Search

PURPOSE: Compared with conventional external-beam radiation therapy (cEBRT) for patients with breast cancer (BC) and prostate cancer (PC), shorter radiation regimens may be associated with lower treatment noncompletion rates. We assess disparities in receipt of shorter radiation regimens and treatment noncompletion for BC and PC. PATIENTS AND METHODS: The 2004-2017 National Cancer Database was queried for adjuvant cEBRT or hypofractionated EBRT (hEBRT) for nonmetastatic BC; and definitive cEBRT, moderate hypofractionation (mEBRT), or stereotactic body radiotherapy (SBRT) for localized PC. Multivariable logistic regression identified factors associated with treatment noncompletion and receipt of shorter regimens. FINDINGS: We identified 170,386 men with PC (median age [interquartile range], 70 [64-75] years; Black, 17.5%; White, 82.5%) and 306,846 women with BC (61 [52-69] years; Black, 12.3%; White, 87.7%). Among patients who received cEBRT for PC, Black men had higher treatment noncompletion rates compared with White (14.1% v 13.0%; odds ratio [95% CI] 1.07 [1.03 to 1.12]; P < .001). In contrast, treatment noncompletion was not disparate with SBRT (Black 1.6% v White 1.3%; 1.20 [0.72 to 2.00], P = .49) or mEBRT (Black 9.0% v White 7.1%; 1.05 [0.72 to 1.54], P = .79). From 2004 to 2017, SBRT (0.07% to 11.8%; 1.32 [1.31 to 1.33]) and mEBRT (0.35% to 9.1%; 1.27 [1.25 to 1.28]) increased (both P < .001); however, Black men were consistently less likely to receive SBRT (7.4% v White, 8.3%; 0.84 [0.79 to 0.89], P < .001). Among women with BC, there were no racial differences in treatment noncompletion; however, hEBRT was associated with lower treatment noncompletion rates (1.0% v cEBRT 2.3%; 0.39 [0.35 to 0.44], P < .001). Although hEBRT for BC increased (0.8% to 35.6%) between 2004 and 2017, Black women were less likely to receive hEBRT (10.4% v 15.3%; 0.78 [0.75 to 0.81], P < .001). INTERPRETATION: Black patients were consistently less likely to receive hypofractionated radiation for PC or BC, despite evidence suggesting that shorter regimens may lower rates of treatment noncompletion with similar oncologic outcomes.

Smoking during breast radiotherapy (RT) may be associated with radiation-induced skin injury (RISI). We aimed to determine if a urinary biomarker of tobacco smoke exposure is associated with increased rates of RISI during and after breast RT.Women with Stage 0-IIIA breast cancer treated with breast-conserving surgery or mastectomy followed by RT to the breast or chest wall with or without regional nodal irradiation were prospectively enrolled on a multicenter study assessing acute/late RISI. 980 patients with urinary cotinine (UCot) measurements (baseline and end-RT) were categorized into three groups. Acute and late RISI was assessed using the ONS Acute Skin Reaction scale and the LENT-SOMA Criteria.Late Grade 2+ and Grade 3+ RISI occurred in 18.2% and 1.9% of patients, respectively-primarily fibrosis, pain, edema, and hyperpigmentation. Grade 2+ late RISI was associated with UCot group (P= 006). Multivariable analysis identified UCot-based light smoker/secondhand smoke exposure (HR 1.79, P= .10) and smoking (HR 1.60, p = .06) as non-significantly associated with an increased risk of late RISI. Hypofractionated breast RT was associated with decreased risk of late RISI (HR 0.51, P=.03). UCot was not associated with acute RISI, multivariable analysis identified race, obesity, RT site/fractionation, and bra size to be associated with acute RISI.Tobacco exposure during breast RT may be associated with an increased risk of late RISI without an effect on acute toxicity. Smoking cessation should be encouraged prior to radiotherapy to minimize these and other ill effects of smoking.

Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.

A concerted commitment across research stakeholders is necessary to increase equity, diversity, and inclusion (EDI) and address barriers to cancer clinical trial recruitment and participation. Racial and ethnic diversity among trial participants is key to understanding intrinsic and extrinsic factors that may affect patient response to cancer treatments. This ASCO and Association of Community Cancer Centers (ACCC) Research Statement presents specific recommendations and strategies for the research community to improve EDI in cancer clinical trials. There are six overarching recommendations: (1) clinical trials are an integral component of high-quality cancer care, and every person with cancer should have the opportunity to participate; (2) trial sponsors and investigators should design and implement trials with a focus on reducing barriers and enhancing EDI, and work with sites to conduct trials in ways that increase participation of under-represented populations; (3) trial sponsors, researchers, and sites should form long-standing partnerships with patients, patient advocacy groups, and community leaders and groups; (4) anyone designing or conducting trials should complete recurring education, training, and evaluation to demonstrate and maintain cross-cultural competencies, mitigation of bias, effective communication, and a commitment to achieving EDI; (5) research stakeholders should invest in programs and policies that increase EDI in trials and in the research workforce; and (6) research stakeholders should collect and publish aggregate data on racial and ethnic diversity of trial participants when reporting results of trials, programs, and interventions to increase EDI. The recommendations are intended to serve as a guide for the research community to improve participation rates among people from racial and ethnic minority populations historically under-represented in cancer clinical trials. ASCO and ACCC will work at all levels to advance the recommendations in this publication.

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common therapeutic complication affecting cancer patients’ quality-of-life. We evaluated clinical characteristics, demographics, and lifestyle factors in association with CIPN following taxane treatment. Methods: Data were extracted from the electronic health record of 3387 patients diagnosed with a primary cancer and receiving taxane (i.e., paclitaxel or docetaxel) at Vanderbilt University Medical Center. Neuropathy was assessed via a validated computer algorithm. Univariate and multivariate regression models were applied to evaluate odds ratios (ORs) and 95% confidence intervals (CIs) of CIPN-associated factors. Results: Female sex (OR = 1.28, 95% CI = 1.01–1.62), high body-mass index (BMI) (OR = 1.31, 95% CI = 1.06–1.61 for overweight, and OR = 1.49, 95% CI = 1.21–1.83 for obesity), diabetes (OR = 1.66, 95% CI = 1.34–2.06), high mean taxane dose (OR = 1.05, 95% CI = 1.03–1.08 per 10 mg/m2), and more treatment cycles (1.12, 95% CI = 1.10–1.14) were positively associated with CIPN. Concurrent chemotherapy (OR = 0.74, 95% CI = 0.58–0.94) and concurrent radiotherapy (OR = 0.77, 95% CI = 0.59–1.00) were inversely associated with CIPN. Obesity and diabetes both had a stronger association with docetaxel CIPN compared to paclitaxel, although interaction was only significant for diabetes and taxane (p = 0.019). Increased BMI was associated with CIPN only among non-diabetic patients (OR:1.34 for overweight and 1.68 for obesity), while diabetes increased CIPN risk across all BMI strata (ORs were 2.65, 2.41, and 2.15 for normal weight, overweight, and obese, respectively) compared to normal-weight non-diabetic patients (p for interaction = 0.039). Conclusions: Female sex, obesity, and diabetes are significantly associated with taxine-induced CIPN. Further research is needed to identify clinical and pharmacologic strategies to prevent and mitigate CIPN in at-risk patient populations.

This case-control study assesses the prevalence of patient-reported delayed or forgone care due to patient-clinician identity discordance among cancer survivors and factors associated with this barrier to care.

