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277 Background: Oncology telehealth (TH) services may improve access, mitigate care delays, and augment care in select settings. However, logistical and workflow barriers hinder the sustainable adoption of TH services by providers. We created a novel oncology TH nurse (OTN) position to address these barriers. Methods: An OTN was introduced into oncology provider groups (physician + advanced practice provider) in a staggered, opt-in fashion across the Duke Cancer Institute between 9/2020 and 12/2020. The OTN performed individualized interventions to decrease provider burden, improve TH workflows, and increase TH utilization. Specific interventions performed by the OTN were recorded. We monitored the primary outcome, TH utilization, as a proportion of all visits at baseline (month 0) and 3 months post-OTN intervention. Patient TH satisfaction surveys were reviewed at baseline and 3 months post-OTN intervention. Provider surveys were sent 3 months post-OTN intervention. Results: The OTN was implemented across 10 provider groups and 25 providers [gastrointestinal (GI) medical oncology (n = 10), thoracic medical oncology (n = 3), melanoma medical oncology (n = 3), adult bone marrow transplant (n = 2), lung cancer screening (n = 2), melanoma surgical oncology (n = 1), hematological malignancies (n = 1), head and neck medical oncology (n = 1), central nervous system radiation oncology (n = 1), and GI radiation oncology (n = 1)]. 25 providers utilized 1 or more OTN interventions: support for patients on the TH platform (n = 13), construction of TH clinic schedule templates (n = 6), creation of workflows to order and obtain outside imaging/labs (n = 5), provider TH education (n = 4), creation of Epic SmartPhrases (n = 4), and identifying patients appropriate for TH (n = 3). Baseline TH utilization was 15.6% of all visits, and 3-month post-OTN utilization was 23.8%. TH patient satisfaction data was available for 10 providers at baseline and 13 providers at 3 months post-OTN. Patients’ global approval rating of TH was 85.0% at baseline and 98.5% at month 3. 16/25 providers returned the post-intervention survey. Providers requested continued assistance from the OTN for supporting patients on the TH platform (43.5%), staff TH education (43.5%), provider TH education (25%), creation of SmartPhrases (25%), and creation of TH clinic templates (13%). Providers requested new additional OTN support to 1) order and retrieve imaging/laboratory tests for TH visits and 2) explore patients' willingness to undergo TH visits. Conclusions: OTN interventions were individualized to providers and evolved over time. While TH utilization was increased at 3 months post-OTN, it is possible that utilization was confounded by the dynamic COVID-19 pandemic and provider/patient preferences over time. Nevertheless, these results demonstrate feasibility of OTN implementation and provide support for this novel role in promoting TH services in oncology.

e24115 Background: The social impact of cancer on patients and their family is well known. Yet, unlike with physical and financial toxicities, no validated tools are available to measure this impact. This study aimed at developing, validating, and implementing a novel social toxicity assessment tool for patients with cancer diagnosis (STAT-C). Methods: Questions were generated through multiple steps including focus groups of patients, their families, and oncology care professionals. Content validity, internal consistency, face validity and factor analysis were conducted. The questionnaire (in Arabic language) was administered to 150 patients with cancer served at King Abdulaziz Medical City, Riyadh, Saudi, Arabia. Results: STAT-C contains 14 items covering three domains: Social Relations domain (eight questions) related to relationship with parents, spouse, children, siblings, friends, members of congregation, and caregiver; Social Activities domain (two questions) measures participation in social events and leisure; and Economic Impact domain (four questions) related to standard of living, finances, and loss of job. The total possible score for each patient for the 14 items in the tool varied between -28 and +28 (Range = 56). Dividing the range by three levels of a socioeconomic toxicity yielded the length of each level, which effectively defined the categories as- Severe social toxicity (SST score: -28 to -9.3), mild social toxicity (MST: -9.2 to 9.5) and no social toxicity (NST: 9.6 to 28). Conclusions: Our study revealed that STAT-C is a valid and reliable tool in assessing the social toxicity of cancer in Arabic-speaking patients. Validating the tool in an English-speaking population is planned. The tool should enable oncology professionals to deliver better patient-centered care as a component of a holistic approach.

