Juravinski Cancer Centre Research Articles

Development of equity, diversity, and inclusion competencies in residents and faculty in oncology through formal and informal learning.

9053 Background: In recent years, a growing body of literature has suggested that patients need their clinicians to provide culturally competent care. A focus on integrated and longitudinal training within the domains of equity, diversity and inclusion (EDI) is needed to equip physicians to meet patients’ needs. Oncology is one such specialty that needs strong skillsets in EDI given its vulnerable and complex patient populations. This study explores how physicians within oncology learn about the domains of EDI through formal and informal learning. Methods: Using constructivist grounded theory (CGT), this study explores EDI competency formation at one academic center – the Juravinski Cancer Center in Hamilton ON, Canada. A purposive sample of 16 staff and resident physicians was taken to incorporate variation sampling - including a variety of ages, genders, and work/training experience. Participants were from both medical and radiation oncology. Semi-structured one-on-one interviews were conducted. Transcripts were generated, anonymized, and analyzed iteratively. Data analysis followed stages of open, axial, and selective coding through which themes were constructed. Interviews were continued until data saturation was reached. Results: Of the 16 participants, there was an even distribution between men (8) and women (8). Mean age was 43 (range 30-65). There were 5 residents and 11 faculty members. 9 were from medical oncology and 7 from radiation oncology. The major themes generated from the study were: the relationship between EDI competencies and professional identify formation, the role of culture and context in influencing exposure and learning about EDI, and the relationship between formal and informal learning opportunities. Conclusions: This study is the first to explore of how oncologists presently develop EDI competencies through formal and informal learning. The study has discovered the role of professional identify formation as a factor influencing learning, the impact of the culture and context of medicine, and the significant interplay between formal and informal learning in developing EDI skillsets. While much learning takes place informally, informed by clinical encounters and personal experiences, there is a need to marry the informal learning opportunities to more structured formal teaching in the training and clinical environment. [Table: see text]

Incidence of venous thromboembolism in newly diagnosed glioblastoma multiforme and associated risk factors: A retrospective chart review.

e14040 Background: Patients diagnosed with glioblastoma multiforme (GBM) are recognized as a population at high risk of developing venous thromboembolism (VTE) (1,2). A retrospective chart review of patients diagnosed with GBM at the Juravinski Cancer Centre (JCC) was performed with the primary objective to assess the incidence of the development of VTE in newly diagnosed GBM. The secondary objective was to identify patients who were at higher risk and who could benefit from prophylactic anticoagulation. Methods: This was a single-centre, retrospective cohort study. We reviewed the charts of 528 patients diagnosed with GBM at the JCC from an 8-year period from January 1, 2013 to December 31, 2020. Information on the following factors was collected: Body-mass index (BMI), comorbidities (hypertension, diabetes, dyslipidemia, smoking history), performance status, location and size of tumour, degree of resection, presence of and location of weakness, baseline blood counts, treatments administered, date of diagnosis and time to death or last follow-up. Results: Over the period of review, a total of 528 patients were identified. 111 patients (21%) were diagnosed with VTE. The location of VTE was as follows: 39 patients (35%) unilateral lower extremity deep venous thrombosis (DVT), 8 (7%) unilateral upper extremity DVT, 8 (7%) bilateral lower extremity DVT, 30 (27%) pulmonary embolism (PE), and 25 (23%) DVT and PE. Most VTE (87%) occurred within 12 months of diagnosis of GBM. On univariate and multivariate analysis, no factors were identified that contributed to an increased risk of VTE. Conclusions: Newly diagnosed patients with GBM have been shown to have a significant risk of developing VTE. The AVERT study (3) demonstrated the preventive benefit of administering a direct oral anticoagulant (DOAC) to cancer patients, including those with GBM, at high risk of developing VTE (3). Thus consideration should be given to treating patients with GBM with a DOAC at the time of diagnosis. The benefit of preventive treatment will need to be balanced against the risk of bleeding in these patients.

Breast cancer learning health system: Patient information from a data and analytics platform characterizes care provided.

In a learning health system (LHS), data gathered from clinical practice informs care and scientific investigation. To demonstrate how a novel data and analytics platform can enable an LHS at a regional cancer center by characterizing the care provided to breast cancer patients. Socioeconomic information, tumor characteristics, treatments and outcomes were extracted from the platform and combined to characterize the patient population and their clinical course. Oncologists were asked to identify examples where clinical practice guidelines (CPGs) or policy changes had varying impacts on practice. These constructs were evaluated by extracting the corresponding data. Breast cancer patients (5768) seen at the Juravinski Cancer Centre between January 2014 and June 2022 were included. The average age was 62.5 years. The commonest histology was invasive ductal carcinoma (74.6%); 77% were estrogen receptor-positive and 15.5% were HER2 Neu positive. Breast-conserving surgery (BCS) occurred in 56%. For the 4294 patients who received systemic therapy, the initial indications were adjuvant (3096), neoadjuvant (828) and palliative (370). Metastases occurred in 531 patients and 495 patients died. Lowest-income patients had a higher mortality rate. For the adoption of CPGs, the uptake for adjuvant bisphosphonate was very low, 8% as predicted, compared to 64% for pertuzumab, a HER2 targeted agent and 40.2% for CD4/6 inhibitors in metastases. During COVID-19, the provincial cancer agency issued a policy to shorten the duration of radiation after BCS. There was a significant reduction in the average number of fractions to the breast by five fractions. Our platform characterized care and the clinical course of breast cancer patients. Practice changes in response to regulatory developments and policy changes were measured. Establishing a data platform is important for an LHS. The next step is for the data to feedback and change practice, that is, close the loop.

