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Leadless pacemakers have emerged as a viable alternative for traditional transvenous pacemakers to reduce the risk of device-related complications.The purpose of this study was to examine the real-world clinical outcomes and complications associated with the implantation of leadless pacemaker devices.Using the National Readmission Database (NRD), we examined patient demographics, and in-hospital and 30-day procedural outcomes after leadless pacemaker implantation from 2016-2018. Our cohort comprised adults (≥18 years) with an ICD-10 procedural code for leadless pacemaker implantation.Our cohort included a total of 7821 patients who underwent leadless pacemaker implantation. Overall immediate procedure-related complications, as defined broadly in this study, occurred in 7.5% of patients. Pericardial effusion without the need for pericardiocentesis occurred in 1.9% of patients, with pericardiocentesis performed in 1.0%. Vascular complications occurred in 2.3% of patients; 0.33% required repair, and device dislodgment occurred in 0.51%. The most significant predictor for procedural complications was end-stage renal disease (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.17-2.32; P = .004), congestive heart failure (OR 1.28; 95% CI 1.01-1.62; P = .04), and coagulopathy (OR 1.77; 95% CI 1.34-2.34; P.001). All-cause readmission occurred in 17.9% of patients within 30 days from device implant, with 1.36% of readmissions being procedure related. At 30 days postimplant and after discharge, 0.25% of patients needed a new pacemaker, and 0.18% had pericardial complications.In our large real-life cohort, we found the rate of serious complications after leadless pacemaker implantation to be relatively low and comparable to prior studies in a high-risk population with multiple comorbid conditions.

Context Reporting temporal trends in adrenocortical carcinoma (ACC) helps guide management strategies. Objective This work aimed to report the trends in disease burden and clinical outcomes over time that cannot be adequately captured from individual clinical trials. Methods A retrospective study was held of ACC patients seen at a referral cancer center between February 1998 and August 2019. Clinical outcomes were compared between an early cohort (February 1998-June 2007) and a late cohort (July 2007-August 2019). Results A total of 621 patients included with a median age at diagnosis of 49.3 years (range, 0.5-86.6 years). There were 285 (45.9%) patients with hormonal overproduction. More patients in the late cohort had stage IV disease compared to the early cohort (36.8% vs 23.1%; P Conclusion ACC clinical outcomes improved over the past 2 decades as more patients had complete resection or received more lines of systemic therapy.

Background Metagenomic next-generation sequencing (mNGS) has emerged as a novel diagnostic tool in infectious diseases. It analyzes genetic material from a given sample without the need for pre-determined sequences, matching it to reference genomes, thus identifying a wide range of pathogens. There is little guidance on the efficient and appropriate use of this tool. The goal of this study was to evaluate clinical utility of mNGS in patients with fever of unclear etiology. Methods We retrospectively analyzed 72 patients at our center from June 2017 to July 2021 with “fever of unclear etiology” and a mNGS test. The assay we used was the Karius Test™, a College of American Pathologists-accredited NGS laboratory. Two independent reviews of each case were performed to determine clinical impact of mNGS using previously published criteria by Hogan et al. Logistic regression was used to identify factors associated with positive clinical impact. Results We included 72 patients, 62.5% males, median age 56. Most common comorbidities were hypertension (43.1%) and diabetes (23.6%). All patients had fever at time of evaluation. 26.4% had cough, 16.7% abdominal pain, and 15.3% shortness of breath. Median turnaround time of the test was 26 hours. At least one organism was reported in 65.3% of cases. Most common identified organisms were EBV (13.9%), CMV (12.5%), and Rickettsia typhi (11.1%). Of those with an infectious etiology of their fever, 86.8% had positive mNGS compared to 43.8% of those with non-infectious etiology (p=0.002). mNGS had positive clinical impact in 40.3% of cases, negative impact in 2.8%, and no impact in 56.9%. Based on logistic regression, older age was the only factor associated with higher odds of positive impact. Chief complaint, positivity of cultures, number of pathogens retrieved, and type of prior antibiotic use were not associated with a higher rate of positive impact. Table 1:DemographicsTable 2:mNGS Test Findings and ImpactAbbreviations: Epstein–Barr Virus (EBV); Cytomegalovirus (CMV); Escherichia coli (E. coli); Herpes Simplex Virus-1 (HSV-1)Figure 1:Organisms Identified on mNGS TestAbbreviations: Staphylococcus epidermis (S. epidermis); Klebsiella pneumoniae (K. pneumoniae); Escherichia coli (E. coli); Epstein–Barr Virus (EBV); Cytomegalovirus (CMV); Herpes Simplex Virus-1 (HSV-1); Candida albicans (C. albicans); Enterococcus faecalis (E. faecalis); Mycobacterium tuberculosis (MTB) Conclusion Overall, mNGS was clinically beneficial in a large percentage of patients, with minimal negative impact. Besides age, we did not identify other factors associated with higher likelihood of positive impact. Larger analyses and further studies on the clinical impact of mNGS in different infectious syndromes are needed to better understand this promising tool in the rapid detection of infectious pathogens. Table 3:Logistic Regression of Positive Clinical Impact of mNGS Fungitell® is an FDA-cleared assay that detects 1,3-β-D-glucan in serum Figure 2:Clinical Impact of mNGS Clinical impact based on previously published criteria by Hogan et al. Disclosures All Authors: No reported disclosures.

