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PURPOSE Compared with people living without HIV (PWOH), people living with HIV (PWH) and cancer have traditionally been excluded from immune checkpoint inhibitor (ICI) trials. Furthermore, there is a paucity of real-world data on the use of ICIs in PWH and cancer. METHODS This retrospective study included PWH treated with anti–PD-1- or anti–PD-L1-based therapies for advanced cancers. Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS). Objective response rates (ORRs) were measured per RECIST 1.1 or other tumor-specific criteria, whenever feasible. Restricted mean survival time (RMST) was used to compare OS and PFS between matched PWH and PWOH with metastatic NSCLC (mNSCLC). RESULTS Among 390 PWH, median age was 58 years, 85% (n = 331) were males, 36% (n = 138) were Black; 70% (n = 274) received anti–PD-1/anti–PD-L1 monotherapy. Most common cancers were NSCLC (28%, n = 111), hepatocellular carcinoma ([HCC]; 11%, n = 44), and head and neck squamous cell carcinoma (HNSCC; 10%, n = 39). Seventy percent (152/216) had CD4+ T cell counts ≥200 cells/µL, and 94% (179/190) had HIV viral load CONCLUSION Among PWH, ICIs demonstrated differential activity across cancer types with no excess toxicity. Safety and activity of ICIs were similar between matched cohorts of PWH and PWOH with mNSCLC.

Background: Disparities driven by socioeconomic factors have been shown to impact outcomes for cancer patients. We sought to explore this relationship among patients with multiple myeloma (MM) who were not considered for hematopoietic stem cell transplant in the first-line setting and how it varied over time. Methods: We queried the National Cancer Database for patients diagnosed with MM between 2004 and 2016 and included only those who received systemic therapy as the first-line treatment. Enrollment rates for therapy were calculated as receipt of systemic therapy as the incident event of interest (numerator) over time to initiation of therapy (denominator) and used to calculate incident rate ratios that were further analyzed using Poisson regression analysis. A multivariate Cox proportional hazards model was constructed for survival analysis, and differences were reported as hazard ratios (HRs). Results: We identified 56,102 patients for enrollment analysis and 50,543 patients for survival analysis. Therapy enrollment in a multivariate model was significantly impacted by race and sex (p 1), whereas female sex, non-Hispanic black race, higher income, and treatment at an academic center were associated with improved survival (HR

BackgroundThe prognostic value of the KRAS proto-oncogene mutation in colorectal cancer has been debated. Herein, we analyzed the National Cancer Database (NCDB) to assess the role of KRAS mutation as a prognostic marker in patients with locally advanced rectal cancer (LARC). MethodsWe identified LARC patients treated with neoadjuvant chemoradiation from 2004-2015 excluding those with stage I/IV disease and unknown KRAS status. Multivariable logistic regression identified variables associated with KRAS positivity. Propensity adjusted univariable and multivariable analyses identified predictors of survival. ResultsOf the 784 eligible patients, 506 were KRAS negative (KRAS-) and 278 were KRAS positive (KRAS+). Median survival was 63.6 months and 76.3 months for KRAS+ and KRAS- patients respectively, with propensity adjusted 3 and 5-year survival of 79.9% vs. 83.6% and 56.7% vs 61.9% respectively (HR 1.56, p 1.074-2.272). Male sex, no insurance, and KRAS+ disease was associated with poorer survival on unadjusted and propensity adjusted multivariable analyses. ConclusionsOur analysis of KRAS+ LARC suggest that KRAS+ disease is associated with poorer overall survival. Given the inherent limitations of retrospective data, prospective validation is warranted.

A minority of patients diagnosed with diffuse large B-cell lymphoma (DLBCL) undergo surgery before the initiation of systemic therapy. The aim of this study is to explore the characteristics of patients undergoing surgery prior to systemic therapy (surgfirst), the predictors for surgfirst, and the survival outcomes.The National Cancer Database was queried for patients with DLBCL diagnosed between 2006 and 2015, and we performed a subgroup analysis of patients that received surgfirst. Time-to-initial therapy (TTI) was defined as the time in days (d) from diagnosis to systemic therapy. Overall survival was measured from the day of diagnosis in terms of months (m).Factors associated with lower likelihood of surgfirst were non-Hispanic Black race (p-value0.005), rural location (p-value0.005), treatment at academic center (p-value0.005), Medicaid insurance (p-value=0.01), comorbidity score=3 (p-value 0.007), year of diagnosis, advanced stages of disease, and presence of B-symptoms. The TTI of systemic therapy was delayed in the surgfirst group - 34 (IQR 22-52) days vs. 23 (IQR 13-38) days, p-value0.005. The five-year overall survival was 62.7% (95% CI 62.1-63.2%) vs. 58.3% (95% CI 57.7-60.0%) - HR 0.87 (95% CI 0.85-0.89), p-value0.005. The factors associated with higher mortality were advanced comorbidities, lower educational status, disease primarily located in the bone, brain, and spinal cord, advanced clinical stage, presence of B-symptoms, and advanced age.Despite the delay in systemic therapy, we could not identify a detrimental impact of surgfirst on survival. This needs to be confirmed in large-scale multicenter studies. We identified clinical and socioeconomic factors that affect treatment selection and survival.

Human immunodeficiency virus (HIV) infection may be a predictor of undertreatment of patients with lymphoma. We hypothesized treatment with systemic therapy (SysT) or hematopoietic stem cell transplantation (HCT) in the first-line setting leads to improved outcomes and sought to compare the predictors for treatment and outcomes with non-HIV (HIV-) patients.Patients with lymphoma diagnosed between 2004 and 2015 were extracted from the National Cancer Database (NCDB). Patients were categorized as HIV+ and HIV-. First-line treatment was categorized as no systemic therapy reported (noSyst), SysT, or HCT. Multivariate analysis to predict treatment and survival was performed.We identified 552,513 lymphoma patients, of whom 11,160 HIV+ versus 349,607 HIV- patients were eligible for analysis. Among HIV+, the positive predictors for SysT were insurance and higher income, whereas female sex and minority racial status predicted lower likelihood for SysT. Forty HIV+ patients underwent HCT. Treatment of HIV+ lymphoma patients resulted in improved outcomes: 3-year overall survival 43.6% in noSyst versus 58.1% SysT (hazard ratio [HR] 0.56; 95% confidence interval [CI], 0.52-0.61; P .005) versus 62.2% HCT (HR 0.42; 95% CI, 0.14-1.3; P = .08). The outcomes were lower compared to non-HIV patients (3-yr overall survival 67.3% with SysT and 62.2% HCT).Patients with lymphoma with HIV benefit from SysT when feasible but outcomes are worse than non-HIV patients. HCT should be offered to HIV+ patients with lymphoma in the appropriate clinic setting. Individual characteristics of the patients and complications could not be evaluated in the present study but should be a focus for future research.

Introduction: Thrombosis and bleeding are recognized complications of the novel coronavirus infection (COVID-19), with a higher incidence described particularly in the critically ill. Methods: A retrospective review of COVID-19 patients admitted to our intensive care units (ICU) between 1 January 2020 and 31 December 2020 was performed. Primary outcomes included clinically significant thrombotic and bleeding events (according to the ISTH definition) in the ICU. Secondary outcomes included mortality vis-a-vis the type of anticoagulation. Results: The cohort included 144 consecutive COVID-19 patients with a median age of 64 years (IQR 54.5–75). The majority were male (85 (59.0%)) and Caucasian (90 (62.5%)) with a median BMI of 30.5 kg/m2 (IQR 25.7–36.1). The median APACHE score at admission to the ICU was 12.5 (IQR 9.5–22). The coagulation parameters at admission were a d-dimer level of 109.2 mg/mL, a platelet count of 217.5 k/mcl, and an INR of 1.4. The anticoagulation strategy at admission included prophylactic anticoagulation for 97 (67.4%) patients and therapeutic anticoagulation for 35 (24.3%) patients, while 12 (8.3%) patients received no anticoagulation. A total of 29 patients (20.1%) suffered from thrombotic or major bleeding complications. These included 17 thrombus events (11.8%)—8 while on prophylactic anticoagulation (7 regular dose and 1 intermediate dose) and 9 while on therapeutic anticoagulation (p-value = 0.02)—and 19 major bleeding events (13.2%) (4 on no anticoagulation, 7 on prophylactic (6 regular dose and 1 intermediate dose), and 8 on therapeutic anticoagulation (p-value = 0.02)). A higher thrombosis risk among patients who received remdesivir (18.8% vs. 5.3% (p-value = 0.01)) and convalescent serum (17.3% vs. 5.8% (p-value = 0.03%)) was noted, but no association with baseline characteristics (age, sex, race, comorbidity), coagulation parameters, or treatments (steroids, mechanical ventilation) could be identified. There were 10 pulmonary embolism cases (6.9%). A total of 99 (68.8%) patients were intubated, and 66 patients (45.8%) died. Mortality was higher, but not statistically significant, in patients with thrombotic or bleeding complications—58.6% vs. 42.6% (p-value = 0.12)—and higher in the bleeding (21.2%) vs. thrombus group (12.1%), p-value = 0.06. It did not significantly differ according to the type of anticoagulation used or the coagulation parameters. Conclusions: This study describes a high incidence of thrombotic and bleeding complications among critically ill COVID-19 patients. The findings of thrombotic events in patients on anticoagulation and major bleeding events in patients on no or prophylactic anticoagulation pose a challenging clinical dilemma in the issue of anticoagulation for COVID-19 patients. The questions raised by this study and previous literature on this subject demonstrate that the role of anticoagulation in COVID-19 patients is worthy of further investigation.

