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Tyrosine kinase inhibitors (TKIs) allow many patients with chronic myeloid leukemia (CML) to live normal life spans but have the potential to impact patients’ health-related quality of life (HRQOL). Patient-reported outcome (PRO) measures can provide valuable information to inform treatment decision-making. Here, we review pivotal studies that used PRO measures to evaluate HRQOL of patients with CML in the first-line and treatment-free remission (TFR), and identify areas for future research. PRO measures commonly studied in patients with CML include the SF-36, FACT-Leu, EORTC QLQ-CML24, and MDASI CML. Cohort or cross-sectional studies provide the most data on PRO measures in patients with CML, with less information available from randomized controlled trials (RCTs). Patients with CML taking TKIs have worse HRQOL compared to matched controls, with a few studies seeing a larger effect in younger patients (

Treatment-free remission (TFR) is a goal for patients with chronic myeloid leukemia (CML). Functional outcomes after discontinuing tyrosine kinase inhibitor (TKI) treatment have not been described. Patient-Reported Outcomes Measurement Information System (PROMIS) measures of social, physical, cognitive, and sexual function were assessed over 36 months in 172 adult patients with chronic phase CML from 14 sites at baseline (on TKI) and after discontinuation. Linear mixed-effects models described the average trajectories for each patient-reported outcome measure after discontinuation and in those who restarted TKI. Of 112 patients in TFR at 12 months, 103 (92.0%) had a 3-point or greater improvement in social function, 80 (71.4%) in social isolation, 11 (9.8%) in satisfaction with sex life, 4 (3.6%) in physical function, and no patients had a 3-point or greater improvement in cognitive function or interest in sexual activity. Patients’ scores worsened after restarting TKI. This novel information on functional outcomes in TFR can help guide patient and clinician decision making.

BACKGROUND: Bortezomib is a common multiple myeloma therapy that can cause treatment-related peripheral neuropathy, a risk factor for falls. The relationship between bortezomib and falls in older patients with multiple myeloma is unknown. METHODS: We analyzed the SEER-Medicare database for patients aged 65 or older diagnosed with multiple myeloma between 2007 and 2013. Claims were analyzed for myeloma treatments, falls, and covariates of interest. We evaluated accidental falls occurring within 12 months after starting first-line multiple myeloma treatment with bortezomib. RESULTS: Bortezomib was used in first-line therapy for 2,052 older adults with new diagnoses of multiple myeloma. Claims for falls were reported in 157 (8%) patients within 12 months after starting bortezomib, compared to 102 (5%) patients not receiving bortezomib (p

Multiple myeloma is a hematologic malignancy that predominantly affects older adults, with a median age at diagnosis of 70 years old. A mainstay of multiple myeloma treatment is lenalidomide, which is an immunomodulatory drug (IMiD) that changed the treatment paradigm for multiple myeloma. This is particularly true for older adults who do not undergo autologous stem cell transplantation (ASCT). Several pivotal trials summarized in this review demonstrate the efficacy and safety of lenalidomide in older adults with multiple myeloma, including significant improvements in response rates, progression-free survival and overall survival in the first-line and relapsed/refractory settings. Potential adverse effects include venous thromboembolism, cytopenias, and second malignancies and the doses tolerated in real-world older patients are often lower than those utilized in clinical trials enrolling select older patients. Given the heterogeneity of aging, several approaches to measuring frailty have been developed and validated to aid in predicting which older adults may benefit from empiric dose reduction to reduce the risk of toxicity and improve the tolerability of treatment. A number of randomized trials have explored a range of approaches utilizing lenalidomide in older adults in both the up-front and relapsed setting, ranging from attenuated maintenance strategies through quadruplet combination therapies including proteasome inhibitors and monoclonal antibodies. This wealth of literature provides a great number of options, which can make it difficult for a clinician to determine a single optimal recommendation for an individual patient. While lenalidomide is currently part of standard of care, the treatment of multiple myeloma is growing rapidly. There is a need to expand clinical trials participation to older adults with multiple myeloma. Incorporation of validated comprehensive geriatric assessments in clinical trials for multiple myeloma could provide a more accurate depiction of the older patient population and is an area for future exploration.

Tyrosine kinase inhibitors (TKIs) allow many patients with chronic myeloid leukemia (CML) to live normal life spans but have the potential to impact patients' health-related quality of life (HRQOL). Patient-reported outcome (PRO) measures can provide valuable information to inform treatment decision-making. Here, we review pivotal studies that used PRO measures to evaluate HRQOL of patients with CML in the first-line and treatment-free remission (TFR), and identify areas for future research.PRO measures commonly studied in patients with CML include the SF-36, FACT-Leu, EORTC QLQ-CML24, and MDASI CML. Cohort or cross-sectional studies provide the most data on PRO measures in patients with CML, with less information available from randomized controlled trials (RCTs). Patients with CML taking TKIs have worse HRQOL compared to matched controls, with a few studies seeing a larger effect in younger patients ( 60 years old). No single TKI consistently has better HRQOL compared to other agents. Fatigue is a predominant symptom associated with impaired HRQOL across many studies. Studies evaluating TFR show stable or improved HRQOL after TKI discontinuation. There are areas of HRQOL detrimental to patients with other types of cancer (e.g., cognition, sexuality) that warrant further evaluation in patients with CML. Understanding the HRQOL of patients with CML is increasingly important as patients live near-normal life expectancies. PRO measures have the potential to inform treatment decisions in this patient population. Future research opportunities include using PRO measures in RCTs and expanding the HRQOL topics studied in patients with CML.

