Citations

459 Background: Quality improvement (QI) addresses local quality gaps to optimize care delivery, while implementation science (IS) seeks to increase adoption of evidence-based practices (EBPs) to close research-practice gaps and improve population health. Identifying opportunities for QI-IS synergy can foster collaboration and ensure attention to rapid and sustainable improvements in evidence-based care. Our objectives were to 1) assess how QI projects submitted for silver or gold certification in our academic medical center addressed evidence-based gaps in cancer care and 2) consider how their methods align with IS approaches. Methods: The QI project database was keyword searched to identify proposals in cancer. Data including detailed description of the quality gap and methods to identify and evaluate interventions were abstracted and entered in a database organized by the DMAIC framework (Define, Measure, Analyze, Improve, and Control). Two investigators reviewed data to identify EBPs and describe evidence using a typology for IS (Type 1 etiology and burden, Type 2 intervention effectiveness, and Type 3 dissemination and implementation in context). Data in DMAIC domains were mapped to relevant IS constructs for side-by-side comparison. Results: The search identified 81 proposals submitted between May 2017 and April 2025, of which 62 targeted cancer-related care gaps (5.2% of applications). Fourteen referenced published EBPs, including American Society for Clinical Oncology or National Comprehensive Cancer Network guidelines and state or federal quality metrics on cancer screening or evaluations for diagnosis and treatment. An additional 17 addressed processes relevant to EBPs, e.g., screening documentation. QI tools like cause-and-effect diagrams identified multilevel causes, but few proposals deployed multilevel interventions (strategies in IS), and none referenced theory. Reported “lessons learned” further detailed unanticipated patient, care team, and system-level challenges. Most (n=24, 77%) of EBP-related proposals addressed Type 2 evidence (e.g., performance, quality, efficiency) but could have also been framed as Type 3 evidence on implementation context/strategies targeting implementation outcomes (e.g., clinician adoption, patient reach, implementation fidelity). Conclusions: Although focused on local improvement, about 1 in every 20 QI proposals addressed implementation of cancer EBPs. Framing QI purpose as addressing Type 3 evidence could help link local QI projects to IS theory and methods to inform strategy selection and evaluation of implementation outcomes that precede service-level outcomes. Organizations that combine rapid-cycle QI improvements and rigorous IS methodologies may more effectively close care gaps and tackle persistent healthcare challenges.

325 Background: Enhanced screening and detection along with novel chemotherapeutic regimens have improved survival among patients with breast cancer. Palliative care plays an important role in both pain management as well as addressing individualized goals of care. Newer treatment options are often implemented in patients with advanced breast cancer and have the potential to cause further treatment related adverse effects. We aim to understand the impact of an inpatient palliative care encounter on outcomes among patients with breast cancer. Methods: We utilized the 2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study. We identified hospitalized patients who have breast cancer and subsequently had a palliative care encounter using appropriate ICD-10 CM codes. We stratified patients based on whether they had a palliative care encounter during the hospitalization or not. A survey multivariable logistic and linear regression analysis was used to calculate adjusted odds ratios (ORs) for the primary and secondary outcomes. A p value of < 0.05 was considered statistically significant. Results: We identified a total of 24770 hospitalized patients with breast cancer, of which 8.70% (2155/24770) had an in-patient palliative care encounter. The overall in-hospital mortality among those with breast cancer was 3.37% (835/24770). Among those who had a palliative care encounter, the overall in-hospital mortality rate was significantly higher at 25.75% (555/2155) (p = < 0.001). Utilizing a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, the inpatient palliative care encounter among hospitalized patients with breast cancer significantly increased the risk for in-hospital mortality (adjusted OR 17.01, 95% confidence interval [CI], 11.11-26.04; p = < 0.001), longer hospital LOS (coefficient 2.63, CI 1.56-3.70; p = 0.001), and lower total hospital charges (coefficient -$14893; CI –[$24071 – $5714], p = 0.001). Conclusions: Our analysis revealed that an in-hospital palliative care encounter among patients with breast cancer was associated with a significantly lower cost of healthcare utilization. We also noted a significantly higher in-hospital mortality and longer length of hospitalization among this subgroup utilizing palliative care. Caution should be exercised in interpreting these results as they may reflect uncontrolled and more advanced disease in patients requiring an inpatient palliative care consultation. Further prospective studies are needed to better understand the financial impact on healthcare utilization as well as short and long-term outcomes in this patient population.