Importance Despite growing literature, there is still limited understanding of factors that can predict outcomes in coronavirus disease 2019 (COVID-19) patients who require intensive care. Objective To evaluate the characteristics of COVID-19 patients admitted to the intensive care unit (ICU) and identify their associations with outcomes. Background There are limited data on the outcomes in COVID-19 patients in Pennsylvania. Design Retrospective study Setting Intensive care units in an academic health system in Western Pennsylvania. Participants Patients with reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 admitted to ICUs as direct admission or transfers from regular floors between March 1, 2020, and April 30, 2020. Main outcome(s) and measure(s) The primary outcome was inpatient mortality. Secondary outcomes included complications during ICU stay, hospital length of stay, discharge disposition, and the need for oxygen at discharge. Categorical variables are described as frequencies and continuous variables as median with interquartile range (IQR). Regression modeling was used to identify the predictors of inpatient mortality in these patients. P-value

BackgroundThe addition of radiation to chemotherapy in elderly patients with PCNSL remains controversial. Our objective was to assess the trend of combined modality treatment (CMT) and compare its survival with chemotherapy alone and radiation alone in non-HIV patients. MethodsWe identified 6,537 patients who received single treatment modality, combined modality treatment, or no treatment at all between 2004 and 2015 from the National Cancer Database. Factors affecting treatment selection were investigated using a logistic regression model. Annual percentage change (APC) was calculated to assess the trend of CMT use. A propensity score weighting methodology was used to compare survival outcomes. FindingsOnly 12.8% of patients received CMT, and this proportion steadily declined between 2004 (17.7%) and 2015 (8.7%), with APC of -6.0% (95% CI -8.0 to -4.0, p-value Conclusion Socioeconomic factors affect the selection of treatment in elderly patients with PCNSL that can alter outcomes. CMT is falling out of favor in this patient population due to the risks of neurotoxicity. Further work should focus on developing strategies that minimize toxicity and access disparities without compromising survival

Several retrospective series have reported that patients with collagen vascular disease (CVD) are at increased risk of radiation (RT) toxicity. However, the evidence is mixed, and many series lack control groups. We performed a meta-analysis including only case-cohort or randomized studies that examined the risk of RT toxicity for patients with CVD compared with controls.Meta-analysis of Observational Studies in Epidemiology guidelines were used to perform a comprehensive search identifying case-control or randomized studies reporting RT toxicity outcomes for patients with CVD versus controls. Data were synthesized from studies reporting grade 2 to 3 or more (G2/3 +) acute and late RT toxicities. Results were analyzed with fixed effects meta-analysis on the random-effects model for between-study heterogeneity; otherwise, the fixed-effects model was used. Hazard ratio or odds ratio (OR) were the effect-size estimators, as appropriate.Ten studies were included, with 4028 patients (CVD: 406, control: 3622). Patients with CVD had higher rates of acute G2/3 + toxicity (26.2% vs 16.5%, OR [odds ratio] 2.01; P.001) and late G2/3 + toxicity (18.4% vs 10.1%, OR 2.37; P.001). Higher rates of late G2/3 + toxicity were observed for CVD patients with systemic lupus erythematous (21% vs 9.7%; OR 2.55, P = .03), systemic scleroderma (31.8% vs 9.7%, OR 3.85; P = .03), rheumatoid arthritis (11.7% vs 8.4%, OR = 2.56; P = .008), and those irradiated to the pelvis/abdomen (32.2% vs 11.9%, OR 3.29; P = .001), breast (14.7% vs 4.4%, OR 3.51; P = .003), thorax (12.5% vs 8.7%, OR 3.46; P.001), and skin (14.6% vs 5.2%, OR 2.59; P = .02). Late grade 5 toxicities were significantly higher for patients with CVD, although absolute rates were low (3.9% vs 0.6%, OR = 7.81; P = .01).Moderate and severe toxicities are more likely in patients with CVD, with variable risk depending on toxicity grade, CVD subtype, treatment site, and dose. Severe toxicities are uncommon. These factors should be considered when informing patients of treatment-related risks and monitoring for morbid treatment sequelae.

Introduction Ankylosing spondylitis is an autoimmune disease with chronic inflammation of the spine and sacroiliac joints that is commonly treated with immunosuppressants including disease-modifying antirheumatic drugs and anti-tumor necrosis factor alpha therapy. Case report A 75-year-old female with active ankylosing spondylitis on treatment with etanercept was referred to us for newly diagnosed IgG kappa free light chain multiple myeloma. After failing induction with revlimid, bortezomib, and dexamethasone, she was initiated on carfilzomib. Following the achievement of adequate response to induction, she underwent an autologous hematopoietic stem cell transplant selected for CD34+ cells with melphalan 200mg/m2 conditioning regimen. Given high-risk cytogenetics, i.e. monosomy 17 (17p) and hypodiploidy, she received two cycles of carfilzomib consolidation post-transplant. The patient tolerated the transplant well with successful engraftment and achieved complete remission of multiple myeloma with no detectable M spike, negative immunofixation study, and normalization of light chain ratio. While being off etanercept since the transplant, she noticed complete relief from joint pains related to her ankylosing spondylitis without a need to use the pain-relieving medications. Management and outcome: The patient has sustained remission of ankylosing spondylitis for two years post-transplant without flares or symptoms. She continues to remain off immunosuppressants. Discussion Although our patient had a coincident and unprecedented resolution of ankylosing spondylitis after receiving the hematopoietic stem cell transplant, this case consolidates the idea of transplant as a potential treatment option for ankylosing spondylitis and other rheumatological conditions.

Despite implementation of the Affordable Care Act (ACA), many Americans remain uninsured and receive care in free clinics. It is unknown what free clinic attendees in Pennsylvania know about health insurance expansion or what they perceive as barriers in enrolling in health insurance. The objective of this study was to assess the perceptions and experiences of free clinic patients from southwestern Pennsylvania when applying for health insurance after implementation of the ACA. We designed and implemented a survey of patients at three free clinics within Allegheny County, Pennsylvania from September 2016 to February 2017. Our survey included 22-items, 7 sociodemographic questions and 15 questions regarding the patient's health status and their perspectives related to obtaining health insurance. Data was obtained from 203 patient surveys; 110 (55.3%) of the respondents were men and 99 (48.8%) were African American. There were 48 respondents (24.1%) who did not report any income at the time of the study, and of those that did report an income, 92 (46.2%) respondents reported an income below 133% of the federal poverty level. The main barriers patients faced when applying for health insurance were: (1) lack of knowledge about health insurance (n = 127, 58.1%), (2) cost of health coverage (n = 85, 41.9%), (3) lack of resources (n = 83, 40.4%), and (4) lack of enrollment documentation (n = 43, 23.8%). Significant work is needed to better educate patients about their eligibility and options for health insurance. Free clinics can play a key role in eliminating barriers to health insurance enrollment.

e21053 Background: Treatment with immune checkpoint inhibitors (CPI) targeting PD-1 or PD-L1 significantly improves progression free survival and overall survival in patients with non-small cell lung cancer (NSCLC). Emerging literature suggests that the proinflammatory state of CPIs may increase the risk of thromboembolism, both venous (VTE) and arterial (ATE), which is of great concern as thromboembolism remains a major cause of mortality in patients with NSCLC. We performed a retrospective cohort study to evaluate thromboembolic outcomes in patients on immunotherapy for NSCLC. Methods: We reviewed the records of all patients diagnosed with stage IV NSCLC between December 2016 and December 2019 and treated with chemotherapy, CPIs, or both in one of the largest integrated academic health systems in Western Pennsylvania. Khorana scores (to predict the risk of future VTE) were calculated for each patient based on available data at the time of diagnosis. Logistic regression analyses were done to evaluate clinical predictors of VTE. Survival outcomes were analyzed using Kaplan-Meier estimates and a log rank test was used to compare survival estimates. Data was analyzed using SPSS v26 (IBM Corp). Results: A total of 110 patients with stage IV NSCLC were identified, 87.1% had ECOG ≤2, 67.0% had adenocarcinoma and 25.7% had squamous cell carcinoma, and 39.1% had PD-L1 staining ≥50%. Immunotherapy related adverse events (IrAE) of any grade were found in 28.2%. Overall, 25.5% received chemotherapy only, 27.7% received CPIs alone, and 45.5% received chemo + CPIs. A Khorana score of ≥2 was found in 43.6% of patients. Prophylactic anticoagulation was used in 0.9% of patients. VTE was detected in 18.3% and ATE in 10.0% of the cohort; therapeutic anticoagulation was given in 14.7% of patients. Median overall survival was 25.5 months (95% CI 18.7-32.3) in patients without VTE versus 13.7 months (95% CI 3.1-24.3) in patients with a VTE diagnosis (HR 1.96, 95% CI 1.11-3.45; p = 0.02). Khorana score of ≥2 was not a significant predictor of VTE in this cohort (univariate OR 1.34, p = 0.53, multivariate OR 1.13, p = 0.81), but was associated with worse survival (HR 2.38, 95% CI 1.48-3.83, p < 0.001). Conclusions: In this retrospective cohort, VTE was associated with decreased overall survival. While no significant association between elevated Khorana score and VTE was identified, elevated Khorana score at the time of diagnosis was an independent predictor of survival in patients with NSCLC. Of note, there was a low rate of prophylactic anticoagulation in this cohort.