12117 Background: Patients with hematologic malignancies are less likely to receive outpatient palliative care (OPC) compared to patients with other cancer types. Little is known about the characteristics or health care utilization of patients with hematologic malignancies who are co-managed by OPC. In this study, we evaluated referral patterns and health care utilization of patients with hematologic malignancies who were seen in an embedded OPC clinic. Methods: We conducted a retrospective cohort study of patients who established care with an embedded OPC nurse practitioner from 3/2016 – 5/2020 at a quaternary academic medical center. We obtained information about patients’ demographics, clinical characteristics, and reasons for referral to OPC from the electronic health record. Information about costs and health care utilization were provided by our finance team. For patients who were followed by OPC for at least 6 months, we used two-tailed t-tests to compare the number of hospitalizations and emergency department (ED) visits, as well as total costs, for the 6 months before and the 6 months after initiating OPC. This was approved by the UCSF IRB. Results: A total of 120 patients received OPC. Median age was 59 years (range 24-89), 48% were female, and 64% were Non-Hispanic White. Myeloma was the most common cancer (n = 50/120, 41.7%), followed by aggressive lymphoma (n = 21/120, 17.5%), and acute myeloid leukemia (n = 18/120, 15%). The primary reason for referral was for symptom management, such as pain (60%, n = 72/120), mood symptoms (12.5%, n = 15/120), and fatigue (7.5%, n = 9/120). Ten percent (n = 12/120) were referred for goals of care conversations prior to stem cell transplant (SCT). An advance directive was on file for 29% (n = 35/120) of patients, of which 34% (n = 12/35) were completed after OPC enrollment. Of the 38 patients who died, the median time from PC enrollment to death was 15.3 months, and 39% died on hospice. For the 65 patients who were followed by OPC for at least 6 months, the total number of inpatient hospitalizations, excluding SCT, went from 0.82 to 0.54 (p = 0.11) per person in the 6 months before compared to the 6 months after initiating OPC. ED visits went from 0.28 to 0.18 (p = 0.33). The total direct cost of inpatient hospitalizations, excluding SCT, decreased from $43,428 to $13,226 (p = 0.01), and the cost of ED visits went from $640 to $297 (p = 0.32) per person. Conclusions: There is an important role for embedded OPC for patients with hematologic malignancies, long before the end-of-life period, to manage symptoms and support decision-making. OPC is associated with a trend towards lower health care utilization and decreased hospitalization costs. Prospective studies are warranted to further explore the impact of OPC on symptoms and patient/caregiver experience, as well as to clarify how OPC impacts health care utilization.

Background: Tyrosine kinase inhibitors (TKIs) enable patients with chronic phase chronic myeloid leukemia (CP-CML) to achieve similar overall survival to the general population, but can cause side effects that negatively impact quality of life (QOL) and contribute to distress. Since most CP-CML patients remain on TKIs indefinitely, there is a need to develop targeted interventions to address their physical and psychosocial complications. Mindfulness meditation interventions have improved QOL and decreased distress, depression, anxiety, fatigue, and pain in patients with solid tumors; however, such interventions have not previously been evaluated in patients with CP-CML. In Being Present-CML, we sought to determine if a mindfulness meditation-based program is feasible and acceptable to patients with CP-CML, and to explore its preliminary efficacy. Methods: Being Present-CML is a prospective, single-arm clinical trial of an 8-week, online mindfulness meditation-based intervention effective in patients with gastrointestinal cancers (Atreya, et al. PLoS One, 2018). Participants were recruited from a single academic institution. Eligibility included adult patients with CP-CML taking TKIs. Participants were instructed to independently play audio-guided meditations at least 5 times per week on a secure website and to participate in once weekly, instructor-led meditation classes on Zoom in assigned cohorts. Qigong was incorporated into the classes to target fatigue, a common TKI side effect. Class content was recorded and uploaded to the website for those unable to attend live. Feasibility was assessed through measurement of recruitment and attrition. Adherence was determined by web capture. Acceptability was determined by feedback from study surveys and qualitative interviews. Preliminary efficacy was evaluated using patient-reported outcome measures (PROMs) at baseline (week 0) and post-intervention (week 8) using the NCCN Distress Thermometer (DT) and Patient-Reported Outcomes Measurement Information System (PROMIS) short forms for anxiety, depression, fatigue, pain interference, and sleep disturbance. A DT score ≥4 is consistent with moderate to severe distress. PROMIS scores use T-scores where the mean score for the general population is 50 (standard deviation [SD] +/-10); higher scores indicate worse symptoms. Descriptive statistics and two-tailed paired t-tests (p Results: Between October 2020-April 2021, 98 eligible participants were approached to participate in the study; 88 (89.8%) patients agreed to learn more, and 37 (37.8%) patients provided consent. The median age was 51 (range 23-72), 51.5% (n=19/37) were male, and 89.1% (n=33/37) were non-Hispanic White. At time of study start, 83.7% (n=31/37) had a BCR-ABL1 PCR transcript ≤1% and a median time since diagnosis of 71 months (range 2-234) (Table 1). Of 37 participants, 29 (78.4%) completed end of study procedures; 4 (10.8%) dropped out, and 4 (10.8%) did not complete week 8 surveys. The median number of audio meditations listened to per participant was 34 with an average of 4.3 per week. The median number of weekly classes attended and/or recordings viewed per participant was 7 (range 1-8). At baseline, participants had a median DT score of 5 (range 2-8). Average baseline PROMIS scores were slightly worse than the general population in depression (51.4, SD 8.8), anxiety (55.9, SD 7.8), sleep disturbance (51.8, SD 6.9), fatigue (53.9, SD 10.6), and pain interference (52.2, SD 9.9). By week 8, the median DT score improved to 3 (p=0.003) (Figure 1). Post-study PROMIS scores improved in sleep disturbance (p=0.001) and depression (p=0.01) (Figure 2), but not anxiety (p=0.12), fatigue (p=0.10), or pain interference (p=0.98). Of those who conducted post-study interviews, 77% (n=20/26) reported their symptoms during the study were not influenced by the COVID-19 pandemic. Nearly all participants found the study helpful (Figure 3) and would recommend it to others (median score of 8 on a 1-10 scale; 10=extremely likely). Conclusions: Patients with CP-CML taking TKIs found the mindfulness meditation-based intervention to be feasible and acceptable. PROM results suggest promise of clinical benefit in this patient population, including patients with well-controlled disease and a long history of CML. A randomized controlled trial is being planned to validate these findings. Figure 1 Figure 1. Disclosures Smith: Astellas Pharma: Consultancy, Research Funding; FUJIFILM: Research Funding; Daiichi Sankyo: Consultancy; Revolutions Medicine: Research Funding; AbbVie: Research Funding; Amgen: Honoraria. Shah: Bristol-Myers Squibb: Research Funding. Atreya: Guardant Health: Research Funding; Pionyr Immunotherapeutics: Membership on an entity's Board of Directors or advisory committees; Array Biopharma: Membership on an entity's Board of Directors or advisory committees; Merck: Research Funding; Bristol-Meyers Squibb: Research Funding; Gossamer Bio: Research Funding; Novartis: Research Funding.

