Kouli, Ayla

Purpose Neutropenic diet (ND) has historically been recommended to reduce infectious complications in patients with cancer. Although its use has declined over the past decade, recent studies, particularly in patients undergoing hematopoietic stem-cell transplantation (HSCT), have renewed concern regarding the safety of a liberalized diet (LD). We performed a meta-analysis of studies comparing ND with LD in patients with cancer. Methods We searched MEDLINE, Embase, and Cochrane databases from inception through January 2026. Comparative studies evaluating ND versus LD in adults or children with cancer were included. Primary outcomes were major infections and bacteremia/fungemia; secondary outcomes were pneumonia, diarrhea, and mortality. Random-effects meta-analyses were performed to calculate pooled relative risks (RRs) with 95% CIs. Results Fifteen studies including 4,320 patients met criteria for analysis. ND was not associated with significant differences in major infections (RR, 1.02 [95% CI, 0.88 to 1.18]; P = .795), bacteremia/fungemia (RR, 0.97 [95% CI, 0.78 to 1.22]; P = .805), pneumonia (RR, 0.98 [95% CI, 0.59 to 1.63]; P = .933), diarrhea (RR, 1.12 [95% CI, 0.96 to 1.31]; P = .159), or mortality (RR, 0.94 [95% CI, 0.77 to 1.15]; P = .632). Sensitivity analyses restricted to randomized controlled trials (RCTs) were consistent. In hematologic malignancy/HSCT studies (9 studies; 1,769 patients), no differences were observed across outcomes. In RCTs limited to these patients (6 studies; 855 patients), ND was associated with lower bacteremia/fungemia risk (RR, 0.67 [95% CI, 0.47 to 0.95]; P = .023), with no differences in other outcomes. Conclusion ND was not associated with reductions in major infections, pneumonia, diarrhea, or mortality compared with LD. These findings do not support routine implementation of ND for patients with short-term neutropenia or lower-risk cancer populations although selected high-risk patients, particularly those undergoing HSCT or experiencing prolonged neutropenia related to hematologic malignancies, may still warrant cautious dietary practices.

e18574 Background: ND has historically been recommended to reduce infectious complications in cancer patients (pts). While the adoption of ND has declined over the last decade, recent studies - particularly in pts undergoing hematopoietic stem cell transplantation (HSCT) - have raised uncertainty regarding the safety of LD. Herein, we performed a meta-analysis of studies directly comparing ND with LD in pts with cancer. Methods: We conducted a systematic search of MEDLINE, Embase, and Cochrane databases from inception through January 2026. Comparative retrospective and prospective studies were included if they were comparing ND with LD in adults or children with cancer. Primary outcomes were major infections and bacteremia/fungemia. Secondary outcomes were pneumonia, diarrhea, and all-cause mortality. Random-effects meta-analyses were performed to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). The review followed PRISMA 2020 guidelines. Results: Fifteen studies enrolling 4,320 patients were included in the primary analysis. Six studies enrolled only adult patients, three were restricted to pediatric populations, and six included mixed adult and pediatric cohorts. Across these studies, ND was not associated with a significant reduction in major infections (RR 1.02, 95% CI 0.88–1.18; p=0.795), bacteremia/fungemia (RR 0.97, 95% CI 0.78–1.22; p=0.805), pneumonia (RR 0.98, 95% CI 0.59–1.63; p=0.933), diarrhea (RR 1.12, 95% CI 0.96–1.31; p=0.159), or all-cause mortality (RR 0.94, 95% CI 0.77–1.15; p=0.632). Sensitivity analyses restricted to RCTs showed consistent results. Subgroup analysis of hematological/HSCT studies (9 studies; 1,769 pts) also showed no differences across outcome. Analysis restricted to RCTs in hematologic/HSCT pts (6 studies; 855 pts) showed no differences in major infections, pneumonia, diarrhea, or mortality; however, ND was associated with a lower risk of bacteremia/fungemia (RR 0.67, 95% CI 0.47–0.95; p=0.023). Heterogeneity across studies was low to moderate. Conclusions: ND was not associated with reductions in major infections, pneumonia, diarrhea, or mortality compared with LD. A reduction in bacteremia/fungemia was observed in RCTs of hematologic malignancy and HSCT pts. Overall, these findings suggest that routine ND implementation is unnecessary for most cancer pts, although cautious dietary practices may remain reasonable in selected high-risk hematologic malignancy/HSCT populations.