Background The Coronavirus Disease 2019 (COVID-19) has significantly impacted cancer patients with some reported mortality as high as 25%. The Immunodeficiency Scoring Index (ISI) was developed as a prognostic tool in allogeneic hematopoietic cell transplant (allo-HCT) recipients with respiratory syncytial virus but also for other respiratory viruses to predict severe infections and mortality. The purpose of our study was to correlate the ISI in HCT recipients with COVID-19 and associated complications such as hospitalization, supplemental oxygen use, and mortality. Methods We performed a cohort study of HCT recipients of all ages with COVID-19 between March 2020 and October 2021. We included only patients who were diagnosed by a PCR-based assay. We excluded patients for whom an ISI score, as previously described, could not be calculated. Outcomes of interest included 60-day mortality, hospital and ICU admission due to COVID-19, and supplemental oxygen requirements. A univariate analysis using Fischer exact testing for nominal variables was performed. Results Out of the 219 HCT with COVID-19, 101 were excluded due to alternative methods of diagnosis (13), lack of laboratory values needed to calculate an ISI at time of COVID-19 diagnosis (79), or COVID-19 diagnosed prior to transplant (9). Out of the remaining 118 patients, the median age was 60 years (range 6-85), most were male (56%), Caucasian (57%), and had no smoking history (64%). Most patients had an alloHCT (66%) with matched related donor [MRD] (25%), or matched unrelated donor [MUD] (21%) (Table 1). Median time from transplant to COVID-19 was 615 days (range 2-5692), median ISI was 3 (range 0-11), and 92% of patients were unvaccinated prior to COVID-19 (Table 1). On univariate analysis, an ISI of moderate to high (score ≥3) was associated with COVID-19 related hospitalization [p=0.0147] and an ISI ≥ 4 was associated with 60-day all-cause (p=0.045) and COVID-19-related (p-0.019) mortality (Table 2). Table 1: Patient Characteristics Abbreviations: Hematopoietic Cell Transplant (HCT); Chronic Obstructive Pulmonary Disease (COPD); Chronic Kidney Disease (CKD); End-Stage Renal Disease (ESRD); Acute Lymphocytic Leukemia (ALL); Acute Myeloid Leukemia (AML); Myelodysplastic Syndrome (MDS); Chronic Lymphocytic Leukemia (CLL); Chronic Myelogenous Leukemia (CML) Myeloproliferative Disorder (MDS); Matched Related Donor (MRD); Matched Unrelated Donor (MUD); Mismatched Unrelated Donor (MMUD); Graft versus Host Disease (GvHD); Lower Respiratory Tract Infection (LRI); White Blood Cell (WBC); Absolute Neutrophil Count (ANC); Absolute Lymphocyte Count (ALC). Table 2: Univariate Analysis of Outcomes due to COVID-19 in HCT Recipients Abbreviations: Immunodeficiency Scoring Index (ISI); Hematopoietic Cell Transplant (HCT); Allogenic (Allo); Autologous (Auto); Lower Respiratory Infection (LRI); High-Flow Nasal Cannula (HFNC) Figure 1: Survival Curve (Kaplan-Meier Curve) Comparing Time to Death in Patients with an ISI Score of 4 or Greater. (Log-rank 0.0295) Conclusion An ISI of 4 or greater was a prognostic marker for worse outcomes such as COVID-related and all-cause mortality in HCT recipients. Whether an aggressive and prompt management of high-risk patients with COVID-19 may impact these outcomes needs to be determined in future studies. Disclosures Gabriella Rondon, MD, Omeros: Advisor/Consultant Ella Ariza-Heredia, MD, MERCK: Grant/Research Support Elizabeth Shpall, MD, Adaptimmune: Advisor/Consultant|Affimed: License agreement|Axio: Advisor/Consultant|Bayer Helathcare Pharmaceuticals: Honoraria|Fibroblasts and FibrioBiologics: Advisor/Consultant|Navan: Advisor/Consultant|NY Blood Center: Advisor/Consultant|Takeda: License agreement Roy F. Chemaly, MD/MPH, Karius: Advisor/Consultant|Karius: Grant/Research Support.