PURPOSE: Cancer disparities persist among medically underserved populations despite widespread efforts to address them. We describe the development of a framework for addressing cancer care disparities across the cancer care continuum (CCC), guided by the CCC domains established by the Institute of Medicine/National Academies of Sciences, Engineering, and Medicine (IOM/NAS). MATERIALS AND METHODS: An environmental scan was conducted to identify strategies and associated experts who are providing or have successfully provided community- and/or patient-centric IOM/NAS-defined domain standards to our target populations. A multistakeholder expert roundtable working group was convened for framework development. A premeeting survey informed agenda development, documented expert practices for target populations, and identified priority areas for meeting focus. RESULTS: The environmental scan identified 84 unique experts across 8 stakeholder groups and 44 patient organizations; 50 were invited to the roundtable and 33 participated. They broadly represented disease sites, geography, and experience with target populations and all CCC domains. The premeeting survey (16 responses) identified coordination of care or patient navigation (66.7%), community engagement (60.0%), and healthcare system changes (53.3%) as priority focus areas. The experts identified access and treatment barriers or gaps within and between CCC domains, specified key notable practices to address these, and developed an actionable framework and recommendations for each priority focus area. CONCLUSION: The framework and recommendations are intended to guide researchers, healthcare leaders, advocates, community- and patient-focused service organizations, and policy leaders to address and promote health equity in cancer care access and treatment outcomes.

Black physicians remain disproportionately underrepresented in certain medical specialties, yet comprehensive assessments in radiation oncology (RO) are lacking. Our purpose was to report current and historical representation trends for Black physicians in the US RO workforce.Public registries were used to assess significant differences in 2016 representation for US vs RO Black academic full-time faculty, residents, and applicants. Historical changes from 1970 to 2016 were reported descriptively. Linear regression was used to assess significant changes for Black residents and faculty from 1995 to 2016.In 2016, Black people represented 3.2% vs 1.5% (P.001), 5.6% vs 3.2% (P = .005), and 6.5% vs 5.4% (P = .352) of US vs RO faculty, residents, and applicants, respectively. Although RO residents nearly doubled from 374 (1974) to 720 (2016), Black residents peaked at 31 in 1984 (5.9%; 31 of 522) and fell to 23 (3.2%; 23 of 720) in 2016 across 91 accredited programs; Black US graduate medical education trainees nearly doubled over the same period: 3506 (1984) to 6905 (2016). From 1995 to 2016, Black US resident representation significantly increased by 0.03%/y, but decreased significantly in RO by -0.20%/y before 2006 and did not change significantly thereafter. Over the same period, Black US faculty representation significantly increased by 0.02%/y, whereas Black RO faculty significantly increased by 0.07%/y before 2006, then decreased significantly by -0.16%/y thereafter. The number of Black RO faculty peaked at 37 in 2006 (3.1%; 37 of 1203) and was 27 (1.5%; 27 of 1769) in 2016, despite the nearly 1.5-fold increase in the number of both RO faculty and Black US faculty overall (4169 in 2006 and 6047 in 2016) during that period.Black physicians remain disproportionately underrepresented in RO despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand barriers to specialty training and inclusion, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the RO physician workforce.

Recent events have reaffirmed that racism is a pervasive disease plaguing the United States and infiltrating the fabric of this nation. As health care professionals dedicated to understanding and alleviating disease, many radiation oncologists have failed to acknowledge how structural racism affects the health and well-being of the patients we aim to serve. The literature is full of descriptive statistics showing the higher incidence and mortality experienced by the Black population for health conditions ranging from infant mortality to infectious disease, including coronavirus disease 2019 (COVID-19). Acknowledgment that the root of health disparities experienced by Black people in this country are based in racism is essential to moving the nation and the field of radiation oncology forward. With this lens, a brief overview of structural and institutional racism shapes a discussion of what radiation oncologists and the organizations that represent them can do to address this scourge. As members of a technological field, we often harness the power of data to advance human health and approach challenging diseases with optimism that multidisciplinary effort can produce cure. A few principles to mitigate the longstanding issues of Black marginalization within the field have been recommended via the ATIP (Acknowledgment, Transparency, Intentionality, and rePresentation) and LEADS (Learn, Engage, Advocate, Defend, Support) approaches. However, additional introspection is encouraged. Just as individuals, practices, and organizations rallied to determine how best to address the issues related to the COVID-19 pandemic, the same investigational fervor must be applied to the issue of racism to combat this sinister and often deadly disease.

Although survival rates for stage I to III breast cancer have greatly increased, in part due to improved treatment options, this progress is threatened by increased cardiovascular (CV) events for survivors. More than 35% of women experience CV injury, left ventricular (LV) dysfunction, exercise

Background The United States (US) radiation oncology workforce is comparatively less diverse than the US population and US medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study is to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training, utilizing the recently established medical student membership category. Methods Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The chi-square test was used to assess for differences between subgroups. Results Compared to members-in-training, student members were more likely to be female (40.0% vs. 31.5%, p = 0.032), Black or African American (10.7% vs. 4.8%, p = 0.009), candidates for or holders of a DO rather than MD degree (5.2% vs. 1.5%, p = 0.002), and from a US medical school that is not affiliated with a radiation oncology residency program (30.5% vs. 20.9%, p = 0.001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs. 5.4%, p = 0.356). There were no indigenous members in either category assessed. Conclusion Medical student members of ASTRO are more diverse in terms of Black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or non-multiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention vs. attrition may increase diversity, equity, and inclusion in radiation oncology.

Ionizing radiation causes injury to the skin that produces a complex clinical presentation that is managed by various paradigms without clear standards. The situation is further complicated by the fact that clinicians and researchers often use different terms and billing codes to describe the spectrum of cutaneous injury. There is, however, general agreement between the two most commonly-used diagnostic scales, the Radiation Therapy Oncology Group and the Common Terminology Criteria for Adverse Events, and in their use to describe skin injury following radiation therapy. These scales are typically used by radiation oncologists to quantify radiation dermatitis, a component of the radiation-related disorders of the skin and subcutaneous tissue family of diagnoses. In rare cases, patients with severe injury may require treatment by wound care or burn specialists, in which case the disease is described as a “radiation burn” and coded as a burn or corrosion. Further compounding the issue, most US government agencies use the term Cutaneous Radiation Injury to indicate skin damage resulting from large, whole-body exposures. In contrast, the US Food and Drug Administration approves products for radiation dermatitis or “burns caused by radiation oncology procedures.” A review of the literature and comparison of clinical presentations shows that each of these terms represents a similar injury, and can be used interchangeably. Herein we provide a comparative review of the commonly used terminology for radiation-induced skin injury. Further, we recommend standardization across clinicians, providers, and researchers involved in the diagnosis, care, and investigation of radiation-induced skin injury. This will facilitate collaboration and broader inclusion criteria for grant-research and clinical trials and will assist in assessing therapeutic options particularly relevant to patient skin pigmentation response differences.