Introduction:Tyrosine kinase inhibitor (TKI) intolerance is commonly encountered in patients with chronic myeloid leukemia in chronic phase (CML-CP). Clinical trials define non-hematologic TKI intolerance as grade 3-4 toxicities, but lower grade toxicities may also impair patients' quality of life and lead to changes in medical management. We sought to compare TKI-intolerant and -tolerant CML-CP patients and their clinical outcomes, including molecular responses, rates of progression, survival, and utilization of allogeneic stem cell transplant (alloSCT). Methods:We performed a single-center, retrospective cohort study of active CML-CP patients in our Hematology clinic between January 2017 and December 2019. We defined TKI intolerance as any grade non-hematologic toxicity that led to a change in TKI management, such as dose reduction or change of TKI. We also reviewed CML-CP patients who underwent alloSCT in the TKI era (2002-2019). AlloSCT patients were identified for chart review by ICD-10 codes and query of the institution's transplant database. Descriptive statistics, Chi-Square tests, and two-tailed t-tests were used to summarize the data. Results:We identified 216 CML-CP patients (Table 1), and 161 (74.5%) met criteria for non-hematologic TKI intolerance. The median age was 59 years-old in TKI-intolerant patients and 49 in tolerant patients (P=0.011). Most patients experienced TKI-intolerance from symptoms (93.2%, n=150); symptoms included fatigue (n=77, 59.2%), arthralgias (n=36, 27.7%), nausea (n=29, 22.3%), headache (n=16, 12.3%), and edema (n=15, 11.5%). The remaining patients were TKI-intolerant based on abnormal laboratory findings such as transaminitis or hyperglycemia (6.8%, n=11/161). Of the 161 TKI-intolerant patients at last follow-up, 130 (80.7%) remained on TKI, 19 (11.8%) were on prescribed discontinuation, 6 (3.72%) were non-adherent, 5 (3.1%) were off TKI for non-CML medical problems, and 1 (0.6%) was on omacetaxine. Dose reductions occurred in the majority who remained on TKIs (n=103/130, 79.2%) and prior to TKI discontinuation (n=13/19, 68.4%). Most TKI-intolerant patients (n=122/161, 75.8%) switched TKIs, with a median of 2 agents used (range 1-5). Of 55 TKI-tolerant patients, 46 (83.6%) were on TKI, 8 (14.5%) were on discontinuation, and 1 (1.8%) was non-adherent. Only 19.6% (n=9/46) patients were dose-reduced, and they rarely changed TKIs (median of 1 agent used). MR4.5 was achieved in 49% (n=79/161) of TKI-intolerant and 41.8% (n=23/55) of TKI-tolerant patients. Only 1 patient in each group progressed to accelerated phase. TKI-intolerant and -tolerant patients had similar times since diagnosis (with a median follow up of 81.7 months and 79.7 months, respectively). Five of 161 (3.1%) TKI-intolerant patients died, all from causes unrelated to CML and TKI therapy. None of the TKI-tolerant patients died during the abstraction period. Twenty CML-CP patients underwent alloSCT from year 2002-2019; 10 (50%) were transplanted for TKI intolerance without other transplant indications (Tables 2 and 3). Three of those 10 patients also had hematologic intolerance. Four (40%) TKI-intolerant patients resumed TKI post-transplant: 3 for disease relapse, 1 for sclerotic GVHD. Seven (70%) developed GVHD, with most cases being chronic (n=6), extensive (n=6), and severe/moderate (n=6). While 80% of patients achieved MR4.5 post-transplant (n=8/10), 30% (n=3/10) experienced transplant-related mortality (TRM) with a mean post-transplant survival of 38.5 months; the remaining 7 patients were alive at a median follow-up of 37.1 months. Conclusion: CML-CP patients with non-hematologic TKI-intolerance achieved similar clinical outcomes as TKI-tolerant patients despite dose reductions and/or switching TKIs. The use of alloSCT was rare in our practice, and CML-CP patients transplanted for TKI intolerance commonly resumed TKI post-alloSCT and frequently developed extensive GVHD. In light of the high survival rate achieved with medical management in CML-CP patients with non-hematologic TKI-intolerance, including no disease- or treatment-related deaths, this analysis does not support the use of alloSCT for patients with non-hematologic TKI-intolerance. Disclosures Schoenbeck: American Society of Hematology:Research Funding.Olin:Astellas:Other: Site PI;Genentech:Consultancy;Daiichi Sankyo:Other: Site PI;Amgen:Consultancy;Genentech:Other: Site PI;Pfizer:Other: Site PI.Logan:Amphivena:Research Funding;Autolus:Research Funding;Jazz:Research Funding;Kadmon:Research Funding;Kite:Research Funding;Pharmacyclics:Research Funding;Abbvie:Consultancy;Amgen:Consultancy;Novartis:Consultancy.Smith:Revolution Medicines:Other: Research Support, Research Funding;Abbvie:Other: Research Support, Research Funding;FujiFilm:Other: Research support, Research Funding;Daiichi Sanyko:Consultancy, Honoraria;Astellas Pharma:Honoraria, Other: Research Support, Research Funding;Sanofi:Honoraria.Shah:Bristol-Myers Squibb:Research Funding.

