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PURPOSE: Since the approval of cyclin‐dependent kinase 4/6 inhibitors in 2015, this oral cancer (OC) therapy has been combined with oral endocrine therapy as first-line treatment in metastatic hormone receptor–positive breast cancer, adding unique toxicity and complexity to the successful administration of this oral medication. Implementation of OC is challenging because of delays in treatment and nonadherence and is worse among vulnerable patient populations. Pharmacists may mitigate these barriers with facilitation of prior authorizations, communication with pharmacies, toxicity management, adherence counseling, and optimization of dosing schedules and regimens. MATERIALS AND METHODS: We conducted a quality improvement project to decrease the average number of treatment day delays during the first six cycles of OC. Patients were enrolled on the OPTIMAL protocol, a high-touch pharmacy intervention incorporating pharmacists within outpatient oncology clinic visits with the providers. Pharmacists met with patients, identified individual barriers to treatment, and performed counseling including toxicity and adherence assessments. RESULTS: A preintervention assessment identified an average treatment day delay of 7.7 (range, 3.2-15.3) days during the first six cycles of OC. During the intervention period, 53 patients were enrolled on the OPTIMAL protocol and experienced an average treatment day delay of 2.1 (0.6-4) days, P < .0001. Delays were characterized as modifiable and unmodifiable. Pharmacists documented 640 interventions, including medication reconciliations and clinical recommendations. Forty-two patients reported treatment-related toxicities, resulting in 33 therapy and 20 dose modifications. CONCLUSION: Our initiative to incorporate pharmacists in clinic visits at an outpatient breast cancer clinic was associated with decreased treatment day delays during the first six cycles of treatment. Pharmacists performed a multitude of meaningful interventions to facilitate treatment in a particularly vulnerable population and play a valuable role in comanaging patients.

Sociolegal barriers to cancer care are defined as health-related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public policy, law, regulation, or programming. Legal support has not been studied in cancer care.The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety-net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English-speaking, Spanish-speaking, or Haitian Creole-speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient-reported outcomes (distress, cancer-related needs, and satisfaction with navigation) at baseline and at 6 months.In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety-six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17-4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35-45.4). No differences in patient-reported outcomes were observed between treatment groups.Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators.In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care. This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation. Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide.

PURPOSE: There are approximately 150,000 women living with metastatic breast cancer (mBC) in the United States. Disparities in de novo mBC incidence and mortality exist across race/ethnicity, socioeconomic status (SES), and rurality. However, how SES and rurality independently impact mBC outcomes across different racial/ethnic groups is not fully understood. The purpose of this study was to determine the impact of SES and rurality on cancer-specific mortality among women with mBC by race/ethnicity. METHODS: We conducted a large, population-based retrospective cohort study in women aged 18 + years diagnosed with de novo mBC using the Surveillance, Epidemiology and End Results Census Tract-level SES and Rurality Database (2000–2015). Associations between SES/rurality and cancer-specific mortality were determined using Fine and Gray regression models. Subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) by race/ethnicity and hormone receptor (HR) status were calculated. RESULTS: A cohort of 33,976 women were included with the majority being White (67%), 17% Black, 0.4% American Indian/Alaskan Native, 6% Asian/Pacific Islander, and 10% Latina/Hispanic. We observed the greatest increased risk of BC mortality among Black women with HR-negative mBC residing in neighborhoods with lower SES (lowest versus highest quintile: SHR 1.38, 95% CI 1.00–1.90) and in rural areas compared to urban areas (SHR 1.27, 95% CI 1.01–1.59). CONCLUSION: Overall, BC-specific survival among women with de novo mBC differs by race/ethnicity, with the greatest adverse impacts of SES and rurality affecting Black women with HR-negative disease.

Type 2 Diabetes (T2D) is a chronic inflammatory disease characterized by inflamed adipose tissue. Patients with triple negative breast cancer (TNBC) and comorbid T2D have higher risk of metastasis and shorter survival. However, mechanisms that couple T2D to TNBC outcomes are unknown. Here we hypothesize that exosomes, small vesicles secreted by tumor microenvironment breast adipocytes, drive epithelial-to-mesenchymal transition (EMT) in TNBC, immune exhaustion and metastasis via Ampk-Akt signaling.Methods: Exosomes were purified from conditioned media of 3T3-L1 mature adipocytes that were insulin-sensitive (IS) or insulin-resistant (IR), then characterized and quantified by NanoSight and surface markers, CD63. Murine 4T1 cells, a TNBC model, were treated with exosomes in vitro (3 days). To establish 3D organoids, 4T1 spheroids were treated with exosomes and embedded in Matrigel. For in vivo models, mammary fat pads of BALB/c mice were injected with 4T1 cells treated with IS vs IR exosomes. 4T1 tumors were harvested and mRNA extracted for qPCR, RNAseq, and Ingenuity Pathway Analysis. Metastatic sites in lung and liver were visualized by H&E staining and clonogenic assay. Immune exhaustion markers of tumor infiltrated lymphocytes (TILs) were measured by flow cytometry. Results: In 4T1 cells treated with IR exosomes, EMT was upregulated and PD-L1 expression increased. Tumor-bearing mice exhibited metastasis in exosome-treated groups, visualized by microscopy and clonogenic assay. Immune exhaustion markers showed modified expression in TILs from exosome-treated groups. RNA-seq analysis revealed differences among exosome-treated groups that suggest dysregulated Ampk-Akt pathways.Conclusion: Exosomes from IR adipocytes modify the tumor microenvironment, increase EMT and immune exhaustion markers on tumor cells and TILs, and promote metastasis to distant organs through Ampk-Akt. Metabolic diseases such as T2D reshape the TNBC tumor microenvironment, promoting metastasis and decreasing survival. Clearly, TNBC patients with T2D should be more closely monitored for metastasis than metabolically normal patients, with metabolic medications considered. Citation Format: Yuhan Qiu, Conor Ross, Naser Jafari, Manohar Kolla, Pablo Llevenes, Christina Ennis, Carla S Mazzeo, Kiana Mahdaviani, Naomi Y Ko, Gerald V Denis. Exosomes produced by adipocytes induce EMT, immune exhaustion and tumor metastasis, in both in vivo and in vitro models of TNBC [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-06-02.

Background Studies suggest that experiences of interpersonal violence victimization (i.e., partner violence, childhood sexual or physical abuse, and sexual assault) might play a role in breast cancer diagnosis and treatment. To address gaps in knowledge, our study aimed to understand how prior interpersonal trauma affects breast cancer. We conducted 20 semi-structured in-person interviews and asked patients how their interpersonal trauma affected their breast cancer experience and if they had suggestions to improve breast cancer care. Methods Patients were recruited through flyers or from providers to whom they had previously disclosed a history of interpersonal violence. One-on-one interviews lasted approximately one hour each. Results were thematically coded in an iterative fashion and analyzed for main themes. Results Three themes addressed the relatedness of interpersonal violence and cancer care: 1) perceptions that violence caused the cancer or led to worse outcomes, 2) how breast cancer diagnosis and treatment can trigger interpersonal violence memory (triggers), and 3) difficulty trusting. In addition, three suggestions emerged that related to improving care: the importance of female providers, improved provider communication, and the potential benefits of a buddy system to pair newly diagnosed breast cancer patients with a history of interpersonal violence with breast cancer survivors with a similar background. Conclusion Interpersonal violence can influence how women feel about their breast cancer diagnoses, interactions with health care providers, and receiving care for cancer. Improving trauma-informed health care practice would be beneficial for women with breast cancer.