Objectives: Prostate cancer incidence is increasing in the Middle East (ME); however, the data of stage at the diagnosis and treatment outcomes are lacking. In developed countries, the incidence of de novo metastatic prostate cancer ranges between 4% and 14%. We hypothesized that the rates of presentation with advanced disease are significantly higher in the ME based on clinical observation. This study aims to examine the stage at the presentation of patients with prostate cancer at a large tertiary center in the ME. Methods: After Institutional Review Board approval, we identified the patients diagnosed with prostate adenocarcinoma and presented to a tertiary care center between January 2010 and July 2015. Clinical, demographic, and pathological characteristics were abstracted. Patients with advanced disease were stratified according to tumor volume based on definitions from practice changing clinical trials. Descriptive and Kaplan–Meier survival analysis was used. Results: A total of 559 patients were identified, with a median age at the diagnosis of 65 years and an age range of 39–94 years. Median prostate-specific antigen (PSA) at the presentation was 10 ng/ml, and almost a quarter of the men (23%) presented with metastatic disease. The most common site of metastasis was the bone (34/89, 38%). High-volume metastasis was present in 30.3%, 9%, and 5.2% of the cohort based on STAMPEDE, CHAARTED, and LATITUDE trial criteria, respectively. Conclusion: This is the first report showing the high proportion of men from ME presenting with de novo metastasis. This could be due to many factors, including the highly variable access to specialist multidisciplinary management, lack of awareness, and lack of PSA screening in the region. There is a clear need to raise the awareness about prostate cancer screening and early detection and to address the rising burden of advanced prostate cancer affecting men in the ME region.

Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2YWe examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2YData comparing dual therapy with OAC and a P2YThe addition of aspirin to OAC and a P2Y

