed PyRadiomics: an open-source radiomics quantification platform for standardized image processing. Since released, it has become a frequently utilized analytic tool in the radiomics literature and has accelerated the capability of combining data from different studies. The subsequent challenge will be the design of multicenter trials with a fixed and immutable version of software, which is currently open-source, readily modified and freely distributed. Generally, this is accomplished with a commercial partner to navigate the regulatory processes.

See related article by van Griethuysen and colleagues, Cancer Res 2017;77:e104–7.

Medical student readiness to treat LGBTQ patients

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Background: The lesbian, gay, bisexual, transgender and queer (LGBTQ) community experiences cancer health disparities. It is thus imperative that medical trainees receive training in the care of LGBTQ populations. Identifying gaps in trainees’ knowledge and comfort in providing care for this population is important in preparing future physicians. Methods: A Likert-scale survey of US medical students at three institutions assessed attitudes, comfort and knowledge in providing care for LGBTQ patients. Results were quantified with descriptive and stratified analyses. Exploratory factor analysis found four factors in which attitude summary measure (ASM) scores were calculated; lower values indicate more agreeability with given attitude items. Total knowledge scores were calculated with higher values indicating greater knowledge. Results: Of 300 medical students who completed the survey, the majority were female (55.7%), white (54.7%), and heterosexual (64.3%). The majority of students felt comfortable (strongly agree/agree) participating in the care of patients who identify as lesbian (94.3%), gay (96.0%), and bisexual (96.3%); this percentage dropped to 82.3% for non-binary and 71.3% for transgender patients. Only 27.0% of students reported confidence in their knowledge of health needs of transgender patients. LGBTQ self-identification, percent of core rotations completed, and having LGBTQ friends/family were significantly associated with various ASM subscales (Table 1). Knowledge questions had high percentages of “neutral” responses, and students who identified as LGBTQ had significantly higher total knowledge scores. Conclusions: Overall, medical students feel comfortable and willing to provide care for LGBTQ patients. However, as in our prior study in oncologists, there is limited knowledge about specific LGBTQ health and cancer needs. More education and training in the needs of transgender and non-binary patients is indicated. [Table: see text]

Medical student clinical cultural awareness in cancer care of sexual and gender minorities

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Background: Health disparities in lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+), or sexual and gender minorities (SGMs), patients are a known in health care. SGMs have higher cancer risk but lower rates of screenings, resulting in a higher likelihood of late-stage disease. Relevant gaps in medical school curricula regarding SGMs must be addressed to prevent these disparities. The purpose of this study is to evaluate medical students’ (MS) clinical cultural awareness in cancer care of SGM patients. Methods: This study was a cross-sectional survey distributed to medical degree students actively enrolled at a large urban academic center. This survey was adapted from a study by Schabath et. Al. The survey had 38 questions on demographics, attitudes, and knowledge of SGM topics. Questions were scored on a Likert scale from ‘strongly disagree’ to ‘strongly agree’ with ‘don’t know’ and ‘prefer not to answer’ as options. Results are reported using descriptive statistics. Results: There were 238 responses. Most respondents were white (63.9%), cis-gender female (57.6%), and heterosexual (78.6%). Distribution according to year are as follows: MS1 36.6%, MS2 14.7%, MS3 27.3%, and MS4 19.3%. Attitudes are listed in the table below. Four of the seven questions on knowledge had “Don’t Know” as the most common response. Notably, 47.1% of respondents did not know if screening gay/bisexual men with anal pap is associated with increased life expectancy. Students were interested in learning guidelines regarding SGM cancer screening and considerations for patients who are on hormone therapy. Conclusions: While most medical students are comfortable treating LGBTQ+ patients, most are not confident in their knowledge. This difference is most profound in knowledge of transgender patients. Schools must consider longitudinal education in SGM topics to improve student knowledge to produce confident and competent providers. Participants Responses to Attitude Items. [Table: see text]

Development and assessment of the effectiveness of an LGBT cultural sensitivity training for oncologists: The COLORS training

