Citations

592 Background: While not all fevers occurring during hematopoietic stem cell transplantation (HCT) are dangerous, episodes of febrile neutropenia tend to be managed aggressively given the significant mortality and morbidity associated with infectious complications of transplantation. This can potentially lead to unnecessary diagnostic testing, antibiotic treatment, and prolonged hospital stays for non-infectious fever etiologies such as engraftment. Our group has previously demonstrated that high-frequency body temperature monitoring (HFTM) using a wearable device detects fevers earlier in transplant recipients (Flora et al, Cancer Cell, 2021). We hypothesized that applying supervised machine learning to HFTM data collected from inpatient allogeneic HCT patients would allow for accurately distinguishing between non-infectious and infectious etiologies of fever and could potentially guide safe de-escalation of antibiotics. Methods: We analyzed 74 independent fever events detected in HCT patients (n=42) outfitted with an FDA-cleared, wireless sensor measuring axillary temperatures every 2 minutes for the duration of their respective hospitalizations. After data filtering, independent fever events were then retrospectively grouped by fever etiology using physician-determined annotation as previously described (Flora et al., 2021). A split ratio of 80:20 was used to create training and test sets from the parent data set, consisting of 59 and 15 fever events for each split, respectively. Training sets were used to create a classification algorithm identifying bacterial infections requiring antibiotics using the machine learning model XGBoost. The performance of this model was then evaluated using test sets of the remaining fevers (n=15). Results: Averaging over 1000 test sets of 15 independent fevers comprising 5 bacterial infection-related fevers and 10 non-infectious fevers, our model correctly identified 82% (mean recall) of cases requiring antibiotics with a mean precision of 0.41. The model also correctly identified 42% of non-infectious fevers (mean true negative rate, 0.42) that would otherwise have been treated with unnecessary antibiotics. The mean AUCPR was 0.58, with the best performing individual model achieving an AUCPR of 0.97. Conclusions: The preliminary results of this study demonstrate that our classification model shows promise for differentiating fevers requiring antibiotics due to bacterial infections from other non-infectious fever etiologies. Prospective studies further developing supervised machine learning models for subcategorization of febrile neutropenia could pave the way for safely de-escalating antibiotics in HCT and other immunocompromised patients undergoing cancer treatment monitored using HFTM.

469 Background: Febrile neutropenia (FN) is a potentially life-threatening complication of myelosuppressive chemotherapy. Multiple professional organizations, including the American Society of Clinical Oncology (ASCO), Infectious Diseases Society of America (IDSA), National Institute for Health and Care Excellence (NICE), European Society for Medical Oncology (ESMO), and National Comprehensive Cancer Network (NCCN), have developed clinical guidelines addressing FN management. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework offers a structured method for assessing the evidence underlying these recommendations. Methods: A comparative analysis was conducted across guidelines. Key domains, including definitions, risk stratification, empiric antimicrobial therapy, duration of antimicrobial therapy, use of granulocyte colony-stimulating factor (G-CSF), and antimicrobial prophylaxis were assessed. Recommendations were analyzed for concordance and the certainty of supporting evidence was appraised using the GRADE framework. The certainty of the evidence was graded as high, moderate, low, or very low. Results: All five guidelines uniformly defined FN as fever ≥38.3°C or sustained ≥38.0°C accompanied by neutropenia (absolute neutrophil count <500 cells/µL), despite very low-certainty evidence supporting these specific thresholds. Risk stratification using validated tools, such as the Multinational Association for Supportive Care in Cancer (MASCC) score and the Clinical Index of Stable Febrile Neutropenia (CISNE), is recommended based on moderate-certainty evidence. Empiric monotherapy with anti-pseudomonal beta-lactam agents is recommended across guidelines and supported by high-certainty evidence. Antifungal therapy is recommended for persistent fever beyond 4–7 days in high-risk patients based on low-certainty data. Variability was noted in the suggested duration of antibacterial therapy and the role of therapeutic G-CSF based on low-certainty evidence. Recommendations for antimicrobial prophylaxis are consistent across high-risk populations. Conclusions: Despite broad agreement in foundational management principles for febrile neutropenia, differences exist in the application of therapeutic G-CSF and the duration of empiric antibiotics. These findings underscore the need for high-quality clinical trials to inform harmonized, evidence-based recommendations. This synthesis identifies priority areas for stewardship initiatives and quality-of-care improvement.