Disparities in breast reconstruction have been observed in national cohorts and single-institution studies based on race, ethnicity, insurance and language. However, little is known regarding whether safety-net hospitals deliver more or less equitable breast reconstruction care in comparison to national cohorts.We performed a retrospective study of patients with either invasive breast cancer or ductal carcinoma in situ (DCIS) diagnosed and treated at our institution (1/1/09-12/31/14). The rate of, timing of, and approach to breast reconstruction were assessed by race, ethnicity, insurance status and primary language among women who underwent mastectomy. Reasons for not performing reconstruction were also analyzed.756 women with DCIS or non-metastatic invasive cancer were identified. Median age was 58.5 years, 56.2% were non-white, 33.1% were non-English-speaking, and 48.9% were Medicaid/uninsured patients. 142 (18.8%) underwent mastectomy during their index operation. 47.9% (N=68) did not complete reconstruction. Reasons for not performing reconstruction included: patient preference (N=22), contraindication to immediate reconstruction (i.e., locoregionally advanced disease prohibiting immediate reconstruction) without follow-up for consideration of delayed reconstruction (N=12), prohibitive medical risk or contraindication (i.e., morbid obesity) (N=8), and progression of disease, prohibiting reconstruction (N=7). Immediate and delayed reconstruction were completed in 43.7% and 8.5% of patients. Rate of reconstruction was inversely associated with tumor stage (OR=0.52, 95% CI: 0.31-0.88), but not race, ethnicity, insurance or language, on multivariate regression.At a safety-net hospital, we observed rates of reconstruction at or above national estimates. After adjustment for clinical attributes, rates did not vary by race, ethnicity, insurance or language. Future research is needed to understand the role of reconstruction in breast cancer care and how to advance shared decision-making among diverse patients.

Background Physical limitations prior to cancer diagnosis may lead to suboptimal health outcomes. Our objective was to evaluate the impacts of poor physical health-related quality of life (HRQOL) and physical functioning (PF) on the risk of contralateral breast cancer (CBC). Methods We performed a nested case-control study of women with invasive unilateral breast cancer (UBC) who did not receive prophylactic contralateral mastectomy using the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey data resource. Among 2938 women aged ≥ 65 years diagnosed with first stage I-III UBC between 1997 and 2011, we identified 100 subsequent CBC cases and 915 matched controls without CBC using incidence density sampling without replacement. Pre-diagnosis physical HRQOL and PF were determined using Medical Outcomes Trust Short Form-36 (SF-36)/Veterans Rand 12-Item Health Survey (VR-12) responses within 2 years prior to first UBC diagnosis. We estimated adjusted odds ratios (OR) and 95% confidence intervals (CI) using conditional logistic regression models. Results Cases and controls were similar with respect to comorbidities, stage, surgery, and radiation treatments, but differed by hormone receptor status (ER/PR-negative, 23% and 11%, respectively) of first UBC. Cases had modestly lower mean pre-diagnosis physical HRQOL (- 1.8) and PF (- 2.2) scores. In multivariable models, we observed an increased CBC risk associated with low physical HRQOL (lowest vs. highest quartile, OR = 1.8; 95% CI 0.8-4.3), but CIs included 1.0. Low PF was associated with a 2.7-fold (95% CI 1.1-6.7) increased CBC risk. Conclusions Findings indicate that low physical HRQOL, specifically poor PF, is associated with CBC risk. Efforts to understand and minimize declines in PF post-breast cancer are well motivated.

PURPOSE: Healthcare systems contribute to disparities in breast cancer outcomes. Patient navigation is a widely cited systembased approach to improve outcomes among populations at risk for delays in care. Patient navigation programs exist in all major Boston hospitals, yet disparities in outcomes persist. The objective of this study was to conduct a baseline assessment of navigation processes at six Boston hospitals that provide breast cancer care in preparation for an implementation trial of standardized navigation across the city. METHODS: We conducted a mixed methods study in six hospitals that provide treatment to breast cancer patients in Boston. We administered a web-based survey to clinical champions (n = 7) across six sites to collect information about the structure of navigation programs. We then conducted in-person workflow assessments at each site using a semi-structured interview guide to understand site-specific implementation processes for patient navigation programs. The target population included administrators, supervisors, and patient navigators who provided breast cancer treatment-focused care. RESULTS: All sites offered patient navigation services to their patients undergoing treatment for breast cancer. We identified wide heterogeneity in terms of how programs were funded/resourced, which patients were targeted for navigation, the type of services provided, and the continuity of those services relative to the patient’s cancer treatment. CONCLUSIONS: The operationalization of patient navigation varies widely across hospitals especially in relation to three core principles in patient navigation: providing patient support across the care continuum, targeting services to those patients most likely to experience delays in care, and systematically screening for and addressing patients’ health-related social needs. Gaps in navigation across the care continuum present opportunities for intervention. TRIAL REGISTRATION: Clinical Trial Registration Number NCT03514433, 5/2/2018

Background Multiple independent risk factors are associated with the prognosis of hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) breast cancer (BC), the most common BC subtype. This study describes U.S. population-based recurrence rates among older, resected women with HR+/HER2- early BC. Methods We conducted a retrospective cohort study of older women diagnosed with incident, invasive stages I-III HR+/HER2- BC who underwent surgery to remove the primary tumor using the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked Database (2007–2015). SEER records and administrative health claims data were used to ascertain patient and tumor-specific characteristics, treatment, and frailty status. Cumulative incidences of BC recurrence were estimated using a validated algorithm for administrative claims data. Multivariable Fine-Gray competing risk models estimated adjusted subdistribution hazards ratios and 95 % confidence intervals for associations with BC recurrence risk. Results Overall, 46,027 women age ≥65 years were included in our analysis. Over a median follow up of 7 years, 6531 women experienced BC recurrence with an estimated 3 and 5-year cumulative incidence rates of 10 % and 16 %, respectively. Higher 3- and 5-year cumulative incidences were observed in women with larger tumor size (5+ cm, 21 % and 28 %), lymph node involvement (4+ nodes, 27 % and 37 %), and with frail health status at diagnosis (13 % and 20 %). Independent of these clinical risk factors, Black, Hispanic and American Indian/Alaskan Native women had significantly increased BC recurrence risks. Conclusions Rates of recurrence in HR+/HER2- early BC differs by several patient and clinical factors, including high-risk tumor characteristics. Racial differences in BC outcomes deserve continued attention from clinicians and policymakers., Highlights • High-risk women with HR+/HER2-breast cancer have two-fold higher recurrence rates. • Greatest risk occurred with stage III disease, 4+ nodes, and tumor sizes >5 cm. • Frailty was significantly associated with higher breast cancer recurrence risk. • Disparities in breast cancer recurrence were observed in racial/ethnic minorities.