1579 Background: Telehealth (TH) utilization for patients at our cancer institute increased in 2020 in response to the COVID-19 pandemic, however oncology-specific TH patient satisfaction is unknown. Methods: Monthly TH utilization at a single large NCI-designated institute from 3/1/2020-11/30/2020 was reviewed. Utilization was calculated as chargeable TH visits (new video, established video, phone) as a proportion of all consult/follow up visits. Patient satisfaction surveys for oncology TH visits for MD/PA/NP providers were reviewed from 4/1/2020-11/30/2020. Surveys were sent after every TH visit, unless the patient had a prior visit in the past 3 months. Percent (%) top box score (TBS) was defined as proportion of responses in the highest possible response category (i.e. very good). % TBS was reported for 14 survey items in 4 domains: technology, access, care provider (CP), and overall assessment. Satisfaction was assessed over time and according to patient factors: generation, gender, insurance type, employment status, and clinic site. The Cochrane-Armitage trend test was used to compare proportions of TBS responses across monthly time points. Results: TH comprised 21% (22,055/103,461) of all encounters in the study period. TH use increased from 9% in 3/2020 to a peak of 47% in 4/2020. In 11/2020, TH use was 18%. 28.0% (2,286/8,173) of TH patient surveys were returned. Multiple patient satisfaction metrics were improved over time (Table). Patients had higher satisfaction with phone compared to video visits with regards to technology (86% vs 76%) and access (80% vs 72%). Millennials (born 1981-1995) had higher satisfaction with access to TH (87%) compared to Gen X (1965-1980) (77%), Baby Boomer (1946-1964) (74%), and Silent Generation (1928-1945) (72%), however all generations had similar levels of satisfaction with technology (range 77-80%). Disabled patients had higher overall satisfaction of TH (82%) versus those working full time or retired (71%). Patients with commercial insurance had worse overall satisfaction of TH compared to other insurance types (65% vs 72%). Patients with encounters in genitourinary, thoracic, and endocrine oncology clinics had the highest levels of overall satisfaction (75%) compared to other clinics (69%). There were no observed differences in TH satisfaction according to gender. Conclusions: TH cancer patient satisfaction is high and has improved over time, however satisfaction differs by patient demographics. Further data are needed to best select patients appropriate for TH.[Table: see text]

e18861 Background: Low -value care contributes to the high costs of cancer treatment. Almost a decade has passed since the American Society of Clinical Oncology (ASCO) Choosing Wisely campaign identified costly diagnostic testing, radiographic imaging, and therapies that are routinely utilized in cancer care despite lacking evidence of benefit. We sought to evaluate the impact of ASCO Choosing Wisely guidelines and to identify barriers to and facilitators of guideline adherence. Methods: A systematic review of published literature from 2012-2021 was performed in accordance with PRISMA guidelines on the trend in use of low value oncology care. All ten of ASCO Choosing Wisely Guidelines were selected for inclusion; these included recommendations focused on cancer screening, staging and surveillance imaging, and systemic treatment and support. The following databases were searched for original research based in the United States: PubMed, CINAHL, Embase, Web of Science, Scopus, and ASCO Meeting abstracts. Eligible studies were examined for information on design, population, and study outcomes, which included guideline adherence and facilitators and barriers to implementation. All citations were independently dual-screened in a blinded fashion by authors (AG, MS). Results: 35 independent studies were identified from 3,590 unique citations and included n = 1,130,216 patients. Data sources captured large claims database analyses (13 studies, n = 1,069,289), institutional studies (14 studies, n = 53,358), patient-reported surveys (2 studies, n = 915), and interventional studies (6 studies, n = 6654). Adherence to ASCO Choosing Wisely guidelines ranged from 13% to 100% overall. Use of low value oncology care varied depending on the area of recommendation, such as cancer screening (44% to 77%), staging and surveillance imaging (30% to 100%), and systemic treatment and support (13% to 100%). Adherence was facilitated by: (a) physician awareness of and education around the recommendations; (b) patient engagement; (c) embedded EHR best practice alerts; (d) guideline alignment with insurance payer requirements; and (e) integrated healthcare systems. Barriers to guideline incorporation included perceived patient anxiety and concerns about patient satisfaction; illness-specific practices; and time needed for patient-provider conversations regarding low value care. Conclusions: Adherence to the ASCO Choosing Wisely guidelines is variable across the cancer care continuum. Health system and policy-level interventions are needed to further reduce the overuse of low value care in oncology.

