The impact of cancer metastases on COVID-19 outcomes: A COVID-19 and Cancer Consortium registry-based retrospective cohort study

BACKGROUND

COVID-19 can have a particularly detrimental effect on patients with cancer, but no studies to date have examined if the presence, or site, of metastatic cancer is related to COVID-19 outcomes.

METHODS

Using the COVID-19 and Cancer Consortium (CCC19) registry, the authors identified 10,065 patients with COVID-19 and cancer (2325 with and 7740 without metastasis at the time of COVID-19 diagnosis). The primary ordinal outcome was COVID-19 severity: not hospitalized, hospitalized but did not receive supplemental O2 , hospitalized and received supplemental O2 , admitted to an intensive care unit, received mechanical ventilation, or died from any cause. The authors used ordinal logistic regression models to compare COVID-19 severity by presence and specific site of metastatic cancer. They used logistic regression models to assess 30-day all-cause mortality.

RESULTS

Compared to patients without metastasis, patients with metastases have increased hospitalization rates (59% vs. 49%) and higher 30 day mortality (18% vs. 9%). Patients with metastasis to bone, lung, liver, lymph nodes, and brain have significantly higher COVID-19 severity (adjusted odds ratios [ORs], 1.38, 1.59, 1.38, 1.00, and 2.21) compared to patients without metastases at those sites. Patients with metastasis to the lung have significantly higher odds of 30-day mortality (adjusted OR, 1.53; 95% confidence interval, 1.17-2.00) when adjusting for COVID-19 severity.

CONCLUSIONS

Patients with metastatic cancer, especially with metastasis to the brain, are more likely to have severe outcomes after COVID-19 whereas patients with metastasis to the lung, compared to patients with cancer metastasis to other sites, have the highest 30-day mortality after COVID-19.

Parent Penalty: Parental Leave Experiences of Trainees and Early-Career Faculty in Oncology Subspecialties

PURPOSE

Prime childbearing years occur during medical training and early career, leaving physicians with tough choices between family planning and career growth. Restrictive workplace parental leave (PL) policies may negatively affect physician well-being. We evaluate existing PL and lactation policies, as well as return-to-work experiences, among oncology trainees and early-career faculty.

METHODS

An anonymous 43-question cross-sectional survey was distributed via e-mail and social media channels between May and June 2021 to oncology trainees and physicians within 5 years of terminal training in the United States. The survey was administered through SurveyMonkey. Descriptive statistics were used to analyze data. Two hundred seventy-five participants were recruited via social media and outreach to program directors and coordinators in adult hematology/oncology and radiation oncology program directors.

RESULTS

The average duration of PL was <6 weeks for most participants. Among those who used PL, 50% felt pressured to work while on PL, 60% felt guilty asking coworkers for help, and 79% were overwhelmed with demands of work and home, whereas only 27% had resources available at workplace to assist with transition back to work. Among those who breastfed at return to work, 31% did not have access to a lactation room, 56% did not have adequate pumping breaks, and 66% did not have pumping breaks mandated in contract.

CONCLUSION

Our findings underline the immense magnitude of problems surrounding inadequate PL and support for lactating mothers among trainees and early-career physicians in oncology subspecialities. Policies and practices around PL and lactation should be restructured to meet the needs of the evolving oncology workforce.

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Importance

Systematic data on the association between anticancer therapies and thromboembolic events (TEEs) in patients with COVID-19 are lacking.

Objective

To assess the association between anticancer therapy exposure within 3 months prior to COVID-19 and TEEs following COVID-19 diagnosis in patients with cancer.

Design, Setting, and Participants

This registry-based retrospective cohort study included patients who were hospitalized and had active cancer and laboratory-confirmed SARS-CoV-2 infection. Data were accrued from March 2020 to December 2021 and analyzed from December 2021 to October 2022.

Exposure

Treatments of interest (TOIs) (endocrine therapy, vascular endothelial growth factor inhibitors/tyrosine kinase inhibitors [VEGFis/TKIs], immunomodulators [IMiDs], immune checkpoint inhibitors [ICIs], chemotherapy) vs reference (no systemic therapy) in 3 months prior to COVID-19.

Main Outcomes and Measures

Main outcomes were (1) venous thromboembolism (VTE) and (2) arterial thromboembolism (ATE). Secondary outcome was severity of COVID-19 (rates of intensive care unit admission, mechanical ventilation, 30-day all-cause mortality following TEEs in TOI vs reference group) at 30-day follow-up.

Results

Of 4988 hospitalized patients with cancer (median [IQR] age, 69 [59-78] years; 2608 [52%] male), 1869 had received 1 or more TOIs. Incidence of VTE was higher in all TOI groups: endocrine therapy, 7%; VEGFis/TKIs, 10%; IMiDs, 8%; ICIs, 12%; and chemotherapy, 10%, compared with patients not receiving systemic therapies (6%). In multivariable log-binomial regression analyses, relative risk of VTE (adjusted risk ratio [aRR], 1.33; 95% CI, 1.04-1.69) but not ATE (aRR, 0.81; 95% CI, 0.56-1.16) was significantly higher in those exposed to all TOIs pooled together vs those with no exposure. Among individual drugs, ICIs were significantly associated with VTE (aRR, 1.45; 95% CI, 1.01-2.07). Also noted were significant associations between VTE and active and progressing cancer (aRR, 1.43; 95% CI, 1.01-2.03), history of VTE (aRR, 3.10; 95% CI, 2.38-4.04), and high-risk site of cancer (aRR, 1.42; 95% CI, 1.14-1.75). Black patients had a higher risk of TEEs (aRR, 1.24; 95% CI, 1.03-1.50) than White patients. Patients with TEEs had high intensive care unit admission (46%) and mechanical ventilation (31%) rates. Relative risk of death in patients with TEEs was higher in those exposed to TOIs vs not (aRR, 1.12; 95% CI, 0.91-1.38) and was significantly associated with poor performance status (aRR, 1.77; 95% CI, 1.30-2.40) and active/progressing cancer (aRR, 1.55; 95% CI, 1.13-2.13).

Conclusions and Relevance

In this cohort study, relative risk of developing VTE was high among patients receiving TOIs and varied by the type of therapy, underlying risk factors, and demographics, such as race and ethnicity. These findings highlight the need for close monitoring and perhaps personalized thromboprophylaxis to prevent morbidity and mortality associated with COVID-19-related thromboembolism in patients with cancer.

Impact of COVID-19 in patients on active melanoma therapy and with history of melanoma

INTRODUCTION

COVID-19 particularly impacted patients with co-morbid conditions, including cancer. Patients with melanoma have not been specifically studied in large numbers. Here, we sought to identify factors that associated with COVID-19 severity among patients with melanoma, particularly assessing outcomes of patients on active targeted or immune therapy.

METHODS

Using the COVID-19 and Cancer Consortium (CCC19) registry, we identified 307 patients with melanoma diagnosed with COVID-19. We used multivariable models to assess demographic, cancer-related, and treatment-related factors associated with COVID-19 severity on a 6-level ordinal severity scale. We assessed whether treatment was associated with increased cardiac or pulmonary dysfunction among hospitalized patients and assessed mortality among patients with a history of melanoma compared with other cancer survivors.

RESULTS

Of 307 patients, 52 received immunotherapy (17%), and 32 targeted therapy (10%) in the previous 3 months. Using multivariable analyses, these treatments were not associated with COVID-19 severity (immunotherapy OR 0.51, 95% CI 0.19 - 1.39; targeted therapy OR 1.89, 95% CI 0.64 - 5.55). Among hospitalized patients, no signals of increased cardiac or pulmonary organ dysfunction, as measured by troponin, brain natriuretic peptide, and oxygenation were noted. Patients with a history of melanoma had similar 90-day mortality compared with other cancer survivors (OR 1.21, 95% CI 0.62 - 2.35).

CONCLUSIONS

Melanoma therapies did not appear to be associated with increased severity of COVID-19 or worsening organ dysfunction. Patients with history of melanoma had similar 90-day survival following COVID-19 compared with other cancer survivors.