Multisystem Immune-Related Adverse Events from Dual-Agent Immunotherapy Use.

little is known about the incidence and characteristics of multisystem immune-related adverse events (irAEs) associated with dual-agent ipilimumab and nivolumab use. A retrospective cohort review was completed that included cancer patients seen at the Juravinski Cancer Centre who received at least one dose of ipilimumab and nivolumab from 2018 to 2022. Patient characteristics, cancer types, and irAEs were recorded. Multivariate logistic and cox regressions were completed, comparing those who developed multisystem irAEs, single irAE, and no irAE. A total of 123 patients were included in this study. Out of 123 patients, 72 (59%) had melanoma, 50/123 (41%) had renal cell carcinoma (RCC), and 1/123 (1%) had breast cancer. Multisystem irAEs were seen in 40% of the overall cohort. The most common irAE type was dermatitis (22%), followed by colitis (19%) and hepatitis (17%). Our study demonstrated that multisystem irAEs are prevalent amongst patients receiving ipilimumab and nivolumab. It is important for both physician education and the counseling and consent of patients to monitor the potential for multiple irAEs.

Multisystem immune-related adverse events from dual agent immunotherapy use.

2635 Background: Immune-related adverse events (irAEs) are commonly seen in cancer patients who undergo immunotherapy treatment. Increasingly, there has been recognition that multiple different irAEs can occur during or/and after a single course of immunotherapy treatment, known as multisystem irAEs, though much remains unknown. The primary objective of this study was to assess for rate of multisystem irAEs in patients who received dual agent ipilimumab and nivolumab for cancer treatment. Methods: A retrospective cohort review was completed that included all cancer patients seen at Juravinski Cancer Centre who received at least one dose of ipilimumab and nivolumab from January 1, 2018 to May 31, 2022. Patient characteristics, cancer types, and number and types of irAEs were recorded. Multivariate logistic regressions were also completed comparing those who developed multisystem irAEs, single irAE, and no irAE. Results: A total of 123 patients were included in this study. Median age was 59 years old, with 69% male. 72 out of 123 patients (59%) had melanoma, 50/123 (41%) had renal cell carcinoma (RCC), and 1/123 (1%) had breast cancer. At least one irAE was seen in 72% of patients who were treated with ipilimumab and nivolumab, and most irAEs occurred during the combination phase (89% of first irAE, 59% of second irAE, 75% of third irAE, and 50% of fourth irAE). Multisystem irAEs were seen in 40% of the overall cohort. The most common irAE type was dermatitis (22%), followed by colitis (19%), hepatitis (17%), and thyroiditis (15%). 30 out of 89 patients (34%) who experienced irAE(s) required hospital admission for inpatient treatment of irAE(s). Patients who experienced multisystem irAEs had significantly higher rates of response to immunotherapy irAE (p < 0.001) and improved overall survival (OS) than those who experienced single or no irAE. Conclusions: From our single-centre cohort study, there appeared to be a higher than previously quoted number of patients who experienced irAEs after receiving ipilimumab and nivolumab, with majority of them developing multisystem irAEs. Many patients experienced debilitating associated symptoms and hospital admission relating to irAEs. It is important for both the counselling and consent of patients, and for patient education, to discuss the possibility of multiple irAEs prior to dual immunotherapy initiation.

Use of antibiotics and outcomes of patients presenting to emergency department with non-neutropenic fever and/or suspected infection.

