Search

Background Hospice and end‐of‐life health care utilization among patients with esophageal cancer are understudied. We used the Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database to analyze hospice use and end‐of‐life treatment patterns. Methods We included patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2000 and 2011 and who had died by December 31, 2013. We evaluated patterns of hospice enrollment, chemotherapy receipt, radiation receipt, acute care hospitalizations, and intensive care unit (ICU) admissions at end of life. We used multivariate logistic regression to evaluate possible associations with hospice use, late ICU admission, and late chemotherapy receipt. Results Our study included 6449 patients; 3597 (55.8%) enrolled in hospice. Among hospice enrolled patients, 31.4% enrolled in the last 7 days of life. Hospice enrollment increased over time, from 43.2% in 2000 to 59.6% in 2013. Patients who were older, female, with stage IV disease, or those with higher socioeconomic status were more likely to enroll in hospice. Among all patients, 19.1% had an ICU admission within the last 30 days and 4.6% received chemotherapy within the last 14 days of life. Those who were Black or Asian (compared to White), married, or had a comorbidity score >1 were more likely to have a late ICU admission. Males and younger patients were more likely to receive chemotherapy at end of life. Conclusion Hospice enrollment rates among patients with esophageal cancer have increased over time; however, a significant percentage of patients enrolls near the end of life. Further research is needed to improve understanding of how end‐of‐life care decisions for these patients are made.

IMPORTANCE: Cancer survivors face ongoing health issues and need access to affordable health care, yet studies examining health care access and affordability in this population are lacking. OBJECTIVES: To evaluate health care access and affordability in a national sample of cancer survivors compared with adults without cancer and to evaluate temporal trends during implementation of the Affordable Care Act. DESIGN, SETTING, AND PARTICIPANTS: We used data from the National Health Interview Survey from 2010 through 2016 to conduct a population-based study of 30 364 participants aged 18 years or older. We grouped participants as cancer survivors (n = 15 182) and those with no reported history of cancer, whom we refer to as control respondents (n = 15 182), matched on age. We excluded individuals reporting a cancer diagnosis prior to age 18 years and those with nonmelanoma skin cancers. MAIN OUTCOMES AND MEASURES: We compared issues with health care access (eg, delayed or forgone care) and affordability (eg, unable to afford medications or health care services) between cancer survivors and control respondents. We also explored trends over time in the proportion of cancer survivors reporting these difficulties. RESULTS: Of the 30 364 participants, 18 356 (57.4%) were women. The mean (SD) age was 63.5 (23.5) years. Cancer survivors were more likely to be insured (14 412 [94.8%] vs 13 978 [92.2%], P

Patients with cancer often experience depression, which can influence treatment outcomes and quality of life. This article evaluates associations among depressive symptoms, use of antidepressants, and hospital length of stay in patients with advanced cancer., Background. Among patients with cancer, depressive symptoms are associated with worse clinical outcomes, including greater health care utilization. As use of antidepressant medications can improve depressive symptoms, we sought to examine relationships among depressive symptoms, antidepressant medications, and hospital length of stay (LOS) in patients with advanced cancer. Materials and Methods. From September 2014 to May 2016, we prospectively enrolled patients with advanced cancer who had an unplanned hospitalization. We performed chart review to obtain information regarding documented depressive symptoms in the 3 months prior to admission and use of antidepressant medications at the time of admission. We compared differences in hospital LOS by presence or absence of depressive symptoms and used adjusted linear regression to examine if antidepressant medications moderated these outcomes. Results. Of 1,036 patients, 126 (12.2%) had depressive symptoms documented prior to admission, and 288 (27.8%) were taking antidepressant medications at the time of admission. Patients with depressive symptoms experienced longer hospital LOS (7.25 vs. 6.13 days; p = .036). Use of antidepressant medications moderated this relationship; among patients not on antidepressant medications, depressive symptoms were associated with longer hospital LOS (7.88 vs. 6.11 days; p = .025), but among those on antidepressant medications, depressive symptoms were not associated with hospital LOS (6.57 vs. 6.17 days; p = .578). Conclusion. Documented depressive symptoms prior to hospital admission were associated with longer hospital LOS. This effect was restricted to patients not on antidepressant medications. Future studies are needed to investigate if use of antidepressant medications decreases LOS for patients hospitalized with advanced cancer and the mechanisms by which this may occur. Implications for Practice. This study investigated the prevalence of documented depressive symptoms in patients with advanced cancer in the 3 months prior to an unplanned hospitalization and the prevalence of use of antidepressant medications at time of hospital admission. The relationship of these variables with hospital length of stay was also examined, and it was found that documented depressive symptoms were associated with prolonged hospital length of stay. Interestingly, antidepressant medications moderated the relationship between depressive symptoms and hospital length of stay. These findings support the need to recognize and address depressive symptoms among patients with advanced cancer, with potential implications for optimizing health care utilization.

Background: Early palliative care interventions enhance patient outcomes, including quality of life, mood, and coping, but it remains unclear whether certain subgroups of patients are more likely to benefit from early palliative care. We explored whether age and sex moderate the improved outcomes seen with early palliative care. Methods: We performed a secondary analysis of data from a randomized trial of 350 patients with advanced lung and non-colorectal gastrointestinal cancer. Patients received an early palliative care intervention integrated with oncology care or usual oncology care alone. We used linear regression to determine if age (older or younger than 65) and sex moderated the effects of the intervention on quality of life (Functional Assessment of Cancer Therapy–General (FACT-G)), depression symptoms (Patient Health Questionnaire 9 (PHQ-9)), and coping (Brief COPE) within lung and gastrointestinal subgroups. Results: At 24 weeks, younger patients with lung cancer receiving early palliative care reported increased use of active coping ( B = 1.74; p = 0.02) and decreased use of avoidant coping ( B = –0.97; p = 0.02), but the effects of early palliative care on these outcomes were not significant for older patients. Male patients with lung cancer assigned to early palliative care reported better quality of life (FACT-G: B = 9.31; p = 0.01) and lower depression scores (PHQ-9: B = –2.82; p = 0.02), but the effects of early palliative care on these outcomes were not significant for female patients. At 24 weeks, we found no age or sex moderation effects within the gastrointestinal cancer subgroup. Conclusion: Age and sex moderate the effects of early palliative care for patients with advanced lung cancer. Early palliative care may need to be tailored to individuals’ unique sociodemographic and clinical characteristics.

Purpose: To evaluate the margin negative (R0) resection rate of neoadjuvant FOLFIRINOX and losartan followed by chemoradiotherapy for locally-advanced pancreatic cancer (LAPC). Methods: LAPC patients (per NCCN), ECOG PS 0-1 were enrolled in a single-institution NCI-sponsored phase II study. Patients received 8 cycles of FOLFIRINOX/losartan. If the tumor was radiographically resectable after chemotherapy, patients received short-course chemoradiotherapy (CRT) in 5 fractions (protons 25 GyE, capecitabine 825 mg/m2 bid). If the tumor had persistent vascular involvement, patients received CRT to 50.4 Gy with a vascular boost to 58.8 Gy. The primary endpoint was R0 resection rate. Secondary endpoints were tolerability, PFS, OS, and circulating biomarkers. Results: Fifty patients were enrolled from 8/2013 to 7/2017, with 49 patients evaluable (1 patient withdrew consent). Median age was 63y (42-78), median tumor size was 41mm (18-68), and was located in the pancreatic head in 63% of patients. Thirty-nine patients completed 8 cycles of FOLFIRINOX/losartan, while 10 had fewer than 8 cycles due to progression (5), losartan intolerance (3) and toxicity (2). Grade 3 or greater toxicity occurred in 25 (51%) patients. Forty-five (92%) patients received CRT: 7 patients (15%) had short -course, while 38 (85%) had long-course. Forty-two (86%) patients underwent attempted surgery, with 34 (69%) patients resected. R0 resection was achieved in 30 patients (61% of evaluable patients, 88% of resected patients). Median follow-up was 17.1 months. Overall mPFS was 17.5 months and mOS 31.4 months. Among resected patients, mPFS was 21.3 months and mOS was 33.0 months. Conclusions: Neoadjuvant FOLFIRINOX/losartan provides downstaging of LAPC allowing for R0 resection in 61% of patients. These findings are being validated in an ongoing multicenter randomized trial. Clinical Trial Number: ClinicalTrials.gov Identifier: NCT01821729 Funding Statement: This study was funded by NIH Proton Beam NCI/Federal Share Program grant C06 CA059267, and in part by the Cancer Clinical Investigator Team Leadership Award awarded by the National Cancer Institute though a supplement to P30CA006516 (TSH); P01CA080124, U01CA224173, R01CA208205 (RKJ, DGD, YB). DGD is also supported through The Samuel Singer Brown Fund for Pancreatic Ductal Adenocarcinoma Research. Declaration of Interests: Dr. Hong reports Novartis, Astra-Zeneca, Clinical Genomics, Taiho (clinical trial funding), EMD Serono (Advisory board). Dr. Ryan reports MPM Capital (consulting). Dr Faris reports Novartis (active employment), N-of-One and Merrimack Pharmaceuticals (consulting), and Exelixis, Takeda, and Roche (clinical trial funding). Dr. Kwak reports Novartis (active employment). Dr. Jain reports honorarium from Amgen; consultant fees from Merck, Ophthotech, Pfizer, SPARC, SynDevRx, XTuit; owns equity in Enlight, Ophthotech, SynDevRx, XTuit; served on the Board of Directors of XTuit and serves on the Boards of Trustees of Tekla Healthcare Investors, Tekla Life Sciences Investors, Tekla Healthcare Opportunities Fund, Tekla World Healthcare Fund. Neither reagents nor funding from these organizations were used in this study. No other authors reported conflicts of interest. Ethics Approval Statement: Patients with LAPC were prospectively enrolled in this NCI-sponsored clinical trial approved by the institutional review board (NCT01821729).