Background Racial and ethnic diversity in clinical trials for cancer treatment is essential for the development of treatments that are effective for all patients and for identifying potential differences in toxicity between different demographics. Mining of social media discussions about clinical trials has been used previously to identify patient barriers to enrollment in clinical trials; however, a comprehensive breakdown of sentiments and barriers by various racial and ethnic groups is lacking. Objective The aim of this study is to use an innovative methodology to analyze web-based conversations about cancer clinical trials and to identify and compare conversation topics, barriers, and sentiments between different racial and ethnic populations. Methods We analyzed 372,283 web-based conversations about cancer clinical trials, of which 179,339 (48.17%) of the discussions had identifiable race information about the individual posting the conversations. Using sophisticated machine learning software and analyses, we were able to identify key sentiments and feelings, topics of interest, and barriers to clinical trials across racial groups. The stage of treatment could also be identified in many of the discussions, allowing for a unique insight into how the sentiments and challenges of patients change throughout the treatment process for each racial group. Results We observed that only 4.01% (372,283/9,284,284) of cancer-related discussions referenced clinical trials. Within these discussions, topics of interest and identified clinical trial barriers discussed by all racial and ethnic groups throughout the treatment process included health care professional interactions, cost of care, fear, anxiety and lack of awareness, risks, treatment experiences, and the clinical trial enrollment process. Health care professional interactions, cost of care, and enrollment processes were notably discussed more frequently in minority populations. Other minor variations in the frequency of discussion topics between ethnic and racial groups throughout the treatment process were identified. Conclusions This study demonstrates the power of digital search technology in health care research. The results are also valuable for identifying the ideal content and timing for the delivery of clinical trial information and resources for different racial and ethnic groups.

Histiocytic sarcoma (HS) is a rare aggressive malignancy with a dismal prognosis and no agreed-upon standard treatment. Classically, the diagnosis of HS has been difficult to confirm and has relied on inaccurate, crude techniques. Therapy often involves intensive chemotherapeutic regimens, surgery, and/or radiotherapy, which are poorly tolerated with variable response rates. Patients often die of diffusely metastatic disease. Modern diagnostic techniques are helping to slowly uncover more uniquely customized therapeutic approaches in this enigmatic disease. We present a review of the current literature regarding HS diagnosis, treatment, and outcomes. Additionally, we describe the first reported case of HS transdifferentiated from follicular lymphoma that had a dramatic and durable response to rituximab/bendamustine alone as initial treatment. Unlike traditional chemotherapy regimens, this treatment was well tolerated and had a good toxicity profile. The combination of rituximab and bendamustine warrants further investigation in the treatment of HS, especially those originating from prior follicular lymphoma. Modern immunohistochemical and molecular profiling techniques are beginning to reveal heterogeneity among HS tumors and potentially therapeutic targets.

PURPOSE/OBJECTIVE(S) Although racial and sociodemographic disparities exist in the rates of treatment noncompletion for patients receiving breast and prostate radiotherapy, shorter regimens may be associated with lower rates of treatment noncompletion. We assessed predictors of treatment noncompletion and racial disparities in access to shorter regimens for patients with prostate cancer (PCa) and breast cancer (BCa). MATERIALS/METHODS Using the 2004-2017 National Cancer Database, men with localized PCa were defined as receiving conventional fractionation if they received 180cGY/fraction (noncompletion: < 41 fractions) or 200cGY/fraction (noncompletion: < 37 fractions). Stereotactic body radiotherapy (SBRT) was defined as five to eight fractions of 600-800cGY/fraction (non-completion: < 5 fractions). Women with non-metastatic BCa who received surgery with radiotherapy were included. Patients receiving 180cGY or 200cGY/fraction were defined as receiving conventional fractionation (noncompletion: < 25 fractions); patients receiving 266cGY, 267cGY, or 270cGY per fraction (noncompletion: < 15 fractions) were defined as receiving hypofractionated regimens. Multivariable logistic regressions assessed predictors of treatment noncompletion and racial disparities in access to shorter regimens. RESULTS 166,436 men with complete data met inclusion criteria (median age 70 years [IQR 64-75]; 19.6% low-risk, 47.3% intermediate-risk; 33.1% high-risk; 17.5% Black; 82.5% white). Black men had higher rates of treatment noncompletion compared with white men (13.5% vs. 12.3%, OR 1.07, 95% CI 1.03-1.12, P < 0.001). SBRT was associated with lower odds of treatment non-completion compared with conventional EBRT (SBRT 1.3% vs. EBRT 13.2%; OR 0.08, 95% CI 0.07-0.1, P < 0.001). Although use of SBRT increased from 0.07% in 2004 to 13.03% in 2017, Black patients were less likely to receive SBRT (5.3% vs. 6.1%, OR 0.77, 95% CI 0.71-0.83, P < 0.001). 306,846 women met inclusion criteria (median age 61 years [IQR 52-69]; 17.4% in situ; 43.0% stage 1; 26.5% stage 2; 13.2% stage 3; 12.3% were Black and 87.7% were white). Treatment noncompletion did not differ significantly for Black (2.8%) vs. White (2.0%) women. Women who received hypofractionated EBRT had lower rates of treatment noncompletion compared to women who received conventional regimens (1.0% vs. 2.3%; OR 0.39, 95% CI 0.35-0.44, P < 0.001). Although rates of hypofractionated EBRT for breast cancer significantly increased from 0.8% in 2004 to 35.6% in 2017, Black patients were significantly less likely to receive hypofractionated EBRT (10.4% vs. 15.3%, OR 0.78, 95% CI 0.75-0.81, P < 0.001). CONCLUSION Although shorter treatment regimens of radiation therapy were associated with lower rates of treatment noncompletion, disparities persisted in receipt of shorter regimens. Our findings underscore the need to identify barriers to treatment completion and racial bias and inequities in access to treatment regimens that are more likely to be completed.

Purpose/Objective(s) Gender & racial/ethnic leadership disparities have been independently identified in academic hematology/oncology (HO) and radiation oncology (RO). Here, we evaluate gender and racial/ethnic intersectionality from the trainee to the leadership level. Materials/Methods All ACGME accredited HO and RO training program websites were queried to identify constituent trainees, academic faculty, program directors (PD) and department chairs (DC), with a leadership position defined as PD or DC. Individual gender & race/ethnicity was determined using externally validated software tools, publicly available descriptors, and image review. We grouped individuals into 6 categories: White Male (WM), White Female (WF), Asian Male (AM), Asian Female (AF), Underrepresented Groups in Medicine (as defined by AAMC) Male (URMM) and Female (URMF). The chi-squared goodness-of-fit test was applied to examine if deviations exist between the observed vs. expected proportions of gender/race dyads in trainees, PD, and DC compared to academic faculty. Results We identified 7,722 individuals from 2019-2020: 1,759 trainees (HO = 1525; RO = 234), 5,726 faculty (HO = 4834; RO = 892), 242 PD (HO = 149; RO = 93) and 237 DC (HO = 144; RO = 93). Leadership positions were most often comprised by WM (52.6%), and least often comprised by URMF (2.9%). Combined HO/RO analysis revealed significant differences in the observed representation of trainees & DC vs expected levels based on total faculty, respectively: WM (33.7% & 60.3% vs. 42.3%), WF (19.2% & 13.9% vs. 22.3%), AM (20.75% & 16.9% vs. 16.4%), AF (17.9% & 2.5% vs. 12.7%), URMM (4.09% & 5.5% vs. 3.5%) and URMF (4.3% & 0.8% vs. 2.8%), P Conclusion Gender & racial/ethnic disparity is present in academic oncology. Specifically, women of all races/ethnicities are proportionally underrepresented in DC positions in HO and RO programs. These data can serve as a benchmark to raise awareness and monitor progress towards a more balanced workforce in oncology.