Where is your lactation room? Lactation policies and practices in oncology trainee and early career physicians

11054

Background: Training and early career years coincide with childbearing and raising young families, which places increased demands on new parents. With increasing numbers of female oncologists in the workforce, there is a need to assess and amend current workplace lactation policies. We surveyed Medical and Radiation Oncology trainees and early career faculty to assess policies and practices regarding lactation during training and early career. Methods: An anonymous 48 question cross-sectional survey developed by researchers with expertise in gender equity was distributed via email and social media channels between May and June 2021 to oncology trainees and physicians within 5 years of terminal training; program directors (PDs) were surveyed separately. Descriptive statistics were used. Results: Of the 255 complete responses, 26% (65) respondents breastfed for any length of time upon return to work. Of these, 54% (35) were trainees and 46% (30) early career faculty. 69% (45) had access to a designated lactation room; however, 57% (37) noted that duration of their pumping breaks was inadequate to access and use the lactation room. Most (60%, 39) did not feel comfortable asking for protected time to pump. Employment contracts did not specifically include pumping breaks for 66% (43), while 34% (22) were unsure about their contract policies surrounding lactation. Of all breastfeeding mothers, 77% (50) felt their colleagues to be supportive of their needs; a minority reported negative responses due to pumping breaks from faculty (11%), co-fellows/colleagues (8%) and clinic staff (15%). 51% (33) bought a wearable pump prior to return to work, of which 70% (23) found it financially burdensome. Most common reasons for buying a wearable pump were to improve efficiency during work hours (61%, 20) and lack of adequate pumping breaks (39%, 13). Among 23 PDs who responded to the survey, 65% (15) had a program policy regarding lactating trainees, 9% (2) blocked clinic appointments to allow pumping breaks, 91% (21) provided lactation rooms, 83% (19) reported the lactation rooms are easily accessible. Conclusions: Both infrastructure and time accommodations made for the lactating parent are inadequate. There is a disconnect between the trainee and PDs’ perception of provided accommodations. Systemic changes that provide adequate time and space for lactation to busy clinicians and trainees is imperative to ensure retention of women oncologists in the workforce.

The parent penalty: Parental leave and return to work in trainees and early-career faculty in oncology

11005

Background: Prime childbearing years occur during medical training and early career, leaving physicians with tough choices between family planning and career growth. Restrictive parental leave (PL) policies can affect physician well-being and limit decisions about reproduction. We evaluated Medical and Radiation Oncology trainees and early career faculty to assess policies and practices regarding PL and return to work. Methods: An anonymous 48 question cross-sectional survey developed by researchers with expertise in gender equity was distributed via email and social media channels between May and June 2021 to oncology trainees and physicians within 5 years of terminal training. Descriptive statistics were used to compare study groups. Results: 255 physicians completed the survey- 54% female, 65% Medical Oncology and 35% Radiation Oncology, 71% trainees and 29% early career faculty. 46% (117) had no formal PL policy during training. PL impacted selection of first job for 37% (94) participants. Of all responders, 114 used PL, either in early career (18%), as a trainee (69%) or both (13%). Duration of PL during training was ≤4 weeks in 37%, 4-6 weeks in 19%, 6-8 weeks in 12% and ≥8 weeks in 24%. 27% of those who took PL as a trainee had to extend training to allow for this. Only 27%(31) of those who took PL had resources available at workplace to assist with transitioning back to work, primarily from informal mentoring by faculty/colleagues (65%, 20). Other important findings are summarized in the Table. Conclusions: In this study evaluating parental leave in oncology trainees and early faculty, almost half of the participants had no formal parental leave policy during training and majority of those who took parental leave during training had parental leave only for 6 weeks or less. Most participants experienced a parental leave penalty: guilt when seeking help and feeling overwhelmed at return to work. Policies and practices around parental leave need to be restructured to meet the needs of the evolving oncology workforce. [Table: see text]

Geographical distribution of prostate cancer clinical trials across the United States

e18561

Background: Prostate cancer is the second leading cause of cancer-related mortality among males in the United States after lung cancer. Among other factors, physical access to clinical trial site plays a pivotal role in the recruitment process and hence impact outcomes. We aim to study the geographical distribution of phase III and IV prostate cancer clinical trials in the United States. Methods: The United States Cancer Statistics Data Visualisation Tool was utilised to estimate the number of new cases of prostate cancer for the latest available years i.e., 2014-2018. An extensive search was carried out at ClinicalTrials.gov registry using advanced search fields – disease (prostate cancer), sex (male), study type (clinical trial), phase (III and IV), country (United States) and study start (from 01/01/2014 to12/31/2018). The trials which were terminated, withdrawn, or suspended were excluded from the study. Both these tools were further explored to provide state-wise distribution of new trials and cases. Results: Between 2014-2018 in the United States, 997, 454 new prostate cancer cases were reported and 59 phase III & IV clinical trials were made available across 51 states. The average number of new prostate cancer cases and trials per state was 19,558 and 17 (range 45-0) respectively. The states with maximum reported number of new cases were California, New York, Florida, and Texas. These accounted for 30.2% of total cases and only 15.5% of total trials. The states with least reported new cases were Alaska, Vermont, Wyoming, and North Dakota. These accounted for 0.84 % of total cases and 2% of total trials [Table]. The states with the minimum number of trials per case were Mississippi (0.00035), Texas (0.00041), Florida (0.00042), New York (0.00045) and California (0.00047) whereas the states with maximum number of trials per case were Alabama (0.2352), District of Colombia (0.0061), Alaska (0.0054) and Vermont (0.0024). Conclusions: Variation in the availability of phase III and IV clinical trials for newly diagnosed prostate cancer cases was noted across 51 states of the US during the study period from 2014-2018. The states with higher disease burden had a much lower ratio of trials available per case despite higher absolute number of clinical trials in comparison to the states with lower disease burden. This highlights the need for better geographical allocation of clinical trials in the future based on the cancer burden for efficient resource utilisation and improved healthcare delivery.[Table: see text]

Racial Disparities in COVID-19 Outcomes Among Black and White Patients With Cancer

IMPORTANCE

Non-Hispanic Black individuals experience a higher burden of COVID-19 than the general population; hence, there is an urgent need to characterize the unique clinical course and outcomes of COVID-19 in Black patients with cancer.

OBJECTIVE

To investigate racial disparities in severity of COVID-19 presentation, clinical complications, and outcomes between Black patients and non-Hispanic White patients with cancer and COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the COVID-19 and Cancer Consortium registry from March 17, 2020, to November 18, 2020, to examine the clinical characteristics and outcomes of COVID-19 in Black patients with cancer. Data analysis was performed from December 2020 to February 2021.

EXPOSURES

Black and White race recorded in patient's electronic health record.

MAIN OUTCOMES AND MEASURES

An a priori 5-level ordinal scale including hospitalization intensive care unit admission, mechanical ventilation, and all-cause death.

RESULTS

Among 3506 included patients (1768 women [50%]; median [IQR] age, 67 [58-77] years), 1068 (30%) were Black and 2438 (70%) were White. Black patients had higher rates of preexisting comorbidities compared with White patients, including obesity (480 Black patients [45%] vs 925 White patients [38%]), diabetes (411 Black patients [38%] vs 574 White patients [24%]), and kidney disease (248 Black patients [23%] vs 392 White patients [16%]). Despite the similar distribution of cancer type, cancer status, and anticancer therapy at the time of COVID-19 diagnosis, Black patients presented with worse illness and had significantly worse COVID-19 severity (unweighted odds ratio, 1.34 [95% CI, 1.15-1.58]; weighted odds ratio, 1.21 [95% CI, 1.11-1.33]).

CONCLUSIONS AND RELEVANCE

These findings suggest that Black patients with cancer experience worse COVID-19 outcomes compared with White patients. Understanding and addressing racial inequities within the causal framework of structural racism is essential to reduce the disproportionate burden of diseases, such as COVID-19 and cancer, in Black patients.

Assessment of Regional Variability in COVID-19 Outcomes Among Patients With Cancer in the United States

IMPORTANCE

The COVID-19 pandemic has had a distinct spatiotemporal pattern in the United States. Patients with cancer are at higher risk of severe complications from COVID-19, but it is not well known whether COVID-19 outcomes in this patient population were associated with geography.

