Durani, Urshila

Background: Adherence to surveillance guidelines in resected colon cancer has significant implications for patient morbidity, cost of care, and healthcare utilization. This study measured the underuse and overuse of imaging for staging and surveillance in stage I–II colon cancer. Methods: The OptumLabs database was queried for administrative claims data on adult patients with stage I–II colon cancer who underwent surgery alone in 2008 through 2016. Use of PET and CT imaging was evaluated during both initial staging (n=6,921) and surveillance for patients with at least 1 year of follow-up (n=5,466). “High use” was defined as >2 CT abdominal/pelvic (CT A/P) or PET scans per year during surveillance. Results: Overall, 27% of patients with stage I–II colon cancer did not have a staging CT A/P or PET scan and 95% did not have a CT chest scan. However, rates of staging CT A/P and CT chest scans increased from 62.0% (2008) to 74.8% (2016) and from 2.3% (2008) to 7.1% (2016), respectively. Staging PET use was overall very low (5.2%). During surveillance, approximately 30% of patients received a CT A/P or PET and 5% received a CT chest scan within the first year after surgery. Of patients who had surveillance CT A/P or PET scans, the proportion receiving >2 scans within the first year (high use) declined from 32.4% (2008) to 9.6% (2016) (P = .01). Conclusions: Although PET use remains appropriately low, many patients with stage I–II colon cancer do not receive appropriate staging and surveillance CT chest scans. Among those who do receive these scans during surveillance, high use has declined significantly over time.

144 Background: Small cell lung cancer (SCLC) is highly responsive to cytotoxic therapy and can be cured in early stages of disease. In this setting, disparities in patient refusal despite provider recommendations are unknown. Methods: All incident limited stage (LS)-SCLC cases from the National Cancer Database were identified from 2004 to 2014. Logistic regression was used to determine factors associated with treatment refusal. Results: 65,664 patients (pts) were identified with LS-SCLC: 44% male, median age 68 years. 3.4% of pts refused radiation and 3.8% refused chemotherapy. The proportion of chemotherapy refusal increased over the study period: 3% in 2004-2006 compared to 5.4% in 2013-2014 [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.55-2.01]; this was not observed for radiation. In multivariate analysis, women were more likely to refuse radiation (OR 1.18, 95% CI 1.06-1.32) and chemotherapy (OR 1.30, 95% CI 1.19-1.43) than men. Women who accepted treatment had higher overall survival compared to those who refused radiation (19.8 vs 5.2 months) or chemotherapy (17.4 vs 3.9 months) (both p < 0.001). Hispanic, Black, and Asian pts were not more likely to refuse treatment than White pts. Older pts were more likely to refuse radiation (OR 1.09 per year, 95% CI 1.08-1.09) and chemotherapy (OR 1.10 per year, 95% CI 1.09-1.11). Charlson comorbidity index (CCI) of 2 was associated with more frequent treatment refusal compared to CCI of 0 (radiation OR 1.96, 95% CI 1.68-2.30; chemotherapy OR 1.54, 95% CI 1.34-1.76). Medicaid as primary insurance predicted a higher risk of refusal compared to private insurance for radiation (OR 2.36, 95% CI 1.81-3.07) and chemotherapy (OR 2.23, 95% CI 1.78-2.80). Treatment at an academic facility predicted a lower risk of radiation refusal (OR 0.71, 95% CI 0.59-0.84) but not chemotherapy refusal. Conclusions: Female sex, comorbidities, and Medicaid insurance were predictors of treatment refusal in LS-SCLC, suggesting that socioeconomic and sex disparities may affect treatment decisions in this life-threatening disease. Further research to identify reasons for refusal via patient and provider interviews can improve care of vulnerable populations with potentially curable cancer.