Introduction: The effect of tyrosine kinase inhibitors (TKIs) on cognition in patients with chronic myeloid leukemia in chronic phase (CML-CP) is not well understood. Memory impairments have been reported in limited studies in CML patients on dasatinib and in gastrointestinal stromal tumor patients on imatinib, but additional research is needed. At our institution, we have observed that CML-CP patients spontaneously report new cognitive dysfunction (CD) while on TKIs. We sought to determine the prevalence of CD in CML-CP patients on TKIs, the TKIs associated with cognitive changes, and the management and outcomes of CML-CP patients with CD at our institution. Methods: We performed a single-center, retrospective cohort study of active CML-CP patients in our Hematology clinic seen between January 2017 and December 2019. Patients were identified by ICD-10 codes and chart notes were reviewed for treatment course. Patients met criteria for CD if they reported new difficulties with cognition while on TKI treatment (as documented in the subjective or review of systems) and had no prior history of cognitive impairment. Descriptive statistics, Chi-square tests, and two-tailed t-tests were used to summarize the data. Results: We identified 216 CML-CP patients who were actively or previously treated with a TKI, with 29 patients (13.4%) reporting CD while taking a TKI. The median age for patients with CD was 51 years (range 23-73), compared to a median age of 56 years (range 20-91) in those without CD (P=0.114); there were no significant differences in sex (P=0.984) or in median time since diagnosis (P=0.167) (Table 1). The 29 patients generated 36 reports of CD, as 7 patients (24.1%) reported 2 types of cognitive changes while on TKI. The types of CD were documented as "mental fog" (n=19/36, 52.8%), memory problems (n=7/36, 19.4%), decreased mental acuity (n=6/36, 16.7%), problems with concentration (n=2/36, 5.6%), word-finding difficulties (n=1/36, 2.8%), and impaired creativity (n=1/36, 2.8%) (Figure 1). Of the 29 patients who reported CD, 5 experienced it on 2 different agents, leading to 34 individual reports of CD. Among the 216 patients with CML-CP treated with TKIs, many used more than 1 agent: 31 used bosutinib, 183 dasatinib, 132 nilotinib, and 10 ponatinib. The percentage of CD reported in patients treated with each TKI was as follows: bosutinib 12.9% (n=4/31), dasatinib 11.5% (n=21/183), imatinib 5.3% (n=7/132), nilotinib 4.1% (n=2/49), and ponatinib 0% (n=0/10) (Table 2). For management, 20.7% (n=6/29) underwent successful prescribed discontinuation, 27.6% (n=8/29) attempted discontinuation but resumed TKI after loss of MMR, 24.1% (n=7/29) underwent TKI dose reductions, 20.7% (n=6/29) changed TKIs, and 6.9% (n=2) had no change in management. In the 6 patients who successfully discontinued TKI, all but 1 (83.3%) reported complete resolution of their CD while off of TKI. For those who attempted discontinuation but had loss of MMR, 6 of 8 (75%) had documented improvement of CD off of treatment; after restarting TKI, CD returned in 5 patients (83.3%). Of the remaining patients who underwent TKI dose reductions (n=7), 1 patient had documented improvement of CD, 2 had no change, and 4 had unspecified outcomes. Of the patients who changed TKIs (n=6), 1 patient had documented improvement of CD, 4 had no change, and 1 had unspecified outcomes. In the 2 with no change in management, outcomes were not specified. Conclusion: Cognitive dysfunction in CML-CP patients was reported with all first- and second-generation TKIs; the analysis of ponatinib was limited by small numbers. Bosutinib had the highest proportion of CD in our cohort, an association that has not been previously reported. Our analysis supports that TKI-associated CD is reversible since it resolved in 78.6% (n=11/14) patients when off of TKI during discontinuation. While 13.4% of our CML-CP patients had CD, due to spontaneous reporting and subtle presentation of cognitive impairment, the true prevalence of CD in CML-CP patients on TKIs is likely substantially higher. Future studies should involve prospective data collection of objective cognitive testing and patient reported outcomes in CML-CP patients for further evaluation of TKI-associated cognitive dysfunction. Disclosures Schoenbeck: American Society of Hematology: Research Funding. Smith:Sanofi: Honoraria; FujiFilm: Other: Research support, Research Funding; Revolution Medicines: Other: Research Support, Research Funding; Astellas Pharma: Honoraria, Other: Research Support, Research Funding; Daiichi Sanyko: Consultancy, Honoraria; Abbvie: Other: Research Support, Research Funding. Shah:Bristol-Myers Squibb: Research Funding.

