Search

The use of social media continues to increase in health care and academia. Health care practice, particularly the oncologic field, is constantly changing because of new knowledge, evidence-based research, clinical trials, and government policies. Therefore, oncology trainees and professionals continue to strive to stay up-to-date with practice guidelines, research, and skills. Although social media as an educational and professional development tool is no longer completely new to medicine and has been embraced, it is still under-researched in terms of various outcomes. Social media plays several key roles in professional development and academic advancement. We reviewed the literature to evaluate how social media can be used for professional development and academic promotion of oncology professionals.

A recent survey of pediatric hematology oncology (PHO) physicians identified that a majority believe fellows are struggling to find jobs that align with their goals. Career development for trainees has historically been home institution-specific, limiting fellows' exposures to career path possibilities. The "virtual-Symposium of Pediatric Hematology/Oncology of New York (v-SYMPHONY)" instituted a tristate Career Development Series for PHO trainees to better address their needs and increase awareness of the variety of PHO career opportunities.The v-SYMPHONY Career Development Series incorporated three sessions: (a) institutional perspective, (b) individual perspectives, and (c) nuts and bolts of job search. Pre- and post-series surveys were administered to participants to measure impact.Forty-one fellows registered for the series and completed a pre-survey. Over half (54%) were in their third or later year of fellowship. Careers with a clinical focus were the most commonly desired career path (59%). Most had received career development advice only from faculty within their institutions (90%). Post-surveys were completed by 11 PHO fellows. Overall, 100% of respondents reported benefiting from the career sessions and recommended the series should be repeated annually. Over 90% learned new information to prepare for the job search.The v-SYMPHONY Career Development Series for PHO fellows across multiple institutions was established and was extremely well received by its participants. PHO fellows agreed that these sessions were beneficial in helping prepare them for the job search process. An annual regional Career Development Series is feasible and is strongly suggested to support PHO fellows.

The American Society of Pediatric Hematology/Oncology (ASPHO) conducted a workshop "Can you hear me now? Cultivating a culture of respect, value, and appreciation within pediatric hematology/oncology" at their annual meeting in May 2022 in hopes of exploring how the members can enhance wellness in a climate of increasing diversity. Initiatives in the past have focused on personal care, but it has been widely shown that administrative and institutional driven initiatives are essential to create an environment of wellness. In this interactive workshop, we discovered that 22% of participants felt their institution does not instill a culture of respect. We offered tools to the audience on multiple levels: graceful self-promotion, diversity and inclusion, and leadership perspective on creating a culture of respect to address the individual, local community, and top-down leadership approaches. Here, we offer a summary on the content of the workshop, and expand upon many of the discussion points that were raised during the workshop. We bring forth novel information on each topic individually from diverse points of view, specific to the field of pediatric hematology/oncology (PHO). We aim to highlight the importance of creating a diverse and respectful work environment in PHO in hopes of ensuring motivated, satisfied, and fulfilled healthcare providers who feel appreciated and valued.

The PHO workforce landscape has been evolving over the past decades, with concern for waning interest in the subspecialty. In this study, we aimed to evaluate perceptions of the PHO workforce (both fellows and faculty), the experience of seeking an initial faculty position, and its impact on fellow stress and anxiety. An anonymous survey consisting of demographics, job search experiences including barriers and helpful tools, and emotional health impacts such as stress and anxiety was developed and distributed to all PHO fellowship programs. Seventy-nine fellows and 83 faculty responded. Faculty were less likely than fellows to perceive that fellows are struggling to find jobs ( P=0.0198). However, faculty were more likely than fellows to perceive that fellows are either “extremely stressed” or “stressed” due to job search ( P=0.0003). By June 2021, 30 of 44 (68%) candidates had been offered a position, and 80% of those had accepted. There were no significant associations between fellow stress level and job offering, proximity to their ideal goals, or change in career type. Common barriers to the job search included geographic constraints and partner employment. Respondents identified centralized job listings, formal training on career development strategies, introduction to various career paths, and more transparency about the job search as needed interventions. The perception of difficulty and stress regarding the job search is endorsed by most, identifying a need for more interventions to improve the job search experience. These data also highlight unmet mentorship and educational needs among PHO fellows in preparing for the job search.

PURPOSE: The COVID-19 pandemic has significantly affected the well-being of healthcare workers to varying degrees. The aim of the current study was to investigate how the pandemic has affected the burnout, stress, and emotional well-being of pediatric hematology oncology (PHO) providers and staff in the New York and New Jersey epicenter. METHODS: The study was conducted in June 2020 during the pandemic through an electronic survey. The survey contained questions surrounding demographics, pandemic experiences, and validated burnout, stress, and emotional well-being measures. RESULTS: Two hundred fifty-two PHO providers and staff responded to the survey. Overall, half of the participants reported high levels of burnout, average stress scores were in the mild-moderate range, and the majority scored in the none-to-mild symptomatology range for their well-being. Self-reported burnout levels before the pandemic and geographic work location were statistically significant risk factors for all outcomes. Additional predictors for some outcomes included hospital role, lack of trust in leadership, and deployment. The majority of participants (87.0%) reported that their hospitals had made mental health resources related to COVID-19 available to them but only 8.4% reported having used them. CONCLUSION: PHO providers and staff in the NYC/NJ area are experiencing a range of emotional experiences during the COVID-19 pandemic, but the majority are not using current resources. With the continuation of the pandemic, we must continue efforts to improve provider and staff distress to mitigate the degree of potential negative short-term and long-term impact.

