AVAHO

PURPOSE: To evaluate outcomes of disease progression based on the sequence of abiraterone and enzalutamide in veterans diagnosed with metastatic castration-resistant prostate cancer (mCRPC).

BACKGROUND: Two of the current options for mCRPC treatment are the novel oral hormonal agents abiraterone and enzalutamide. After progression on one of these agents, one option is to switch to the other agent not previously used. Previously published retrospective studies and one prospective study have shown a difference in outcomes favoring abiraterone followed by enzalutamide, while others have shown no difference based on sequence. The optimal sequence of abiraterone and enzalutamide is still unclear.

METHODS: This was a retrospective chart review of patients who received abiraterone and enzalutamide in sequence for the treatment of mCRPC within our healthcare system from April 28, 2011 through October 31, 2019. Baseline demographic information such as age, race, Gleason score, and prior treatments were collected. The primary outcome was combined prostate-specific antigen progression-free survival (cPSA-PFS). Secondary outcomes included radiographic PFS (rPFS), overall survival (OS), adverse events causing treatment discontinuation, and medication adherence. Between-group survival differences were estimated by the Kaplan-Meier method and an unadjusted Cox regression model.

RESULTS: A total of 77 patients met criteria for study inclusion, with 51 in the abiraterone-to-enzalutamide group (ABI-ENZ) and 26 in the enzalutamide-to-abiraterone group (ENZ-ABI). For the primary outcome of cPSA-PFS, the median survival of the ABI-ENZ and ENZ-ABI groups was 17.3 months (95% CI, 10.3-24.3 months) and 10.2 months (95% CI, 8.5-11.8 months), respectively, which was significantly different (log-rank P=0.009) in favor of the ABI-ENZ sequence (HR 0.46; 95% CI, 0.26-0.83). Secondary outcomes of rPFS and OS were not significantly different between groups.

CONCLUSION: This study adds to the evidence supporting the sequence of abiraterone before enzalutamide for improving PSA-PFS. It is thought this might be related to differences in mechanisms of resistance between the two drugs. This benefit has not yet translated to an improvement in rPFS and OS. Based on the results of this study in conjunction with previously published studies, use of abiraterone before enzalutamide should be considered over the alternate sequence.

PURPOSE: To evaluate outcomes of disease progression based on the sequence of abiraterone and enzalutamide in veterans diagnosed with metastatic castration-resistant prostate cancer (mCRPC).

BACKGROUND: Two of the current options for mCRPC treatment are the novel oral hormonal agents abiraterone and enzalutamide. After progression on one of these agents, one option is to switch to the other agent not previously used. Previously published retrospective studies and one prospective study have shown a difference in outcomes favoring abiraterone followed by enzalutamide, while others have shown no difference based on sequence. The optimal sequence of abiraterone and enzalutamide is still unclear.

METHODS: This was a retrospective chart review of patients who received abiraterone and enzalutamide in sequence for the treatment of mCRPC within our healthcare system from April 28, 2011 through October 31, 2019. Baseline demographic information such as age, race, Gleason score, and prior treatments were collected. The primary outcome was combined prostate-specific antigen progression-free survival (cPSA-PFS). Secondary outcomes included radiographic PFS (rPFS), overall survival (OS), adverse events causing treatment discontinuation, and medication adherence. Between-group survival differences were estimated by the Kaplan-Meier method and an unadjusted Cox regression model.

RESULTS: A total of 77 patients met criteria for study inclusion, with 51 in the abiraterone-to-enzalutamide group (ABI-ENZ) and 26 in the enzalutamide-to-abiraterone group (ENZ-ABI). For the primary outcome of cPSA-PFS, the median survival of the ABI-ENZ and ENZ-ABI groups was 17.3 months (95% CI, 10.3-24.3 months) and 10.2 months (95% CI, 8.5-11.8 months), respectively, which was significantly different (log-rank P=0.009) in favor of the ABI-ENZ sequence (HR 0.46; 95% CI, 0.26-0.83). Secondary outcomes of rPFS and OS were not significantly different between groups.

CONCLUSION: This study adds to the evidence supporting the sequence of abiraterone before enzalutamide for improving PSA-PFS. It is thought this might be related to differences in mechanisms of resistance between the two drugs. This benefit has not yet translated to an improvement in rPFS and OS. Based on the results of this study in conjunction with previously published studies, use of abiraterone before enzalutamide should be considered over the alternate sequence.

PURPOSE: To evaluate outcomes of disease progression based on the sequence of abiraterone and enzalutamide in veterans diagnosed with metastatic castration-resistant prostate cancer (mCRPC).

BACKGROUND: Two of the current options for mCRPC treatment are the novel oral hormonal agents abiraterone and enzalutamide. After progression on one of these agents, one option is to switch to the other agent not previously used. Previously published retrospective studies and one prospective study have shown a difference in outcomes favoring abiraterone followed by enzalutamide, while others have shown no difference based on sequence. The optimal sequence of abiraterone and enzalutamide is still unclear.

METHODS: This was a retrospective chart review of patients who received abiraterone and enzalutamide in sequence for the treatment of mCRPC within our healthcare system from April 28, 2011 through October 31, 2019. Baseline demographic information such as age, race, Gleason score, and prior treatments were collected. The primary outcome was combined prostate-specific antigen progression-free survival (cPSA-PFS). Secondary outcomes included radiographic PFS (rPFS), overall survival (OS), adverse events causing treatment discontinuation, and medication adherence. Between-group survival differences were estimated by the Kaplan-Meier method and an unadjusted Cox regression model.

RESULTS: A total of 77 patients met criteria for study inclusion, with 51 in the abiraterone-to-enzalutamide group (ABI-ENZ) and 26 in the enzalutamide-to-abiraterone group (ENZ-ABI). For the primary outcome of cPSA-PFS, the median survival of the ABI-ENZ and ENZ-ABI groups was 17.3 months (95% CI, 10.3-24.3 months) and 10.2 months (95% CI, 8.5-11.8 months), respectively, which was significantly different (log-rank P=0.009) in favor of the ABI-ENZ sequence (HR 0.46; 95% CI, 0.26-0.83). Secondary outcomes of rPFS and OS were not significantly different between groups.