e18693 Background: Current guidelines are clear about antibiotic choices for cancer patients presenting to emergency department (ED) with febrile neutropenia. However, there is little known about antibiotic use and outcomes of cancer patients who present to ED with non-neutropenic fever. The objective of this study was to identify antibiotic prescribing pattern of patients with solid tumor malignancies who presented to Juravinski Hospital (JH) emergency department (ED) with non-neutropenic fever or/and suspected infection. Methods: A retrospective cohort review was completed. All patients with solid tumor malignancies followed by an oncologist at Juravinski Cancer Centre (JCC) who presented to JH ED with non-neutropenic fever or suspected infection from July 1 to December 31, 2020 were identified from an electronic database. Patients’ baseline characteristics, antibiotics used, and outcome information were collected. The primary outcome was proportion of patients who received broad spectrum antibiotic(s) (either Piperacillin and Tazobactam, a Carbapenem, or/and Cefepime) during ED visit or hospital admission. Results: A total of 581 patients were identified and 275 met inclusion criteria. Median age was 71 years, with 46% male. Most common cancer types were breast (21%), lung (18%), gastrointestinal (16%), and genitourinary (13%). Most patients had advanced cancer [stage 4 (59%), stage 3 (14%)], and 37% were on active systemic treatment at the time of ED presentation. A source of infection was identified in 68% of patients, which included 83/187 (44%) respiratory, 32/187 (17%) cutaneous or soft tissue, 24/187 (13%) genitourinary, 20/187 (11%) gastrointestinal, 14/187 (5%) hepatobiliary, and 12/187 iatrogenic (4%). Majority of ED visits (73%) resulted in hospital admission. Median duration of hospital stay was 6 days, and death occurred in 12% of the admitted patients. Broad-spectrum intravenous antibiotics were used in 47% of patients, and most of the time (78%) was the first antibiotic type given after arrival in ED. Conclusions: In our single-centre study, nearly half of patients with solid tumor malignancies who presented to ED with non-neutropenic fever or/and suspected infection received broad spectrum intravenous antibiotics typically recommended in febrile neutropenia protocols. These data suggest a need for quality improvement strategies to improve antibiotic stewardship for patients with solid tumour malignancies presenting to ED with non-neutropenic fever.

Knowledge to Practice in Oncology Rehabilitation: A Survey Evaluating Physical Activity Promotion for Cancer Survivors

<h3>Research Objectives</h3> To determine the prevalence and content of discussions regarding physical activity (PA) promotion between cancer survivors and their oncology care team at a cancer treatment institution in Canada. <h3>Design</h3> A cross-sectional survey was used to gather data on PA discussions between cancer survivors and their oncology care team. <h3>Setting</h3> Participants were recruited from the Juravinski Cancer Centre (JCC) in Hamilton, Ontario. The JCC is an outpatient facility administering cancer treatments including chemotherapy and radiation. <h3>Participants</h3> One hundred participants completed a survey following a regularly scheduled appointment. Eligible participants were adult cancer survivors (any stage and type) at any time point in their cancer treatment. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> The survey included thirteen questions regarding PA-related content discussed, satisfaction with PA education, and an assessment of PA level (using the Godin Leisure-Time Exercise Questionnaire). <h3>Results</h3> Most respondents were females (76%) diagnosed with breast cancer (61%). Overall, 66% of respondents had PA-related discussions with their care team at one point during care. Most (54%) said they were satisfied with the PA education provided during treatment. However, only 37% of respondents were considered ‘sufficiently active' based on the Godin Leisure Time Exercise Questionnaire. Of respondents who discussed PA, those receiving education from a medical oncologist were significantly more likely to be ‘sufficiently active' compared to those who received it from a different type of provider (p=0.02). <h3>Conclusions</h3> Most cancer survivors had discussions around PA with an oncology care provider at some point during their cancer treatment and were satisfied with the PA education provided. Further research is needed to determine optimal strategies for facilitating PA promotion and to close the gap between PA discussions and actual cancer survivor behaviour. <h3>Author(s) Disclosures</h3> The authors declare no conflicts. This project was supported by the Canadian Cancer Society and the Juravinski Hospital and Cancer Centre Foundation-BRIGHT Run Fund (grant #: T210).

A Retrospective Cohort Study of Donor Cell Leukemia

Rationale: Donor cell leukemia (DCL) is formally defined as the new onset of hematological malignancy following an allogeneic hematopoietic stem cell transplantation (alloHSCT) that is derived from the donor. DCL is a rare but increasingly recognized complication with more than 100 cases being reported in the literature and an incidence between 0.12 to 5% (1-6). The identification of DCL is crucial in order to determine the most appropriate therapy for the patient. The underlying mechanisms that contribute to DCL remain largely unknown with no formal guidelines pertaining to prevention. Objective: To determine the incidence of DCL in a patient cohort and better characterize this patient population in terms of natural history, response to therapy, clinical course, and outcomes. Methods: A retrospective chart review was conducted to identify DCL cases that were diagnosed between 2012 to 2022 at the Juravinski Cancer Center (JCC) in Hamilton, Ontario. All patients were 18 years of age or older and diagnosed with a hematological malignancy that was treated with a sex mismatched alloHSCT. DCL was defined as a new presentation of hematological malignancy as per the 2022 WHO classification (7), with the source being from the donor, as confirmed by chimerism status testing with short tandem repeat polymerase chain reaction (STR-PCR) and karyotyping. Results: We identified four patients with confirmed DCL (Table 1). These patients previously received a sex mismatched alloHSCT between 2005 to 2017. A total of 205 patients at JCC received a sex mismatched alloHSCT during the same time span of 2005 to 2017. The incidence of DCL in this cohort was 1.95%. Three patients developed AML and one patient had B-ALL. Three patients were female, and one was male, with a median age of 64.5 years. Three cases were from sibling-matched donors. All patients had normal clonal cell next generation sequencing using a NN-gene myeloid panel (OGT), whereas two patients had an abnormal donor clonal karyotype (inversion 16, deletion 20q, trisomy 21). The latency period between initial malignancy and DCL was between 8 months to 13 years post-transplant. Three patients were alive at time of chart review, with a 25% mortality rate. Conclusions: The time span of the DCL latency period is broad, ranging from months to upwards of a decade. In patients with leukemia diagnosed following sex mismatched alloHSCT, regardless of when it occurs following the initial malignancy, both relapse of leukemia and DCL should be considered as potential differentials. DCL may be the product of somatic and/or germline mutations that warrants additional genetic testing and counselling prior to transplantation. The concept of more comprehensive molecular and cytogenetic testing to identify somatic and germline mutations in related donors prior to alloHSCT to assist with prevention of DCL needs to be explored further.