PURPOSE Conflict-induced cross-border travel for medical treatment is commonly observed in the Middle East. There has been little research conducted on the financial impact this has on patients with cancer or on how cancer centers can adapt their services to meet the needs of this population. This study examines the experience of Iraqi patients seeking care in Lebanon, aiming to understand the social and financial contexts of conflict-related cross-border travel for cancer diagnosis and treatment. PATIENTS AND METHODS After institutional review board approval, 60 Iraqi patients and caregivers seeking cancer care at a major tertiary referral center in Lebanon were interviewed. RESULTS Fifty-four respondents (90%) reported high levels of financial distress. Patients relied on the sale of possessions (48%), the sale of homes (30%), and vast networks to raise funds for treatment. Thematic analysis revealed several key drivers for undergoing cross-border treatment, including the conflict-driven exodus of Iraqi oncology specialists; the destruction of hospitals or road blockages; referrals by Iraqi physicians to Lebanese hospitals; the geographic proximity of Lebanon; and the lack of diagnostic equipment, radiotherapy machines, and reliable provision of chemotherapy in Iraqi hospitals. CONCLUSION As a phenomenon distinct from medical tourism, conflict-related deficiencies in health care at home force patients with limited financial resources to undergo cancer treatment in neighboring countries. We highlight the importance of shared decision making and consider the unique socioeconomic status of this population of patients when planning treatment.

Introduction: Contrast-induced acute kidney injury (CI-AKI) remains one of the leading causes of hospital acquired AKI. Patients with baseline chronic kidney disease (CKD) and/or elevated risk scores are at increased risk of developing CI-AKI. Contrast minimization devices have been proposed as a mechanism for contrast usage reduction in the cath lab. Since May 2017, the cardiac catheterization lab at the Michael E DeBakey VA Medical Center has used the Osprey Medical DyeVert contrast minimization device. Methods: We retrospectively evaluated the outcomes of 120 patients with known CKD who underwent cardiac catheterization with the DyeVert Contrast Reduction System for contrast monitoring and minimization. Results: The results of 120 DyeVert cases from Q2 2019 through Q4 2020 were analyzed. The mean baseline eGFR of the evaluated patients was 50. Mean overall contrast media volume (CMV) savings were 37 +/- 21 mL per procedure or 36%. 90% of DyeVert cases achieved a procedure CMV/eGFR ratio < 3. Mean attempted CMV/eGFR ratio was 2.5 versus actual ratio of 1.6 after device contrast diversion. Conclusions: Our results suggest that contrast minimization devices in the cath lab can reduce the overall contrast media volume usage and result in improved CMV/eGFR ratios for at-risk patients undergoing coronary angiography.

Context The role of cytoreduction of adrenocortical carcinoma (ACC) remains poorly understood. Objective To analyze the impact of cytoreductive surgery of the primary tumor in patients with metastatic ACC. Design and Setting We performed a multicentric, retrospective paired cohort study comparing the overall survival (OS) in patients with metastatic ACC who were treated either with cytoreductive surgery (CR group) or without cytoreductive surgery (no-CR group) of the primary tumor. Data were retrieved from 9 referral centers in the American-Australian-Asian Adrenal Alliance collaborative research group. Patients Patients aged ≥18 years with metastatic ACC at initial presentation who were treated between January 1, 1995, and May 31, 2019. Intervention Performance (or not) of cytoreductive surgery of the primary tumor. Main outcome and measures A propensity score match was done using age and the number of organs with metastasis (≤2 or >2). The main outcome was OS, determined from the date of diagnosis until death or until last follow-up for living patients. Results Of 339 patients pooled, 239 were paired and included: 128 in the CR group and 111 in the no-CR group. The mean follow-up was 67 months. Patients in the no-CR group had greater risk of death than did patients in the CR group (hazard ratio [HR] = 3.18; 95% CI, 2.34-4.32). Independent predictors of survival included age (HR = 1.02; 95% CI, 1.00-1.03), hormone excess (HR = 2.56; 95% CI, 1.66-3.92), and local metastasis therapy (HR = 0.41; 95% CI, 0.47-0.65). Conclusion Cytoreductive surgery of the primary tumor in patients with metastatic ACC is associated with prolonged survival.

