Delay In Initiation Of Chemotherapy Research Articles

Dose delay, dose reduction, and early treatment discontinuation in Black and White women receiving chemotherapy for nonmetastatic breast cancer.

To describe reasons for deviations from planned chemotherapy treatments in women with nonmetastatic breast cancer that contribute to less-than-planned receipt of chemotherapy. Electronic medical records for patients receiving chemotherapy were reviewed for adverse events and treatment modifications. Log-binomial regression models were used to estimate relative risks (RRs) with 95% CIs to examine associations between chemotherapy modifications, patient characteristics, and treatment modalities. Delays in chemotherapy initiation (7%) were for surgical complications (58%), personal reasons (16%), and other (26%; port malfunction, infections, and obtaining extra imaging). Delays during chemotherapy (38%) were for infections (20%), neutropenia (13%), and personal reasons (13%). Dose reductions (38%) were for neuropathy (36%), unknown causes (9%), anemia (9%), and neutropenia (8%). Early treatment discontinuations (23%) were for neuropathy (29%). Patients receiving paclitaxel/nab-paclitaxel (RR 2.05; 95% CI, 1.47-2.87) and an anthracycline (RR 1.89; 95% CI, 1.39-2.57) reported more dose delays during chemotherapy. Black race (RR 1.46; 95% CI, 1.07-2.00), stage 3 (RR 1.79; 95% CI, 1.09-2.93), and paclitaxel/nab-paclitaxel receipt (RR 1.39; 95% CI, 1.02-1.90) increased the likelihood of dose reduction. Both Black race (RR 2.06; 95% CI, 1.35-3.15) and receipt of paclitaxel/nab-paclitaxel (RR 1.93; 95% CI, 1.19-3.13) increased the likelihood of early discontinuation. Patients receiving anthracyclines had higher rates of hospitalizations during chemotherapy (RR: 1.79; 95% CI, 1.11-2.89). Toxicities are the most common reason for treatment modifications and need close monitoring in high-risk groups for timely intervention. Dose reductions and early treatment discontinuations occurred more for Black patients and need further study.

Reducing the time to chemotherapy start for planned admissions.

e23201 Background: Planned hospital admissions for chemotherapy should be initiated shortly after arrival. Between January 2022 and May 2023, 25.7% of sarcoma patients at Medstar Washington Hospital Center admitted for chemotherapy experienced initiation of chemotherapy delays of more than 6 hours. Delays in chemotherapy initiation can lead to prolonged hospitalization with associated higher costs, increased risk of hospital acquired conditions, and decreased patient satisfaction. Methods: Discussions with team members involved in the initiation of inpatient chemotherapy process identified the following issues contributing to delay: absence of recent lab results, challenges with IV access, missing chemotherapy consent forms, absence of chemotherapy orders, failure to notify team members of patient arrival, lack of dose adjustments based on lab work, and insufficient pharmacy staffing. As our chemotherapy floor policy is to start pre-medications once the chemotherapy is on the unit, we defined the time to chemotherapy start as the time of the first pre-medication minus the time the patient checked in to the hospital’s admissions office. Patients with unforeseen issues such as a new fever on arrival were excluded. We obtained baseline data for sarcoma admissions between January 2022 to May 2023. Two Plan-Do-Study-Act (PDSA) cycles were implemented. The first cycle involved the introduction of a chemotherapy calendar. The second cycle implemented a group email system to finalize all arrangements for the admission. We collected about 3 months of data for each PDSA cycle. Results: Pre-intervention, there were 101 sarcoma admissions with 14.9% of patients starting chemotherapy in < 3 hours while 25.7% took > 6 hours. In the post-intervention data combining both PDSA cycles, 6.8% of patients started chemotherapy in < 3 hours while 43.2% took > 6 hours. As such, the average time to chemotherapy start was increased in post-intervention groups (table 1) despite improvements in many of the common issues. The median time to chemotherapy start based on the number of agents the patient was receiving was 4.98, 6.4, and 7.18 hours respectively for 1, 2, and 3 agents in the post-intervention group. Conclusions: Despite multiple attempts, the median time to chemotherapy start increased in the post-intervention groups. Our interventions targeted many of the barriers except insufficient pharmacy staff. With the median start time increasing based on the number of agents the patient was receiving, it appears that pharmacy mixing and delivery chemotherapy is likely one of the main causes of the delays. Subsequent discussions with the pharmacy team revealed plans to increase staffing as a proactive measure to address this issue. [Table: see text]