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Background: Published studies report oncologists have limited knowledge about LGBT health and cancer needs but also report high interest in receiving education regarding the unique health needs of LGBT patients with cancer. As such, our group developed the Curriculum for Oncologists on LGBT populations to Optimize Relevance and Skills (COLORS), an interactive web-based LGBT cultural sensitivity training for oncologists that focused on focused on improving knowledge and communication skill-building. We report here on the results from two single-arm feasibility/acceptability trials and one randomized pragmatic trial (RPT) demonstrating effectiveness of the COLORS training. Methods: The first single-arm trial included 44 oncologists from three cancer centers in Florida and the second single-arm trial included 50 oncology fellows recruited through ASCO. The RPT included 225 oncologists randomly selected for equal distribution across the U.S., and participants were randomly assigned to either the COLORS training or a publicly available, web-based LGBT comparison training. Each of these studies included pre- and post-training assessments of LGBT-related knowledge, attitudes, and affirming practices. The RCT included a 3-month follow-up assessment to gauge retention of LGBT-affirming knowledge, attitudes, and practices over time. Results: Both single arm trials demonstrated that the COLORS training was feasible, acceptable, and results from the pre- and post-training assessments suggested the training improved knowledge, attitudes, and affirming practice behaviors. In the RPT, those randomized to COLORS demonstrated significant improvements in LGBT-related attitudes pre- to post-training (p < 0.01), and no significant changes in attitudes were observed among those randomized to the comparison training (p = 0.98). Both trainings yielded significant (p < 0.01) increases from pre- to post-training in LGBT-affirming practice behaviors. Likewise, both trainings yielded significant (p < 0.01) improvements in knowledge from pre- to post-training. Similar significant findings were observed when we analyzed the 3-month follow-up assessment. Conclusions: Results from the prior single-arm trials and the current RCT demonstrate that the COLORS training is effective in improving oncologist knowledge, attitudes, and affirming clinical practices related to the care of LGBT patients with cancer. Part of this work was funded by the Bristol Myers Squibb (BMS) Foundation and BMS Company.

Volume doubling time and radiomic features predict tumor behavior of screen-detected lung cancers

BACKGROUND: Image-based biomarkers could have translational implications by characterizing tumor behavior of lung cancers diagnosed during lung cancer screening. In this study, peritumoral and intratumoral radiomics and volume doubling time (VDT) were used to identify high-risk subsets of lung patients diagnosed in lung cancer screening that are associated with poor survival outcomes. METHODS: Data and images were acquired from the National Lung Screening Trial. VDT was calculated between two consequent screening intervals approximately 1 year apart; peritumoral and intratumoral radiomics were extracted from the baseline screen. Overall survival (OS) was the main endpoint. Classification and Regression Tree analyses identified the most predictive covariates to classify patient outcomes. RESULTS: Decision tree analysis stratified patients into three risk-groups (low, intermediate, and high) based on VDT and one radiomic feature (compactness). High-risk patients had extremely poor survival outcomes (hazard ratio [HR] = 8.15; 25% 5-year OS) versus low-risk patients (HR = 1.00; 83.3% 5-year OS). Among early-stage lung cancers, high-risk patients had poor survival outcomes (HR = 9.07; 44.4% 5-year OS) versus the low-risk group (HR = 1.00; 90.9% 5-year OS). For VDT, the decision tree analysis identified a novel cut-point of 279 days and using this cut-point VDT alone discriminated between aggressive (HR = 4.18; 45% 5-year OS) versus indolent/low-risk cancers (HR = 1.00; 82.8% 5-year OS). CONCLUSION: We utilized peritumoral and intratumoral radiomic features and VDT to generate a model that identify a high-risk group of screen-detected lung cancers associated with poor survival outcomes. These vulnerable subset of screen-detected lung cancers may be candidates for more aggressive surveillance/follow-up and treatment, such as adjuvant therapy.

Assessing the effectiveness of a LGBT cultural competency training for oncologists: study protocol for a randomized pragmatic trial

BACKGROUND

LGBT patients may have unique psychosocial cancer care needs, and healthcare providers should have knowledge and understanding of these unique needs to effectively address disparities through the delivery of personalized healthcare. As such, our group developed and piloted a web-based LGBT cultural competency training designed specifically for oncologists called the Curriculum for Oncologists on LGBT populations to Optimize Relevance and Skills (COLORS). We designed a randomized pragmatic trial for oncologists to compare the effectiveness of the COLORS training versus a general online LGBT cultural competency training in improving LGBT-related knowledge, attitudes, and clinical practices.