CONCLUSION: This study adds to the evidence supporting the sequence of abiraterone before enzalutamide for improving PSA-PFS. It is thought this might be related to differences in mechanisms of resistance between the two drugs. This benefit has not yet translated to an improvement in rPFS and OS. Based on the results of this study in conjunction with previously published studies, use of abiraterone before enzalutamide should be considered over the alternate sequence.

BACKGROUND: Signet ring cell carcinoma of the esophagus (SRCCE) is an aggressive tumor that represents approximately 3.5-5.0% of all esophageal cancers. Prior studies have shown a strong correlation between treating facility and survival for different cancers, but this has not been studied in SRCCE. The goal of this study is to assess differences in survival based on the type of treatment facility.

METHODS: There were 1,442 patients with SRCCE identified using the histology 8490 and topography codes C15.0-C15.9 in the National Cancer Database (NCDB). Descriptive analysis, Kaplan-Meier curves, and a multivariable Cox hazard regression analysis were all utilized to determine the significance and impact of treatment facility type, race, age, sex, tumor stage, use of adjuvant or neoadjuvant radiation, and surgical margins on survival.

RESULTS: The cohort was mostly male (86.6%) and Non-Hispanic Caucasian (96.3%) with 52.7% receiving treatment at academic centers followed by 35.9% at community programs and 11.4% at integrated cancer programs. As age increased, mortality also increased (HR = 1.02; 95% CI: 1.01-1.02, p < 0.001). Both Hispanic Caucasians (HR = 2.09; 95% CI: 1.21-3.62, = 0.009) and Africans Americans (HR = 1.69; 95% CI: 1.04-2.75, = 0.036) had an increased risk of mortality when compared to Non-Hispanic Caucasians. Patients at academic facilities demonstrated a decreased risk of mortality when compared to community programs (HR = 0.73; 95% CI: 0.63-0.86, p < 0.001) and integrated cancer programs (HR = 0.74; 95% CI: 0.60- 0.93, = 0.008).

CONCLUSION: For patients diagnosed with SRCCE, receiving treatment at academic centers resulted in better survival probabilities compared to nonacademic facilities. Older patients, African Americans and Hispanic Caucasians, increasing tumor stage, positive surgical margins, and comorbidities with Charlson- Deyo scores of 1 and 2+ were all associated with an increased risk of mortality from SRCCE.

BACKGROUND: Signet ring cell carcinoma of the esophagus (SRCCE) is an aggressive tumor that represents approximately 3.5-5.0% of all esophageal cancers. Prior studies have shown a strong correlation between treating facility and survival for different cancers, but this has not been studied in SRCCE. The goal of this study is to assess differences in survival based on the type of treatment facility.

METHODS: There were 1,442 patients with SRCCE identified using the histology 8490 and topography codes C15.0-C15.9 in the National Cancer Database (NCDB). Descriptive analysis, Kaplan-Meier curves, and a multivariable Cox hazard regression analysis were all utilized to determine the significance and impact of treatment facility type, race, age, sex, tumor stage, use of adjuvant or neoadjuvant radiation, and surgical margins on survival.

RESULTS: The cohort was mostly male (86.6%) and Non-Hispanic Caucasian (96.3%) with 52.7% receiving treatment at academic centers followed by 35.9% at community programs and 11.4% at integrated cancer programs. As age increased, mortality also increased (HR = 1.02; 95% CI: 1.01-1.02, p < 0.001). Both Hispanic Caucasians (HR = 2.09; 95% CI: 1.21-3.62, = 0.009) and Africans Americans (HR = 1.69; 95% CI: 1.04-2.75, = 0.036) had an increased risk of mortality when compared to Non-Hispanic Caucasians. Patients at academic facilities demonstrated a decreased risk of mortality when compared to community programs (HR = 0.73; 95% CI: 0.63-0.86, p < 0.001) and integrated cancer programs (HR = 0.74; 95% CI: 0.60- 0.93, = 0.008).

CONCLUSION: For patients diagnosed with SRCCE, receiving treatment at academic centers resulted in better survival probabilities compared to nonacademic facilities. Older patients, African Americans and Hispanic Caucasians, increasing tumor stage, positive surgical margins, and comorbidities with Charlson- Deyo scores of 1 and 2+ were all associated with an increased risk of mortality from SRCCE.

BACKGROUND: Signet ring cell carcinoma of the esophagus (SRCCE) is an aggressive tumor that represents approximately 3.5-5.0% of all esophageal cancers. Prior studies have shown a strong correlation between treating facility and survival for different cancers, but this has not been studied in SRCCE. The goal of this study is to assess differences in survival based on the type of treatment facility.

METHODS: There were 1,442 patients with SRCCE identified using the histology 8490 and topography codes C15.0-C15.9 in the National Cancer Database (NCDB). Descriptive analysis, Kaplan-Meier curves, and a multivariable Cox hazard regression analysis were all utilized to determine the significance and impact of treatment facility type, race, age, sex, tumor stage, use of adjuvant or neoadjuvant radiation, and surgical margins on survival.

RESULTS: The cohort was mostly male (86.6%) and Non-Hispanic Caucasian (96.3%) with 52.7% receiving treatment at academic centers followed by 35.9% at community programs and 11.4% at integrated cancer programs. As age increased, mortality also increased (HR = 1.02; 95% CI: 1.01-1.02, p < 0.001). Both Hispanic Caucasians (HR = 2.09; 95% CI: 1.21-3.62, = 0.009) and Africans Americans (HR = 1.69; 95% CI: 1.04-2.75, = 0.036) had an increased risk of mortality when compared to Non-Hispanic Caucasians. Patients at academic facilities demonstrated a decreased risk of mortality when compared to community programs (HR = 0.73; 95% CI: 0.63-0.86, p < 0.001) and integrated cancer programs (HR = 0.74; 95% CI: 0.60- 0.93, = 0.008).