Frailty is assessed when making treatment decisions among older women with breast cancer (BC), which in turn impacts survival. We evaluated associations between pre-diagnosis frailty and risks of BC-specific and all-cause mortality in older women. We conducted a retrospective cohort study of Medicare beneficiaries ages ≥ 65 years with stage I–III BC using the Surveillance, Epidemiology and End Results-Medicare Health Outcome Survey Data Resource. Frailty was measured using the deficit-accumulation frailty index, categorized as robust, pre-frail, or frail, at baseline and during follow-up. Fine and Gray competing risk and Cox proportional hazards models were used to estimate subdistribution hazard ratios (SHR) and hazard ratios (HR) with 95% confidence intervals (CI) for BC-specific and all-cause mortality, respectively. Among 2411 women with a median age of 75 years at BC diagnosis, 49.5% were categorized as robust, 29.4% were pre-frail and 21.1% were frail. Fewer frail women compared to robust women received breast-conserving surgery (52.8% vs. 61.5%, frail vs. robust, respectively) and radiation (43.5% vs. 51.8%). In multivariable analyses, degree of frailty was not associated with BC-specific mortality (frail vs robust SHR 1.47, 95% CI 0.97–2.24). However, frail women with BC had higher risks of all-cause mortality compared to robust women with BC (HR 2.32, 95% CI 1.84–2.92). Among a cohort of older women with BC, higher degrees of frailty were associated with higher risk of all-cause mortality, but not BC-specific mortality. Future study should examine if preventing progression of frailty may improve all-cause mortality.

PURPOSE: Hospital readmissions occur commonly in those receiving cancer care and result in impaired quality of life and increased costs. Causes of readmission in safety net hospitals that serve vulnerable populations are not well understood. The primary goal of this project was to identify potentially avoidable and intervenable causes of readmissions to an urban safety net hospital. METHODS: A retrospective chart review was performed on patients who were readmitted within 30 days of discharge from the hematology and oncology service at Boston Medical Center over the 6-month period between October 2018 and March 2019. Charts were reviewed by three internal medicine residents and discussed under the supervision of an attending oncologist. RESULTS: Two hundred ninety-one patient encounters involving 203 unique patients were identified in the 6-month study period. Of these 291 encounters, 80 encounters (27.5%) were followed by a readmission within 30 days and occurred in 61 (30.0%) unique patients. Nineteen (31.1%) of these 61 patients experienced two readmissions within 30 days of discharge. Twenty-five readmissions (31.3%) were classified as potentially avoidable, with the most common cause of potentially avoidable readmissions attributed to ascitic or pleural fluid reaccumulation (8, 32%). The majority of presumed nonpreventable readmissions were due to expected complications of cancer progression and treatment-related side effects. DISCUSSION: In conclusion, readmissions were common, and a modifiable reason for 30-day readmissions was identified. Addressing recurrent ascitic and pleural fluid reaccumulation in the outpatient setting could help to reduce inpatient hospital readmission on an inpatient oncology service.

PURPOSE Frailty is assessed when making treatment decisions among older women with breast cancer (BC), which in turn impacts survival. We evaluated associations between frailty and risks of BC-specific and all-cause mortality in older women. METHODS We conducted a retrospective cohort study of Medicare beneficiaries ages ≥65 years with stage I-III BC using the Surveillance, Epidemiology and End Results Medicare Health Outcome Survey Data Resource. Frailty was measured using the deficit-accumulation frailty index, categorized as robust, pre-frail or frail, at baseline and during follow-up. Fine and Gray competing risk and Cox proportional hazards models were used to estimate sub-distribution hazard ratios (SHR) and hazard ratios (HR) with 95% confidence intervals (CI) for BC-specific and all-cause mortality, respectively. RESULTS Among 2,411 women with a median age of 75 years at BC diagnosis, 50% were categorized as robust, 29% were pre-frail and 21% were frail. Compared to robust women, fewer frail women received breast-conserving surgery (52% vs. 63%) and radiation (44% vs. 52%). In multivariable analyses, frail women had higher risks of all-cause mortality compared to robust women (HR 2.16, 95% CI 1.80-2.60). CONCLUSION Frail women in our study had a higher cumulative hazard of BC-specific death, but this observed higher risk was not significant after accounting for differences in treatment and competing risks of other-cause death. Measuring frailty may help determine overall life expectancy but not BC-specific death. Table. Risk of Breast Cancer-Specific and All-cause Mortality, using time-varying DAFI measureEventsCrude SHRRobust 95%CIP-valueMinimally Adjusted SHRaRobust 95%CIP-valueFully Adjusted SHRbRobust 95%CIP-valueBreast Cancer-Specific MortalityDAFI CategoriesRobust891.001.001.00Pre-frail691.250.91 – 1.700.161.150.84 – 1.590.381.060.77 – 1.480.72Frail621.531.11 – 2.110.011.371.00 – 1.900.051.190.85 – 1.660.31All-Cause MortalityDAFI CategoriesRobust2721.001.001.00Pre-frail2241.551.30 – 1.84 Citation Format: Connie H Yan, Chandler Coleman, Nadia A Nabulsi, Brian Chiu, Naomi Y Ko, Kent Hoskins, Gregory S Calip. Associations between frailty and cancer-specific mortality among older women with breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-13.

Introduction Oral chemotherapy agents have become increasingly common for the treatment of various malignancies, specifically in the metastatic setting. In metastatic breast cancer, oral chemotherapy is now considered the standard of care for first-line treatment due to progression-free survival and overall survival benefits. Oral agents are also considered to be a convenient and less toxic therapy option, improving quality of life. However, these benefits are offset by challenges in the delay to initiation of therapy, adherence, and toxicity management which may lead to high co-pays, delays in treatment, increased clinic visits, and non-adherence. These issues can be augmented at a safety net hospital charged to care for the most vulnerable patients. Close monitoring and follow-up are critical but can be complex and pose an additional burden on the treating oncologist. Pharmacists can serve as an extender to the oncologist and may help mitigate many of these clinical and operational barriers through adherence strategies, toxicity management, care coordination, and optimization of dosing schedules and regimens. Methods/Materials We conducted a quality improvement (QI) initiative aimed to decrease the average number of treatment day delays experienced by patients receiving oral chemotherapy for the treatment of MBC during the first six cycles of chemotherapy. A secondary aim was to improve adherence and patient-provider satisfaction. A protocol was designed and implemented utilizing pharmacists to provide assistance with obtaining the medications through a specialty pharmacy, oral chemotherapy counseling, toxicity assessments, and strategies to help optimize oral adherence (OPTIMAL protocol). Pharmacists conducted live in-person visits and telemedicine visits at weekly to monthly intervals to supplement the ongoing routine care of the oncology provider. All treatment and supportive care recommendations, in addition to any identified barriers, were communicated to the provider. Results A baseline assessment of 63 patients receiving oral oncolytic therapy from December 1st, 2018 through November 26th, 2019 was completed. Patients experienced most delays during cycle 1, with an average of 14.5 days of delay (range 1 - 34 days). The most common reasons for delay throughout the first six cycles of therapy were toxicity development, receipt of medication from the pharmacy, and patient adherence. A separate analysis of patients on CDK4/6 inhibitors (n=8) identified an average treatment day delay of 7.7 days (range 3.2 - 15.3 days) during the first six cycles of chemotherapy. Over a 7-month period, fifteen patients were enrolled in the OPTIMAL protocol and experienced an average treatment day delay of 2.9 days (range 0 - 6.8 days) during the first six cycles. Pharmacists made 206 documented interventions amongst the patients on the protocol, encompassing medication reconciliations, therapy counseling, and clinical recommendations. Eleven patients reported treatment-related toxicities, resulting in six therapy modifications and two-dose modifications. Four patients experienced progression on oral oncolytic therapy and subsequently went on to other treatment options. Conclusion Our protocol to incorporate pharmacists in initial and follow-up clinic visits at an outpatient breast cancer clinic within a safety net hospital was associated with decreased treatment day delays. Pharmacists performed a large number of meaningful clinical and operational interventions to facilitate medication treatment in a, particularly vulnerable population. This intervention supports the valuable and versatile role pharmacists can play in co-managing patients with the rest of the healthcare team. Citation Format: Jasmine Patel, David Michael Hughes, Kathryn Quinn, Tsion Fikre, Naomi Ko. Effect of an outpatient pharmacy team to improve management and adherence to oral chemotherapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-26.

