Patient Characteristics and Outcomes of Nodular Lymphocyte-Predominant Hodgkin’s Lymphoma at a Safety-Net System Compared to an Academic Comprehensive Cancer Center

Patient Characteristics and Outcomes of Nodular Lymphocyte Predominant Hodgkin Lymphoma at a Safety-Net System Compared to an Academic Comprehensive Cancer Center

Background: Breast cancer outcomes in the United States continue to improve, but sociodemographic disparities remain prevalent and impact care delivery and outcomes in vulnerable populations. Safety-net health systems are intended to address inequities by providing access to care for the uninsured/underinsured. Care delivery in a safety-net setting is often inherently complicated by limited resources at these institutions. Here, we present the overall survival (OS) data of breast cancer patients treated at a large safety-net system, compared to the national average. Methods: Parkland Health (PH) is the safety-net system for Dallas County and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients diagnosed with invasive breast cancer between 2018 to 2020 at PH were reviewed and data on demographics, treatment, and outcomes were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Survival data was analyzed using Cox proportional hazard model. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: Of the 657 patients included in the study, the majority (82.5%) belonged to racial and ethnic minorities (Hispanic 50.2%; Black 32.3%). Compared to the NCDB, PH patients were more often uninsured (67% vs 1.6%) or enrolled on Medicaid (14.5% vs 6.9%), and less often on Medicare (8.5% v. 43%) (p< 0.01). Triple negative breast cancer (TNBC) phenotype and late-stage diagnosis (stage III/IV) rates were higher at PH compared to NCDB (TNBC 22.8% vs 10.7%, p< 0.01; late stage 30.6% vs 13.2%, p< 0.01). At a median follow up of 33 (range 24-43) months in PH and 28 (range 21-36) months in NCDB, the unadjusted OS for the PH population was 86.3% vs 92.6% for the NCDB population (p < 0.01). Within the PH population, Black race, higher stage, and TNBC were associated with decreased OS. There was a significant interaction between Black race and TNBC. When combining all patients (PH+NCDB), site of care (PH) was associated with a higher risk of death from breast cancer (HR 1.467, 95% CI 1.192-1.805, p< 0.0005), however, multivariate analysis did not show a significant difference based on site of care. Factors associated with a significantly increased risk of death in this multivariate analysis (corrected for interaction between Black race and TNBC phenotype) included age, late-stage diagnosis, TNBC, Black race, and uninsured status (Table 1). Conclusions: Breast cancer patients treated at PH were more likely to have adverse disease characteristics compared to the NCDB population. When accounting for these risk factors in multivariate analysis, patients treated at PH had similar outcomes compared to the national average. Our findings reinforce the critical role of safety-net systems in promoting health equity and eliminating disparities. Table 1 Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Outcomes of breast cancer in a minority-enriched population treated at a large safety-net system: Is site of care a predictor of poor outcomes? [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-06.

Treatment Patterns and Outcomes in Adolescent and Young Adults with Nodular Lymphocyte Predominant Hodgkin Lymphoma: An Impact Cohort Population-Based Study