e13635 Background: Melanoma is an aggressive skin malignancy with rising global incidence, for which checkpoint inhibitors (CPI) and BRAF-targeted therapies are standard of care in advanced disease. However, access to molecular diagnostics and CPI remains limited in conflict-affected regions such as Syria. Real-world data describing melanoma management in this setting are scarce. Methods: We conducted a retrospective study of all patients diagnosed with melanoma between 2022 and 2024 at Al-Bairouni University Hospital (ABUH), Syria’s primary oncology referral center. Demographic and clinical characteristics were analyzed for the entire cohort, and patients with advanced disease were evaluated for molecular testing and treatment patterns. Semi-structured interviews were conducted in a mixed advanced cancer subset (N = 35) to explore barriers to immunotherapy access. Results: Among 115 patients with melanoma, the median age at diagnosis was 57 years (IQR 44.5–67), and 54.7% were male. At presentation, 18.3% had stage I disease, 1.7% stage II, 2.6% stage III, and 40.9% stage IV disease; staging was unavailable in 36.5%. Among patients with advanced melanoma (n = 47), BRAF testing was performed in 17 (36.2%), with targeted therapy administered to 5/16 BRAF-positive patients. Only 7/47 patients (14.9%) received CPI, primarily as monotherapy. In the qualitative subset (predominantly lung cancer), five major barriers to immunotherapy access emerged: financial toxicity (n = 22), limited drug availability (n = 9), limited patient awareness (n = 8), geographic/logistical challenges (n = 5), and system delays (n = 4). Conclusions: Despite a substantial burden of advanced melanoma, access to molecular testing, targeted therapy and CPI in Syria remains limited. Qualitative findings highlight financial and structural barriers as primary drivers of limited access, underscoring the need for improved drug availability, diagnostic infrastructure, and patient education in conflict-affected settings.

3592 Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent dose-limiting toxicity from oxaliplatin that impairs quality of life in gastrointestinal (GI) cancer patients (pts). While strategies to limit exposure exist, their impact on survival remains debated. We evaluated whether reduced oxaliplatin exposure (ROE) maintains survival while mitigating toxicity. Methods: We conducted a systematic review and meta-analysis (PubMed, Embase, Scopus, Web of Science, EBM Reviews) of studies comparing ROE vs standard-duration oxaliplatin-based chemotherapy in GI cancers. ROE was defined as planned limitation of oxaliplatin exposure, including shortened duration (3-4 months), maintenance-based de-escalation, or stop-and-go strategies. Primary endpoints were disease-free survival (DFS) in curative settings, progression-free survival (PFS) in palliative settings, and overall survival (OS). Secondary endpoints included grade ≥3 CIPN and grade ≥3 adverse events (AEs). Random-effects models used Hartung-Knapp-Sidik-Jonkman correction. Heterogeneity was assessed via I² and Cochran’s Q. Results: 24 studies, comprising 15 randomized controlled trials (RCTs) and 9 retrospective cohorts, were included (N = 30,404 pts; ROE: 13,348; control: 17,056). Settings included adjuvant colorectal cancer (CRC; n = 14), metastatic CRC (mCRC; n = 5), gastric cancer (GC) (adjuvant n = 1, metastatic n = 3), and metastatic pancreatic cancer (PDAC) (n = 1). ROE strategies included shortened duration (n = 14), maintenance (n = 8), and stop-and-go (n = 2). In adjuvant CRC, ROE did not compromise DFS (HR 1.07; 95% CI, 0.98-1.16; p = 0.12; I² = 21.7%), including