Bansal, Vasu

e24089 Background: Pancreatic cancer is associated with high symptom burden and frequent acute care utilization. Although early palliative care improves quality of life in advanced malignancies, real-world data describing its timing and downstream impact in pancreatic cancer remain limited. Methods: We conducted a retrospective cohort study using Epic Cosmos (2015–2025). Adults (≥18 years) with pancreatic cancer were identified using ICD-10 code C25.*. Early palliative care was defined as a documented palliative care encounter (ICD-10 Z51.5) within 0–2 months of cancer diagnosis. Patients were categorized as early palliative care versus not-early palliative care (late or no palliative care). A landmark approach was applied, with outcomes assessed beginning 2 months after diagnosis to mitigate immortal time bias. Outcomes included opioid use, antiemetic use, occupational/physical therapy (OT/PT) utilization, emergency department (ED) encounters resulting in inpatient admission, and inpatient length of stay. Results: Among 4,641 patients with pancreatic cancer, 464 (10.0%) received early palliative care, 365 (7.9%) received palliative care later, and 3,812 (82.1%) had no documented palliative care encounter. Compared with patients without early palliative care, early palliative care recipients demonstrated higher utilization of symptom-directed interventions, including opioids (40.6% vs 22.5%), antiemetics (37.2% vs 20.3%), and occupational/physical therapy services (6.2% vs 3.2%). Early palliative care was associated with a higher proportion of emergency department encounters resulting in inpatient admission (52.5% vs 23.6%), consistent with earlier consolidation of symptom-driven care. Mean inpatient length of stay was similar between groups (6.0 vs 6.2 days). Overall survival appeared comparable between groups; however, survival estimates in EHR-based analyses are limited by residual confounding and timing constraints. Conclusions: In a large national EHR cohort, early palliative care within two months of pancreatic cancer diagnosis was infrequently used but was associated with greater engagement in symptom-directed medications and supportive services, as well as a distinct downstream pattern of acute care utilization. These findings suggest that earlier integration of palliative care may improve coordination of symptom-focused care and represent an actionable quality-of-care target in pancreatic cancer.

e23055 Background: Geographic distance to care has been associated with outcomes in solid tumors, reflecting differences in access, follow-up, and supportive care. However, its relationship with biologic transplant toxicities such as graft-versus-host disease (GVHD) has not been well characterized. Understanding whether access-related factors are associated with immune-mediated complications is important for systems-level optimization of post-transplant care and survivorship. Methods: We conducted a retrospective cohort study of adult patients undergoing allogeneic hematopoietic cell transplantation using the CIBMTR hs1802 publicly available dataset. Distance from patient residence to the transplant center was categorized as less than 20 miles, 20 to 50 miles, 50 to 150 miles, and greater than 150 miles, with less than 20 miles as the reference group. Primary outcomes were acute GVHD and chronic GVHD within one year after transplantation. Secondary outcomes included overall survival. Multivariable Cox proportional hazards models were used to evaluate associations between distance and outcomes, adjusting for age, sex, race and ethnicity, HCT comorbidity index, conditioning intensity, donor type, GVHD prophylaxis, transplant era, disease type, and total body irradiation use. Results: A total of 5,473 patients were included, with a median follow-up of 60.2 months. Crude rates of acute GVHD increased with greater distance from the transplant center, occurring in 40.2 percent of patients living less than 20 miles away and 45.1 percent of those living more than 150 miles away. In adjusted analyses, residence more than 150 miles from the transplant center was associated with a higher risk of acute GVHD compared with less than 20 miles, with an adjusted hazard ratio of 1.15 and a 95 percent confidence interval of 1.00 to 1.31. No significant differences were observed for intermediate distance categories. For chronic GVHD within one year, patients living more than 150 miles away had a lower recorded risk compared with those living less than 20 miles away, with an adjusted hazard ratio of 0.79 and a 95 percent confidence interval of 0.71 to 0.88. Distance to transplant center was not significantly associated with overall survival. Conclusions: Greater geographic distance from transplant centers is associated with a higher risk of severe GVHD after allo-HCT. These findings suggest that access to specialized post-transplant care and close monitoring may influence immune-mediated outcomes. Strategies to improve follow-up care, including enhanced care coordination and telemedicine, may help mitigate GVHD-related disparities and inform health policy efforts aimed at improving access to specialized transplant services, reimbursement for remote monitoring, and regional models of post-transplant care delivery.