Hepatocellular carcinoma commonly metastasizes to organs, but there are few reports of vertebral metastases causing cord compression. Here, we present a case of thoracic cord compression in a patient with advanced hepatocellular carcinoma. Providers’ and patient’s awareness of this risk is important, as this is an oncological emergency.

Background: The differential occurrence of second primary cancers by race following ovarian cancer is poorly understood. Our objective was to determine the incidence of second primary gynecologic cancers (SPGC) following definitive therapy for ovarian cancer. Specifically, we aimed to determine differences in SPGC incidence by Asian ethnic subgroups. Methods: We identified 27,602 women ages 20 years and older and diagnosed with first primary epithelial ovarian cancer between 2000 and 2016 who received surgery and chemotherapy in 18 population-based Surveillance, Epidemiology and End Results Program registries. We compared the incidence of SPGC with expected incidence rates in the general population of women using estimated standardized incidence ratios (SIR) and 95% confidence intervals (CI). Results: The incidence of SPGC was lower among White women (SIR = 0.73; 95% CI, 0.59–0.89), and higher among Black (SIR = 1.80; 95% CI, 0.96–3.08) and Asian/Pacific Islander (API) women (SIR = 1.83; 95% CI, 1.07–2.93). Increased risk of vaginal cancers was observed among all women, although risk estimates were highest among API women (SIR = 26.76; 95% CI, 5.52–78.2) and were also significant for risk of uterine cancers (SIR = 2.53; 95% CI, 1.35–4.33). Among API women, only Filipinas had significantly increased incidence of SPGC overall including both uterine and vaginal cancers. Conclusions: Risk of SPGC following treatment of ovarian cancer differs by race and ethnicity, with Filipina women having the highest rates of second gynecologic cancers among Asian women. Impact: Ensuring access and adherence to surveillance may mitigate ethnic differences in the early detection and incidence of second gynecologic cancers.

Genomic testing in early-stage hormone-positive breast cancer is the standard of care. However, decisions based on genomic testing results are predicated on the assumption that patients receive endocrine treatment. We sought to investigate racial differences in genomic testing and adjuvant treatment in breast cancer. A retrospective, population-based hospital registry study using the National Cancer Database. Participants included women with stages I–II, ER + breast cancer between 2010 and 2014. Sociodemographic factors were analyzed. Primary outcomes were the utilization of genomic testing and receipt of endocrine therapy. Logistic regression modeling was used to compute crude and adjusted odds of genomic testing and receipt of endocrine therapy. Among a total sample size of 387,008 patients, 147,863 (38.2%) underwent genomic testing. Older age (≥ 70 years) was associated with a lower adjusted odd of genomic testing (OR 0.33; 95% CI 0.32–0.34, p =

Objective To understand the role of racial residential segregation on Black-White disparities in breast cancer presentation, treatment, and outcomes. Summary of background data Racial disparities in breast cancer treatment and outcomes are well documented. Black individuals present at advanced stage, are less likely to receive appropriate surgical and adjuvant treatment, and have lower overall and stage-specific survival relative to White individuals. Methods Using data from the Surveillance, Epidemiology, and End Results program, we performed a retrospective cohort study of Black and White patients diagnosed with invasive breast cancer from 2005 to 2015 within the 100 most populous participating counties. The racial index of dissimilarity was used as a validated measure of residential segregation. Multivariable regression was performed, predicting advanced stage at diagnosis (stage III/IV), surgery for localized disease (stage I/II), and overall stage-specific survival. Results After adjusting for age at diagnosis, estrogen/progesterone receptor status, and region, Black patients have a 49% greater risk (relative risk [RR] 1.49 95% confidence interval [CI] 1.27, 1.74) of presenting at advanced stage with increasing segregation, while there was no observed difference in Whites (RR 1.04, 95% CI 0.93, 1.16). Black patients were 3% less likely to undergo surgical resection for localized disease (RR 0.97, 95% CI 0.95, 0.99) with increasing segregation, while Whites saw no significant difference. Black patients had a 29% increased hazard of death (RR 1.29, 95% CI 1.04, 1.60) with increasing segregation; there was no significant difference among White patients. Conclusions Our data suggest that residential racial segregation has a significant association with Black-White racial disparities in breast cancer. These findings illustrate the importance of addressing structural racism and residential segregation in efforts to reduce Black-White breast cancer disparities.

The size distribution of adipocytes in fat tissue provides important information about metabolic status and overall health of patients. Histological measurements of biopsied adipose tissue can reveal cardiovascular and/or cancer risks, to complement typical prognosis parameters such as body mass index, hypertension or diabetes. Yet, current methods for adipocyte quantification are problematic and insufficient. Methods such as hand-tracing are tedious and time-consuming, ellipse approximation lacks precision, and fully automated methods have not proven reliable. A semi-automated method fills the gap in goal-directed computational algorithms, specifically for high-throughput adipocyte quantification. Here, we design and develop a tool, AdipoCyze, which incorporates a novel semi-automated tracing algorithm, along with benchmark methods, and use breast histological images from the Komen for the Cure Foundation to assess utility. Speed and precision of the new approach are superior to conventional methods and accuracy is comparable, suggesting a viable option to quantify adipocytes, while increasing user flexibility. This platform is the first to provide multiple methods of quantification in a single tool. Widespread laboratory and clinical use of this program may enhance productivity and performance, and yield insight into patient metabolism, which may help evaluate risks for breast cancer progression in patients with comorbidities of obesity. ABBREVIATIONS BMI: body mass index.