PURPOSE Medical student mistreatment is pervasive, yet whether all physicians have a shared understanding of the problem is unclear. The authors presented professionally designed trigger videos to physicians from six different specialties to determine if they perceive mistreatment and its severity similarly. METHOD From October 2016 to August 2018, resident and attending physicians from 10 U.S. medical schools viewed five trigger videos showing behaviors that could be perceived as mistreatment. They completed a survey exploring their perceptions. The authors compared perceptions of mistreatment across specialties and, for each scenario, evaluated the relationship between specialty and perception of mistreatment. RESULTS Six-hundred and fifty resident and attending physicians participated. There were statistically significant differences in perception of mistreatment across specialties for three of the five scenarios: aggressive questioning (range 74.1%-91.2%), negative feedback (range 25.4%-63.7%), and assignment of inappropriate tasks (range 5.5%-25.5%) (P ≤ .001, for all). After adjusting for gender, race, professional role, and prior mistreatment, physicians in surgery viewed three scenarios (aggressive questioning, negative feedback, inappropriate tasks) as less likely to represent mistreatment compared to internal medicine physicians. Physicians from obstetrics and gynecology and from "other" specialties perceived less mistreatment in two scenarios (aggressive questioning, negative feedback) while family physicians perceived more mistreatment in one scenario (negative feedback) compared to internal medicine physicians. The mean severity of perceived mistreatment on a 1 to 7 scale (7 most serious) also varied statistically significantly across the specialties for three scenarios: aggressive questioning (range 4.4-5.4, P < .001), ethnic insensitivity (range 5.1-6.1, P = .001), and sexual harassment (range 5.5-6.3, P = .004). CONCLUSIONS Specialty was associated with differences in the perception of mistreatment and in the rating of its severity. Further investigation is needed to understand why these perceptions of mistreatment vary among specialties and how to address these differences.

LAG-3, through interaction with a variety of ligands, regulates T cell function via inhibition of T cell proliferation and activation. It has been demonstrated to be overexpressed on tumor infiltrating lymphocytes (TILs) of a variety of cancers with associated poor outcomes. The purpose of this study is to characterize the expression pattern and clinical significance of LAG-3 in pediatric Hodgkin lymphoma (HL). Patient tumor samples from Children's Oncology Group clinical trial AHOD0031 with matched patient outcome data were analyzed for the expression of LAG-3 and PD-L1 using immunohistochemistry. 73/115 patients (63%) demonstrated positive LAG-3 staining. No demographic or survival outcome data were significantly associated with LAG-3 expression. Interestingly, patients with the lowest density of expression were found to have the worst EFS, and those with highest density of expression demonstrated the best EFS. There was a positive statistically significant relationship between presence of LAG-3 and PD-L1 expression. This project is innovative in its characterization of LAG-3 as an immune checkpoint target in pediatric HL.

The impact of the coronavirus 2019 (COVID-19) pandemic on the emotional health of health care workers continues to be an area of active research. However, few studies have focused on those working in pediatrics and its subspecialties, as well as ancillary and non-patient-facing staff. The purpose of this study was to determine the prevalence and associated predictors of burnout and emotional well-being of providers and staff.An anonymous electronic survey was developed evaluating demographics, pandemic experiences, possible predictor variables, and three main outcomes of burnout, psychological distress, and perceived stress. Pediatric hematology oncology (PHO) chiefs and program directors across the country were invited to participate and disseminate the survey to their programs.A total of 682/1950 (35% of invited) individuals responded to all predictor and outcome variables. Over half reported high levels of burnout and some reported moderate/high levels of distress. Prepandemic burnout and decreased trust in leadership were associated with all three outcomes. Additional predictors included having a child ≤18 years at home, hospital role, and worrying about patient care or relationship with their patients. The majority (n = 444/682, 65.5%) reported that their institution had made COVID-19-related mental health resources available. However, only 6.5% (n = 44/682) reported utilizing these resources.While the majority of PHO providers and staff were resilient during the early stages of the COVID-19 pandemic, many reported high levels of burnout, yet few are utilizing institutional resources. This study has highlighted several actionable areas to help identify and address factors that are wearing down the emotional well-being of providers and staff.

Objective:Frontline health-care workers and patients with COVID-19 have been identified as high-risk groups for psychological problems. Experience of working or staying in quarantine wards generated psychological stressors for health-care workers and patients with COVID-19. The present study aimed to investigate the psychological symptoms of hospitalized patients with COVID-19 and the health-care workers treating them during the outbreak period, examine the effects of psychological stressors on mental health in both populations and perceived coping resources for both sides.Methods:Three hundred and eleven health-care workers working in a COVID-19 designated hospital in Wuhan, China, and 148 hospitalized patients with COVID-19 in the same hospital participated in this cross-sectional survey conducted in February 2020. Psychological symptoms, psychological stressors, and perceived coping resources were reported by both groups.Results:Thirty-three percent of health-care workers and 35.2% of patients with COVID-19 had significant psychological symptoms that were indicative of a high risk for psychological disorders. Pandemic-related psychological stressors contributed to psychological symptoms for both populations. Concern about patients was one aspect of psychological stressors of frontline health-care workers and both groups perceived support from the opposite side as an important external coping resource.Conclusion:The results shed light on the need to provide psychological support to both frontline health-care workers and patients with COVID-19 and suggest enhancing the treatment alliance might be effective to improve mental health for both populations during the crisis.