Purpose To measure the association between patient financial strain and symptom burden and quality of life (QOL) for patients with new diagnoses of lung or colorectal cancer. Patients and Methods Patients participating in the Cancer Care Outcomes Research and Surveillance study were interviewed about their financial reserves, QOL, and symptom burden at 4 months of diagnosis and, for survivors, at 12 months of diagnosis. We assessed the association of patient-reported financial reserves with patient-reported outcomes including the Brief Pain Inventory, symptom burden on the basis of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30, and QOL on the basis of the EuroQoL-5 Dimension scale. Multivariable linear regression models were fit for each outcome and cancer type, adjusting for age, race/ethnicity, sex, income, insurance, stage at diagnosis, and comorbidity. Results Among patients with lung and colorectal cancer, 40% and 33%, respectively, reported limited financial reserves (≤ 2 months). Relative to patients with more than 12 months of financial reserves, those with limited financial reserves reported significantly increased pain (adjusted mean difference, 5.03 [95% CI, 3.29 to 7.22] and 3.45 [95% CI, 1.25 to 5.66], respectively, for lung and colorectal), greater symptom burden (5.25 [95% CI, 3.29 to .22] and 5.31 [95% CI, 3.58 to 7.04]), and poorer QOL (4.70 [95% CI, 2.82 to 6.58] and 5.22 [95% CI, 3.61 to 6.82]). With decreasing financial reserves, a clear dose-response relationship was present across all measures of well-being. These associations were also manifest for survivors reporting outcomes again at 1 year and persisted after adjustment for stage, comorbidity, insurance, and other clinical attributes. Conclusion Patients with cancer and limited financial reserves are more likely to have higher symptom burden and decreased QOL. Assessment of financial reserves may help identify patients who need intensive support.

e19373 Background: Increasing healthcare costs often result in many individuals and families foregoing required care, delaying care, or non-adhering to prescribed medication. Hematopoietic cell transplantation (HCT) is a highly specialized procedure that has the potential to adversely affect the socioeconomic well-being of patients and their family. Financial well-being in patients undergoing evaluation for HCT has been inadequately studied. In this prospective cohort study, we examined financial toxicity in a cohort of patients being considered for HCT at the Duke Adult Bone Marrow Transplant Clinic. Methods: This is a prospective cohort review of patients age ≥18 years undergoing evaluation for allogeneic HCT between 1/1/2017 – 1/1/2020. Patients that completed a baseline financial health survey and the comprehensive score for financial toxicity-functional assessment of chronic illness therapy (COST-FACIT) survey were included. Financial health was measured via baseline survey and financial distress was assessed via the validated COST-FACIT measure. The primary outcome was financial distress. Results: Of 157 consecutive patients, 112 (71.3%) completed financial toxicity assessments. Of these, 63.4% were male, had a mean age of 61.0, were predominantly white (74.4%), and majority had household incomes less than $90,000 (53.7%). Primary diagnosis at screening was leukemia (35.4%) and myelodysplastic neoplasm (31.7%). Overall, 94.5% noted an inability to see a physician in the prior year due to cost, 76.8% had not filled a prescription due to cost, 73.2% reduced spending on basics like food or clothing to pay for cancer care, 69.5% borrowed money or used a credit card to pay for cancer care, 54.9% used all or a portion of their savings to pay for cancer care, and 54.9% reduced spending on leisure activities like vacations, eating out, or movies to pay for cancer care. Overall, 31 (37.8%) respondents noted mild financial distress while 26 (34.1%) noted moderate-to-high financial distress. Conclusions: Previous studies in the solid tumor and hematological malignancy fields have noted similar results in financial toxicity. However, this is the first study of its kind to demonstrate prevalent financial toxicity present in a cohort of patients undergoing evaluation for HCT. Early interventions by physician and social work led teams may benefit patients who are at risk for financial distress. Future directions include investigating factors associated with high financial toxicity in HCT, and whether financial distress is related to worse outcomes after transplant.

12093 Background: The National Comprehensive Cancer Network (NCCN) defines distress as an unpleasant, multidimensional experience that may interfere with patient behavior, emotions, and ability to cope with illness. Distress screening is a critical aspect of comprehensive cancer treatment, but the relationship between patient-reported distress and healthcare utilization remains unclear. We assessed this relationship in patients with advanced cancers historically associated with high utilization, specifically non-small cell lung cancer (NSCLC) and non-colorectal gastrointestinal (NCRGI) cancer. Methods: We extracted data from the electronic medical record of adult patients with metastatic NSCLC and NCRGI cancers who were receiving active treatment, visited outpatient Duke Cancer Institute clinics between July 2013 and January 2017, and completed at least two self-report NCCN Distress Thermometer (DT) and Problem List (PL) surveys as part of routine clinical care between July 2013 and March 2019. Mixed effects logistic regression was used to estimate the odds of hospitalization or emergency room (ER) visit within either 3 or 6 months after each self-reported DT, with adjustment for age at first distress score, sex, primary tumor site, race (white vs. non-white) and duration of participation (i.e., time from first distress score to 3 months after the last distress score) information from the EMR. Results: A total of 11,027 DT scores were collected from 848 patients, with 508 (60%) having NSCLC, 340 (40%) having NCRGI cancer, and 192 (23%) reporting actionable distress (i.e., DT score ≥4). Actionable distress was associated with higher odds of hospitalization or visiting the ER within 3 months (OR = 1.37; 95% CI = 1.19, 1.58; p < 0.001) and 6 months (OR = 1.19; 95% CI = 1.03, 1.37; p = 0.019) after DT self-report. Patients who had an average DT score of ≥4 were more likely to report the following problems at least once: worry (89% of patients), nervousness (79%), fatigue (95%), pain (92%), sleep problems (79%), and eating problems (79%). Conclusions: Patient-reported distress is associated with greater healthcare utilization in patients with advanced NSCLC and NCRGI cancers who are receiving active treatment. These patients report high burden of physical and emotional problems. Actionable distress may be a useful indicator of patients in need of specialist palliative care interventions.