e19559 Background: Timely initiation of systemic therapy is critical in multiple myeloma (MM), yet real-world variation in time to treatment initiation (TTI) and its association with clinical outcomes, treatment-related toxicities, and supportive care utilization remain incompletely characterized. Methods: We conducted a retrospective cohort study using the Epic Cosmos database (2015–2025). Adults with MM were identified using ICD-10-CM code C90. TTI was defined as days from MM diagnosis to first exposure to systemic anti-myeloma therapy, including proteasome inhibitors, immunomodulatory drugs, or anti-CD38 monoclonal antibodies. Patients were stratified into TTI < 30 days (n = 90015), 30–60(n = 81190), and > 60 days(119,245). Primary outcomes included mortality, infection (sepsis or pneumonia), AKI within 30 days, DVT/PE, and bone marrow transplant (BMT). Secondary outcomes included hemodialysis initiation, febrile neutropenia, thrombocytopenia, herpes zoster reactivation, and use of bone-protective therapy (zoledronic acid, pamidronate, or denosumab) and antiviral prophylaxis (acyclovir/valacyclovir). Outcomes are presented as unadjusted percentages with 95% confidence intervals. Results: Mortality demonstrated a U-shaped association with TTI, occurring in 22.99%, 21.32%, and 21.32% of patients in the < 30-day, 30–60-day, and > 60-day cohorts, respectively. Infection rates were 16.42%, 17.11%, and 17.30%, while AKI < 30 occurred in 16.01%, 16.38%, and 16.49%. BMT utilization was highest in the 30–60-day cohort (19.14%) compared with < 30 days (18.28%) and > 60 days (18.21%). VTE rates increased modestly with delayed treatment (9.39%, 9.82%, and 10.10%). HD occurred in 3.15%, 3.08%, and 3.07% of patients. Febrile neutropenia occurred in 17.15%, 18.03%, and 17.55%, thrombocytopenia in 13.34%, 13.93%, and 13.86%, and herpes zoster reactivation in 1.21%, 1.29%, and 1.42%. Antiviral prophylaxis use was highest in the 30–60-day cohort (91.25%) compared with < 30 days (88.48%) and > 60 days (88.23%). Bone-protective therapy use was also highest in the 30–60-day cohort (31.68%) versus < 30 days (28.90%) and > 60 days (23.79%). Conclusions: In this large real-world analysis, initiation of systemic therapy within 30–60 days of MM diagnosis was associated with lower mortality, higher transplant utilization, and greater use of guideline-recommended supportive care compared with both earlier and delayed treatment initiation. Patients treated within 30 days appeared to represent a higher-acuity phenotype, while delays beyond 60 days were associated with lower supportive care uptake and higher thrombotic risk. These findings suggest that time to treatment initiation may reflect both disease severity and care delivery quality, and identify a potentially actionable window to optimize treatment pathways and supportive care in multiple myeloma.