CONCLUSION: For patients diagnosed with SRCCE, receiving treatment at academic centers resulted in better survival probabilities compared to nonacademic facilities. Older patients, African Americans and Hispanic Caucasians, increasing tumor stage, positive surgical margins, and comorbidities with Charlson- Deyo scores of 1 and 2+ were all associated with an increased risk of mortality from SRCCE.

BACKGROUND: Colorectal cancer (CRC) screening guidelines generally recommend healthy lifestyle choices for cancer prevention. However, studies have shown inconsistent associations between various risk factors and advanced neoplasia (AN) development. AIM: To identify potentially modifiable baseline dietary and lifestyle risk factors associated with AN among an asymptomatic Veteran population, while accounting for prior colonoscopic findings and varying surveillance intensity.

METHODS: We used data from a prospective colonoscopy screening study collected by the VA Cooperative Studies Program. From 1994 to 1997, 3,121 asymptomatic Veterans aged 50-75 received a baseline colonoscopy screening, at which time they selfreported dietary and lifestyle information. Veterans were subsequently assigned to colonoscopy surveillance regimens and followed for 10 years. AN was defined as invasive CRC or any adenoma ≥1 cm, or with villous histology, or high-grade dysplasia. To detect associations with AN diagnosis, we utilized a longitudinal joint model with two sub-models. A multivariate logistic regression modeled the longitudinal probability of AN, while a time-to-event process adjusted for survival. Here we focus on the multivariate logistic regression, representing associations of dietary and lifestyle risk factors with the odds of being diagnosed with AN.

RESULTS: Of the 3,121 Veterans, 1,915 received at least one colonoscopy following baseline screening. Among the 1,915, we detected a significant positive association with AN for current daily smokers (odds ratio (OR) 1.43, 95% CI: 1.02-2.01) compared to those with prior or no history. We found a protective effect for each 100 IU of dietary vitamin D consumed (OR 0.95, 95% CI: 0.95-0.99). We did not detect any significant associations with BMI, red meat consumption, or physical activity. We found that African American race had a lower odds of AN compared to Caucasian race (OR 0.57, 95% CI: 0.32-0.97).

CONCLUSIONS: We identified smoking status and vitamin D consumption as potentially modifiable baseline risk factors associated with AN development. While these results suggest possible points of intervention and targeted screening, more evidence is required across more diverse populations. Future efforts should focus on understanding changes in such risk factors on associations with AN for patients over time. Finally, racial differences in AN incidence merit further investigation.

BACKGROUND: Colorectal cancer (CRC) screening guidelines generally recommend healthy lifestyle choices for cancer prevention. However, studies have shown inconsistent associations between various risk factors and advanced neoplasia (AN) development. AIM: To identify potentially modifiable baseline dietary and lifestyle risk factors associated with AN among an asymptomatic Veteran population, while accounting for prior colonoscopic findings and varying surveillance intensity.

METHODS: We used data from a prospective colonoscopy screening study collected by the VA Cooperative Studies Program. From 1994 to 1997, 3,121 asymptomatic Veterans aged 50-75 received a baseline colonoscopy screening, at which time they selfreported dietary and lifestyle information. Veterans were subsequently assigned to colonoscopy surveillance regimens and followed for 10 years. AN was defined as invasive CRC or any adenoma ≥1 cm, or with villous histology, or high-grade dysplasia. To detect associations with AN diagnosis, we utilized a longitudinal joint model with two sub-models. A multivariate logistic regression modeled the longitudinal probability of AN, while a time-to-event process adjusted for survival. Here we focus on the multivariate logistic regression, representing associations of dietary and lifestyle risk factors with the odds of being diagnosed with AN.

RESULTS: Of the 3,121 Veterans, 1,915 received at least one colonoscopy following baseline screening. Among the 1,915, we detected a significant positive association with AN for current daily smokers (odds ratio (OR) 1.43, 95% CI: 1.02-2.01) compared to those with prior or no history. We found a protective effect for each 100 IU of dietary vitamin D consumed (OR 0.95, 95% CI: 0.95-0.99). We did not detect any significant associations with BMI, red meat consumption, or physical activity. We found that African American race had a lower odds of AN compared to Caucasian race (OR 0.57, 95% CI: 0.32-0.97).

CONCLUSIONS: We identified smoking status and vitamin D consumption as potentially modifiable baseline risk factors associated with AN development. While these results suggest possible points of intervention and targeted screening, more evidence is required across more diverse populations. Future efforts should focus on understanding changes in such risk factors on associations with AN for patients over time. Finally, racial differences in AN incidence merit further investigation.

BACKGROUND: Colorectal cancer (CRC) screening guidelines generally recommend healthy lifestyle choices for cancer prevention. However, studies have shown inconsistent associations between various risk factors and advanced neoplasia (AN) development. AIM: To identify potentially modifiable baseline dietary and lifestyle risk factors associated with AN among an asymptomatic Veteran population, while accounting for prior colonoscopic findings and varying surveillance intensity.

METHODS: We used data from a prospective colonoscopy screening study collected by the VA Cooperative Studies Program. From 1994 to 1997, 3,121 asymptomatic Veterans aged 50-75 received a baseline colonoscopy screening, at which time they selfreported dietary and lifestyle information. Veterans were subsequently assigned to colonoscopy surveillance regimens and followed for 10 years. AN was defined as invasive CRC or any adenoma ≥1 cm, or with villous histology, or high-grade dysplasia. To detect associations with AN diagnosis, we utilized a longitudinal joint model with two sub-models. A multivariate logistic regression modeled the longitudinal probability of AN, while a time-to-event process adjusted for survival. Here we focus on the multivariate logistic regression, representing associations of dietary and lifestyle risk factors with the odds of being diagnosed with AN.