Purpose The US community-based, phase IIIB UPFRONT trial was designed to compare three frontline bortezomib-based regimens in transplantation-ineligible patients with myeloma. Patients and Methods Patients (N = 502) were randomly assigned 1:1:1 to 24 weeks (eight 21-day cycles) of induction with bortezomib-dexamethasone (VD; n = 168; intravenous bortezomib 1.3 mg/m2, days 1, 4, 8, and 11 plus oral dexamethasone 20 mg, days 1, 2, 4, 5, 8, 9, 11, and 12 [cycles 1 to 4], or 1, 2, 4, and 5 [cycles 5 to 8]), bortezomib-thalidomide-dexamethasone (VTD; n = 167; bortezomib and dexamethasone as before plus oral thalidomide 100 mg, days 1 to 21), or bortezomib-melphalan-prednisone (VMP; n = 167; bortezomib as before plus oral melphalan 9 mg/m2 and oral prednisone 60 mg/m2, days 1 to 4, every other cycle), followed by 25 weeks (five 35-day cycles) of bortezomib maintenance (1.6 mg/m2, days 1, 8, 15, and 22). The primary end point was progression-free survival. Results After 42.7 months' median follow-up, median progression-free survival with VD, VTD, and VMP was 14.7, 15.4, and 17.3 months, respectively; median overall survival was 49.8, 51.5, and 53.1 months, with no significant differences among treatments for either end point (global P = .46 and P = .79, respectively, Wald test). Overall response rates were 73% (VD), 80% (VTD), and 70% (VMP). Adverse events were more common with VTD than VD or VMP. Bortezomib maintenance was feasible without producing cumulative toxicity. Conclusion Although all bortezomib-containing regimens produced good outcomes, VTD and VMP did not appear to offer an advantage over VD in transplantation-ineligible patients with myeloma treated in US community practice.

101 Background: Cancer patients face many supportive care needs. In crowded clinics with rising care complexity, clinicians struggle to assess and manage these needs. Duke Cancer Patient Support Program (DCPSP) services aim to bridge this gap, but many patients are unaware of these services. We hypothesized that a DCPSP mobile application (app) is a feasible approach to this problem. Methods: We developed an app to enhance DCPSP awareness and facilitate weekly symptom reporting (via the Edmonton Symptom Assessment Scale, ESAS). Based upon symptoms, the app presents information cards and recommendations for specific DCPSP services. We enrolled 50 patients with advanced cancer (2 arms; 25 app intervention, 25 control) and 10 caregivers to a 12-week pilot trial. The primary outcome was feasibility. Secondary measures assessed knowledge/engagement of DCPSP services, usability, satisfaction, quality of life (QoL), and activation. We interviewed a subset of participants about the experience. Results: Forty-five patients completed the study, exceeding our pre-determined feasibility threshold. Most patients were age 50-64; the most common cancers were breast (42%) and lung (18%). Knowledge/use of DCPSP services increased in both arms, with a larger trend in the intervention arm (2.5 vs 4.0 composite score increase). App patients (n=25) completed a median of 7 ESAS surveys for an overall response rate of 57%. The most commonly-reported moderate/severe symptoms were fatigue (40%), drowsiness (22%), and pain (20%), with 54% of surveys from 23 of 25 patients reporting at least one moderate/severe symptom. These patients averaged 20 app interactions versus 9 interactions for those without a moderate/severe symptom. Satisfaction scores were high, and qualitative feedback was positive. We found no differences in QoL or patient activation across study arms. Caregivers had significant improvement in awareness/use of services (median increase 4.5, p=0.01). Conclusions: The D-SCAN app is a feasible approach to augmenting supportive care awareness and navigation, with high satisfaction and usability scores. The trend towards enhanced awareness and engagement of DCPSP services in app utilizers warrants further testing. Clinical trial information: NCT03628794.