OBJECTIVE

To quantify spatiotemporal variation in COVID-19 outcomes among patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This registry-based retrospective cohort study included patients with a historical diagnosis of invasive malignant neoplasm and laboratory-confirmed SARS-CoV-2 infection between March and November 2020. Data were collected from cancer care delivery centers in the United States.

EXPOSURES

Patient residence was categorized into 9 US census divisions. Cancer center characteristics included academic or community classification, rural-urban continuum code (RUCC), and social vulnerability index.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day all-cause mortality. The secondary composite outcome consisted of receipt of mechanical ventilation, intensive care unit admission, and all-cause death. Multilevel mixed-effects models estimated associations of center-level and census division-level exposures with outcomes after adjustment for patient-level risk factors and quantified variation in adjusted outcomes across centers, census divisions, and calendar time.

RESULTS

Data for 4749 patients (median [IQR] age, 66 [56-76] years; 2439 [51.4%] female individuals, 1079 [22.7%] non-Hispanic Black individuals, and 690 [14.5%] Hispanic individuals) were reported from 83 centers in the Northeast (1564 patients [32.9%]), Midwest (1638 [34.5%]), South (894 [18.8%]), and West (653 [13.8%]). After adjustment for patient characteristics, including month of COVID-19 diagnosis, estimated 30-day mortality rates ranged from 5.2% to 26.6% across centers. Patients from centers located in metropolitan areas with population less than 250 000 (RUCC 3) had lower odds of 30-day mortality compared with patients from centers in metropolitan areas with population at least 1 million (RUCC 1) (adjusted odds ratio [aOR], 0.31; 95% CI, 0.11-0.84). The type of center was not significantly associated with primary or secondary outcomes. There were no statistically significant differences in outcome rates across the 9 census divisions, but adjusted mortality rates significantly improved over time (eg, September to November vs March to May: aOR, 0.32; 95% CI, 0.17-0.58).

CONCLUSIONS AND RELEVANCE

In this registry-based cohort study, significant differences in COVID-19 outcomes across US census divisions were not observed. However, substantial heterogeneity in COVID-19 outcomes across cancer care delivery centers was found. Attention to implementing standardized guidelines for the care of patients with cancer and COVID-19 could improve outcomes for these vulnerable patients.

Satisfaction of hem/onc patients with video visits during the COVID-19 pandemic at a tertiary care center in Michigan

185

Background: In early 2020, the WHO declared the COVID-19 pandemic a public health emergency. Consequently, medical institutions minimized health care services to facilitate social distancing and telemedicine became the forefront of patient-provider interaction. Herein, we present the results of our study that explored patient satisfaction with video visits during the pandemic at a tertiary care center. Methods: A 12-question survey (table) was emailed following a video visit with a Hem/Onc provider carried out between February and December 2020, questions were answered anonymously. The survey also collected patient demographics. The survey evaluated 5 aspects of telemedicine using a five-point graded scale. Results: A total of 1107 patients responded. Median age was 65 years (25-97) with 51.5% over 65, 64% were females and 36% males. Based on zip codes of primary residence and 2015-2019 US Census data, a significant proportion lived in inner-city Detroit, 77.3% were Caucasians, and 15.2% African Americans. Median household income was 66.8K (Michigan’s median is 57K). Regarding access: ease of scheduling appointments, ease of contacting the office and ability to schedule desired appointments, were respectively given positive responses (good, very good, or fair) by 97.61%, 97.32%, and 98.4%. Regarding CP: ability to explain problem, show concern for worries, include patients in decisions, and discussion of treatment plan, were respectively given positive responses by 99.09%, 99.26%, 98.9%, 99.35%. Regarding telemedicine technology: ease of talking to CP, quality of video, and audio connections, were respectively given positive responses by 94.27%, 90.77%, and 91.42%. For the overall visit assessment, 98.58% gave a positive response for the video staff performance. Regarding their comfort level to return to clinic: 78.75% were comfortable and 10.14% were not. Conclusions: Patients reported an overall high level of satisfaction with telemedicine. One area of improvement is the technological aspect. More than 50% were older than 65 years and a significant proportion lived in underserved areas which indicates that telemedicine is easily accessible. Moreover, around 80% were comfortable to return to clinic while 10% were not which highlights the importance of offering both telemedicine and in-person care.[Table: see text]

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Primary pancreatic adenocarcinoma (PPDA) and metastatic pancreatic adenocarcinoma (MPDA): Are they genomically distinct?

e16226

Background: PDA is an aggressive disease with a dismal prognosis. Advances in next-generation sequencing (NGS) have enabled targeted therapies, revolutionizing treatments of several solid tumors. Their role in the management of PDA is limited, in part due to the paucity in our understanding of targetable genomic events. We sought to evaluate genomic differences between PPDA and MPDA in the tumor and tumor immune microenvironment (TIME). The genomic changes after chemotherapy (CTX) administration were also evaluated. Methods: NGS data derived from tumor samples of 150 unique patients was analyzed. Targeted 648 gene DNA sequencing was performed using the Tempus xT and xO assays. Patients were allocated into 2 cohorts: PPDA (n = 75) and MPDA (n = 75), which were overall similar in terms of their demographics. The frequencies of somatic mutations were compared. The immune infiltrate was imputed from RNAseq. Proportions of immune cells (IC), and the tumor mutational burden (TMB) relative to the proportion of IC in the TIME, were also analyzed. Kaplan Meier Survival estimates for most frequent mutations and TMB were calculated. Results: The most frequently mutated genes amongst the 150 study subjects were: KRAS (92.7%), TP53 (76.7%), CDKN2A (45.3%), SMAD4 (31.3%), ATM (12.7%) and ARID1A (10.7%). Patients in the MPDA cohort had a higher rate of mutation in several genes when compared to PPDA, most notably in TP53 (85.3% vs 68.0%, p = 0.010), ARID1A (16.0 vs 5.3%, p = 0.037) CDKN2A (49.3 vs. 41.3%, p = 0.3) and SMAD4 (33.3 vs. 29.3 p = 0.7). We also evaluated if the genetic changes between PPDA and MPDA are associated with alterations in the TMB and differences in the TIME. A higher TMB was seen amongst patients in the MPDA vs PPDA cohort (2.73 vs 1.73 Mut/Mb, p = 0.008). TMB was also significantly increased after CTX (2.22 vs 1.63 Mut/Mb p = 0.049). TMB ≥ 3 was associated with decreased odds of progression free survival ≥ 12 months (OR 0.26 95% CI 0.078-0.822, p = 0.023). Regarding immune infiltrate, the proportion of CD4 and CD8 T cells were higher in the PPDA cohort. Macrophages and NK cells were more prevalent the MPDA cohort. TMB had a positive correlation with the degree of macrophage infiltration in the TIME (Multivariate estimate: 1.70, p value 0.01). Conclusions: PPDA and MPDA are biologically dissimilar entities with genomic disparity. Associated differences were observed in TMB and TIME. There is a differential increase in the spectrum of mutations in MPDA as compared to PPDA, specifically in p53, ARID1A, CDKN2A and SMAD4. The burden of increased mutations in MPDA is associated with an increase in the TMB and tumor associated macrophages. The role of serial NGS in the management of PDA both in early and late disease should be investigated further to identify evolving genomic changes that correlate with outcome.

Outcomes of in-hospital cardiopulmonary resuscitation for cardiac arrest in adult patients with metastatic solid cancers: A Nationwide Inpatient Sample database analysis from 2012 to 2014

BACKGROUND

Cardiopulmonary arrest is known to have a poor prognosis, further worsened by preexisting comorbidities. With improved treatment, the prevalence of metastatic cancers is rapidly increasing; however, the outcomes of in-hospital cardiopulmonary resuscitation (ICPR) remain to be well described. This study examines the epidemiology, associations, and outcomes of ICPR in these patients.

METHODS

This is a retrospective cohort analysis of the Nationwide Inpatient Sample database (2012-2014) including patients aged ≥18 years with metastatic cancers. Primary outcome was inpatient mortality following ICPR. Factors associated with the primary outcome were analyzed using univariate/multivariate logistic regression analysis.