212 Background: Endometrial cancer significantly impacts the Appalachian population compared to the overall United States population. Evidence supports that this difference may be due to health disparities, which includes access to affordable healthy food, obesity, and metabolic syndromes in addition to care disparities. Methods: We queried the Kentucky Cancer Registry’s online public Cancer Incidence and Mortality Registry to determine changes in age adjusted invasive corpus uteri cancer incidence and mortality rates in Appalachian (AK) and Non-Appalachian Kentucky (NAK) counties over time. Incidence rate ratios were used to analyze the difference in endometrial cancer incidence and mortality between AK and NAK populations across several time periods. The z-test for two population proportions was used to analyze differences in incidence and mortality between AK and NAK. Results: Incidence of endometrial cancer was higher in AK vs. NAK at the beginning (P < 0.002) and end (P < 0.001) of the period examined, although there was no statistically significant difference in mortality between AK vs NAK. Incidence and mortality increased in both AK (P < 0.01) and NAK (P < 0.001) across the period studied. Conclusions: Incidence in endometrial cancer in Appalachian Kentucky was significantly higher than non-Appalachian Kentucky, although mortality was not higher in the final years studied. Lower socioeconomic status, access to affordable nutritious foods, and health likely contributed to an increased incidence of endometrial cancer. With an increase in chronic diseases such as obesity prevailing in AK, there is increased exposure to unopposed estrogen, which increases the risk for developing endometrial cancer and may be reflected in these results. Education and lack of access to healthcare also are contributing factors. Although the cancer care disparities seen in Appalachia are commonly viewed as byproducts of the region’s unique culture, they can also be viewed as local expression of challenges in global oncology facing resource poor, rural regions around the world. Efforts to reduce the risk in Appalachia will require addressing the underlying problems seen in other communities worldwide with rising endometrial cancer incidence – poverty, health literacy, obesity, rising rates of diabetes, exercise and environmental pollution. Year Incidence AK (/100,000) Incidence NAK (/100,000) % Higher Incidence AK Mortality AK (/100,000) Mortality NAK (/100,000) % Higher Mortality AK 2001-2005 25.3 21.0 20.5% 1.6 1.6 0.0% 2006-2010 27.2 22.1 23.1% 1.5 1.6 -6.3% 2011-2015 30.3 24.7 22.7% 2.0 1.7 17.6% 2016-2020 31.8 26.0 22.3% 2.5 2.6 -3.8%

207 Background: CAR-T & bispecific antibodies (BsAb) for large B-cell lymphoma offer deep responses, but have unique toxicities requiring close monitoring. Different practice settings have varied strategies for managing these toxicities, leading to increased costs, healthcare resource use, & reduced quality of life. With no direct comparison, rationale for therapy selection may vary. This study explores provider choices, sequencing strategies & access barriers. Methods: A survey of US-based Hematologists was conducted on practice demographics, therapy availability, preferences, & barriers in LBCL. Responses were analyzed across clinical scenarios. Results: Responses were received from 45 physicians. Availability of CAR-T & BsAb varied with 75% prescribing both, & only BsAb being available at 9% of providers’ centers. There was a strong preference for CAR-T over BsAb—higher among academic vs. nonacademic providers (96% vs. 78%; p = 0.03) & at CAR-T vs. non-CAR-T centers (100% vs. 72%; p = 0.001). Even at BsAb-only centers, preference leaned toward CAR-T, though notably lower compared to CAR-T centers. Among centers without either, 86% preferred CAR-T. Practice volume had no impact. Reasons for favoring CAR-T included perceived better outcomes (55%), shorter treatment (26%), center choice (19%), more experience (48%), & curative potential (21%). BsAb selection was driven by CAR-T unavailability & logistical barriers (distance to specialized center, insurance delays, referral complexity, manufacturing time, & hospitalization needs). Axi-cel was preferred by 69% ( p = 0.0001) vs. other CAR-T for third-line or later due to experience with use, response rates, center choice, & logistical ease. Liso-cel (26%) & Tisa-cel (2%) were chosen for perceived favorable toxicity over Axi-cel. Axi-cel was also preferred second-line vs. Liso-cel (73% vs. 24%; p < 0.0001) for similar reasons. Among BsAb, Epcoritamab was favored by 56% for administration ease (subcutaneous), experience, & center preference; Glofitamab by 42% for shorter duration, experience, & center preference. There was no difference by academic vs nonacademic practice & volume for both CAR-T & BsAb. In patients with prior non-CAR-T anti-CD19 therapy, providers chose CD19 CAR-T over CD20 BsAb (80% vs. 18%; p < 0.0001). For relapse after second-line CAR-T, 78% providers preferred BsAb as the next line over other options ( p < 0.0001) due to more favorable response rates, toxicity profile, & experience with use. Providers prioritized response rates, survival, & toxicity profile in their treatment decisions. Logistics, duration, frequency, & cost were less important. There were no differences based on practice setting & CAR-T experience. Conclusions: Despite higher preference for CAR-T due to perceived superior outcomes, access barriers exist. Efforts to streamline referral pathways, logistics, & expand availability are crucial to improve outcomes.