METHODS/DESIGN

Study procedures include an 8-step approach for recruitment, randomization, retention, and completion of the interventions. Oncologists of any subspecialty who are currently practicing physicians will be identified from the American Medical Association Masterfile. Approximately 5000 oncologists will be sent a FedEx envelope with an invitation letter and study timeline. Electronic consent is obtained using a secure REDCap (Research Electronic Data Capture) portal hosted at the Moffitt Cancer Center (Tampa, FL) where the oncologists will complete the eligibility questionnaire, pre-training assessments, and then will be randomized to complete the COLORS training or an online general healthcare training offered by the National LGBT Health Education Center. Effectiveness of both trainings will be assessed utilizing self-reported measures of LGBT-related knowledge, attitudes, and affirming clinical practices. The measures will be collected before and directly after training completion, as well as 3-month post-training completion. The primary outcomes are changes in knowledge, attitudes, and practice behaviors regarding LGBT cancer patients from pre-test to post-test training in the COLORS training vs. the comparison training.

DISCUSSION

The overarching premise of this trial is to assess the effectiveness of the COLORS cultural competency training program. If successful, among oncologists who completed the COLORS training should yield statistically significantly improvements in knowledge, attitudes, and affirming practice.

Association between ibrutinib treatment and hypertension

BACKGROUND

Ibrutinib is a tyrosine kinase inhibitor most commonly associated with atrial fibrillation. However, additional cardiotoxicities have been identified, including accelerated hypertension. The incidence and risk factors of new or worsening hypertension following ibrutinib treatment are not as well known.

METHODS

We conducted a retrospective study of 144 patients diagnosed with B cell malignancies treated with ibrutinib (n=93) versus conventional chemoimmunotherapy (n=51) and evaluated their effects on blood pressure at 1, 2, 3 and 6 months after treatment initiation. Descriptive statistics were used to compare baseline characteristics for each treatment group. Fisher's exact test was used to identify covariates significantly associated with the development of hypertension. Repeated measures analyses were conducted to analyse longitudinal blood pressure changes.

RESULTS

Both treatments had similar prevalence of baseline hypertension at 63.4% and 66.7%, respectively. There were no differences between treatments by age, sex and baseline cardiac comorbidities. Both systolic and diastolic blood pressure significantly increased over time with ibrutinib compared with baseline, whereas conventional chemoimmunotherapy was not associated with significant changes in blood pressure. Baseline hypertensive status did not affect the degree of blood pressure change over time. A significant increase in systolic blood pressure (defined as more than 10 mm Hg) was noted for ibrutinib (36.6%) compared with conventional chemoimmunotherapy (7.9%) at 1 month after treatment initiation. Despite being hypertensive at follow-up, 61.2% of patients who were treated with ibrutinib did not receive adequate blood pressure management (increase or addition of blood pressure medications). Within the ibrutinib group, of patients who developed more than 20 mm Hg increase in systolic blood pressure, only 52.9% had hypertension management changes.

CONCLUSIONS

Ibrutinib is associated with the development of hypertension and worsening of blood pressure. Cardiologists and oncologists must be aware of this cardiotoxicity to allow timely management of blood pressure elevations.

Accounting for EGFR Mutations in Epidemiologic Analyses of Non-Small Cell Lung Cancers: Examples Based on the International Lung Cancer Consortium Data

BACKGROUND

Somatic EGFR mutations define a subset of non-small cell lung cancers (NSCLC) that have clinical impact on NSCLC risk and outcome. However, EGFR-mutation-status is often missing in epidemiologic datasets. We developed and tested pragmatic approaches to account for EGFR-mutation-status based on variables commonly included in epidemiologic datasets and evaluated the clinical utility of these approaches.

METHODS

Through analysis of the International Lung Cancer Consortium (ILCCO) epidemiologic datasets, we developed a regression model for EGFR-status; we then applied a clinical-restriction approach using the optimal cut-point, and a second epidemiologic, multiple imputation approach to ILCCO survival analyses that did and did not account for EGFR-status.

RESULTS

Of 35,356 ILCCO patients with NSCLC, EGFR-mutation-status was available in 4,231 patients. A model regressing known EGFR-mutation-status on clinical and demographic variables achieved a concordance index of 0.75 (95% CI, 0.74-0.77) in the training and 0.77 (95% CI, 0.74-0.79) in the testing dataset. At an optimal cut-point of probability-score = 0.335, sensitivity = 69% and specificity = 72.5% for determining EGFR-wildtype status. In both restriction-based and imputation-based regression analyses of the individual roles of BMI on overall survival of patients with NSCLC, similar results were observed between overall and EGFR-mutation-negative cohort analyses of patients of all ancestries. However, our approach identified some differences: EGFR-mutated Asian patients did not incur a survival benefit from being obese, as observed in EGFR-wildtype Asian patients.

CONCLUSIONS

We introduce a pragmatic method to evaluate the potential impact of EGFR-status on epidemiological analyses of NSCLC.