in high-risk subgroups (HR 1.14; 95% CI, 0.93-1.40; p = 0.14; I² = 38.9%); OS was also not different between groups (HR 1.00; 95% CI, 0.94-1.07; p = 0.89; I² = 0%), including high-risk pts (HR 1.01; 95% CI, 0.93-1.10; p = 0.68; I² = 0%). In mCRC, ROE showed no detriment to PFS (HR 1.11; 95% CI, 0.99-1.25; p = 0.07; I² = 0%) or OS (HR 1.06; 95% CI, 0.92-1.23; p = 0.33; I² = 0%). Similarly, in metastatic gastric cancer, PFS (HR 0.82; 95% CI, 0.34-1.99; p = 0.44; I² = 77.3%) and OS (HR 0.90; 95% CI, 0.67-1.21; p = 0.26; I² = 0%) were comparable. Findings remained concordant after restricting the analysis to only RCTs. Pooled analysis was not feasible for PDAC and adjuvant GC studies, but individual study findings were consistent with the above. ROE significantly reduced the risk of grade ≥3 CIPN (OR 0.32; 95% CI, 0.20-0.53; p < 0.001; I² = 80.6%) and overall grade ≥3 AEs (OR 0.65; 95% CI, 0.50-0.86; p = 0.01; I² = 59.9%). Conclusions: Across GI malignancies, ROE was not associated with inferior DFS, PFS, or OS and was associated with lower rates of severe neurotoxicity and high-grade AEs. These findings support planned limitation of oxaliplatin exposure as a strategy to improve the therapeutic index of oxaliplatin-based chemotherapy across disease settings.

1557 Background: Immunotherapy is now a standard-of-care treatment for lung cancer across most stages. Access to immunotherapy and molecular diagnostic tests in conflict-affected countries such as Syria remains poorly described. As the principal cancer center in Syria, Al-Bairouni University Hospital (ABUH) provides care for nearly three-quarters of all cancer cases nationally. We conducted this study to evaluate access to immunotherapy and molecular diagnostic services at ABUH. Methods: A mixed-methods study was performed between 2022 and 2024 at ABUH. This study included a retrospective cohort of all patients diagnosed with lung adenocarcinoma. Quantitative data included disease stage at diagnosis, molecular testing rates, and immunotherapy utilization. In addition, a qualitative patient survey was thematically analyzed to explore barriers to treatment access in a separate cohort of patients with mixed tumor types. Results: Among 2,920 patients diagnosed with lung cancer, 1,393 (47.7%) had lung adenocarcinoma. The median age at diagnosis was 61 years; 79.7% of patients were male. Smoking history was as follows: Current 792 (56.9%), Former 268 (19.2%), never smoked 318 (22.8%) At presentation, 3 patients (0.2%) had stage I disease, 40 (2.9%) stage II, 174 (12.5%) stage III, and 778 (55.8%) stage IV disease, staging was unknown for the rest of the patients. EGFR mutation testing was performed by ABUH for 226/1393 patients (16.2%) only, with positive results identified in 124 cases (8.9%). PD-L1 testing was conducted by ABUH in only 32/1393 patients (2.3%) and was positive in 23 (1.65%). Of all patients with lung adenocarcinoma, only 5 patients (0.6%) with stage IV disease received immunotherapy. All were treated with nivolumab. Thematic analysis of qualitative data (35 patients) revealed that high treatment costs and limited drug availability are the primary barriers to accessing immunotherapy. Conclusions: This study represents the first evaluation of access to immunotherapy for patients with lung cancer in Syria. Even at ABUH, the country's main cancer center, access to immunotherapy and molecular testing remains markedly limited. International collaboration is necessary to expand diagnostic infrastructure, standardize data reporting, and enhance financial protection mechanisms. These are critical steps toward achieving better cancer care in Syria.