e19536 Background: Chronic kidney disease (CKD) may impair physiologic resilience during chimeric antigen receptor (CAR) T-cell therapy for multiple myeloma (MM). While cytokine response syndrome (CRS) and immune cell-associated neurotoxicity syndromes (ICANS) have been described in MM CAR-T recipients with CKD, the broader cardiopulmonary, infectious, renal, and economic implications of CKD remain insufficiently defined. We examined the national impact of CKD on mortality, immune cell effector toxicities, organ dysfunction, infections and resource utilization. Methods: Adult MM hospitalizations receiving CAR T-cell therapy were identified from the National Inpatient Sample (2018–2022) using ICD-10-PCS codes. Patients with ESRD were excluded. CKD was categorized as CKD3a+ (eGFR <60 mL/min) versus no CKD/CKD1–2. Outcomes included in-hospital mortality, CRS (2021–2022), ICANS (2022), cardiac arrhythmias, acute kidney injury (AKI), renal replacement therapy, respiratory failure, infections and total hospitalization cost (calculated using TOTCHG variable and adjusted cost to charge ratio). Comparative analysis was done using chi-square testing. Multivariate analysis adjusted for demographics, comorbidities, and hospital characteristics. Results: Among 2,045 weighted MM CAR-T hospitalizations, 7.6% had CKD3a+. Overall CRS rates were similar (66.7% vs 64.9%; p=0.839) between CKD3a+ vs no/CKD1-2. Overall ICANS rates were also comparable (16.7% vs 17.3%; p=0.941). Differences in CRS/ICANS grades were not significant. CKD3a+ patients experienced sharply higher AKI (58.1% vs 13.0%; p<0.001; adjusted odds ratio [OR] 9.2, p<0.001). Renal replacement therapy was more frequent in CKD3a+ but non-significant (3.2% vs 0.8%; p=0.196). Acute respiratory failure was more frequent (9.7% vs 2.9%; p=0.045) in patients with CKD. Cardiac arrhythmias were numerically higher but non-significant (25.8% vs 20.6%; p=0.527; adjusted OR 1.3, 95% CI 0.4–4.9; p=0.673). Infections were amplified, including gram-negative bacteremia (3.2% vs 0.3%; p=0.026), sepsis (9.7% vs 2.6%; p=0.040), and septic shock (3.2% vs 0.3%; p=0.027) in patients with CKD. Inpatient mortality was numerically higher (6.5% vs 1.9%; p=0.101), though nonsignificant after adjustment (OR 6.9; p=0.319). Hospital costs were substantially higher in CKD3a+ (USD 346,769 vs 239,175; p=0.006), though not significant in adjusted models (OR 1.3; p=0.120). Conclusions: CKD3a+ is associated with markedly increased AKI, higher respiratory failure and infections, with a trend towards higher hospitalization costs. Inpatient mortality, CRS and ICANS rates were similar. CKD3a+ represents a significant vulnerability that amplifies downstream complications in MM CAR-T recipients, warranting enhanced pre-treatment risk stratification, infection surveillance and renal-preserving strategies.

e19054 Background: Chronic kidney disease (CKD) may potentiate toxicity and impair organ resilience in recipients of chimeric antigen receptor (CAR) T-cell therapy for diffuse large B-cell lymphoma (DLBCL). While cytokine response syndrome (CRS) and immune cell effector neurotoxicity syndrome (ICANS) have been reported with CKD, the cardiac, infectious, and economic sequelae are insufficiently described. We evaluated these outcomes across CKD strata from a national database. Methods: Using the National Inpatient Sample (2017–2022), we identified adult DLBCL hospitalizations receiving CAR T-cell therapy. ESRD patients were excluded. CKD was examined in two frameworks: CKD3a+ (eGFR <60 mL/min) versus no/CKD1–2, and CKD3b+ (eGFR <45 mL/min) versus no–CKD3a. Outcomes included in-hospital mortality, CRS (2021–2022), ICANS (2022), cardiac events, infections, acute kidney injury (AKI), renal replacement therapy and total hospitalization costs (calculated using TOTCHG variable and adjusted cost to charge ratio) and comparative analyses was done using chi-square testing. Multivariable models adjusted for demographics, comorbidities, and hospital characteristics. Results: In a cohort of 5,400 hospitalized DLBCL patients receiving CAR-T, those with CKD stage 3a or