465 Background: Molecular testing is crucial in advancing precision medicine, enabling oncologists to tailor targeted treatment strategies for cancer patients (pts). The National Comprehensive Cancer Network (NCCN) and ASCO guidelines recommend comprehensive biomarker testing for pts with mPC. However, compliance can vary considerably among institutions. This study aimed to assess current practices of molecular testing in diverse healthcare settings across the state of Florida and identify opportunities for improvement to optimize outcomes for pts diagnosed with mPC. Methods: We conducted a detailed 12-question survey, distributed both electronically and in-person to evaluate the molecular testing practices of healthcare providers throughout the state. The survey assessed multiple parameters including adherence to testing, reviewing test results to guide treatment decisions, and the availability of different supportive resources in biomarker testing. This initiative was executed in partnership with the Florida Society of Clinical Oncology and industry partners. Results: A total of 40 responses were collected from 11 institutions in Florida, including 5 academic centers and 6 community-based hospitals. Notably, 22.5% of respondents reported that their institutions either do not fully comply with NCCN guidelines or lack protocols to identify eligible pts and 67.5% stated they are responsible for their own biomarker education and updates. Only 56.4% consistently review molecular testing results during disease progression to guide treatment decisions. Nearly all institutions lack clinical decision support tools in the electronic medical records (EMR) to support testing, and 82.5% receive biomarker results outside the EMR. Additionally, 38.5% lack a standard process for obtaining prior authorization for testing. Furthermore, 38.5% lack a multidisciplinary review process for genetic test results, and 76.3% reported that their biomarker testing process does not involve geneticists or genetic counselors. Conclusions: Our study identified critical gaps in adherence to biomarker testing guidelines with many practices lacking decision support tools across healthcare institutions in Florida. Potential areas for improvement include better standardization of result integration into EMR, targeted educational initiatives, and stronger multidisciplinary collaborations. The implementation of these measures aims to improve the quality of care and outcomes for pts with mPC.

511 Background: Long-term survivorship care is essential for cancer patients, encompassing surveillance, symptom management, psychosocial effects, chronic condition care and health promotion. In low-resource settings such as Peru, financial toxicity (FT) is a pervasive challenge that may hinder access to these services. However, the extent of FT and its association with survivorship care gaps remains understudied in Latin America. Methods: A cross-sectional online survey was conducted among 218 adult cancer survivors in Peru (2024). FT was assessed using the validated COST-FACIT tool. Survivorship care was evaluated across five domains: (1) recurrence and new cancer surveillance, (2) physical effects, (3) psychosocial effects, (4) health promotion, and (5) chronic conditions. Data included demographics, cancer history, monthly income and type of insurance. Multivariable logistic regression identified predictors of severe FT, adjusting for demographics, income, insurance, and urban/rural residence. Results: Participants were predominantly female (78%), aged 45–64 (50.5%), and urban-dwelling (50.9% reside in the capital city). Breast (42.2%), cervical (18.3%), and ovarian (12.4%) cancers were most common. All respondents reported FT, with 66.5% severe and 30.3% moderate. Only 4.1% received care in all five domains. Gaps were highest in chronic condition care (20.2%) and health promotion (22.9%). Insurance coverage included public (70.7%), private (15.8%), and none (13.4%). In adjusted analysis, survivors reporting perceived adequate survivorship care (OR = 0.27, p = 0.002) and recurrence surveillance (OR = 0.30, p = 0.013) had lower odds of severe FT. Higher income was protective (OR = 0.15, p = 0.024). Conclusions: FT is universal among Peruvian cancer survivors and linked to critical gaps in survivorship care, particularly chronic disease and preventive health. The inverse association between comprehensive care and FT severity suggests that structured survivorship programs that integrate financial navigation, care coordination, and insurance expansion could mitigate FT. Findings underscore the urgency of policy reforms to reduce out-of-pocket costs and adapt survivorship models tested in low- and middle-income countries. While this cross-sectional study identifies strong associations, it cannot establish causality, and findings may be subject to selection bias inherent in online surveys.