Background Cardiovascular health is of increasing concern to breast cancer survivors and their health care providers, as many survivors are more likely to die from cardiovascular disease than cancer. Implementing clinical decision support tools to address cardiovascular risk factor awareness in the oncology setting may enhance survivors’ attainment or maintenance of cardiovascular health. Objective We sought to evaluate survivors’ awareness of cardiovascular risk factors and examine the usability of a novel electronic health record enabled cardiovascular health tool from the perspective of both breast cancer survivors and oncology providers. Methods Breast cancer survivors (n=49) recruited from a survivorship clinic interacted with the cardiovascular health tool and completed pre and posttool assessments about cardiovascular health knowledge and perceptions of the tool. Oncologists, physician assistants, and nurse practitioners (n=20) who provide care to survivors also viewed the cardiovascular health tool and completed assessments of perceived usability and acceptability. Results Enrolled breast cancer survivors (84% White race, 4% Hispanic ethnicity) had been diagnosed 10.8 years ago (SD 6.0) with American Joint Committee on Cancer stage 0, I, or II (45/49, 92%). Prior to viewing the tool, 65% of survivors (32/49) reported not knowing their level for one or more cardiovascular health factors (range 0-4). On average, only 45% (range 0%-86%) of survivors’ known cardiovascular health factors were at an ideal level. More than 50% of survivors had ideal smoking status (45/48, 94%) or blood glucose level (29/45, 64%); meanwhile, less than 50% had ideal blood pressure (12/49, 24%), body mass index (12/49, 24%), cholesterol level (17/35, 49%), diet (7/49, 14%), and physical activity (10/49. 20%). More than 90% of survivors thought the tool was easy to understand (46/47, 98%), improved their understanding (43/47, 91%), and was helpful (45/47, 96%); overall, 94% (44/47 survivors) liked the tool. A majority of survivors (44/47, 94%) thought oncologists should discuss cardiovascular health during survivorship care. Most (12/20, 60%) oncology providers (female: 12/20, 60%; physicians: 14/20, 70%) had been practicing for more than 5 years. Most providers agreed the tool provided useful information (18/20, 90%), would help their effectiveness (18/20, 90%), was easy to use (20/20, 100%), and presented information in a useful format (19/20, 95%); and 85% of providers (17/20) reported they would use the tool most or all of the time when providing survivorship care. Conclusions These usability data demonstrate acceptability of a cardiovascular health clinical decision support tool in oncology practices. Oncology providers and breast cancer survivors would likely value the integration of such apps in survivorship care. By increasing awareness and communication regarding cardiovascular health, electronic health record–enabled tools may improve survivorship care delivery for breast cancer and ultimately patient outcomes.

The COVID-19 pandemic that continues to ravage communities all over the United States is serving to highlight some of the long-standing inequities that have plagued our nation. At the time this article was written, members of the Black community accounted for 52% of COVID-19 deaths in Milwaukee County.1Milwaukee CountyMilwaukee County COVID-19 dashboard.https://mcoem.maps.arcgis.com/apps/opsdashboard/index.html#/018eedbe075046779b8062b5fe1055bfDate accessed: April 28, 2020Google Scholar This is a striking disparity in a county where only 27% of the population identifies as Black.2United States CensusQuick facts: Milwaukee County.https://www.census.gov/quickfacts/milwaukeecountywisconsinDate accessed: April 28, 2020Google Scholar Similar disparities are noted throughout the United States as other minority and vulnerable populations fall victim to complications from the virus.3City of ChicagoCity of Chicago COVID-19 data.https://www.chicago.gov/city/en/sites/covid-19/home/latest-data.htmlDate accessed: April 28, 2020Google Scholar,4State of LouisianaState of Louisiana COVID-19 data.http://ldh.la.gov/Coronavirus/Date accessed: April 28, 2020Google Scholar

Background American Society of Clinical Oncology guidelines recommend that patients ≥65 years of age starting chemotherapy undergo a geriatric assessment (GA) to inform and guide management; however, little is known about resources available in community oncology practices to implement these guidelines and to facilitate geriatric oncology research. Materials and Methods Oncology practices within the National Cancer Institute Community Oncology Research Program (NCORP) were electronically surveyed in 2017 regarding the availability of specialty providers, supportive services, and practice characteristics, as part of a larger survey of cancer care delivery research capacity. Results Of the 943 NCORP practices, 504 (54%) responded to the survey, representing 210 practice groups. The median new cancer cases per year ≥65 years of age was 457 (interquartile range 227–939). Of respondents, only 2.0% of practices had a fellowship-trained geriatric oncologist on staff. Geriatricians were available for consultation or comanagement at 37% of sites, and of those, only 13% had availability within the oncology clinic (5% of overall). Practice size of ≥1,000 new adult cancer cases (ages ≥18) per year was associated with higher odds (1.81, confidence interval 1.02–3.23) of geriatrician availability. Other multidisciplinary care professionals that could support GA were variably available onsite: social worker (84%), nurse navigator (81%), pharmacist (77%), dietician (71%), rehabilitative medicine (57%), psychologist (42%), and psychiatrist (37%). Conclusion Only a third of community oncology practices have access to a geriatrician within their group and only 5% of community sites have access within the oncology clinic. Use of primarily self-administered GA tools that direct referrals to available services may be an effective implementation strategy for guideline-based care. Implications for Practice Only a minority of community oncology practices in the U.S. have access to geriatric specialty care. Developing models of care that use patient-reported measures and/or other geriatric screening tools to assess and guide interventions in older adults, rather than geriatric consultations, are likely the most practical methods to improve the care of this vulnerable population.

Purpose Despite high response rates, there has been reluctance to use radiation therapy for patients with relapsed/refractory (r/r) Hodgkin (HL) or aggressive non-Hodgkin lymphoma (NHL) given concerns for subacute and late toxicities. Symptomatic pneumonitis, a subacute toxicity, has an incidence of 17% to 24% (≥grade 2) even with intensity modulated radiation therapy. Proton therapy (PT), which has no exit radiation dose, is associated with a lower dose to lung compared with other radiation techniques. As risk of radiation pneumonitis is associated with lung dose, we evaluated whether pneumonitis rates are lower with PT. Methods and Materials Within an international, multi-institutional cohort, we retrospectively evaluated the incidence and grade of radiation pneumonitis (National Cancer Institute Common Terminology Criteria for Adverse Events v4) among patients with r/r HL or NHL treated with PT. Results A total of 85 patients with r/r lymphoma (66% HL, 34% NHL; 46% primary chemorefractory) received thoracic PT from 2009 to 2017 in the consolidation (45%) or salvage (54%) setting. Median dose was 36 Gy(RBE). Before PT, patients underwent a median of 1 salvage systemic therapy (range, 0-4); 40% received PT within 4 months of transplant. With a median follow-up of 26.3 months among living patients, 11 patients developed symptomatic (grade 2) pneumonitis (12.8%). No grade 3 or higher pneumonitis was observed. Dose to lung, including mean lung dose, lung V5, and V20, significantly predicted risk of symptomatic pneumonitis, but not receipt of brentuximab, history of bleomycin toxicity, sex, or peritransplant radiation. Conclusions PT for relapsed/refractory lymphoma was associated with favorable rates of pneumonitis compared with historical controls. We confirm that among patients treated with PT, pneumonitis risk is associated with mean lung and lung V20 dose. These findings highlight how advancements in radiation delivery may improve the therapeutic ratio for patients with relapsed/refractory lymphoma. PT may be considered as a treatment modality for patients with relapsed/refractory lymphoma in the consolidation or salvage setting.

There is currently much interest in identifying and mitigating gender inequity within medicine, the greater workforce and society as a whole. We provide an evidence-based review of current and historical trends in gender diversity in the RO physician workforce and identify potential barriers to diversity and inclusion in training, professional development, and career advancement. Next, we move to actionable items, addressing methods to mitigate bias, harassment, and other impediments to professional productivity and characterizing leadership lessons and imperatives for departmental, institutional, and organizational leaders.