Hepatitis B screening to reduce the risk of viral reactivation in gynecologic oncology patients receiving chemotherapy at a regional tertiary cancer center: A quality improvement initiative.

332 Background: In 2020, ASCO released a Provisional Clinical Opinion recommending universal hepatitis B virus (HBV) screening prior to systemic chemotherapy to reduce the risk of reactivation and associated morbidities. There is limited data for HBV prevalence and risk factors in gynecologic oncology. In gynecologic oncology patients at the Juravinski Cancer Centre, median baseline screening rate over 6 months was 0%. Our aim was to increase the rate of HBV screening to 70% in gynecologic oncology patients initiating chemotherapy over 6 months and compare real-world efficacy of risk factor-based vs. universal screening. Methods: We performed an interrupted time series study using the Model for Improvement methodology. Four interventions were introduced to address identified screening barriers: provider education, standardization of a testing protocol, integration with existing clinical workflow, and biweekly feedback reports. These were modified in response to outcomes and stakeholder feedback in Plan-Do-Study-Act cycles. Process and outcome measures data were collected by chart review and analyzed on statistical process control and run charts. Retrospective chart review collected demographic and disease data including Centers for Disease Control (CDC) hepatitis risk factors. Results: From Dec 1/20 to Nov 30/21, there were 381 new chemotherapy initiations in gynecology patients. The proportion of physicians screening increased significantly from 0% to 85%, and HBV monthly screening rates increased significantly from 0% to 72.2% by month 8 and were sustained for 4 months at last analysis. The integrated clinic screening protocol and feedback report interventions were each associated with increased screening rates. Of 330 unique patients initiating chemotherapy, 175 were screened (53%). Although ≥95% lacked data for 4 CDC hepatitis risk factors, 60.9% had ≥1 risk factor, and 11.2% had ≥2. HBV surface antigen (HBSAg) was non-reactive in all screened patients, but anti-HBV core (HBc) antibody was reactive in 5 (2.9%), indicative of prior infection. Real world risk factor-based screening in those with ≥1 CDC risk factor would have only identified 3/5 seropositive patients. In the screened population, risk-factor based screening had sensitivity 60%, specificity 38.8%, PPV 2.8%, NPV 97.1%. There were no HBV reactivations. Conclusions: Implementation of 4 interventions to increase HBV screening in gynecologic oncology patients receiving chemotherapy significantly improved screening rates, achieving our target at 8 months with sustained improvement. Risk-factor based screening lacks sensitivity compared to universal screening which may impact management. Lessons learned from this initiative may be applicable to other interventions to reduce infectious morbidity in oncologic populations.

Hepatitis B screening to reduce the risk of viral reactivation in gynecologic oncology patients receiving chemotherapy at a regional tertiary cancer center: A quality improvement initiative.

e18628 Background: In 2020, ASCO released a Provisional Clinical Opinion recommending universal hepatitis B virus (HBV) screening prior to systemic chemotherapy to reduce the risk of reactivation and associated morbidities. There is limited data for HBV prevalence and risk factors in gynecologic oncology. In gynecologic oncology patients at the Juravinski Cancer Centre, median baseline screening rate over 6 months was 0%. Our aim was to increase the rate of HBV screening to 70% in gynecologic oncology patients initiating chemotherapy over 6 months and compare real-world efficacy of risk factor-based vs. universal screening. Methods: We performed an interrupted time series study using the Model for Improvement methodology. Four interventions were introduced to address identified screening barriers: provider education, standardization of a testing protocol, integration with existing clinical workflow, and biweekly feedback reports. These were modified in response to outcomes and stakeholder feedback in Plan-Do-Study-Act cycles. Process and outcome measures data were collected by chart review and analyzed on statistical process control and run charts. Retrospective chart review collected demographic and disease data including Centers for Disease Control (CDC) hepatitis risk factors. Results: From Dec 1/20 to Nov 30/21, there were 381 new chemotherapy initiations in gynecology patients. The proportion of physicians screening increased significantly from 0% to 85%, and HBV monthly screening rates increased significantly from 0% to 72.2% by month 8 and were sustained for 4 months at last analysis. The integrated clinic screening protocol and feedback report interventions were each associated with increased screening rates. Of 330 unique patients initiating chemotherapy, 175 were screened (53%). Although ≥95% lacked data for 4 CDC hepatitis risk factors, 60.9% had ≥1 risk factor, and 11.2% had ≥2. HBV surface antigen (HBSAg) was non-reactive in all screened patients, but anti-HBV core (HBc) antibody was reactive in 5 (2.9%), indicative of prior infection. Real world risk factor-based screening in those with ≥1 CDC risk factor would have only identified 3/5 seropositive patients. In the screened population, risk-factor based screening had sensitivity 60%, specificity 38.8%, PPV 2.8%, NPV 97.1%. There were no HBV reactivations. Conclusions: Implementation of 4 interventions to increase HBV screening in gynecologic oncology patients receiving chemotherapy significantly improved screening rates, achieving our target at 8 months with sustained improvement. Risk-factor based screening lacks sensitivity compared to universal screening which may impact management. Lessons learned from this initiative may be applicable to other interventions to reduce infectious morbidity in oncologic populations.