The aim of this study was to determine (1) whether preoperative factors can predict resectability of borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant FOLFIRINOX, (2) which patients might benefit from adjuvant therapy, and (3) survival differences between resected BR/LA patients who received neoadjuvant FOLFIRINOX and upfront resected patients.Patients with BR/LA PDAC are often treated with FOLFIRINOX to obtain a margin-negative resection, yet selection of patients for resection remains challenging.Clinicopathologic data of PDAC patients surgically explored between 04/2011-11/2016 in a single institution were retrospectively collected.Following neoadjuvant FOLFIRINOX, 141 patients were surgically explored (BR: 49%, LA: 51%) and 110 (78%) were resected. Resected patients had lower preoperative CA 19-9 levels (21 vs 40 U/mL, P = 0.03) and smaller tumors on preoperative computed tomography (CT) scan (2.3 vs 3.0 cm, P = 0.03), but no predictors of resectability were identified. Median overall survival (OS) was 34.2 months from diagnosis for all FOLFIRINOX patients and 37.7 months for resected patients. Among resected patients, preoperative CA 19-9100 U/mL and8 months between diagnosis and surgery predicted a shorter postoperative disease-free survival (DFS); Charlson comorbidity index1, preoperative CA 19-9100 U/mL and tumor size (3.0 cm on CT or2.5 cm on pathology) predicted decreased OS. DFS and OS were significantly better for BR/LA PDAC patients treated with neoadjuvant FOLFIRINOX compared with upfront resected patients (DFS: 29.1 vs 13.7, P0.001; OS: 37.7 vs 25.1 months from diagnosis, P = 0.01).BR/LA PDAC patients with no progression on neoadjuvant FOLFIRINOX should be offered surgical exploration. Except size, traditional pathological parameters fail to predict survival among resected FOLFIRINOX patients. Resected FOLFIRINOX patients have survival that appears to be superior than that of resectable patients who go directly to surgery.

Background Despite recommendations from professional organizations supporting early hospice enrollment for patients with cancer, little research exists regarding end-of-life (EOL) practices for patients with malignant glioma (MG). We evaluated rates and correlates of hospice enrollment and hospice length of stay (LOS) among patients with MG. Methods Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, we identified adult patients who were diagnosed with MG from January 1, 2002 to December 31, 2011 and who died before December 31, 2012. We extracted sociodemographic and clinical data and used univariate logistic regression analyses to compare characteristics of hospice recipients versus nonrecipients. We performed multivariable logistic regression analyses to examine predictors of hospice enrollment >3 or >7 days prior to death. Results We identified 12437 eligible patients (46% female), of whom 7849 (63%) were enrolled in hospice before death. On multivariable regression analysis, older age, female sex, higher level of education, white race, and lower median household income predicted hospice enrollment. Of those enrolled in hospice, 6996 (89%) were enrolled for >3 days, and 6047 (77%) were enrolled for >7 days. Older age, female sex, and urban residence were predictors of longer LOS (3- or 7-day minimum) on multivariable analysis. Median LOS on hospice for all enrolled patients was 21 days (interquartile range, 8-45 days). Conclusions We identified important disparities in hospice utilization among patients with MG, with differences by race, sex, age, level of education, and rural versus urban residence. Further investigation of these barriers to earlier and more widespread hospice utilization is needed.

Many patients with serious illness struggle to talk about the possibility of dying; yet basic prognostic awareness is crucial for informed decision making. In this article, we aim to help outpatient clinicians working with seriously ill patients ambivalent, uncomfortable, or fearful of further discussion about the future. We describe a dual framework that focuses on living well while acknowledging the possibility of dying and equips clinicians to help patients hold both possibilities. This dual framework facilitates the developmental process of living as fully as possible while also preparing for the possibility of dying.

Measuring quality of care delivery is essential to palliative care program growth and sustainability. We formed the Carolinas Consortium for Palliative Care and collected a quality data registry to monitor our practice and inform quality improvement efforts.We analyzed all palliative care consultations in patients with cancer in our quality registry from March 2008 through October 2011 using 18 palliative care quality measures. Descriptive metric adherence was calculated after analyzing the relevant population for measurement.We used a paper-based, prospective method to monitor adherence for quality measures in a community-based palliative care consortium.We demonstrate that measures evaluating process assessment (range 63%-100%), as opposed to interventions (range 3%-17%), are better documented.Analyzing data on quality is feasible and valuable in community-based palliative care. Overall, processes to collect data on quality using nontechnology methods may underestimate true adherence to quality measures.

OBJECTIVE Our aim was to assess quality of life (QOL) and functionality in a large cohort of patients ≥5-years after pancreaticoduodenectomy (PD). BACKGROUND Long-term QOL outcomes after PD for benign or malignant disease are largely undocumented. METHODS We administered the EORTC QLQ-C30 questionnaire to patients who underwent PD for neoplasms from 1998 to 2011 and compared their scores with an age- and sex-matched normal population. Clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (>20) based on validated interpretation of clinically important differences. RESULTS Of 305 PD survivors, 245 (80.3%) responded, of whom 157 (64.1%) underwent PD for nonmalignant lesions. Median follow-up was 9.1 years (range 5.1 -21.2 yrs). New-onset diabetes developed in 10.6%; 50.4% reported taking pancreatic enzymes; 54.6% reported needing antacids. Compared with the age- and sex-adjusted controls, PD survivors demonstrated higher global QOL (78.7 vs 69.7, CR small, P < 0.001), physical (86.7 vs 77.9, CR small, P < 0.001) and role-functioning scores (86.3 vs 74.1, CR medium, P < 0.001). Using linear regression and adjusting for socioeconomic variables, there were no differences in QOL or functional scores in the benign versus malignant subgroups. Older age at operation was associated with worse physical-functioning (-0.4/yr, P = 0.008). Taking pancrelipase (-6.8, P = 0.035) or antacids (-6.3, P = 0.044) were both associated with lower social-functioning scores. CONCLUSIONS Patients who had a PD demonstrated better global QOL, physical- and role-functioning scores at 5-years when compared with age- and sex-matched controls. Approximately half of the patients required pancreatic enzyme replacement, while only 11% developed new-onset diabetes.

BACKGROUND Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.