Abstract Background: In conflict zones like Syria, accessing cancer care presents immense challenges. However, there is a critical lack of data on the specific barriers patients face. This study aimed to document these obstacles for breast cancer patients in Syria following 14 years of civil war. We surveyed patients presenting for cancer care to better understand the challenges they faced. Methods: This cross-sectional study included adult patients with a confirmed breast cancer diagnosis presenting to Al-Bairouni University Hospital for care. Data was collected through face-to-face interviews using a structured questionnaire adapted for the Syrian context. The survey covered six key areas: Demographic & Clinical, Healthcare System Barriers, Financial Barriers, Geographic & Security barriers, Reasons for Diagnostic Delays, and Psychosocial Impact. Multivariate analysis via logistic regression was conducted to determine which responses were associated with a higher odds ratio (OR) of having a late-stage (III/IV) cancer diagnosis. Results: A total of 109 patients diagnosed with breast cancer were enrolled. The mean age was 51.4 years (±15.2 SD). Advanced diagnostics (CT/MRI/biopsy) and radiation therapy were inaccessible for 58% (n=63) and 63% (n=69) of patients. Systemic therapy drugs were "rarely" or "never" available for 33% (n=36) of patients, and 14% (n=15) reported waiting over three months for an appointment. The costs of medications "greatly" or "very greatly" impacted 86% (n=94) of patients. Over two-thirds of patients reported that essential pain control medications (e.g., morphine) were "rarely" or "never" available (66%, n=72). Nearly two-thirds (67%, n =73) reported that security concerns "greatly" or "somewhat" affected their ability to access treatment. An overwhelming 89% (n=97) of patients reported a negative psychological impact from their treatment course. Patient responses associated with a higher OR of late-stage cancer diagnosis are present in Table 1. Conclusions: Breast cancer patients in Syria confront overwhelming systemic, financial, and security barriers that compromise their care and contribute to advanced diagnoses. The findings highlight a profound humanitarian crisis and underscore the urgent need for targeted public health and aid interventions to support cancer care in conflict settings. Citation Format: A. Al-Bitar, A. Kouli, F. Nahhat, M. Saifo. Systemic Barriers to Breast Cancer Care in Conflict-Affected Syria [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS5-11-14.

813 Background: Epidemiological data on gastrointestinal (GI) cancers in conflict-affected regions such as Syria are severely limited. Our study aims to fill in significant gaps in data by evaluating the demographics of Syrian patients diagnosed with new GI malignancies over a three-year period. Methods: This is a retrospective epidemiological study conducted at Al-Bairouni University Hospital – Syria’s national cancer center serving 60-70% of the country’s cancer patients. We included all patients diagnosed with GI malignancies (esophagogastric [EG], hepatocellular [HCC], biliary tract [BTC], pancreatic [PC], colorectal [CRC] cancers, and others) between Jan 2022 - Dec 2024. Data extracted from hospital records included sex, age at diagnosis, cancer stage, smoking status, and governorate of residence. Patients were grouped by disease group and year to assess annual trends. Institutional ethical approval was obtained to perform the study. Results: A total of 3,493 patients were diagnosed with GI cancers during the study period: 1,220 in 2022, 905 in 2023, and 1,368 in 2024 (Table 1). Across all years, a consistent male predominance was observed (60.1%). The average age at diagnosis was 59 years, 37.8% of patients were smokers, and 48.3% of all cases had advanced/metastatic disease at diagnosis. CRC (1,779) and EG (830) were the most common GI cancers. The highest patient loads originated from Damascus (17.6%) and Rural Damascus (17.5%), followed by central governorates such as Homs (9.7%) and Hama (9.3%). Notably, patients from more distant and underserved governorates such as