Fitness Assessment of Elderly Patients with AML and Outcomes

Background:AML is a complex disease that encompasses a huge variation of cytogenetic and mutational backgrounds, which is often complicated by age related functional deficits (Klepin et al. 2013). Given the expanding availability of reduced-intensity treatment options, patient fitness and frailty measures have become increasingly instrumental in the decision between a wide range of treatment options. Furthermore, studies have also demonstrated potential benefits in older patients who receive intensive induction chemotherapy (Julisson 2011), creating a need for additional assessments to identify suitable induction candidates. Some frailty-associated assessments including timed-up-and-go test (TUGT) and the short physical performance battery have been linked to outcomes but are not yet in broad clinical use (Kleplin et al. 2013, Khalaf et al. 2020). To minimize the burden of implementing new patient assessments, we evaluated the utility of commonly available clinical measures of frailty-associated factors including sit-to-stand test and iADL status in predicting patient outcomes.Methods:We performed a retrospective cohort study of elderly patients newly diagnosed with AML at Juravinski Cancer Center between Jan 2019 and Dec 2020. We examined a total of 44 patients aged 65+. The primary outcome was overall survival (OS). Significant risk factors were identified using the Cox proportional hazards model.Results:43 patients had sufficient data and were included in the analysis. The median age was 70 years (range 65-89), 53% were female and 47% were male. At the time of review, 21 patients were deceased (48.8%). The median survival time was 345 days. 26 patients received full induction treatment (7+3, FLAG-IDA, or Vyxeos), and 18 received conservative treatment (LDAC, azacytidine, or supportive care). The clinical wellness of the patients at diagnosis time was assessed by baseline clinical and laboratory findings. (Table 1) The Cox regression model was used to examine these variables in predicting overall survival (Figure 1). As expected, the ELN risk group was significantly correlated with OS (HR 2.94 95%CI [1.41-6.11]), along with laboratory measures of disease burden including blood blast count (HR 1.02 [1.00-1.03]), WBC, (HR 1.02 [1.01-1.03]) and ANC (HR 1.05 [1.02-1.08]).We then assessed the influence of patient fitness factors on OS. The HCT-CI score was used as an aggregate comorbidities measure. While typically used for post-SCT prognosis, we found that HCT-CI assessed at diagnosis time was a significant predictor of OS (HR 1.22[1.04-1.45]). When added to a multivariate Cox model including ELN and age, the HCT-CI independently predicted OS (p = 0.003) and improved prediction efficiency by the Akaike information criteria (115 vs 122). This corroborates earlier findings by Sorror et al. 2017, who showed incorporation of biochemical and AML-specific variables to HCT-CI yields improved prognostic value. Within the HCT-CI, the AST and cardiac disease scores were the most associated with OS (HR 1.03[1.00-1.05] and 2.27[1.09-4.76]). While clinical and laboratory assessments were readily available, functional assessments of frailty were scarce. Previously reported frailty measures such as KPS score or TUGT were not assessed at the study center. OT/PT routinely administer sit-to-stand or standing balance tests as a part of fall risk assessment. However, this data was only available for 18 patients (41.8%). Independent sit-to-stand was not detected as a significant OS predictor (HR 0.63[0.14-2.83]), possibly related to the very limited sample size. BMI was marginally predictive (HR 1.07[0.99 - 1.08]), but unlike HCT-CI it was not an independent predictor when combined with ELN. Patient age did not significantly predict OS.Conclusion:This single center retrospective study was aimed at examining the role of existing clinical or functional measures of fitness and frailty in predicting overall survival. HCT-CI and ELN were found to be the most predictive factors amongst the variables examined, suggesting that a morbidity index such as HCT-CI could provide prognostic utility. However, functional assessments of frailty were not readily completed, limiting the ability to evaluate their usefulness. A future larger prospective study focused on optimizing and incorporating routine functional assessments of frailty is needed to address this topic. [Display omitted] DisclosuresLeber: Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Otsuka: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Astellas: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; TaiHo: Honoraria, Membership on an entity's Board of Directors or advisory committees; AMGEN: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pfizer: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Khalaf: Novartis: Honoraria; Paladin: Honoraria; Pfizer: Honoraria.