501 Background: Targeted treatment options have significantly improved outcomes for patients with chronic lymphocytic leukemia (CLL), but oncology healthcare professionals (HCPs) who provide care for fewer numbers of patients with CLL are challenged to remain current with continuously changing treatment paradigms. To assess ongoing educational needs, we analyzed the treatment choices made by HCPs in an online survey for select cases of poor-prognosis CLL and compared these with the choices of experts in CLL treatment for the same clinical scenarios. Methods: As part of a CME program, HCPs could access an online algorithm to enter specific characteristics of a CLL case scenario and receive treatment recommendations from 5 US-based CLL experts. Experts made recommendations in July 2024 for 146 possible case patients built into the algorithm. After entering their case characteristics, HCPs were asked to enter their planned treatment prior to viewing the expert recommendations. We compared expert and HCP treatment choices across various case scenarios that were entered into the algorithm, with a focus on previously untreated CLL with del(17p)/mutated TP53 or R/R CLL. Results: Between August 2024 and February 2025, 346 cases were entered into the algorithm by 174 HCPs. Among responding HCPs, 38% were based in the UK/EU, 24% in the US, and 10% in Asia; 62% treated ≤10 patients with CLL per month and 49% sought recommendations for a specific patient in their practice. Among 231 cases of previously untreated CLL entered, 91 (39%) sought recommendations for del(17p)/mutated TP53 disease. For cases with no major comorbidities and previously untreated CLL with del(17p)/mutated TP53 , all experts recommended acalabrutinib or zanubrutinib; in 19 cases submitted by HCPs practicing in locations where second-generation BTK inhibitors (BTKi) are approved for CLL (including the US, EU, and Japan), 58% planned 1 of these treatments for this case scenario, 17% planned ibrutinib-based therapy, and 11% planned venetoclax-based therapy. Among case scenarios requiring third-line therapy after progressing with 2 regimens including a covalent BTKi and venetoclax plus an anti-CD20 Ab (with progression <2 years after completing treatment), all experts would recommend a noncovalent BTKi (eg, pirtobrutinib), with 1 expert indicating they would also consider CAR T-cell therapy. For the same case scenario among 6 US-based HCPs, 1 planned pirtobrutinib and 3 planned CAR T-cell therapy. Overall, after reviewing expert recommendations, 61% of HCP respondents whose planned treatment differed from the experts indicated that they would change their approach, and 20% indicated barriers to implementing the recommendations. Conclusions: Our findings provide insight into potential educational needs among HCPs who manage patients with CLL, suggesting that targeted expert-led education could benefit these HCPs.

262 Background: According to the American Cancer Society, nearly half (47%) of cancer patients and survivors incurred medical debts to pay for cancer care, although most (98%) had health care coverage (2024 Survivor Views Survey). The financial toxicity from high cost of cancer care is itself a risk factor for cancer mortality – hazard ratio of 1.8 among those requiring bankruptcy protection (Ramsey SD, J Clin Oncol 2016). Charity care, also known as financial assistance, plays a vital role in alleviating the medical debt for low-income patients. The Affordable Care Act requires non-profit hospitals to publish charity care policies to maintain their tax-exempt status. We studied the criteria for hospital charity care among NCI-designated cancer centers in the US. Methods: We included all NCI-designated cancer centers with a clinical program as of December 1, 2024. We searched their cancer center websites for charity care eligibility policies in 2024 and obtained the following information: income limit as percentage of the federal poverty guidelines (FPG), eligibility criteria beyond income, and supporting documents required for charity care application. Cancer centers were grouped into the following regions based on US Census classification: Northeast, Midwest, South, and West. Results: We found 64 NCI-designated clinical cancer centers - all non-profit institutions. Charity care policies were readily available. The median income cutoffs for free and discounted care were 200% of the FPG (range, 100%-600%) and 400% of the FPG (range, 200%-800%), respectively. These income cutoffs were similar among the four geographic regions. Most centers (52%) allowed not only uninsured but also underinsured or insured patients experiencing hardship. A minority of the policies (13%) applied different rules for insured patients. Majority of the centers (52%) allowed financial assistance when medical bills exceed a certain hardship limit even if income cutoffs were not met. Only 3 centers (5%) required medical bills to exceed a minimum threshold for eligibility. Residency requirements included US citizenship or permanent residency (27%), state (33%), service area (14%), county (2%), not necessary (11%) or not stated (34%). Most policies (64%) mentioned investigating a patient's assets. Specific documents required for submission included income (98%), pay stub (88%), tax return (84%), asset (73%), proof of residency/citizenship (44%), and bank account (61%). Conclusions: NCI-designated cancer centers apply a relatively uniform range of financial eligibility criteria for free and discounted charity care. Approximately 1 in 4 centers require evidence of US citizenship or permanent residency while 1 in 2 centers restrict eligibility to in-state residents. Future studies into the awareness, accessibility, and utilization of charity care will provide insight into how to optimize this resource for the neediest population.