RESULTS: Of the 3,121 Veterans, 1,915 received at least one colonoscopy following baseline screening. Among the 1,915, we detected a significant positive association with AN for current daily smokers (odds ratio (OR) 1.43, 95% CI: 1.02-2.01) compared to those with prior or no history. We found a protective effect for each 100 IU of dietary vitamin D consumed (OR 0.95, 95% CI: 0.95-0.99). We did not detect any significant associations with BMI, red meat consumption, or physical activity. We found that African American race had a lower odds of AN compared to Caucasian race (OR 0.57, 95% CI: 0.32-0.97).

CONCLUSIONS: We identified smoking status and vitamin D consumption as potentially modifiable baseline risk factors associated with AN development. While these results suggest possible points of intervention and targeted screening, more evidence is required across more diverse populations. Future efforts should focus on understanding changes in such risk factors on associations with AN for patients over time. Finally, racial differences in AN incidence merit further investigation.

Burnout is common in hematology/oncology practice where work pressure is high, patients are complex, and outcomes are variable. We hypothesized that a short story club could be helpful to improve community, humanism, and transcendence; and thereby to decrease burnout. Most of the potential participants indicated little time for preparation and we, therefore, chose short stories rather than books as reading material. The meetings began in April 2019 and continued until April 2020 when they were suspended for the COVID-19 epidemic. Participants included oncologists (6), oncology fellows (2), psychologist (1), social workers (2), research writer (1) and, student (1). Of these, 7 were females and 6 were males; 4 in senior and 9 in junior positions. Country of origin of participants was USA (6), India (3), Syria (2), Pakistan (1) and, Poland (1). Meetings were held every two months, each time with different stories, focus, themes, and points of view. Readings included classical stories, modern stories, and personal essays, from the eyes of other oncologists, country doctor, patients, nurses, or students. Stories included “The Doctor” by Chekhov, “The Country Doctor” by Kafka, “Three Questions” by Tolstoy, “Elephant Hills” and “Indian Camp” each by Hemingway, “Interpreter of Maladies” by Lahiri, “Get your Own Fatal Disease” by Yalom, “Caves of Lascaux” by Karmel, “The Plagiarist” by Seamon and three essays on “undying,” end-of-life and love. Themes included falling in love with a patient, empathy, loneliness, burnout, communication, helplessness, and end-of-life issues. Discussions lasted two hours and promoted a sense of belonging and community; sharing of feelings and concerns; and transcendence of everyday burdens. Attendance was more than 80% at each meeting and all participants indicated an interest in continuing the club for the foreseeable future. Short story clubs may be one way to overcome or prevent burnout in oncology. Further quantitative and qualitative studies are needed.

Burnout is common in hematology/oncology practice where work pressure is high, patients are complex, and outcomes are variable. We hypothesized that a short story club could be helpful to improve community, humanism, and transcendence; and thereby to decrease burnout. Most of the potential participants indicated little time for preparation and we, therefore, chose short stories rather than books as reading material. The meetings began in April 2019 and continued until April 2020 when they were suspended for the COVID-19 epidemic. Participants included oncologists (6), oncology fellows (2), psychologist (1), social workers (2), research writer (1) and, student (1). Of these, 7 were females and 6 were males; 4 in senior and 9 in junior positions. Country of origin of participants was USA (6), India (3), Syria (2), Pakistan (1) and, Poland (1). Meetings were held every two months, each time with different stories, focus, themes, and points of view. Readings included classical stories, modern stories, and personal essays, from the eyes of other oncologists, country doctor, patients, nurses, or students. Stories included “The Doctor” by Chekhov, “The Country Doctor” by Kafka, “Three Questions” by Tolstoy, “Elephant Hills” and “Indian Camp” each by Hemingway, “Interpreter of Maladies” by Lahiri, “Get your Own Fatal Disease” by Yalom, “Caves of Lascaux” by Karmel, “The Plagiarist” by Seamon and three essays on “undying,” end-of-life and love. Themes included falling in love with a patient, empathy, loneliness, burnout, communication, helplessness, and end-of-life issues. Discussions lasted two hours and promoted a sense of belonging and community; sharing of feelings and concerns; and transcendence of everyday burdens. Attendance was more than 80% at each meeting and all participants indicated an interest in continuing the club for the foreseeable future. Short story clubs may be one way to overcome or prevent burnout in oncology. Further quantitative and qualitative studies are needed.

Burnout is common in hematology/oncology practice where work pressure is high, patients are complex, and outcomes are variable. We hypothesized that a short story club could be helpful to improve community, humanism, and transcendence; and thereby to decrease burnout. Most of the potential participants indicated little time for preparation and we, therefore, chose short stories rather than books as reading material. The meetings began in April 2019 and continued until April 2020 when they were suspended for the COVID-19 epidemic. Participants included oncologists (6), oncology fellows (2), psychologist (1), social workers (2), research writer (1) and, student (1). Of these, 7 were females and 6 were males; 4 in senior and 9 in junior positions. Country of origin of participants was USA (6), India (3), Syria (2), Pakistan (1) and, Poland (1). Meetings were held every two months, each time with different stories, focus, themes, and points of view. Readings included classical stories, modern stories, and personal essays, from the eyes of other oncologists, country doctor, patients, nurses, or students. Stories included “The Doctor” by Chekhov, “The Country Doctor” by Kafka, “Three Questions” by Tolstoy, “Elephant Hills” and “Indian Camp” each by Hemingway, “Interpreter of Maladies” by Lahiri, “Get your Own Fatal Disease” by Yalom, “Caves of Lascaux” by Karmel, “The Plagiarist” by Seamon and three essays on “undying,” end-of-life and love. Themes included falling in love with a patient, empathy, loneliness, burnout, communication, helplessness, and end-of-life issues. Discussions lasted two hours and promoted a sense of belonging and community; sharing of feelings and concerns; and transcendence of everyday burdens. Attendance was more than 80% at each meeting and all participants indicated an interest in continuing the club for the foreseeable future. Short story clubs may be one way to overcome or prevent burnout in oncology. Further quantitative and qualitative studies are needed.