QLTI-11. TIMELINE FROM INITIAL MRI TO INTERVENTION IN NEWLY DIAGNOSED HIGH GRADE GLIOMA

Abstract OBJECTIVE Prompt treatment of high-grade glioma is crucial for prolonging life. In an attempt to identify factors that lead to delays in treatment, we evaluated the amount of time between initial MRI and treatment start date for our patients with newly diagnosed high grade glioma. METHODS This was a retrospective chart review study. Adults over the age of 18 years of age with newly diagnosed high grade glioma were included if they were seen by the neuro-oncology department at Loma Linda University Medical Center. Reviewed charts were dated from November 2020 to August 2022. We evaluated the amount of time between initial MRI and several important milestones in the diagnosis and treatment of high grade glioma, including resection; biopsy results; neuro-oncology consult; radiation-oncology consult; date that chemotherapy was ordered, received by the patient, and initiated; and radiation therapy start date. RESULTS Twenty-two patients with new diagnosis of high-grade glioma were identified. Six patients were excluded due to complicated treatment courses involving outside facilities. Sixteen patients were included in the study. Thirteen patients (81%) had a diagnosis of glioblastoma, 2 (12%) had a diagnosis of diffuse midline glioma, and 1 (6%) had a diagnosis of anaplastic astrocytoma. The mean number of days between initial MRI and chemotherapy start date was 88. Prolonged timelines were seen in all analyzed metrics. CONCLUSIONS There is a significant delay in chemotherapy initiation for patients with high grade glioma at our facility. We also provide a framework for other institutions to evaluate their system processes in order to improve care delivery.

A contrast-enhanced CT-based whole-spleen radiomics signature for early prediction of oxaliplatin-related thrombocytopenia in patients with gastrointestinal malignancies: a retrospective study.

Thrombocytopenia is a common adverse event of oxaliplatin-based chemotherapy. Grade 2 or higher oxaliplatin-related thrombocytopenia may result in dose reduction, discontinuation or delay initiation of chemotherapy and may adversely affect the therapeutic efficacy and even overall survival of patients. Early recognition of patients at risk of developing grade 2 or higher thrombocytopenia is critical. However, to date there is no well-established method to early identify patients at high risk. The aims of this study were to develop and validate a contrast-enhanced CT-based whole-spleen radiomics signature for early prediction of grade 2 or higher thrombocytopenia in patients with gastrointestinal malignancies treated with oxaliplatin-based chemotherapy and to explore the incremental value of combining the radiomics signature and conventional clinical factors for risk prediction. A total of 119 patients with gastrointestinal malignancies receiving oxaliplatin-based chemotherapy from March 2017 to December 2020 were retrospectively included and randomly divided into a training cohort (n=85) and a validation cohort (n=34). Grade 2 or higher thrombocytopenia occurred in 26.1% of patients (22 and nine patients in the training and validation cohort, respectively) with a median time interval of 101 days from the start of chemotherapy. The whole-spleen radiomics features were extracted on the portal venous phase of the first follow-up CT images. The least absolute shrinkage and selection operator (LASSO) algorithm was applied to select radiomics features and to build the radiomics signature for the prediction of grade 2 or higher thrombocytopenia. A clinical model that included clinical factors only and a clinical-radiomics model that incorporated clinical factors and radiomics signature were constructed. The performances of both models were evaluated and compared in the training, validation and the whole cohorts. The radiomics signature yielded favorable performance in predicting grade 2 or higher thrombocytopenia, with the area under the curve (AUC), sensitivity and specificity being 0.865, 81.8% and 84.1% in the training cohort and 0.747, 77.8% and 80.0% in the validation cohort. The AUCs of the clinical-radiomics model in the training and validation cohorts reached 0.913 (95% CI [0.720-0.935]) and 0.867 (95% CI [0.727-1.000]), greater than the AUCs of the clinical model. Integrated discrimination improvement (IDI) index showed that incorporating radiomic signature into conventional clinical factors significantly improved the predictive accuracy by 17.0% (95% CI [4.9%-29.1%], p = 0.006) in the whole cohort. Contrast-enhanced CT-based whole-spleen radiomics signature might serve as an early predictor for grade 2 or higher thrombocytopenia during oxaliplatin-based chemotherapy in patients with gastrointestinal malignancies and provide incremental value over conventional clinical factors.

Evaluating Disparities in Colon Cancer Survival in American Indian/Alaskan Native Patients Using the National Cancer Database.