102 Background: Electronic patient-reported outcome measures (ePROs) offer a new strategy for symptom assessment that can improve quality of life and prolong survival in routine cancer care. However, ePRO systems are often separate from existing electronic medical records (EMRs) and not well integrated into oncology clinics. In this pilot project, we assessed the feasibility and utility of integrating ePROs into our existing EMR and clinical workflows. Methods: The 10-question Edmonton Symptom Assessment Scale (ESAS) was integrated into the Epic EMR at three outpatient clinics in the Duke Cancer Institute. Patients with active MyChart accounts were offered the ESAS survey prior to their visit, via the patient portal. ePRO data were routed to clinicians in tabular and graphical formats. A “SmartPhrase” facilitated easy data integration into clinical notes. We subsequently interviewed clinicians and optimized workflows. Several patient engagement strategies were used, including automated messages, phone call reminders, and electronic tablets, to increase response rate. Results: It was feasible to quickly customize and activate an ePRO in Epic. Over 10 months, 161 patients completed 208 ePRO surveys. Initially, 10-20% of eligible patients completed the MyChart questionnaire. Patient engagement strategies, including phone calls and personalized MyChart messages, had little effect. Ultimately, tablets were introduced in the clinic check-in process, increasing response rates to >90%. Clinicians reported positive regard for the system, and an impact on patient symptom management. Clinician workflow optimization resulted in minimal “clicks” in the EMR, and the SmartPhrase was used in 128 clinical notes. Conclusions: Integration of ePROs into the clinical setting poses three challenges: technical implementation, workflow optimization, and patient engagement. While technical implementation is important, it was the easiest to solve, with patient engagement as the greatest barrier. Clinicians value an integrated ePRO system that automatically routes data to the clinical note. The key to successful ePRO integration is in ease of use for both patients and clinicians.

4580 Background: Mutation/inactivation of VHL in clear cell renal cell carcinoma (ccRCC) leads to upregulation of hypoxia inducible factors ( HIFs) and angiogenesis. However, ccRCC is characterized by high intra-tumor heterogeneity (ITH). Random small samples such as those in percutaneous biopsies are likely limited for characterization of molecular alterations in heterogeneous ccRCCs. We hypothesize that whole-tumor dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) is useful to noninvasively identify ITH in ccRCC. Methods: This IRB-approved, prospective, HIPAA-compliant study, included 62 ccRCCs. 3T DCE MRI was obtained prior to nephrectomy. Surgical specimens were sectioned to match MRI acquisition plane. 182 snap frozen samples (49 tumors) and adjacent uninvolved renal parenchyma (URP) were collected. RNA isolations, cDNA library preparation and mRNA sequencing were performed using standard protocols. RNA expression in 81 tumor samples were correlated (Spearman ranked) with % enhancement in a region of interest (ROI) drawn in the same location of the tumor on pre- and 3 different post-contrast DCE MRI phases. Gene function overrepresentation (OR) analyses were done on top positively and negatively correlated genes. False discovery rate (FDR) < 0.1 was considered statistically significant. Results: Principal component analysis of > 20,000 genes indicated distinct gene expression in tumors from URP. Unsupervised clustering showed enrichment of ccA samples (better prognosis) compared to ccB samples (worse prognosis). Importantly, ccA and ccB samples coexisted in 25% of tumors. DCE-MRI % enhancement correlated with expression of > 300 genes (p < 0.003, FDR < 0.1). OR analyses placed angiogenic pathway gene processes and the immune/inflammatory response processes within the top 5 positively- and negatively-correlated gene functions, respectively. HIF2 target genes correlated positively with % enhancement. Conclusions: DCE MRI detects specific molecular signatures and may help overcome the challenges of ITH in ccRCC. Further research is needed to explore the potential role of DCE MRI to assess response to antiangiogenic and immune-based therapies.

11615 Background: Deficiencies and barriers exist to delivering comprehensive and affordable cancer care. Understanding the variation in organizational commitment, existing programs, and expected outcomes for screening and management of financial distress is needed. Methods: Representatives from 17 of 27 NCCN Member Institutions (63%) completed an online survey in November 2018 conducted by the NCCN Best Practices Committee. Centers were classified based on number of unique patients seen per year, as large ( > 10,000) (76%), or small ( < 10,000) (34%). The survey focused on institutions’ screening and management practices for patient financial distress, perceived barriers in implementation, and leadership attitudes. Results: Routine screening for financial distress was reported by 77% of centers, and most used social worker assessments (94%). 56% screened patients throughout the cancer journey. Help with drug costs, meal or gas vouchers and payment plans were offered by 100% of centers. Formal pre-authorization programs and assistance with claims and denials was offered by 81%. Charity care for medical costs was provided by 100% of the large centers compared to only 33% of small centers (p = 0.03). Median number of social workers (24 vs. 3; p = 0.01) and pharmacy representatives (6 vs. 2; p = 0.02) was also different between large and small centers. 76% evaluated the impact of financial advocacy services through number of patients assisted (85%), bad debt and charity write-offs (85%) or patient satisfaction surveys (54%). 6% and 12% reported overall effectiveness of institutional practice for screening and management of financial distress as poor/ very poor respectively. Inadequate staffing and real time resources (69%), limited institutional budget (50%), lack of reimbursement (50%), and clinical time constraints (50%) were reported as potential barriers in provision of these services. 94% agreed about stronger integration of financial advocacy services into oncology practice and 84% felt that success of these services should be a quality metric. 31% of large centers vs. 100% of small centers plan to increase staffing in this area in the next 5 years. Conclusions: Majority of NCCN Member Institutions report screening and management programs for financial distress, though the actual practices and range of services vary widely. Information from this study can help centers benchmark their performance relative to similar cancer programs and identify best practices in this area.