The B7 family ligand HERV-H LTR-associating protein 2 (HHLA2) is an attractive target for cancer immunotherapy due to its co-inhibitory function, over-expression in human cancers, and association with poor prognoses. However, the knowledge of the HHLA2 pathway is incomplete. HHLA2 has an established positive receptor transmembrane and immunoglobulin domain containing 2 (TMIGD2) but a poorly characterized negative receptor human killer cell immunoglobulin-like receptor, three Ig domains and long cytoplasmic tail (KIR3DL3). Here, KIR3DL3 and TMIGD2 simultaneously bound to different sites of HHLA2. KIR3DL3 was mainly expressed on CD56(dim) NK and terminally differentiated effector memory CD8+ T (CD8+ T(EMRA)) cells. KIR3DL3(+) CD8+ T(EMRA) acquired an NK-like phenotype and function. HHLA2 engagement recruited KIR3DL3 to the immunological synapse and co-inhibited CD8+ T and NK cell function and killing, inducing immune evasive HHLA2(+) tumors. KIR3DL3 recruited SHP-1 and SHP-2 to attenuate Vav1, ERK1/2, AKT and NF-κB signaling. HHLA2(+) tumors from human kidney, lung, gallbladder and stomach were infiltrated by KIR3DL3(+) immune cells. KIR3DL3 blockade inhibited tumor growth in multiple humanized mouse models. Thus, our findings elucidated the molecular and cellular basis for the inhibitory function of KIR3DL3, demonstrating that the KIR3DL3-HHLA2 pathway is a potential immunotherapeutic target for cancer.

INTRODUCTION: Medical students have limited preclinical exposure to pediatrics. We created an optional preclinical curriculum for first-year medical students called “Preseason Pediatrics” (PSP). This 6-month curriculum teaches pediatric-specific knowledge and clinical skills, consisting of monthly resident-led didactic sessions followed by complementary resident-mentored clinical experiences. METHODS: Participants completed a survey before and after completion of PSP. Knowledge was assessed with multiple-choice questions pertaining to each topic covered in PSP and perceived skills, with a 5-point Likert scale ranging from not at all (1) to extremely (5) for skills taught. Skill maintenance was assessed with a newborn objective structured clinical exam (OSCE) 6 months after PSP completion in 2016. Students beginning their pediatric clerkship also completed a survey, comparing students who did and did not complete PSP. RESULTS: From 2014 to 2017, 135 first-year medical students participated. Percent correct scores on pediatric knowledge increased in 4/5 topics covered, and students perceived increases in their pediatric skills in all course domains. 86.8% (n = 92/106) of students reported feeling more prepared for the pediatric clerkship. 94.3% (n = 100/106) would recommend the PSP experience to other students. Third-year students who participated in PSP reported higher comfort with pediatric patients prior to their clerkship. CONCLUSIONS: PSP is a successful novel preclinical program introducing students to pediatrics. We demonstrated that didactics paired with resident-mentored clinical experiences improved pediatric knowledge, clinical-based skills, and perceived clerkship preparedness. Students may academically and professionally benefit from such earlier exposure to pediatrics.

11026 Background: There are limited data on the extent of adolescent and young adult (AYA) education in pediatric and medical oncology fellowship programs. The purpose of this study was to assess the prevalence and content of AYA-focused training during pediatric and medical oncology fellowship and identify knowledge gaps for targeted educational curricular development. Methods: An anonymous, web-based survey for educators and trainees was developed, piloted and optimized by a study team comprising pediatric and adult oncologists. The survey contained questions on respondent demographics, AYA curriculum, provider comfort in managing specific AYA care domains, and priorities for future AYA educational content. In October 2021, email invitations containing the survey link were sent to program directors (PDs) and associate program directors (APDs) at 251 hematology/oncology fellowship programs (with 119 pediatric and 178 adult PDs/APDs) identified through the American Medical Association’s Fellowship and Residency Electronic Interactive Database Access. PDs were asked to participate and also distribute the survey to current fellows. The survey remained open for 3 months. Fisher’s exact test was used to assess for associations between discrete variables including amount of current education vs level of importance and demographic groups. Results: Respondents represented 69 programs (27%). There were 130 respondents who completed curriculum and demographic questions and 112 who completed detailed topic questions. Respondents comprised 51 PDs/APDs (32 pediatric and 19 adult) and 58 fellows (33 pediatric and 25 adult). 85% of PDs (44/51) do not have a formal AYA curriculum. Of these, 80% (35/44) offer some topic-specific lectures, while 20% (9/44) provide little/no education in any topics. For nearly all topics, at least 45% of respondents reported little/no education. Although onco-fertility and survivorship are the most frequently taught topics, 36% and 42% of respondents, respectively, reported little/no education in these areas. Substance abuse is least commonly taught. Both PDs and fellows believe that AYA topics are more important for inclusion in future curricula despite how infrequently they are currently taught (very/extremely important for inclusion vs moderate/great deal of current amount of education, p = 0.0001 for all topics). Overall, respondents indicated the most important topics for inclusion in fellowship curriculum were onco-fertility (82%), survivorship (78%), and communication (77%). Conclusions: These data highlight the large gap in hematology/oncology fellowship education in AYA topics and a paucity of formal educational curricula. Efforts are needed to provide both medical and pediatric oncology fellows with the knowledge and skills required to provide optimal care for AYAs.