Age, sex, and racial/ethnic disparities exist, but are understudied in pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database to determine whether survival and treatment disparities persist after adjusting for demographic and clinical characteristics. Our study included PDAC patients diagnosed between 1992 and 2011. We used Cox regression to compare survival across age, sex, and race/ethnicity within early‐stage and late‐stage cancer subgroups, adjusting for marital status, urban location, socioeconomics, SEER region, comorbidities, stage, lymph node status, tumor location, tumor grade, diagnosis year, and treatment received. We used logistic regression to compare differences in treatment received across age, sex, and race/ethnicity. Among 20,896 patients, 84% were White, 9% Black, 5% Asian, and 2% Hispanic. Median age was 75; 56% were female and 53% had late‐stage cancer. Among early‐stage patients in the adjusted Cox model, older patient subgroups had worse survival compared with ages 66–69 (HR > 1.1, P 69); no survival differences existed between sexes. Black (HR = 1.1, P = 0.01) and Hispanic (HR = 1.2, P

BACKGROUND Monoclonal antibodies (mAb) targeting PD-1/PD-L1 have revolutionized melanoma treatment, yet data regarding effectiveness and tolerability across age groups is limited. We sought to determine the impact of age on overall survival (OS), progression-free survival (PFS), and rates of immune-mediated toxicities in patients treated with anti-PD-1/anti-PD-L1 mAb at two academic medical centers. METHODS We retrospectively collected data on all patients with metastatic melanoma treated with anti-PD-1/PD-L1 mAb between May 2009 and April 2015. We used Kaplan-Meier and Cox regression analyses to assess OS and PFS and identify factors associated with these outcomes. We also compared rates of autoimmune toxicity across age groups. RESULTS Of 254 patients, 57 (22.4%) were

Gastrointestinal (GI) cancers commonly include cancers of the colon, rectum, anus, pancreas, stomach, liver, bile ducts, and gallbladder. In the following chapter, we discuss some of the more common chemotherapies used in GI oncology, with a focus on mechanism of action, schedule, and toxicity. We also provide an overview of the clinical situations; one may see these chemotherapies and the role of radiation.

Objectives Neoadjuvant treatments are increasingly used for patients with pancreatic ductal adenocarcinoma (PDAC), yet some experience early mortality after resection. We sought to identify predictors of early mortality after PDAC resection and determine their interaction with neoadjuvant therapy. Methods We performed a retrospective study of patients with PDAC resection from March 2011 to March 2014. We compared those who died within one year after surgery to those living beyond 1 year, and those who received neoadjuvant therapy to those taken directly to surgery. We used logistic regression to identify predictors of early mortality and determine their interaction with neoadjuvant therapy. Results Of 191 patients who underwent resection, 59 (30.9%) died within 1 year and 79 (41.4%) received neoadjuvant therapy. Early mortality patients were older, with higher comorbidity, and more likely to have lymph node positivity. Patients receiving neoadjuvant therapy were younger, with lower comorbidity, and more likely to have upfront unresectable disease. Predictors of early mortality included: higher comorbidity, poorly differentiated tumor grade, and lymph node positivity. We found that neoadjuvant therapy moderated the effects of comorbidity and lymph node positivity on early mortality risk. Conclusions We identified predictors of early mortality after PDAC resection and determined their interaction with neoadjuvant therapy.

96 Background: Though uninsurance rates declined after the Affordable Care Act, the number of underinsured, or individuals who spend > 10% of their income on out-of-pocket (OOP) medical costs, continues to rise. In patients with metastatic breast cancer (MBC), underinsurance may lead to financial toxicity (FT), or patient-level financial burden and distress, since diagnosis and treatment is extremely costly. This study explores health insurance literacy and the association between FT and health insurance status in women receiving treatment for MBC. Methods: This cross-sectional study utilized survey data collected from 2017-2019 in women age ≥18 receiving treatment for MBC at two academic medical centers in Alabama. FT was measured by the Comprehensive Score for Financial Toxicity (COST) tool (11-item scale from 0-44, with lower scores indicating worse FT). Health insurance status and OOP costs were self-reported. Effect sizes were calculated using Cohen’s d or Cramer’s V. Mixed and generalized linear models clustered by site and treating medical oncologist estimated the association between FT and health insurance status. Results: In 81 women with MBC, median COST score was 24 (interquartile range [IQR] 17-30), 44% had private insurance, 40% Medicare, and 16% Medicaid. Though 25% and 33% of surveyed patients did not know their health insurance premium or deductible cost, respectively, privately insured patients more often knew the cost of their premiums (97%; V = 0.58) and deductibles (81%; V = 0.33) compared to publicly insured patients. In adjusted models, FT levels did not differ significantly based on health insurance type (private insurance COST 21, 95% confidence interval [CI] 18-25; Medicaid COST 23, 95% CI 17-29; Medicare COST 24, 95% CI 20-27). However, risk of severe FT (COST ≤13) was 147% higher for privately insured patients versus Medicare beneficiaries (risk ratio 2.47, 95% CI 1.44-4.21). Conclusions: Despite higher levels of health insurance literacy, privately insured patients receiving treatment for MBC may be at increased risk of severe FT. Further research is needed to understand causes of underinsurance in patients with MBC, which could lead to cancer-related FT.

71 Background: Annual influenza vaccination is recommended for individuals 6 months and older. Older adults are at high-risk of developing influenza and complications associated with the virus. However, < 50% of patients with cancer receive the influenza vaccine annually. In previous work at our institution, a quality improvement project identified that only 40% of adult patients initiating parenteral anticancer therapy between September and December 2017 were documented to have received the influenza vaccine. Therefore, a multidisciplinary student pharmacist-directed pilot intervention was developed to improve influenza vaccine documentation and administration rates, and we sought to investigate the impact of this intervention. Methods: All adult patients (≥65 years old) scheduled for parenteral anticancer therapy during November 2018 were screened for influenza vaccination documentation. Patients were identified by reviewing infusion center schedule. Under supervision of board-certified oncology pharmacists, two student pharmacists evaluated influenza vaccination documentation in the institution/network electronic medical record (EMR) and outside records. Patients with unknown vaccination history were identified for interview by pharmacy students. The student pharmacists collaborated with oncology nurses and clinicians to order and administer influenza vaccine to patients who agreed to vaccination. Influenza vaccination status was updated in the EMR following record reviews/interviews. Results: Student pharmacists screened 617 patient EMRs and interviewed 124 patients to verify vaccination status. Furthermore, 33 patients received influenza vaccination as a direct result of student pharmacist intervention. Overall, rate of influenza vaccination status documentation was 60.5%. Conclusions: Compared with historic data, we found promising results for a student pharmacist-directed pilot intervention, which demonstrated the potential to improve influenza vaccination status documentation and administration among older adults receiving parenteral anticancer therapy.

23 Background: Patients with cancer receiving chemotherapy often present to the ED and require hospitalization to manage acute issues. However, little work has sought to understand characteristics associated with hospitalizations for patients with cancer receiving chemotherapy who present to the ED. Methods: As part of a quality improvement initiative, we reviewed ED visits within 30-days of patients receiving intravenous chemotherapy at Massachusetts General Hospital from October 2017-January 2018. We used descriptive statistics to compare sociodemographic and clinical factors for hospitalized and non-hospitalized patients. We used logistic regression to explore variables independently associated with being hospitalized. We also compared death rates within 6 months between groups. Results: We identified 500 ED visits during our study period, which resulted in 350 (70.0%) hospitalizations. Hospitalized and non-hospitalized patients did not differ by age (mean 64.1 vs 63.4, P = 0.61), sex (48.9% vs 51.3% female, P = 0.61), or presence of metastatic disease (71.1% vs 68.7%, P = 0.59). Hospitalized patients were more likely to have gastrointestinal (25.7% vs 20.7%) and lung (14.0% vs 11.3%) cancer; less likely to have breast cancer (7.4% vs 16.7%, P < 0.01). Hospitalized patients were more likely to come to the ED on a Thursday (15.7% vs 6.7%); less likely to come on a Wednesday (10.3% vs 19.3%, P < 0.01). On logistic regression, factors associated with higher likelihood of being hospitalized included white race (OR = 1.84, P = 0.03), and presenting with fever/cold symptoms (OR = 2.64, P < 0.01), fatigue (OR = 2.15, P = 0.04), or dyspnea (OR = 2.29, P = 0.04). Death rates within 6 months were higher for the hospitalized patients (50.0% vs 18.7%, P < 0.01). Conclusions: Patients with cancer who visited the ED within 30-days of receiving intravenous chemotherapy often require hospitalization. We identified factors associated with higher likelihood of hospitalization, including patient characteristics, presenting symptoms, and the day of the week. Our findings should inform future efforts to enhance care delivery and outcomes for patients with cancer receiving chemotherapy.