Background Despite efforts to ameliorate disparities in cancer care and clinical trials, barriers persist. As part of a multiphase community-engaged assessment, an exploratory community-engaged research partnership, forged between an academic hospital and a community-based organization, set out to explore perceptions of cancer care and cancer clinical trials by black Bostonians. Materials and methods Key informant interviews with health care providers and patient advocates in community health centers (CHCs), organizers from grassroots coalitions focused on cancer, informed the development of a focus group protocol. Six focus groups were conducted with black residents in Boston, including groups of cancer survivors and family members. Transcripts were coded thematically and a code-based report was generated and analyzed by community and academic stakeholders. Results While some participants identified clinical trials as beneficial, overall perceptions conjured feelings of fear and exploitation. Participants describe barriers to clinical trial participation in the context of cancer care experiences, which included negative interactions with providers and mistrust. Primary care physicians (PCPs) reported being levied as a trusted resource for patients undergoing care, but lamented the absence of a mechanism by which to gain information about cancer care and clinical trials. Conclusions Confusion about cancer care and clinical trials persists, even among individuals who have undergone treatment for cancer. Greater coordination between PCPs and CHC care teams and oncology care teams may improve patient experiences with cancer care, while also serving as a mechanism to disseminate information about treatment options and clinical trials. Implications for practice Inequities in cancer care and clinical trial participation persist. The findings of this study indicate that greater coordination with primary care physicians (PCPs) and community health center (CHC) providers may be an important step for both improving the quality of cancer care in communities and increasing awareness of clinical trials. However, PCPs and CHCs are often stretched to capacity with caring for their communities. This leaves the oncology community well positioned to create programs to bridge the communication gaps and provide resources necessary to support oncologic care along the cancer continuum, from prevention through survivorship.

11009 Background: Gender & racial/ethnic leadership disparities have been independently identified in academic hematology/oncology (HO) and radiation oncology (RO). Here, we evaluate gender and racial/ethnic intersectionality from the trainee to the leadership level. Methods: All ACGME accredited HO and RO training program websites were queried to identify constituent trainees, academic faculty, program directors (PD) and department chairs (DC), with a leadership position defined as PD or DC. Individual gender & race/ethnicity was determined using externally validated software tools (Gender-API, NamSor, & Onolytics), publicly available descriptors, and image review. We grouped individuals into 6 categories: White Male (WM), White Female (WF), Asian Male (AM), Asian Female (AF), Underrepresented Groups in Medicine (as defined by AAMC) Male (URMM) and Female (URMF). The chi-squared goodness-of-fit test was applied to examine if deviations exist between the observed vs. expected proportions of gender/race dyads in trainees, PD, and DC compared to academic faculty. Results: We identified 7,722 individuals from 2019-2020: 1,759 trainees (HO=1525; RO=234), 5,726 faculty (HO=4834; RO=892), 242 PD (HO=149; RO=93) and 237 DC (HO=144; RO=93). Leadership positions were most often comprised by WM (52.6%), and least often comprised by URMF (2.9%). Combined HO/RO analysis revealed significant differences in the observed representation of trainees & DC vs expected levels based on total faculty, respectively: WM (33.7% & 60.3% vs. 42.3%), WF (19.2% & 13.9% vs. 22.3%), AM (20.75% & 16.9% vs. 16.4%), AF (17.9% & 2.5% vs. 12.7%), URMM (4.09% & 5.5% vs. 3.5%) and URMF (4.3% & 0.8% vs. 2.8%), p

This topic addresses the treatment of newly diagnosed patients with favorable prognosis stage I and II Hodgkin lymphoma. In most cases, combined modality therapy (chemotherapy followed by involved site radiation therapy) constitutes the current standard of care. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. By combining the most recent medical literature and expert opinion, this revised guideline can aid clinicians in the appropriate use of combined modality therapy for favorable prognosis stage I and II Hodgkin lymphoma. Increasing information about the late effects of treatment has led to attempts to decrease toxicity by using less chemotherapy (decreased duration and/or intensity or different agents) and less radiation therapy (reduced volume and/or dose) while maintaining excellent efficacy.

“The chance for a cure, the chance to live, should no longer remain an accident of geography” (1). This is one of the key messages in “Closing the cancer divide: A blueprint to expand access in low and middle income countries” (1). This article highlights the growing burden of global cancer disparities and makes a compelling case that the time for unified action to close this divide is now. There is growing consensus that information and communication technologies (ICTs) have tremendous potential to catalyze global health collaborations. Advanced ICTs can be used to leverage the recent major upsurge in global health interest into greater space-time flexible collaborative action against cancer and for enhancing greater effectiveness of existing global health initiatives. The recent call for greater action in closing the cancer divide through collaborations, including that in International Journal of Radiation, Oncology, Biology, Physics (IJROBP), inspired the 2015 Global Health Catalyst cancer summit, which brought together a unique combination of global oncology leaders, diaspora leaders, and ICT and palliative care experts, industry, nonprofits, and policy makers. The summit provided a forum for networking, knowledge sharing, and discussion of some of the emerging models for ICT-powered global health collaborations in radiation oncology care, research, and education, as well as avenues for complementary outreach, including engagement with the diaspora. This article summarizes the discussions and recommendations from the summit and highlights the emerging ICT-powered models for radiation oncology global health, avenues for greater outreach (ubuntu, a term signifying the idea that “I am because we are,” or human connectedness [see discussion below]) for greater impact and sustainability, as well as emerging areas for scaling up and increased action toward closing the cancer divide. At the primary level, a distressing illustration of the cancer divide can be seen in Africa, where most of Africa’s more than 2000 languages do not even have a word for cancer (2). Thus, in that geography, many people die painfully of cancer and, sadly, do not know it. In areas more familiar with cancer, a great lack of cancer prevention education or awareness of the importance of early detection contributes to over one third of preventable cancer deaths (3). This problem is further exacerbated by a culture of silence and strong social stigma associated with the disease (4); even young doctors do not want to specialize in oncology, a medical area that talks only about pain and death. The stigma also means that the overwhelming majority of patients only present late with the disease when it is too late to cure them; the ensuing deaths then further reinforce the stigma that cancer is essentially a death sentence. At a secondary level, the cancer divide is illustrated by the lack of capacity to manage patients once their disease is diagnosed, a problem inherent in poor health care systems. For example, approximately half of Africa’s 54 countries still have no radiation therapy services typically needed in the treatment of more than 50% of cancer patients (5). Limitations to radiation therapy in low- and middle-income countries (LMICs) include the number of radiation therapy centers, the number of treatment units, the critical shortage in health care workforce, the lack of safety regulatory infrastructure, and the perception that radiation therapy is a complex and expensive solution. Without greater investment and collaboration in radiation therapy services, this will only exacerbate the burden of cancer and make the cancer divide worse. Meanwhile, at the tertiary level, the cancer divide is appropriately captured by what has been called “the pain divide” (6). Here, many people dying with cancer do so in excruciating pain, due to a lack of basic pain medication and other palliative options. Such harrowing deaths with needless suffering bolster the physical and social trauma of cancer and the reason why many people in LMICs do not even want to talk about cancer. A word of African origin, which people do like to talk about, is ubuntu. Popularized worldwide by African Nobel Prize winners Desmond Tutu and Nelson Mandela, ubuntu signifies the idea that “I am because we are,” or human connectedness. This ethos rings particularly true in today’s hyperconnected world, where we all share in the bounty of the expanding internet or ICTs and where local health has become global health and vice versa. Ubuntu also represents an operating system underlying ICTs used for cloud computing, including in radiation oncology. The recent call for greater action in closing the cancer divide through collaborations (1, 7–9), including more recently in radiation oncology (8), inspired the 2015 Global Health Catalyst (GHC) cancer summit (10), which brought together a unique combination of global oncology leaders, industry, policy makers, and African diaspora leaders. Here the African diaspora refers to Africans settled outside of the African continent. Building on a recent publication (11), a central theme of the summit was the use of ICTs to catalyze high-impact international collaborations in cancer care, research, and education with Africa. This article summarizes the summit proceedings and highlights the emerging ICT-powered models for radiation oncology global health, avenues for greater partnership (ubuntu), and outreach beyond the traditional, as well as emerging areas for scaling up and increased action toward closing the cancer divide.