Purpose of Review The concept of telehealth has been around since the early twentieth century and has been used in different healthcare specialties. However, with the recent COVID-19 pandemic necessitating physical distancing, there has been an increased emphasis and utilization of this mode of healthcare delivery. With increasing reliance on telehealth services, data from investigator groups have brought to light several merits as well as failings of telehealth. Recent Findings Telehealth services have been associated with improved healthcare outcomes while remaining a cost-effective mode of healthcare delivery. Improving access and timeliness of care has also been observed by multiple telehealth-related studies. Finally, telehealth services are also anticipated to serve as part of emergency preparedness protocol and have shown to reduce provider-patient supply-demand mismatch, prevalent in certain subspecialties. With these benefits come certain challenges that have been highlighted in the literature. Indiscriminate utilization of telehealth services may widen public health disparities among minority groups and may increase overall healthcare expenditure due to overutilization of care, and the digital platform may jeopardize security of patient data. Summary COVID-19 has been a catalyst in increasing utilization of telehealth services. As we move forward from the current pandemic, lessons learned from the studies demonstrating benefits and challenges associated with telehealth should be taken into account when drafting post-pandemic telehealth policies. Special attention should be paid to ensure that telehealth narrows, and not widens, the currently existing disparities in access to healthcare.

Purpose of Review To identify and address the challenges associated with the care of ACS patients during the coronavirus 2019 pandemic. Recent Findings The COVID-19 pandemic has had a considerable global impact with over 2.0 million deaths worldwide so far. There has been considerable evidence suggesting that COVID-19 increases the risk of acute coronary syndromes (ACS). Summary We propose characterizing ACS patients into 3 distinct categories to better assist in appropriate triage and management: critically ill patients, non-critically ill ST elevation myocardial infarction (STEMI) patients, and non-critically ill non-ST elevation myocardial infarction (NSTEMI)/unstable angina (UA) patients. We thoroughly review treatments strategies, management considerations, and current consensus statements for the care of COVID-19 patients with ACS. As we continue to gain more experience with management of COVID-19 in ACS patients and as health-care workers and patients continue to get vaccinated, we must continue to adapt our strategies to treat this high-risk group of patients.

BackgroundThere is no effective systemic therapy for metastatic adrenal cortical carcinoma (ACC) after failure of platinum-based chemotherapy. The efficacies of single-agent oral multikinase inhibitors (MKIs) or salvage immune checkpoint inhibitors (CPIs) have been very limited. It is unknown whether combining CPIs, such as pembrolizumab (PEM), with other therapies, such as MKIs, could yield higher response rates in ACC, yet this combination has shown promise in other cancers. Herein, we describe the first case series using PEM in combination with the MKI lenvatinib (LEN) in patients with progressive, metastatic ACC.MethodsA retrospective case series describing the use of LEN/PEM as salvage therapy in patients with progressive/metastatic ACC.ResultsEight patients were treated with the LEN/PEM combination therapy. Half were female, and the median age at time of diagnosis was 38 years (range 21–49). Three (37.5%) patients had hormonally active ACC. The median number of prior lines of systemic therapy was 4 (range 2–9). Six (75%) patients had had disease progression on prior CPIs and five (62.5%) patients had progressed on prior MKI therapy. The median progression-free survival was 5.5 months (95% CI 1.8–not reached) and median duration of therapy was 8.5 months (range 2–22). Two (25%) patients had a partial response, one (12.5%) patient had stable disease, and five (62.5%) patients had progressive disease. None of the eight patients stopped therapy because of adverse events.ConclusionsIn our small cohort of heavily pretreated patients with ACC, the combination of LEN/PEM was associated with objective responses in a subset of patients without significant toxicity. This combination should be formally investigated in phase II clinical trial with robust correlative studies to identify predictors for response.