Background: Patients with hematologic malignancies are less likely to be referred to palliative care (PC) compared to those with solid malignancies. There is little that is known about the healthcare utilization of patients with hematologic malignancies who receive outpatient PC concurrently with cancer-directed therapy. The aim of this study was to describe the demographic and clinical characteristics and health care utilization of patients with hematologic malignancies who received longitudinal, concurrent outpatient PC. Methods: We conducted a single-center, retrospective cohort study of all patients with hematologic malignancies who received embedded outpatient PC at the malignant hematology clinic between April 1, 2017 and December 31, 2018. Patients were referred to PC by their primary oncologist or hematology nurse practitioner (NP). Patients referred to PC were seen by a PC NP with expertise in hematologic malignancies. Follow-up visits with the outpatient PC NP were scheduled as needed. Demographics, clinical characteristics, and reasons for referral were extracted from the electronic health record. For patients who were followed by PC for at least 6 months, the number of hospitalizations and emergency department (ED) visits, as well as inpatient costs were compared from the 6 months prior to enrollment in PC to the 6 months after enrollment in PC. Approval for this study was obtained from the UCSF IRB. Results: Overall, 80 patients who were seen in the malignant hematology clinic were referred for embedded PC during our study period. Of these patients, 45% (n= 36) were female. Median age was 57 years (range: 27-89). Common primary diagnoses were myeloma (47.3%, n= 38), lymphoma (18.8%, n= 15), and acute myeloid leukemia (15%, n= 12). The most frequent reasons for referral to PC were pain (32.7%, n= 34), fatigue (16.3%, n= 17), and mood disorders (11.5%, n= 12). There were 9 referrals (8.7%) for advance care planning prior to bone marrow transplant (BMT). One quarter of the patients (n= 20) were referred to PC for two or more reasons. Patients were followed in the PC clinic for a median of 3.18 months (mean 8.03 months, range 0 - 36 months, SD 9.6 months) and patients had a median of 3 PC visits (mean 5, range 1-27, SD 6). The median overall survival of the patient population was 36.5 months (SD 35.8 months). There were 31 patients who were followed in the PC clinic for at least 6 months and were included in our healthcare utilization analyses. The total number of hospital encounters decreased from 1.48 inpatient admissions/ED visits in the 6-months before enrollment in PC to 0.71 per patient in the 6-months after enrollment in PC (p=0.04). Total inpatient direct costs per patient were $52,250.65 in the 6 months before PC enrollment and $30,360.90 in the 6 months after enrollment (p=0.18). The cost of inpatient medical hospitalizations went from $23,457.68 to $4,621.26 per patient (p=0.05), the cost of procedure-based hospitalizations, which included hospitalization for BMT, went from $27,667.84 to $25,434.48 (p=0.90), and the cost of ED visits went from $1,125.13 to $305.16 (p=0.25). Conclusion: Our study suggests that outpatient PC has an important role for patients with hematologic malignancies far upstream of the end-of-life period. Patients were referred for a wide variety of reasons, including management of various symptoms and advance care planning prior to BMT. There was a statistically significant and substantial decrease in the number of hospital and ED encounters per patient after enrollment in PC. There was also a trend towards overall cost savings, although this did not reach statistical significance. Further research is warranted to explore the effects of outpatient PC co-management on symptoms, rates of advance care planning, and patient/family experience for patients with hematologic malignancies. Disclosures Schoenbeck: American Society of Hematology: Research Funding. Mannis:Glycomimetics, Forty Seven, Inc, Jazz Pharmaceuticals: Research Funding; AbbVie, Agios, Bristol-Myers Squibb, Genentech: Consultancy.

Multiple myeloma is a hematologic malignancy that predominantly affects older adults, with a median age at diagnosis of 70 years old. A mainstay of multiple myeloma treatment is lenalidomide, which is an immunomodulatory drug (IMiD) that changed the treatment paradigm for multiple myeloma. This is particularly true for older adults who do not undergo autologous stem cell transplantation (ASCT). Several pivotal trials summarized in this review demonstrate the efficacy and safety of lenalidomide in older adults with multiple myeloma, including significant improvements in response rates, progression-free survival and overall survival in the first-line and relapsed/refractory settings. Potential adverse effects include venous thromboembolism, cytopenias, and second malignancies and the doses tolerated in real-world older patients are often lower than those utilized in clinical trials enrolling select older patients. Given the heterogeneity of aging, several approaches to measuring frailty have been developed and validated to aid in predicting which older adults may benefit from empiric dose reduction to reduce the risk of toxicity and improve the tolerability of treatment. A number of randomized trials have explored a range of approaches utilizing lenalidomide in older adults in both the up-front and relapsed setting, ranging from attenuated maintenance strategies through quadruplet combination therapies including proteasome inhibitors and monoclonal antibodies. This wealth of literature provides a great number of options, which can make it difficult for a clinician to determine a single optimal recommendation for an individual patient. While lenalidomide is currently part of standard of care, the treatment of multiple myeloma is growing rapidly. There is a need to expand clinical trials participation to older adults with multiple myeloma. Incorporation of validated comprehensive geriatric assessments in clinical trials for multiple myeloma could provide a more accurate depiction of the older patient population and is an area for future exploration.

