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Because time to treatment has been shown to be associated with increase in the risk of death for Non Small Cell Lung Cancer (NSCLC) patients, we examined the prevalence and magnitude of racial disparities in mean time to radiation therapy (TTRT) for Stage I-III non-small cell lung cancer patients across a variety of treatment facilities.Utilizing the United States National Cancer Database (NCDB), we determined differences in TTRT between different races and different treatment facilities.Concordant with past research, we found that non-White patients and patients treated at academic facilities, regardless of race, have longer mean TTRT, and that racial disparities in TTRT extend across all treatment facilities (allThese findings shed light on the potential presence of and impact of structural racism on patients seeking cancer treatment, and the need for further investigation behind the reasonings behind longer TTI for non-White patients. To elucidate the real-world applicability of these results, further investigation into the societal determinants that perpetuate disparity in time to radiation therapy, and potential interventions in the clinical setting to improve cultural and racial sensitivity among healthcare professionals is recommended.

BACKGROUND Childhood cancer survivors (CCS) are at elevated risk of secondary malignancies (SM). Enhanced screening for SM is recommended, but compliance is poor. We hypothesized that CCS with adult-onset SM (colorectal cancer [CRC], melanoma, or breast cancer [BC]) would present with more advanced disease and have decreased overall survival (OS). METHODS The Surveillance, Epidemiology, and End Results Program was queried for patients diagnosed with cancer at age less than or equal to 18 also diagnosed with adult-onset CRC, melanoma, or BC. A cohort without a history of prior malignancy was likewise identified. Tumor features and clinical outcomes were compared. RESULTS CCS with a SM (n = 224) were compared with patients without a childhood cancer history (n = 1,392,670). CCS were diagnosed younger (BC = 37.6 vs. 61.3, p

Objective: The seven-vaccine series protects infants from several preventable diseases, yet disparities in its use remain in the United States. Methods: We assessed the seven-vaccine immunization rate and its predictors in infants 19–35 months using the National Immunization Survey from 2009 to 2018. Results: The seven-vaccine series rate was 72.8%, well short of the healthy people 2020 target of 90%. African American infants, infants born to mothers with less than high school education, and infants in families with an income below poverty were less likely to get the complete series. Conclusion: Disparities still exist in protecting infants from preventable diseases in the United States.

Background The results of the Cancer and Leukemia Group B (CALGB) 9343 trial showed that radiation therapy (RT) did not improve survival for women older than 70 y with early-stage estrogen receptor + breast cancer treated with breast conserving surgery and adjuvant endocrine therapy. In 2005, guidelines were modified to allow for RT omission; however, minimal change in clinical practice has occurred. The aim of this study was to determine if CALGB long-term follow-up data have affected RT utilization, and to characterize the population still receiving RT after breast conserving surgery. Methods The Surveillance, Epidemiology, and End Results–Medicare database was used to identify women diagnosed with early-stage breast cancer from 2004 to 2015 who matched the CALGB 9343 inclusion criteria. Multivariate logistic regression was carried out to identify the factors that affect the receipt of radiation therapy. We also plotted the overall use of RT over time juxtaposed with the temporal trends of CALGB 9343 clinical trial data, guideline recommendations, and publishing of long-term survival data. Results The study cohort included 25,723 Medicare beneficiaries, of whom 20,328 (79%) received RT and 5395 (21%) did not receive RT. In a multivariate model, the frequency of RT omission increased over time, with those diagnosed in year 2015 being 2.72 times more likely to omit RT compared with those diagnosed in 2004 (95% confidence interval 2.31-3.19). Conclusions This study investigated the impact of long-term CALGB 9343 data on clinical practice. The results of this study support results from previous studies, extend the dates of analysis, and indicate that after long-term follow-up of CALGB 9343 data, RT was less used, but overall trends did not dramatically decrease.