RESULTS

Among all admissions with metastatic cancers (n = 5,500,684), 0.47% (n = 26,070) received ICPR. Inpatient mortality was 81.77% (n = 8905) versus 68.90% among those without metastatic solid cancers and receiving ICPR. Inpatient palliative care encounter was documented in 18.95% of patients with metastatic cancer who received ICPR. On multivariate logistic regression, some of the notable factors associated with higher mortality included being of African American or Hispanic race and hospital admission over the weekend. Factors associated with lower mortality included female sex, elective admission, and head and neck as the primary site. Admissions with ICPR were associated with higher mean total charge of hospitalization (by $48,670) compared with admissions without ICPR. Of those who survived ICPR, 43.82% were transferred to another facility after discharge.

CONCLUSIONS

Among adult patients with metastatic solid cancers having ICPR, 81.8% died within the same hospital admission. Race and admission type predicted mortality. Despite known poor prognosis, only a minority had palliative care.

LAY SUMMARY

Cardiopulmonary resuscitation during hospitalization for patients who have metastatic cancer has a very poor outcome with a mortality rate of 81.77%. Inpatient cardiopulmonary resuscitation in these patients is also associated with a significantly higher cost of care, longer length of stay, and high rate of transfer to a different health care facility upon discharge. Knowledge of these outcomes is helpful in discussing the pros and cons of pursuing aggressive resuscitative interventions with patients and families.

Hepatic failure in malignancy: A nationwide analysis

e19257

Background: Hepatic failure (HeF) accounts for 6% of all liver-related mortality and 7% liver transplants (LT) in the US. Epidemiologically, while viral hepatitis, acetaminophen and drug injuries are common; malignancy-related HeF remains relatively unexplored. Methods: We performed a retrospective study using nationwide inpatient database (NIS) 2016, which is the largest US inpatient database. HeF admissions were identified as primary diagnosis (through ICD-10 codes) and stratified into two major groups with and without cancer. The cancer group was subdivided into solid (excluding hepato-cellular cancer (HCC)) and non-solid malignancies. Primary outcome was inpatient mortality while secondary outcomes included Length of stay (LOS), Total charge (TCHG), LT and respiratory failure requiring ventilation (MV). Results: 71,000 inpatients met inclusion criteria for HeF, of which 7,715(10.87%) had an underlying malignancy. 39.4%( n = 3,045) had solid malignancies (excluding HCC), 8.4%( n = 650) had non-solid malignancies and 56%( n = 4,020) had HCC. Mean LOS was 5.4 days (95% CI 5.4-5.6, p = 0.23) and mean TCHG was 63,240$(95% CI 57,258$-69,222$, p = 0.03). African Americans (61.2 % vs 53.6%, p = 0.001) and males (12.05% vs 8.71%, p = 0.001) were preponderant in the cancer group. Inpatient mortality was higher in the cancer group (15.3% vs 5.5% p = 0.000), among which solid cancer (20.39%) predominated over non-solids (13.85%) and HCC (11.71%). LT was higher in cancer group (3.7 % vs 2%), whereas no difference in MV was found. Multivariable analysis results are summarized in the table below. Conclusions: HeF patients with underlying malignancy have higher mortality, LOS, TCHG and LT rates. Furthermore, high median income, large center admissions, HCC and Charlson index < = 3 among others were associated with higher odds of undergoing LT in HeF. This study sheds light on the epidemiology and impact of HeF in cancers, as well as disparities in LT among GI cancer patients with HeF. [Table: see text]

Total mesorectal excision compared to local excision in locally advanced rectal cancer achieving complete pathological response with neoadjuvant therapy: A National Cancer Database Analysis

4107

Background: Total mesorectal excision (TME) is the standard surgical intervention for patients with locally advanced rectal cancer (LARC) regardless of response to neoadjuvant therapy. In this study, we perform a comprehensive review of the National Cancer Database (NCDP) to compare the clinical and surgical outcomes of TME to local excision (LE) in patients with LARC. Methods: NCDP was systematically researched to abstract all patients with stage II and III rectal adenocarcinoma between the years 2004 and 2015. We subsequently excluded all the patients who did not achieve complete pathological response (pT0) after neoadjuvant therapy. The patients were then divided into two groups; those who underwent TME and those who underwent LE. Data were analyzed using SPSS v. 26.0, SAS v. 9.4. Results: A total of 4,705 were included in the study; 4,589 in the TME group and 116 in the LE group. Baseline characteristics were similar between the groups except for age. A total of 81(1.8%) of patients in the TME group and 8(6.9%) of patients in the LE group did not receive radiation (p=0.006) and 19(0.4%) of patients the TME group and 4(3.4%) of patients in the LE group did not receive chemotherapy. There was no difference in median overall survival between TME and LE groups. The median length of hospital stay was remarkably shorter in the LE group compared to the TME group (1 day vs 6 days, p<0.0001). The rate of 30-day and 90-day postoperative mortality were similar between the two groups (p-value=0.334 and 0.06, respectively). In the LE group, 4 (3.4%) of patients were readmitted within 30 days of the resection compared to 374 (8.5%) in the TME group but was not a statistically significant difference (p=0.059). Conclusions: In this study, TME and LE had similar overall survival and time to 25% mortality in patients with LARC who achieved complete pathological response after neoadjuvant therapy. Also, LE had a shorter hospital stay compared to the TME group. This study is limited by its retrospective nature, however these interesting observations warrant further investigation in randomized clinical trials. [Table: see text]

Impact of tuberculosis on mortality and healthcare resource utilization in cancer patients: A nationwide inpatient sample analysis

e13625

Background: Tuberculosis (TB) is a major public health concern. Patients with malignancy are at increased risk of developing TB as a result of depressed cellular immunity. The aim of the study is to analyze the prevalence, mortality and healthcare resource utilization of cancer patients with TB. Methods: Adult patients with malignancy and TB (cases) were identified using ICD10 code from Nationwide Inpatient Sample database 2017 and their data was compared to cancer patients without TB (controls). Univariate and multivariable logistic and Poisson regression models were used to analyze mortality and healthcare resource utilization. Results: Among 2,099,294 adult cancer patients admitted in 2017, 1115 were found to have TB. Majority (84%) had pulmonary TB. Mean age of patients was 60.3 years with 65% males and white predominance (33%). Overall prevalence of TB in cancer population was 51.3/100,000 patients, with highest being in Hodgkin lymphoma (182.6/100,000) followed by and MDS/ MPN patients (113.2/100,000) (p < 0.01). Among solid organ malignancies, lung cancer had the highest prevalence of TB (92.1/100,000). After adjusting for the demographic and patient related variables, TB was found to be an independent risk factor for mortality in cancer patients (adjusted HR 1.7, 95% CI 1.13-2.66, p = 0.017). The mortality of cases during inpatient stay was 10.2% compared to 6.2% in controls. The mean length of stay for cases was 12.4 days vs 6.3 days in controls (adjusted coef +6.12, 95% CI 3.64-8.59, P < 0.001) and mean hospital charges in cases was $136,026 vs $67,381 in controls (adjusted coef 68,680, 95% CI 39,053.5-98,306.9, p < 0.001). On multivariate analysis, predictors of mortality in cancer patients with TB were older age, malnutrition, uninsured status, higher Charlson comorbidity score ( = > 3), ICU care, venous thrombo-embolism and Acute renal failure requiring dialysis. Conclusions: TB significantly increases the morbidity and mortality in cancer patients. Widespread TB screening, prompt recognition of infection and treatment can considerably reduce health care costs. [Table: see text]

Perioperative chemotherapy versus adjuvant chemoradiation in resectable gastric cancer: A national cancer database analysis