Purpose A metastatic cancer diagnosis is associated with high levels of distress in patients and caregivers, which may be alleviated by mindfulness interventions. Research on scalable, tailored, online mindfulness training programs is needed. We sought to test the feasibility and acceptability of a remotely delivered 8-week mindfulness-based intervention, Being Present 2.0 (BP2.0). Methods We performed a single-arm feasibility study of BP2.0 among patients with any metastatic gastrointestinal cancer receiving chemotherapy, with or without an informal caregiver. Participants were instructed to practice mindfulness using pre-recorded guided meditations 5 times per week using a study-specific website and to attend a weekly live, interactive virtual meeting facilitated by a trained instructor. The web-based platform enabled direct measurement of adherence. Results The study enrolled 46 of 74 (62%) patients contacted, together with 23 caregivers (69 participants total), from May to October 2018. Median patient age was 52 (range 20-70 years), 39% were male, 67% non-Hispanic white, 65% had colorectal cancer, and 78% lived outside of San Francisco. The top reasons cited for participation were to reduce stress/anxiety and learn how to meditate. Mean baseline National Comprehensive Cancer Network Distress Thermometer (NCCN DT) scores were 4.7 (patients) and 5.8 (caregivers). The study discontinuation rate was 20% (eight patients and six caregivers). Among the remaining 55 participants, 43 (78%) listened to at least one audio recording and/or attended at least one virtual meeting, although adherence data was incomplete. The retention rate was 71%, with 39 participants completing at least one follow-up assessment. In post-intervention qualitative interviews, 88% of respondents reported a positive experience. Compared to baseline, participants reported significantly reduced post-intervention NCCN DT scores (mean 3.1; P = .012). Conclusion The BP2.0 online mindfulness-based program is feasible and acceptable for patients with metastatic gastrointestinal cancer and caregivers. These results will guide plans for a follow-up efficacy study. ClinicalTrials.gov Identifier: NCT03528863.

Advance care planning and end-of-life care for patients with hematologic malignancies who die after hematopoietic cell transplant

Background: Patients with BCR-ABL-negative myeloproliferative neoplasms (MPNs) are prone to thrombohemorrhagic complications. Vitamin K antagonists (VKA) or low weight molecular heparin (LWMH) are considered standard treatments for venous or arterial thromboses in BCR-ABL-negative MPN patients. However, there is little information regarding the safety and efficacy of direct oral anticoagulants (DOACs) in this population. Our primary aim was to determine the prevalence and outcomes of DOAC use in BCR-ABL-negative MPN patients at our institution. Methods: We performed a single-center, retrospective cohort study of all active BCR-ABL-negative MPN patients in the UCSF Hematology Clinic between January 2017 and March 2019. Patients were identified by ICD-10 codes and chart abstraction. Problem and medication lists were reviewed for appropriate diagnoses and medications. Provider notes were reviewed for anticoagulation indication, treatment course, and hemorrhagic or thrombotic complications. Descriptive statistics were used to summarize the data. Results: Of 299 patients with BCR-ABL-negative MPNs, 42 were treated with anticoagulation during our abstraction period. Of the 42 patients, 22 (52%) were treated with DOACs, 17 (41%) with warfarin, and 3 (7%) with LWMH. Of the 22 patients on DOACs, the median age was 74 (range 39-94) with a female to male ratio of 1.2:1. Of those on DOACs, the most common diagnosis was essential thrombocythemia (ET) (n=9; 41%), followed by primary myelofibrosis (MF) and post-ET or post-PV myelofibrosis (n=7; 32%), polycythemia vera (PV) (n=5; 22%), and MPN-Unclassifiable (n=1; 5%). All ET and PV patients (except 1 ET) were high-risk by IPSET-thrombosis and clinical criteria, and all primary myelofibrosis and post-ET or post-PV myelofibrosis patients were intermediate-2 by DIPSS-plus. Most patients were JAK2 V617F positive (n=19; 86%), with the remainder positive for CALR type 2 (n=2; 9%) and type 1 (n=1; 5%). Almost all ET and PV patients were concurrently treated with hydroxyurea (12/14; 86%) and 1 out of 5 PV patients was also treated with phlebotomy. Roughly one-third of patients (n=8; 36%) remained on aspirin while on a DOAC. Of the 22 patients, 15 (68%) were prescribed DOACs for thrombosis treatment and prophylaxis. The primary indications were pulmonary embolus (PE) (n=5), deep venous thrombosis (DVT) (n=4), splanchnic thrombosis (SVT) (n=3), organ ischemia (n=2), and cerebral sinus thrombosis (CVT) (n=1). The remaining 7 patients were on DOACs for atrial fibrillation, although two had histories of prior thrombotic events (PE and stroke). Nine (41%) of the patients on DOACs had a history of more than one significant venous or arterial thrombotic event. Most were on long-term anticoagulation with a median DOAC prescription of 26 months (range 4 to 62). Nineteen patients (86%) remained on a DOAC at their last provider visit, with two having completed treatments for provoked PEs and one discontinued for thrombocytopenia. DOACs prescribed for thrombosis indications included apixaban (n=8), rivaroxaban (n=5), and dabigatran (n=2). Of the 22 patients on DOACs, none experienced significant thrombotic events and one patient had a hemorrhagic event shortly before establishing care at our institution; a post-PV MF patient on dabigatran for a splanchnic thrombosis had an upper gastrointestinal bleed and required reversal with idarucizumab. Of the patients on warfarin and LWMH, there were 4 significant thrombohemorrhagic events: 1 bleeding and 3 clotting. The bleeding event happened in a high risk ET patient on warfarin plus aspirin for a splanchnic vein thrombosis (INR 2.2). Three clotting events occurred in high risk ET and PV patients on warfarin. One was concurrently diagnosed with a DVT, PE, and arterial thrombus (INR 2.1), and the other two were diagnosed with portal vein thromboses (INRs of 1.8 and 2.2). None were taking hydroxyurea or aspirin at time of their recurrent thrombosis. Conclusions: DOACs were used more frequently than warfarin or LWMH in our high and intermediate risk BCR-ABL-negative MPN patients with no clotting events but one notable hemorrhagic event. Future research regarding the safety and efficacy of DOAC use in BCR-ABL-negative MPNs, including randomized controlled trials, should be considered. Disclosures Damon: Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Logan:Incyte: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy; TeneoBio: Consultancy; Kadmon: Research Funding; Pharmacyclics: Research Funding; Abbvie: Consultancy; Astellas: Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Kiadis: Consultancy; Kite: Research Funding; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz: Research Funding. Olin:MedImmune: Research Funding; Ignyta: Research Funding; Clovis: Research Funding; Mirati Therapeutics: Research Funding; AstraZeneca: Research Funding; Genentech: Consultancy, Research Funding; Pfizer: Research Funding; Spectrum: Research Funding; Jazz Pharmaceuticals: Consultancy, Honoraria; Novartis: Research Funding; Revolution Medicine: Consultancy; Daiichi Sankyo: Research Funding; Astellas: Research Funding. Smith:Revolution Medicines: Research Funding; Astellas Pharma: Research Funding; fujiFilm: Research Funding; Abbvie: Research Funding.