Using long-term survival data from the C9343 trial as a temporal reference point, this study aimed to determine radiation therapy (RT) treatment trends for older patients with early-stage breast cancer. The study also examined rates of adherence to adjuvant endocrine therapy (AET). The surveillance, epidemiology, and end results–medicare database was used to identify women with a diagnosis of breast cancer from 2007 through 2016. Bivariate associations were calculated to determine variable characteristics by time frame (group 1: 2007–2012 vs. group 2: 2013–2016). Multivariate logistic regression was used to estimate the effect of group on the RT use and AET adherence. The temporal rates for both RT and AET adherence over time were plotted. The final study cohort included 12,210 Medicare beneficiaries. Use of RT differed significantly between the groups, with a higher proportion omitting RT in the later period (25% of group 2 vs. 20% of group 1; p

Introduction: The relationship between survival and time to the start of adjuvant chemotherapy (AC) among breast cancer patients is unclear. Most breast cancer patients start adjuvant chemotherapy within a few weeks after surgery, but it is still unclear whether a delay in the initiation of chemotherapy will lead to adverse outcomes.Methods: Women diagnosed between 2004 and 2016 with invasive breast cancer (stages I-III) and treated with surgery and adjuvant chemotherapy were selected from the National Cancer Database (n= 443,100). We evaluated factors associated with prolonged time to start adjuvant chemotherapy (≥60, ≥90, and ≥120 days after surgical resection) using multivariable log binomial models to estimate risk ratios (RRs) and 95% CIs. Cox proportional hazards model was used to investigate the effect of delay on survival.Results: The average time to adjuvant chemotherapy was 47.93 days (±29.17 days). Non-Hispanic African American patients had higher risk of 60-day delay (RR, 1.41; 95% CI, 1.38 to 1.43), 90-day delay (RR, 1.55; 95% CI, 1.50 to 1.60), and 120-day delay (RR, 1.69; 95% CI, 1.61 to 1.78) compared with non-Hispanic white patients. Early initiation of chemotherapy, less than 1 month (RR, 0.893; 95% CI, 0.86 to 0.92), 1-2 month (RR, 0.80; 95% CI, 0.77 to 0.82), and 2-3 month (RR, 0.87; 95% CI, 0.84 to 0.90); was associated with decreased overall mortality. Non-Hispanic African Americans (RR, 1.16; 95% CI, 1.13 to 1.19) were associated with increased overall mortality compared to non-Hispanic whites. Conclusion: Black breast cancer patients experience clinically relevant delays in the initiation of adjuvant chemotherapy more often than white patients, which may in part explain the increased mortality observed among black patients. Efforts should be made to reduce the time to surgery when possible to enhance overall survival.

Background Acute myeloid leukemia, the most common acute leukemia in adults, has a poor overall survival. Studies have suggested that certain socioeconomic factors such as living in a rural or farming area are associated with worse outcomes. Since 42% of acute myeloid leukemia patients seen in our academic center reside in a rural area, we have a unique opportunity to study outcomes of patients in rural versus urban settings. Aim This analysis evaluates the effect of geography and socioeconomic factors on the biology, treatment, and overall survival of patients with acute myeloid leukemia, with the goal of understanding health care disparities. Methods and results Patient characteristics, cytogenetic data, treatment history, and overall survival were collected and analyzed to identify differences between urban and rural residency. This cohort included 42% of patients who resided in a rural area at the time of acute myeloid leukemia diagnosis. There was no difference in overall survival between the cohorts. The 1 year overall survival for the entire cohort was 47.9%. There was no difference detected in rates of adverse cytogenetics between the rural and urban cohorts. Similar numbers of patients received induction chemotherapy or proceeded to allogeneic stem cell transplant between the cohorts. Conclusions This study highlights that similar outcomes can be achieved in rural and urban patients, suggesting that intensive efforts at telehealth, education, and collaboration with local oncology practices may be beneficial.

Using long-term survival data from the C9343 trial as a temporal reference point, this study aimed to determine radiation therapy (RT) treatment trends for older patients with early-stage breast cancer. The study also examined rates of adherence to adjuvant endocrine therapy (AET).The surveillance, epidemiology, and end results-medicare database was used to identify women with a diagnosis of breast cancer from 2007 through 2016. Bivariate associations were calculated to determine variable characteristics by time frame (group 1: 2007-2012 vs. group 2: 2013-2016). Multivariate logistic regression was used to estimate the effect of group on the RT use and AET adherence. The temporal rates for both RT and AET adherence over time were plotted.The final study cohort included 12,210 Medicare beneficiaries. Use of RT differed significantly between the groups, with a higher proportion omitting RT in the later period (25% of group 2 vs. 20% of group 1; p 0.001). In both groups, after adjustment for covariates, the patients with RT omitted were statistically less likely to adhere to AET [group 1: odds ratio (OR), 0.74; p 0.001 vs. group 2: OR, 0.66; p 0.001].This study, 15 years after publication of the of the C9343 trial results, showed minimal change in practice, with most older women receiving RT. Importantly, AET adherence was significantly lower in the non-RT group. For women who meet the criteria to have adjuvant RT omitted, nonadherence to AET could result in undertreatment of their breast cancer, and RT should not be considered overtreatment.