e16096 Background: The tropism of cancer metastases is poorly understood yet holds prognostic value. Clear cell renal cell carcinoma (ccRCC) exhibits a broad pattern of metastases, making it an optimal model to study organotropism. Notably, when ccRCC metastasizes to the pancreas (PM) independently of other sites, it is associated with favorable outcomes in patients for unclear reasons. Here, we comprehensively analyzed the clinical and molecular profile of patients with PM. Methods: RCC patients with PM from UTSW and Cleveland Clinic were identified. Clinicopathologic data and oncologic outcomes were analyzed. Whole exome sequencing (WES), RNAseq, and histologic assessment of primary and metastatic tumors from PM patients were conducted. Results: 31 RCC patients with PM were identified. We observed remarkably favorable outcomes in our PM cohort, with a median overall survival (OS) of 10.7 years from metastatic diagnosis and a long latency between initial diagnosis and development of metastasis (median 69 months in patients who were non-metastatic at diagnosis). OS was independent of both metastatic tumor burden and known IMDC prognostic factors. We discovered that tumors from PM patients were markedly uniform and clustered together by gene expression analysis. WES and DNA copy number analyses revealed a high frequency of VHL and PBRM1 mutations, 3p loss, and 5q amplification, along with a lower frequency of 9p, 14q and 4q losses and BAP1 mutations, characteristic of indolent ccRCC. Furthermore, the genomic and histologic features of tumors from patients with PM can be recapitulated in patient-derived xenograft models. Conclusions: To our knowledge, this is the first report to unravel molecular determinants of organotropism, and we highlight that organotropism can be an independent prognostic factor. Understanding tumor heterogeneity may help refine prognostic models for metastatic RCC and hold implications for improved personalization of therapy.

97 Background: Insurance plans vary coverage for infusional (IV) vs oral drugs, leading some to suggest that patients on oral drugs pay more OOP than those on IV drugs. 43 states have passed laws requiring insurers to cover oral drugs equivalently to IV drugs. Yet, there is little evidence that these “parity laws” are effective. Our aim was to estimate impact of parity laws on OOP expenses for oral vs IV drugs. Methods: We sought to determine how quickly patients on oral vs IV drugs reach their plan’s annual OOP maximum (max) as a surrogate for OOP expense. We used 2017 data from Healthcare.gov public use files to generate cost-sharing profiles for all 3,092 unique Marketplace plans. Chronic lymphocytic leukemia (CLL) and metastatic hormone sensitive prostate cancer (mHSPC) were chosen as two representative malignancies since both have accepted, first-line, IV and oral treatment options. We created guideline-concordant, first-line treatment regimens for simulated patients with CLL (oral ibrutinib vs IV bendamustine/rituximab) or mHSPC (oral abiraterone vs IV docetaxel). Drug, professional, facility, imaging, and lab claims were simulated to calculate OOP costs. The mean number of days to reach the OOP maximum for each Marketplace plan and treatment regimen were recorded. We assessed variation according to insurance coverage levels (“metal tier”: Catastrophic, Bronze, Silver, Gold, Platinum). Results: For CLL patients, 95% of plans reached OOP max in approximately one month of treatment for both oral and IV drugs (oral: mean 36 days; IV: mean 29 days). 99% of mHSPC patients reached their OOP max for oral treatment in a mean 15 days, but only 57% of plans reached OOP max for IV mHSPC treatment. Metal tier impacts time to reach OOP max (table). Conclusions: Parity laws do not lower patient costs when both IV and oral treatment options are expensive. In these cases, patients reach the OOP max rapidly. The small subset of patients most likely to benefit from parity laws are those on oral therapy for a disease where the comparable IV drug is inexpensive (eg, generic docetaxel for mHSPC). [Table: see text]