IMPACT

The proposed method is generalizable in the common occurrence in which EGFR-status data are missing.

Gene-gene interaction of AhRwith and within the Wntcascade affects susceptibility to lung cancer

BACKGROUND

Aberrant Wnt signalling, regulating cell development and stemness, influences the development of many cancer types. The Aryl hydrocarbon receptor (AhR) mediates tumorigenesis of environmental pollutants. Complex interaction patterns of genes assigned to AhR/Wnt-signalling were recently associated with lung cancer susceptibility.

AIM

To assess the association and predictive ability of AhR/Wnt-genes with lung cancer in cases and controls of European descent.

METHODS

Odds ratios (OR) were estimated for genomic variants assigned to the Wnt agonist and the antagonistic genes DKK2, DKK3, DKK4, FRZB, SFRP4 and Axin2. Logistic regression models with variable selection were trained, validated and tested to predict lung cancer, at which other previously identified SNPs that have been robustly associated with lung cancer risk could also enter the model. Furthermore, decision trees were created to investigate variant × variant interaction. All analyses were performed for overall lung cancer and for subgroups.

RESULTS

No genome-wide significant association of AhR/Wnt-genes with overall lung cancer was observed, but within the subgroups of ever smokers (e.g., maker rs2722278 SFRP4; OR  = 1.20; 95% CI 1.13-1.27; p  = 5.6 × 10-10) and never smokers (e.g., maker rs1133683 Axin2; OR  = 1.27; 95% CI 1.19-1.35; p  = 1.0 × 10-12). Although predictability is poor, AhR/Wnt-variants are unexpectedly overrepresented in optimized prediction scores for overall lung cancer and for small cell lung cancer. Remarkably, the score for never-smokers contained solely two AhR/Wnt-variants. The optimal decision tree for never smokers consists of 7 AhR/Wnt-variants and only two lung cancer variants.

CONCLUSIONS

The role of variants belonging to Wnt/AhR-pathways in lung cancer susceptibility may be underrated in main-effects association analysis. Complex interaction patterns in individuals of European descent have moderate predictive capacity for lung cancer or subgroups thereof, especially in never smokers.

Real-world survival analysis by tumor mutational burden in non-small cell lung cancer: a multisite U.S. study

BACKGROUND

Tumor mutational burden (TMB) is a potential biomarker to predict tumor response to immuno-oncology agents in patients with metastatic non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

A multi-site cohort study evaluated patients diagnosed with stage IV NSCLC between 2012 and 2019 who had received comprehensive genomic profiling (CGP) and any NSCLC-related treatment at 9 U.S. cancer centers. Baseline characteristics and clinical outcomes were compared between patients with TMB <10 and TMB ≥10.

RESULTS

Among the 667 patients with CGP results, most patients received CGP from Foundation Medicine (64%) or Caris (20%). Patients with TMB ≥10 (vs. TMB <10) were associated with a positive smoking history. TMB was associated with ALK (p = 0.01), EGFR (p < 0.01), and TP53 (p < 0.05) alterations. TMB >10 showed a significant association towards longer overall survival (OS) (HR: 0.43, 95% CI: 0.21-0.88, p = 0.02) and progression-free survival (PFS) (HR: 0.43, 95% CI: 0.21-0.85, p = 0.02) in patients treated with first-line immunotherapy and tested by Foundation Medicine or Caris at treatment initiation.

CONCLUSIONS

TMB levels greater than or equal to 10 mut/Mb, when tested by Foundation Medicine or Caris at treatment initiation, were significantly associated with improved OS and PFS among patients treated with first-line immunotherapy-containing regimens. Additional prospective research is warranted to validate this biomarker along with PD-L1 expression.

Iam hiQ-a novel pair of accuracy indices for imputed genotypes

BACKGROUND

Imputation of untyped markers is a standard tool in genome-wide association studies to close the gap between directly genotyped and other known DNA variants. However, high accuracy with which genotypes are imputed is fundamental. Several accuracy measures have been proposed and some are implemented in imputation software, unfortunately diversely across platforms. In the present paper, we introduce Iam hiQ, an independent pair of accuracy measures that can be applied to dosage files, the output of all imputation software. Iam (imputation accuracy measure) quantifies the average amount of individual-specific versus population-specific genotype information in a linear manner. hiQ (heterogeneity in quantities of dosages) addresses the inter-individual heterogeneity between dosages of a marker across the sample at hand.