Abstract Introduction: The role of surveillance imaging in diffuse large B-cell lymphoma (DLBCL) after treatment with curative intent is debated. In 2013, the American Society of Hematology (ASH) Choosing Wisely® campaign (Hicks LK, et al. Blood 2013) released a recommendation to "limit surveillance CT scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma." This was based on previous studies demonstrating a lack of survival benefit as well as a significant impact on the patient in terms of cost, anxiety, incidental findings and radiation exposure. Similar findings have been described regarding the use of PET imaging, especially in low risk patients. We aimed to study the changes in practice patterns of surveillance imaging for DLBCL survivors treated with curative intent before and after the publication of the ASH Choosing Wisely® campaign. Methods: Administrative claims data from a large U.S commercial insurance database (OptumLabs Data Warehouse) were used to retrospectively identify adult patients with an incident diagnosis of DLBCL between 2008 and 2016 and at least one year of follow-up. We excluded those who did not receive treatment with curative intent: RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) x 6 cycles or RCHOP x 3-5 cycles plus radiation. Patients were also excluded if they had a co-existing or second cancer, or if they received any chemotherapy/radiation during their surveillance period, as to exclude anyone with a recurrence of their lymphoma. The surveillance period started 90 days after the last chemotherapy or radiation and continued for the duration of follow-up. Surveillance imaging was defined as any PET, PET-CT, CT chest, CT abdomen, and/or CT pelvis. To examine trends over time, three time periods were defined: 2008-2010, 2011-2013 and 2014-2016. The Cochran Armitage test was used to test the trend hypothesis. Results: A total of 1,472 patients were included. Cohort characteristics by time period are described in Table 1. Surveillance imaging frequency decreased from 84% in Year 1 of surveillance to 43% in Year 5 (Figure 1). Overall, surveillance imaging during the first 3 surveillance years significantly decreased over the three time periods (Figure 2) (P<0.01 for Years 1 and 2, P=0.04 for Year 3). Imaging surveillance for the first two years of surveillance did not significantly decrease from 2008-2010 to 2011-2013 (P>0.05), but significantly decreased from 2011-2013 to 2014-2016 (P<0.01). Of the groups that received imaging surveillance during year 1, the median number of scans during the first year was 2 (inter-quartile range, 1-2) and did not significantly change over time. In addition, PET/PET-CT surveillance decreased from 49% in Year 1 to <10% in Year 5. PET/PET-CT also decreased over the three time periods, from 62% (2008-2010) to 48% (2011-2013) to 43% (2014-2016) during the first year of surveillance and 40% to 31% to 25% during the second year. Younger age (<65 years versus ≥65 years) was associated with higher imaging utilization (86% versus 81%, respectively), and specifically PET/PET-CT utilization (55% versus 43%, respectively), during the first year of surveillance. However, race (white versus non-white) did not significantly affect imaging (85% versus 83%) or PET utilization (50% versus 47%) during the first year of surveillance. Conclusions: Our study demonstrates that the rate of surveillance CT and PET imaging in DLBCL patients treated with curative intent decreased significantly in the years after the publication of the ASH Choosing Wisely® campaign. However, over half of the DLBCL patients diagnosed in 2014-2016 continued to undergo surveillance imaging, indicating either incomplete guideline dissemination or ongoing debate regarding optimal surveillance practice. Future studies are necessary to determine whether such a decline in surveillance imaging is sustained and to examine factors (patient, provider, and payer) associated with surveillance imaging in DLBCL. Disclosures No relevant conflicts of interest to declare.