10043 Background: While the addition of anti-GD2 immunotherapy led to improvement in outcomes in patients on the Children’s Oncology Group (COG) ANBL0032 study, relapse remains a concern. Prior studies demonstrated the prognostic importance of time to first relapse, however, the effect of immunotherapy on timing and patterns of relapse in neuroblastoma (NBL) have yet to be evaluated. The purpose of this exploratory analysis was to describe the impact of immunotherapy on patterns of relapse in patients with high-risk NBL, including a descriptive comparison of sites of relapse based on post-consolidation treatment received [dinutuximab with cytokines and isotretinoin (DIN) vs isotretinoin alone (ISO)]. Methods: A retrospective, descriptive analysis of patients on ANBL0032 was performed, including patients randomized to DIN or ISO and those non-randomly assigned to DIN after ISO arm closure. Pt characteristics including age, stage, MYCN amplification status, tumor grade, mitosis-karyorrhexis index (MKI) and ploidy were summarized descriptively and relapse sites were tabulated. For DIN patients who subsequently relapsed, overall survival (OS) was calculated starting from the time of first relapse after enrollment on ANBL0032 (“post-relapse OS”). Kaplan-Meier OS curves were generated based on site of relapse. Results: The analytic cohort included 1,431 (DIN = 1,327; ISO = 104) patients. Among DIN patients, 492 relapsed, many in > 1 site. In the randomized cohort (n = 248), 122 relapsed (DIN = 68/144; ISO = 54/104). The frequencies (DIN; ISO) by site of relapse in the randomized cohort were: bone (53%; 54%), CNS (16%; 11%), lymph node (13%; 17%), abdominal (10%; 17%), paraspinal (6%; 2%), liver (3%; 4%), other soft tissue (22%; 7%). A higher proportion of ISO patients had marrow relapse (29.4% DIN; 48.2% ISO); however, the proportion of DIN patients with lung relapses appeared higher (9% vs 2%). Among all relapsed patients, the proportion with bone relapse did not appear to differ between treatment groups, regardless of MYCN status. Among patients with MYCN amplified disease, the proportion with marrow relapse did not appear to differ based on treatment [21/149 (14.1%) DIN; 3/20 (15.0%) ISO]; however, among patients with MYCN non-amplified disease, the proportion with marrow relapse appeared higher in the ISO group [16/23; 69.6%] vs the DIN group [52/193 (26.9%)]. Conclusions: In this exploratory analysis of patients on COG ANBL0032, the pattern for site of relapse appears to differ between patients treated with DIN vs ISO. While immunotherapy remains the treatment of choice in this population, the findings from this retrospective exploratory analysis warrant further investigation to decrease the risk for post-immunotherapy relapse. Clinical trial information: NCT00026312.

Although the seminal event in sickle cell disease is the polymerization of abnormal hemoglobin, the downstream pathophysiology of vasoocclusion results from heterotypic interactions between the altered, adhesive sickle cell red blood cells, neutrophils, endothelium, and platelets. Ischemia reperfusion injury, hemolysis, and oxidant damage all contribute to heightened inflammation and activation of the hemostatic system. These various pathways are the focus of emerging treatments with potential to ameliorate disease manifestations. This review summarizes the considerable progress in development of these agents despite challenges in selection of study end points and complex pathophysiology.

COVID‐19 has upended medical practice and education, but has also catalyzed enhancements in the field. Early on, a local group of researchers united to investigate the impact of the pandemic on pediatric hematology oncology (PHO). From this group, a regional educational series was established, “virtual‐Symposium of Pediatric Hematology/Oncology of New York” (v‐SYMPHONY). The implementation of these endeavors while PHO fellowship applications are declining has highlighted our perceptions that education, mentoring, and career expectations are not keeping up with the needs of current trainees. We describe our regional experience joining together to further education and research, and reflect on the current landscape of PHO training and workforce.

Purpose Although humanism and professionalism are central tenets to the practice of medicine, few formal curricula exist for medical trainees. Following a national needs assessment among pediatric hematology-oncology (PHO) fellows, we created a novel curriculum entitled "Humanism and Professionalism for Pediatric Hematology-Oncology" (HP-PHO). In this study, we measure outcomes of this curricular intervention. Method We cluster-randomized 20 PHO fellowship programs to deliver usual training in humanism and professionalism (UT) or the novel curriculum (intervention) during the 2016-2017 academic year. The primary outcome measure was the Pediatric Hematology-Oncology Self-Assessment in Humanism (PHOSAH). Secondary measures included the Maslach Burnout Inventory, Patient-Provider Orientation Scale, Empowerment at Work Scale, and a 5-point satisfaction scale. Participating fellows completed pre- and posttests at the beginning and end of the academic year, respectively, and we calculated change scores for each study instrument. Results Cluster randomization yielded 59 intervention and 41 UT fellows. The nine intervention sites administered 33 of 36 modules. Change scores on the PHOSAH were not significantly different between the UT and intervention arms. However, fellows on the intervention arm gave significantly higher ratings on several items within the satisfaction scale related to physician burnout, physician depression, balancing professional duties and personal life, and humanism overall. Conclusions Exposure to the HP-PHO curriculum did not alter fellows' self-assessed humanism and professionalism skills. However, intervention fellows expressed significantly higher levels of satisfaction in their humanism training, indicating the curriculum's potential for positive impact on the fellows' perceived learning environment.

Residents serve as teachers in both formal and informal settings in medicine. As a result, the Accreditation Council for Graduate Medical Education (ACGME) requires the development of teaching competency. However, many residency programs lack Resident as Teacher (RAT) curricula; those that do have variable content and structure. Based on established conceptual frameworks, we created a longitudinal pediatric resident teaching group (PRTG). The members were self-selected pediatric residents who participated in faculty-led interactive didactic sessions focused on teaching skill development and were linked with resident-led teaching and mentoring of preclinical medical students in pediatrics. To assess program efficacy, residents completed a self-assessment of teaching skills prior to and at the end of each year of the program, and students completed evaluations of the residents’ teaching abilities. PRTG residents reported a significantly increased usage of teaching skills, as well as increased confidence and comfort teaching. Students assessed the residents to be “good” or “above average” teachers and found their learning “equivalent to” or “better than” when taught by an attending. PRTG residents found the program to be a feasible time commitment with the didactic skills session content useful and easily integrated into their teaching practice. The PRTG curriculum provides a consistent longitudinal framework for teaching skill acquisition that can enhance existing RAT programs to foster residents’ comfort teaching and skill usage.