7066

Background: In patients with resectable gastric cancer, the use of either perioperative chemotherapy (POC) or adjuvant chemoradiotherapy (CRT) are acceptable treatment options in addition to surgical resection. Both approaches improved overall survival (OS) compared to surgery alone. Randomized controlled trials comparing these two modalities are lacking. This study uses real-world data to compare the clinical outcomes of these two approaches. Methods: We identified gastric cancer patients in the NCDB who had definitive surgery between years 2004 and 2015. They were divided into two cohorts: POC and adjuvant CRT. We compared the OS and surgical outcomes in both groups. Kaplan-Meier method and multivariable Cox regression model were used to estimate survival. Results: Of 75,654 patients who underwent definitive surgical resection, 1,920 had POC and 9,161 had adjuvant CRT. Median OS was 56 months with POC and 38.5 months with CRT. After adjusting for age, gender, race, insurance status, comorbidity index, and treatment facility, patients who received POC had an 18% reduction in all-cause mortality compared to those who received adjuvant CRT (p <0.0001, 95% confidence interval 0.74- 0.88). Although, 30- and 90-day mortality was slightly higher with POC compared to CRT (0.047 vs. 0.03%, p<0.0001 and 1.46 vs. 0.45%, p<0.0001 for 30 and 90 day mortality, respectively). Length of hospital stay for primary tumor resection was similar between the two groups; but the 30 day readmission rate after surgery was higher with CRT compared to POC (12.74 vs. 8.33%, p<0.0001). Conclusions: Among patients undergoing definitive surgical resection for gastric cancer, our study shows an association between the use of POC (vs. adjuvant CRT) and improvement in OS. In the POC cohort, while there was a slight increase in postoperative mortality, this was surpassed by the benefit derived from use of POC, resulting in net improvement of survival. These interesting observations warrant confirmation in randomized clinical trials. [Table: see text]

Etanercept with extracorporeal photopheresis (ECP) for steroid-refractory acute graft versus host disease following allogeneic hematopoietic stem cell transplantation

7543

Background: Acute graft versus host disease (aGVHD) is a well-described complication of allogeneic stem cell transplantation (allo-SCT). Complete response to steroids is achieved in 40-50% of cases, with steroid refractory GVHD requiring second line therapy. Currently, there is no accepted standard of care in this setting. In our study, we assessed the safety and efficacy of etanercept with ECP for steroid refractory aGVHD in a single center tertiary care hospital. Methods: Thirty adult patients who underwent peripheral blood allo-SCT and developed steroid-refractory aGVHD between January 2010 - July 2019 were retrospectively analyzed. Patients were planned to receive etanercept 25 mg subcutaneously twice weekly for at least 4 weeks. Safety was assessed by estimating infection related mortality. For efficacy, we analyzed the change in grade of aGVHD using the Wilcoxon signed-rank test. Results: Median age at the time of allo-SCT was 57.6 years and the most common indication for transplant was Myelodysplastic syndrome. Median time from allo-SCT to steroid initiation was 39.5 days (range 14-183 days). Median time from steroid initiation to etanercept was 6 days, with 7.5 median number of etanercept doses received. A total of 25 patients (83.3%) received ECP. As depicted in the table, there was a significant improvement in severity of aGVHD after etanercept therapy compared to that before its initiation. Overall response rate was 83.3%, while overall mortality was 86.7%. Median overall survival for responders was 306 days (range 59-2005 days) and for non-responders was 181 days (range 89-261 days). Death attributed to infection alone occurred in 28% (n=7), infection along with GVHD in 28% (n=7) and infection with relapsed disease in 1 patient. Active infection within 6 months of transplant occurred in 93.3% patients. Conclusions: The use of Etanercept with ECP resulted in improvement of steroid refractory aGVHD following allo-SCT, with responses noted in the majority of patients. High rates of infection related mortality were also noted and remain a cause of concern. [Table: see text]

Inpatient outcomes and predictors of mortality in patients with gastrointestinal malignancies presenting with sepsis: A nationwide analysis

4045

Background: Sepsis is a frequent cause of morbidity and mortality in patients with malignancy. However, there is paucity of literature on mortality, hospital charges and overall healthcare utilization among patients with GI malignancy, which we hope to characterize in this study. Methods: We queried retrospective data from the Nationwide Inpatient Sample (NIS) database for the year 2016. Sepsis (Dx1) was identified using ICD-10 code as primary diagnosis in patients with known GI malignancies (Dx2). Univariate and multivariate Poisson regression analysis was done to study outcomes. Propensity score matching was done to minimize confounding factors. Primary outcome was inpatient mortality. Secondary outcomes were Length of Stay (LOS), Total Charge (TOTCHG) and ICU admission. Results: A total of 43,240 patients with GI malignancy were admitted in 2016 with sepsis. Two most common GI malignancies admitted with sepsis were colorectal (35%) and hepato-cellular cancer (HCC) (28.2%). Overall mortality in GI cancer was 19.8% vs 10.2% in all cancers (p<0.01). There was male (59%) and Caucasian (63%) preponderance. Out of all hospital admissions for GI malignancy, 41.4% were secondary to sepsis. E. coli (31%) infection and gram-negative bacteremia (15%) were the most common causes of sepsis. Sepsis with GI malignancy was associated with length of stay of 7.4 days vs 5.4 days (coef 2.44, 95% CI 2.3-6.7 p=0.04) and a mean hospital charge of $88,728 vs $ 54, 668 (coef 34,140, 95% CI 44,264-90,646, p<0.01) as compared to without sepsis. After adjusting for demographic and patient related variables, independent predictors of mortality were old age, uninsured, African Americans, septic shock requiring pressor support, AKI, inpatient hemodialysis, metabolic encephalopathy and acute respiratory failure. Conclusions: Sepsis poses a substantial healthcare burden in patients with GI malignancy and is a major cause of mortality. Early antibiotic treatment is necessary for sepsis control in patients with GI malignancy. [Table: see text]

Neoadjuvant treatment with chemotherapy or chemoradiation in stage III non-small cell lung cancer: Analysis of the National Cancer Database

7046

Background: Use of neoadjuvant chemotherapy (Neo-chemo) improves survival in locally advanced NSCLC. However, data regarding the benefit of adding radiation (Neo-CRT) is limited. Meta-analyses suggest that the use of Neo-CRT could lead to significant tumor downstaging but with increase in therapy-related mortality. Methods: Patients with resected stage III NSCLC were identified from the NCDB between 2010 and 2015. Patients were divided into two groups based on the type of neoadjuvant therapy received (Neo-chemo vs. Neo-CRT). Surgical and survival outcomes were compared. Kaplan-Meier method and log-rank test were used for survival analysis. Results: Of the 136,942 patients with stage III NSCLC, 15,804 patients had definitive surgery. Mean age was higher for those who received Neo-chemo (63.8 vs. 61.8 years, p<0.0001). Median overall survival (OS) for Neo-CRT was 49.8 months and for Neo-chemo was 53.6 months. After adjusting for treatment facility, age, gender, race, comorbidity index, insurance status, T and N stage, there was a 12% reduction in mortality with use of Neo-chemo compared to Neo-CRT (p=0.03, 95% confidence interval 0.78-0.98). 3 years OS for Neo-CRT and Neo-chemo was 51.1 and 54.3%, respectively. The 30-day operative mortality rate was slightly higher in the Neo-chemo group (4.6 vs. 3.2%, p=0.004) but 90-day mortality rates were similar (7.41% vs. 6.83%, p=0.37). Length of hospital stay for primary tumor resection was shorter for the Neo-chemo group (5 vs. 6 days, p<0.0001); however, there was no significant difference in 30-day readmission rates between the two groups (91.53% vs. 94.01%, p=0.09). Conclusions: In this study, neoadjuvant chemotherapy resulted in 12% lower mortality compared to neoadjuvant chemoradiation despite the notable increase in the rate of complete pathologic tumor and nodal response achieved with the addition of neoadjuvant radiation. There was no difference in R0 resection rates, postoperative mortality or readmissions between the two groups. [Table: see text]

Inpatient mortality, healthcare resource utilization, and complications of elective laparoscopic versus open colectomy in colon cancer patients: A nationwide inpatient sample analysis