Studies demonstrate higher mortality rates from colon cancer in American Indian/Alaskan Native (AI/AN) patients compared to non-Hispanic White (nHW). We aim to identify factors that contribute to survival disparities. We used the National Cancer Database to identify AI/AN (n = 2127) and nHW (n = 527,045) patients with stage I-IV colon cancer from 2004 to 2016. Overall survival among stage I-IV colon cancer patients was estimated by Kaplan-Meier analysis; Cox proportional hazard ratios were used to identify independent predictors of survival. AI/AN patients with stage I-III disease had significantly shorter median survival than nHW (73 vs 77months, respectively; p < 0.001); there were no differences in survival for stage IV. Adjusted analyses demonstrated that AI/AN race was an independent predictor of higher overall mortality compared to nHW (HR 1.19, 95% CI 1.01-1.33, p = 0.002). Importantly, compared to nHW, AI/AN were younger, had more comorbidities, had greater rurality, had more left-sided colon cancers, had higher stage but lower grade tumors, were less frequently treated at an academic facility, were more likely to experience a delay in initiation of chemotherapy, and were less likely to receive adjuvant chemotherapy for stage III disease. We found no differences in sex, receipt of surgery, or adequacy of lymph node dissection. We found patient, tumor, and treatment factors that potentially contribute to worse survival rates observed in AI/AN colon cancer patients. Limitations include the heterogeneity of AI/AN patients and the use of overall survival as an endpoint. Additional studies are needed to implement strategies to eliminate disparities.

Morbidity after secondary cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy for ovarian cancer: An analysis of a randomized phase II trial

ObjectiveTo assess postoperative complications after secondary cytoreductive surgery (SCS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC), we conducted an exploratory analysis of patients with platinum-sensitive recurrent ovarian cancer enrolled in a randomized phase II trial. MethodsComplications occurring within 30 days of surgery were graded using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0; only hemoglobin and platelet levels were assessed. Patients were grouped by CTCAE grade ≥ 3 and < 3 complications. ResultsAmong 83 eligible patients, 33 (40%) had grade ≥ 3 complications and 50 (60%) had grade < 3 complications; anemia and abdominal infections were the most common. There were no perioperative mortalities. Time to initiation of postoperative chemotherapy for patients with grade ≥ 3 and grade < 3 events was 34 days (range, 18–60) and 31 days (range, 21–43), respectively (P = .017). Median progression-free survival (PFS) did not significantly differ between patients with grade ≥ 3 and grade < 3 complications (11.2 months [95% CI: 9.3–14.4] vs 14.9 months [95% CI: 11.3–16.5], respectively; P = .186), nor did median overall survival (OS) (46.9 months [95% CI: 34-NE] vs 68.2 months [95% CI: 52.1-NE], respectively; P = .053). ConclusionPostoperative complications following SCS with or without HIPEC were associated with slight delays in chemotherapy initiation but did not significantly impact oncologic outcomes.

Frailty as a predictor of delayed initiation of adjuvant chemotherapy in patients with ovarian cancer

ObjectiveThis study aimed to identify whether frailty is associated with the time between surgery and the initiation of chemotherapy for patients with ovarian cancer.MethodsThis retrospective cohort study included patients 18...

Association between Serum Biomarkers with Postoperative Complications and Delay of Adjuvant Chemotherapy Initiation in Ovarian Cancer Patients Undergoing Primary Cytoreductive Surgery: A Pilot Study

This study sought to describe and relate the factors associated with complications and delays in adjuvant chemotherapy in patients with ovarian cancer treated with primary cytoreductive surgery. Serum from patients diagnosed with ovarian cancer scheduled for primary cytoreductive surgery were analyzed for prealbumin, 25-OH Vitamin D, intracellular adhesion molecule 1 (ICAM-1), interleukin 6 (IL-6), interleukin 8 (IL-8), monocyte chemoattractant protein 1 (MCP-1), monocyte chemoattractant protein 2 (MCP-2), macrophage derived chemokine (MDC). Postoperative complications were identified using common terminology criteria for adverse events 4.0 and 30 day after surgery. Delays in adjuvant chemotherapy were defined as >1 week interval between surgery and initiation. Patients with postoperative complications (39.6%) were significantly older, had lower serum prealbumin levels, and higher serum IL-6 and IL-8 than those without. Univariate logistic regression found that age (OR: 1.12, 95%CI: 1.00-1.35) and IL-6 (OR: 1.02, 95%CI: 0.99-1.05) were associated with postoperative complications, whereas age remained significant after multivariate analysis (OR:1.14, 95%CI: 1.00-1.29). Patients with delays in chemotherapy exhibited greater BMI and lower 25-OH Vitamin D than those without. Multivariate analysis found that increasing levels of 25-OH Vitamin D were associated with a lower risk of delayed chemotherapy initiation after controlling for age, body mass index, and tumor grade (OR: 0.93, 95%CI:0.87-0.99). This work suggests that in addition to age being predictive of postoperative complications, serum 25-OH Vitamin D may a provide insight into a patient’s risk for postsurgical delays in chemotherapy initiation. These findings should, however, be confirmed in a larger study including robust survival analysis.

Time from diagnosis to treatment is associated with survival in patients with acute myeloid leukaemia: An analysis of 55 985 patients from the National Cancer Database.