Introduction: In Forsyth County, North Carolina, 52% of Black residents live in three zip codes—27101, 27105, and 27107—that comprise East/South East Winston- Salem. Cancer incidence and mortality are significantly higher in Forsyth County when compared with the US average (11.2% and 30.7%, respectively). Given the harmful history of systemic anti-Black racism in the region, including forced segregation and eugenics, we sought to hear directly from stakeholders to better understand the knowledge, attitudes, beliefs, and experiences around cancer care and clinical trials (CTs) amongst Black residents in our catchment area. Methods: We collaborated with a Black-owned research group to implement a qualitative study using racially-concordant facilitators. Key informant interviews (n=14) were held with stakeholders, including health care providers (n=4), patients (n=24), caregivers (n=8), and patient advocates (n=13) in the local Black community; results informed the development of a focus group protocol. Four focus groups were conducted with black residents in Forsyth County including groups of cancer survivors and family members (n=46 participants total). Transcripts were coded using NVivo12 Plus and a code-based report was thematically generated and analyzed by community and academic stakeholders. Results: While many participants endorsed past participation in a CT, little knowledge about the structure and purpose of CTs was evident. None of the participants, including providers, could express that cancer patients enrolled in CTs would never only receive a placebo; cancer patients would always at least be given the standard of care (SOC), or when patients progress through SOC, would possibly be provided with a new therapeutic drug. Participants described cancer CTs as “riskier” because of the seriousness of the disease being treated. They also did not associate non-interventional trials focused on changing health behaviors or patient- reported outcomes with CTs. Barriers to CT participation included mistrust and fear of experimentation; facilitators of participation included personal benefit or benefit to others, monetary incentives, and personalized communication and treatment strategies. Conclusion: Limited patient, caregiver, and stakeholder knowledge about CTs suggested the need for an intervention to address this gap. A population health navigator (PHN) program was created to provide culturally concordant navigation to traditionally underserved patients (Hispanic, Black, rural). The role of the PHN includes educating patients on the importance of CTs and standardizes CT education to help normalize the role of research in cancer care. Based on results of this qualitative study, the PHN program is being adapted to provide culturally tailored education to increase overall CT awareness, knowledge, participation, and adherence among Black patients. Citation Format: Kelsey Shore, Carla Strom, Kathryn Weaver, Derek Falk, Karen Winkfield. Exploring knowledge and perceptions of cancer care and clinical trials in the local Black community to develop culturally-tailored interventions [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-022.

Introduction: Disparities persist related to supportive care interventions across the cancer continuum for racially and ethnically diverse patients. To meet these unique needs and mitigate the complexities of cancer care, we developed a non-nurse Population Health Navigator (PHN) program to reduce barriers to timely, quality care among traditionally underserved populations. The PHN is a novel approach to address concerns expressed by the community as part of a targeted outreach and engagement strategy by providing culturally and linguistically concordant navigation to reduce barriers to care, increase knowledge and awareness of clinical trials, and address supportive care needs. Methods: We purposively sampled patients presenting for oncology care to enroll a diverse sample with regards to race, ethnicity, insurance coverage, age, and cancer type. Participants completed a single interviewer-administered survey regarding their patient experience, including the 34-item Supportive Care Needs Survey assessing adult cancer patients’ perceived needs (Boyes et al., 2009). Race and ethnicity were self-reported at time of survey completion. ANOVA and chi-square/Fisher’s exact tests compared responses of non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic patients. Results: A majority of survey participants (N=247; participation rate 85%) were female (54.5%) and currently receiving active treatment (60.5%) with a median time since cancer diagnosis of 2.8 years. The racial and ethnic distribution of the sample was 50.6% NHW, 27.3% NHB, and 22.3% Hispanic. Hispanics were more likely to report less than a high school education (47.3% vs 10.4% NHW and 17.9% NHB) and not having enough money to meet the daily needs of their families (45.5% vs 13.6% NHW and 17.9% NHB), p0.10) between racial and ethnic groups. Conclusion: Among patients seeking care at the Wake Forest Baptist Comprehensive Cancer Center, differences in supportive care needs were identified for certain racial/ethnic populations. Implementation of a PHN program with non-nurse navigators may be a cost-effective way to provide culturally and linguistically appropriate support for patients with cancer, allowing for programmatic work to be responsive to the needs of underserved communities and ultimately helping to reduce cancer disparities. Citation Format: Kelsey Shore, Kathryn E. Weaver, Karen M. Winkfield, Janet A. Tooze, Carla Strom, Jimmy Ruiz. Supportive care needs in diverse cancer patients treated at a Comprehensive Cancer Center [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D046.

Disparities in access to cancer care and treatment outcomes among racial, ethnic and underserved populations have been observed for decades. Despite a plethora of national and local initiatives aimed at addressing these disparities, progress to date has been limited. Guided by the domains of the cancer care continuum (CCC) established by the IOM/NASEM [1] the Diverse Cancer Communities Working Group [2] (CWG) will deliver a framework with domains, processes and activities which when disseminated and implemented in the US, will contribute in an impactful way to addressing cancer care disparities. To achieve our goal, we utilized methodology similar to that used to identify best practices in recruiting diverse patients into cancer clinical trials.[3] We conducted an environmental scan to identify strategies and associated experts who successfully provided community and/or patient-centric, IOM defined domain standards in our population of interest. The environmental scan was conducted between March and September 2018, resulting in the identification of 84 unique experts and 44 unique patient organizations. The identified experts had documented processes and best practices along the six CCC domains as follows: Prevention & Risk Reduction (29%); Screening (30%); Diagnosis (11%); Treatment (8%); Survivorship (18%); and End-of-Life (5%). Of the 84 participants, 26% are experts in all six domains, 36% are experts in multiple domains, and 14% are also experts in Patient Navigator Research Programs. Drawing from our environmental scan, the CWG engaged the experts and advocates to develop the foundation for a theoretical underpinning of an evidence-based, practical continuum of care framework. Highest cross-cancer-continuum areas of impact included 1) patient navigation which addresses barriers to enable patients to progress successfully along the cancer continuum of care, 2) excellence in community engagement, a necessary mandate to build trust in among minority and underserved populations, and 3) implementation of health care system changes based on real-world examples. Additionally, experts focused on opportunities to close gaps between the CCC domains with specific emphasis on screening, diagnosis, treatment, and survivorship, with the understanding that health care system change is often effectively sustained by long-term policy implementation that ultimately increases access, utilization and standardization across the continuum. This adapted framework is intended to guide researchers, health care leaders and policy leaders to promote health equity in cancer outcomes. References: [1] Institute of Medicine 2013. Delivering High-Quality Cancer Care; Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. https://doi.org/10.17226/18359; [2] URL: http://shcllc.info/cancer-working-group/ [3] URL: http://ascopubs.org/doi/full/10.1200/JOP.18.00638 Citation Format: Jeanne M. Regnante, Karen Winkfield, MD, PhD, Ellen Sonet, JD, MBA, Evelyn Gonzalez, Karen M. Freund, MD, Simon Craddock Lee, PhD, Scarlett Lin Gomez, PhD, MPH, Nina Bickell, MD, Lynette Bonar, PhD, Michelle Vichnin, MD, Nicole Richie, PhD, Richardae Araojo, PharmD, Andrea Ferris, MBA, Thomas Farrington, Linda Fleisher, PhD, MPH, Carolyn Fang, PhD, Laura Lee Hall, PhD, Renee Nicolas, Shyrea Thompson, Marilyn Metcalf, PhD, Patti Fine Jewell, PhD, Marianne Gandee, Anna Forte, PhD, Elizabeth Franklin. PhD, Patti Doykos, PhD. Securing the cancer continuum of care model for racially and ethnically diverse and medically underserved populations [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D080.