4109

Background: Laparoscopic colectomy (LC) has become an accepted safe and alternative technique to open surgical colectomy (OC) as a treatment option for colon cancer. We compared inpatient mortality, hospital resource utilization and complications in patients who underwent LC vs OC. Methods: All patients with known diagnosis of colon cancer who underwent elective colonic resection were identified using Nationwide Inpatient Sample (NIS) 2017. Univariate and multivariate linear and logistic regression was performed to compare the outcomes of patients who underwent LC vs OC. Results: In our cohort, 171, 480 adult patients with colon cancer were identified. The number of males and females were equal. The mean age was 67.2 years. They were predominantly Caucasians (67.6%). OC was performed on 3,869 patients. Of 1,345 patients who underwent LC, 385 were converted to OC. As compared to OC, LC was associated with lower postoperative complications including anastomotic leak, stricture, intestinal obstruction(1% vs 10.8%, p<0.01), blood transfusion(2.2 % vs 11.2% p=0.01), malnutrition(0.2% vs 4.4% p=0.02), shock(0.7% vs 1.8%,p=0.04), ICU care(1.9% vs 5.3%), mean length of stay (5.9 days vs 8.7 days, p=0.01), lower hospital charge (88,642$ vs 106,315 $,p<0.01) and lower mortality(0.3% vs 1.9%(p=0.02). There was a trend towards decreased venous thromboembolism (0.3% vs 1.7 %, p=0.9) and post-operative ileus (0.1% vs 0.7% p=0.60) in LC as compared to OC. On multivariate analysis, independent predictors of undergoing LC were younger age, teaching and large bed-sized hospital and lower Charlson comorbidity index. Race, insurance status and income had no significant association with selection of operative approach (Table). Conclusions: In our cohort, laparoscopic colectomy was found to have better peri and post-operative clinical outcomes including decreased inpatient mortality and hospital resource utilization. It should be promoted as the curative surgical option for colon cancer whenever clinically indicated. [Table: see text]

Immunotherapy in patients with advanced stage non-squamous (non-Sq) non-small cell lung cancer (NSCLC) with activating genetic mutations: Single institution retrospective study

e21577

Background: Immunotherapy has dramatically changed the landscape of lung cancer management. However, its efficacy remains controversial in patients with activating mutations. We report retrospective analysis of clinical outcomes of advanced stage NSCLC patients with activating mutations treated with immune checkpoint inhibitors throughout their disease course. Methods: We analyze all adult patients diagnosed with advanced NSCLC in our institution between January 2014 and January 2018, and who had activating mutations in EGFR, MET, or BRAF genes or ALK rearrangement. Patients in both arms must be treated with at least one line of tyrosine kinase inhibitors (TKI). The investigation arm were patients who received immunotherapy at any time during their disease course. The control arm were patients who did not receive immunotherapy. The primary endpoint was overall survival (OS). Secondary endpoints were objective response rate (ORR) and disease control rate (DCR) in the investigation arm. Results: A total of 47 patients met the inclusion criteria: 27 patients received immunotherapy after or before TKI failure, while 20 patients did not receive immunotherapy. Baseline characteristics were similar in both groups. The average age at diagnosis was 65 years and 40% were males. 68% of patients were at stage IV at the time of diagnosis, 43% were never smokers, and 40% had brain metastases. EGFR mutations accounted for 76.6% of alterations, while ALK rearrangement was demonstrated in 17%, MET and BRAF mutations in 4.3% and 2.1% respectively. Among 27 patients in the immunotherapy group, 3 received chemotherapy simultaneously, 11 patients had received prior chemotherapy, while 13 patients were chemotherapy naive. Complete response was achieved in one case. The ORR was 22.2% and DCR was 37%. Targeted therapy was re-introduced in 9 patients after discontinuation of immunotherapy, of whom 3 responded. The median OS was 44 months (95%CI 28.9-59.4) in immunotherapy group versus 35.7 months (95% CI 23.9-47.4) in control group (P-value 0.34). Conclusions: Immunotherapy, as single agent or in combination with chemotherapy, is associated with better OS trend in patients with advanced NSCLC who harbor activation mutations and failed TKI. This effect was not statistically significant. The prospective data in this population is also limited and controversial. More trials are warranted to evaluate the efficacy of immunotherapy in this group.

Survival outcomes of neoadjuvant versus adjuvant chemotherapy in early-stage pancreatic adenocarcinoma: A subgroup analysis of the National Cancer Database

e16777

Background: Early-stage disease is diagnosed in 10-20% of patients with pancreatic adenocarcinoma (PAC). The current standard of care is upfront surgery followed by adjuvant chemotherapy (AC). The administration of the latter may be limited due to postoperative complications. The aim of this study is to determine the subgroups of patients with early-stage PAC who derive maximum benefit of neoadjuvant chemotherapy (NAC). Methods: Using the National Cancer Database 2004-15, we identified 20,003 patients with clinical stage I or II PAC who had surgery and received chemotherapy in any sequence. The baseline characteristics were compared using Pearson's chi‐square test between patients who received NAC versus AC. A separate multivariate Cox-proportional Hazard regression analysis was done for each subgroup to identify patients with the maximum survival benefit from NAC. Hazard ratio (HR) < 1 connotes survival benefit in favor of NAC. Results: Of the study population, 24% of the patients received NAC. The patients in the NAC group had more PAC of head (80% vs 73%), stage II disease (72% vs 53%), CA19-9 levels 50 U/ml (66% vs 59%), multiagent chemotherapy (68% vs 27%) and were treated at an academic facility (66% vs 52%) compared to the AC group. The p-value was < 0.001 for all comparisons. The age and sex distribution were similar in both groups. On multivariate survival analysis in the overall population, NAC had improved survival compared to AC (HR 0.88 95%CI 0.82-0.93, p < 0.001). Subgroup multivariate survival analysis is shown in the table. Conclusions: In early stage PAC, there is a trend towards survival benefit of NAC compared to AC in most subgroups. The maximum benefit is seen in younger patients with Stage II disease, high CA19-9 levels and fewer comorbidities who receive multiagent chemotherapy. This finding may partly be explained by better tolerability of preoperative compared to postoperative chemotherapy. A randomized clinical trial is needed to establish the optimal chemotherapy timing in patients with early-stage PAC who are treated with curative intent. [Table: see text]

Overall survival (OS) in metastatic melanoma since the introduction of immunotherapy: A National Cancer Database analysis

e19333

Background: Metastatic melanoma historically had a very poor prognosis and survival until the utilization of immunotherapy. Ipilimumab, the first immune checkpoint (ICP) inhibitor was approved in March 2011, followed soon after by the approval of PD-1 and PD-L1 inhibitors. We aim to conduct a real-world analysis of survival outcomes before and after 2011 in metastatic melanoma and its subtypes. We will also explore the impact of race on the clinical presentation and outcomes of melanoma. Methods: Adults with metastatic melanoma were identified from the NCDB (2004-2015). Kaplan Meier method was used to estimate survival and Cox proportional hazards model was used to determine hazard ratio (HR) for death after adjusting for age, race, sex, comorbidity index, melanoma type, education, income, insurance, facility type and geographical location. Odds of having metastatic disease at diagnosis were estimated using multivariate log regression analysis. Results: Of the 20,691 metastatic melanoma cases, 19,492 (94.2%) were cutaneous, 326 (1.6%) were ocular and 873 (4.2%) were mucosal. The effect of immunotherapy use on survival in metastatic melanoma was assessed by comparing years 2011-2015 versus 2004-2010. After the introduction of immunotherapy in 2011, the adjusted survival for metastatic melanoma had improved in Caucasians (HR 0.80, p < 0.001, CI 0.77-0.83) but not in African Americans (HR 0.80, p value = 0.08, CI 0.62-1.03). Although, AA constituted a minority in each melanoma group (1.7% cases of cutaneous, 1.5% of ocular and 8.1% of mucosal melanoma), their odds of having metastatic disease at onset was higher in both cutaneous (OR 2.60, p < 0.001 CI 2.28-2.95) and mucosal melanoma (OR 1.85, p < 0.001 CI 1.39-2.47) compared to Caucasians. Conclusions: Real-world data suggested a 20% improvement in survival of metastatic melanoma since the introduction of ICP inhibitors except in the subgroups of ocular melanoma and African Americans. The disproportionately high odds of metastatic disease at presentation in African American patients with melanoma suggests the need for improvement in care delivery, specifically in terms of early detection. [Table: see text]

Knowledge, Attitudes, and Practices Pertaining to Lung Cancer Screening Among Primary Care Physicians in a Public Urban Health Network

INTRODUCTION

Lung cancer screening (LCS) with annual low-dose computed tomography in high-risk groups decreases the mortality related to lung cancer. Its implementation rate has been low, and knowledge relating to LCS has not been assessed in providers treating underserved populations.