Acute myeloid leukaemia (AML) is conventionally thought of as a medical emergency. However, several studies on the association of time from diagnosis to treatment with survival did not have concordant results. Here we analyse 55 985 AML patients from the National Cancer Database, and we show that in patients less than 60 years old a five-day delay in chemotherapy initiation leads to worse long-term survival. The difference is small [hazard ratio (HR) 1.05, 95% confidence interval (CI) 1.01-1.09 in multivariate analysis] but statistically significant. This study raises the issue of power to detect small differences in retrospective studies.

Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

BackgroundThere are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries.MethodsThis study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS).ResultsOf 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19–3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16–0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015–2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50–7.06]). Exploratory analysis revealed no association between surgical delays and DFS.ConclusionWhile majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes.

Movement Through Chemotherapy Delay to Initiation Among Breast Cancer Patients: A Qualitative Analysis.

Purpose(Neo) adjuvant chemotherapy decreases the risk of recurrence and improves overall survival among breast cancer patients; however, delays in chemotherapy initiation are associated with adverse health outcomes. The causes of delay are complex and include interrelated social, economic, cultural, environmental, and health system factors. Project Start was a qualitative study designed to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy.Patients and MethodsWomen diagnosed with primary invasive breast cancer who experienced ≥60 day delay in (neo) adjuvant chemotherapy initiation were included. Participants completed semi-structured interviews exploring barriers and facilitators to starting chemotherapy. Interviews were transcribed and coded to identify themes using the Sort and Sift, Think and Shift analytic approach. This analysis included thorough examination of the data by advancing through iterative analytic phases to identify core topics within and across transcripts.ResultsWe enrolled (N=22) participants with median age at diagnosis 53.5 years (range 27–70) who identified as Latina (n=8), Black (n=5), and non-Latina White (n=9). Participants described a common chemotherapy initiation process reflecting their unique needs as they transitioned through four stages: 1) receiving diagnosis and treatment recommendations; 2) processing treatment options; 3) “Flipping the Switch”; and 4) activating treatment and engaging in care. Limited explicit insight into their chemotherapy delay was expressed. Engagement across the self-, family-, community-, and medical-realms revealed interlinked and pivotal sources of support that helped participants navigate toward initiating chemotherapy. Specifically, the overarching themes included logistical, emotional, financial, and social sources of support and the relationship of these sources of support to participants’ perceived self-efficacy to move toward initiating treatment.ConclusionActivating women to be engaged in the treatment process across multiple levels appeared to facilitate initiating chemotherapy. Multilevel interventions that engage the patient, family, community, and medical team may support the initiation of timely chemotherapy.

Abstract PO-117: Differences in personal social networks among black and white women diagnosed with breast cancer, with and without delays in initiation of chemotherapy

Abstract Background: Black women are less likely to be married and report greater support from extended relatives than White women in the general population. However, little information exists about women's personal networks and how differences may influence treatment management after a diagnosis of breast cancer. Methods: We included women from two studies—study 1: 191 Black and White women from the INSIGHT-BC study who were diagnosed with stages I-IV invasive breast cancer from 2017-2021; and study 2: 24 Black and White women diagnosed with stages I-III invasive breast cancer from 2017-2020 who received adjuvant chemotherapy and were recruited based on whether they had no or any (&amp;gt;45 days) delay in initiation of treatment. In each study, women responded to questions on personal networks in an online EgoWeb 2.0 survey on average 3.7 (study 1) and 7.8 (study 2) months after diagnosis. Specifically, women were asked to name 15 network members and answered questions about the characteristics of each of these people and the relationships among them. We used analysis of covariance to evaluate age-adjusted differences in the composition of women's personal social networks by race, or race and delays. Results: Mean age was 59.9 (median=61.0) years in the larger and 57.8 (median=58.5) years in the smaller group. In study 1 (N=191), white women reported a larger proportion of persons over age 55 (56.0% vs. 46.4%, p=0.01), with a college education or more (60.1% vs. 48.0%, p=0.04), who were rated as having a very healthy lifestyle (52.6 vs. 38.8%, p=0.03), with whom they had contact 2 times or less in the 30 days (35.6% vs. 19.2%, p=0.003), and of the same race as the respondent (89.7% vs. 73.2%, p&amp;lt;0.001) in their personal social networks. Black women reported a higher proportion of network contacts with whom they had contact &amp;gt;2 times per week in the last 30 days (57.9 vs. 41.6%, p=0.005) and who provided types of support other than those delineated in the Medical Outcomes Study model (62.4% vs. 45.6%, p=0.03). In study 2 (N=24), irrespective of chemotherapy delays, black women reported higher proportions of relatives (+33.6%, 95% CI: 17.0%, 50.2%) and lower proportions of friends in their network (-29.9%, 95% CI: -46.0%, -13.9%), and higher network density (0.27, 95% CI: 0.13, 0.41). However, Black women with chemotherapy delays reported a higher proportion of people in their social network with whom they did not feel close compared to White women without delays (10.6%, 95% CI: 0.6%, 20.5%) and compared to all other groups (+11.0%, 95% CI: 3.1%, 18.8%). Black women with chemotherapy delays also reported a lower proportion of females (-15.1% 95% CI: -28.4%, -1.7%) in their network compared with non-delayed White women. Conclusions: Differences in social networks were consistent with prior findings but pointed to characteristics that may signify challenges with obtaining support in women's personal networks during breast cancer treatment such as lower proportions of close relationships and female network ties, that may lead to treatment delays. Citation Format: Candyce Kroenke, Rhonda Aoki, Andrea Altschuler, Alyce Adams, David Kennedy. Differences in personal social networks among black and white women diagnosed with breast cancer, with and without delays in initiation of chemotherapy [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-117.