Background Breast cancer and hepatitis C virus (HCV) infection are major health problems in the U.S. Despite these highly prevalent diseases, there is limited information on the effect of HCV infection among patients with breast cancer receiving chemotherapy and the potential challenges they face during treatment. Currently, there are no guidelines for chemotherapy administration in HCV-positive patients with breast cancer. Materials and methods We performed a retrospective case-control analysis on six patients with breast cancer with active HCV infection and 12 HCV-negative matched controls who received chemotherapy between January 2000 and April 2015. We investigated dose delays, dose changes, hospitalization, hematologic reasons for dose delays, and variation in blood counts during chemotherapy from the patients' medical records. Fisher's exact test was used for statistical comparison of the outcome variables between the two groups. Results When compared with the HCV-negative patients, the HCV-positive group was at a significantly higher risk of dose delays (100% vs. 33%, p value .013), dose changes (67% vs. 8%, p value .022), hospitalization during chemotherapy (83% vs. 25%, p value .043), and hematotoxicity related dose delays (83% vs. 8%, p value .003). HCV-positive patients took a longer time to complete treatment than the HCV-negative group. Conclusion Patients with HCV receiving chemotherapy for breast cancer are more likely to experience complications such as dose delays, dose modifications, and hospitalization. Future studies to confirm our findings and investigate on the effect of concurrent HCV and breast cancer treatment are warranted. Implications for practice This study found that hepatitis C infection is associated with a greater risk of treatment delays and dose modifications in patients with breast cancer receiving cytotoxic chemotherapy. Hepatitis C-positive patients have a higher treatment burden with dose changes, hospitalizations, and longer treatment periods than noninfected patients. Further prospective investigations to confirm these findings are warranted in a larger patient population. Given that hepatitis C infection can be curable with direct-acting antivirals, treatment of hepatitis C may alleviate treatment challenges during chemotherapy and improve survival for patients with breast cancer.

Background Venous thromboembolism (VTE) prophylaxis has become routine for patients undergoing most operations, but it remains controversial for breast operations due to a perceived low risk of VTE. There is limited evidence to support routine or extended VTE prophylaxis in breast surgery. We investigated the benefits and risks of the Caprini risk stratification tool and corresponding prevention program, including extended prophylaxis for high-risk groups, in patients undergoing operations for benign and malignant breast lesions. Study Design Using Boston Medical Center data, we reviewed records of patients who underwent lumpectomy or total mastectomy (with or without axillary surgery and/or reconstruction), between 2011 and 2018, to collect information about operation, Caprini score, administration of prophylaxis, and postoperative VTE or bleeding events. Descriptive statistics were performed. Results Seven hundred fifty patients underwent 881 operations; 48.9% were at low or moderate risk of VTE, 43.8% were at high risk, and 7.3% were at highest risk. There were no VTE events in the low- and moderate-risk groups, 5 (1.3%) in the high-risk, and 1 (1.6%) in the highest-risk group. One patient was diagnosed with VTE during hospitalization. None of the 5 patients who developed VTE after discharge was prescribed the recommended extended chemoprophylaxis. There were 19 bleeding events that did not require reoperation; 3 patients returned to the operating room. There was no correlation of bleeding with receipt of extended chemoprophylaxis. Conclusions The Caprini protocol can identify high-risk breast surgery patients who may benefit from extended VTE chemoprophylaxis, as well as low-risk patients who require no chemoprophylaxis. Furthermore, administration of extended chemoprophylaxis was not associated with an increased risk of bleeding.

Background Breast cancer patients with early-stage disease are increasingly administered neoadjuvant chemotherapy (NAC) to downstage their tumors prior to surgery. In this setting, approximately 31% of patients fail to respond to therapy. This demonstrates the need for techniques capable of providing personalized feedback about treatment response at the earliest stages of therapy to identify patients likely to benefit from changing treatment. Diffuse optical spectroscopic imaging (DOSI) has emerged as a promising functional imaging technique for NAC monitoring. DOSI uses non-ionizing near-infrared light to provide non-invasive measures of absolute concentrations of tissue chromophores such as oxyhemoglobin. In 2011, we reported a new DOSI prognostic marker, oxyhemoglobin flare: a transient increase in oxyhemoglobin capable of discriminating NAC responders within the first day of treatment. In this follow-up study, DOSI was used to confirm the presence of the flare as well as to investigate whether DOSI markers of NAC response are regimen dependent. Methods This dual-center study examined 54 breast tumors receiving NAC measured with DOSI before therapy and the first week following chemotherapy administration. Patients were treated with either a standard of care maximum tolerated dose (MTD) regimen or an investigational metronomic (MET) regimen. Changes in tumor chromophores were tracked throughout the first week and compared to pathologic response and treatment regimen at specific days utilizing generalized estimating equations (GEE). Results Within patients receiving MTD therapy, the oxyhemoglobin flare was confirmed as a prognostic DOSI marker for response appearing as soon as day 1 with post hoc GEE analysis demonstrating a difference of 48.77% between responders and non-responders (p p = 0.0010) between patients receiving MTD and MET regimens. Conclusions DOSI optical biomarkers are differentially sensitive to MTD and MET regimens at early timepoints suggesting the specific treatment regimen should be considered in future DOSI studies. Additionally, DOSI may help to identify regimen-specific responses in a more personalized manner, potentially providing critical feedback necessary to implement adaptive changes to the treatment strategy.

Purpose The role of germline genetic testing in breast cancer patients is crucial, especially in the setting of the recent trials showing the benefit of PARP inhibitors. The goal of this study was to identify racial disparities in genetic counseling and testing in patients with high-risk breast cancer. Methods Patients with 2 unique breast cancer diagnoses were examined to understand demographics, insurance coverage, characteristics of breast cancer, and whether they were recommended for and received genetic counseling and testing. Results A total of 69 patients with a dual diagnosis of breast cancer between the years 2000 and 2017 were identified (42% identified as White compared to 58% that identified as non-White). White patients were more likely to be recommended for genetic counseling (OR = 2.85; 95% CI, 1.07-7.93, P < .05), be referred for genetic counseling (OR = 3.17; 95% CI, 1.19-8.86, P < .05), receive counseling (OR = 3.82; 95% CI, 1.42-10.83, P < .01), and undergo genetic testing (OR = 2.88; 95% CI, 0.97-9.09, P = .056) compared to non-White patients. Patients with private insurance were significantly more likely to be recommended for genetic counseling (OR 5.63, P < .005), referred (OR 6.11, P < .005), receive counseling (OR 4.21, P < .05), and undergo testing (OR 4.10, P < .05). When controlled for insurance, there was no significant racial differences in the rates of GC recommendation, referral, counseling, or testing. Conclusion The findings of this study suggest that disparities in genetic counseling and testing are largely driven by differences in health insurance.