MATERIALS AND METHODS

An institutional review board-approved anonymous survey was sent to primary care physicians of the Cook County Health system, a safety-net healthcare system. The survey assessed the knowledge pertaining to LCS guidelines, providers' experience with LCS, and their recommendations for quality improvement using 24 questions. The predictors of LCS within the previous 6 months were identified using logistic regression analysis.

RESULTS

Of the 152 survey responses, 43% were from nontrainees with diverse training backgrounds. Adequate knowledge of LCS was demonstrated by 72% of the respondents, and pretest counseling was the domain most often answered incorrectly in the questionnaire. LCS had been ordered in the previous 6 months by 57% of the respondents. However, 88% estimated that they had screened < 50% of eligible patients. Higher patient volume, more experience, and family medicine training predicted for ordering LCS in the previous 6 months. In addition, 82.2% indicated that prompts in the electronic medical records would increase LCS, and 78.3% reported that receiving statistics about their LCS practice would increase LCS performance.

CONCLUSIONS

Primary care physicians in the hospital healthcare system had reasonable knowledge of LCS, but the implementation rate was low. We have identified areas for improvement relating to LCS implementation.

Clinical outcomes of patient migration in locally advanced rectal cancer from community cancer centers: An analysis of the National Cancer Database

81

Background: With cancer care changing at a rapid pace, patients are becoming increasingly involved with their management and oftentimes migrating to a different facility to seek better care. Our study evaluated the characteristics of such patients who were initially diagnosed at a community cancer center (CCC) and how this affects clinical outcomes. Methods: The National Cancer Database identified 11,977 patients with stage II/III rectal cancer initially diagnosed at a CCC between 2005 and 2015. Clinical characteristics and outcomes between patients who received all of their treatments at the CCC versus those who received part or all of their treatments elsewhere were compared using rank-sum and X2 tests where appropriate. Cox model was used for survival analysis. Results: Of the total population, 51% were stage II and 49% were stage III. Gender and ethnic distributions were similar between the groups. Approximately 44 % of patients received all their treatment at the CCC and 56% had part or all of their care elsewhere. Patients who migrated were younger (63 vs 65 years, p<0.001) and had govt insurance (43.5 vs 35.8%, p<0.001). On multivariate analysis, age <65 years (OR 1.12, 95% CI 1.02-1.24), govt insurance (OR 1.17, 95% CI 1.06-1.29), Charlson/Deyo comorbid score <2 (OR 1.29, 95% CI 1.11-1.49), higher income (OR 1.21, 95% CI 1.16-1.27) and Stage III (OR 1.15, 95% CI 1.07-1.24) were associated with higher probability of migration. The treatment characteristics and outcomes are shown in Table. The 5y-OS rate was better in patients who received part or all of their treatment at other institutions (adjusted HR 0.80, 95% CI 0.74-0.86, p<0.001). Conclusions: Further studies are needed to provide direction for future strategies to reduce the apparent survival disparities in patients who migrate from CCC.

[Table: see text]

Incidence and outcomes of heparin-induced thrombocytopenia in solid malignancy: an analysis of the National Inpatient Sample Database

Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction to heparin products characterized by thrombocytopenia with or without thrombosis. This study aimed to determine the incidence, morbidity, mortality and economic burden of HIT in solid-malignancy-related hospitalizations. We analyzed the National Inpatient Sample Database (NIS), the largest public database of hospital admissions in the United States, from January 2012 to September 2015. The primary outcome of the study was the incidence of HIT. Secondary outcomes included incidence of venous thrombosis (acute deep venous thrombosis and pulmonary embolism), arterial thrombosis (thrombotic stroke, myocardial infarctions and other arterial thromboembolism), mortality associated with HIT, length of stay, total hospital charges and disposition. During the study period, 7 437 049 hospitalizations had an associated diagnosis of solid malignancy. Approximately 0·08% (n = 6225) hospitalizations had a secondary diagnosis of HIT in this population. The standardized incidence of total thrombotic events was higher in the solid malignancy with HIT compared to the solid malignancy without HIT group (24·7% vs. 6·8%, P < 0·001). The standardized mortality rate was 4·8% in solid malignancy with HIT compared to 3·4% in the without HIT group (OR, 1·53; 95% CI, 1·25-1·89; P < 0·001). HIT in solid malignancy is a rare condition but associated with increased morbidity and mortality.

Predictors of transfer to different facility at discharge in patients admitted with metastatic solid malignancy: Five-year National Inpatient Sample (NIS) database analysis

38

Background: Improvement in cancer treatment has led to an increase in prevalence of metastatic malignancy (met-Ca) with a rise in healthcare utilization secondary to this. We aim to identify predictive factors for transfer at discharge to another non-acute facility, such as nursing home and sub-acute rehab. Methods: This is a retrospective cohort analysis of NIS database (from years 2010 to 2014.) Inclusion criteria was any admission of adults (≥18 years) with met-Ca (identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes.) Patients transferred in from a different acute care hospital or another type of health facility were excluded. Primary outcome was transfer upon discharge to a different facility (transfer out) excluding acute care hospital. Statistical analysis was done using STATA. Results: There were 3,204,631 admissions with met-Ca, 15.3% (n= 490,735) had transfer out. Of these, 50.6% were females, 69.6% Caucasians and mean age was 70.9 years. On multivariate regression analysis, African Americans had higher odds for transfer out versus Caucasians (OR 1.06 p <0.005). Admission type- weekend vs weekday and elective vs non elective were also associated with this outcome (OR 1.08 p<0.005 and OR 0.56 p<0.005). Odds ratio for other predictors are shown below (p value <0.005 for all). Conclusions: Age, race, increased length of stay, cancer type, hospital size and teaching status, admission type and insurance type had a significant predictive value for transfer out after discharge in patients with met-Ca. A future area of exploration is the development of a scoring system to predict risk of transfer to a different facility at discharge- this will allow early mobilization of resources for these patients with complex healthcare needs. [Table: see text]

Outcomes of in-hospital cardiopulmonary resuscitation (ICPR) for cardiac arrest in adult patients with metastatic solid cancers: A nationwide inpatient sample (NIS) database analysis from 2012 to 2014

44

Background: Cardiopulmonary arrest is known to have a poor prognosis which is further worsened by existing co-morbidities. The prevalence of metastatic malignancy is rapidly increasing with improved cancer treatments and yet the outcomes of ICPR are not well studied in these patients. We aim to study the epidemiology, associations and outcomes in this subpopulation. Methods: Retrospective cohort analysis of the 2012 to 2014 NIS database. We included patients ≥ 18 years with the International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for ICPR and diagnosis codes for solid metastatic cancers. Primary diagnosis of cardiopulmonary arrest was excluded (represents out‐of‐hospital arrest.) Primary outcome was inpatient mortality following ICPR and the factors associated were analyzed using logistic regression. Results: Amongst 1,432,240 admissions of adults with metastatic solid cancers, 0.6% (n = 8840) received ICPR, of which 82% (n = 7245) died in the same admission. Inpatient mortality following ICPR in adults without metastatic solid cancers was 68.7%. For adults with metastatic solid cancers receiving ICPR, mean age was 65.9 years, 57.7% were males and 60.6% Caucasian. Also, 11.5% of them had an inpatient palliative care encounter. On multivariate logistic regression analysis, African Americans had higher mortality than Caucasians (OR 1.5, p 0.01) while elective admission and age < 50 years had lower mortality (OR 0.5, p < 0.05 and OR 0.5, p 0.01 respectively.) There was no difference in mortality based on site of primary tumor, gender, day of admission, Charlson Comorbidity Index, insurance status and hospital teaching status, location or size. Conclusions: Amongst adult patients with metastatic solid cancers receiving ICPR, 82% died within the same admission. Race, age and admission type predicted mortality. Despite known poor prognosis, only 11.5% had a palliative care encounter. [Table: see text]