The inevitable emergence of acquired resistance is a major limitation to the clinical benefit of precision medicine strategies. Single-lesion tumor biopsies have long been the mainstay of understanding acquired resistance, but recent data suggest tumor biopsies may under-represent the molecular heterogeneity of acquired resistance. Alternatively, studies have suggested that liquid biopsy approaches analyzing cell-free DNA (cfDNA) may offer significant advantages, but extensive prospective comparisons of matched liquid vs. tumor biopsies obtained at the time of acquired resistance are lacking. Here, we assess systematic liquid biopsy upon acquired resistance to targeted therapy in 44 patients across seven molecularly defined subtypes of gastrointestinal cancers. Liquid biopsy at disease progression identified at least one functionally validated molecular mechanism of resistance in 75% of patients, wherein 52% exhibited >1 resistance alteration (range 2-9, median 3 per patient). In 23 patients in whom a matched post-progression tumor biopsy could be obtained, tumor biopsy was less effective than liquid biopsy in identifying resistance mechanisms, with resistance alterations detected in only 48% of patients, and multiple resistance mechanisms detected in only 9% of cases. In matched cases, liquid biopsy detected at least one resistance alteration not detected in tumor biopsy in 78% of cases. Targeted analysis and whole-exome sequencing of serial cfDNA, multiple post-progression biopsies, and rapid autopsy specimens from select cases revealed key insights into the geographic and complex characteristics of heterogeneity captured by liquid biopsy in the setting of acquired resistance. These data illustrate that acquired resistance is characterized by frequent and profound tumor heterogeneity, and suggests that liquid biopsy may more effectively identify heterogeneous clinically relevant resistance alterations compared to standard tumor biopsy. Citation Format: Aparna R. Parikh, Ignaty Leshchiner, Liudmila Elagina, Lipika Goyal, Chaya Levovitz, Giulia Siravegna, Dimitri Livitz, Kahn Rhrissorrakrai, Liz Martin, Emily E. Van Seventer, Megan Hanna, Kara Slowik, Filippo Utro, Christopher J. Pinto, Alicia Wong, Brian P. Danysh, Ferran Fece de la Cruz, Isobel J. Fetter, Brandon Nadres, Heather A. Shahzade, Jill N. Allen, Lawrence S. Blaszkowsky, Jeffrey W. Clark, Bruce Giantonio, Janet E. Murphy, Ryan D. Nipp, Eric Roeland, David P. Ryan, Colin D. Weekes, Eunice L. Kwak, Jason E. Faris, Francois Aguet, Ipsita Guha, Mehlika Hazar-Rethinam, Dora Dias-Santagata, David T. Ting, Andrew X. Zhu, Theodore S. Hong, Todd R. Golub, A J. Iafrate, Viktor Adalsteinsson, Alberto Bardelli, Laxmi Parida, Dejan Juric, Gad Getz, Ryan B. Corcoran. Liquid biopsy versus tissue biopsy to assess acquired resistance and tumor heterogeneity in gastrointestinal cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-257.

11554 Background: Hospitalized patients with cancer often have impaired function, as measured by activities of daily living (ADLs), related to age, comorbidities, and both cancer and treatment-related morbidity. However, the relationship between functional impairment and patients’ symptom burden and clinical outcomes has not been well described. Methods: We prospectively enrolled patients with advanced cancer with unplanned hospitalizations at an academic medical center. Upon admission, nurses assessed patients’ ADLs (mobility, feeding, bathing, dressing, and grooming). We used the Edmonton Symptom Assessment Scale (ESAS) and Patient Health Questionnaire-4 to assess physical and psychological symptoms, comparing symptom burden between patients with and without ADL impairment. We used regression models adjusted for age, sex, education, Charlson comorbidity index, months since advanced cancer diagnosis, and cancer type to assess the relationship between any ADL impairment on admission and hospital length of stay, the composite outcome of death or readmission within 90 days of discharge, and survival. Results: Among 932 patients, 40.2% had at least one ADL impairment. Patients with ADL impairment were older (Mean = 67.2 vs 60.8 years, p < 0.001), had higher Charlson comorbidity index (Mean = 1.1 vs 0.7, p < 0.001), and higher physical symptom burden (ESAS Physical Mean = 35.2 vs 30.9, p < 0.001). Those with ADL impairment were more likely to have moderate to severe constipation (46.7% vs. 36.0%, p < 0.01), pain (74.9% vs. 63.1%, p < 0.01), drowsiness (76.6% vs. 68.3%, p < 0.01), as well as symptoms of depression (38.3% vs. 23.6%, p < 0.01) and anxiety (35.9% vs. 22.4%, p < 0.01). In adjusted models, ADL impairment was associated with longer hospital length of stay (B = 1.30, p < 0.01), higher odds of death or readmission within 90 days (odds ratio = 2.26, p < 0.01), and higher mortality (hazard ratio = 1.73, p < 0.01). Conclusions: Hospitalized patients with advanced cancer who have functional impairment experience a significantly higher symptom burden and worse health outcomes compared to those without functional impairment. These findings highlight the need to assess and address functional impairment among this population to enhance their quality of life and care.

3563 Background: Colorectal cancer (CRC) incidence in patients younger than 50 years of age is steadily rising by 2% annually. Early-onset CRC usually presents with more aggressive features; however, data on prognosis are widely conflicting. Clinicians may hold an age-related bias in treating younger patients, but this proclivity and its effects have not been quantified. Methods: Patients with a history of metastatic CRC who consented to a departmental chart review protocol were collected between 2014 and 2018 at Massachusetts General Hospital. The cohort was divided into two groups based on age at initial diagnosis: < 50 and ≥50. Data were gathered on treatments and clinicopathological features. A log-rank test compared survival from the diagnosis of metastatic disease between age groups. The distributions of clinicopathological features were compared using Wilcoxon rank sum tests. Results: 464 metastatic CRC patients were identified. 155 patients (33%) were < 50 (median age 43, 49% female) and 309 patients (67%) were ≥50 (median age 61, 45% female). Sex did not significantly differ between the two groups (p = 0.45). Patients < 50 received more lines of therapy after metastatic diagnosis than patients ≥50 (mean 2.7 v. 2.2; p = 0.002). Younger patients also received more resections of distant metastases (mean 0.62 v. 0.48; p = 0.01). A higher rate of enrollment in clinical trials for patients < 50 approached significance (p = 0.06). Even so, patients < 50 did not see a significant survival benefit over older patients (2/5-year survival from metastatic diagnosis 77%/47% v. 73%/38%, p = 0.23). Patients < 50 had a lower proportion of right-sided tumors (p = 0.0002) and BRAF mutations (p = 0.0009). There was no difference in MSI status (p = 0.28), RAS mutational status (p = 0.40), mucinous features (p = 0.53), or signet ring features (p = 0.26). Conclusions: Overall survival in patients < 50 is similar to patients ≥50, despite patients < 50 receiving more aggressive therapy. Further study is warranted to better understand these differences. Potential areas of interest include performance status, age-related treatment bias, and biological factors.

11549 Background: Oncologists often struggle with managing the unique care needs of older adults with cancer. We sought to determine the feasibility of delivering a transdisciplinary geriatric intervention designed to address the geriatric (physical function & comorbidity) and palliative care (symptoms & prognostic understanding) needs of older adults with cancer. Methods: We randomly assigned patients age ≥65 with newly diagnosed incurable gastrointestinal (GI) or lung cancer to receive a transdisciplinary geriatric intervention or usual care. Intervention patients received two visits with a geriatrician who was trained to address patients’ palliative care needs in addition to conducting a geriatric assessment. We defined the intervention as feasible if > 70% of patients enrolled in the study and > 75% completed study visits and surveys. At baseline and week 12, we assessed patients’ quality of life (QOL, Functional Assessment of Cancer Therapy General), symptoms (Edmonton Symptom Assessment System), and communication confidence (Perceived Efficacy in Patient Physician Interactions). As this was a pilot study, we calculated mean change scores in outcomes and estimated intervention effect sizes (ES). Results: From 2/2017-6/2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age = 72.3 [range 65.2-91.8]; 45.2% female; cancer types: 56.5% GI, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 76.2% attended both. Overall, 77.8% completed all study surveys. Compared to usual care, intervention patients had less decrement in QOL scores (-0.77 vs -3.84, ES = .21), greater reduction in the number of moderate/severe symptoms (-0.69 vs +1.04, ES = .58), and more improvement in communication confidence (+1.06 vs -0.80, ES = .38). Conclusions: In this trial of older adults with advanced cancer, more than half enrolled in the study and over 75% of those who enrolled completed all study visits and surveys. Our effect size estimates suggest that a transdisciplinary intervention targeting patients’ geriatric and palliative care needs may be a promising approach to improve patients’ QOL, symptom burden, and communication confidence. Clinical trial information: NCT02868112.

