Saha, Souvik

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.

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.