INTRODUCTION: With the increasing availability of novel targeted therapies and next-generation sequencing (NGS) hematology panels, the treatment paradigm for patients with acute myeloid leukemia (AML) has recently been altered. Specifically, patients who bear mutations within the FMS-like tyrosine kinase (FLT3) gene or the isocitrate dehydrogenase (IDH) 1 or IDH2 genes may now be candidates for targeted treatments either in the frontline or relapsed or refractory (R/R) settings. The sequential targeted approach to AML patients who harbor mutations within both FLT3 and IDH genes has yet to be elucidated.

CASE PRESENTATION: Herein, we report a case of an elderly patient with FLT3 and IDH1 mutations who underwent induction chemotherapy in combination with midostaurin, and subsequently, ivosidenib in the R/R setting. Clonal evaluation was demonstrated with repeated cytogenetic analysis and NGS of blood and bone marrow specimens. At diagnosis, the patient’s AML harbored several pathogenic gene variants, including FLT3 and IDH1 mutations. Following induction chemotherapy with midostaurin, the patient’s FLT3 mutation was no longer detected. Upon relapse, the FLT3 mutation was still undetectable, however the IDH1 mutation remained. Unfortunately, the patient’s AML did not respond to ivosidenib, and expansion of a leukemic clone with a BCOR mutation was observed.

CONCLUSION: This case conveys the use of multiple targeted therapies in a sequential fashion for an AML patient with frequent completion of NGS panels to monitor clonal evolution. Given that a considerable minority of patients harbor both FLT3 and IDH mutations, further investigations evaluating optimal sequencing or combinations of targeted therapies are required.

INTRODUCTION: With the increasing availability of novel targeted therapies and next-generation sequencing (NGS) hematology panels, the treatment paradigm for patients with acute myeloid leukemia (AML) has recently been altered. Specifically, patients who bear mutations within the FMS-like tyrosine kinase (FLT3) gene or the isocitrate dehydrogenase (IDH) 1 or IDH2 genes may now be candidates for targeted treatments either in the frontline or relapsed or refractory (R/R) settings. The sequential targeted approach to AML patients who harbor mutations within both FLT3 and IDH genes has yet to be elucidated.

CASE PRESENTATION: Herein, we report a case of an elderly patient with FLT3 and IDH1 mutations who underwent induction chemotherapy in combination with midostaurin, and subsequently, ivosidenib in the R/R setting. Clonal evaluation was demonstrated with repeated cytogenetic analysis and NGS of blood and bone marrow specimens. At diagnosis, the patient’s AML harbored several pathogenic gene variants, including FLT3 and IDH1 mutations. Following induction chemotherapy with midostaurin, the patient’s FLT3 mutation was no longer detected. Upon relapse, the FLT3 mutation was still undetectable, however the IDH1 mutation remained. Unfortunately, the patient’s AML did not respond to ivosidenib, and expansion of a leukemic clone with a BCOR mutation was observed.

CONCLUSION: This case conveys the use of multiple targeted therapies in a sequential fashion for an AML patient with frequent completion of NGS panels to monitor clonal evolution. Given that a considerable minority of patients harbor both FLT3 and IDH mutations, further investigations evaluating optimal sequencing or combinations of targeted therapies are required.

INTRODUCTION: With the increasing availability of novel targeted therapies and next-generation sequencing (NGS) hematology panels, the treatment paradigm for patients with acute myeloid leukemia (AML) has recently been altered. Specifically, patients who bear mutations within the FMS-like tyrosine kinase (FLT3) gene or the isocitrate dehydrogenase (IDH) 1 or IDH2 genes may now be candidates for targeted treatments either in the frontline or relapsed or refractory (R/R) settings. The sequential targeted approach to AML patients who harbor mutations within both FLT3 and IDH genes has yet to be elucidated.

CASE PRESENTATION: Herein, we report a case of an elderly patient with FLT3 and IDH1 mutations who underwent induction chemotherapy in combination with midostaurin, and subsequently, ivosidenib in the R/R setting. Clonal evaluation was demonstrated with repeated cytogenetic analysis and NGS of blood and bone marrow specimens. At diagnosis, the patient’s AML harbored several pathogenic gene variants, including FLT3 and IDH1 mutations. Following induction chemotherapy with midostaurin, the patient’s FLT3 mutation was no longer detected. Upon relapse, the FLT3 mutation was still undetectable, however the IDH1 mutation remained. Unfortunately, the patient’s AML did not respond to ivosidenib, and expansion of a leukemic clone with a BCOR mutation was observed.

CONCLUSION: This case conveys the use of multiple targeted therapies in a sequential fashion for an AML patient with frequent completion of NGS panels to monitor clonal evolution. Given that a considerable minority of patients harbor both FLT3 and IDH mutations, further investigations evaluating optimal sequencing or combinations of targeted therapies are required.

PURPOSE: Examine whether baseline colonoscopy findings are associated with non-Colorectal Cancer (CRC) mortality in a Veteran screening population.

BACKGROUND: Although screening colonoscopy findings are associated with future risk of CRC mortality, whether these findings are also associated with non- CRC mortality remains unknown.

METHODS: The Cooperative Studies Program (CSP) #380 cohort is comprised of 3,121 Veterans age 50-75 who underwent screening colonoscopy from 1994-97. Veterans were followed for 10 years or death, as verified in electronic medical records. Those who died from CRC-specific causes were excluded from this analysis (n=18, 0.6%). Hazard ratios (HR) for risk factors on non-CRC mortality were calculated by Cox Proportional Hazard model, adjusting for demographics, baseline comorbidities, and lifestyle factors. Information on comorbidities, family history, diet, physical activity, and medications were obtained from self-reported questionnaires at baseline.