20 Background: More than 20% of US clinical trials fail to accrue sufficient patients and terminate prematurely, impeding innovation and negating the valuable contributions of participating patients. The aim of this study is to estimate availability of patients for each trial opening in the national oncology clinical research portfolio to provide a benchmark for better understanding feasibility of clinical trial enrollment goals. Methods: The Database for Aggregate Analysis of ClinicalTrials.gov, up-to-date as of September 3, 2017, was used to identify actively-recruiting, interventional oncology trials at US sites. Observational studies were excluded as not all are registered. Trials were categorized via Medical Subject Headings or free text condition terms and sorted by cancer diagnosis. Trial slot availability was estimated between September 1, 2017, to August 31, 2018. Availability was estimated from total anticipated enrollment, assuming a constant recruitment rate. Estimates for studies with both foreign and US sites were pro-rated to calculate available enrollment in the US alone. The 2017 American Cancer Society cancer incidence estimates were used to approximate total US cancer diagnoses. Results: 4598 oncology trials were identified. Overall, an estimated 12.6 cancer patients are available for each clinical trial slot. The estimates by cancer diagnosis were: colorectal: 24.7 patients per trial slot; lung & bronchus: 20.1; prostate: 17.6; breast (female): 13.8; leukemia 11.6; and brain & other nervous system: 6.0. Conclusions: Across all diagnoses, 1 in 13 patients must enroll to meet accrual demands. This ratio varies by diagnosis. If cancer incidence is too low, trials with unrealistic accrual goals may be doomed at inception. In diagnoses with high disease burden, trial failure may be due to poor patient access or suboptimal design. [Table: see text]

207 Background: Despite the recognized side effect of financial toxicity after cancer, treatment decisions for breast cancer rarely include the costs of care. We sought to determine women’s experiences with breast cancer treatment costs, and their preferences for cost transparency at diagnosis. Methods: Women ≥18 years old with a history of breast cancer completed an 88-question electronic survey based on validated or published items. Descriptive statistics and regression analysis were used. Results: In total, 607 women with stage 0-III breast cancer participated. Median age at diagnosis was 49.6 years. Median time from diagnosis was 6.7 years (range 0.1-37.1). The majority had private (70%) insurance or Medicare (25%), and reported an annual household income ≥$74,000. 43% reported considering costs in treatment decisions. Median reported out-of-pocket (OOP) costs were $3,500; 25% reported OOP costs ≥$8,000, 10% reported OOP costs ≥$18,000 and 5% reported OOP costs ≥$30,000. 15.5% reported significant to catastrophic financial burden. Bilateral mastectomy +/- reconstruction vs lumpectomy (OR 1.9, p 0.03), greater stage at diagnosis (stage 3 vs 0, OR 3.9, p < 0.01), and discussion of costs during the clinical encounter (OR 2.3, p < 0.01) were associated with a higher risk of financial harm. Women who reported discussing costs were more likely to be stage 2 or 3 (56% vs 40%, p = 0.02), less likely to be depressed (24% vs 30%, p = 0.03), and had less insurance coverage (trend p = 0.02) compared to those who did not. Older age (OR 0.95, p < 0.01), increasing household income (overall p < 0.001), better insurance coverage (OR 0.5, p < 0.001), and longer time since diagnosis (OR 0.65, p < 0.001) was associated with a decreased risk of financial harm. 78% of participants never discussed costs with their cancer team. 79% preferred cost transparency prior to embarking on care, and 40% preferred that doctors consider costs when making recommendations. Conclusions: Many women with breast cancer reported significant financial burden related to their care, and the vast majority preferred knowing costs at diagnosis. Cost transparency may improve the quality of preference-sensitive treatment decisions and reduce the risk of financial harm.

Purpose The Veterans Affairs (VA) healthcare system treats approximately 3% of patients with cancer in the United States each year. We measured the quality of nonmetastatic colorectal cancer (CRC) care in VA as indicated by concordance with National Comprehensive Cancer Network practice guidelines (six indicators) and timeliness of care (three indicators). Patients and Methods A retrospective medical record abstraction was done for 2,492 patients with incident stages I to III CRC diagnosed between October 1, 2003, and March 31, 2006, who underwent definitive CRC surgery. Patients were treated at one or more of 128 VA medical centers. The proportion of patients receiving guideline-concordant care and time intervals between care processes were calculated. Results More than 80% of patients had preoperative carcinoembryonic antigen determination (ie, stages II to III disease) and documented clear surgical margins (ie, stages II to III disease). Between 72% and 80% of patients had appropriate referral to a medical oncologist (ie, stages II to III disease), preoperative computed tomography scan of the abdomen and pelvis (ie, stages II to III disease), and adjuvant fluorouracil-based chemotherapy (ie, stage III disease). Less than half of patients with stages I to III CRC (43.5%) had a follow-up colonoscopy 7 to 18 months after surgery. The mean number of days between major treatment events included the following: 26.6 days (standard deviation [SD], 38.2; median, 20 days) between diagnosis and initiation of treatment (in stages II to III disease); 64.9 days (SD, 54.9; median, 50 days) between definitive surgery and start of adjuvant chemotherapy (in stages II to III disease); and 444.1 days (SD, 182.1; median, 393 days) between definitive surgery and follow-up colonoscopies (in stages I to III disease). Conclusion Although there is opportunity for improvement in the area of cancer surveillance, the VA performs well in meeting established guidelines for diagnosis and treatment of CRC.