Patterns of Relapse in Small Cell Lung Cancer: Competing Risks of Thoracic versus CNS Relapse

Introduction: Treatment algorithms for small cell lung cancer (SCLC) are determined largely by the Veterans Affairs Lung Cancer Staging Group (VALCSG) staging (limited (LS) versus extensive (ES) stage). Relapse occurs frequently; however, patterns of relapse, in particular the competing risk of thoracic and central nervous system relapse, are not well described. This study describes patterns of relapse in SCLC patients treated at a large tertiary institution in Ontario, Canada. Materials and Methods: A retrospective cohort of SCLC patients treated at the Juravinski Cancer Centre was reviewed. Data were abstracted from the medical record on demographic, disease, treatment and outcome variables. The primary outcome was a description of the patterns of relapse stratified by disease stage. Multivariate analysis was performed to identify prognostic variables for thoracic and CNS relapse. Results: Two hundred and twenty nine patients were treated during the study period (LS—83, ES—146). Relapse occurred in the majority of patients (isolated thoracic—28%, isolated CNS—9%, extrathoracic—9%, thoracic/extrathoracic—14%, systemic and CNS—13%). The median OS was consistent with published data (LS—21.8 months, ES—8.9 months). ES disease and elevated LDH were prognostic for increased thoracic relapse, whereas poor PS and older age were prognostic for lower central nervous system (CNS) relapse. Discussion: Thoracic relapse and CNS relapse represent competing risks for patients with SCLC. Decisions about incorporating thoracic or CNS radiation are complex. More research is needed to incorporate performance status and LDH into treatment algorithms.

Outcomes in Elderly Patients with Glioblastoma Multiforme Treated with Short-Course Radiation Alone Compared to Short-Course Radiation and Concurrent and Adjuvant Temozolomide Based on Performance Status and Extent of Resection.

(1) Background: Studies in elderly patients over the age of 65 with glioblastoma have shown survival benefits of short-course radiation therapy with concurrent and adjuvant temozolomide, making it the standard of care adopted at Juravinski Cancer Center. Our study retrospectively examines patients with GBM aged ≥ 70 at the JCC treated with short-course radiation alone compared to those treated with short-course radiation and concurrent and adjuvant TMZ, to determine if there is a difference in outcomes based on performance status. (2) Methods: A retrospective chart review was conducted at JCC using patients diagnosed with GBM in 2014–2017 (treated with the old protocol of short-course RT alone) versus those diagnosed in 2017–2019 (treated with the new protocol of short-course radiation and TMZ). Patient demographics, treatments, outcomes, and baseline KPS were analyzed. (3) Results: No clear benefit and more neurologic decline post treatment were seen in patients with borderline performance status and subtotal resection who underwent concurrent treatment with temozolomide and radiation. The addition of temozolomide was most helpful in patients with good performance status and a gross total resection. Variable outcomes were seen in patients with mixed traits. (4) Conclusions: This study suggests that performance status and extent of resection are significant determinants of patient response to treatment. In the case of elderly patients with borderline performance status and GTR or those with good performance status and STR, also described as “mixed traits”, it may be beneficial to pursue single modality treatment, ideally based on MGMT promoter methylation status as opposed to bimodality treatment in order to maintain the best QOL.

Recurrent disease in patients with stage III melanoma in the era of adjuvant immune and targeted therapy.

e21570 Background: Advancements in systemic therapy have reduced recurrence, and the adoption of nodal surveillance in place of dissection has reduced morbidity for patients with Stage III melanoma. The objective of this study was to describe the timing and pattern of recurrence in stage III melanoma patients and evaluate the impact of adjuvant treatment and nodal surveillance. Methods: A multicenter retrospective chart review of patients with pathologically confirmed Stage III cutaneous melanoma seen at either the Juravinski Cancer Centre or Walker Family Cancer Centre in Ontario, Canada from January 1, 2017 to December 31, 2019. Results: There were 137 patients with Stage III melanoma: 18% IIIA, 22% IIIB, 52% IIIC, and 8% Stage IIID as per the 8th American Joint Committee on Cancer (AJCC) 2018 staging system. 103 (75%) patients had sentinel lymph node biopsy (SLNB) only as part of initial surgical therapy, 6 (4%) had SLNB with completion dissection, and 25 (18%) had upfront radical nodal dissection. 67 (49%) patients received adjuvant therapy, of which 50 (74%) had immunotherapy, 17 (25%) received BRAF-targeted therapy, and 1 (1%) had interferon. 54 (39%) patients developed recurrent disease, with a median time to recurrence of 8.5 months (IQR: 4.3-14.9). The recurrence rates were 63% in patients who did not have adjuvant treatment and 37% in those who had adjuvant therapy, with a median time-to-recurrence of 7.5 and 9.0 months respectively. There were 30 (56%) loco-regional recurrences and 24 (44%) distant recurrences. Of the patients with loco-regional recurrence, 26 (87%) had SLNB only compared to 4 (13%) who had upfront or completion dissection. 12 (24%) patients recurred while on adjuvant treatment (7 distant recurrences and 5 loco-regional recurrences), and 8 (13%) patients recurred following completion of adjuvant treatment (5 distant recurrences and 3 loco-regional recurrences). Recurrences were detected by patients, clinicians, CT and nodal US surveillance in 43%, 20%, 28% and 9% of cases, respectively. The majority of loco-regional recurrence was detected clinically (67%) rather than by radiologic surveillance (33%). Of the 30 loco-regional recurrences, 24 underwent surgical resection of the recurrence, 4 had subsequent systemic therapy without surgery, 1 had intra-tumoral injections and 1 had no treatment. Conclusions: Recurrences in Stage III melanoma occur early, often within a year, with higher rates of loco-regional rather than distant disease. Recurrence rates were lower in those who received adjuvant therapy, but the majority of recurrences were detected by patients or clinicians, including loco-regional recurrences in patients who had SLNB only despite surveillance nodal US.