Abstract Background Hodgkin lymphoma is a rare hematological malignancy, with 8,500 new cases per year in the United States. Prior studies in oncology have shown that higher patient volume, whether at the treatment facility or provider level, is associated with reduced mortality and improved overall survival (OS). We used a national oncology data set to test our hypothesis that a volume-outcome relationship may also exist in classical Hodgkin lymphoma. Methods Using the National Cancer Data Base (NCDB), we identified patients diagnosed with classical Hodgkin lymphoma between 2003 and 2014. The NCDB is a nationwide oncology outcomes database for ~70% of newly diagnosed cases from more than 1,500 accredited cancer programs in the United States and Puerto Rico. We classified the facilities by quartiles (Q; mean patients with HL treated per year): Q1: < 3.19, Q2: 3.2 to 5.0, Q3: 5.01 to 9.19, and Q4: ≥9.2. Our primary outcome of interest was all-cause mortality. We used random intercepts to account for clustering of patients within facilities and a Cox regression model to determine the volume-outcome relationship, adjusting for demographic (sex, age, race, ethnicity), socioeconomic (income, education, insurance type), geographic (area of residence, treatment facility location, travel distance), and comorbid (Charlson-Deyo score) factors, as well as year of diagnosis. Kaplan-Meier analysis was performed to examine the impact of patient volume (by quartile) on overall survival. Results There were 47,633 patients with classical Hodgkin lymphoma treated at 1,310 facilities. The median age at diagnosis was 40 years, and 54.2% were men. The median annual facility volume was 2.7 patients per year (range, 1 to 42.8). The distribution of facilities according to patient volume was: Q1: 58.4%, Q2: 22.4%, Q3: 13.3%, and Q4: 5.9%. After a median follow-up of 58 months, the highest volume quartile (Q4) had significantly higher 5- and 12-year overall survival rates compared to Q1-Q3 (Table 1). Overall survival by quartile is depicted as a Kaplan-Meier curve (Figure 1). Compared to the patients treated at Q4 facilities, those treated at lower-quartile facilities had a higher risk of death (Q3 hazard ratio [HR], 1.18 [95% CI, 1.10 to 1.27]; Q2 HR, 1.21 [95% CI, 1.13 to 1.30]; Q1 HR, 1.19 [95% CI, 1.11 to 1.28]) after adjustment for the sociodemographic factors discussed in our methods. Multivariable analysis showed that facility volume as a continuous variable was independently associated with all-cause mortality (Figure 2) (P<0.0001). Compared with facilities treating 10 patients per year, facilities treating 20, 30, and 40 patients per year had approximately 10%, 17%, and 23% lower overall mortality rates. Conclusions Patients treated for classical Hodgkin lymphoma at higher-volume facilities had a lower risk of mortality compared with those treated at lower-volume facilities. This adds to the growing body of evidence that a volume-outcomes relationship exists in some of the less common hematologic malignancies. Further research is needed to ascertain whether such differences in survival are related to provider-level or facility-level attributes, and whether patients with Hodgkin lymphoma will benefit from referral to high-volume centers. Disclosures No relevant conflicts of interest to declare.

Abstract Background: Gastric cancer is one of the most pro-thrombotic tumor types, and after accounting for prevalence, it may be responsible for a significant burden of cancer-associated venous thromboembolism (VTE). Patients with gastric cancer are also at high risk for gastrointestinal bleeds (GIB), making primary thromboprophylaxis and anticoagulation an ongoing treatment challenge. Due to these competing risks, patients with gastric cancer may not be eligible for clinical trials of thromboprophylaxis and treatment of cancer-associated VTE. Additional information regarding the severity and outcomes of both gastrointestinal hemorrhage and VTE in patients with gastric cancer would be useful to guide clinical decision-making. Aim: To determine the annual rates, inpatient mortality, length of stay and cost of VTE- and GIB-related admissions in patients with gastric cancer. Methods: We queried the 2009-2014 Nationwide Inpatient Sample (NIS) database, a nationally weighted hospital admissions database developed for the Healthcare Cost and Utilization Project, to identify adults (age ≥ 18 years) hospitalized with gastric cancer. Hospitalizations in which VTE or GIB were among the top-five discharge diagnoses, were considered an admission complicated by one of these events. In-hospital outcomes of patients with VTE were compared to those with GIB. We used linear regression models to analyze trends in outcomes over time and binary logistic regression with forward modeling to identify predictors of inpatient mortality. All statistical analyses were conducted with SPSS, version 24 (IBM, Armonk, NY). Results: Among a total of 253,680 admissions with gastric cancer, 17,831 (6.7%) experienced a GIB whereas 10,992(4.2%) had VTE. Of those patients who experienced VTE, the majority (49.7%) developed pulmonary embolism, followed by lower extremity deep vein thrombosis (41.8%) and upper extremity deep vein thrombosis (8.54%). The patients included in this study were mainly white (53.7%) men (63.6%) with a median age of 67 (IQR:20) years; and a mean of 6 (SD: 2.83) chronic medical conditions. The annual GI bleed rate remained stable during the study period (16% in 2009 to 17.2% in 2014: p = 0.67) with a significant downtrend in inpatient mortality (18.8% in 2009 to 13.7% in 2014: p <0.01). In contrast, the annual rates of VTE-related admissions showed a small but significant uptrend (15% in 2009 to 18.1% in 2014: p <0.01) and an uptrend in the inpatient mortality during the study period (15.7% in 2009 to 19.2% in 2014: p <0.01). The overall inpatient mortality was higher among patients with VTE than with GI bleeds (10.2% vs 6.5%, p < 0.01; OR univariate: 1.51, CI: 1.42 - 1.61, p < 0.01). The negative effect of VTE on inpatient mortality persisted after adjusting for possible confounders such as metastatic disease, several comorbidities and demographics (OR: 1.39, CI: 1.30 - 1.49, p < 0.01). The VTE-associated admissions had a slightly longer length of stay (median, 6 vs 4 days, p < 0.01) with a significantly higher cost compared to GI bleed ($45,599 vs $31,219, respectively, p < 0.01). Conclusion: In this NIS cohort of hospitalized patients with gastric cancer, GIB was more frequently observed than VTE, but those with VTE had higher inpatient mortality, longer length of stay, and higher hospital costs. Clinicians should be aware of patient-specific risk factors for both VTE and GI bleed and take these factors into account when discussing VTE prophylaxis and treatment with patients. Future studies should look to identify those patients with gastric cancer who would benefit most from primary VTE prophylaxis as well as identify ideal agents for the treatment of gastric cancer-associated VTE. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