A qualitative study informing about barriers and facilitators associated to chemotherapy initiation among breast cancer patients: Next steps for an intervention.

247 Background: (Neo)Adjuvant chemotherapy decreases the risk of recurrence and improves overall survival among breast cancer patients; however, delays in chemotherapy initiation are associated with adverse outcomes. The causes of delay are complex and include interrelated social, economic, cultural, environmental, and health system factors . Project Start was a qualitative study designed to assess and identify the multilevel factors contributing to the barriers and facilitators of chemotherapy initiation. Methods: English or Spanish-speaking women, ≥18 years, diagnosed with primary invasive breast cancer experiencing (neo)-adjuvant chemotherapy initiation delay ( ≥60 days) were included. Participants completed semi-structured interviews designed to explore perceptions about individual, community, and system-level barriers and facilitators contributing to chemotherapy initiation. Interviews were audio-recorded, transcribed verbatim, and coded using the Sort and Sift, Think and Shift qualitative approach to identify concepts and themes within and across transcripts. To supplement qualitative data, sociodemographic data and health literacy/numeracy, physician trust, and social support questionnaires were obtained. Results: Participants (n = 22) identified as: Latina (n = 8); Black (n = 5); and non-Latina White (n = 9). While the interview guide included questions addressing chemotherapy delays, explicit insight into chemotherapy delay was rare. Participants described barriers and facilitators at the patient, family, medical, and community levels. Barriers at the patient level included patient’s hesitancy to initiate chemo due to shock, fear, and denial. Within the family level, we learned of participant’s family roles (e.g., caregiving, income), treatment costs, and the need for emotional support (e.g., not shutting family members out). Participants sought out and relied heavily on support from their communities (e.g., churches, other patients, survivors). Patients described their reliance on the medical team for information, the trust needed to navigate their treatment process, and the challenge of managing information associated with their treatment. Participants described the importance of self-efficacy to take an active role in treatment. Conclusions: Project Start is informing the design of a pilot study aimed to test the acceptability and feasibility of a navigation intervention. Using facilitators and barriers identified from Project Start, we are developing a checklist that will serve as a tool to identify the support each patient needs. Once areas of need are identified, appropriate referrals will be made in a personalized and culturally sensitive way with the goal of increasing self-efficacy and activating patients to avoid treatment delays.

Outcomes after mastectomy with immediate breast reconstruction for breast cancer in a multiethnic, middle-income Asian setting

BackgroundAlthough immediate breast reconstruction is increasingly becoming popular worldwide, evidence from resource-limited settings is scarce. We investigated factors associated with immediate breast reconstruction in a multiethnic, middle-income Asian setting. Short-term surgical complications, timing of initiation of chemotherapy, and survival outcomes were compared between women undergoing mastectomy alone and their counterparts receiving immediate breast reconstruction. MethodsThis historical cohort study included women who underwent mastectomy after diagnosis with stage 0 to stage IIIa breast cancer from 2011 to 2015 in a tertiary hospital. Multivariable regression analyses were used to assess factors associated with immediate breast reconstruction and to measure clinical outcomes. ResultOut of 790 patients with early breast cancer who had undergone mastectomy, only 68 (8.6%) received immediate breast reconstruction. Immediate breast reconstruction was independently associated with younger age at diagnosis, recent calendar years, Chinese ethnicity, higher education level, and invasive ductal carcinomas. Although immediate breast reconstruction was associated with a higher risk of short-term local surgical complications (adjusted odds ratio: 3.58 [95% confidence interval 1.75–7.30]), there were no significant differences in terms of delay in initiation of chemotherapy, 5-year disease-free survival, and 5-year overall survival between both groups in the multivariable analyses. ConclusionAlthough associated with short-term surgical complications, immediate breast reconstruction after mastectomy does not appear to be associated with delays in initiation of chemotherapy, recurrence, or mortality after breast cancer. These findings are valuable in facilitating shared surgical decision-making, improving access to immediate breast reconstruction, and setting priorities for surgical trainings in middle-income settings.