11621 Background: Several studies have demonstrated discordance between how patients perceive their goal of treatment versus how they perceive their oncologist’s goal. Studies evaluating the extent and risk factors of this discordance are lacking. Methods: We conducted a cross-sectional study of 559 patients with incurable lung, gastrointestinal, breast, and brain cancers. We used the Perception of Treatment and Prognosis Questionnaire to assess patients’ perceptions of both their treatment goal and their oncologist’s goal and categorized responses: 1) patients who reported that both their goal and their oncologist’s goal was concordant (either to cure or not to cure); and 2) patients who reported discordant perceptions of their goal versus their oncologist’s goal. We assessed patients’ psychological distress using the Hospital-Anxiety-and-Depression-Scale and used linear regression to assess the relationship between patients’ perceptions of their treatment goal and psychological outcomes. Results: 61.7% of patients reported that both their goal and their oncologist’s goal was non-curative; 19.3% reported that both their goal and their oncologist’s goal was to cure their cancer; and 19.0% reported discordance between their goal and their perception of the oncologist’s goal. Older age (OR = 0.98, P = 0.01), non-Hispanic ethnicity (OR = 0.31, P = 0.049), and higher education (OR = 0.62, P = 0.042) were associated with lower likelihood of reporting discordant goals. Patients with discordant perceptions of their goal and their oncologist’s goal reported higher anxiety (B = 1.56, P = 0.003) compared to those who reported that both their goal and their oncologist’s goal was curative. Patients who reported both their goal and the oncologist’s goal was non-curative had higher depression symptoms (B = 1.06, P = 0.013) compared to those who reported that both their goal and the oncologists’ goal was curative. Conclusions: One-fifth of patients with advanced cancer report discrepancies between their perceptions of their own and their oncologists’ treatment goal which is associated with psychological distress. Tools are needed to identify patients at risk of cognitive dissonance about their prognosis.

Background: Avoiding acute care services can improve cancer care and reduce cost. The US Centers for Medicare and Medicaid Services’ (CMS) new oncology outcome measure (OP-35) defines 30-day post-chemotherapy inpatient (IP) and/or emergency department (ED) events (IP/ED) as “potentially avoidable” if involving any of 10 toxicities, including nausea or vomiting (NV). Evidence demonstrates meaningful gaps in oncologists’ adherence to antiemetic prophylaxis guidelines for highly emetogenic chemotherapy (HEC), and that NV-related IP use costs >$10,000; yet the incidence of avoidable acute care events involving NV is not well studied. Methods: We assessed chemotherapy courses using IBM Explorys electronic health records (4Q 2012–1Q 2018). We identified rates of IP/ED ≤30 days post-chemotherapy, and OP-35 toxicities (NV, anemia, dehydration, diarrhea, fever, neutropenia, pain, pneumonia, or sepsis) by ICD-9, ICD-10, procedure codes, and CMS criteria. We evaluated cisplatin, anthracycline + cyclophosphamide (AC), carboplatin (>14 days apart, as a proxy for AUC ≥4), oxaliplatin (OX), and other non-HEC chemotherapy. We assessed guideline adherence, defined as triple prophylaxis (NK1 RA + 5HT3 RA +dexamethasone) rates at HEC initiation. Results: In 17,609 HEC and 56,624 non-HEC courses, we observed 30-day IP/ED utilization in 29% and 19% of courses, respectively (Table 1). For HEC, 76% of IP/ED use involved ≥1 of the 10 CMS toxicities, most often anemia (42%), pain (41%), dehydration (24%), and NV (24%). Rates of all-cause IP/ED, IP/ED with OP-35 toxicity, and NV-related IP/ED were consistent for HEC and OX. Gaps in triple prophylaxis were common in HEC. Conclusion: Roughly one-third of patients receiving HEC or OX experienced IP/ED events ≤30 days after chemotherapy. Three-quarters of IP/ED events involved ≥1 of 10 OP-35 toxicities linked by CMS to potentially avoidable acute care; of these, one-third involved NV. NV-associated acute care use is considerable, costly, and potentially avoidable with better adherence to antiemesis guidelines.

392 Background: Optimal timing and duration of FFX for resectable, borderline resectable, and LAPC has not been established. The PRODIGE 24/CCTG PA.6 study used 12 cycles of adjuvant modified FFX (eliminating bolus 5FU, irinotecan at 150mg/m2) demonstrating superior DFS (21.6 mo) over gemcitabine (12.8 mo). However, only 48% of patients (pts) received 70% of intended chemo dosing, and 66.4% of pts completed all doses due to postoperative tolerability. We conducted total neoadjuvant therapy (TNT) studies in borderline and LAPC. (LAPC study included Losartan experimentally.) Dose intensity of TNT with FFX is compared to the benchmark adjuvant data. Methods: In this retrospective analysis, chemotherapy data were analyzed from NCT01821729 (LAPC) and NCT01591733 (Borderline). Both studies included 8 cycles of neoadjuvant FFX: b5FU 400mg/m2, CI 5U 1200mg/m2/d x 2d, oxaliplatin 85mg/m2, and irinotecan 180mg/m2. Results: 92 pts were studied: Borderline n = 43, LAPC n = 49. Sixteen of 92 (17.3%) patients discontinued chemotherapy prior to 8 cycles due to: withdrawal of consent (2), chemotherapy toxicity (6), progression (4), and disease-related complications (4). 82.6% of patients completed 8 doses. 61.4% of all bFU was given at the intended dose of 400 mg/m2. The mean relative dose intensity of b5FU (the actual cumulative dose relative to the planned cumulative dose over 8 cycles) was 72%. 65.5% of patients required a reduction in b5FU over eight cycles. Data for all chemotherapy are presented in Table 1. Overall, 71 of 92 patients (77.2%) had > 70% dose of FFX, with mean relative dose intensity of 81.2%. Among surgically resected patients, mPFS was 21.3 months in LAPC (n = 34) and 48.6 months in Borderline (n = 33). Conclusions: Compared to adjuvant therapy, dose intensity was achieved in a higher proportion of participants with TNT, utilizing a FFX regimen that included b5FU and irinotecan at 180mg/m2. PFS among resected patients reflects this highly active treatment. [Table: see text]

391 Background: Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal cancer. Immunotherapy (IO) has shown minimal activity. In preclinical models, radiation (XRT) increases likelihood of response to IO via an abscopal effect where local tx (treatment) of a tumor leads to an antitumor response distantly, with synergy between XRT and dual checkpoint blockade. In this study, we assessed CTLA-4 and PD-1 blockade with XRT as a strategy to stimulate an immune response for patients (pts) with PDAC. Methods: In this open-label, single arm phase-2 study, we enrolled 25 metastatic PDAC pts in an exploratory cohort. Eligible pts had histologically-confirmed PDAC, ECOG PS 0-1, and progression on at least 1 line of tx. Tx consisted of Ipilimumab (1 mg/kg every 6 wks), Nivolumab (240 mg every 2 wks) and 3 fractions of 8 Gy of XRT at cycle 2. Tx continued until PD, discontinuation or withdrawal. Endpoints include Disease Control Rate (DCR), ORR, PFS, OS and safety. Radiological evaluations were every 3 months. Response was defined as disease control outside of the radiation field. We obtained serial tumor biopsies pre-tx, during checkpoint blockade alone and 2 weeks after XRT. Intention to treat analysis includes all pts receiving at least one dose of study tx. Results: 22 pts were enrolled and evaluable from 6/2017-6/2018, median age 60 years (32-75), 73% male and 100% MSS. DCR was 27% and ORR was 14% with 1 pt having a complete response. All responses were out of the radiation field. Median PFS was 76 days in the entire cohort; 163 days for pts with disease control vs 62.5 days for pts with PD or who came off study prior to initial imaging. 7 pts did not receive XRT due to clinical progression. Treatment-related adverse events (AEs) were reported in 12/22 pts (54.5%). 8/22 pts (36.4%) experienced grade ≥ 3 toxicities. Elevated lipase, lymphopenia, fatigue, hyperglycemia, mucositis and hepatitis were the most common AEs. 1/22 (4.5%) pt had a grade 5 AE possibly related to tx. Conclusions: Dual blockade of CTLA-4 and PD-1 with XRT is feasible and demonstrates promising activity in pts with metastatic PDAC. We will report the updated efficacy and safety data as well as outcomes from the correlative serial biopsies upon completion. Clinical trial information: NCT03104439.