Elucidating Barriers to Advance Care Planning in Malignant Hematology Clinics: A Single Centre Experience in Ontario, Canada

Introduction: Advance care planning (ACP) is a patient-centered process with clear benefits for patients. Despite the widespread recognition of ACP as an integral part of quality cancer care,compliance with ACP provision remains suboptimal especially in malignant hematology. Many barriers to end-of-life discussions among hematologists have been identified in the literature. This study aims to describe a baseline rate of ACP with hematology outpatients at the end-of-life and the local barriers to ACP, which could inform future quality improvement (QI) initiatives in this area. Setting/participants: Malignant hematologists (n = 10), hematology fellows (n=2), and hematology clinic nurses (n=4) of the Juravinski Cancer Centre (JCC) in Hamilton, Ontario, Canada participated in this study. Methods: A retrospective chart audit was undertaken to establish the baseline rate of ACP for the target population at our centre. Subsequently, key stakeholder interviews were held with our local multiple myeloma (MM) specialists to document barriers to ACP from their perspectives. The emerging themes were synthesized using a Fishbone diagram and validated by the JCC hematology clinic staff through multivoting. Results: The baseline rate of ACP with hematology outpatients at the end-of-life at our centre is 40%. The are three main local barriers to ACP with the target population: 1) lack of patient initiative; 2) time/scheduling constraints; and 3) competing priorities. Discussion: Patients who participate in ACP are much more likely to have their end-of-life wishes followed than those who do not. Malignant hematology patients are at the greatest risk of not having ACP discussions with their clinicians due to several patient, provider, and system barriers. Patient- and system-level barriers have been identified as the most prevalent at the JCC, necessitating a tailored QI initiative to achieve the standard of care. Disclosures Hillis: Roche: Honoraria.

Abstract P1-15-09: What are the outcomes of importance for patient education in breast cancer?

Abstract Background: Patient education is an important component of quality cancer care. However, there remains much debate about its effects, merits and limitations. There is a lack of consensus on the intended effects of educational interventions and a lack of standardized outcome measures to assess quality. As a result, multiple outcomes measures are used without consistency and in differing combinations in the literature making it difficult to compare relative efficacy of interventions. The primary objective of this study was to identify outcomes of importance for patient education interventions in breast cancer. Methods: A generic qualitative study using interpretive description was conducted to discover what key stakeholders in the process of patient education in breast cancer (patients, physicians and nurses) would identify as outcomes of importance. The study population included breast cancer patients, physicians and nurses caring for breast cancer patients at the Juravinski Hospital and Cancer Centre in Hamilton, Ontario. Four focus groups and one semi-structured interview was conducted using purposeful sampling and an iterative design. Results: Eight patients, five nurses and four physicians participated in this study. Five common themes to all groups with respect to outcomes of importance in patient education were discovered: improving knowledge, improving coping ability, providing an orientation to the cancer system, enabling shared decision making and impacting behaviour during cancer treatment. Conclusion: Despite the surprising variability and inconsistency of outcomes discovered in the patient education literature, this qualitative study demonstrated that patients, physicians and nurses generally agree on what constitute important outcomes and serves as a first step in the process of developing validated outcomes for patient education interventions in cancer. Citation Format: Ghazaleh Kazemi, Mark Levine, Harold Reiter, Christina Sinding. What are the outcomes of importance for patient education in breast cancer? [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-15-09.

Trial marketing in the Pan-Canadian Early Detection of Lung Cancer Study.