PURPOSE In a professional setting, the introduction of female speakers without their professional title may have an impact on the public’s perception of the female speaker. We examined how professional titles were used during speakers’ introductions at the ASCO Annual Meeting. METHODS We conducted a retrospective, observational study of video-archived speaker introductions at the 2017 and 2018 ASCO Annual Meetings. A “professional address” was defined as the professional title followed by the speaker’s full name or last name. Multivariable logistic regressions were used to identify factors associated with the form of address. RESULTS Of 2,511 videos reviewed, 781 met inclusion criteria. Female speakers were addressed less often by their professional title compared with male speakers (62% v 81%; P < .001). Males were less likely to use a professional address when introducing female speakers compared with females when introducing male speakers (53% v 80%; P < .01). When women performed speaker introductions, no gender differences in professional address were observed (75% v 82%; P = .13). Female speakers were more likely to be introduced by first name only (17% v 3%; P < .001). Male introducers were more likely to address female speakers by first name only compared with female introducers (24% v 7%; P < .01). In a multivariable regression including gender, degree, academic rank, and geographic location of the speaker’s institution, male speakers were more likely to receive a professional address compared with female speakers (odds ratio, 2.43; 95% CI, 1.71 to 3.47; P < .01). CONCLUSION When introduced by men, female speakers were less likely to receive a professional address and more likely to be introduced by first name only compared with their male peers.

Abstract Background: Neutropenic fever is a common complication of therapy for many cancers. Previous studies have shown high rates of in-hospital mortality ranging from 10-14% (Chindaprasirt J., et al, Asian Pac J Cancer Prev 2013; Kuderer N. M., et al, Cancer 2006; Lal A., et al,Asian Pac J Cancer Prev2008; Lyman G. H., et al,Cancer 2010). However, outcomes have not been studied in recent years since the release of updated infectious disease guidelines and improvements in supportive care. Methods: We queried years 2009 to 2013 of the National Inpatient Sample to determine the incidence, mortality, and length of stay for neutropenic fever hospitalizations. The National Inpatient Sample is a nationally weighted sample of all hospital discharges in the United States, derived from discharge billing records from hospitals across the country. Patients aged 18 and older with a principal diagnosis of neutropenia [International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 288.00 and 288.03] and associated fever (ICD-9-CM code 780.61) were included. Patients with multiple malignancies, no malignancies, or admitted for an obstetric procedure/complication were excluded. Baseline characteristics, associated infections, and in-hospital complications were analyzed using descriptive statistics. Mortality and length of stay were our primary outcomes. Multivariable logistic regression was performed to identify predictors of mortality and longer length of stay. Results: A total of156,132 admissions with neutropenic fever occurred between 2009 and 2013. The average incidence of hospitalization for neutropenic fever was 85 per 100,000 total admissions, and did not change significantly over time. The distribution of admissions according to major types of malignancy was: solid tumors (54%); non-Hodgkin lymphoma (20%); acute myeloid leukemia (12%); acute lymphocytic leukemia (4%); and multiple myeloma (4%). The overall mortality was 2% and did not change significantly over time. The median length of stay was 4 days (interquartile range, 3-7). Pneumonia was the most commonly diagnosed infection (9%), followed by urinary tract infection (7%), bacteremia (4%), skin/soft tissue infection (4%), and upper respiratory tract infection/bronchitis (3%). Diagnosis of a fungal infection was uncommon (2%). Acute renal failure was the most common complication (7%), while acute respiratory failure (2%) and cardiac or pulmonary arrest (<1%) were uncommon. In multivariable analysis, age >59, acute myeloid leukemia, acute lymphocytic leukemia, and chronic lymphocytic leukemia (versus solid tumors), pneumonia, fungal infection and weighted Elixhauser comorbidity index >14 were significant predictors of mortality (Table 1) and increased length of stay (Table 2). Race, insurance, median household income, non-Hodgkin lymphoma, chronic myeloid leukemia, and multiple myeloma (versus solid tumor), and intestinal infection were also predictors of increased length of stay but not mortality. Conclusions: Our study is the first to examine a nationally representative cohort of cancer patients in the hospital with neutropenic fever and identified a relatively low mortality rate. We identified age, underlying comorbidities, type of cancer, and type of infection as significant predictors of mortality. Given the low morbidity and mortality rate, further studies should be done to improve risk stratification of patients with neutropenic fever and prevent unnecessary hospitalization. Table 1 Predictors of in-hospital mortality in patients with neutropenic fever Table 1. Predictors of in-hospital mortality in patients with neutropenic fever Table 2 Predictors of length of stay > 2 days in patients with neutropenic fever Table 2. Predictors of length of stay > 2 days in patients with neutropenic fever Disclosures No relevant conflicts of interest to declare.