112 Background: Reducing hospitalizations for chemotherapy-related toxicities represents an opportunity to improve both the quality and cost of cancer treatment. Nausea and vomiting (NV) account for almost 10% of “avoidable” toxicity-related post-chemotherapy hospitalizations (2016 Medicare data). We sought to evaluate the event cost of NV-related hospitalizations among patients with cancer from a US payer perspective. Methods: From a large US claims database (Truven MarketScan), we identified hospitalizations with NV as the primary diagnosis and cancer as a secondary diagnosis (01/2011-06/2017). This method increases specificity for NV as the principal hospitalization factor, while underreporting the prevalence of NV as a contributory factor. To determine event costs, we evaluated hospital and other reimbursement during the hospitalization. To explore subgroup differences, we stratified results by tumor type, payer type, admission route, receipt of highly emetogenic chemotherapy (HEC; 2017 definition includes carboplatin AUC ≥4) and antiemetic prophylaxis. We adjusted all costs to 2017 US dollars. Results: Among 918,192 hospitalizations involving cancer, we identified 80,995 with both NV and a cancer diagnosis code. Of these, 5,293 had NV as the primary diagnosis and 62 lacked cost data. Patients (mean age = 57.7±16.2) were 67% female. Median hospital length of stay was 4 days and mean cost per hospitalization was $15,085. Non-Medicare admissions (82%) had a higher mean cost vs. Medicare ($15,737 vs. $12,111, p < 0.01). We found < $1,000 difference between the highest and lowest cost per hospitalization among the 6 most common tumor types. We found the 65% of patients with a chemotherapy claim ≤30 days prior to hospitalization had costs of $13,882 per event. Among the 45% of chemotherapies that were HEC, > 50% lacked an NK1 receptor antagonist as prophylaxis. Conclusions: The average cost of NV-related hospitalizations among patients with cancer exceeds $15,000 per event, highlighting the need to effectively address this symptom. Roughly half the hospitalizations involved HEC, with over half of those patients not receiving guideline-based antiemetic prophylaxis.

208 Background: Despite multiple cancer cachexia (CC) trials evaluating novel agents, the FDA has not approved a single drug to date. One key challenge in CC trials is selection of endpoints. The aim of this study was to explore changes in body composition and associations with functional and patient-reported outcomes (PROs) to clarify CC trial endpoint selection. Methods: We identified metastatic solid tumor cancer patients receiving cancer-directed therapies at a single cancer center (2016-2018). Patients completed all assessments at study enrollment and 3 months from enrollment. We analyzed body composition utilizing cross-sectional computed tomography (CT) scans at the third lumbar vertebra. Functional assessments included the 6-minute walk test (6MWT), Timed Up-and-Go (TUG) test, and Short Physical Performance Battery (SPPB). PROs included the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) and Functional Assessment of Cancer Therapy Fatigue (FACT-F). We examined changes in body composition and functional assessments from enrollment to 3 months using paired t-tests. We utilized linear regression models to assess the relationship between changes in body composition and changes in functional assessment adjusting for age and sex. Results: A total of 57 patients completed baseline assessments; 19 patients did not complete 3-month assessments (5 died, 1 hospice, 13 withdrew). Of the 38 patients with complete data (mean age 61.8 years, 47% female, 71% GI malignancy), 50% received chemotherapy, 16% immunotherapy, and 34% combination therapy. From enrollment to 3 months, we observed an increase in total adipose tissue (16.9±52.4 cm2, 95% CI -33.79-0.63; p = 0.059), but not weight or skeletal muscle. Greater losses in skeletal muscle were associated with greater declines in 6MWT (B = 0.036, p = 0.014) and SBBP (B = 2.444, p = 0.002), but not the TUG. We observed no association with change in weight with all functional outcomes or PROs. Moreover, we found no association with body composition and PROs from enrollment to 3 months. Conclusions: In future CC trials, changes in longitudinal body composition rather than weight should be utilized. Furthermore, changes in skeletal muscle and the 6MWT and/or SBBP may be preferred endpoints.

190 Background: Inpatient supportive care interventions are targeted to patients with advanced solid tumors due to perceived higher symptom burden. Yet, few studies have characterized symptom prevalence in hospitalized patients with curable cancers. We aimed to describe and compare symptom burden and palliative care utilization in hospitalized patients with curable and incurable cancers to determine the allocation of such supportive care resources. Methods: We conducted a single center study of 1549 patients (238 curable hematologic, 239 curable solid, 123 incurable hematologic, 949 incurable solid cancers) who experienced an unplanned hospitalization between 9/14 - 4/17. On admission, we assessed patients’ physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire - 4 and Primary Care PTSD Screen). Results: The median number of moderate to severe symptoms reported by patients with curable hematologic, curable solid, incurable hematologic, and incurable solid cancers were 5 [3-6], 5 [3-7], 5 [4-6], and 6 [4-7], respectively. Most patients reported moderate to severe fatigue (83.6%, 82.9%, 81.3%, 86.9%). Table 1 depicts rates of psychological distress. In adjusted analyses patients with incurable solid cancers reported higher symptom burden (β = 7.6, p < 0.01), depression (β = 0.4, p = 0.01), and anxiety (β = 0.3, p = 0.03) symptoms, but no difference in PTSD symptoms. Among patients in top quartile of symptom burden, palliative care was consulted in 16.2%, 7.9%, 23.8%, and 49.6% (p < 0.01) of patients with curable hematologic, curable solid, incurable hematologic, and incurable solid cancers, respectively. Conclusions: Hospitalized patients with solid and hematologic cancers experience substantial physical and psychological symptoms regardless of the curability of their illness. Palliative care is rarely consulted for highly symptomatic patients with curable cancers. Inpatient supportive care interventions should target the needs of all highly symptomatic patients with cancer. [Table: see text]

203 Background: Hospitalized patients with cancer often have impaired ADLs related to age, comorbidities, and both cancer and treatment-related morbidity. However, the relationship between ADL impairment and patients’ symptom burden and clinical outcomes has not been well described. Methods: We prospectively enrolled patients with advanced cancer with unplanned hospitalizations at an academic medical center. Upon admission, nurses assessed patients’ ADLs (mobility, feeding, bathing, dressing, and grooming). We used the Edmonton Symptom Assessment Scale (ESAS) and Patient Health Questionnaire-4 to assess physical and psychological symptoms, comparing symptom burden between patients with and without ADL impairment. We used regression models adjusted for age, sex, education, Charlson comorbidity index, months since advanced cancer diagnosis, and cancer type to assess the relationship between any ADL impairment and hospital length of stay, the composite outcome of death or readmission within 90 days of discharge, and survival. Results: Among 932 patients, 40.2% had at least one ADL impairment. Patients with ADL impairment were older (67.2 vs. 60.8 years, p

74 Background: U.S. National Antiemetic Guidelines recommend upfront triple prophylaxis (NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone) for patients receiving highly emetogenic chemotherapy (HEC), including carboplatin AUC ≥ 4 per 2017 guidelines. While existing data show gaps in guideline compliance, variation between individual physicians is less studied, and a realistic target compliance rate remains unknown. Methods: In a large electronic health record database (IBM Explorys), we identified HEC courses of therapy initiated from 2012 to 2017. Guideline compliance was defined as triple prophylaxis at chemotherapy initiation. Patient courses for ≥ 7 day cycles of cisplatin or anthracycline + cyclophosphamide (AC), or carboplatin (≥ 14 day cycles as a proxy for AUC ≥ 4) were ascribed to oncologists based on encounter frequency. We then ranked physicians treating ≥ 5 HEC courses and evaluated guideline compliance and individual physician variation. Results: In total, 10,074 HEC courses were identified and attributed to 451 unique physicians. Overall antiemetic guideline compliance with cisplatin and AC averaged 68% and 81% respectively. When ranked by compliance, the top 20% of physicians were 2.5 - 1.5 times as compliant as the bottom 20% (cisplatin 100% vs 40%; AC 100% vs 67%). For cisplatin, 32% of physicians had > 90% compliance; the remaining 68% were evenly distributed from 0 - 90%. For AC, 56% of physicians had > 90% compliance, and another 14% had 80 - 90%; the remaining 30% were evenly distributed. For carboplatin, 62% of physicians had ≤ 10% compliance, and another 17% had 11 - 20%; however, the majority of these data preceded guideline inclusion of carboplatin AUC ≥ 4 as HEC. Rates were independent of course volume per physician. Conclusions: Considerable physician-level variation exists in triple antiemetic prophylaxis guideline adherence for HEC. Hundreds of physicians had > 90% compliance with guidelines, suggesting 90% is a realistic target. However, the majority exhibited substantial gaps in NK1 RA use in HEC, placing patients unnecessarily at risk for CINV. Interventions are needed to bolster triple antiemetic prophylaxis in HEC, perhaps especially for carboplatin.