Lung cancer remains the leading cause of cancer death worldwide and the search for modifiable risk factors to improve survival is ongoing. There is a growing appreciation for a biological relationship between opioids and lung cancer progression. Our goal was to evaluate the association between perioperative opioid use and long-term survival after lung cancer resection.A retrospective analysis of 2006 to 2012 Surveillance, Epidemiology, and End Results Medicare datasets identified all patients undergoing pulmonary resection for non-small cell lung cancer stages I to III. Patients were stratified by filling opioid prescriptions only 30 days before or after surgery (standard group), filling opioid prescriptions greater than 30 days before surgery (chronic group), or filling opioid prescriptions greater than 90 days after surgery but not before surgery (prolonged group). Kaplan-Meier survival analysis compared each group; risk-adjusted survival analysis was performed using the Cox proportional hazards model.We identified 3273 patients, including 1385 in the standard group (42.3%), 1441 in the chronic group (44.0%), and 447 in the prolonged group (13.7%). Of previously opioid-naive patients, 447 of 1832 (24.4%) became new prolonged opioid users. Kaplan-Meier survival analysis illustrated lower overall and disease-specific survival in chronic and prolonged opioid groups (both P.01). After risk adjustment, chronic (hazard ratio = 1.27; 95% confidence interval, 1.09-1.47; P.01) and prolonged (hazard ratio = 1.42; 95% confidence interval, 1.17-1.73; P.01) opioid use were independently associated with reduced long-term survival.Chronic and prolonged opioid use were independently associated with reduced long-term, disease-specific survival after lung cancer resection. These findings provide epidemiologic support for a biological relationship between opioid use and lung cancer progression.

e18529 Background: Multiple studies indicate that rural patients experience disproportionately adverse cancer related outcomes, compared to their urban counterparts. This has been attributed to inequities in access to healthcare, monetary and technological resources, disease characteristics, adverse health status and lower life expectancy of rural populace. Whether treating patients with uniform protocols can help mitigate outcome disparities remains to be determined. Methods: We conducted a retrospective cohort study to evaluate survival outcomes of Head-Neck Squamous Cell Cancer (HNSCC) patients from rural versus urban locales. Only patients with locally advanced HNSCC who completed radiotherapy (RT) at the Emily Couric Clinical Cancer Center were included. Rural patients had access to affordable lodging for the duration of radiotherapy (RT), were treated regardless of health insurance status and by the same multidisciplinary team. Patients with distant metastases were excluded. Patients were classified as urban or rural using the Rural-Urban Commuting Areas (RUCA) zip-code database. Overall survival (OS) was analyzed using Kaplan-Meier curves and log-rank test. OS was modeled with a COX proportional hazards model, adjusting for several covariates including race, age, gender, HPV status, smoking, treatment received (RT, chemotherapy, surgery) and stage. Results: 230 patients with Stage I-IVB HNSCC who met the inclusion criteria were analyzed, of which 136 were categorized as residentially urban and 94 were categorized as rural. Approximately 83% were male, 87% were Caucasian and 71% were smokers (52% current smokers and 19% former smokers). In addition to RT, 42% patients had undergone surgery and 57% received chemotherapy. There was no statistically significant difference in OS for patients residing in rural vs urban zip-codes (HR 1.36, p = 0.24). Rural patients were less likely to undergo surgery (34% vs 44%, p = 0.04), and more likely to receive chemotherapy (67% vs 54%, p = 0.0325), likely indicating more advanced tumor stage at diagnosis. Conclusions: Rural and urban patients had similar OS when treated with similar treatment protocols. Improving access to uniform treatment regimens may help mitigate the widening gap in cancer-related outcomes between rural and urban populations.