Authors: Nasir Qureshi, MBBS Fabian Robles, MS Mai Badran, MBBS Nisha Unni, MD Hsiao C Li, MD Samira Syed, MD Glenda Delgado-Ramos, MD Sangeetha Reddy, MD Heather McArthur, MD Navid Sadeghi, MD Title: Minority participation in breast cancer therapeutic trials at an NCI-CCC affiliated safety-net system: Advancing equity in clinical research. Introduction: Participation of under-represented minorities (URMs) in clinical trials enhances the generalizability of the findings and can also improve clinical outcomes. Multiple factors, such as access, language barrier, distrust, and misconceptions, negatively impact URM enrollments in cancer clinical trials. Here we describe our approach to increase participation of breast cancer URMs in therapeutic trials at an academic-affiliated safety-net system. Methods: Parkland Health (PH) is a large safety-net system in Dallas County, Texas, and is affiliated with the NCI-CCC designated Harold C. Simmons Comprehensive Cancer Center (SCCC) at UT Southwestern. A dedicated team of SCCC research coordinators support the clinical trial operations at PH. In 2020, several steps were taken to increase access and enrollment of URMs in breast cancer trials at PH including review and optimization of the trial portfolio (more trials in curative intent setting), proactive screening, increasing provider awareness, and addition of a bilingual (English/Spanish) patient navigator to the research team. Data for 2018-2019 (pre-intervention) and 2021-2022 (post-intervention) is presented here. Data for 2020 is excluded due to the impact of COVID-19 pandemic on trial operations. Results: Racial and ethnic minorities composed the majority of breast cancer patients at PH (52% Hispanics, 32% Blacks). Ten percent of new patients at PH presented with metastatic disease. In 2018-2019, PH's portfolio included 13 therapeutic trials, 5 of which (38%) were in metastatic setting and 3 required a biomarker. A total of 47 breast cancer patients were enrolled in 11 therapeutic trials at PH, accounting for an average annual accrual rate of 6.1% (7.6% in 2018 and 4.5% in 2019). Accrual to trials in the metastatic setting accounted for 11% (5/47) of enrollments. Two trials in the metastatic setting had zero accruals. In 2021-2022, 16 trials were open at PH, including 7 cooperative group, 4 industry-sponsored (ISTs), and 5 Investigator-Initiated trials (IITs). Five trials (31%) were in metastatic setting and 4 required a genomic biomarker. A total of 87 patients were enrolled in 2021-22, representing an 85% increase in the accruals over the baseline (2018-2019). The annual accrual rates for 2021 and 2022 were 10.5% (43/409) and 10.4% (44/423), respectively. In 2021-22, 63 were enrolled in cooperative group studies, 20 in IITs, and 4 in ISTs. Accrual to trials in the metastatic setting accounted for 6% (5/87) of enrollments. Two studies had zero accruals. The majority of the trial participants (77/87; 89%) belonged to URMs (64 Hispanic, 13 Black). Overall participation rate was 67% (87/129) and was significantly higher in Hispanics compared to Blacks (77% vs 41% - p < 0.001). Among Black patients who declined participation, 42% (8/19) cited lack of interest as the reason, which may reflect distrust or misperceptions regarding clinical trials. Conclusions: The collaboration between academic centers and safety-net systems provides a unique opportunity to promote equity in clinical trials by increasing access and enrollment of URMs. Developing a balanced portfolio that matches the patient population, enhanced screening, and incorporating clinical trial patient navigation at our institution resulted in a sustained increase in the number of URM trial participants. Given the lower participation rate among eligible Black patients, we aim to expand our clinical trial navigation program to better address the distrust and misperceptions regarding clinical trials, as a strategy to further improve trial participation at our institution. Citation Format: Nasir Qureshi, Fabian Robles. Minority participation in breast cancer therapeutic trials at an NCI-CCC affiliated safety-net system: Advancing equity in clinical research [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-09-10.

Unraveling the Transcriptional Landscape of Nodular Lymphocyte-Predominant Hodgkin Lymphoma and T-Cell/Histiocyte Rich Large B-Cell Lymphoma: Impact of Tumor Microenvironment and Checkpoint Gene Expression

90 Background: Racial and ethnic minorities remain under-represented in cancer clinical trials. Strategies to improve access and participation of diverse populations in clinical trials is therefore a key step to improve outcomes and eliminate disparities. Methods: Parkland Health (PH) is the safety-net system for Dallas County, Texas, and is affiliated with the UT Southwestern/Harold C. Simmons Comprehensive Cancer Center (SCCC). Trial operations at PH is mainly supported by a dedicated team of SCCC research coordinators. Interventions employed to increase minority access and accruals were focused on optimizing the portfolio, increasing provider awareness, and enhanced screening. A bilingual research patient navigator was also added to the research team to improve patient education and engagement. Transportation and childcare assistance are routinely provided for patients at PH. Accrual data for 2021, compared to 2017-2020, is presented here. Results: The majority (73%) of breast cancer patients at PH are uninsured and 88% belong to racial/ethnic minorities (57% Hispanics, 31% Blacks). Of the 15 therapeutic breast cancer trials open at SCCC in 2021, 12 (80%) were open at PH. The PH breast cancer trial portfolio included 4 cooperative group, 5 industry-sponsored (ISTs), and 3 investigator-initiated studies (IITs). Four trials were in metastatic setting and 8 were in curative intent setting. Four trials required a genomic biomarker. Forty-three patients were enrolled in therapeutic trials at PH in 2021. This represents 10.3% (43/418) of new cases during the same time period. Thirty-two were enrolled in cooperative group studies, 10 in IITs, and 1 in ISTs. The majority (93%) of the trial participants belonged to under-represented minorities. Number of trial participants in 2021 increased by 48% compared to the best year in the past 5 years (29 patients enrolled in 2018). Conclusions: Collaboration between academic institutions and safety-net systems presents a unique opportunity to provide clinical trial options to under-represented minorities. In this setting, interventions to improve trial portfolio, provider awareness, screening process, and patient education, as well as addition of a patient research navigator resulted in a significant increase in the number of minority participants in breast cancer trials at our safety-net hospital.