e19021 Background: Blinatumomab, a bispecific (CD3/CD19) T-cell engager, is indicated for the treatment of acute lymphoblastic leukemia (ALL). The initial portion of each cycle is administered in the inpatient setting for close monitoring for cytokine release syndrome and neurotoxicity. Real world data are lacking on the cost of hospitalization, length of stay (LOS), and mortality in inpatients treated with blinatumomab. The goal of this study was to analyze the clinical outcomes of inpatient blinatumomab administration utilizing a national database. Methods: The ICD-10 diagnosis and procedure codes were used to identify Blinatumomab admissions and related complications from the 2018 version of the Nationwide Inpatient Sample (NIS) database from the Healthcare Cost and Utilization Project (HCUP). Weighted analysis was used to calculate national estimates. Logistic regression analyses were used to examine predictors of hospital outcomes (in-hospital mortality, length of stay, and cost), with p < 0.05 considered statistically significant. Data were analyzed using SAS v9.4 (SAS Institute, Cary, NC). Results: A total of 228 patients received inpatient blinatumomab in this cohort. Median age was 46 years old (IQR 26.8, 63.0) and 59.2% were males, 50.4% were white, and 47.4% had private insurance. The majority of patients received care at an urban teaching (96.1%) or large hospital (76.3%). The most relevant inpatient complications during hospitalization included hypotension (7.5%), pneumonia (6.1%), sepsis (9.2%), seizure (2.2%), neutropenia (6.1%), thrombocytopenia (14.0), tumor lysis syndrome (3.9%), and acute kidney injury (9.6%). Median LOS was 9.0 days (IQR 3.0-16.2) and median hospitalization charge was $114,936 USD (IQR 51,984.2-240,557.5). On multivariate regression analysis, dialysis (OR 1.67, 95% CI 1.05-2.65), blood product transfusion (OR 1.5, 95% CI 1.14-1.97), sepsis (OR 2.63, 95% CI 1.86-3.73), neutropenia (OR 1.86, 95% CI 1.23-2.81), and pancreatitis (OR 1.46, 95% CI 1.11-1.91) were all associated with longer LOS. Dialysis (OR 1.83, 95% CI 1.29-2.6), transfusions (OR 1.52, 95% CI 1.01-2.28), sepsis (OR 1.87, 95% CI 1.20-2.91) and neutropenia (OR 1.84, 95% 1.04-3.24) significantly increased the cost of hospitalization. Conclusions: In this cross-sectional study of a large national cohort of patients receiving inpatient blinatumomab, multiple blinatumomab associated toxicities led to increased LOS and cost of hospitalization.

e19501 Background: Chimeric antigen receptor T-cell therapies (CAR-T) improve relapse free survival and durable remission rates in patients with relapsed/refractory large B-cell lymphoma (LBCL) and received US FDA approval in 2017. The cytokine release syndrome (CRS) and immune-effector cell associated neurotoxicity (ICANS) due to CAR-T cell therapy require close inpatient monitoring. Real world data are lacking regarding the cost of hospitalization, length of stay (LOS), toxicity, and mortality associated with CAR-T. The goal of this study was to analyze the clinical outcomes of inpatient CAR-T utilizing a national database. Methods: Data was collected from the 2018 version of the Nationwide Inpatient Sample (NIS) database. Patients who received CAR-T were identified with ICD-10 disease and procedure codes . Complex weights were used to enable appropriate national projections. The association between toxicity (particularly related to CRS and ICANS) and outcomes was examined using logistic regression analyses (p < 0.05 statistically significant). SAS v9.4 (SAS Institute, Cary, NC) was used for data analysis. Results: 306 patients met selection criteria. Demographic criteria were as follows: 61.1% males, 62.4% white, median age 58.0 years old (IQR 45.2-65.0), and private insurance (56.9%). A majority received care at urban teaching (97.7%) and large hospitals (73.2%). Relevant complications during hospitalization included hypotension (24.5%), pneumonia (8.5%), sepsis (9.8%), seizure (5.9%), neutropenia (24.5%), thrombocytopenia (8.8%), tumor lysis syndrome (TLS) (3.3%), and acute kidney injury (AKI) (14.1%). Median LOS was 16 days (IQR 12.0-22.0), median charge for hospitalization was $493,887 USD (IQR 143,400.0-1,182,940.0), and inpatient mortality was 5.2%. On multivariate regression analysis, inpatient mortality was significantly higher in those with intubation (OR 30.1, 95%CI 3.45-262), sepsis (OR 9.49, 95%CI 1.48-60.7), TLS (OR 18.9, 95%CI 2.52-140), AKI (OR 24.7, 95% CI 1.37-447) and thrombocytopenia (OR 53.4, 95% CI 2.19-1,298). LOS was higher in those with blood transfusion (OR 1.29, 95% CI 1.08-1.53), sepsis (OR 2.04, 95% CI 1.59-2.61), pancreatitis (OR 2.03, 95% CI 1.09-3.77), pneumonia (OR 1.39, 95%CI 1.04-1.87) and treatment in urban teaching hospitals (OR 1.53, 95%CI 1.02-2.30). Increased hospitalization charges were associated with hypotension (OR 1.54, 95%CI 1.14-2.08) and with treatment at urban teaching hospitals (OR 7.46, 95%CI 4.67-11.9) and medium size hospitals (OR 1.49, 95%CI 1.04-2.15). Conclusions: Inpatient mortality, median LOS, and hospitalization charges in inpatients treated with CAR-T can be significantly increased not only by inpatient complications, but also by the size and type of the treating facility. These findings highlight the financial burden of CAR-T cell therapy in the real world and can be used to shape future healthcare policy.

e18683 Background: Cancer-directed therapy, including cytotoxic chemotherapy and immunotherapy, is a known risk factor for decreased SARS-CoV-2 seroconversion after vaccination, as a result of impaired viral immunity. Outcomes of COVID-19 infection are worse in patients on active treatment, especially those with hematologic malignancies or undergoing stem cell transplantation. The association between cancer subtypes and seroconversion rates is not well established. The goal of this study was to investigate predictive factors for SARS CoV-2 seroconversion and infection. Methods: We reviewed the electronic medical records of all patients with documented SARS CoV-2 antibody levels (between 7/2020-8/2021) in one of the largest integrated health systems in Pennsylvania. Patients who had a diagnosis of hematologic or solid malignancy, were on active treatment (including adjuvant), and had received ≥1 dose of an FDA authorized SARS CoV-2 vaccine were included. Data regarding SARS CoV-2 serology, vaccination, cancer history, and treatment regimens for each patient were collected systematically. Positive serology (reflecting seroconversion) was defined as any value ≥0.8 units/mL. Logistic regression analyses were used to examine predictors of seroconversion. Data was analyzed using SPSS v26 (IBM Corp). Results: A total of 292 patients met the inclusion criteria. Hematologic malignancy was present in 80.5% of the patients and solid tumors in 26.7%. Active disease was present in 71.6% of the cohort. Two vaccine doses were given to 92.5% of the patients and 54.8% of patients received a booster dose (95.2% received mRNA vaccines, either BNT162b2 (Pfizer BioNTech) or mRNA-1273 (Moderna)). A history of COVID-19 infection was present in 15.1% of patients, 59.1% of whom were seropositive. Rates of seroconversion were equivalent in those who received the BNT162b2 (70.2%) or mRNA-1273 (70.9%) vaccines. Seroconversion rates were 69.9% in those with active disease, 81.9% without evidence of disease, and varied by diagnosis as follows (indolent B-cell lymphoma 73.3%, aggressive B-cell lymphoma (BCL) 55.9%, plasma cell dyscrasia 80.1%, CLL 39.5%, myeloid disorder 90.2%, lung cancer 80%, breast cancer 80%, GI cancers 81.3%, and GU cancers 76.9%). On univariate regression, receipt of treatment for CLL (OR 5.79, 95% CI 2.92-11.48, p < 0.001) and aggressive BCL (OR 2.44, 95% CI 1.17-5.09) were predictive of negative serology. Results were not changed on multivariate regression when adjusted for age and active treatment. Conclusions: In this retrospective cohort of vaccinated patients on cancer-directed therapy, treatment for aggressive BCL and CLL was associated with negative seroconversion. In addition, more breakthrough infections occurred in seropositive patients, suggestive of underlying immunodeficiency related to treatment or decreased vaccine efficacy despite formation of virus-specific antibodies.