Neonatal neutropenia is a common laboratory finding noted on the complete blood cell count of neonates in the intensive care unit. Neonatal neutropenia has various causes, ranging from maternal conditions to congenital syndromes to immune-mediated processes. However, not all neonatal neutropenia is clinically relevant; it often does not increase the risk of infection. In this review, we will discuss neutrophil function and development, review the causes of neonatal neutropenia, and describe their clinical relevance, evaluation, and management options.

Introduction: The workforce of Pediatric Hematology Oncology (PHO) has been evolving over the last decade. Recently, fellowship application volume has declined, with almost half of the programs at least partly unfilled during the previous MATCH. A perceived paucity of PHO jobs for graduating fellows may exacerbate this declining interest in the field. By surveying fellows, fellowship program directors, and PHO division chiefs, this study aims to investigate PHO fellows' preparation for, and experience with, the search for an initial faculty position. Methods: After pilot testing with faculty and fellows, all PHO division chiefs and program directors from 115 programs (N=222) were invited to complete the survey and to disseminate the instrument to their fellows. The survey included questions on demographics, job search preparation, job search experiences including barriers and helpful tools, and consequences for well-being such as stress and anxiety. Results: Some programs chose not to participate, evidenced by representation from 35 states, and many states with multiple fellowship programs only had one response from program leadership. A total of 166 individuals responded to all questions, representing approximately 24% response rate. Of the participants 83 were fellows and 83 were program leaders including fellowship program directors and division chiefs. Nearly 82% (n=136/166) of all respondents believe that PHO fellows are struggling to find a job that aligns with their goals. Program leaders identified common barriers influencing fellows' job search including geographic constraints (N=60/83, 73%) followed by only a few jobs available (N=51/83, 61%), clinical focus constraints (N=43/83, 52%), and few positions being posted (N=41/83, 49%). Fellows who have started the job search process commonly reported geographic constraints as a barrier (N=26/46, 57%), followed by partner employment opportunities (N=17/46, 37%), and their own clinical interests (N=15, 33%). Of 42 open-ended responses written by fellows, almost half (N=18/42, 43%) cited limited number of jobs available, and 21% (N=9/42) cited difficulties related to job postings. Almost half of fellows (47%, n=37/79) reported a lack of formal education on the job search process, as opposed to less than 10% of leadership (n=8/83) who agreed. When offered, education most commonly involved strategies for CV building (37%, n=31/83) and less frequently focused on the rest of the job process including negotiation, job talking, interviewing, and writing cover letters. Nearly all (N=79/83, 95%) of program leaders believe that fellows are somewhat/extremely stressed about the job search process. 75% (n=59/79) of fellows self-reported feeling somewhat/extremely stressed due to the job search process. Nearly 20% (n=15/79) of fellows self-reported severe anxiety over the job search process, and another 25% (n=21/79) reported moderate anxiety. Conclusions: This study highlights numerous shortcomings in the job search process among PHO fellows. A majority perceive difficulty securing a job which aligns with one's goals. While geography was the most cited barrier, finding a position with the optimal clinical focus was also problematic, a finding especially worrisome given the increasing popularity of additional 4 th year fellowship training in PHO. Other commonly recognized challenges surround the number of positions available as well as how those positions are publicized. Importantly, the job search may negatively impact wellness. Fellows' reports of stress and anxiety surrounding the job search, also acknowledged by program leaders should prompt change. Next steps include follow up studies including qualitative interviews to better understand the fellows' experiences, development of educational programs to prepare fellows for the job search process, enhanced career counseling, as well as improved support programs focused on the relevant stressors. Educational interventions to help prepare CVs, cover letters, and practice interviewing or negotiation may be able to help alleviate some of the stress fellows experience while undergoing the job search process. These data represent a need to further understand the PHO workforce to determine why fellows and leadership sense difficulty in securing a position that aligns with one's goals, as well as whether these perceptions represent the realities of the current workforce. Disclosures No relevant conflicts of interest to declare.

Neuroblastoma, the most common extracranial solid tumor of childhood, can present in multiple primary sites, but the extent of genetic heterogeneity among tumor foci, as well as the presence or absence of common oncogenic drivers, remains unknown. Although PHOX2B genetic aberrations can cause familial neuroblastoma, they demonstrate incomplete penetrance with respect to neuroblastoma pathogenesis, suggesting that additional undescribed oncogenic drivers are necessary for tumor development. We performed comprehensive molecular characterization of neuroblastoma tumors from two siblings affected by familial multifocal neuroblastoma, including whole exome sequencing and single-nucleotide polymorphism (SNP) arrays of tumor and matched blood samples. Data were processed and analyzed using established bioinformatics algorithms to evaluate for germline and somatic mutations and copy number variations (CNVs). We confirmed the presence of a PHOX2B deletion and NF1 mutation across all tumor samples and the germline genome. Matched tumor-blood whole exome sequencing also identified 365 genes that contained nonsilent coding mutations across all tumor samples, with no recurrent mutations across all tumors. SNP arrays also showed significant heterogeneity with respect to CNVs. The only common CNV across all tumors was 17q gain, with differing chromosomal coordinates across samples but a common region of overlap distal to 17q21.31, suggesting this adverse prognostic biomarker may offer insight about additional drivers for multifocal neuroblastoma in patients with germline PHOX2B or NF1 aberrations. Molecular characterization of all tumors from patients with multifocal primary neuroblastoma has potential to yield novel insights on neuroblastoma pathogenesis.