Outcomes of Nodular Lymphocyte Predominant Hodgkin's Lymphoma (NLPHL) Patients Treated with R-CHOP.

Introduction: Despite the increased awareness and advocacy for health equity, racial and socioeconomic disparities remain prevalent among breast cancer patients. Since lack of access to care is a major barrier, safety-net systems that provide services for the uninsured/underinsured play a significant role in promoting health equity and eliminating disparities. Understanding the patient population treated within these systems, which are often resource-limited, can help develop strategies to improve care delivery and outcomes. Here, we describe characteristics of breast cancer patients treated at a large safety-net system. Methods: Parkland Health (PH) is the safety-net system for Dallas County, and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients with a new invasive breast cancer diagnosis between 2018 to 2020 at PH were reviewed and data on demographics and clinical presentation were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: A total of 657 patients at PH were included in the analysis (50.2% Hispanic; 32.3% Black). Median age at diagnosis was 53 years (range 46-61), with 39.1% of patients < 50 (12.3% < 40). The majority of patients were uninsured at the time of diagnosis (67.0%). Hispanic patients were younger than others (median age 49 years (range 43-57) vs 57 (range 48-63), p < 0.01), with 51.2% < 50. Late-stage diagnosis was observed in 30.6% of patients (stage III 16.4%, stage IV 14.2%), and triple negative breast cancer (TNBC) accounted for 22.8% of cases. While the stage distribution was not statistically different between racial and ethnic subgroups (p=0.66), black patients were diagnosed with TNBC at a significantly higher rate compared to others (30.2% vs 19.3%, p < 0.01). Although a trend towards higher rate of HER2(+) disease was noted among Hispanics, this difference did not reach the level of statistical significance (22.7% vs 16.5%, p=0.06). One hundred eighty-nine patients (28.8%) were diagnosed outside PH. Compared to Black patients, Hispanic patients were more often diagnosed in the community (22.2% vs 32.4%, p=0.01). Of the 564 patients with stage I-III, 340 (60.3%) had T2-4 and 203 (36.0%) had node positive disease at diagnosis. Median time to treatment initiation (TTI) was 51 days (range 35-76) and was significantly longer in patients who were diagnosed in the community compared to those diagnosed at PH, median 63 days (range 44-96) vs 48 (range 34-70), p < 0.01. Compared to the NCDB, PH patients were younger (39.1% vs 18.4% < 50 years, p < 0.01), presented at a higher rate with late-stage disease (30.6% vs 13.2%, p < 0.01) and TNBC (22.8% vs 10.7%, p < 0.01), and had a longer median time from diagnosis to treatment initiation - 51 days (range 35-76) vs 33 (range 21-49), p < 0.01. Conclusion: Breast cancer patients at PH were significantly different from the national average, with over a third below the USPSTF recommended breast cancer screening age. The rate of late-stage diagnosis at PH was more than two-fold the national average. Lowering the screening age to 40, expansion of outreach mammography programs, improving patient navigation, and simplifying access to indigent care programs are among strategies to promote health equity. Considering the high disease burden among safety-net patients, a systematic effort to increase resources at safety-net health systems is warranted. Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-05.

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