Background While HCT provides the best chance for cure for eligible patients with AML, barriers limit the number able to receive HCT. Virginia (VA) has some of the wealthiest and poorest counties in the country. We hypothesize that there are geographic variations in the rate and estimated unmet need of HCT for patients with AML in VA. Understanding geographic differences may help improve access to HCT. Methods All patients aged 20-74 years diagnosed with AML in 2013-2015 were identified by the VA Department of Health and classified by residence into 8 regions: Southwest, Southside, Valley, Central, Northern, Richmond, Eastern, and Hampton Roads. Socioeconomic (SES) factors including sex, age, race, marital status, education, employment, income, and health insurance were examined by region. Number of patients receiving first HCT by region were obtained from CIBMTR data. Unmet need was calculated by estimating the number of potential patients for HCT and subtracting the actual number of HCTs (Besse et al., 2015). Results 690 patients were diagnosed with AML in VA between 2013 and 2015; 153 first HCTs were reported to CIBMTR during the same time period. The rate of HCT and unmet need varied among the different geographic regions (Figure 1). The only SES factor that correlated with HCT rate was race/ethnicity (P=0.0334). The Southside, which had a higher percentage of non-Hispanic Black or African American population (31%), had a lower HCT rate (8%) compared to the Northern region, which had a Black or African American population of 12%, but a HCT rate of 29% (Figure 2). The Northern region had the highest median income ($105,000) and one of the highest rates of proceeding to HCT (29%) (Figure 3). In contrast, the Southside, which had the lowest median income ($40,000), had only 8% of patients proceeding to HCT and an estimated unmet need of 88%. Private vs public insurance, marital status, education, and gender did not correlate with HCT rates. Conclusions There are geographic differences in rates of HCT for patients with AML in VA. Regions with a higher non-Hispanic Black or African American population had lower rates of receiving HCT. Further study is needed to determine if the decreased rates in regions with a higher non-Hispanic Black or African American population are related to donor availability or SES barriers. Future steps to eliminate these SES barriers will be vital to increase the access of patients receiving a potentially curative HCT in VA.

Background: Rural communities may not have access to adequate health care, but the effect of geographic residence on patient outcomes and molecular characteristics of acute myeloid leukemia (AML) is poorly understood. Several studies have investigated the effect of various demographics (such as race, gender, zip code) and environmental exposures on the development and outcome of AML. Evidence is lacking to suggest a link between genetic abnormalities and residence. Methods: A single center, retrospective chart review was conducted on patients with AML diagnosed between 9/2015 and 8/2018. Consecutive patients with a new diagnosis of AML and a clinical next generation sequencing panel (Illumina TruSight Myeloid 54 gene panel) performed during their initial leukemia workup were included. Patients were excluded if they had APML or CML in blast crisis. Data collected included demographic information (including zip code), smoking history, BMI, cytogenetic data, treatment regimen, and overall survival. Patients were grouped into urban and rural subsets based on their county of residency as described in the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties. Zip codes were used to extrapolate socioeconomic data including education and income level. Cytogenetic data was used to risk stratify patients per ELN criteria. Mutational profile, cytogenetics and overall survival (OS) were compared between the groups. Mutations analyzed were limited to ASXL1, DNMT3A, FLT3, IDH1, IDH2, NPM1, NRAS, TET2, and TP53, as these are often used in medical decision making. Multivariate logistic regression was conducted to evaluate differences between the groups. Time to event data were analyzed using log-rank tests, Kaplan-Meier method, and Cox proportional hazard regression model. Results: 113 patients were included in this study. Median age of the entire cohort was 66.3 years old. 59% (n = 67) were male. 24% (n = 27) of patients were from a rural area; 76% (n = 86) were from an urban area. There was no difference in median age, race, prior MDS or MPN, number of patients who underwent chemotherapy or number of patients who underwent allogeneic stem cell transplant (ASCT) as demonstrated in Table 1. Patients from both cohorts also had similar risk cytogenetics (urban cohort: favorable: n = 5, 5.8%; intermediate: n = 35; 40.7%; adverse: n=46; 53.5%; rural cohort: favorable: n = 3, 11.1%; intermediate: n = 14; 51.9%; adverse: n = 10, 37%; p = 0.282). In the rural cohort, 15% of patients reported income below the poverty level; in the urban cohort, 10.2% reported income below the poverty level (p < 0.0001). Fewer patients in the rural cohort were high school graduates as compared to the urban cohort (82.7% versus 87.8%, p < 0.0001). Rural patients traveled an average of 145 miles for treatment; urban patients traveled 57 miles (p < 0.0001). Mutation frequency is described in Table 2. ASXL1 mutation was more frequent in the urban cohort as compared to the rural cohort (p = 0.032). There was no difference in frequency of other mutations between the cohorts. The 2 year survival rate was 46% (n = 52) for the cohort; 2 year survival rate for the rural cohort was 70% (n = 19) and for the urban cohort was 38% (n = 33) (p = 0.011; Figure 1). 53 patients (urban: n =39, 66.1%; rural: n = 14, 77.8%; p = 0.35) underwent induction chemotherapy. Rural patients who underwent induction chemotherapy had an improved OS as compared to urban patients who underwent induction chemotherapy (p = 0.005). Conclusion: In this single center retrospective study, our data demonstrates: 1. Urban patients had an increased frequency of ASXL1 mutations; 2. Rural patients were more likely to live below the poverty level and not graduate high school; 3. Rural patients traveled a greater distance for treatment; 4. OS was improved in rural patients in this limited cohort. Our rural patients may have improved OS due to our close co-management with rural centers. These studies suggest that the biology of the AML is not worse in the rural cohort and intensive efforts at access, remote monitoring, and communication with local physicians may result in outcomes similar to urban patients. Further studies will be investigating improving access to leukemia and transplant care for patients with AML. Disclosures Balkrishnan: Merck and Company: Consultancy. Keng:Agios: Membership on an entity's Board of Directors or advisory committees.