BACKGROUND: Adrenocortical carcinoma (ACC) in an aggressive malignancy with suboptimal response to frontline chemotherapy and without established second line treatment. cMET activation is associated with ACC resistance to chemotherapy. Cabozantinib is a multi-kinase inhibitor that targets the VEGFR, c-MET, AXL, and RET receptors. We report interim data about using cabozantinib in ACC through a prospective phase II clinical trial. Methods: This is an investigator-initiated, open label clinical trial to evaluate the efficacy and safety of cabozantinib in patients with unresectable/metastatic ACC (ClinicalTrials.gov Identifier: NCT03370718). The primary objective is 4-month progression-free survival rate (PFS4). Participants are ≥ 18 years old with histologically confirmed ACC. Subjects who used mitotane within 6 months of consent must have mitotane serum level of < 2 mg/L. Cabozantinib starting dose is 60 mg daily with possible dose reductions. Subjects stopped treatment at time of disease progression, death, or occurrence of severe adverse events. Objective tumor responses were assessed per RECIST v.1.1 criteria. Adverse effects were graded per CTCAE v.4.03 Results: At time of data cut off (Oct 28, 2019), we screened 16 patients for enrollment. Ten patients (3 females) received cabozantinib out of whom 5 had history of mitotane use. Nine patients were eligible for response evaluation, defined as having at least one follow up imaging. One patient was taken off study after one week due to hypertensive crisis. Median age at time of diagnosis was 45 years (range 32 - 72). Five patients had hormonally active ACC. Median number of prior lines of systemic therapy was 2 (range 0 -5). Median duration of cabozantinib therapy was 6.6 months (range 0.7 -11.3). Eight patients (80%) were without evidence of progression at 4 months (achieved study endpoint). At time of data cut off, 1 patient had partial response (53% reduction over 8.8 months and ongoing), 3 patients had stable disease, and 5 patients had progressive disease. Nine patients were alive with disease and one patient died (not drug related). Grade 3/4 clinical adverse events included thromboembolic events (3 patients), severe hypertension (1 patient), intracranial hemorrhage secondary to hypertensive crisis (1 patient), weight loss (1 patient), and abdominal pain (1 patient). Grade 3/4 laboratory adverse events included increased AST (2 patient), increased ALT (1 patient), increased GGT, increased amylase (1 patient), increased lipase (1 patient) and hyponatremia (1 patient). Conclusions: In this interim analysis of phase II study, majority of subjects reached the study primary endpoint (PFS4). These data are in favor of continuing study accrual to assess magnitude of response to therapy and safety profile in ACC. Aggressive blood pressure management and close monitoring of liver enzymes are crucial to ensure the safety of study subjects.

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with high risk of recurrence despite macroscopically complete surgical resection. The main predictors of ACC recurrence include advanced disease stage, incomplete surgical resection, cortisol production, certain genetic alterations, and high proliferation rate (Ki-67 proliferation index). Mitotane has been the mainstay adjuvant therapy of ACC. However, the use of mitotane is based on retrospective and occasionally conflicting evidence. As mitotane levels can take a few months before reaching therapeutic levels, there is an emerging practice of combining platinum-based chemotherapy with mitotane in the adjuvant setting. Retrospective data indicate that radiotherapy is an option for select patients, particularly those with positive resection margins. There are multiple knowledge gaps in selecting patients for adjuvant therapy. It is of great importance to establish risk calculators to predict recurrence and to implement molecular profiling of ACC to guide adjuvant therapy. The role of immunotherapy in metastatic ACC is emerging and if deemed efficacious, then future studies will be needed to ascertain the role of adjuvant immunotherapy in ACC.

Personalized cell therapy targeting tumor antigens with expanded tumor-infiltrating lymphocytes (TILs) has shown great promise in metastatic melanoma (MM) since the 90s. However, MM was first-in line to benefit from the wave of checkpoint inhibitors (CPI), which shifted the focus of immunotherapy almost fully to immune CPI. Still, the majority of patients fail to benefit from CPI treatment, raising the intriguing question on how TIL therapy may fit into the changing landscape of melanoma treatment. We took advantage of data from a unique cohort of patients with MM treated with T-cell therapy in consecutive clinical trials at our institution across the last 10 years. Based on detailed data on patient characteristics, pre-TIL and post-TIL treatments and long-term follow-up, we were able to address the important issue of how TIL therapy can be positioned in the current CPI era. We found that previous progression on anticytotoxic T-lymphocyte-associated protein 4 do not seem to harm neither rate nor duration of response to TIL therapy. Importantly, even in the hard-to-treat population of patients who progressed on antiprogrammed cell death protein 1 (anti-PD-1), an objective response rate of 32% was achieved, including durable responses. Yet, median progression-free survival was reduced in this anti-PD-1 refractory population. Trial registration number: ClinicalTrials.gov ID: NCT00937625, NCT02379195 and NCT02354690.