209 Background: Given body composition predicts toxicity for patients receiving cytotoxic chemotherapy, we explored changes in body composition and biomarkers as predictors of immune-related adverse events (irAEs) and health care utilization. Methods: We conducted a longitudinal study of patients with metastatic solid tumor receiving immunotherapy (07/2014-10/2017). Eligible patients had a computed tomography (CT) scan prior to first-line immunotherapy with at least two additional CT scans at three, six or nine months after immunotherapy initiation. We analyzed body composition using cross-sectional CT scans at the third lumbar vertebra. We utilized mixed effect linear regression models to assess longitudinal changes in body composition (weight, skeletal muscle, total adipose). We examined associations of baseline body composition and biomarkers (albumin, neutrophil-lymphocyte ratio (NLR)) with the incidence of irAEs and healthcare utilization (hospitalizations/ED visits) using logistic regression. Results: Of 140 patients treated with immunotherapy, 61 met inclusion criteria. The majority (80%) received prior chemotherapy and the most common malignancies included lung (26%), head and neck (20%), and melanoma (20%). We found that one-third (n=19) experienced an irAE and colitis (53%) was the most common irAE. Patients experienced substantial weight loss over time (B= -1.88, p

BACKGROUND: Patients with malignant gliomas have a poor prognosis and high symptom burden. Caregivers of these patients face significant challenges due to the impact of the cancer on their loved ones neurological and mental faculties. We have previously shown that rates of clinically significant anxiety symptoms in caregivers of this population are high (50%). We sought to evaluate whether caregiving burden was associated with anxiety symptoms in caregivers of patients with malignant gliomas. METHODS: We conducted a prospective study in patients with newly diagnosed malignant gliomas and their caregivers, collecting caregivers self-report data within 6 weeks of diagnosis. We assessed caregivers anxiety symptoms with the Hospital Anxiety and Depression Scale, with subscale scores >7 considered clinically significant. We evaluated caregiving burden using the Caregiver Reaction Assessment (CRA) subscales, with the following domains: impact on schedule, caregivers esteem, lack of family support, impact on health, and impact on finances. We used a linear regression model to identify associations between the CRA subscales and anxiety symptoms. RESULTS: Fifty percent (38/76) of caregivers experienced clinically significant anxiety symptoms. Caregiving burden was significantly associated with anxiety symptoms F(5, 69)=11.525, p

93 Background: Time-driven activity-based costing (TDABC) can be used by health systems to identify inefficiencies and improve the patient experience in clinical encounters. This quality improvement project utilized a Plan, Do, Study, Act (PDSA) cycle to evaluate routine clinic-based care for women with metastatic breast cancer (MBC). Methods: A project plan was developed to directly observe the time spent by MBC patients in clinic (Plan). Patient clinical encounters could include a physician visit along with scans, infusion, and/or labs. We then created process maps of typical patient clinical experiences (Do). Next, we tabulated times (mean, standard deviation [SD]) that patients spent in waiting areas and with each clinical team member (physician, fellow, nurse practitioner, registered nurse, medical assistant, chaplain, social worker, pharmacist, navigator) to identify care inefficiencies (Study). Lastly, we discussed results with providers and identified and implemented strategies for improving efficiency (Act). Results: We directly observed clinic visits (n = 33) for MBC patients from November 2016 to June 2017. On average, patients spent 219 minutes (SD 108) at clinic visits including 71 minutes (SD 45) spent with clinical team members and 85 minutes (SD 43) spent in waiting areas. We identified several opportunities for efficiency improvement, including the delay prior to rooming by medical assistants (n = 31; mean 22, SD 20 minutes), delays with port lab draws in infusion (n = 5; mean 22, SD 13 minutes), and delays awaiting drug from pharmacy (n = 22; mean 15, SD 29 minutes). To improve efficiency, we implemented strategies including having a dedicated infusion nurse assigned to draw labs from patient ports and modifications to medical assistants’ workflow. Conclusions: In this PDSA cycle, we found that patients spend a substantial amount of time at clinic visits, and the majority of this time is spent in waiting areas. Our use of process mapping and evaluation of time spent receiving care identified important opportunities for improving care delivery and efficiency for patients with MBC.

The TRIBE trial compared the FOLFOXIRI regimen plus bevacizumab with FOLFIRI plus bevacizumab in patients with metastatic colorectal cancer. FOLFOXIRI plus bevacizumab is an acceptable therapeutic option, but the results of the TRIBE trial do not establish this regimen as the best treatment option for patients with metastatic colorectal cancer.

had mutated immunoglobulin heavy chain variable gene (IGHV), 69 (51%) were ZAP70 negative and 76 (63%) had either 13q deletion or normal interphase cytogenetics, determined by fl uorescence in situ hybridization. Th e median time between the fi rst and last CD38 measurements was 3.4 years (range 0.2 – 11.3). CD38 expression was measured a median of 5.5 times (range 2 – 19). Patients with CLL were followed for a median of 7.7 years (range 1.3 – 30.4). During this time, 60 patients (44%) progressed and required therapy, while 76 patients (56%) did not need therapy. Of the 60 patients who were treated, 20 had received therapy prior to the fi rst CD38 measurement. What is the extent of CD38 variation in CLL lymphocytes over time in individual patients? As seen in Figure 1(A), the CD38 values in the entire cohort had a wide range, but in many patients these values remained relatively stable. For example, fi ve patients (4%) had fi rst CD38 values above 30% with subsequent CD38 values below 30%. Fourteen patients (10%) had fi rst CD38 values below 30% with later CD38 values above 30%. For the 60 patients who required therapy, two (3%) patients had a fi rst CD38 value above 30% with a subsequent CD38 value less than 30%, while nine patients (15%) had a fi rst CD38 value less than 30% and a subsequent CD38 value above 30%. Th e clinical outcomes (overall survival and time to therapy) of patients with CD38 values that were always less than the 30% cut-off were superior to those of patients with CD38 values always greater than 30% or both above and below 30% [Figures 1(B) and 1(C)]. Th ese results indicate that CD38 expression varies in approximately 15% of patients, crossing an established CD38 cut-off that has prognostic signifi cance, and that the clinical outcome of these patients is similar to that of patients with consistently high CD38 expression. What is the prognostic signifi cance of the fi rst, maximum and minimum CD38, as well as CD38 range? Evaluating these values as continuous variables, we found that an elevated fi rst CD38 measurement was associated with a signifi cantly more rapid time to therapy (TTT, hazard ratio [HR] 1.011, 95% confi dence interval [CI] 1.002 – 1.02, p 0.016, Wald test), and was associated with a trend toward a lower overall survival

A growing set of quality measures is being implemented to evaluate all components of cancer care, from diagnosis through the end of life. We investigated the Quality Oncology Practice Initiative (QOPI) quality measures portfolio. Additionally, we explored the effect of quality measure type on conformance.We performed QOPI data collections twice per year from fall 2007 through fall 2010 and spring 2012, using chart review of the Durham Veterans Administration outpatient oncology clinic. We categorized QOPI measures as nontreatment-related supportive care (NTSC), treatment-related supportive care (TSC), diagnostic, or therapeutic. Descriptive statistics and χ(2) were used to compare longitudinal conformance.The majority of QOPI measures in spring 2012 assess processes of chemotherapy treatment (therapeutic, 54.3%; TSC, 8.7%) or diagnostic modalities (19.6%). Measures targeting NTSC are few (17.4%) but increased from three measures in fall 2007 to eight measures in spring 2012. During those 5 years, average conformance to NTSC, TSC, diagnostic, and therapeutic measures was 71.4%, 86.1%, 89.3%, and 75.4%, respectively (P.001). Within the NTSC measures, emotional well-being and constipation assessment were least documented (41.0% and 46.3%, respectively). In spring 2012, NTSC measure conformance (75.8%) remained significantly lower than diagnostic measure conformance (91.5%; P.001).Most QOPI quality measures assess diagnosis or treatment processes of care and not supportive care. Aggregate conformance to the NTSC measures was lower than that of other categories. The differential conformance demonstrates the necessity of standardized documentation methods and quality improvement efforts that remain commensurate with the increasing portfolio of supportive care measures.