BackgroundTo achieve progress in cancer treatment, socioeconomic disparities impacting the care need to be recognized and addressed. We hypothesized that social determinants of health may predict a delay in systemic therapy for metastatic hepatocellular carcinoma patients (HCC) and sought to examine the impact of the Affordable Care Act (ACA).MethodsNational Cancer Database (NCDB) was queried for patients with metastatic hepatocellular carcinoma diagnosed from 2004-2015 and considered for first line systemic therapy within 6 months (180 days) of diagnosis. Time to initiation (TTI) was defined as the time in days(d) from diagnosis of cancer to initiation of systemic therapy. Survival was measured in months(m) from the day of diagnosis. Multivariate analyses were performed using 2010 as a cut-off between pre-and post-ACA for analysis.Results630 patients meeting the eligibility criteria. Median TTI in the group was 57d. The only factor associated with delayed TTI (defined as the fourth quartile of TTI) in a multivariate logistic regression was non-Hispanic Black (NHB) race Odds Ratio OR 1.94(95%CI 1.0–3.3), p-value=0.052. The OR showed improvement with implementation of ACA – OR3.6(95%CI 1.4-9.4),p-value 0.008 during pre-ACA vs. 1.3(0.5-3.1),p-value=0.6 post-ACA. There was a non-significant trend towards higher mortality among NHB vs. NHW (HR 1.2, 95% CI 1.0-1.6) and lower mortality for those insured vs. uninsured (HR 0.8, 95% CI 0.5-1.1. ConclusionRace appears to impact timeliness to therapy in metastatic HCC patients and was positively impacted by ACA. Continued research to monitor disparities in care and identify underlying mechanisms to mitigate them are warranted.

Background: Male breast cancer (MBC) accounts for 1% of all breast cancers and there is a paucity of data on factors impacting the treatment strategies and outcomes. We sought to use a large national database to examine trends and predictors of the use of adjuvant radiation (Adj-RT), as well as any association with outcome. Methods: We queried the National Cancer Database (NCDB) for patients with stages I-III MBC treated with surgery (breast conservation surgery-BCS or mastectomy-MS) within 180 days of diagnosis (years 2004–2015). Multivariable logistic regression identified predictors of adj-RT receipt. Multivariable Cox regression evaluated predictors of survival. Propensity matching for adj-RT was used to account for indication biases. Results: We identified 6,217 patients meeting the eligibility criteria (1457 BCS vs. 4760 MS). The majority of patients were Caucasian (85%) and in an age range of 50–80 years (74%). Although adj-RT was omitted for 30% of BCS patients, the utilization was higher compared to MS (OR=26, p-value=0.001). The predictors of adj-RT use included African-American race, more advanced stage, higher grade, presence of lymphovascular invasion, and ER/Her-2 positivity for the entire cohort and increased age, urban location and higher income for BCS. Adj-RT was associated with lower mortality in the propensity matched model (overall HR for BCS=0.28, p-value

Background: Patients with advanced cancers are among the most vulnerable group of patients. We sought to analyze the impact of Affordable Care Act (ACA) on the interaction of socioeconomic factors with treatment and survival in patients with metastatic colorectal cancers. Methods: National Cancer Database (NCDB) was queried for patients with Stage-IV colon(CCa) and rectal cancers(R-Ca) diagnosed 2004–2015 and excluded those who did not receive any therapies within 6 months of diagnosis. Enrollment-rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy (denominator) and used to calculate incident-rate ratios that was analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER

Background/aim To examine the impact of ACA and the association of socioeconomic factors on delay in initial treatment for multiple myeloma (MM). Patients and methods Patients diagnosed with MM between 2004-2016 were identified in the National Cancer Database (NCDB). Time-to-initial treatment (TTI) was defined as the number of days from diagnosis to initial therapy. Patients were classified into quartiles and those belonging to the fourth quartile for TTI constituted the delayed treatment group. Study period was divided into pre-ACA and post-ACA using 2010 as the cut-off. Results A total of 65,723 patients met the eligibility criteria. Median TTI was 13 (IQR=5-27) days. Racial-ethnic minorities were associated with delayed-TTI. Delayed treatment was more likely for Hispanics pre-ACA but not post-ACA, while non-Hispanic Blacks (NHB) were more likely to have delayed treatment both, pre- and post-ACA. Conclusion While ACA has been shown to help mitigate healthcare disparities in certain cancer diagnoses, the study suggests that the effect is still limited among MM patients.

The COVID-19 crisis has had an unprecedented impact on resident education and well-being: social distancing guidelines have limited patient volumes and forced virtual learning, while personal protective equipment (PPE) shortages, school/daycare closures, and visa restrictions have served as additional stressors. Our study aimed to analyze the effects of COVID-19 crisis-related stressors on residents’ professional and personal lives. In April 2020, we administered a survey to residents at a large academic hospital system in order to assess the impact of the pandemic on residency training after >6 weeks of a modified schedule. The primary outcome was to determine which factors or resident characteristics were related to stress during the pandemic. Our secondary goals were to examine which resident characteristics were related to survey responses. Data were analyzed with regression analyses. Ninety-six of 205 residents completed the survey (47% response rate). For our primary outcome, anxiety about PPE (P 0.001). Additionally, compared to juniors, seniors believed that the pandemic was more disruptive, modified schedules were effective, and virtual meetings were less effective while virtual lectures were more effective (all P ≤ 0.05) Furthermore, the pandemic experience has allowed seniors in particular to feel more confident to lead in future health crises (P ≤ 0.05). Medicine and surgery residency programs should be cognizant of and closely monitor the effects of COVID-19 crisis-related factors on residents’ stress and anxiety levels. Transparent communication, telemedicine, online lectures/meetings, procedure simulations, advocacy groups, and wellness resources may help to mitigate some of the challenges posed by the pandemic.

Introduction Primary CNS lymphoma (PCNSL) is an aggressive form of lymphoid malignancy that occurs exclusively in the brain, meninges, spinal cord, and eyes. The incidence of PCNSL has been increasing, particularly in the elderly population, with a median age at diagnosis of 66 years (Olson J.E. et al., Cancer 2002). The primary modality of treatment for this deadly disease is systemic chemotherapy that includes high-dose methotrexate (HD-MTX), with or without whole-brain radiation. Due to the toxicity of HD-MTX, physicians tend to avoid using it in the elderly population. This was confirmed in previous reports from the 1990s (Panageas K.S. et al., Cancer 2007). In this comprehensive population-based analysis, we sought to examine the patterns of treatment and survival in elderly patients in the 2000s and sought to investigate clinical and socioeconomic predictors of treatment selection. Methods We conducted a retrospective cohort analysis using de-identified data accessed from the national cancer database (NCDB). The NCDB provided records of 2985 patients diagnosed with PCNSL between 2004 and 2015. We excluded patients who are younger than 65 years old, those who tested positive for HIV, and those who started treatment >120 days since diagnosis to account for immortal time bias. Patients were divided into four groups based on treatment received: combined modality treatment (CMT), chemotherapy alone, radiation alone, and no treatment. Exploratory analysis of the patient groups was performed. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Multivariate regression models were used to analyze predictors of the selection of any treatment versus no treatment and for selecting chemotherapy versus no chemotherapy. To account for variable baseline characteristics, we used propensity score weighting methodology to calculate estimates of interest. Survival estimates were performed using the Kaplan-Meier method, and survival differences were tested using the wilcoxon-rank test. Results We identified 1096 patients with PCNSL who fulfilled the inclusion criteria. The median age was 73 (IQR: 68-79). There were 52% males. The majority of the patients were whites (92%), lived in a metropolitan area (78%), treated at an academic/research center (57%). The most common treatment modality used was chemotherapy alone (48%), followed by CMT (22%), no treatment (16%), and radiation alone (13%). On multivariate analysis, age (OR: 0.94, 95% CI 0.92-0.96) and comorbidity score (OR: 0.63, 95% CI 0.52-0.76) significantly predicted receiving any type of treatment. Both age (OR: 0.91, 95% CI 0.89-0.94) and distance (OR: 1.006, 95% CI 1.001-1.01) were predictors of receiving chemotherapy. Median follow up was 12 months (IQR: 3-44). Median OS in months for the four groups was: 43.1 for CMT, 19.4 for chemotherapy alone, 17.2 for radiation alone, and 2.3 for no treatment. (wilcoxon-rank test p-value: 75 year old had lower median OS in general, but receiving CMT had a survival advantage as well. (Figures 1 and 2) Conclusions The majority of PCNSL patients in our analysis received treatment. Our results showed an increased trend of chemotherapy use in elderly patients compared with earlier reports, where radiation alone was the most common treatment modality. The median OS of patients was longer compared with the 1990s data (17 vs. 7 months). CMT was associated with better OS compared with no treatment and chemotherapy alone. Although this was numerically better compared with radiation alone, it was not statistically significant. Younger patients and patients with lower comorbidity scores were more likely to receive treatment. Younger patients and patients who live further from the treating facility were more likely to receive chemotherapy. Longer distance may have led to less radiation use due to the need for complex planning and frequent visits associated with radiation therapy. Our study is limited by its retrospective nature, which makes it at risk of selection bias. Using propensity score weighting methodology strengthens our results. Also, the NCDB lacks certain pertinent variables, such as details of chemotherapy regimens, and toxicity information especially for radiation in the CMT arm which will have practical implications. Disclosures Fazal: Glaxosmith Kline: Consultancy, Speakers Bureau; Incyte Corporation: Consultancy, Honoraria, Speakers Bureau; Karyopham: Speakers Bureau; Celgene: Speakers Bureau; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jansen: Speakers Bureau; Stemline: Consultancy, Speakers Bureau; Gilead/Kite: Consultancy, Speakers Bureau; Agios: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Jazz Pharma: Consultancy, Speakers Bureau. Kahn:Genetech: Honoraria; Takeda: Honoraria; Karyopharm: Honoraria; Seattle Genetics: Honoraria; Abbvie: Honoraria; Celgene: Honoraria; AstraZeneca: Honoraria; Beigene: Honoraria.