Deir ez-Zor (7.0%), Aleppo (6.58%), and Al-Hasakeh (6.79%) accounted for a significant proportion of the GI cancers presenting to our center. Conclusions: To our knowledge, this study provides the first comprehensive multi-year dataset of GI cancers in Syria, with representation from all 14 governorates in the country. More than a third of our cohort were smokers and nearly half were diagnosed with advanced disease, demonstrating a need for public heath efforts to tackle tobacco use and improve screening & early detection. This dataset offers a foundation for future public health planning and research efforts in the region. Demographics of GI cancers diagnosed 2022-2024. Diagnosis 2022 Cases 2023 Cases 2024 Cases Total Cases Average Age Male Sex (%) Smokers (%) Advanced/Metastatic at diagnosis EG 311 217 302 830 56.1 519 (62.5%) 379 (45.7%) 370 (44.6%) HCC 88 46 61 195 59.2 134 (68.7%) 82 (42.1%) 116 (59.5%) BTC 34 43 54 131 58.4 69(52.7%) 40 (30.5%) 79 (60.3%) PC 118 122 160 400 58.4 249 (62.3%) 180 (45%) 247 (61.8%) CRC 620 444 715 1779 57.6 1008 (56.7%) 582 (32.7%) 805 (45.2%) Others (anal, small intestine, unknown primary) 49 33 76 158 55.5 75 (47.5%) 59 (37.3%) 69 (43.7%)

809 Background: Barriers to necessary care can pose a significant burden on patients with cancer, even more so in places of conflict. Following a devastating 14-year war in Syria, there is limited data published on access to cancer care and the impact that barriers to management have on our patients. We surveyed patients presenting for cancer care to better understand the challenges they faced. Methods: This cross-sectional study included adult patients with a confirmed gastrointestinal (GI) cancer diagnosis presenting to Al-Bairouni University Hospital for care. Data was collected through face-to-face interviews using a structured questionnaire adapted for the Syrian context. The survey covered six key areas: Demographic & Clinical, Healthcare System Barriers, Financial Barriers, Geographic & Security Barriers, Reasons for Diagnostic Delays, and Psychosocial Impact. Multivariate analysis via logistic regression was conducted to determine which responses were associated with a higher odds ratio (OR) of having a late-stage (III/IV) cancer diagnosis. Results: A total of 122 patients diagnosed with a GI cancer were enrolled. The mean age was 57.4 years (±11.2 SD), with a male predominance (68%, n=83). Advanced diagnostics (CT/MRI/biopsy) and radiation therapy were inaccessible for 55% (n =67) and 61% (n =74) of patients, respectively. Systemic therapy drugs were "rarely" or "never" available for 35% (n=43) of patients, and 12% (n=15) reported waiting over three months for an appointment. The costs of medications "greatly" or "very greatly" impacted 88% (n=107) of patients. Over two-thirds of patients reported that essential pain control medications (e.g., morphine) were "rarely" or "never" available (68%, n=83). Nearly two-thirds (65%, n =79) reported that security concerns "greatly" or "somewhat" affected their ability to access treatment. An overwhelming 87% (n=106) of patients reported a negative psychological impact from their treatment course. Patient responses associated with a higher OR of late-stage cancer diagnosis are present in the table. Conclusions: Patients in Syria with GI cancers face profound systemic, financial, geographic, and psychosocial challenges throughout their care journey. More than half were diagnosed at advanced stages, with diagnostic delays strongly linked to prolonged waiting times and financial strain. Financial toxicity was highly evident, resulting in treatment compromise and asset liquidation. This data should serve as a reference for future public health and humanitarian efforts in the region. Factors associated with late-stage (III/IV) diagnosis of GI malignancies (multivariate logistic regression). Variable Adjusted Odds Ratio (aOR) 95% Confidence Interval p-value Waiting Time First Oncology appointment >1 month 3.10 1.45 - 6.62 0.003 * Unemployed due to cancer 2.85 1.20 - 6.78 0.018 * Sold Assets to Finance Care 2.40 1.10 - 5.25 0.028 * *Statistically significant at p < 0.05.