The number of older adults continues to increase in the United States. According to the Census Bureau’s projections, nearly one in five Americans will be aged 65 and older in 2030, compared with approximately one in eight in 2010.1 The majority of individuals with cancer are elderly. Projections suggest that approximately 60% of cancer incidence and 70% of cancer-related mortality will occur in individuals aged 65 and older.2,3 The burden of pain in individuals with cancer is well documented.4 Fatigue, pain, and distress are the most commonly reported symptoms, according to multiple studies, and this has been poorly studied in elderly adults.5–7 Inadequately controlled pain can adversely affect individuals and their families. The World Health Organization (WHO), international and national professional organizations, and governmental agencies have stressed the importance of pain management as part of routine cancer care.4,8 Limited attention has been paid to the management of cancer pain treatment with a focus on the elderly population. Although older adults are less likely to report pain, there are no data supporting a change in pain perception. Depression, cognitive impairment, and other comorbidities may play a part in this underreporting.9 Pain severity directly correlates with basic and instrumental activity of daily living disability.10 Comprehensive geriatric assessment has been shown to aid in care management, with some evidence of applicability to the care of elderly adults with cancer.11,12 A geriatric evaluation and management unit (GEMU) is a specialized program of services provided by an interdisciplinary team of healthcare professionals usually consisting of a geriatrician, a social worker, and a nurse. These services are targeted for older adults who have geriatric conditions that benefit from geriatric evaluation and management, such as problems with functional status, gait balance and risk for falls, polypharmacy, cognitive status, affective status, nutritional status, pain, and social function. Such services may be provided in an inpatient or out-patient setting and include evaluation and management components. It has been demonstrated that inpatient GEMUs positively influence bodily pain, mental health, and functional status.13 A previous study of a subset of individuals with cancer from the above-mentioned randomized controlled trial comparing inpatient GEMUs with usual inpatient care showed a substantial improvement in pain control that was sustained at 1 year regardless of the type of outpatient care.14 The reasons for this positive effect are unknown, but it was hypothesized that it might be related to better pain assessment and management, better interdisciplinary care, and more-effective use of physical and occupational therapy and other supportive services.

Caregiver, relational, and patient factors have been associated with the health of family members and friends providing care to patients with early-stage cancer. Little research has examined whether findings extend to family caregivers of patients with incurable cancer, who experience unique and substantial caregiving burdens. We examined correlates of mental and physical health among caregivers of patients with newly-diagnosed incurable lung or non-colorectal gastrointestinal cancer. At baseline for a trial of early palliative care, caregivers of participating patients (N = 275) reported their mental and physical health (Medical Outcome Survey-Short Form-36); patients reported their quality of life (Functional Assessment of Cancer Therapy-General). Analyses used hierarchical linear regression with two-tailed significance tests. Caregivers’ mental health was worse than the U.S. national population (M = 44.31, p

Sarcopenia, the loss of skeletal muscle mass, is common in chronic disease, and has been hypothesised to contribute to fatigue and breathlessness [1, 2]. The research gold standard for assessing sarcopenia relies on whole-body, cross-sectional imaging, an impractical approach in routine care [3]. A more practical alternative measures lumbar skeletal muscle density at L3 using computed tomography (CT) normalised for height, termed the skeletal muscle index (SMI) [4]. While evidence suggests that reduced lumbar SMI correlates with adverse clinical outcomes, such as mortality in lung or colorectal cancers [5], little research has explored how this measure of sarcopenia relates to breathlessness or exercise tolerance., Thoracic sarcopenia can feasibly be measured from routine CT scans but does not correlate to patient-centred outcomes http://ow.ly/102UkQ

Context Patients with incurable cancer engage in several coping styles to manage the impact of cancer and its treatment. The Brief COPE is a widely used measure intended to capture multiple and distinct types of coping. The Brief COPE has not been validated among patients with incurable cancer. Objectives We sought to validate seven subscales of the Brief COPE in a large sample of patients newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers ( N = 350). Methods Participants completed the Brief COPE and measures assessing quality of life (QOL) (Functional Assessment of Cancer Therapy—General) and psychological distress (Hospital Anxiety and Depression Scale) within eight weeks of diagnosis of incurable cancer. We evaluated the psychometric properties of the Brief COPE using a confirmatory factor analysis and tests of correlation with the QOL and distress scales. Results The Brief COPE factors were consistent with the original subscales, although the Behavioral Disengagement Scale had low internal consistency. Factors showed anticipated relationships with QOL and distress measures, except emotional support coping, which was correlated with increased depression and anxiety. We also conducted an exploratory high-order factor analysis to determine if subscales' score variances grouped together. The high-order factor analysis resulted in two factors, with active, emotional support, positive reframing, and acceptance loading onto one factor and denial and self-blame loading onto the second. Conclusion The selected subscales of the Brief COPE are appropriate measures of coping among individuals newly diagnosed with incurable lung and gastrointestinal cancers.

BACKGROUND Larger tumor size and lymph node involvement are traditionally associated with increased colon cancer-specific mortality. OBJECTIVE We sought to determine whether patients with very small tumors associated with lymph node involvement are at paradoxically increased risk of colon cancer-specific mortality in comparison with those who have larger tumors and lymph node involvement. DESIGN This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results database. SETTING Geographic areas included in one of the 18 Surveillance, Epidemiology, and End Results registries were used. PATIENTS We identified 99,594 patients with nonmetastatic colon adenocarcinoma treated with surgery between 1988 and 2001. MAIN OUTCOME MEASURES The primary predictor variables were regional lymph node involvement and primary tumor size by longest dimension, grouped into the following predetermined strata

Patients with incurable cancer face many physical and emotional stressors, yet little is known about their coping strategies or the relationship between their coping strategies, quality of life (QOL), and mood.As part of a randomized trial of palliative care, this study assessed baseline QOL (Functional Assessment of Cancer Therapy-General), mood (Hospital Anxiety and Depression Scale), and coping (Brief COPE) in patients within 8 weeks of a diagnosis of incurable lung or gastrointestinal cancer and before randomization. To examine associations between coping strategies, QOL, and mood, we used linear regression, adjusting for patients' age, sex, marital status, and cancer type.There were 350 participants (mean age, 64.9 years), and the majority were male (54.0%), were married (70.0%), and had lung cancer (54.6%). Most reported high utilization of emotional support coping (77.0%), whereas fewer reported high utilization of acceptance (44.8%), self-blame (37.9%), and denial (28.2%). Emotional support (QOL: β = 2.65, P.01; depression: β = -0.56, P = .02) and acceptance (QOL: β = 1.55, P.01; depression: β = -0.37, P = .01; anxiety: β = -0.34, P = .02) correlated with better QOL and mood. Denial (QOL: β = -1.97, P.01; depression: β = 0.36, P = .01; anxiety: β = 0.61, P.01) and self-blame (QOL: β = -2.31, P.01; depression: β = 0.58, P.01; anxiety: β = 0.66, P.01) correlated with worse QOL and mood.Patients with newly diagnosed, incurable cancer use a variety of coping strategies. The use of emotional support and acceptance coping strategies correlated with better QOL and mood, whereas the use of denial and self-blame negatively correlated with these outcomes. Interventions to improve patients' QOL and mood should seek to cultivate the use of adaptive coping strategies. Cancer 2016;122:2110-6. © 2016 American Cancer Society.