Purpose: To identify new pharmacologically targetable immune checkpoints in pediatric Hodgkin lymphoma. Background: The role of PD-1/PD-L1 axis in Hodgkin lymphoma (HL) has led to FDA approval for use of inhibitors of this pathway in chemotherapy-refractory HL. There are numerous additional B7/CD28 immune checkpoints that may similarly represent useful targets but have not yet been evaluated in HL. HHLA-2 is the newest member of the B7/CD28 family of immune checkpoint regulators that typically help tumor immune escape via inhibition T-cell activity and tumor killing. The prevalence of HHLA-2 has been demonstrated with expression on a wide range of adult cancers, with associated poor outcomes. HHLA-2 has yet to be evaluated in pediatric cancers, except for osteosarcoma where it was found to have increased expression and associated with worse five-year EFS. The purpose of this study is to characterize the expression pattern and clinical significance of HHLA-2 in pediatric HL using immunohistochemistry. Methods: Patient tumor samples from prior Children’s Oncology Group clinical trials with matched patient outcome data containing over 300 patient samples were obtained. 95% confidence intervals were calculated based on a range of observed prevalence of immune checkpoint expression for this initial pilot cohort of 100 samples. Using immunohistochemistry, paraffin-embedded samples were tested for the expression of HHLA-2 and B7x. Samples were also stained for CD30 to better delineate Reed Sternberg cells (RS) from the remainder of the tumor microenvironment. Immune checkpoint staining was compared to known positive controls of A204 cell line for HHLA-2 and SKBR3 for B7x, and negative controls of 3T3 cells. Expression intensity was scored by a pediatric pathologist. Results: The initial tissue microarray contained 128 unique HL cases; only 121 tissue samples were evaluable as HL tissue. Samples from 52 patients demonstrated positive HHLA-2 staining (43%); however, there was no identifiable B7x staining. HHLA-2 staining ranged from weak to moderate, with 23% (12/52) of positive samples demonstrating moderate staining. RS staining was observed in 77% of samples (40/52), with the remaining samples containing positively staining lymphocytes. Conclusion: This project is innovative in its characterization of HHLA-2 as a novel immune checkpoint target in pediatric HL. With these preliminary results we will validate these results with the remaining 200 patient samples and explore the relationship of expression with standard tumor characteristics, including stage and patient outcomes such as ESF and OS. These results can help discover new prognostic biomarkers and guide future treatment as therapeutic antibodies are currently being developed. We hope that the information from this project will be used to support new clinical trials for pediatric patients with Hodgkin lymphoma. Citation Format: Scott Moerdler, Damini Chand, Michelle Ewart, XingXing Zang, Peter Cole. HHLA2 is a new immune checkpoint expressed in pediatric Hodgkin lymphoma [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr A17.

10531 Background: The role of the PD-1/PD-L1 axis in Hodgkin Lymphoma (HL) has led to FDA approval for use of inhibitors in chemotherapy-refractory HL. Numerous additional immune checkpoints may be useful targets, but have not yet been evaluated in HL. LAG-3, a related checkpoint, has been demonstrated to be overexpressed on tumor infiltrating lymphocytes (TILs) of a variety of cancers with associated poor outcomes. LAG-3 is known to inhibit T cell proliferation and activation, representing a possible therapeutic pathway for anti-tumor immunity. However, LAG-3 has yet to be evaluated in pediatric cancers. The purpose of this study is to characterize the expression pattern and clinical significance of LAG-3 in pediatric HL using immunohistochemistry. Methods: Patient tumor samples from prior Children’s Oncology Group clinical trials (AHOD0031) with matched patient outcome data containing 200 patient samples were obtained. 95% confidence intervals were calculated based on a range of observed prevalence of immune checkpoint expression. Using immunohistochemistry, paraffin embedded samples were tested for the expression of LAG-3 and PD-L1. Samples were stained for CD30 to better delineate Reed Sternberg cells from the remainder of the tumor microenvironment. Immune checkpoint staining was compared to positive controls of normal tonsil tissue, and negative controls of 3T3 cells. Expression intensity was scored by a Pediatric Pathologist. Results: 115 unique HL patient cases with evaluable HL tissue and correlating clinical outcome data were analyzed. Samples from 73/115 patients (63%) demonstrated positive LAG-3 staining, defined as over 10% of TILs expressing LAG-3. No demographic data including gender, race/ethnicity, age, or stage were significantly associated with LAG-3 expression. While not statistically significant there was a numerical difference in event free survival (EFS) and patients with LAG-3 expression demonstrated worse EFS. In terms of degree of LAG-3 expression, patients with the lowest positive expression were found to have the worst EFS, and those with highest expression demonstrated the best EFS. 97% of patient cases were found to be PD-L1 positive. 71/73 (97%) of patients who expressed LAG3 were also PDL1+, and 71/106 (67%) of PDL1+ cases were also LAG3+. LAG-3 and PD-L1 were found to be independent (p = 0.09). Conclusions: This project is innovative in its characterization of LAG-3 as an immune checkpoint target in pediatric HL. We hope that the information from this project will be used to support new clinical trials for pediatric patients with Hodgkin lymphoma.

Programmed death 1 (PD-1), a member of the B7-CD28 immunoglobulin superfamily, and its ligands PD-L1/PD-L2 inhibit T-cell activation. They also play a key role in the tumor microenvironment, allowing for cancer immune escape. PD-1 is induced on a variety of immune cells, including tumor-infiltrating lymphocytes (TILs), while PD-L1 is found on many types of solid tumors including ovarian cancer and some TILs. The use of immunocheckpoint inhibitors like anti-PD-1 and anti-PD-L1 therapies has been shown to reactivate the immune system to attack tumor cells. Ovarian cancers have been shown to be responsive to anti-PD-1 and anti-PD-L1 therapies, though immunocheckpoint inhibitors are not enough. Current research is evaluating combination therapies to improve response rates.