Introduction: Patient adherence is critical to the efficacy of oral cancer chemotherapy. At a major safety net hospital, we sought to define the adherence to oral cancer therapy amongst our diverse and socioeconomically disadvantaged patient population. We designed a high-touch, pharmacist driven program called Boston Medical Center’s Specialty Pharmacy Adherence Program (B-SPAP), to see if this intervention could improve adherence to oral cancer treatment. Methods: We conducted a prospective intervention study of adult patients undergoing treatment with an oral oncology agent for advanced cancer or hematologic malignancy. The intervention incorporated the Multinational Association of Supportive Care in Cancer Oral Agent Teaching Tool by a clinical pharmacist for 30-60 minutes at initial, 3, 6, and 12 month study visits. Patients completed Patient Activation Measure (PAM) and Trust in Physician (TIP) surveys during visits. The primary endpoints were adherence (medication adherence ratio (MAR) (= sum of days’ supply for all fills in period/number of days in period) x100), and persistence (presence or absence of a >/= 45 day treatment gap). We utilized a 2:1 matched historical control design on type of chemotherapy agent. Linear regression models examined differences in adherence and persistence between intervention and controls. Data: There were 218 patients, 74 intervention and 144 historical controls. 54% of patients identified as Black, 28% Caucasian, 7% Asian, 6% other, 17% as Hispanic/Latino. 37% do not use English as their preferred language. 24% reported finishing high school. 30% are on Medicaid, 42% on Medicare, 10% had commercial insurance. The MAR in the intervention group was 92 (SD 14.6) compared with 93 (SD 10.8) in the historical control group (p=0.4). 78% of patients in the intervention group were persistent compared with 80% of historical controls (p=0.9). Non-English speaking patients had higher MAR=94.5 than English speaking patients, MAR=91 (β 3.5, SE 1.7, p=0.04). There were no differences in MAR in relation to age, marital status, or charlson comorbidity index. For the intervention patients, the average TIP Score was 48 (max of 55). TIP score did not differ by race (white=47, non-white 49, p=0.4) or language (English=49, non-English=47, p=0.3). The average PAM score was 43 (max of 52). Conclusions: Adherence to oral cancer therapies amongst our diverse patient population is high, over 90 adherent days in a 100 day period. Our high-touch, pharmacist driven intervention did not improve adherence or persistence between controls and intervention due to high rates in the control population. Interestingly we found that non-English speaking patients were more likely to be adherent than English speaking patients. Our findings suggest that equal access among a diverse patient population at a safety net institution can result in high adherence and positive outcomes despite socio-demographic factors that often lead to disparities in cancer care. Citation Format: Claire E.P. Smith, David Hughes, Scott Gould, Anne Buck, Naomi Y. Ko. Prospective cohort study of a pharmacist-driven medication management program to improve oral cancer therapy adherence in an underserved, diverse urban setting [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A065.

Background: Hepatitis C virus (HCV) infection is a major health problem in the United States and breast cancer is the second most common cancer in US women. Despite these prevalent diseases, there is limited information available on the effects of a concurrent HCV infection among breast cancer patients receiving chemotherapy and the problems they face during their treatment. There are limited guidelines for chemotherapy treatment in HCV positive breast cancer patients. Methods: We performed a retrospective 2:1 matched case control analysis on breast cancer patients with a confirmed active HCV infection who received chemotherapy at Boston Medical Center between January 2000 and April 2015. Cases with HCV infection (n=6) were matched with controls (n=12) who were HCV negative. The controls were matched on age (decade) of diagnosis, stage of breast cancer, and intended chemotherapy regimen. We investigated dose delays, dose changes, hospitalization, hematologic reasons for dose delays, and variation in blood counts during the treatment period in these patients from their medical records. Statistical analysis was done using R version 3.4.0 to compare these outcomes of interest between the two groups. Fisher’s exact and Wilcoxon rank sum tests were used to compare the categorical and continuous variables respectively. Results: The HCV positive group was at a significantly higher risk of dose delays (100% vs. 33%, p = 0.01), dose changes (67% vs. 8%, p = 0.02), and hospitalization during chemotherapy (83% vs. 25%, p = 0.04) than their HCV matched controls. The risk of getting a dose delay due to hematotoxicity was significantly higher in the HCV positive group than the HCV negative group (83% vs. 8%, p = 0.003). The HCV positive patients took longer time to complete their treatment cycles than the HCV negative group. Conclusions: Chronic HCV infection in breast cancer patients receiving chemotherapy may be complicated by their active HCV infection. Treatment challenges due to dose changes, dose delays and hospitalizations were significantly more common when compared to controls. Chemotherapy delays and dose changes during breast cancer treatment has a negative consequence. In the era of curative treatment for HCV, future studies focused on the effect and treatment of concurrent HCV and breast cancer treatment is warranted. Citation Format: Saptaparni Ghosh, Minghua L Chen, Janice Weinberg, Naomi Y Ko. Effects of hepatitis C virus infection on the safety of chemotherapy for breast cancer patients: A retrospective chart analysis [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-14-12.

Background & Objectives Breast cancer outcome disparities for racial and ethnic minorities continues to be a problem in the United States. Genomic testing in early stage hormone positive breast cancer is the current standard of care given the useful predictive and prognostic value of testing. However, chemotherapy treatment decisions based on genomic testing results are predicated on the assumption that patient adhere to adjuvant endocrine treatment. Factors that could contribute to ongoing disparities for racial and ethnic minorities include both the utilization of genomic testing and adherence to hormonal therapy. Understanding these patterns of care across the United States with a large dataset has not yet been done. Methods We analyzed a cohort from the National Cancer Database (NCDB) of 387,008 female patients diagnosed with Stage I-II, ER+ breast cancer between 2010 and 2014. Demographic variables included age, race, ethnicity, insurance status, income, education, Charlson-Deyo comorbidity score. Clinicopathologic and treatment variables included tumor grade, histology, receptor status, facility type, delivery of treatment at >1 facility and receipt of genomic testing. Descriptive statistics using chi-square testing were computed to describe patient, tumor and treatment characteristics. Logistic regression analysis was used to calculate odds of genomic testing and receipt of hormone therapy among patients who did or did not receive genomic testing. Results Among a total sample size of 387,008, median age was 63 years old, majority white (87%), non-Hispanic (95.4%), without co-morbidities (88%). A total of 147,863 (38.2%) patients underwent genomic testing. Compared to patients with ages 18- Citation Format: Naomi Y Ko, Mustafa Q Muhammad, Michael R Cassidy, Lauren Oshry, Ariel E Hirsch. Socio-demographic differences in utilization of genomic testing and receipt of endocrine therapy in the National Cancer Database [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-12-03.

PURPOSE: To examine the impact of pre-diagnosis depressive symptoms and mental health-related quality of life (HRQOL) on survival among older patients with multiple myeloma (MM). METHODS: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data resource. Patients aged 65 years and older diagnosed with first primary MM between 1998 and 2014 were identified and presence of depressive symptoms was determined based on responses to 3 depression screening questions prior to MM diagnosis. Veterans-RAND-12 mental component scores (MCS) were analyzed to evaluate mental HRQOL. We used multivariable Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for risks of all-cause and cancer-specific mortality. RESULTS: Of 522 patients, mean (SD) age at diagnosis was 76.9 (6.1) years and 158 (30%) reported depressive symptoms. Patients with depressive symptoms had a higher number of comorbid conditions and nearly all (84%) scored below the median MCS. Pre-diagnosis depressive symptoms were not associated with all-cause (HR=1.01, 95% CI: 0.79–1.29) or cancer-specific mortality (HR=0.94, 95% CI: 0.69–1.28). MM patients scoring in the second MCS tertile (versus the highest tertile) had a modestly increased risk of all-cause (HR=1.19, 95% CI 0.91–1.55) and cancer-specific mortality (HR=1.17, 95% CI 0.86–1.60), but these estimates were not statistically significant. CONCLUSION: Pre-diagnosis depressive symptoms and lower mental HRQoL did not impact survival among older MM patients. Highly prevalent depressive symptoms among older MM patients deserves clinical attention. Such efforts can inform clinicians in tailoring care for this vulnerable population.