RESULTS

Applying both measures to a large case-control sample of the International Lung Cancer Consortium (ILCCO), comprising 27,065 individuals, we found meaningful thresholds for Iam and hiQ suitable to classify markers of poor accuracy. We demonstrate how Manhattan-like plots and moving averages of Iam and hiQ can be useful to identify regions enriched with less accurate imputed markers, whereas these regions would by missed when applying the accuracy measure info (implemented in IMPUTE2).

CONCLUSION

We recommend using Iam hiQ additional to other accuracy scores for variant filtering before stepping into the analysis of imputed GWAS data.

Abstract PO-063: Medical students' knowledge and comfort in participating in cancer prevention for LGBTQ+ patients

Background: The majority of US medical schools have a required curriculum related to the care of LGBTQ+ people, which varies in length and content across schools. All medical specialties and sub-specialties have a component of need for cancer care; either in prevention, treatment, or care planning. As such, it is imperative that medical trainees receive relevant training in the care of LGBTQ+ populations, a community experiencing significant cancer health disparities. Assessing trainees' knowledge and confidence in providing care is an important aspect of preparing the next generation of physicians. Methods: This abstract reports on survey results from 3 US medical schools (New York University, University of Miami, University of Texas San Antonio) assessing the knowledge, attitudes and comfort in providing care for LGBTQ+ people. The survey was comprised of 54 Likert response (1=strongly disagree; 7=strongly agree) choice questions on: attitudes (30), knowledge (10), student demographics (13) and desire for additional LGBTQ+ education (1). Results were analyzed using descriptive and quantitative analyses. Results: A total of 360 medical students completed the survey and analyses revealed the majority of students had positive attitudes towards caring for LGBTQ+ patients, but lacked comfort in providing care for transgender/non binary patients (TNB) in general (p=0.05); specific cancer prevention care for TNB (p&lt; 0.01); reproductive care for TNB (p&lt; 0.01) and sexual heath (p=0.01). There was a significant correlation between high knowledge scores and comfort in asking a patient's pronouns (p&lt;0.01). More than 80% felt comfortable discussing cancer prevention care with LGB patients and 75% believed it was important to know the sexual orientation of patient to provide the best care. Eighty percent agreed there should be mandatory LGBTQ+ education in medical school. As in our prior studies, total knowledge scores did not correlate with attitudes. Conclusions: Medical students feel comfortable and willing to provide cancer prevention care for LGB patients but may need more education and training in the unique needs of TNB patients. Medical schools should consider specific education in cancer prevention and treatment for TNB populations.

Citation Format: Gwendolyn P. Quinn, Christina Tamargo, Devin Murphy, Megan Sutter, Lydia Fein, Fabio Ferrari, Amani Sampson, Mia Charifosn, Matthew B. Schabath. Medical students' knowledge and comfort in participating in cancer prevention for LGBTQ+ patients [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-063.

Integrated Biomarkers for the Management of Indeterminate Pulmonary Nodules

Rationale: Patients with indeterminate pulmonary nodules (IPNs) at risk of cancer undergo high rates of invasive, costly, and morbid procedures. Objectives: To train and externally validate a risk prediction model that combined clinical, blood, and imaging biomarkers to improve the noninvasive management of IPNs. Methods: In this prospectively collected, retrospective blinded evaluation study, probability of cancer was calculated for 456 patient nodules using the Mayo Clinic model, and patients were categorized into low-, intermediate-, and high-risk groups. A combined biomarker model (CBM) including clinical variables, serum high sensitivity CYFRA 21-1 level, and a radiomic signature was trained in cohort 1 (n = 170) and validated in cohorts 2-4 (total n = 286). All patients were pooled to recalibrate the model for clinical implementation. The clinical utility of the CBM compared with current clinical care was evaluated in 2 cohorts. Measurements and Main Results: The CBM provided improved diagnostic accuracy over the Mayo Clinic model with an improvement in area under the curve of 0.124 (95% bootstrap confidence interval, 0.091-0.156; P < 2 × 10-16). Applying 10% and 70% risk thresholds resulted in a bias-corrected clinical reclassification index for cases and control subjects of 0.15 and 0.12, respectively. A clinical utility analysis of patient medical records estimated that a CBM-guided strategy would have reduced invasive procedures from 62.9% to 50.6% in the intermediate-risk benign population and shortened the median time to diagnosis of cancer from 60 to 21 days in intermediate-risk cancers. Conclusions: Integration of clinical, blood, and image biomarkers improves noninvasive diagnosis of patients with IPNs, potentially reducing the rate of unnecessary invasive procedures while shortening the time to diagnosis.