3555Background: MET amp is a well described driver of acquired EGFR antibody (Ab) resistance. Blood-based genomic profiling of cell free (cf)DNA is a safe and efficient means to identify pts with a...

e22146Background: People living with cancer face challenges too numerous to attend to during brief clinic visits, and thus may benefit from additional help with supportive care needs. While patient...

e18615Background: Improvements in cancer outcomes require the successful conduct of clinical trials, but trial enrollment has been a persistent challenge with more than 1 in 5 trials failing to acc...

6522Background: Dying in a preferred place is an essential component of high quality cancer care. Comprehensive national trends and disparities in place of death are unknown as prior research is li...

e15691Background: Impact of the preventive oral glutamine intake on the development of peripheral neuropathy (PN) was examined along with adjuvant (adj) FOLFOX applied in high and low risk colon ca...

161 Background: People living with cancer face challenges too numerous to attend to during brief clinic visits, and thus may benefit from additional help with supportive care needs. While patient navigators offer promise, they are a limited resource. Digital navigation offers a scalable solution, to extend navigators’ reach and connect patients with existing resources, thereby enhancing our ability to address unmet needs. Methods: Utilizing a “design thinking” approach, we developed and tested a digital navigation platform to enhance utilization of support resources in the Duke Cancer Institute (DCI). The alpha version of the application (app) was based upon insights gleaned from interactions with patients, caregivers, advisory board members, and staff. It was then tested among adult patients with advanced cancer at the DCI. Subjects participated in qualitative interviews with design/content experts, to elicit supportive care needs and gauge interest in utilizing the app to improve their care experiences. Detailed notes were taken, and emerging themes compiled. Results: We enrolled 10 patients and caregivers. Subjects reported feeling overwhelmed by information, feeling that “they don’t know where to start when looking for support.” They also expressed uncertainty about what questions to ask, and said they are not always comfortable asking for help. All struggled to define “supportive care;” only one knew it refers to a set of services. Subjects felt a digital navigation app would enable them to explore and access services as needed, to help them “feel less alone,” and to know “someone or something was there for them.” They expressed dislike for being asked lots of questions, wanting to explore options on their own instead of being led somewhere. Digital navigation has the promise to increase their sense of control, with one subject noting: “I like to know what my options are and decide for myself…people try to assume they know what you need all the time.” Conclusions: Digital supportive care navigation may be an effective, scalable, and cost-efficient intervention to support patients and caregivers, and ultimately improve outcomes. Further refinement and testing of this approach is needed.

30 Background: Survivorship care plans (SCPs) are individualized documents that summarize cancer treatment received and provide guidelines for monitoring and maintaining survivors’ health. While SCPs are intended to facilitate care coordination, they are rarely used in the primary care setting. We aimed to understand the informational needs and delivery preferences of PCPs, cancer survivors, cancer specialists, and nurses related to SCPs. Methods: We conducted semi-structured interviews with a purposeful sample of PCPs (n = 10), cancer specialists (n = 5), nurses (n = 5), and cancer survivors (n = 5). After reviewing a sample SCP based on the published ASCO template, participants were asked about acceptability, appropriateness, feasibility, fidelity, implementation, and sustainability. De-identified transcripts were qualitatively analyzed using NVivo software. Results: 25 interviews were completed (RR 45%). Emergent themes included informational needs and delivery preferences. Informational needs include clarifying roles and responsibilities of allied professionals; the roles of the PCP for follow-up care should be clear, outlined and with content summarizing their responsibilities regarding screening, and surveillance. Additionally, SCPs should emphasize side and late effects of cancer treatment for the benefit of patients and providers. Delivery preferences include using sustainable and accessible electronic formats to improve provider communication and streamlining documentation for the intended audience. Electronic SCPs could be frequently updated with pertinent information about patient needs and care over time. Conclusions: Understanding the needs and preferences of PCPs may address current limitations of SCPs in coordinating survivor care. Future SCPs may be electronic and accessible, with content and guidance targeted to the PCP’s role.