Recruitment to clinical trials is suboptimal, increasing costs, and delaying the potential implementation of clinical advances. Among other barriers, the lack of marketing experience among trialists may limit recruitment. In this observational study, in the context of the Pan-Canadian Early Detection of Lung Cancer Trial, we assessed the value of a motivational survey of study participants in planning a tailored advertising campaign and analysed the value of individual components of advertising in generating telephone calls to the study and recruited subjects. The Pan-Canadian Early Detection of Lung Cancer Trial was a single arm study assessing risk modelling for lung cancer screening by low-dose computed tomography scan and autofluorescence bronchoscopy. Individuals were recruited to eight sites across Canada without a central marketing plan. On contact with the study, individuals reported how they heard about the study according to a predefined list. One site, the Juravinski Cancer Centre, worked with a marketing expert to develop a survey to assess participant motivations, source of study awareness, and personal habits. The survey was used to develop a media campaign for recruitment. Media events were collected from all sites. The primary analysis assessed the number of telephone contacts and recruited subjects associated with various media factors. Individual print media characteristics were assessed for their effect on recruitment. At all sites, 7059 individuals contacted the study, and 2537 were eligible and recruited. Among 52 individuals completing the Juravinski Cancer Centre survey, motivation included concern for personal risk of lung cancer (71%), followed by desire to contribute to a cure (67%), followed by personal knowledge of a person with lung cancer (50%). Most reported hearing of the study from the newspaper (58%) despite no print ad yet being distributed. With survey input, a newsprint campaign was executed. The number of media events varied by site (median: 13, range: 3-28). Among all recruits, 56.4% reported referral by newspaper followed by family/friend (14%). Telephone contacts and recruited subjects per event varied significantly by site, while unpaid media events appeared superior to paid events. Print media characteristics associated with increased telephone contacts and recruitment included use of a rational appeal (vs a mixed rational-emotional), less use of white space, and larger headline font. A survey of trial candidates provides useful information regarding personal motivation, media use, and lifestyle. Unpaid media events appear superior in generating recruitment, while print media may be superior to radio and television in selecting eligible recruits. The utility of individual print media characteristics appears to differ from the commercial advertising literature. Further research on marketing in clinical trials is encouraged to improve recruitment ( ClinicalTrials.gov registration: NCT00751660, https://clinicaltrials.gov/ct2/show/NCT00751660 ).

Trial in Progress: Feasibility and Validation Study of the LSC17 Score in Acute Myeloid Leukemia Patients

Trial in Progress: Feasibility and Validation Study of the LSC17 Score in Acute Myeloid Leukemia Patients

Using Magnetic Resonance Perfusion to Stratify Overall Survival in Treated High-Grade Gliomas.

MR perfusion imaging is a relatively new technique that may aid in identifying recurrent tumor (RT) in those with radically treated high-grade gliomas (HGG). We aim to assess the relationship between dynamic susceptibility contrast-enhanced MR perfusion (DSC-MRP) and overall survival to establish a baseline for future research and to determine the utility of DSC-MRP as a clinical decision-making and prognostic tool. We conducted a retrospective cohort study. Adults with pathologically confirmed HGG at the Juravinski Cancer Centre, Ontario between January 2011 and April 2014 with at least one post-treatment DSC-MRP were included. DSC-MRP was interpreted as positive or negative for tumor recurrence by experienced radiologists. The primary outcome was overall survival. Sixty-one patients were enrolled. Median survival for patients with a positive DSC-MRP scan was 4.5 months compared with 10.2 months for those with a negative DSC-MRP scan (hazard ratio [unadjusted] = 2.51; 95% confidence interval = 1.10-5.67; p-value = 0.03). Multivariable modeling (adjusted) that included all pre-selected variables showed similar results. Survival time in patients with HGG is generally low, and almost all patients will demonstrate RT. Our data suggest a positive DSC-MRP correlates with lower overall survival and may signify the presence of highly active RT. These results generate a hypothesis that there may be a prognostic role for the use of serial DSC-MRP for tumor surveillance. More importantly, this biomarker may aid in decision making for treatment plans and palliation.

Outcomes of trimodality bladder-sparing therapy for muscle-invasive bladder cancer.

Although radical cystectomy is considered the standard of care for muscle-invasive bladder cancer (MIBC), recent data has suggested comparable survival outcomes for bladder-sparing trimodality therapy (TMT). We conducted a retrospective, single-institution analysis of MIBC patients to evaluate the efficacy of TMT as an alternative, curative approach to surgical intervention. We conducted a retrospective analysis of MIBC patients assessed by a multidisciplinary team at the Juravinski Cancer Centre from 2010-2016. Patients underwent transurethral resection of bladder tumor (TURBT) followed by radiotherapy with or without concurrent chemotherapy. Patients could receive neoadjuvant treatment. Clinical data and response rates were summarized, and overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. Our analytic cohort included 115 patients, of whom 53 underwent TMT and 62 underwent radiotherapy alone following TURBT. Median age at diagnosis was 79 years and median followup was 21 months. Complete response rates in those receiving TMT and radiation without chemotherapy were 84.4% and 66.7%, respectively. For TMT patients, three-year OS and DFS were 68.5% and 49.6%, respectively. Patients who received TMT had reduction in risk of mortality (hazard ratio [HR] 0.49; p=0.026) and disease recurrence (HR 0.55; p=0.017) compared to those who had radiation without chemotherapy. Overall, four patients had grade 3 or higher late toxicity. In this single-institution analysis, TMT appears to be a safe and effective approach in the short-term management of MIBC in appropriately selected patients. Extended followup and analysis are necessary to validate these results.