Geographic distribution of clinical trials for breast cancer across the United States, 2011-2015

140

Background: Access to clinical trials is paramount for delivery of high quality cancer care. We aim to study the geographical distribution of phase 3 & 4 clinical trials for females with breast cancer across 51 states between 2011 & 2015. Methods: We searched Clinicaltrials.gov registry for phase 3 & 4 clinical trials in US for females with breast cancer & those first posted from 01/01/2011 to 12/31/2015. New cases of female breast cancer from 2011 to 2015 were estimated with U.S. Cancer Statistics Data Visualizations Tool (www.cdc.gov/cancer/dataviz). Results: We found 88 phase 3 & 4 clinical trials over 51 states. The average number (no.) of new cancer cases and no. of trials per state were 22,985 and 34.4 (range: 16 - 57) respectively. On average, each state had 0.003 (SD: 0.002) trials per case. States with maximum number of cases and trials were California, New York, Texas and Florida. These accounted for 30.7% of total cases, but only 12.5% of total trials. Also, these four states had the lowest no. of clinical trials per case while District of Columbia had the highest (0.0123). The states with the lowest no. of clinical trials included Rhode Island, Vermont, Wyoming & Alaska (3.7% of total trials). Table with data regarding states with lowest and highest cancer burden is attached. Conclusions: For breast cancer in females during the years 2011 to 2015, the ratio of available phase 3 & 4 clinical trials to new cancer cases was quite low when examined state-wise. The gap widened as the cancer burden increased resulting in the lowest no. of clinical trials per case in the states with maximum cancer burden. This highlights the need of better allocation of resources and efforts across the nation when conducting clinical trials. [Table: see text]

Epidermal Growth Factor Receptor-mutated Lung Cancer as the Initial Manifestation of Germline TP53 Mutation Associated Cancer

Epidermal growth factor receptor (EGFR) mutation-driven lung cancer is a rare occurrence in patients with Li-Fraumeni syndrome (LFS) characterized by germline mutations in the tumor protein 53 (TP53) gene. Here we describe a case of primary EGFR mutation-driven lung adenocarcinoma in a young woman with LFS. There is only one other reported case with such presentation. We review the interactions between the TP53 gene and EGFR pathways facilitating lung carcinogenesis. We also review other cases with similar presentations described in the literature and the response to tyrosine kinase inhibitors (TKI) in this rare patient population.

Regorafenib tolerance and outcomes in inner-city minority colorectal cancer population

722

Background: Regorafenib (REG) is an oral multikinase inhibitor used for treatment of metastatic colon cancer after progression on fluorouracil, oxaliplatin and irinotecan therapy. The FDA approval was based on CORRECT trial showing improvements in progression-free survival (PFS) and overall survival (OS). Another trial (CONCUR) showed similar results. However, these trials included predominantly Whites and Asians. Our study aimed to evaluate treatment outcomes in the underserved, mainly African Americans and Hispanics. Methods: Cook County hospital is the 3rd largest public hospital in the US. All patients with an order for REG were identified from our pharmacy database. Charts were retrospectively reviewed for cancer stage, age, ethnicity, previous treatments, PFS and OS. Patients with non-colorectal cancer, incomplete data, no evidence of REG usage were excluded. Statistical analysis was done by t-test on subgroups. Results: A total of 42 patients were screened and 30 were included in the study. A comparison of outcomes with CORRECT and CONCUR trials is presented in Table 1. Our study patients, despite being less heavily pre-treated, had a worse OS compared to the clinical trials, with similar PFS. There was a trend towards better PFS and OS in women in our study of 4.3 and 4.8 months compared to men with 1.9 and 3.3 months respectively (p = NS). Six (20%) patients discontinued REG due to intolerance within a median of 1.2 months. The intolerant patients had a significantly higher median BMI of 31 compared to 24.9 for patients who continued the medication to progression (p = 0.019). Conclusions: Compared to CORRECT and CONCUR trials, population of predominantly AA and Hispanics showed a trend towards worse OS despite being less heavily pre-treated indicating worse outcomes in minorities treated with REG. Women showed better PFS and OS compared to men in our study. Patients unable to tolerate REG had significantly higher BMI, indicating a need to study dosing in this subgroup. [Table: see text]

Factors affecting adherence to standard cisplatin (CDDP)-based chemotherapy regimen for locally advanced squamous cell head and neck (H&N) cancer in an inner city safety net hospital

252

Background: The non-operative standard of care for advanced, non-metastatic H&N cancer is high dose CDDP (100 mg/m2) given every 21 days for 3 cycles concurrent with radiation. Many patients are either started on or switched to an alternative regimen due to pre-treatment co-morbidities or development of CDDP related toxicity. In clinical practice, the percentage of patients not receiving current standard of care and reasons thereof are not well defined. This and the consequence of such deviation from treatment is what we propose to study. Methods: This is a retrospective study including 45 patients from 2014-2016 with advanced, non-metastatic H&N cancer treated with definitive concurrent chemoradiation. All patients were evaluated by ENT, Medical and Radiation Oncology and were presented to the multidisciplinary H&N Tumor board. Results: In the studied population, 73.3% were African Americans , 82.2 % males, 91.1% smokers and 97.7 % ECOG 0-1 at presentation. In all, 11.1% patients were unable to receive CDDP and received an alternate drug because of frailty, ECOG 2 status, pre-existing CKD, hearing problems or neuropathy. Of the 40 patients (88.8%) receiving CDDP, only 8 (17.7%) completed 3 cycles on schedule without changes. Of the remaining 32 (71.1%) receiving CDDP, 13 (40.6 %) were switched to alternate drug and 19 (59.3%) required only a dose decrease/delay. The reasons included CDDP related toxicity (54.05%), frailty or comorbidities (27%), worsening ECOG and fluid overload due to CDDP associated hydration. Toxicities leading to change in regimen included mostly AKI (63.15%) and also neutropenia, ototoxicity, nausea, vomiting and diarrhea. Mean duration of radiation therapy in patients receiving standard regimen was 52.2 days and in patients deviating from standard regimen was 55.1 days. Data supporting trend of poorer outcomes in those who deviate from standard regimen will be reported later. Conclusions: Majority of patients (82.2%) with advanced, non-metastatic H&N cancer being treated with definitive concurrent chemoradiation deviate from standard of care CDDP regimen with at least half due to cisplatin related toxicity.

Efficacy of olanzapine for prevention of chemotherapy-induced nausea and vomiting: A systematic review and meta-analysis

e21692

Background: Olanzapine is an atypical antipsychotic medication which has shown efficacy in prevention of chemotherapy-induced nausea and vomiting (CINV) in multiple trials. This study aims to investigate the efficacy of Olanzapine to prevent CINV with an up-to-date systematic review and meta-analysis. Methods: A literature search of Ovid MEDLINE, Embase and Cochrane library was performed to identify randomized controlled trials of olanzapine compared to other antiemetic therapy (5HT3 and/or NK1 antagonist with or without steroids) for prevention of CINV in patients age >=18 years up until December 2016. The primary endpoint was no emesis or nausea episodes in acute (0-24hrs), delayed (24-120hrs) and overall (0-120hrs) period in patients receiving highly or moderately emetogenic chemotherapy (HEC or MEC). Statistical analysis was performed using Review Manager (RevMan 5.3). The Mantel–Haenszel method was applied and random effect analysis model was used to calculate risk ratios. Results: From the literature, 12 RCTs met the inclusion criteria. The age range of patients was 18-89 years. Seven trials included only patients who received HEC while 5 trials included patients receiving either HEC or MEC in various proportions. Olanzapine was statistically superior for 5 primary endpoints except for no nausea in acute period (Table 1). In the non-steroids cohort, olanzapine was superior for no emesis in all 3 periods but statistically significant only for delayed period. Conclusions: Olanzapine is superior to other antiemetic therapy for prevention of CINV. It is less expensive and can improve patient’s quality of life and chemotherapy adherence. [Table: see text]