Background: Patients with multiple myeloma are frequently treated with bortezomib, a proteasome inhibitor, which is associated with treatment-related peripheral neuropathy. Older adults are at increased risk of falls compared to the general population, often leading to associated morbidity and mortality. While an association between peripheral neuropathy and falls in older adults is well-established, the relationship between bortezomib and falls in older multiple myeloma patients is unknown. Our primary aim was to determine if older patients with multiple myeloma treated with bortezomib as first-line therapy had an increased incidence of falls within the first 12 months after starting treatment. Our secondary aim was to assess the overall survival of patients who fell compared to those who did not among patients who lived more than 12 months after initiating treatment. Methods: We analyzed the SEER-Medicare database for all patients 65 years old or older diagnosed with multiple myeloma between 2007 and 2013 and were enrolled in fee-for-service Medicare part A, B and D plans. The patients' corresponding Medicare claims data were analyzed through 2014 for myeloma treatments, fall claims, and covariates of interest. The primary outcome was accidental falls (E880-E888) occurring between 14 days to 12 months after starting multiple myeloma treatment. First-line therapy was defined as any anti-myeloma treatment administered within 14 days of starting multiple myeloma treatment, with bortezomib treatment being the focal independent variable. Cox regression was performed to determine the relative risk of having a fall after controlling for other covariates. Patients who started bortezomib after first-line therapy were censored at time of bortezomib commencement. The survival analysis included only patients who survived more than 12 months of starting treatment to allow landmark analysis of falls in the first year. Results: Of 4,084 older adults with new multiple myeloma diagnoses undergoing first-line therapy, the median age was 75 (range 65-97) with 51% males. Bortezomib was used in first-line therapy for 2,052 (50%) patients, of which 157 (8%) patients experienced a fall within 12 months after starting treatment compared to 102 (5%) of patients not receiving bortezomib (p < 0.001). Bortezomib was associated with a 28% increase risk of falls (HR 1.29; 95% CI 1.00-1.65; p = 0.047). In multivariate analysis, bortezomib was not associated with an increased incidence of falls after controlling for age, gender, race, proxies for Charlson Comorbidity Index (CCI) and poor performance status, pre-existing peripheral neuropathy, falls within the 12 months prior to starting first-line myeloma treatment, depression, polypharmacy, and first-line treatment with lenalidomide (Table 1). Advancing age, history of fall(s), depression, and polypharmacy (defined as more than 10 unique prescription medications at initiation of first-line treatment), were all associated with an increased risk of falls, consistent with prior literature. In a landmark analysis of those who survived 12 months following the start of treatment, a fall was associated with a 26% increased risk of hazard for death (aHR 1.26; 95% CI 1.02-1.56; p = 0.033) after controlling for other covariates. The median OS of those with a fall was 35.7 months (95% CI 29.1-48.4) compared to 49.1 months (95% CI 47.1-52.8) for those without (p < 0.0001). Conclusion: In older adults with multiple myeloma, treatment with bortezomib was not associated with increased risk of a patient having a diagnostic code for falls. However, experiencing a fall within the year after starting treatment was associated with decreased overall survival. Limitations of the study include that the incidence of falls is likely underestimated in billing data, given prior data from our group showing a rate of self-reported falls of 26% in the year after diagnosis. Additional research, including prospective trials involving fall assessments, should be considered in older patients with multiple myeloma. Disclosures Wildes: Janssen: Research Funding; Carevive: Consultancy. Fiala:Incyte: Research Funding.