Background Male breast cancer (MBC) is a rare disease for which there is limited understanding of treatment patterns and prognostic factors. Methods Men with TNM stage I to stage III breast cancer diagnosed between 2004 and 2014 in the National Cancer Data Base were included. Trends in treatment modalities were described using the average annual percentage change (AAPC) and estimated using Joinpoint software for the analysis of trends. Kaplan‐Meier curves and the multivariate Cox proportional hazards regression model were used to compare survival between subgroups and to identify prognostic factors. Results A total of 10,873 MBC cases were included, with a median age at diagnosis of 64 years. Breast‐conserving surgery was performed in 24% of patients, and 70% of patients undergoing breast conservation received radiotherapy. Approximately 44% of patients received chemotherapy, and 62% of patients with estrogen receptor–positive disease received endocrine therapy. Oncotype DX was ordered in 35% of patients with lymph node–negative, estrogen receptor–positive/human epidermal growth factor receptor 2 (HER2)‐negative tumors. During the study period, there was a significant increase in the rates of total mastectomy, contralateral prophylactic mastectomy, radiotherapy after breast conservation, ordering of Oncotype DX, and the use of endocrine therapy ( P < .05). On multivariate analysis, factors found to be associated with worse overall survival were older age, black race, higher Charlson Comorbidity Index, high tumor grade and stage of disease, and undergoing total mastectomy. Residing in a higher income area; having progesterone receptor–positive tumors; and receipt of chemotherapy, radiotherapy, and endocrine therapy were associated with better overall survival. Conclusions Despite the lack of prospective randomized trials in patients with MBC, the results of the current study demonstrated that the treatment of this disease has evolved over the years. These findings further the understanding of the modern treatment and prognosis of MBC, and identify several areas for further research.

6581 Background: While AC is recommended for all patients with stage IIA, IIB, and IIIA NSCLC, its use and benefit among the elderly population is unclear. Methods: We identified patients with stage IIA, IIB, or IIIA NSCLC using the National Cancer Database from 2006-2014. Patients were divided into age groups ≤65, 66-70, 71-75, 76-80, > 80 years. Trends in AC use, factors influencing AC administration, and outcomes associated with AC were studied. Results: Out of 27368 patients, 13464 received AC and 13904 did not. 11% had stage IIA disease, 50% had stage IIB disease and 39% had stage IIIA disease. AC use was lower with increasing age (49% age ≤65 vs. 3% age > 80 (P < 0.0001)). Temporal use of chemotherapy for each age group was unchanged from 2006-2014. In multivariate logistic regression analysis, factors predictive of lower AC use were older age, Medicare or Medicaid insurance, academic center, and higher Charlson Comorbidity Index (CCI). Stage IIIA (OR 1.4, 95% CI 1.3-1.6) and Stage IIB (OR 1.3, 95% CI 1.2-1.4) had a higher chance of receiving AC than stage IIA. In a Cox proportional hazard model, younger age, female sex, academic center, private insurance, higher income, lower CCI, West coast center and AC were associated with better outcomes. When stratified by age and stage, AC was still associated with better survival (Table). Conclusions: AC utilization in stages IIA, IIB and IIIA NSCLC remains low, despite its association with improved survival in the elderly. Future clinical trials may be needed focused on elderly patients to establish the best regimen to optimize outcomes. [Table: see text]