345 Background: Pediatric febrile neutropenia (PFN) requires emergent evaluation due to risk of invasive bacterial infection. In the management of PFN, there are varying, accepted definitions for fever requiring emergency evaluation and neutropenia requiring admission. Problem statement: From September 1, 2022 - May 31, 2023, 15.1% (n = 11/73) of emergency department (ED) visits and 17.1% (n = 6/35) of admissions for PFN at Mayo Clinic Rochester may be considered unnecessary due to patients not meeting updated clinical criteria. Aim: Decrease unnecessary ED visits and hospitalizations for PFN by 50% from 15.1% to 7.5% (for ED visits) and from 17.1% to 8.6% (for hospitalizations) by 02/29/2024 without adversely impacting mortality from invasive bacterial infection. Methods: We used the DMAIC framework for process improvement. Interventions included (1) adoption of a higher fever definition for PFN, (2) adoption of a risk-stratified neutropenia definition for hospital admission, (3) provided electronic fever plans with definitions to all families, (4) re-iterated that parents call on-call provider with any concern for fever, (5) educated pediatric oncology staff on definition and management of fevers in pediatric oncology patients, and (6) educated pediatric emergency department staff on definition and management of fevers in pediatric oncology patients. Interventions were tested with rapid tests of change. Relevant clinical characteristics, variables, and outcomes for all patients from pediatric oncology were tracked for all encounters of pediatric oncology patients presenting to the ED for acute illnesses. Results: At baseline,15.1% (n = 11/73) of ED visits for PFN were considered unnecessary due to patients not meeting clinical criteria for emergency evaluation. Post-interventions, unnecessary ED visits for PFN had decreased to 3.4% (n = 1/32). At baseline, 17.1% (n = 6/35) of hospitalizations were considered unnecessary due to patients not meeting clinical criteria for admission. Post-interventions, 7.7% (n = 2/26) of hospitalizations were considered unnecessary. There were no patient deaths from invasive bacterial infection among this cohort at baseline or after interventions. Conclusions: Multiple interventions including adoption of a higher, accepted fever threshold and risk stratified neutropenia definition for PFN was associated with a reduction of unnecessary ED visits and hospitalizations for PFN without an increase in mortality from invasive bacterial infection. The projected medical expense savings of approximately $144,000-$210,000 per year.

230 Background: The burden of symptoms and financial toxicity are well-documented adverse effects of cancer treatments. Recently, logistic toxicity has emerged, referring to the detrimental impact of logistical demands associated with cancer treatment on patient well-being. For non- English speaking patients, language barriers can affect their treatment experience, increasing logistic burdens. Methods: Between September 2024 and May 2025, semi-structured qualitative interviews were conducted with 21 low English proficiency (LEP)/non-English speaking adults with cancer. The interviews explored logistic challenges faced due to LEP and its impact on patients' cancer care experience. Transcripts were analyzed using an inductive thematic analysis approach. Results: Of the 39 identified eligible individuals, 26 provided consent, and 21 (81%) completed the interview. The most common primary language of the participants was Spanish (9, 43%), followed by Somali (3, 14%), Arabic and Korean (2, 9%), and Amharic, Mandarin, Hmong, Russian, and Vietnamese (1, 5%). Seven major themes emerged regarding the logistic burdens of cancer care: (1) communication challenges, (2) navigating healthcare systems, (3) emotional distress from diagnosis and communication barriers, (4) financial toxicity, (5) transportation challenges, (6) adverse treatment effects, and (7) concerns about the political climate and its impact on resources. Conclusions: The increase in non-English languages in the U.S. highlights the need to understand the unique challenges faced by these patients. This study identified logistic toxicity themes consistent with previous research, while also revealing unique challenges. Further research is necessary to explore strategies to mitigate logistic burdens among those with LEP. Theme Illustrative Quotes Communication challenges “Communication with the psychologist was challenging … I couldn’t express myself effectively and it left me unsatisfied with the interaction.” Navigating healthcare systems “dealing with the insurance, it has been difficult … I have to depend on another person to help me” Emotional distress from diagnosis and communication barriers “In addition to my sickness, the lack of communication and understanding… makes me very sad.” Financial toxicity “...there's no income. There is nothing to feed our children.” Transportation challenges “I have to leave home 2 or 3 hours in advance because people will help me, not within my time, but within their own time.” Adverse treatment effects “I noticed weird feelings in my limbs. I'm not able to write down or hold anything. It makes everything difficult.” Concerns about current political climate and its impact on existing resources “… that they don't want Spanish spoken in the United States. They're not going to provide help for people like me at the hospitals…”