e18107 Background: Appalachian women have a higher burden of both morbidity and mortality from female cancers of the breast, ovary and cervix, and have documented treatment delay and poor adherence. The environmental and sociobehavioral risk factors that could contribute towards these issues such as patient non adherence and treatment delay have not been studied. Methods: We conducted a detailed survey of women seeking cancer related preventative care in a tertiary care cancer center in the Appalachian region of Virginia. Survey questions included health behaviors, financial issues, and past health history. The survey was administered to 200 women and a total of 158 complete responses (42 in women with cancer in the recent past) were obtained. Results: There were significant differences between women with and without female cancers with the cancer group being older, less likely to be married, be unemployed and more likely to have received mammograms (All p < 0.05). In multivariate analyses , the major risk factor associated with delaying treatment was the lack of health insurance in the previous year (RR: 0.25, 95% CI: 0.082-0.73). Conclusions: Women in Appalachia face significant barriers in receiving diagnoses and treatment for female cancer including lack of employment, health care insurance and social support. These factors need to be considered while designing interventions to improve access and adherence to cancer treatments in this population.

Background— A key to reduce and eradicate racial disparities in hypertension outcomes is to understand their causes. We aimed at evaluating racial differences in antihypertensive drug utilization patterns and blood pressure control by insurance status, age, sex, and presence of comorbidities. Methods and Results— A total of 8796 hypertensive individuals ≥18 years of age were identified from the National Health and Nutrition Examination Survey (2003–2012) in a repeated cross-sectional study. During the study period, all 3 racial groups (whites, blacks, and Hispanics) experienced substantial increase in hypertension treatment and control. The overall treatment rates were 73.9% (95% confidence interval [CI], 71.6%–76.2%), 70.8% (95% CI, 68.6%–73.0%), and 60.7% (95% CI, 57.0%–64.3%) and hypertension control rates were 42.9% (95% CI, 40.5%–45.2%), 36.9% (95% CI, 34.7%–39.2%), and 31.2% (95% CI, 28.6%–33.9%) for whites, blacks, and Hispanics, respectively. When stratified by insurance status, blacks (odds ratio, 0.74 [95% CI, 0.64–0.86] for insured and 0.59 [95% CI, 0.36–0.94] for uninsured) and Hispanics (odds ratio, 0.74 [95% CI, 0.60–0.91] for insured and 0.58 [95% CI, 0.36–0.94] for uninsured) persistently had lower rates of hypertension control compared with whites. Racial disparities also persisted in subgroups stratified by age (≥60 and Conclusions— Black and Hispanic patients had poorer hypertension control compared with whites, and these differences were more pronounced in younger and uninsured patients. Although black patients received more intensive antihypertensive therapy, Hispanics were undertreated. Future studies should further explore all aspects of these disparities to improve cardiovascular outcomes.