Introduction Gray-zone lymphoma (GZL) is a rare lymphoid neoplasm initially described in 2005. The world health organization first recognized it as a separate entity in 2008. These tumors have intermediate morphologic and phenotypic features between diffuse large B-cell lymphoma and Hodgkin lymphoma. There is no treatment guidelines given the rarity of the disease, and being relatively a new entity. In this first population-based analysis of GZL, we focus on combined modality treatment (CMT; chemotherapy and radiation) versus chemotherapy alone as a primary treatment strategy. We sought to examine the effect of each modality on survival and investigate clinical and socioeconomic predictors of treatment selection and survival using the national cancer database (NCDB). Methods We conducted a retrospective cohort analysis using de-identified data accessed from the NCDB. The NCDB provided records of 2176 patients diagnosed with GZL between 2004 and 2016. We excluded patients without histologic or cytologic confirmation of the diagnosis or patient with unrecorded stage information. We also excluded patients who started treatment after 4 months of diagnosis to account for immortal time bias. Treatment was categorized as CMT or chemotherapy alone. Exploratory analysis of the patient groups was performed. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Multivariate regression models were used to analyze the predictors of treatment selection and survival. We used propensity score matching methodology for the comparative survival analysis. Survival estimates were performed using the Kaplan-Meier method and survival differences were assessed using the log-rank test. Results We identified 1047 patients with GZL who were treated with CMT or chemotherapy alone between 2004 and 2016. The median age was 63 (IQR 47-74), there were 56.7% Males. The majority of the patients were non-Hispanic whites (80.7%), had insurance (96.1%), had comorbidity score of 0 (75.4%), belonged to a metropolitan areas (83.4%), and were treated at a comprehensive community cancer centers or academic programs (65.5% combined). Only 164 patients (15.7%) received CMT, while 883 (84.3%) received chemotherapy alone. Treatment selection was affected by clinical factors (age and advanced stage) but not socioeconomic factors. Median follow up for the 811 patients with available survival data was 28.8 months (IQR 12.36-50.25). The use of CMT and higher median income were associated with better survival, while increased age, higher comorbidity score, and presence of B symptoms were associated with worse survival. Median overall survival was significantly higher in CMT group compared with chemotherapy alone group (HR 0.541, 95% CI 0.351-0.833, p-value 0.005). Discussion Number of patients with GZL increased gradually over the years, which reflects increased insight and recognition of this disease entity. The use of CMT is continuously increasing over the years. Receiving CMT had a survival advantage over chemotherapy alone. In contrary to a multicenter retrospective analysis by Evans et al where advanced stage was the only important predictor of survival in GZL, our analysis showed other clinical and socioeconomic factors that affected outcomes. Radiation is associated with increased cost, it requires complex planning, and creates significant psychosocial burden, in addition to toxicity which could have contributed to its less use with older patients. A previous retrospective report showed no effect on survival with use of consolidative radiation in 37 patients. Larger sample size in our cohort could have contributed to a different outcome. Our study is limited by its retrospective nature and lack of certain pertinent variables, such as details of chemotherapy regimens. Being a relatively new entity limited median follow up to 2.4 years. Longer follow up and larger prospective studies are needed to evaluate the role of consolidative radiation in GZL and its toxicity. Our study adds to the sparse literature about GZL and identifies clinical and socioeconomic factors that can affect treatment selection and outcome that should be taken in consideration in future research. Figure 1 Disclosures Fazal: Jazz Pharma: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Jansen: Speakers Bureau; Stemline: Consultancy, Speakers Bureau; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Gilead/Kite: Consultancy, Speakers Bureau; Agios: Consultancy, Speakers Bureau; Incyte Corporation: Consultancy, Honoraria, Speakers Bureau; Karyopham: Speakers Bureau; Celgene: Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Glaxosmith Kline: Consultancy, Speakers Bureau; Takeda: Consultancy, Speakers Bureau. Kahn:AstraZeneca: Honoraria; Celgene: Honoraria; Seattle Genetics: Honoraria; Genetech: Honoraria; Abbvie: Honoraria; Beigene: Honoraria; Takeda: Honoraria; Karyopharm: Honoraria.

Hospitalized patients with hematological malignancy (HM) suffer an increased incidence of venous thromboembolism (VTE). We sought to identify risk factors and rate of VTE in hospitalized patients with HM using National Inpatient Sample (NIS) for the years 2011 to 2015. We used ICD-9 codes to identify patients with HM as the primary diagnosis and VTE as a secondary diagnosis for hospitalization. The rate of VTE was highest in patients with acute myeloid leukemia (6.6%) followed by acute lymphocytic leukemia (6.1%) and non-Hodgkin's lymphoma (6.0%). The highest risk of VTE occurred among patients with HM receiving chemotherapy (OR 1.68; 95% CI 1.567-1.809) followed by infection such as pneumonia (OR 1.31; 95% CI 1.201-1.436) and sepsis (OR = 1.66; 95% CI = 1.524-1.621). Chemotherapy had the highest risk of developing VTE during hospitalization followed by sepsis and pneumonia. The identification of patients with HM most at risk for VTE could be used to design and test prophylactic strategy.

Extramedullary hematopoiesis is common in chronic hemolytic anemias such as pyruvate kinase deficiency. It is commonly associated with hepatosplenomegaly or lymphadenopathy; however, it can rarely also present as a mass in the chest, abdomen, or paraspinal region. Here, we present a case of an adult patient with pyruvate kinase deficiency and history of splenectomy. He presented with sepsis and brisk leukocytosis secondary to pneumonia and was also found to have diffuse intraabdominal lymphadenopathy along with a paravertebral mass. The radiological findings raised concerns for a systemic lymphoproliferative disorder and there was a suggestion for further workup with a biopsy. However, given the patient's underlying pyruvate kinase deficiency, we hypothesized that the paravertebral mass is likely a result of extramedullary hematopoiesis in the setting of bone marrow stress from infection and ongoing hemolysis; thus, we decided against biopsy. Repeat imaging six weeks after the presentation showed resolution of the paravertebral mass, which consolidated our hypothesis. This highlights the importance of avoiding invasive diagnostic procedures in asymptomatic patients with chronic hemolysis who may present with diffuse mass lesions.

BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) followed by resection and postoperative multi-agent chemotherapy (maChT) is the standard of care for locally advanced rectal cancer. Using this approach, maChT administration can be delayed for several months, leading to concern for distant metastases. To counteract this, a novel treatment approach known as total neoadjuvant therapy (TNT) has gained popularity, in which patients receive both maChT and nCRT prior to resection. We utilized the National Cancer Database to examine temporal trends in TNT usage, and any potential effect on survival. AIM To study the temporal trends in the usage of TNT and evaluate its efficacy compared to neoadjuvant chemoradiation. METHODS We queried the National Cancer Database for patients with locally advanced rectal cancer, Stage II-III, from 2004-2015 treated with nCRT or TNT. TNT was defined as maChT initiated ≥ 90 d prior to nCRT initiation. Overall survival was calculated from the date of diagnosis to the date of last contact or death using Kaplan-Meier curves to present the cumulative probability of survival, with log-rank statistics to assess significance. Multivariable cox regression was used to identify predictors of survival and propensity score analysis accounted for bias. RESULTS We identified 9066 eligible patients, with 8812 and 254 patients receiving neoadjuvant chemoradiation followed by maChT and TNT, respectively. Nodal involvement, stage III disease, and treatment in recent years were predictive of TNT use. There was greater use of TNT with more advanced stage, specifically > 1 node involved (odds ratio [OR] = 2.88, 95% confidence interval [CI]: 2.11-3.93, P < 0.01) and stage III disease (OR = 2.88, 95%CI: 2.11-3.93, P < 0.01). From 2010 to 2012 the use of TNT increased (OR = 2.41, 95%CI: 1.27-4.56, P < 0.01) with a greater increase from 2013 to 2015 (OR = 6.62, 95%CI: 3.57-12.25, P < 0.01). Both the TNT and neoadjuvant chemoradiation arms had a similar 5-year survival at 76% and 78% respectively. Multivariable analysis with propensity score demonstrated that increased age, high comorbidity score, higher grade, African American race, and female gender had worse overall survival. CONCLUSION Our data demonstrates a rising trend in TNT use, particularly in patients with worse disease. Patients treated with TNT and nCRT had similar survival. Randomized trials evaluating TNT are underway.