RESULTS: Of the included 3,103 Veterans, most were male (n=3,021, 96.8%), white (n=2,609, 83.6%), with a mean age of 62.9. During the 10-year follow-up period, 837 (27.0%) Veterans died from non-CRC causes. The risk of non-CRC mortality was higher in Veterans with ≥3 small adenomas (HR 1.45, p=0.02), advanced adenomas (HR 1.34, p=0.04), or CRC (HR 3.00, =0.05) on baseline colonoscopy when compared to Veterans without neoplasia. Additionally, increasing age (HR 1.07, <0.001), modified Charlson score (HR 1.57 for 3-4 points, <0.001, compared to 0-2 points) and current smoking (HR 2.09, <0.001, compared to former and non-smokers) were associated with higher non-CRC mortality. On the other hand, increasing physical activity (HR 0.88, <0.001), family history of CRC (HR 0.75, =0.02), and increased BMI (HR 0.73-0.75, <0.01) were associated with reduced non-CRC mortality. Neither race, NSAID use (including aspirin), or dietary factors impacted non-CRC mortality.

CONCLUSIONS: In a Veteran CRC screening population, we found that high-risk adenomas or CRC on baseline colonoscopy were independently associated with increased non-CRC mortality within 10 years. Future work will examine the cause-specific factors associated with non-CRC mortality in these groups to 1) identify potential high-yield strategies for tailored non-CRC mortality risk reduction during CRC screening, and 2) better determine when competing risks of non-CRC mortality outweigh the benefit of follow up colonoscopy.

PURPOSE: Examine whether baseline colonoscopy findings are associated with non-Colorectal Cancer (CRC) mortality in a Veteran screening population.

BACKGROUND: Although screening colonoscopy findings are associated with future risk of CRC mortality, whether these findings are also associated with non- CRC mortality remains unknown.

METHODS: The Cooperative Studies Program (CSP) #380 cohort is comprised of 3,121 Veterans age 50-75 who underwent screening colonoscopy from 1994-97. Veterans were followed for 10 years or death, as verified in electronic medical records. Those who died from CRC-specific causes were excluded from this analysis (n=18, 0.6%). Hazard ratios (HR) for risk factors on non-CRC mortality were calculated by Cox Proportional Hazard model, adjusting for demographics, baseline comorbidities, and lifestyle factors. Information on comorbidities, family history, diet, physical activity, and medications were obtained from self-reported questionnaires at baseline.

RESULTS: Of the included 3,103 Veterans, most were male (n=3,021, 96.8%), white (n=2,609, 83.6%), with a mean age of 62.9. During the 10-year follow-up period, 837 (27.0%) Veterans died from non-CRC causes. The risk of non-CRC mortality was higher in Veterans with ≥3 small adenomas (HR 1.45, p=0.02), advanced adenomas (HR 1.34, p=0.04), or CRC (HR 3.00, =0.05) on baseline colonoscopy when compared to Veterans without neoplasia. Additionally, increasing age (HR 1.07, <0.001), modified Charlson score (HR 1.57 for 3-4 points, <0.001, compared to 0-2 points) and current smoking (HR 2.09, <0.001, compared to former and non-smokers) were associated with higher non-CRC mortality. On the other hand, increasing physical activity (HR 0.88, <0.001), family history of CRC (HR 0.75, =0.02), and increased BMI (HR 0.73-0.75, <0.01) were associated with reduced non-CRC mortality. Neither race, NSAID use (including aspirin), or dietary factors impacted non-CRC mortality.

CONCLUSIONS: In a Veteran CRC screening population, we found that high-risk adenomas or CRC on baseline colonoscopy were independently associated with increased non-CRC mortality within 10 years. Future work will examine the cause-specific factors associated with non-CRC mortality in these groups to 1) identify potential high-yield strategies for tailored non-CRC mortality risk reduction during CRC screening, and 2) better determine when competing risks of non-CRC mortality outweigh the benefit of follow up colonoscopy.

PURPOSE: Examine whether baseline colonoscopy findings are associated with non-Colorectal Cancer (CRC) mortality in a Veteran screening population.

BACKGROUND: Although screening colonoscopy findings are associated with future risk of CRC mortality, whether these findings are also associated with non- CRC mortality remains unknown.

METHODS: The Cooperative Studies Program (CSP) #380 cohort is comprised of 3,121 Veterans age 50-75 who underwent screening colonoscopy from 1994-97. Veterans were followed for 10 years or death, as verified in electronic medical records. Those who died from CRC-specific causes were excluded from this analysis (n=18, 0.6%). Hazard ratios (HR) for risk factors on non-CRC mortality were calculated by Cox Proportional Hazard model, adjusting for demographics, baseline comorbidities, and lifestyle factors. Information on comorbidities, family history, diet, physical activity, and medications were obtained from self-reported questionnaires at baseline.

RESULTS: Of the included 3,103 Veterans, most were male (n=3,021, 96.8%), white (n=2,609, 83.6%), with a mean age of 62.9. During the 10-year follow-up period, 837 (27.0%) Veterans died from non-CRC causes. The risk of non-CRC mortality was higher in Veterans with ≥3 small adenomas (HR 1.45, p=0.02), advanced adenomas (HR 1.34, p=0.04), or CRC (HR 3.00, =0.05) on baseline colonoscopy when compared to Veterans without neoplasia. Additionally, increasing age (HR 1.07, <0.001), modified Charlson score (HR 1.57 for 3-4 points, <0.001, compared to 0-2 points) and current smoking (HR 2.09, <0.001, compared to former and non-smokers) were associated with higher non-CRC mortality. On the other hand, increasing physical activity (HR 0.88, <0.001), family history of CRC (HR 0.75, =0.02), and increased BMI (HR 0.73-0.75, <0.01) were associated with reduced non-CRC mortality. Neither race, NSAID use (including aspirin), or dietary factors impacted non-CRC mortality.