Factors influencing treatment delays in a safety net hospital: teachable moments?

<h3>Objectives:</h3> Delays in diagnosis and treatment of ovarian cancer contribute to decreased overall survival. A post-hoc analysis of a GOG study demonstrated that initiation of chemotherapy more than 25 days after surgery adversely affected survival. Furthermore, previous studies have shown that socio-demographic factors also play a role in treatment delays. We sought to determine factors contributing to delays in treatment initiation and reasons for delay in chemotherapy administration in patients receiving primary treatment of epithelial ovarian cancer at our safety net hospital. <h3>Methods:</h3> All patients with epithelial ovarian cancer seen between 1/1/2009 and 12/1/2019 were identified. Only patients who had primary chemotherapy at our safety net hospital were included. Demographic variables included race, ethnicity, median household income (MHI), and age for patients undergoing both primary cytoreductive surgery (PCRS) and neoadjuvant chemotherapy (NACT). A delay in initiation of chemotherapy was defined as > 25 days post surgery (whether undergoing PCRS or interval cytoreduction after NACT). Time to treatment initiation (TTI) was defined as date of gynecologic oncology consult to surgery (for PCRS) or first cycle of chemotherapy (for NACT). Delays between cycles of chemotherapy were noted through chart review. Linear regression analyses were performed using demographic variables as predictors for treatment duration (with p value set at 0.05). <h3>Results:</h3> 101 patients were identified that met inclusion criteria. The median age in this cohort was 61 years (range 25-82). 18 (17.8%) were Black and 75 (74.3%) were Hispanic. 81 (80.2%) patients had a MHI less than $60,000. 63 (62.4%) patients underwent PCRS and 38 (37.6%) patients underwent NACT. 77.2% of patients did not initiate adjuvant chemotherapy until > 25 days post surgery. The median TTI in the PCRS group was 15 days; however, 53 (84.1%) patients undergoing PCRS received their first cycle of chemotherapy > 25 days post surgery. The median TTI in the NACT group was 19 days, and 25 (65.8%) patients who completed NACT received their first cycle of adjuvant chemotherapy > 25 days after surgery. Black patients undergoing PCRS experienced a 30 day longer TTI than White patients (p=0.013). TTI for patients undergoing PCRS and living in an area with a median household income < $30,000 was 42 days versus 14 days in patients living in an area with median household income >$60,000 (p=0.033). In patients greater than 65 years old undergoing NACT, the time from interval cytoreductive surgery to adjuvant chemotherapy start was longer: 27 days for patients age < 65 years versus 39 days for patients ≥65 years (p=0.005). There were 76 total delays in chemotherapy administration identified. 39 (60.9%) of these were due to medical reasons and 37 (48.6%) were due to non-medical reasons. Specifically, 5 (6.5%) were due to regimen intolerance; 11 (14.5%) were due to hospitalizations or surgeries; 15 (19.7%) were due to patient factors such as transportation; 22 (28.9%) were due to scheduling barriers; and 23 (30.1%) were due to lab abnormalities. <h3>Conclusions:</h3> Significant delays exist in initiation of treatment and completion of treatment in patients receiving first line therapy for epithelial ovarian cancer. Race, income, and age were predictors of delays in treatment. Both medical as well as non-medical factors precluded timely delivery of treatment. Future quality studies at our institution will investigate whether these changes decrease delays in cancer care.

Improving Outpatient Infusion Clinic Wait Times at a Comprehensive Cancer Center.

Many factors contribute to long wait times for patients on the day of their chemotherapy infusion appointments. Longer wait time leads to nonoptimal care, increased costs, and decreased patient satisfaction. We conducted a quality improvement project to reduce the infusion wait times at a Comprehensive Cancer Center. A multidisciplinary working group of physicians, infusion center nurses, pharmacists, information technology analysts, the Chief Medical Officer, and patient advocates formed a working group. Wait times were analyzed, and the contributing factors to long wait time were identified. Plan-Do-Study-Act cycles were implemented and included labeling patients ready to treat earlier, loading premedications into the medication dispensing system, increasing the number of pharmacy staff, and improving communication using a secure messaging system. The outcome measure was time from patient appointment to initiation of first drug at the infusion center. The secondary outcome measure was patient wait time satisfaction on the basis of Press Ganey score. Postintervention, the mean time from appointment to initiation of first drug decreased 17.6 minutes (P < .001; 95% CI, 16.3 to 18.9), from 58.1 minutes to 40.5 minutes (43.5% decrease). Patient wait time satisfaction score increased 8.9 points (P < .001; 95% CI, 6.0 to 11.82), from 76.2 to 85.1 (11.7% increase). Exploring real-time data and using a classic quality improvement methodology allowed a Comprehensive Cancer Center to identify deficiencies and prevent delays in chemotherapy initiation. This significantly improved patient wait time and patient satisfaction.