IntroductionThe purpose of this research was to assess the feasibility, acceptability and potential effectiveness of a program to support the occupational performance of urban breast cancer survivo...

Women with hormone receptor (HR)-positive early-stage breast cancer (BC) have five-year survival rates of > 90% but remain at serious risk for developing distant metastases beyond five years from diagnosis. This retrospective cohort study used data from the Surveillance, Epidemiology, and End Results (SEER) registries to examine associations between distant recurrence-free interval (DRFI) and risk of BC-specific mortality following distant relapse. The analysis includes 1,057 women with second primary stage IV BC who were initially diagnosed with AJCC stages I–III HR-positive BC between1990 and 2016. Overall, 65% of women had a preceding DRFI of ≥ 5 years. Five-year BC-specific survival following development of distant recurrence was 52% for women with DRFI ≥ 5 years compared to 31% in women with DRFI of p = 0.002). The results of this study may inform patient-clinician discussions surrounding prognosis and treatment selection among HR-positive patients who develop a distant recurrence of disease.

Frailty is assessed when making treatment decisions among older women with breast cancer (BC), which in turn impacts survival. We evaluated associations between pre-diagnosis frailty and risks of BC-specific and all-cause mortality in older women.We conducted a retrospective cohort study of Medicare beneficiaries ages ≥ 65 years with stage I-III BC using the Surveillance, Epidemiology and End Results-Medicare Health Outcome Survey Data Resource. Frailty was measured using the deficit-accumulation frailty index, categorized as robust, pre-frail, or frail, at baseline and during follow-up. Fine and Gray competing risk and Cox proportional hazards models were used to estimate subdistribution hazard ratios (SHR) and hazard ratios (HR) with 95% confidence intervals (CI) for BC-specific and all-cause mortality, respectively.Among 2411 women with a median age of 75 years at BC diagnosis, 49.5% were categorized as robust, 29.4% were pre-frail and 21.1% were frail. Fewer frail women compared to robust women received breast-conserving surgery (52.8% vs. 61.5%, frail vs. robust, respectively) and radiation (43.5% vs. 51.8%). In multivariable analyses, degree of frailty was not associated with BC-specific mortality (frail vs robust SHR 1.47, 95% CI 0.97-2.24). However, frail women with BC had higher risks of all-cause mortality compared to robust women with BC (HR 2.32, 95% CI 1.84-2.92).Among a cohort of older women with BC, higher degrees of frailty were associated with higher risk of all-cause mortality, but not BC-specific mortality. Future study should examine if preventing progression of frailty may improve all-cause mortality.

Introduction: Breast cancer survivors have an increased risk of contralateral breast cancer (CBC), among whom minority breast cancer patients are at increased risk of this adverse outcome. Studies evaluating CBC risk by race/ethnicity frequently aggregate Asian/Pacific Islanders (API) into a single group or exclude them. The purpose of this study was to determine the impact of socioeconomic status (SES) on the risk of CBC among subgroups of API breast cancer survivors. Method: We conducted a population-based retrospective cohort study of women ages 18+ years diagnosed with unilateral Stage I-III breast cancer using the Surveillance, Epidemiology and End Results Census Tract-level SES and Rurality Database (2000-2016). Women included in the study received cancer-directed surgery and the primary outcome of interest was asynchronous CBC occurring. SES was classified using the Yost index, a validated time-dependent composite score with the 1st quintile representing the lowest and 5th quintile being the highest SES. API women were categorized into Chinese, Japanese, Filipina, Hawaiian, Korean, Vietnamese, Indian/Pakistani, and other Asian/Pacific Islanders. We determined overall associations between SES and the risk of CBC using Fine and Gray regression models accounting for competing risks comparing API women to Non-Hispanic White (NHW) women. Multivariable adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were estimated and stratified by API subgroups. Results: From a cohort of 44,362 API female breast cancer patients included, one quarter of the cohort were Filipina (25%), 18% were Chinese, 14% were Japanese, 8% were Indian/Pakistani, and 17% were other API. API women living in the lowest SES areas were more likely to be uninsured or have Medicaid coverage (21% vs. 6%) and have Stage lll first primary breast cancer (14% vs. 10%) compared to API women living in the highest SES areas. Overall, API breast cancer patients as an aggregate group did not have significantly increased risk of CBC compared to NHW patients. In stratified subgroups, risk estimates for CBC were higher among Chinese women (SHR 1.24, 95% CI 1.08-1.41), Filipina (SHR 1.37, 95% CI 1.23-1.52), and Hawaiian women (SHR 1.67, 95% CI 1.37-2.08) when compared to NHW women after adjusting for demographics and baseline clinical characteristics. Lower SES was not associated with increased CBC risk among API women overall. However, the risk of CBC is significantly lower among Chinese and Vietnamese women and higher among Filipina women who lived in areas lower SES quintile compared to women who lived in area with the highest SES quintile when examining impact of SES within API subgroups. Conclusion: Chinese, Filipina, and Hawaiian women have higher risk of CBC when compared to NHW. When disaggregated API women into subgroups, the impact of SES on the risk of CBC differs significantly across API subgroups. Citation Format: Hsiao- Ching Huang, Jenny S. Guadamuz, Kent F. Hoskins, Naomi Y. Ko, Gregory S. Calip. Impact of socioeconomic status on the risk of contralateral breast cancer among Asian/Pacific Islander subgroups [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3630.

e18554 Background: Low-income and minority women are less likely to receive breast cancer treatments and have higher mortality rates compared with other women.We examined economic hardship, health literacy, and numeracy by race/ethnicity and whether these factors were associated with differences in receipt of recommended treatment. Methods: We conducted a telephone survey in 2018-2020 of adult women diagnosed with stage I-III breast cancer between 2013-2016 at three centers in Boston and New York. We asked women about treatment receipt and factors contributing to decision-making. We used X2 and Fischer exact tests to examine associations between economic distress, health literacy/numeracy, and treatment receipt by race/ethnicity. Results: Among 326 respondents (AAPOR cooperation rate 63-80% across sites), 55% were Non-Hispanic (NH) White, 23% were NH Black, and 14% Hispanic; 15% were Medicaid-insured. Due to item non-response, sample sizes ranged from 294-315 per question. A substantial proportion of women, and particularly Black and Hispanic women, reported economic distress, worse finances over time, and low literacy/numeracy (Table). Overall, 7% (n = 22) did not initiate at least one recommended treatment. Although we observed no differences in treatment by race/ethnicity (p = 0.70), those not initiating recommended treatment(s) reported more worry about paying large medical bills (52% vs. 27%) and covering visit costs (27 vs. 10%); p < .05 for both. Conclusions: In a diverse sample of breast cancer survivors, financial distress was common, particularly for non-White participants; non-White women also had lower literacy/numeracy. Although we observed some associations of these factors (but not race/ethnicity) with less receipt of recommended treatments, because few women declined treatments, understanding the scope of impact is limited. However, our results highlight the importance of up-front and longer-term assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures on financial distress and the focus on health literacy/numeracy among a diverse population.[Table: see text]