e16147 Background: Gall bladder (GB) cancer is rare but an aggressive disease especially when presenting at an advanced stage. There is controversy regarding the best treatment approach for locally advanced disease. In this NCDB analysis, we aim to study treatment patterns for T3, T4, and/or N1 GB cancer and estimate survival for each treatment modality. We also sought to investigate clinical and socioeconomic predictors of treatment selection. Methods: We conducted a retrospective cohort analysis using de-identified data accessed from the NCDB. The NCDB provided records of 39,229 patients diagnosed with GB cancer between 2004-2017. We excluded patients who were not treated at the reporting facility, those with no histologic confirmation of the diagnosis, those with no survival data available and those with T1, T2 and metastatic disease. We did exploratory analysis and divided patients into six arms based on treatment modality (Table). Stepwise multivariable regression models were used to analyze predictors of treatment selection. Survival estimates were calculated using the Kaplan Meier and proportional Cox hazard regression methods. Results: We identified 7,004 patients with GB cancer who fulfilled the inclusion and exclusion criteria. Median age was 68 years. There were 69.5% females, and the majority of patients were white (66.1%). Receiving treatment at an academic/research center (OR 0.37, 95% CI 0.19-0.73, p

e21217 Background: Constituting up to 85% of all lung cancer, non-small cell lung cancer (NSCLC) is unfortunately often discovered in the metastatic setting. Profiling tumors for driver mutations and assessing PD-L1 expression have become essential in tailoring treatment. National guidelines recommend that patients with PD-L1 expression ≥ 50% may receive immunotherapy (IO) alone or chemotherapy in conjunction with immunotherapy (ChT/IO). At present, there is no strong data suggesting that the addition of chemotherapy to IO is superior to IO alone in this patient subgroup, and treatment decision is entirely physician dependent. This decision is often based on factors such as age, performance status, co-morbidities and disease burden with elderly/frail patients receiving IO alone compared to the younger population with higher disease burden receiving the combination. The aim of our study was to evaluate whether there is a difference in survival outcomes for patients with high PD-L1 expression receiving combination ChT/IO versus IO alone. Methods: We performed a retrospective analysis on stage IV NSCLC patients treated with either ChT plus pembrolizumab or pembrolizumab monotherapy in the first line setting from December 2016 to December 2019. PD-L1 status was evaluated for all patients and only patients with PD-L1 expression ≥ 50% were included in the analysis. Univariable and multivariable analyses identified characteristics predictive of overall survival (OS) and progression-free survival (PFS). OS was calculated using Kaplan Meier curves to present the cumulative probability of survival, and log-rank statistics were used to assess statistical significance between groups. Results: 195 patients were evaluated out of which 82 (42%) patients were identified as having PD-L1 expression ≥ 50%. 13 (13.4%) out of 82 patients received chemotherapy alone and were therefore excluded from the analysis. 49 (71%) patients received IO alone compared to 20 (29%) who received combination ChT/IO. Median PFS was 8.1 months (IO alone group) vs 9.9 months (ChT/IO group) with a hazard ratio (HR) of 0.95 (95% confidence interval [CI] 0.54-1.7, p = 0.87). Median OS was 13.7 months (IO alone group) vs 19 months (ChT/IO group) with a HR of 0.76 (95% [CI] 0.41-1.4, p = 0.42). Our results did not show a statistically significant difference between patients treated with IO alone vs combination ChT/IO. Conclusions: Our retrospective analysis revealed that although there was no statistically significant difference between high PD-L1 NSCLC patients receiving ChT/IO vs IO alone with respect to survival, there was a trend towards improved PFS and particularly OS in favor of the group receiving chemotherapy in combination with immunotherapy. Given our small sample size, further studies are needed to determine the benefit of adding chemotherapy to IO for NSCLC patients with high PD-L1 expression.

e21213 Background: Lung cancer is the leading cause of death in males and females in the United States. Approximately 85% of all cases are classified as non-small cell lung cancer (NSCLC) with majority diagnosed at an advanced stage. Unfortunately, response to traditional chemotherapy (ChT) has been poor with a five-year survival rate of 6% in metastatic NSCLC. Immune checkpoint inhibitors (ICI) have changed the therapeutic landscape for advanced NSCLC and are being utilized alone or in combination with ChT as the standard first-line therapy. With widespread use of ICIs, immune-related adverse events (irAE) are commonly seen and in some studies their occurrence correlates with improved outcomes. The aim of our study was to evaluate whether development of irAEs has an impact on survival in NSCLC. Methods: We performed a retrospective analysis on stage IV NSCLC patients treated with ChT, ChT plus ICI, or ICI monotherapy from December 2016 to December 2019. Univariable and multivariable analyses identified characteristics predictive of progression-free survival (PFS) and overall survival (OS). OS was calculated using Kaplan Meier curves. Log-rank statistics were used to assess statistical significance between groups. Multivariable logistic regression was performed to identify predictors of survival. Results: 193 patients were evaluated out of which 92 (47.2%) received ChT plus pembrolizumab, 69 (35.4%) received pembrolizumab alone and 32 (16.4%) received ChT alone. 130 patients were found to have no irAEs compared to 57 patients who were noted to have any grade of irAE. The median PFS was 17.4 months (irAE group) vs. 8.5 months (non-irAE group) with hazard ratio (HR) of 0.58 (95% CI: 0.41 to 0.80, p = 0.001). The median OS was 29.4 months (irAE group) vs. 14.4 months (non-irAE group) with HR of 0.56 (95% CI: 0.39 to 0.82, p = 0.0026). A multivariate analysis was performed for age, gender, ECOG performance status, insurance status, BMI, PDL1 status and smoking history, amongst other variables. Worse survival outcomes were noted with an ECOG performance status ≥ 2, no history of smoking, and involvement of palliative care. Multivariable logistic regression analysis showed that PDL-1 expression > 50% was the only predictor of developing an irAE. Of note, receipt of ChT in combination with pembrolizumab compared to pembrolizumab alone did not predict for development of irAE. Conclusions: Development of irAEs was associated with doubling of PFS and OS, regardless of whether the ICI was administered alone or in combination with ChT. The differences were statistically significant regardless of age, gender, race, BMI, insurance status or performance status. Our study highlights the correlation between development of irAEs and improved survival outcomes in advanced NSCLC patients treated with ICIs.

e16260 Background: Pancreatic ductal adenocarcinoma (PDAC) remains one of poor prognosis, portending a 5-year survival rate of 9% when considering all stages. Although the mainstay of treatment of PDAC remains cytotoxic chemotherapy in both the early and advanced stages, recent advances in tumor profiling and germline testing have allowed for the incorporation of poly-ADP-ribose polymerase (PARP) inhibitors, immune checkpoint inhibitors and targeted therapy to be utilized in the maintenance and subsequent-line settings for metastatic PDAC, respectively. We sought to identify our institutional compliance rate in germline testing and tumor profiling in all patients diagnosed with PDAC. Methods: A retrospective review was conducted of all patients diagnosed with PDAC from 2017-2019 at Allegheny General Hospital. Data analysis was completed using IBM SPSS v23. Summary statistics were presented using percentages for categorical variables and medians with interquartile ranges for continuous variables. Results: Out of 171 patients reviewed, 121 received and completed treatment in our institution, and were included in the analysis. Median age was 69 years. 55 patients (45%) were male and 66 (55%) were female. Germline testing was done in 28 patients (23%) and tumor molecular profiling was done in 25 patients (21%). Testing for microsatellite instability was performed in 28 patients (23%). Testing for programmed death-ligand (PD-L1) expression was done in 16 patients (13%). On univariate analysis, family history of malignancy was a predictor for germline testing (OR 5.3; 95% CI 1.4-2.01; p=0.01). No predictors were identified in association with tumor molecular profiling likely due to low sample size. Conclusions: Our analysis reveals an institutional compliance rate of 20-23% in adherence to national guidelines with respect to germline testing and tumor profiling in the management of PDAC. A family history of malignancy demonstrated predictive association with germline testing. Factors which may limit pathological evaluation of microsatellite stability status, assessment of PD-L1 expression and molecular profiling include lack of institutional protocol for reflex histological testing, financial or insurance constraints, and lack of adequate tissue. As part of our Quality improvement project, we identified that incorporation of reflex histological testing based on tumor-type, standardization of tissue biopsy to optimize yield, and utilization of support staff, such as Oncology Navigators, to facilitate scheduling for germline testing may increase compliance rates.