higher (CKD3a+; n=165; 3.1%) had higher rates of AKI (33.3% vs 11.6%; p<0.001) and renal replacement therapy (6.1% vs 1.4%; p=0.040) compared to no/CKD1–2 (n=5,235. Total hospitalization cost was higher (USD 456,198 vs 365,182; p=0.024) and grade 4 ICANS occurred more frequently (10.0% vs 1.4%; p=0.046). Mortality (6.1% vs 2.8%; p=0.259), pneumonia (12.1% vs 6.1%; p=0.246) and cardiac arrhythmias (33.3% vs 21.2%; p=0.094) were increased numerically. After multivariable adjustment, most differences diminished (mortality odds ratio [OR] 1.8, p=0.617; AKI OR 1.2, p=0.735). Among patients with CKD stage 3b or higher (CKD3b+; n=80; 1.5%), complications were more pronounced. In-hospital mortality was substantially higher (12.5% vs 2.7%; p=0.017), along with grade 4 CRS (7.7% vs 1.0%; p=0.011), acute myocardial infarction (6.3% vs 0.7%; p=0.007) and AKI (50.0% vs 11.7%; p<0.001). The cost of hospitalization (USD 446,074 vs 366,826; p=0.197) trended higher. Adjusted models confirmed markedly increased mortality (OR 10.2, 1.5–67.8; p=0.016) but other outcomes were not significant. Conclusions: CKD3b+ is associated with substantially higher mortality with signal of augmented high-grade CRS and cardiac events, whereas CKD3a+ exhibited worsening in renal outcomes and higher cost that attenuated after adjustment. These findings position pre-existing renal dysfunction especially CKD3b+ as a clinically salient risk substrate warranting pre-emptive risk stratification, vigilant cardiac monitoring and proactive organ-support pathways to mitigate downstream morbidity and mortality.

e18579 Background: Outcomes after allogeneic hematopoietic cell transplantation (allo-HCT) are often summarized using overall survival (OS) or treatment related mortality (TRM), which may obscure distinct biologic and toxicity driven pathways of failure. Major organ toxicities are important causes of morbidity and mortality but are rarely evaluated as competing events alongside relapse. We sought to characterize relapse and major organ failure as distinct competing pathways after allo-HCT. Methods: We analyzed adult allo-HCT recipients from the CIBMTR RT17-01 publicly available dataset (2008-2016). The primary endpoint was the first post transplant failure pathway, defined as relapse, major organ failure (MOF) requiring dialysis or diagnosed as thrombotic microangiopathy (TMA), veno-occlusive disease (VOD), or idiopathic pneumonia syndrome (IPS), or death without prior relapse or MOF. Competing risk methods estimated cumulative incidence, and cause specific Cox models evaluated associations between conditioning intensity and outcomes, adjusting for clinical and transplant related covariates, with the renal component of the hematopoietic cell transplantation comorbidity index (HCT-CI) removed. Results: The cohort included 13,187 adult recipients with a median age of 58.6 years, of whom 59.3 percent were male. Conditioning intensity was myeloablative (MAC) in 6,134 patients, reduced intensity (RIC) in 4,795, and non myeloablative (NMA) in 2,221. The first failure pathway was relapse in 5,157 patients, MOF in 1,511, and death without relapse or MOF in 2,535. At one year, cumulative incidence was 32.4 percent for relapse, 10.4 percent for MOF, and 13.1 percent for death without either event. IPS and dialysis requiring renal failure were the most frequent MOF events. Compared with MAC, RIC was associated with higher relapse risk (adjusted hazard ratio [aHR] 1.14; 95 percent confidence interval [CI] 1.07-1.23) and lower MOF risk (aHR 0.72; 95 percent CI 0.64-0.82). NMA conditioning showed a further shift toward relapse (aHR 1.42; 95 percent CI 1.30-1.54) with greater reduction in MOF risk (aHR 0.55; 95 percent CI 0.46-0.66). Conclusions: Relapse and MOF represent distinct competing pathways of failure after allo-HCT. Conditioning intensity influences which pathway predominates, with less intensive regimens shifting risk from organ toxicity toward relapse. Pathway based competing risk analyses provide insight beyond traditional survival endpoints and may support more individualized transplant decision making.