Ensuring healthcare access is critical to maintain health and prevent illness. Studies demonstrate gender disparities in healthcare access. Less is known about how these vary with age, race/ethnicity, and atherosclerotic cardiovascular disease. We utilized cross-sectional data from 2016 to 2019 CDC Behavioral Risk Factor Surveillance System (BRFSS), a U.S. telephone-based survey of adults (≥18 years). Measures of difficulty accessing healthcare included absence of healthcare coverage, delay in healthcare access, absence of primary care physician,1-year since last checkup, inability to see doctor due to cost, and cost-related medication non-adherence. We studied the association between gender and these variables using multivariable-adjusted logistic regression models, stratifying by age, race/ethnicity, and atherosclerotic cardiovascular disease status. Our population consisted of 1,737,397 individuals; 54% were older (≥45 years), 51% women, 63% non-Hispanic White, 12% non-Hispanic Black,17% Hispanic, 9% reported atherosclerotic cardiovascular disease. In multivariable-adjusted models, women were more likely to report delay in healthcare access: odds ratio (OR) and (95% confidence interval): 1.26 (1.11, 1.43) [p 0.001], inability to see doctor due to cost: 1.29 (1.22, 1.36) [p 0.001], cost-related medication non-adherence: 1.24 (1.01, 1.50) [p = 0.04]. Women were less likely to report lack of healthcare coverage: 0.71 (0.66, 0.75) [p 0.001] and not having a primary care physician: 0.50 (0.48, 0.52) [p 0.001]. Disparities were pronounced in younger (45 years) and Black women. Identifying these barriers, particularly among younger women and Black women, is crucial to ensure equitable healthcare access to all individuals.

6562Background: Conflict-induced cross-border travel for cancer care is commonly observed in the Middle East region. There has been very little research conducted on the impact this has on patients...

e552 Background: Current data suggest that prostate cancer incidence is increasing in the Middle East and North Africa (MENA) region however remains significantly lower than the United States and Europe. No data are available regarding stage at diagnosis or treatment. SEER data from the US suggest that only 4% of patients present with metastatic disease. We hypothesized that rates of presentation with stage 4 disease are significantly higher in the MENA region. Methods: After IRB approval, a review of prostate cancer cases presenting to the leading tertiary referral center in Lebanon from January 2010 to July 2015 was undertaken. From September 2014 these data were collected prospectively. The American University of Beirut Medical Center sees approximately one third of all cancer cases in the country and is a major referral center for Syria and Iraq. Results: 582 cases were identified, median age at diagnosis was 68 (range 43-97); median PSA at diagnosis was 10.2ng/ml (range 2.3 – 3490), median Gleason score was 7. 480 patients had staging data available; 77.4% (449) presented with organ-confined disease, 22.6% (136) presented with stage 4 disease at diagnosis. 12% of this cohort were from Iraq, 57.6% presenting with stage 4 disease. Increasing age correlated with higher stage at presentation in this cohort. In patients presenting with PSA > 20, 62.3% were found to have stage 4 disease. Conclusions: This is the first report of prostate cancer stage at diagnosis from a large cohort of patients from the Middle East showing a median age at diagnosis of 68 and 22.6% presenting with stage 4 disease. These data highlight the importance of multi-disciplinary management and health-care system planning for the rising burden of prostate cancer affecting the MENA population.