572 Background: Neoadjuvant endocrine therapy (NET) is sometimes used to shrink hormone receptor-positive (HR+) breast cancers to improve breast conservation rates and reduce axillary nodal burden. At the beginning of the COVID-19 pandemic, several organizations endorsed NET use to mitigate the harm of surgery delay when cancer operations were less available due to infection transmission concerns. However, the real-world patterns of NET during this period are understudied. This study investigated the alteration of NET utilization patterns during the COVID-19 pandemic in the United States using the National Cancer Database (NCDB). Methods: We identified patients diagnosed with stage I-III invasive HR+/human epidermal growth factor receptor 2-negative (HER2-) breast cancer between 2018-2022 in the NCDB. Estrogen receptor and/or progesterone receptor positivity was required for inclusion in the cohort. Receipt of NET was defined as initiation of endocrine therapy ≥ 14 days before the patient’s first surgical procedure. The study cohort generation and statistical analysis were conducted using Stata and R 4.4.3. A two-tailed p value < 0.05 was considered statistically significant. Results: 495,098 patients were included in the cohort, 195,371 in 2018-2019 (pre-pandemic), 91,686 in 2020 (early pandemic), 106,157 in 2021 (mid-pandemic), and 101,884 in 2022 (late pandemic). NET utilization was increased in the early pandemic compared to the pre-pandemic (seen in 5.8% vs 2.4% of the cohort, Chi-square p value < 0.001), but this use fell back to 3.4% in the mid-pandemic and 3.5% in the late-pandemic. The median (IQR) duration of NET was 15.7 (6.4-26.6) weeks in the pre-pandemic, 9.3 (5.4-18.7) weeks in the early pandemic, 13.2 (5.8-25.7) weeks in the mid-pandemic, and 12.0 (6-24.6) weeks in late pandemic (Kruskal-Wallis p value = 0.001). The transient increase in NET utilization during the early pandemic was more pronounced among patients with tumors < 5 cm and node-negative disease. Conclusions: Our study identified a significant shift in the utilization of NET for HR+/HER2- breast cancer during the COVID-19 pandemic. Pandemic-era NET policies produced a short-lived practice change that was only partially sustained once surgical access normalized. NET utilization (%) by subgroup and year for stage I-III HR+/HER2- breast cancer. Variable Category 2018-2019 2020 2021 2022 Overall NET Use 2.4 5.8 3.4 3.5 Age Group (years old) <50 2.2 4.9 3.9 4.0 >=50 2.4 6.0 3.3 3.4 Tumor Size <5 cm 2.0 5.5 2.9 3.1 >=5 cm 9.0 9.7 11.2 11.6 Histology Subtype Ductal 2.2 5.5 3.3 3.4 Lobular 3.6 7.1 4.4 4.8 Ductal/Lobular 2.6 6.2 4.3 3.6 Other 1.9 6.7 2.5 2.6 KI67 <20% 2.5 6.4 3.4 3.3 >=20% 2.3 5.5 3.5 3.7 Tumor Grade Well differentiated 1.9 5.8 2.4 2.6 Moderately differentiated 2.7 6.1 3.9 3.9 Poorly differentiated/undifferentiated 2.9 4.8 4.3 4.8 Node Positivity Positive 5.2 5.6 9.3 9.5 Negative 2.0 5.8 2.6 2.7

566 Background: Video telemedicine visits (VTVs) have the potential to overcome disparities in access to cancer care for many socially, geographically, and economically disadvantaged populations. Internet connectivity, digital literacy, and socioeconomic factors are traditionally cited as influencing VTV utilization. However, digital diffusion has occurred rapidly across several sectors, including healthcare, since the onset of the COVID-19 pandemic, and less is known about how these factors have evolved to influence VTV utilization behavior over this time. Through a qualitative approach, we aimed to: (1) explore the lived experiences of cancer patients who transitioned to VTV use as compared to those who persistently did not, and (2) identify similarities and differences between these two groups that could inform targeted interventions to support access and patient acceptance of VTVs in the setting of cancer care. Methods: During June 2024, we conducted semi-structured interviews with 24 patients (Mean age 71.3 years, range 42-88; female 50%) receiving ongoing, longitudinal cancer care at our academic medical center since July 2021 who had not used VTVs through at least October 2022. Using purposeful sampling, patients were equally divided according to VTV utilization behaviors defined as “transitioned users” (TU; i.e. those who transitioned to VTV utilization after October 2022) and “persistent non-users” (PNU). Transcripts were analyzed using a combined deductive–inductive thematic approach and categorized into themes of barriers and facilitators across three domains consistent with the COM-B model: capabilities (C), opportunities (O), and motivations (M). Results: TU patients frequently cited a reduction in travel and logistical considerations as a primary reason for uptake of VTVs. PNU patients frequently reported digital literacy barriers, particularly among older patients, as primary reasons for lack of VTV utilization. TU patients reported more experience and comfort in technical skills as compared to PNU participants. PNU patients also reported less frequent offering of VTV as an option by their care teams over time, implying they may have transitioned to VTV utilization if it had been offered with more regularity. Both study groups desired improved internet access and technical support to enhance (or, in the case of PNU patients, enable) VTV utilization. Conclusions: These findings suggest that multi-modal care delivery may best serve current patient populations, not requiring, yet offering VTV services as an adjunct to in-person care. Longer term, individual barriers to VTV use will also need to be addressed to further optimize access for patients who desire to incorporate this care modality.

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.