Background: Patients with BCR-ABL-negative myeloproliferative neoplasms (MPNs) have high symptom burdens that negatively impact quality of life, including risk for developing chronic pain and psychosocial complications. The NCCN guidelines recommended the use of the MPN Symptom Assessment Form Total Symptom Score (MPN-SAF TSS) starting in 2017 to assess symptom burden. Our primary aim was to determine if the MPN-SAF TSS has been incorporated into patient care, and if not, how well BCR-ABL-negative MPN symptoms are captured by review of systems (ROS). Our secondary aim was to evaluate the prevalence of anxiety, depression, chronic pain, and opiate use in our patient population. Methods: We performed a single-center, cross-sectional study of all active BCR-ABL-negative MPN patients in the UCSF Hematology Clinic between January 2017 and March 2019. We reviewed all hematology visits for completion of the MPN-SAF TSS, and the most recent visit for the number symptoms from the MPN-SAF TSS explicitly captured in ROS or problem list and relevant medications. Descriptive statistics were used to summarize the data. Patients whose disease transformed into acute leukemia or were post-allogeneic stem cell transplantation were excluded. Results: Of 299 patients with BCR-ABL-negative MPN diagnoses, the median age was 66 (range 20-98) with an equal number of males (n=150) and females (n=149). Essential thrombocythemia (ET) was the most common diagnosis (n=109; 37%), followed by polycythemia vera (PV) (n=90; 30%), primary myelofibrosis (MF) (n=49; 16%), post-PV or post-ET MF (n=29; 10%), and MPN-Unclassifiable or overlap (n=22; 7%). Most were JAK2 V617F positive (n=213; 71%) and high-risk (n=148; 49.5%) by clinical criteria, IPSET-thrombosis, and DIPSS-plus. Nearly all were on active treatment (91%), with aspirin (n=205; 69%), hydroxyurea (n=130; 43.5%), phlebotomy (n=61; 20%), and ruxolitinib (n=37; 12%) being the most frequent treatments. Significant disease-related vascular complications were documented in 20.7% of patients. The 299 patients were evaluated by 22 hematology providers. The MPN-SAF TSS was formally documented in 1 patient (0.3%). Of the 10 symptoms in the MPN-SAF TSS, the median number documented as positive or negative on ROS was 3 (range 0-8), with 0 or 1 symptoms documented in 82 patients (27.4%). The mean number of positive symptoms was 0.7 (range 0-4) with at least 1 positive symptom reported by 44.7%. The most frequently charted symptoms were fever (n=182; 60.9%), unintentional weight loss (n=137; 45.8%), abdominal pain (n=137; 45.8%), and night sweats (n=130; 43.5%). More unique MPN symptoms were documented less frequently, including pruritis (n=89; 29.8%), early satiety (n=56; 18.7%), bone pain (n=28; 9.4%), and problems with concentration (n=3; 1%). The most common positive symptoms were fatigue (n=90; 73%), pruritis (n=30; 33.7%) and bone pain (n=9; 32%). Pain and psychological symptoms were infrequently charted in hematology clinic. Pain medications were used by 20.4% with nearly half (48%) on opiates, but chronic pain was on the provider problem list for only 5.7% of patients. Anxiety/depression medications were used by 20.4%, but anxiety/depression was on the provider problem list in only 4% of patients. Conclusions: To our knowledge, this is the first study to assess the implementation of the MPN-SAF TSS into clinical practice since the NCCN recommendations went into effect. The MPN-SAF TSS is not being utilized in regular practice at our site and a low number of disease-related symptoms are documented in clinic notes. Fatigue is the predominant symptom in our patients, which is similar to previously published studies. The discrepancy between medications taken and symptoms documented suggests that patients have a higher symptom burden than reported. Implementing a standardized way of consistently capturing patients' MPN-related symptoms in hematology practice will be explored in future quality improvement research. Disclosures Damon: Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Logan:Incyte: Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz: Research Funding; Kite: Research Funding; Kadmon: Research Funding; Pharmacyclics: Research Funding; Novartis: Consultancy; TeneoBio: Consultancy; Kiadis: Consultancy; Astellas: Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees. Mannis:Jazz: Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Kite: Membership on an entity's Board of Directors or advisory committees; Abbvie/Genentech: Membership on an entity's Board of Directors or advisory committees; Forty Seven: Membership on an entity's Board of Directors or advisory committees; Curis: Membership on an entity's Board of Directors or advisory committees. Olin:Spectrum: Research Funding; Novartis: Research Funding; Mirati Therapeutics: Research Funding; MedImmune: Research Funding; Ignyta: Research Funding; Clovis: Research Funding; Daiichi Sankyo: Research Funding; Astellas: Research Funding; Genentech: Consultancy, Research Funding; Pfizer: Research Funding; Jazz Pharmaceuticals: Consultancy, Honoraria; Revolution Medicine: Consultancy; AstraZeneca: Research Funding. Shah:Bristol-Myers Squibb: Research Funding. Atreya:Immunotherapeutics: Honoraria; Guardant Health: Research Funding; Novartis: Research Funding; Merck: Research Funding; Kura Oncology: Research Funding; Array Biopharma: Honoraria; Pionyr: Honoraria; Bristol-Meyers Squibb: Research Funding. Smith:Astellas Pharma: Research Funding; Abbvie: Research Funding; fujiFilm: Research Funding; Revolution Medicines: Research Funding.

18 Background: Unlike most metastatic solid tumors, many advanced hematologic malignancies are treated with curative intent. Accordingly, aggressive interventions often continue until late in the disease course because it can be difficult to discern when cure is no longer possible. This is particularly true for recipients of allogeneic hematopoietic cell transplant (alloHCT). We hypothesized that alloHCT recipients and their providers would be less likely to utilize specialty Palliative Care (PC) services or to engage in early communication regarding advance care planning. Methods: This was a single-center, retrospective chart review of all alloHCT recipients at the University of California, San Francisco who died between 2012-2016. Patients were excluded if there was insufficient data available for analysis. Results: Of the 122 alloHCT deaths identified, 75 met inclusion criteria. The median age at alloHCT was 55, and most patients were Caucasian (69%), were transplanted for acute leukemia or MDS (77%), and received a well-matched allograft (81%). 57% died from disease relapse and 20% died from treatment-related causes. 61% of alloHCT recipients died in the hospital, with 37% dying in an ICU. 52% of patients received chemotherapy within 2 months of death, and 17% within 2 weeks. While 79% of patients were DNR/DNI at the time of death, the median time from change of code status to death was 4.5 days. 80% of patients had no prior code status documented in an outpatient note, and a specific goals-of-care conversation was documented in < 25% of outpatient charts. The PC service was consulted for the majority of patients (57%), although the median time from consultation to death was 13 days, with 23% of all consultations occurring within 3 days of death. Only 16% of patients accessed specialty PC services more than 30 days prior to their death. Conclusions: Despite high rates of both disease- and treatment-related mortality, as well as significant morbidity associated with alloHCT, recipients of alloHCT at our institution infrequently engaged in early conversations about end-of-life care and rarely utilized specialty PC services more than 1 month prior to dying.