606 Background: NCCN guidelines are among the most comprehensive and widely adopted clinical practice standards in oncology, frequently used by both clinicians and payors across the United States. Theys encompass three main categories: treatment, detection/prevention/risk reduction, and supportive care. While the evidence base for treatment recommendations has been examined in prior studies—and early detection guidelines largely align with those from other major medical societies—the strength of evidence supporting recommendations in supportive care guidelines remains poorly characterized. Methods: We conducted a systematic analysis of the categories of evidence and consensus (EC) supporting recommendations in 5 widely utilized NCCN supportive care guidelines (versions 2025): antiemesis, cancer-related fatigue, distress management, hematopoietic growth factors, and smoking cessation. Recommendations were classified into the following EC levels: category 1 (high-level evidence with uniform consensus [>85%]), category 2A (lower-level evidence with uniform consensus), category 2B (lower-level evidence with moderate consensus [50–84%]), and category 3 (any level of evidence with major disagreement). Results: Of the 120 recommendations found in the 5 guidelines of supportive care, the proportions of category I, IIA, IIB, and III EC were 18%, 82%, and 0%, and 0%, respectively. Recommendations with category I EC were found in antiemesis supportive care (30%), cancer-related fatigue (21%), distress management (12%), hematopoietic growth factors (20%), and smoking cessation (13%) guidelines. Conclusions: A substantial proportion of recommendations in the NCCN supportive care guidelines are derived from lower levels of evidence. While these guidelines are invaluable in standardizing care and guiding clinical decision-making, their reliance on expert opinion underscores a critical gap in the oncology evidence base. This situation presents both a challenge and a compelling opportunity to design and conduct rigorous clinical research that can validate current practices, inform future recommendations, and further improve patient outcomes. Level of recommendation by guideline. Guideline Recommendations I IIA IIB III Antiemesis 23 30% 70% 0% 0% Cancer-related fatigue 19 21% 79% 0% 0% Distress management 43 12% 88% 0% 0% Growth factors 19 20% 80% 0% 0% Smoking cessation 16 13% 87% 0% 0%

560 Background: Early diagnosis remains a critical challenge in oncology, particularly for the five deadliest cancers: lung, breast, prostate, colorectal, and pancreatic. These cancers often present with nonspecific symptoms, leading to repeated healthcare visits without a timely suspicion of malignancy. Artificial intelligence (AI) offers an opportunity to augment clinical decision-making and support earlier identification of cancer. C the Signs , an AI cancer prediction platform, has been widely adopted across the UK with substantial evidence supporting its ability to identify cancer at earlier stages. Methods: This retrospective study assessed the performance of C the Signs in intercepting cancer earlier than physician diagnosis. De-identified electronic medical records were accessed via the Mayo Data Platform, spanning a 20-year period from January 1, 2002 to December 31, 2021. The study cohort included 55,375 patients diagnosed with lung, breast, prostate, colorectal or pancreatic cancer. The primary outcome was the proportion of cases identified earlier by the AI model, measured in annual increments up to five years prior to physician diagnosis. Additional analyses were conducted across the five target cancer types. Results: The C the Signs platform identified 14,528 patients (26.2%) with cancer earlier than the original physician diagnosis. Early identification occurred across multiple time points: 8.9% in year 1, 4.7% in year 2, 4.4% in year 3, 4.3% in year 4, and 3.9% in year 5. Across cancer types, the highest early interception rate was observed in prostate cancer (31.7%), while breast cancer showed the lowest impact (21.0%). Conclusions: Use of the C the Signs AI cancer prediction platform demonstrated meaningful improvements in early cancer interception, particularly for lung and prostate cancers. These findings highlight the potential of AI tools to enhance early diagnosis and support timely clinical interventions, offering a scalable solution to improve cancer outcomes across populations.