CONCLUSIONS: In a Veteran CRC screening population, we found that high-risk adenomas or CRC on baseline colonoscopy were independently associated with increased non-CRC mortality within 10 years. Future work will examine the cause-specific factors associated with non-CRC mortality in these groups to 1) identify potential high-yield strategies for tailored non-CRC mortality risk reduction during CRC screening, and 2) better determine when competing risks of non-CRC mortality outweigh the benefit of follow up colonoscopy.

BACKGROUND/RATIONALE: Chronic lymphocytic leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) are indolent hematologic malignancies that account for one-quarter of all lymphomas primarily affecting older patients. Survival has improved due to the development of novel oral drugs with 85.1% 5-year survival in 2019. Ibrutinib is an oral Bruton’s tyrosine kinase inhibitor that interferes with malignant B-cell proliferation and survival. The National Comprehensive Cancer Network recommends ibrutinib as a category one treatment recommendation in all settings of CLL including relapsed/refractory disease and adverse cytogenetics. This study aims to improve clinical knowledge of ibrutinib’s efficacy and safety in a Veteran population.

OBJECTIVES: The primary objective was to determine the efficacy of ibrutinib in the Veteran population as defined by progression-free survival. Secondary objectives included overall survival, overall response, duration of therapy, and prevalence of adverse drug reactions.

METHODS: This was a single center, retrospective study conducted at the Southern Arizona VA Health Care System. A retrospective chart review of patients age 18-89 with CLL or SLL treated with ibrutinib between November 1st, 2013 to August 1st, 2019 was conducted. The Kaplan-Meier method was used to estimate overall survival and progression-free survival. Descriptive statistics was used for all other endpoints. RESULTS: Twenty-three patients were included in this study. Progression free survival and overall survival at 63 months (5.25 years) was 68.2% and 72.7%, respectively. The average duration of therapy was 20.3 months with 65.2% achieving partial response, 17.3% with stable disease, and 17.3% with progression of disease. The most common adverse events were gastrointestinal (21.7%) and cardiac (17.4%) including 3 patients who developed atrial fibrillation; 34.7% of patients required a dose reduction due to toxicity.

CONCLUSION: Use of ibrutinib in the Veteran population had similar progression-free survival as the clinical trials that led to its approval; however, slightly lower overall survival was noted compared to the clinical trials. The rate of atrial fibrillation was higher in the Veteran population compared to clinical trials, whereas the prevalence of gastrointestinal, dermatologic, neurologic, and musculoskeletal adverse events was consistent with published data.

BACKGROUND/RATIONALE: Chronic lymphocytic leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) are indolent hematologic malignancies that account for one-quarter of all lymphomas primarily affecting older patients. Survival has improved due to the development of novel oral drugs with 85.1% 5-year survival in 2019. Ibrutinib is an oral Bruton’s tyrosine kinase inhibitor that interferes with malignant B-cell proliferation and survival. The National Comprehensive Cancer Network recommends ibrutinib as a category one treatment recommendation in all settings of CLL including relapsed/refractory disease and adverse cytogenetics. This study aims to improve clinical knowledge of ibrutinib’s efficacy and safety in a Veteran population.

OBJECTIVES: The primary objective was to determine the efficacy of ibrutinib in the Veteran population as defined by progression-free survival. Secondary objectives included overall survival, overall response, duration of therapy, and prevalence of adverse drug reactions.

METHODS: This was a single center, retrospective study conducted at the Southern Arizona VA Health Care System. A retrospective chart review of patients age 18-89 with CLL or SLL treated with ibrutinib between November 1st, 2013 to August 1st, 2019 was conducted. The Kaplan-Meier method was used to estimate overall survival and progression-free survival. Descriptive statistics was used for all other endpoints. RESULTS: Twenty-three patients were included in this study. Progression free survival and overall survival at 63 months (5.25 years) was 68.2% and 72.7%, respectively. The average duration of therapy was 20.3 months with 65.2% achieving partial response, 17.3% with stable disease, and 17.3% with progression of disease. The most common adverse events were gastrointestinal (21.7%) and cardiac (17.4%) including 3 patients who developed atrial fibrillation; 34.7% of patients required a dose reduction due to toxicity.

CONCLUSION: Use of ibrutinib in the Veteran population had similar progression-free survival as the clinical trials that led to its approval; however, slightly lower overall survival was noted compared to the clinical trials. The rate of atrial fibrillation was higher in the Veteran population compared to clinical trials, whereas the prevalence of gastrointestinal, dermatologic, neurologic, and musculoskeletal adverse events was consistent with published data.

BACKGROUND/RATIONALE: Chronic lymphocytic leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) are indolent hematologic malignancies that account for one-quarter of all lymphomas primarily affecting older patients. Survival has improved due to the development of novel oral drugs with 85.1% 5-year survival in 2019. Ibrutinib is an oral Bruton’s tyrosine kinase inhibitor that interferes with malignant B-cell proliferation and survival. The National Comprehensive Cancer Network recommends ibrutinib as a category one treatment recommendation in all settings of CLL including relapsed/refractory disease and adverse cytogenetics. This study aims to improve clinical knowledge of ibrutinib’s efficacy and safety in a Veteran population.

OBJECTIVES: The primary objective was to determine the efficacy of ibrutinib in the Veteran population as defined by progression-free survival. Secondary objectives included overall survival, overall response, duration of therapy, and prevalence of adverse drug reactions.