e15713 Background: Fruquintinib demonstrated overall survival benefit in heavily pretreated metastatic colorectal cancer (mCRC) in FRESCO and FRESCO-2. The FDA approved fruquintinib on Nov 8, 2023 for adult patients with mCRC after standard chemotherapy plus anti-VEGF therapy, with anti-EGFR therapy when appropriate (e.g., RAS wild-type). Observed geographic variation in post-approval uptake suggests potential disparities in the delivery of evidence-based medicine across U.S. regions. Methods: We conducted a retrospective cohort study using Epic Cosmos, a database of over 300 million patient records from over 1,500 hospitals nationwide. We identified adults with metastatic colorectal cancer (mCRC) with prior standard systemic therapy exposure and recorded fruquintinib exposure following FDA approval beginning Nov 8, 2023. Fruquintinib uptake was analyzed by U.S. Census region and state, expressed as the proportion of eligible mCRC patients receiving fruquintinib within each geography. Results: Among 116,116 pre-treated mCRC patients, 6,722 (5.79%) had recorded fruquintinib exposure during the post-approval period. Uptake varied nearly five-fold across states (2.27%–11.33%) (Table). High-uptake states were disproportionately concentrated in the central U.S./Midwest, whereas multiple low-uptake states were observed in the West and Northeast, suggesting broader regional variation beyond state-to-state differences. Conclusions: In a large national EHR-derived cohort of pre-treated mCRC patients after U.S. approval, fruquintinib uptake demonstrated substantial geographic variation. These findings raise concern for inequities in delivery of evidence-based later-line therapy and highlight the need to identify modifiable system- and site-level drivers (e.g., access, referral patterns, treatment infrastructure) to promote equitable adoption. Fruquintinib uptake among eligible metastatic colorectal cancer patients by U.S. state. Rank Geography Eligible mCRC (N) Fruquintinib uptake (%) Overall Overall 116,116 5.79 Top 1 Oklahoma 1,236 11.33 2 Kansas 1,312 10.75 3 Indiana 2,448 10.70 4 Missouri 1,521 9.47 5 Connecticut 2,208 9.24 Bottom 1 Washington 1,232 2.27 2 Nevada 441 2.72 3 Rhode Island 476 2.73 4 Tennessee 1490 2.82 5 Maine 614 2.93 Fruquintinib uptake is reported as the proportion of eligible pre-treated metastatic colorectal cancer (mCRC) patients with recorded fruquintinib exposure following U.S. FDA approval. States are ranked by uptake percentage.