Objective To determine how otolaryngologists and pediatric oncologists differ in their initial approach to diagnosing head and neck masses in children and adolescents. Methods We designed an electronic 28-question survey consisting of 4 clinical cases and one referral case varying by patient age, history, and physical exam findings. The survey was sent anonymously to pediatric oncologists and otolaryngologists at institutions in the United States and Canada. Results Two hundred and thirty one pediatric oncologists (29.4%) and 87 otolaryngologists (39.5%) completed the survey. Otolaryngologists were significantly more likely to recommend performing an FNA than oncologists in all four cases; less than 7% of pediatric oncologists recommended FNA for head and neck mass evaluation. Of providers who recommended FNA, otolaryngologists were more likely to do so because of diagnostic yield when compared to pediatric oncologists. However, when referred a patient with an FNA demonstrating non-Hodgkin lymphoma, the majority of pediatric oncologists (73.6%) and otolaryngologists (78.7%) would complete the staging work-up and begin treatment. If the same patient was referred with an FNA that demonstrated non-specific inflammation, most oncologists (91.0%) and otolaryngologists (94.4%) would biopsy the mass. Conclusion Otolaryngologists and pediatric oncologists differ in their initial approach to diagnosing head and neck masses in children, yet they both would recommend treating a patient with a positive FNA. This highlights important differences in the diagnostic process depending on which provider sees the patient first. Further studies assessing the sensitivity and specificity are needed to determine the true diagnostic yield of FNAs in the assessment of head and neck masses in children and adolescents, especially with increasing need for molecular and genomic profiling.

Background: Sickle cell disease is one of the most common inherited red blood cell disorders, yet many are not aware of their carrier status (Treadwell, J Nat Med Assoc, 2006), which can lead to confusion around pregnancy and newborn diagnosis. Furthermore, data is emerging about the severe and life-threatening risks of sickle cell trait (Kark, NEJM, 1987 and Olaniran, Am J Nephro, 2019). The American College of Obstetricians and Gynecologists' guidelines recommend that pregnant women of African, Mediterranean and Southeast Asian descent be screened for hemoglobinopathies with a complete blood count (CBC) and hemoglobin electrophoresis (ACOG, Opinion #691, 2017). However, adherence to this practice and frequency of improper screening with Sickledex is unknown. Proper screening and counseling can impact families' knowledge and allow them to establish relationships with hematology providers earlier. Objectives: We sought to assess prenatal hemoglobinopathy screening practice patterns and methods of Obstetrics & Gynecology (OBGYN) and Family Medicine (FM) providers in the Tri-State regional area. Methods: A cross-sectional electronic survey was administered to OBGYN and FM practitioners from six tri-state area institutions using publicly available information and contacts at each institution. Questions focused on prenatal hemoglobinopathy screening practices using case scenarios with variations on parental trait status and ethnicities. Chi-square analyses were used to compare the two provider groups on categorical variables. Results: There were 167 total responses; 120 surveys were complete, of which 87 were OBGYN and 33 FM providers. Respondents were mainly faculty (69/120, 58%) and from academic medical centers (n=107). 42% of providers reported that they ask "76-100%" of their patients about a personal history of sickle cell disease or trait. When asked about the proportion of pregnant patients with a positive family history of a hemoglobinopathy, there was a significant difference between OBGYN and FM providers, with 95% of OBGYN providers responding that they screen "76-100%" of those patients as opposed to only 75% of FM providers screening with the same frequency (p=0.0034). When asked about screening practices for patients without a personal/family history of a hemoglobinopathy, OBGYN providers consistently screen more frequently (Figure 1). When analyzed by ethnic background, screening practices were significantly different only between the subspecialty providers who "always" or "often" screened for hemoglobinopathies in mothers of Asian descent (p=0.03). Over 73% of providers report that they "always" screen patients of Mediterranean, Asian, and Middle Eastern descent and 84% always screen patients of Black descent. Over 30% of all respondents said they would use Sickledex for screening in case scenarios for a Black/African American mother, even when it was already known that she is a sickle cell carrier. In cases where the mother's hemoglobinopathy status was unknown, over 80% of providers responded that they would "always" evaluate with a hemoglobin electrophoresis regardless of Black/African American or Mediterranean descent. In terms of referrals to Hematology, in a case where both parents have sickle cell trait 46% of providers would "never" refer that family to Hematology. Conclusion: This pilot survey highlights differences in the methods and likelihood of prenatal hemoglobinopathy screening based on the type of prenatal care provider. Screening differences can lead to variations in prenatal guidance, diagnostic procedures, informed decision-making and knowledge of families referred to pediatric hematology clinics. This is the first study analyzing prenatal screening for hemoglobinopathies in OBGYN and FM. This study demonstrates that not all prenatal providers adhere to existing ACOG recommendations regarding which patients to screen for hemoglobinopathies and suggests an actionable area in which to enhance education for prenatal providers. Specifically, providers need to be educated that the use of Sickledex is an inappropriate laboratory screening test, since it will not detect other hemoglobinopathies. Improving prenatal screening practices by collaborating with hematologists may increase adherence to guidelines and allow for earlier relationship building with hematology. Figure 1 Disclosures Manwani: GBT: Consultancy, Research Funding; Novartis: Consultancy; Pfizer: Consultancy.