PURPOSE: Intravenous (IV) bisphosphonates reduce the risk of skeletal-related events in patients with multiple myeloma (MM). However, data describing racial differences in IV bisphosphonate utilization outside of clinical trial settings are limited. We evaluated population-level IV bisphosphonate initiation and discontinuation among patients of age ≥ 65 years with MM. METHODS: We conducted a retrospective cohort study of patients of age ≥ 65 years diagnosed with first primary MM between 2001 and 2011. Patients were identified using the SEER-Medicare linked database and followed through December 2013. Cumulative incidences of IV bisphosphonate initiation and time to discontinuation among users were compared between racial and ethnic groups. In Fine and Gray competing risk models, we estimated subdistribution hazard ratios (SHRs) and 95% CIs for initiation and discontinuation. RESULTS: We included 14,231 eligible patients with MM (median age, 76 years; 52% male). Over a median follow-up of 23.1 months, 54% of patients received at least one IV bisphosphonate dose. Our final analytical sample included 10,456 non-Hispanic (NH) Whites, 2,267 NH Blacks, 548 Asian and Pacific islanders, and 815 Hispanic and Latino patients. A higher proportion of White patients (56.1%) newly received IV bisphosphonates after MM diagnosis compared with NH Blacks (45.4%). Compared with White patients, NH Black patients were less likely to initiate IV bisphosphonates (SHR, 0.74; 95% CI, 0.70 to 0.79) and slightly more likely to discontinue treatment (SHR, 1.10; 95% CI, 1.01 to 1.19). CONCLUSION: Approximately half of the patients with MM of age ≥ 65 years did not receive IV bisphosphonates, with significant delay among racial minority groups. These findings highlight the need for improvement of IV bisphosphonate uptake in patients with MM of age ≥ 65 years.

Purpose and Objectives: Although systemic therapy is the standard treatment for metastatic breast cancer, the value of locoregional treatment (LRT) to the primary tumor and its impact on survival is controversial. This study evaluates survival outcomes in patients with metastatic breast cancer after receiving LRT (surgery and/or radiation therapy) to the primary tumor. Materials and Methods: The National Cancer Database (NCDB) identified 16,128 qualifying cases of stage IV breast cancer (M1, 2004-2013) who received systemic therapy with or without local therapy. Treatment modality was divided into surgery, radiation therapy (RT), surgery with RT (Sx+RT), and no LRT. Median survival and three-year actuarial survival rates (OS) were analyzed for each treatment group. On multivariate analyses, adjusted hazard ratios (HR) with 95% confidence interval were computed using Cox regression modeling to adjust for patient characteristics, year of diagnosis, clinical T and N staging, and facility type. Additionally, survival outcomes for each treatment group were analyzed by metastasis groups (bone, visceral, multiple). Results: A temporal trend of each treatment modality used in years 2004 – 2013 illustrated that the relative use of LRT decreased from 47.2% to 36.2% (p for trend = 0.041). Overall, the median follow-up was 28.3 months and median survival for all patients was 37.2 months. With 9,761 deaths reported, the estimated 3-year survival rate for all patients was 51.3%. The Sx+RT group (n = 2,166) had the highest 3-year survival rate of 69.4%, followed by the surgery group (n = 4,293) with 57.6%, no LRT group (n = 8,955) with 44.3%, and RT group (n = 714) with 41.5% (p < 0.0001). On multivariate analysis, a decreased hazard of death (adjusted HR, 95% CI) was noted in radiation patients compared to no LRT group but without statistical significance (0.91, 0.81-1.0, p = 0.057). Patients receiving surgery (0.68, 0.65-0.71, p < 0.0001) and Sx+RT group (0.46, 0.43-0.49, p < 0.0001) reported statistically significant improved survival compared to the no LRT group. Additionally, later year of diagnosis, low Charlson-Deyo score, high income, private insurance, white race, age 18 - Conclusion: Patients with metastatic breast cancer have a large range of survival rates. Locoregional treatment, especially surgery followed by RT, in addition to systemic therapy was associated with improved survival in metastatic breast cancer patients. When survival rates for each treatment modality was stratified by metastasis location, the most favorable survival was observed for the surgery with follow-up radiation group, which is consistent with the overall analysis. Citation Format: Kim KN, Huang D, Qureshi MM, Ko NY, Hirsch AE. The impact of locoregional treatment on survival in patients with metastatic breast cancer: A national cancer database analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-16-02.

Breast cancer is the most common cancer diagnosed in women worldwide. Over the years, breast cancer treatment has undergone revolutionary changes especially for women with hormone receptor positive metastatic disease. As a result, women are living longer with their disease, particularly in developed countries. The use of cyclin-dependent kinase (CDK) 4/6 inhibitors with antiestrogen therapy is a relatively new therapeutic option which has been shown to improve progression-free survival. Hematologic adverse events, most frequently neutropenia, are well-known side effects of CDK 4/6 inhibitors. However, to our knowledge, aplastic anemia has never been reported. We report a case of aplastic anemia in a patient with metastatic breast cancer treated with palbociclib after multiple prior lines of therapy.

Background: The CPS+EG system, based on pretreatment clinical and post-treatment pathologic stage (CPS), estrogen receptor status (E), and tumor grade (G), has been used to refine estimations of prognosis in patients with hormone receptor-positive (HR+), HER2 negative (HER2-) early breast cancer who receive neoadjuvant chemotherapy. However, it is unclear if this tool effectively characterizes risk in all patient subgroups. Racial disparities exist in treatment and survival among women with early breast cancer, particularly among non-Hispanic Black women compared with non-Hispanic White women. Our objective was to describe racial disparities in the overall survival of women with HR+/HER2- early breast cancer across risk groups characterized by CPS+EG scores. Methods: We utilized the National Cancer Database to perform a hospital-based, retrospective cohort study of breast cancer patients ages 18 years and older. Women diagnosed with first primary stages I-III HR+/HER2- breast cancer between 2010 and 2017 with complete clinical information to calculate a CPS+EG score were included. We grouped patients into four categories based on their CPS+EG score (0-1, 2, 3, and 4+). Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios and 95% CI for associations between the CPS+EG and overall survival. Results: A cohort of 758,424 women (mean [SD] age, 62.2 [12.5] years; median [interquartile range] follow-up of 50.7 [33.2-72.0] months) were included in the analysis. Our analysis included 614,210 (81.0%) non-Hispanic White, 67,794 (8.9%) non-Hispanic Black, 38,229 (5.0%) Hispanic, 26,956 (3.6%) Asian/Pacific Islander, and 11,235 (1.5%) women of other racial/ethnic groups. Within the total cohort, 412,734 (54.4%) patients had CPS+EG scores of 0-1, 216,726 (28.6%) had a score of 2, 91,656 (12.1%) had a score of 3, and 37,308 (4.92%) had a score of 4 or greater. A one-unit increase in CPS+EG score was associated with 1.45-times greater mortality risk (95% CI, 1.43-1.47; p Citation Format: Kent A. Hanson, Kent F. Hoskins, Naomi Y. Ko, Gregory S. Calip. Racial/ethnic disparities in the survival of HR+/HER2- early breast cancer using the CPS+EG scoring system [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-097.