Lung cancer is the leading cause of cancer-related death worldwide, with a 5-year survival rate of ~18% (1-3). Non-small cell lung cancer (NSCLC) comprises 85% of all lung cancer cases. Great strides have been made with the development of more advanced diagnosis, prognosis, and treatment strategies. Despite improvements, African American patients (AAs) continue to present with more advanced stages and later-stage metastatic tumors of lung cancer at diagnosis. The severe types of lung cancer can reduce the 5-year survival rate to only 4% (4). The disparities may partially be due to the socioeconomic disadvantages of AAs in receiving cancer services (5). Etiologically, cigarette smoking and exposure to secondhand smoking are leading preventable causes of lung cancer and premature death in the United States (US) (5). Notably, menthol cigarettes, which have been particularly marketed to communities with high AA population (7), can cause deeper inhalation, increased absorption of tobacco toxicants, a higher nicotine dependence and reduced cessation success (6-8). Some genetic alterations have been suggested to contribute to the disparities of breast cancer (9), but genetic factors have not been well studied in lung cancer disparities. Utilizing the genomic data from the Precision Oncology Initiative (POI) cohort at the Wake Forest Baptist Comprehensive Cancer Center (WFBCCC), our initial analysis has shown that TP53 has a significantly higher mutation rate in AA patients, which was validated with the TCGA cohort (10). Furthermore, codons including Cysteine 176 (C176) and C242 mutated more frequently in AA than CA patients. Considering the four amino acids in the zinc-binding region (C176, Histidine 179 [H179], C238, and C242), AA patients have a higher mutation rate than CA patients within both our POI (15% v.s. 5%, P=5E-4) and the TCGA (14% vs. 6%, P Citation Format: Liang Liu, Farideh Mehraein-Ghomi, Elizabeth Forbes, Umit Topaloglu, W. Jeffrey Petty, Stefan Grant, Jimmy Ruiz, Kristie L. Foley, Karen Winkfield, Boris Pasche, Wei Zhang. TP53 mutations reprogram fatty acid metabolism and tumor microenvironment in African American patients with non-small cell lung cancer [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C001.

Introduction: Enhanced participation in clinical trials has been proposed as a strategy to reduce rural cancer disparities. We examined rural-urban differences in clinical trials knowledge and participation among cancer patients seeking oncology care to prepare for outreach activities with rural communities in our cancer center catchment area. Methods: We purposively sampled patients presenting for oncology care to enroll a diverse sample with regards to race, ethnicity, insurance coverage, age, and rural-urban residence. Participants completed a single survey assessing their patient experience, including 7 items assessing oncology clinical trial knowledge (Ellis et al., 2016), two scales assessing attitudes towards clinical trials (positive beliefs and patient involvement) scored from 0-100 (Jenkinson et al., 2005), and reported participation in clinical research or trials as part of cancer treatment. Rural residence was categorized according to the Federal Office of Rural Health Policy (Rural Urban Commuting Areas Codes 4-10). T-tests and chi-square/Fisher’s exact test compared responses of rural and urban residents. Results: A majority of survey participants (85% participation rate, N=249, 54.4% female; 50.2% White non-Hispanic, 26.9% Black non-Hispanic, 22.1% Hispanic; 22.1% rural; 47.4% High School education or less) were currently receiving active treatment (60.8%); the median time since cancer diagnosis was 2.8 years. Common cancer types included hematologic (36.1%), breast (20.5%), gastrointestinal (12.9%), and thoracic (9.6%). Most participants had heard of a clinical trial (81.1%); 38.6% reported participation in a clinical trial as part of their cancer treatment. Overall clinical trial knowledge was low (mean correct answers= 2.9 of 7, std=1.9); participants held relatively positive clinical trial attitudes (positive beliefs mean=78.8, std=15.8 & patient involvement=76.9, std=15.1). There were no significant differences by rural/urban residence for knowledge or beliefs (all p>.10). There was a statistically significant difference in reported clinical trial participation; 52.7% of rural participants reported participating in a clinical research study/trial vs 34.5% of urban participants, p Citation Format: Kathryn E Weaver, Janet A Tooze, Jimmy Ruiz, Carla Strom, Kelsey M Shore, Karen M Winkfield. Clinical trials knowledge and participation in rural and urban cancer survivors at a Comprehensive Cancer Center in the Appalachian region [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A048.

Introduction: Participation in cancer clinical trials (CTs) is historically low, particularly for underserved populations, including racial/ethnic minorities. Wake Forest Baptist Comprehensive Cancer Center developed a population health navigation program to improve access to cancer care and CTs among Hispanic patients through linguistically and culturally concordant navigation services. The role of the Hispanic Patient Navigator (HPN) includes educating all navigated patients about CTs. To inform expansion of the program, we sought to understand the knowledge and attitudes of underserved patients at WFBCCC regarding CTs and CT participation. Methods: Patients receiving cancer care in the adult oncology clinic at WFBCCC were purposively sampled to enroll a diverse sample with regards to race, ethnicity, insurance coverage, age, and rural-urban residence. Survey domains included CT knowledge (Ellis et al., 2016) attitudes about CTs (positive beliefs and patient involvement scored from 0-100; Jenkinson et al., 2005) and participation in clinical research as part of cancer care. ANOVA and chi-square/Fisher’s exact tests compared responses by race and ethnicity. Results: We enrolled 247 participants (85% participation); 50.6% were White, non-Hispanic (NHW), 27.1% Black, non-Hispanic (NHB), and 22.3% Hispanic, all races. The majority were female (54.5%) with a median time since cancer diagnosis of 2.8 years. Common cancer types included hematologic (36.4%), breast (20.6%), gastrointestinal (12.6%), and thoracic (9.3%). Hispanics were more likely to report less than a high school education (47.3% vs 10.4% NHW and 17.9% NHB) and not having enough money to meet the daily needs of their families (45.5% vs 13.6% NHW and 17.9% NHB), p.05 for both comparisons. A larger proportion of NHWs had heard of clinical trials (92.8%), compared to 79.1% NHBs, and 56.4% of Hispanics. NHWs also had greater CT knowledge (mean=3.5, 0-7 scale) than NHBs (mean=2.5), and Hispanics (mean=1.9), p Citation Format: Carla Strom, Karen M. Winkfield, Janet A. Tooze, Jimmy Ruiz, Kelsey Shore, Kathryn E. Weaver. The patient experience: Clinical trial knowledge, attitudes and participation among diverse populations [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A047.