10576 Background: Type 2 diabetes mellitus (T2DM) and excess adiposity are independent risk factors for pancreatic cancer. Pancreatic cancer risk within T2DM across body-mass index (BMI) strata is heterogeneous in real-world cohorts and lean T2DM individuals may represent a distinct high risk phenotype. We compared pancreatic cancer incidence and post-diagnosis survival across BMI strata. Methods: We performed a retrospective comparative outcomes analysis using the TriNetX network. Adults with T2DM (HbA1c ≥6.5%) were categorized as obese (BMI ≥30 kg/m²) or lean (BMI <25 kg/m²). The lean cohort additionally excluded any patient with prior BMI of >25 kg/m² to control for cancer associated weight loss. The index event was first T2DM diagnosis, and outcomes were evaluated after a 365-day window. Patients with pancreatic cancer prior to the outcome window were excluded. Propensity score matching was done using the following parameters: age, sex, smoking status, pancreatitis, pancreatic cysts, chronic kidney disease, gallstones, family history of pancreatic cancer, and HbA1c. Outcomes assessed were incident pancreatic cancer over 10 years and all-cause mortality among patients with pancreatic cancer and T2DM. Results: Total number of patients in the obese group was 1,759,075 with mean age of 57 ± 13.4 years and in the lean cohort were 205,193 with a mean age of 61.8 ± 16.6 years. After propensity score matching, there were 204,086 patients in each group. Mean HbA1c levels were 7.4 ± 1.8% in the obese group and 7.9 ± 2.2% in the lean BMI group. The incidence of pancreatic cancer was 0.16% (n = 335) in obese patients as compared to 0.23% in lean (n = 478) patients with a risk difference of 0.07% (p <0.001). Obesity was associated with lower pancreatic cancer risk (RR 0.692, 95% CI 0.603–0.797; p < 0.001). In the subgroup analysis of patients diagnosed with pancreatic cancer, obese patients had longer median survival (1,109 vs 651 days) with HR 0.853 (95% CI 0.793 - 0.918; p <0.001). Conclusions: Lean adults with T2DM had a higher incidence of pancreatic cancer and worse post-diagnosis survival than obese patients. These results identify lean T2DM as a distinct high-risk phenotype and demonstrate that pancreatic cancer risk within T2DM is heterogeneous and not solely attributable to excess adiposity. Further investigation is needed to elucidate the biological mechanisms underlying this association and its implications for clinical risk assessment. Pancreatic cancer incidence and associated risk estimates among obese and lean adults with type 2 diabetes mellitus. Cohort Pancreatic cancer incidence RD RR Obese T2DM(n = 204,086) 0.16% (n = 335) 0.07% (95% CI: 0.04 - 0.10), p < 0.001 1.44 (95% CI: 1.25 - 1.66) Lean T2DM(n = 204,086) 0.23% (n = 478) Abbreviations: CI, confidence interval; RD, risk difference; RR, relative risk; T2DM, type 2 diabetes mellitus.

Abstract Background: Renal allograft thrombosis, though commonly attributed to surgical or anatomical causes, is increasingly linked to inherited thrombophilia, including Factor V Leiden, prothrombin gene mutations, and deficiencies in protein C, protein S, or antithrombin III. These conditions raise the risk of early graft thrombosis and may impair graft survival. While therapeutic anticoagulation has been proposed as a preventive strategy, there are no established guidelines to direct its use in transplant recipients with thrombophilia. Methods: We systematically searched PubMed, Embase, and the Cochrane Library from inception to July 2025 to assess the role of therapeutic anticoagulation in kidney transplant recipients with thrombophilia. Two reviewers independently screened 275 titles and abstracts, as well as 35 full-text articles, using Covidence. Eligible studies included observational cohorts and case series (with≥2 patients) that reported anticoagulation outcomes in adult transplant recipients with thrombophilia. Case reports (n=1), reviews, pediatric studies were excluded. No randomized controlled trials were identified. Eleven observational studies met our inclusion criteria. Results: Type of anticoagulation medication, timing of use, and outcome reporting were heterogeneous. Only one retrospective cohort study directly compared anticoagulated and non-anticoagulated patients, reporting no thrombotic events in the anticoagulated group versus two in the control group. Several studies suggested benefits of anticoagulation, particularly in patients with antiphospholipid syndrome or lupus anticoagulant. Bleeding complications were reported in some of the studies, with major bleeding rates ranging from 20% to 30% in some cohorts. One study noted a 30% rate of perinephric hematomas in patients receiving perioperative heparin. Due to significant heterogeneity in study design, anticoagulation protocols, thrombophilia, and outcomes reported, meta-analysis was not feasible. Conclusion: Therapeutic anticoagulation may reduce thrombotic risk in kidney transplant recipients with thrombophilia, but bleeding complications and limited comparative evidence preclude general recommendations. Randomized and controlled studies are needed to better define indications and safety. Until then, anticoagulation decisions should be individualized based on patient risk factors and clinical context.