2062 Background: High dose methotrexate-based regimens remain the most effective treatment against PCNSL but optimal consolidative strategy has yet to be determined. There is lack of high scale clinical trials comparing WBRT versus ASCT as consolidation therapy. Only two phase II randomized clinical trials (PRECIS and IELSG 32) have addressed this question. In this comprehensive national cancer database (NCDB) analysis, we examine the effect of WBRT versus ASCT on survival in PCNSL, we also sought to investigate clinical and socioeconomic predictors of treatment selection Methods: We conducted a retrospective cohort analysis using de-identified data accessed from the NCDB. The NCDB provided records of 16579 patients diagnosed with PCNSL between 2004 and 2016. We excluded patients who tested positive for HIV, and those who started chemotherapy > 120 days or started radiation > 365 days since diagnosis, to account for immortal time bias. Patients were divided into two treatment groups based on consolidation therapy: ASCT and WBRT. Multivariable regression models were used to analyze predictors of treatment selection. To account for variable baseline characteristics, we used propensity score weighting methodology. Survival estimates were calculated using the Kaplan-Meier and Cox proportional hazard regression methods Results: We identified 1620 patients with PCNSL who fulfilled the inclusion criteria. ASCT and WBRT were received by 197 patients and 1423 patients, respectively (Table). On multivariable analysis, increased age decreased the odds of receiving ASCT (OR 0.997, CI: 0.996-0.999, P

Introduction: An effective immune response to vaccination may be related to nutritional status. This study examined the association of plasma mineral levels with hemagglutination inhibition (HI) titers produced in response to influenza vaccine in older adults. Methods: Prior to (Day 0) and 21 (range = 19–28) days after receiving the 2013–14 influenza vaccine, 109 adults ages 51–81 years, provided blood samples. Serum samples were tested for HI activity against the A/H1N1 and A/H3N2 2013–2014 vaccine virus strains. Plasma minerals were collected in zinc-free tubes and assayed by inductively coupled plasma mass spectrometry. HI titers were reported as seroprotection (≥1:40) and seroconversion (≥ 4-fold rise from Day 0 (minimum HI = 1:10) to Day 21). Both HI titers and mineral values were skewed and thus log2 transformed. Magnesium (Mg), phosphorus (P), zinc (Zn), copper (Cu), iron (Fe), potassium (K) and the Cu to Zn ratio were tested. Logistic regression analyses were used to determine the associations between mineral levels and seroconversion and seroprotection of HI titers for each influenza A strain. Results: Participants were 61% white, 28% male, 39% diabetic, and 81% overweight/obese with a mean age of 62.6 y. In logistic regression, Day 21 A/H1N1 seroprotection was associated with P and Zn at Day 21(P < 0.05). Seroconversion of A/H1N1 was associated with Day 21 Cu, P, and Mg (P < 0.03). Day 21 A/H3N2 seroprotection and seroconversion were associated with Day 21 P (P < 0.05). Conclusions: Phosphorus was associated with seroprotection and seroconversion to influenza A after vaccination; these associations warrant additional studies with larger, more diverse population groups.

Background Socioeconomic disparities impact access to treatment and outcomes for patients with cancer. Affordable Care Act (ACA) sought to mitigate some of these disparities In the present study, we examined the influence of socioeconomic factors on patients facing delay in treatment initiation and the impact of Affordable Care Act (ACA). Methods We queried the National Cancer Database (NCDB) for patients with MM (ICD-0-3 code 9732) diagnosed from 2004-2016 who received any therapy. Active MM patients were defined as those treated within 120 days of diagnosis. Time to initiation (TTI) was defined as time in days (d) from diagnosis of cancer to initial myeloma therapy and divided into quartiles. Patients belonging to 4th quartile for TTI constituted the delayed treatment group (delayed-TTI). Study period was divided into pre-ACA and post-ACA using 2010 as cut-off. Multivariate logistic regression analysis was used and p-value 0.05 was used for statistical significance. Results We identified 65,723 patients meeting the eligibility criteria (28,814 pre-ACA and 36,909 post-ACA respectively). Median age was 68 (Interquartile Range IQR 59-76) years, included 55.1% males and majority insured patients (96.4%). Racial distribution was 66%(non hispanic whites-NHW), 20%(non hispanic blacks-NHB), 6%(Hispanics-H). Median TTI were 13 (IQR 5-27) days overall and 42 (33-58) days for delayed-TTI group. NHB and H races were associated with delayed-TTI in the multivariate model - Odds Ratio OR 1.18 (IQR 1.09-1.27)p-value Citation Format: Thejus Jayakrishnan, Veli Bakalov, Natalie Callander, Santhosh Sadashiv, Sikander Ailawadhi. Impact of the Affordable Care Act on timeliness to treatment for patients with multiple myeloma [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-204.

Background The treatment options in Multiple Myeloma (MM) are variable and may involve combinations of chemotherapy, immunomodulatory therapy, monoclonal antibodies and stem cell transplant. In the present study, we hypothesized that socioeconomic factors impact the treatment and survival of patients with MM who receive systemic therapy as firstline treatment. Methods We queried the National Cancer Database (NCDB) for patients with MM (ICD-0-3 code 9732) diagnosed from 2004-2016. We included only that received systemic therapy as first line treatment. Active MM patients were defined as those treated within 120 days of diagnosis. Enrollment rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy or TTI (denominator) and used to calculate incident-rate ratios that was further analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER, 1, p-value Citation Format: Thejus Jayakrishnan, Veli Bakalov, Zena Chahine, John Lister, Rodney Wegner, Santhosh Sadashiv. Disparities in the enrollment to systemic therapy and survival for patients with multiple myeloma [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-212.

Background While we strive for progress in treatment and outcomes, it is imperative that disparities driven by socioeconomic factors are also recognized and addressed. We hypothesized that social determinants of health may predict delay in systemic therapy for metastatic hepatocellular carcinoma patients (HCC) and sought to examine the impact of Affordable Care Act (ACA). Methods National Cancer Database (NCDB) was queried for patients with metastatic hepatocellular carcinoma diagnosed from 2004-2015 and considered for first line systemic therapy within 6 months (180 days) of diagnosis. Time to initiation (TTI) was defined as time in days(d) from diagnosis of cancer to initiation of systemic therapy. Survival was measured in months(m) from the day of diagnosis. Multivariate analyses was performed using 2010 as cut-off between pre- and post-ACA for analysis. Results 630 patients meeting the eligibility criteria. Median TTI in the group was 57d. Only factor associated with delayed TTI (defined as forth quartile of TTI) in a multivariate logistic regression was non-Hispanic Black (NHB) race Odds Ratio OR 1.94(95%CI 1.0–3.3), p-value=0.052. The OR showed improvement with implementation of ACA – OR3.6(95%CI 1.4-9.4),p- value 0.008 during pre-ACA vs. 1.3(0.5-3.1),p-value=0.6 post-ACA. There were non- significant trend towards higher mortality among NHB vs. NHW (HR 1.2, 95% CI 1.0- 1.6) and lower mortality for those insured vs. uninsured (HR 0.8, 95% CI 0.5-1.1. Conclusion Race appears to impact timeliness to therapy in metastatic HCC patients and was positively impacted by ACA. Continued research to monitor disparities in care and identify underlying mechanisms to mitigate them are warranted. Citation Format: Thejus Jayakrishnan, Veli Bakalov, Gene Finley, Dulabh Monga, Rodney Wegner. Influence of social determinants of health on timeliness to treatment for metastatic HCC and the impact of Affordable Care Act [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-206.

Background Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma (NHL), accounting for approximately 22% of newly diagnosed non-Hodgkin's lymphoma per year in the United States. Combination chemoimmunotherapy with or without radiation therapy is recommended for the upfront treatment of DLBCL (Yang Liu, AJH,2019). A minority of patients undergo surgery prior to the initiation of systemic therapy for symptom relief or treatment of complications related to the disease. There are concerns on the delay in initiation of systemic therapy when surgery is performed and the potential impact on long term survival in this aggressive chemosensitive disease. We aimed to explore the characteristics of patients undergoing surgery prior to systemic therapy (sxfirst), the predictors for sxfirst and the survival outcomes. Methods We queried the National Cancer Database for patients with DLBCL (ICD-0-3 code 9680) diagnosed from 2006-2015. Inclusion criteria were patients that received systemic therapy as first-line course of treatment and excluded patients with incomplete or missing data for disease stage, treatment characteristics and follow-up. We also excluded patients who underwent biopsy procedures for diagnosis and local procedures such as tumor destruction or ablation. Subgroup analysis of patients that received sxfirst was performed. Time-to-initial therapy (TTI) was defined as time in days (d) from diagnosis to systemic therapy. Survival was measured in terms of months (m) from the day of diagnosis. Stepwise multivariate logistic regression analysis for predictors of sxfirst and propensity score adjusted survival analysis was performed. Results Of 208,748 patients with DLBCL, 138,096 patients met the inclusion criteria of whom 6,381 (4.6%) were sxfirst. The characteristics of sxfirst are summarized in Table 1. Median age was 66 (interquartile range IQR 55-75) years and 61.1% were males. Majority were non-Hispanic whites, had private or medicare insurance, had comorbidity score of 0 and stage I disease. Most patients were treated in comprehensive community cancer centers. The top 5 extra-nodal disease sites were gastrointestinal (26.2%), male reproductive system (16.4%), brain and spinal cord (6.4%), endocrine system (4.1%) and head and neck (3.0%). The median follow up was 47.6 (IQR 14.0-78.9) months. The predictors for sxfirst are described in Table 2. The following disease sites were associated with higher likelihood of sxfirst: male reproductive system (p-value=3 (p-value 0.007), more recent year of diagnosis, advanced stages of disease and presence of B-symptoms. The TTI for systemic therapy was delayed in sxfirst group - 34 (IQR 22-51) days vs. 21 (IQR 11-35) days, p-value Conclusion The findings of the present study are twofold. First, the present study describes the characteristics and predictors of sxfirst among DLBCL patients. Second, if surgery is absolutely necessary prior to systemically treating DLBCL, the study suggests that the delay does not seem to impact long term survival of these patients and is similar to the 5-year overall survival (64%) reported for DLBCL when all stages and treatment strategies are combined (seer.cancer.gov/statfacts/dlbcl). While there are unmeasured confounding factors as a result of the absence of adequate prognostic markers and treatment characteristics in the database, it is possible that surgery truly doesn't impact the survival outcomes significantly. Further evaluation of this practical question is warranted in large scale prospective studies. Disclosures Khan: Abbvie: Honoraria; Genentech: Honoraria; AstraZeneca: Honoraria; Takeda: Honoraria; Celgene: Honoraria; Karyopharm: Honoraria; Beigene: Honoraria; Seattle Genetics: Honoraria. Fazal:Stemline: Consultancy, Speakers Bureau; Jazz Pharma: Consultancy, Speakers Bureau; Jansen: Speakers Bureau; Karyopham: Speakers Bureau; Incyte Corporation: Consultancy, Honoraria, Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Agios: Consultancy, Speakers Bureau; Glaxosmith Kline: Consultancy, Speakers Bureau; Gilead/Kite: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Celgene: Speakers Bureau; Amgen: Consultancy, Speakers Bureau; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