In the United States, endometrial cancer is the fourth most common malignancy among women, with an estimated 61,380 new cases and 10,920 deaths in 2017 (1). The incidence is increasing more rapidly among African American (AfAm) women than other racial/ethnic groups (2), and the 5-year survival rate in AfAms is much lower than other racial/ethnic groups, including Caucasian Americans (CaAm) (62% vs. 84%) (3, 4). Endometrioid-type endometrial carcinoma (EEC) accounts for about 75% of all endometrial carcinomas. Many patients with early-stage and low-grade EEC can be cured by surgery alone, but for women who present with higher-grade advanced-stage EEC, more aggressive therapy is needed. Studies have shown a close gene/environment interaction in endometrial cancer development and progression (5-7); however, why AfAm women have a higher mortality rate and why their incidence of endometrial cancer is increasing more rapidly remain unknown. To address this issue, we analyzed gene mutation profiles in AfAm and CaAm women with EEC, using samples and genomic data from The Cancer Genome Atlas (TCGA) including 397 patients with EEC (284 CaAm, 67 AfAm, and 46 other races) (8). We found that tumor suppressor gene, TP53, was the top differentially mutated gene that occurred more frequently in AfAm patients with EEC. This is consistent with our recent publication that the TP53 tumor suppressor is more frequently mutated in AfAm patients compared to CaAm patients when several cancer types (e.g., lung, colorectal, bladder, prostate and breast cancer) were analyzed together (9). Moreover, survival analysis of TCGA patients with EEC showed that patients with TP53 mutations have generally poorer outcomes than those with wild-type TP53. Furthermore, our pathway analysis using the RNA sequencing (RNA-Seq) data from TCGA showed that fatty acid metabolism pathway is upregulated in AfAm patients with EEC compared to their CaAm counterparts. Further analysis showed that TP53 mutations are also associated with downregulation of AMP-activated protein kinase (AMPK) and activation of mTOR (mammalian target of rapamycin) pathways, which can lead to dysregulation of fatty acid metabolism and promotion of tumorigenesis (10). Furthermore, obesity is a significant risk factor for EC (11, 12), consistent with our TCGA data analysis showing that AfAm patients with EEC were more likely to be obese than CaAm patients (39.1 vs. 34.6, mean BMI indexes) and with our observation in a cohort of 247 patients, including 47 AfAm and 196 CaAm patients with EEC (35.5 vs. 33.6, mean BMI indexes) from the Precision Oncology Initiative (POI) at Wake Forest Baptist Cancer Center (WFBCC). Of note, inhibition of AMPK activity also leads to obesity and type 2 diabetes (13). Thus, differential TP53 mutations emerge as a major genetic factor that contributes to cancer health disparity. Citation Format: Farideh Mehraein-Ghomi, Liang Liu, Umit Topaloglu, Karen Winkfield, Michael Kelly, Boris Pasche, Wei Zhang. Dysregulation of fatty acid metabolism by TP53 mutations underlies more aggressive endometrial cancers in African American women [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C002.

TPS602 Background: Modern treatment for breast cancer (BC) has led to improved survival; however, this improvement can be offset by an increase in cancer therapy-related morbidity and mortality. Over one-third of early stage BC patients treated with cancer therapy experience CV injury, left ventricular (LV) dysfunction, exercise intolerance, or fatigue. CV disease is a leading cause of mortality in BC survivors. There is limited information on the time course and long-term CV health of BC survivors. UPBEAT, a multicenter study, will prospectively evaluate CV risk factors and outcomes in early stage BC patients, treated with modern anticancer therapies. This will facilitate evaluation of primary CV prevention strategies in this patient population. Methods: This is a prospective cohort study of 840 patients with early stage (I-III) BC treated with chemotherapy +/- radiation and 160 controls. Baseline and serial longitudinal measures will examine the influence of cancer treatment on CV function, exercise capacity and fatigue, and the future development of CV events. The comprehensive assessment includes: ascertainment of cardiac biomarkers, CV risk factors, comorbidities, functional status (e.g., disability measures, expanded short physical performance battery), neurocognitive tests, behavioral risk factors, socio-demographics, and quality of life at baseline, 3-, 12-, and 24-mos. Outcomes measured at the same time points include a deep phenotyping of CV dysfunction (via cardiac MRI assessing LV end diastolic volume, LV end systolic volume, LV ejection fraction, myocardial strain, strain rate, left atrial volumes and mass, and aortic stiffness), exercise intolerance (submaximal as 6-minute walk test and maximal as VO2 peak via cardiopulmonary exercise test), and fatigue (via FACT-F). Eligibility criteria: age > 18 years; ECOG 0-2, able to walk without symptoms; receiving chemotherapy +/- HER2 targeted agent(s). To date, 244 participants are enrolled through 12 NCORP or ECOG-ACRIN sites. An additional 7 sites are onboarding and will be enrolling later in the year. Participants will be followed for 9 years with active surveillance of CV events (i.e., heart failure, myocardial infarction, stroke, all-cause and CV death). EA NCORP Grant: 2 UG1 CA189828 06; Research Base Grant: 2UG1 CA189824; R01: 1R01CA199167. Clinical trial information: NCT02791581 .

This survey study assesses the role that physician cultural competency plays in racial disparities in cancer incidence and outcomes.

Research conducted through clinical trials is essential for evaluating new treatment modalities, establishing new standards of cancer care, and ultimately improving and prolonging the lives of patients with cancer. However, participation in trials has been low, and this is attributable to various factors including patient financial barriers. Such financial barriers include the rising cost of cancer care; a lack of transparency in coverage policy; and the perception of ethical, compliance, or institutional impediments to patient financial support. ASCO convened a roundtable discussion with a variety of stakeholders to define the scope of the problem, as well as to identify clinical practice and policy solutions applicable at the institutional and system-wide levels. This statement summarizes key discussions from the ASCO Roundtable, as well as findings from the literature, and provides ASCO’s recommendations for overcoming financial barriers that may otherwise prevent participation in clinical trials. These recommendations broadly address the following key areas: (1) improving the policy environment for coverage of clinical trials; (2) facilitating transparency among providers, patients, and payers for trial-related out-of-pocket costs; (3) refuting the specter of inducement to enable targeted financial support for patients; and (4) improving the available data on costs of cancer clinical trials.

Background Non-Hodgkin lymphoma (NHL) is the most common cancer in people with HIV. Although 95% of HIV patients are in developing countries like Peru, the majority of these studies have been conducted in developed countries. In this study we aim to evaluate prognostic factors associated with outcomes in HIV positive patients undergoing systemic therapy for treatment of NHL. Methods This retrospective study includes patients with NHL seen in the Instituto Nacional de Enfermedades Neoplasicas (INEN) between 2004 to 2014. Patients were divided into two groups: antiretroviral therapy (ART) -naïve (n = 34) and those previously treated, ART-exposed (n = 13), at the time of diagnosis. All patients received chemotherapy and ART. The medical records were reviewed. Data were analyzed using t-test and chi-square test. Survival curves were estimated by the Kaplan-Meier method and comparison was done by log-rank test. Multivariate analysis for overall survival (OS) was performed with the Cox proportional hazard regression model. Results All ART-exposed patients were from the capital city (p = 0.039); they had significantly lower hemoglobin levels compared to ART-naïve patients (p = 0.026). The median OS was 47.7 months with a 5-yr OS of 36.1%. The median OS for ART naïve patients was significantly higher than that for ART-exposed patients (57.05 and 21.09 months, respectively; p = 0.018). Advanced stage and low serum albumin were associated with lower OS in both groups. Age > 60 was associated with worse outcomes in the ART-naïve cohort. Conclusions Advanced stage, low serum albumin and previous ART treatment were the primary prognostic factors associated with poorer outcomes in patients with NHL and HIV infection. In ART-naïve patients, age > 60 was associated with worse outcomes but in this cohort, older patients still had better overall outcomes than ART-exposed patients.

Primary breast lymphoma (PBL) comprises