Abstract PS7-75: Why do women experience a delay to chemotherapy? A qualitative analysis

Abstract Background: (Neo) Adjuvant chemotherapy decreases the risk of recurrence and improves overall survival among breast cancer patients, however, delays in chemotherapy initiation are associated with adverse outcomes. While the determinants of such delays are not clearly understood, delays are more likely to occur in those: with additional comorbidities, belonging to a low social economic status, without a partner, enrolled in public health insurance, or who identify as Latino/Hispanic or Black/African Americans. The causes of disparities in the delivery of care among breast cancer patients are complex and include interrelated social, economic, cultural, environmental, and health system factors. The goal of Project Start was to conduct a qualitative investigation to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy in the context of breast cancer treatment. Methods: We enrolled English or Spanish speaking women, ≥18 years, diagnosed with primary invasive breast cancer who experienced a ≥ 60 days delay to chemotherapy initiation, whether adjuvant or neoadjuvant (determined from the date of surgery or the date of histopathologic diagnosis). Participants were identified through electronic medical record review and approached in clinic to participate. Semi-structured interviews were conducted in-person or over the phone to explore participants’ perceptions about individual, community, and system level barriers and facilitators contributing to starting chemotherapy. Interviews were audio-recorded, transcribed verbatim, and coded using the Sort and Sift, Think and Shift qualitative approach to identify concepts and topics within and across transcripts. Participants completed brief questionnaires collecting sociodemographic characteristics, health literacy and numeracy, physician trust, and social support to supplement the qualitative data. Quantitative data were summarized using descriptive statistics. Results: Seventeen participants completed semi-structured interviews and questionnaires (mean age 49.9 years; range 30-70 years). Participants identified as: Latina (n=7); Black (n=2); and non-Latina White (n=8). Most completed interviews in English (n=15) and over half had lower educational attainment (i.e., middle school, high school, associate’s degree; n=10). While the interview included questions addressing chemotherapy delays, explicit insight into chemotherapy delay was rare among participants. When discussing their process to chemotherapy, participants described barriers and facilitators at the patient, family, medical, and community levels contributing to their timeline to start chemotherapy. At the patient level, participants discussed their fear and anxiety, the command over their diagnosis, and the importance of playing an active role in treatment. Within the family realm, participants described their family roles (e.g., caregiving, income), treatment costs, and the need for emotional support (e.g., not shutting family members out). Participants sought out and relied heavily on support from their communities (e.g., churches, other patients, survivors). Finally, patients described their reliance on the medical team for information, the trust needed to navigate their treatment process, and the challenge of managing information associated with their treatment. Conclusions: Women expressed the importance of managing individual stressors, family roles and support, medical information, and community support. Activating women to be engaged in the treatment process at multiple levels appeared to facilitate initiating chemotherapy. Multilevel interventions that engage the patient, family, medical team, and community may provide the supports to enable the initiation of timely chemotherapy. Citation Format: Ashley J. Housten, Edna Paredes, Cassandra L. Harris, Mariana Chavez-MacGregor. Why do women experience a delay to chemotherapy? A qualitative analysis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-75.