BACKGROUND GVHD remains a major cause of morbidity and mortality after allo HSCT. The past few years have shown a number of successful advances in cellular therapies for the treatment of hematologic malignancies. It is logical to expand the use of these therapies earlier, in strategies aimed at prevention. Several studies showed that regulatory T cells (Treg) can reduce the incidence of aGVHD. METHODS Studies were identified using electronic databases (Medline, Embase, and Cochrane). Preclinical studies were excluded. Data analysis was performed using GraphPad Software 8.4.2. RESULTS 160 patients were identified from 7 clinical studies. 85% of the patients had acute leukemia and were in complete remission at the time of transplant. Tregs were isolated from either UCB or PB. Tregs were expanded ex-vivo using IL-2, CD3/CD28 ab coated beads and K562 cells in three studies (n=40). 1.Ex-vivo expanded Treg: In a phase I study (Brunstein et al) of UCB-derived Tregs in 23 pts undergoing double umbilical cord transplantation, Tregs were cultured with antiCD3/anti CD28 and IL-2. Ex-vivo expanded Tregs were given on day+1 and day+15. Eighteen pts received Treg cells at dose of >3x106 cells/kg. Grade II-IV aGvHD was seen in 39% of pts who received ≥3x106 cells/kg vs 43% in historical controls. In this study, CsA+MMF or sirolimus+MMF were used for GvHD prophylaxis. In a follow up study of 11 patients, Tregs were markedly expanded using K562 cells. Higher Treg doses were achieved up to 100x106cells/kg and the median proportion of CD4+CD127-FOXP3+ within the infused products was 87%. Grade II-IV aGVHD was 9% at 100 days vs 45% in control group. Treg cells were not detected in the peripheral blood after 14 days of infusion. In a phase II study (Kellner et al; Zeng et al), three of six pts undergoing PB MUD received ex-vivo expanded UCB-derived Tregs 1x106/kg at day-1. All developed aGVHD due to the high donor Tcon cells in the graft with donor Tcon:UCB Treg ratio as high as 356:1. Sixth patient was given 1x107 cells/kg Tregs in the presence of anti CD3/28 microbeads and IL-2 with Treg:Tcon ratio of 1:40. No aGVHD was observed in this patient compared to the others who received Treg at the dose of 1x106cells/kg. 2.Unexpanded Treg: In a study (Di Ianni et al) involving 26 high risk leukemia pts undergoing haplo-transplant with TBI based conditioning, 21 pts were infused with donor Tregs at a dose of 2x106 cells/kg and five pts were infused with Treg at a dose of 4x106 cells/kg on day -4, followed by Tcon infusion ranging from 0.5x106 to 2x106 cells/kg on day 0. No post-transplant immune suppression was given. Grade II-IV aGVHD was observed in 2 out of 26 patients who received 4x106cells/kg Tregs and 2x 106cells/kg Tcons. No GVHD was observed in pts who received 2x106cells/kg Tregs followed by 0.5-1x106 cells/kg Tcons. A phase II study by the same group (Martelli et al) reported on an additional 17 pts who received Tregs (2x106cells/kg) at day-4 co-infused with Tcon (1x106cells/kg) at day 0. Six of 41 (15%) evaluable pts developed grade II-IV aGVHD (vs 11% in historical cohort) with two pts requiring a short course of immunosuppression. Incidence of relapse was lower in Treg group than historical controls (5% vs 21%). In a phase I/II study (Meyer et al), 12 pts with hematological malignancies who underwent HLA-matched transplantation received purified Tregs (1-3x106cells/kg) on day0 followed by Tcon (1-3x106cells/kg) on day+2. GVHD was seen in 80% of pts with 50% being grade III in pts who received frozen Tregs. Upon revising protocol, 7 pts were given fresh Treg. The patients also received either tacrolimus or sirolimus for immunosuppression. None of 7 pts in revised cohort developed GVHD. Recent study applied hyper-fractionated TBI to the conditioning regimen in 12 pts out of 40 to further reduce leukemia relapse in Treg/Tcon based haplo-HSCT. Treg was administered at the dose of 2x106cells/kg and Tcon at 1x106cells/kg. No post-transplant GvHD prophylaxis was given. Grade II-IV aGVHD was observed in 12 pts. CONCLUSION These studies suggest that Treg therapy may represent an effective prevention strategy against acute GvHD (figure 1). Stimulated Treg expansion strategies and higher doses of Treg appear to be associated with lower incidence of aGVHD. Treg infusion was well-tolerated without serious adverse events. Large prospective clinical trials are warranted in order to establish the optimal infusion dose, optimal expansion strategies and dosing schedule. Disclosures No relevant conflicts of interest to declare.

Sepsis is the leading cause of death in hospitalized patients and beyond the hospital stay and these long-term sequelae are due in part to unresolved inflammation. Metabolic shift from oxidative phosphorylation to aerobic glycolysis links metabolism to inflammation and such a shift is commonly observed in sepsis under normoxic conditions. By shifting the metabolic state from aerobic glycolysis to oxidative phosphorylation, we hypothesized it would reverse unresolved inflammation and subsequently improve outcome. We propose a shift from aerobic glycolysis to oxidative phosphorylation as a sepsis therapy by targeting the pathways involved in the conversion of pyruvate into acetyl-CoA via pyruvate dehydrogenase (PDH). Chemical manipulation of PDH using dichloroacetic acid (DCA) will promote oxidative phosphorylation over glycolysis and decrease inflammation. We tested our hypothesis in a Drosophila melanogaster model of surviving sepsis infected with Staphylococcus aureus. Drosophila were divided into 3 groups: unmanipulated, sham and sepsis survivors, all treated with linezolid; each group was either treated or not with DCA for one week following sepsis. We followed lifespan, measured gene expression of Toll, defensin, cecropin A, and drosomycin, and levels of lactate, pyruvate, acetyl-CoA as well as TCA metabolites. In our model, metabolic effects of sepsis are modified by DCA with normalized lactate, TCA metabolites, and was associated with improved lifespan of sepsis survivors, yet had no lifespan effects on unmanipulated and sham flies. While Drosomycin and cecropin A expression increased in sepsis survivors, DCA treatment decreased both and selectively increased defensin.

e19530 Background: Intensive chemotherapy (IC) regimens are rarely used in patients with myelodysplastic syndromes (MDS) for many reasons including advanced age at diagnosis, the frailty of these patients, the presence of several comorbidities and potentially increased mortality when such regimens are used. Additionally, very little literature exists on its safety and long-term benefit in this population. Aim: To evaluate the safety and effectiveness of IC regimens in patients with MDS. Methods: We searched MEDLINE, Embase, Scopus and Cochrane databases from each database's inception from 1990 to January 27th, 2020. Keywords include: “MDS”, “induction chemotherapy” and “remission induction”. Studies evaluating different IC regimens with MDS were included. IC studies for patients with relapsed/ refractory MDS were excluded. Studies that combined acute myeloid leukemia (AML) and MDS outcomes were excluded. The random-effects model was used to pool relative risks and incidence rates. Main endpoints were overall remission rates (ORR), 30- and 60-days mortality, 1-year, 2-year and 5-year overall survival (OS). Results: Characteristics: From 2001 records, we included 13 studies [1,164 patients, median age 60.1 years (range, 17-88), males 58.9%, 58.4% patients had abnormal cytogenetics, median bone marrow blasts 17.8% (range 4 -29%), 4 studies were randomized]. Induction outcome: IC regimes included “7+3, FLAG, s-HAM, and few other regimens. Response: ORR was 55%, including 52% CR rate. Safety: 30- and 60-days mortality were 7%, 15%, respectively. Survival outcome: median survival was 11.6 months, 1-year, 2-year and 5-year OS were 48%, 21% and 5%, respectively. Randomized studies comparison: adding growth factors to IC did not show statistically significant effects on outcomes regarding induction mortality, ORR and OS (p-value > .05). Conclusions: IC is rarely used in MDS patients and its use is associated with high mortality rates and low long-term survival. Limitations to our studies include the long span of this review over 3 decades and the difficulty of using published studies that combines MDS and AML patients’ outcome. More studies are needed in this population of interest in the future.