Background Burnout is plaguing doctors at all levels with severe consequences. Despite high emotional intensity, burnout rates among pediatric hematology-oncology (PHO) faculty have been less than previously described (Roth, PBC, 2011). The landscape of burnout among PHO fellows remains unknown. Objectives Describe the prevalence, determinants, and associated outcomes of burnout among PHO fellows. Methods 115 PHO fellows enrolled in a humanism curriculum study were administered the Maslach burnout inventory, empowerment at work scale, patient-provider orientation scale (PPOS), and satisfaction in training scale. Secondary analyses were performed using chi square analysis for demographic risk factors, and t-test for the continuous outcome variables. Results A total of 45/115 fellows (39.1%) met criteria for high level of burnout. No demographic variables were identified as statistically significant risk factors to predict high levels of burnout, including year of fellowship. The prevalence of high-level burnout among 2nd and 3rd year fellows was not significantly lower than that of 1st year fellows (36% vs 46%, p=0.3), revealing burnout to be an issue across the full fellowship experience. Program size was not significantly associated with level of burnout, though there was a trend towards large programs contributing a higher proportion of fellows with high levels of burnout (62.2% of fellows with high burnout trained in large programs vs 47.1% of those without high burnout). Those who met criteria for high burnout were associated with poor outcomes (Table 1). Conclusions This study identified more than 1/3 of current PHO trainees experiencing high levels of burnout. Interestingly, research years may not be as protective as thought and those at larger programs might be at higher risk, though more data are required. High level burnout is associated with decreased satisfaction with training, poor empowerment, and less patient-centered care. These data beg the need for longitudinal investigation of burnout in PHO fellows, both for their own well-being but also for the possible impact on patient care.

BACKGROUND Targeted cancer treatments are almost always first studied in adults, even when there is a biologically plausible potential for efficacy in children. Through compassionate use programs, children who are not eligible for a clinical trial and for whom there are no known effective therapies may obtain access to investigational agents, including drugs under development for adults. However, little is known about pediatric oncologists' experiences with applying for and obtaining compassionate use agents. METHODS This study surveyed 132 pediatric oncologists to assess awareness and utilization of compassionate use programs, to identify barriers to their use, and to evaluate available institutional support and resources. RESULTS We found that the process of applying for access to drugs in development is poorly understood, which presents a barrier to obtaining investigational drugs. Fifty-seven percent of the pediatric oncologists applied for compassionate use. Providers from larger institutions or with more than 15 years of clinical experience were more likely to complete an application and obtain investigational agents for their patients. CONCLUSION Identified perceived and actual barriers to compassionate use application submission suggest pediatric oncologists may benefit from educational resources and support to ensure children with cancer equal access to investigational agents and care.

e18627Background: Targeted cancer treatments are almost always first studied in adults even when there is a biologically plausible potential for efficacy in children. Through compassionate use (CU)...

This resource features a guide for teaching about seizures, as well as a detailed manual for simulation of seizure activities geared towards pediatric interns and residents. The detailed instructor's manual provides the framework for the initial simulation case, which is followed by an educational slide presentation for which the instructor's manual provides detailed talking points. This is followed by a second simulation case, also detailed in the instructor's manual. Pediatric emergencies are not commonplace, but when the situation arises residents must be prepared. This simulation activity reviews general knowledge of seizures, a common pediatric condition, as well as reviews team and leadership roles and provides the residents with the opportunity to practice their skills in a real-time case.

Background: Targeted cancer treatments are almost always studied first in adults, and even when there is a biologically plausible potential for efficacy in children, studies very rarely include pediatric patients. Through compassionate use (expanded access) programs, children who are not eligible for clinical trials and for whom there are no satisfactory therapies available may have access to experimental therapies, including drugs under development for adults. Even when potential benefits of a promising experimental treatment may outweigh the potential risks of a relatively untested drug, the process to obtain the drug is complex. A physician must obtain a patient's consent, agreement from a pharmaceutical company to provide an investigational drug, and approvals from the FDA and an IRB. These time-consuming and poorly understood steps often present barriers to obtaining access to investigational drugs. Some physicians and patients do not know that applying for investigational drugs is an option. Objectives: 1) To design a web portal to assist families and physicians with submission of compassionate use applications for promising, investigational drugs for children with cancer, and 2) To study pediatric oncologists’ awareness and utilization of the compassionate use program, and identify barriers to its use. Methods: The Compassionate Use Navigator is a new program of Kids v Cancer (www.kidsvcancer.org/compassionate-use) that provides: a) An option for physicians to request help from Compassionate Use Navigator staff in completing a compassionate use application; b) Information on rules and procedures for obtaining expanded access for physicians and patients, including FDA and pharmaceutical company contacts; c) Instructions on how to apply for compassionate use; and d) Develops a registry of outcomes of compassionate use applications for children. A questionnaire has been developed to assess pediatric oncologists’ experiences with and barriers affecting use of compassionate use programs to be distributed before and after go-live of the Navigator in February 2016. Results: The Compassionate Use Navigator was created as a web-based tool and concierge service for pediatric oncologists and families who want to gain access to investigational drugs outside of clinical trials when no satisfactory FDA-approved treatment options are available. Conclusion: The complex process to obtain compassionate use of an investigational drug may be a barrier to utilization of the program, particularly in childhood cancer. Studies are needed to explore the effects of the Compassionate Use Navigator on the number of applications over time, and evaluate pediatric oncologists’ perceptions about the compassionate use program before and after implementation of the Compassionate Use Navigator. Citation Format: Elena Gerasimov, Lindy Zhang, Scott Moerdler, Michael Roth, Nancy Goodman, Daniel Weiser. Compassionate use navigator addresses challenges and facilitates access to investigational drugs for pediatric oncologists. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-146.