S2624 Liver Injury in Acute Myeloid Leukemia

INTRODUCTION: Hepatic involvement in acute myeloid leukemia (AML) is rare and associated with a high mortality rate. Given the potential hepatotoxicity of chemotherapy, treating patients with hepatic dysfunction requires administering attenuated doses or delaying therapy resulting in possible worse outcome. We report a case of a patient with elevated transaminases at the time of diagnosis of AML in whom treatment with attenuated dose chemotherapy was promptly started. CASE DESCRIPTION/METHODS: A 66-year-old male with no pertinent history came to the emergency room with neck fullness and right sided tooth pain associated with a 10lb weight loss. On admission he was febrile to 100.4F, vitals otherwise normal. Laboratory results revealed leukocytosis with WBC 138.8 (abs neutrophil count 1.4 Thou/mL and 25 Thou/mL of blasts), Hb 11.9, Hct 37.2, PLT 16,000. A CT neck showed right 2nd molar infection and lytic lesions of the maxilla. A peripheral flow cytometry and bone marrow biopsy were consistent with AML. The LFTs showed T bili 1.2, AST 163, ALT 138, ALP 114. Further workup including, abdominal ultrasound, viral hepatitis, ANA and anti-smooth muscle antibody were unremarkable. On day 2, T bili 3.2, AST 524, ALT 587, ALP 169. At this time, it was thought that the transaminitis was secondary to AML and induction chemotherapy with cytarabine and daunorubicin (50% reduction) was started. On day 7 of chemotherapy, the transaminases improved to normal limits indicating the liver injury was reversible and secondary to AML (Figure 1). Unfortunately, our patient did not achieve remission and died 35 days after admission. DISCUSSION: Although liver infiltration by AML is rare, it should be considered early. It usually presents with elevated LFTs in a mixed hepatocellular and cholestatic pattern. In addition to our case, there are several case reports suggesting AML as an etiology of elevated LFTs. Definitive diagnosis relies on liver biopsy which can be difficult to obtain in the presence of coagulopathy. The improvement of transaminases after initiating chemotherapy and negative work-up for other etiologies suggests that AML is the cause of hepatitis. Prompt initiation of chemotherapy in AML patients is of utmost importance. Studies suggest that semi intensive dosing or delays in chemotherapy initiation result in decreased survival and higher mortalities. It is important to recognize AML as a possible, and potentially reversible, cause of hepatic dysfunction in order to prevent treatment delays and poor outcomes.Figure 1.: Level of transaminases throughout admission. Dashed orange line corresponds to the time that chemotherapy was initiated.Table 1.: Laboratory, imaging and treatment findings in eight previous studies reporting liver involvement in AML

Feasibility of fertility preservation in pre-pubertal males scheduled to receive chemotherapy

Overall incidence rates of childhood cancer vary between 50-200/million children across the world. Childhood cancer survival rates are high, as are the late effects of gonadotoxic agents, such as infertility, in cancer survivors. While cryopreservation of sperm in adults is widely used, cryopreservation of testicular tissue in pre-pubertal boys has only recently been applied as a means to help preserve future fertility in pre-pubertal boys with cancer. The objective of this study is to present our experience of pre-pubertal pre-chemo fertility preservation. We reviewed all pre-pubertal patients who underwent pre-chemo fertility preservation at a large cancer center for feasibility and safety. All pre-pubertal pre-chemotherapy patients who underwent fertility preservation using testicular sperm extraction (TESE) were analyzed. Parents were informed that: the procedure was experimental, given that it is unknown if the tissue will be of use in the future; the procedure had to be performed under an anesthetic for another procedure (infusion port, bone marrow aspirates); the procedure would not be covered by insurance. A unilateral window technique was utilized as most patients were to undergo chemotherapy within 48 hours of TESE. Safety data including rates of infection, hematoma development or delay in chemotherapy initiation were recorded. A total of 22 pre-pubertal males had a mean age of 7.613 years constituted the study population. Mean FSH level was 6.9±6.3 (range 0.3-15.4) iU/ml. Most (71%) were Tanner stage 1, mean testicular volume 3.6±1.9. The most common childhood cancers in this cohort were sarcomas (55%), immune deficiencies (23%), and leukemias (14%). The procedure took an average of 22 . The tissue was sent to the sperm bank where it was cryopreserved. Viability testing on the first 10 specimens revealed healthy testicular tissue. No wound infections or scrotal hematomas occurred postoperatively. All patients were able to commence chemotherapy on schedule, usually within 24 hours or less of the fertility procedure. Fertility preservation in pre-pubertal pre-chemotherapy patients is a safe and feasible operation.

Safety and feasibility of in-hospital early chemotherapy initiation after surgery in patients with stage II-IV colon cancer.

Although it is recommended to initiate postoperative chemotherapy for colon cancer within 8 weeks after surgery, the feasibility and impact of initiating chemotherapy before discharge after surgical resection has not been investigated.Patients with stage II–IV colon cancer who received postoperative chemotherapy were dichotomized into early (chemotherapy initiation before discharge) and control (chemotherapy initiation after discharge) groups. A multivariable logistic regression model was used to determine factors associated with delayed chemotherapy, defined as more than 6 or 8 weeks after surgery.From January 2004 to December 2012, of 729 patients with stage II–IV colon adenocarcinoma, 555 patients (76.1%) underwent postoperative chemotherapy. Of them, 181 (32.6%) patients were included in the early group. Time to initiation of chemotherapy was significantly shorter in the early group than in the control group (14.9 days vs 31.5 days, P < . 001). Multivariate analysis revealed that tumor stage and chemotherapy initiation strategy (odds ratio 8.4; 95% confidence interval, 1–66, P = .041) were independent predictors of delayed initiation of chemotherapy at more than 8 weeks. There was no difference in the completion rate of planned chemotherapy cycles between the 2 groups (P > .05).The strategy of initiating chemotherapy before discharge after surgery is safe and feasible and might reduce the potential delay in chemotherapy initiation in patients with colon cancer.