METHODS: This was a single center, retrospective study conducted at the Southern Arizona VA Health Care System. A retrospective chart review of patients age 18-89 with CLL or SLL treated with ibrutinib between November 1st, 2013 to August 1st, 2019 was conducted. The Kaplan-Meier method was used to estimate overall survival and progression-free survival. Descriptive statistics was used for all other endpoints. RESULTS: Twenty-three patients were included in this study. Progression free survival and overall survival at 63 months (5.25 years) was 68.2% and 72.7%, respectively. The average duration of therapy was 20.3 months with 65.2% achieving partial response, 17.3% with stable disease, and 17.3% with progression of disease. The most common adverse events were gastrointestinal (21.7%) and cardiac (17.4%) including 3 patients who developed atrial fibrillation; 34.7% of patients required a dose reduction due to toxicity.

CONCLUSION: Use of ibrutinib in the Veteran population had similar progression-free survival as the clinical trials that led to its approval; however, slightly lower overall survival was noted compared to the clinical trials. The rate of atrial fibrillation was higher in the Veteran population compared to clinical trials, whereas the prevalence of gastrointestinal, dermatologic, neurologic, and musculoskeletal adverse events was consistent with published data.

INTRODUCTION: FOLFIRINOX (fluorouracil, leucovorin, irinotecan and oxaliplatin) has increased survival rates for pancreatic cancer, but has adverse effects of febrile neutropenia, thrombocytopenia, and neuropathy. Transient dysarthria is a rare adverse effect associated with this regimen. We report a case of transient dysarthria as an isolated adverse effect associated with FOLFIRINOX.

CASE REPORT: A 45-year-old woman with stage 3 pancreatic adenocarcinoma was being treated with neoadjuvant FOLFIRINOX. She developed severe dysarthria and generalized weakness after completing Day 1 of her second cycle. Upon ED evaluation, she was given methylprednisolone and diphenhydramine with complete resolution of symptoms. At 3rd cycle, intravenous atropine was given prior to irinotecan infusion. Eight hours after initiation of the infusion, she developed slowed speech and dysarthria. Her vitals remained stable. On physical exam, she was drowsy and had slowed mentation, with slow and slurred speech. No other focal deficits were identified. Her symptoms resolved on follow up evaluation.

DISCUSSION: Acute cholinergic syndrome is a wellknown side effect associated with irinotecan containing chemotherapy regimens such as FOLFIRINOX. Symptoms include diarrhea, flushing, hypersalivation, lacrimation, abdominal cramping, diaphoresis, visual disturbances, bradycardia and shortness of breath. Self-limiting recurrent dysarthria is a rare adverse effect associated with both irinotecan and oxaliplatin. The exact mechanism contributing to dysarthria is unknown. According to Matsuoka et al, irinotecan is thought to bind to the active site of acetylcholinesterase, resulting in an increased cholinergic response. It is known that among the brainstem nuclei, hypoglossal nerve carries the highest density of cholinergic receptors. Hence irinotecan may cause overstimulation of hypoglossal nerve leading to dysarthria. Oxaliplatin is known to potentiate the cholinergic effects of irinotecan by causing neuronal hyperexcitation. Hence infusion of oxaliplatin prior to irinotecan may make dysarthria more prominent. Infusing irinotecan before oxaliplatin is shown to minimize dysarthria. Atropine is known to work well in preventing acute cholinergic syndrome but has shown mixed results in treating dysarthria. It is reassuring that irinotecan-induced dysarthria is self-limiting, but an increased awareness among physicians is needed so that this adverse effect is not misdiagnosed as a stroke.

INTRODUCTION: FOLFIRINOX (fluorouracil, leucovorin, irinotecan and oxaliplatin) has increased survival rates for pancreatic cancer, but has adverse effects of febrile neutropenia, thrombocytopenia, and neuropathy. Transient dysarthria is a rare adverse effect associated with this regimen. We report a case of transient dysarthria as an isolated adverse effect associated with FOLFIRINOX.

CASE REPORT: A 45-year-old woman with stage 3 pancreatic adenocarcinoma was being treated with neoadjuvant FOLFIRINOX. She developed severe dysarthria and generalized weakness after completing Day 1 of her second cycle. Upon ED evaluation, she was given methylprednisolone and diphenhydramine with complete resolution of symptoms. At 3rd cycle, intravenous atropine was given prior to irinotecan infusion. Eight hours after initiation of the infusion, she developed slowed speech and dysarthria. Her vitals remained stable. On physical exam, she was drowsy and had slowed mentation, with slow and slurred speech. No other focal deficits were identified. Her symptoms resolved on follow up evaluation.

DISCUSSION: Acute cholinergic syndrome is a wellknown side effect associated with irinotecan containing chemotherapy regimens such as FOLFIRINOX. Symptoms include diarrhea, flushing, hypersalivation, lacrimation, abdominal cramping, diaphoresis, visual disturbances, bradycardia and shortness of breath. Self-limiting recurrent dysarthria is a rare adverse effect associated with both irinotecan and oxaliplatin. The exact mechanism contributing to dysarthria is unknown. According to Matsuoka et al, irinotecan is thought to bind to the active site of acetylcholinesterase, resulting in an increased cholinergic response. It is known that among the brainstem nuclei, hypoglossal nerve carries the highest density of cholinergic receptors. Hence irinotecan may cause overstimulation of hypoglossal nerve leading to dysarthria. Oxaliplatin is known to potentiate the cholinergic effects of irinotecan by causing neuronal hyperexcitation. Hence infusion of oxaliplatin prior to irinotecan may make dysarthria more prominent. Infusing irinotecan before oxaliplatin is shown to minimize dysarthria. Atropine is known to work well in preventing acute cholinergic syndrome but has shown mixed results in treating dysarthria. It is reassuring that irinotecan-induced dysarthria is self-limiting, but an increased awareness among physicians is needed so that this adverse effect is not misdiagnosed as a stroke.

INTRODUCTION: FOLFIRINOX (fluorouracil, leucovorin, irinotecan and oxaliplatin) has increased survival rates for pancreatic cancer, but has adverse effects of febrile neutropenia, thrombocytopenia, and neuropathy. Transient dysarthria is a rare adverse effect associated with this regimen. We report a case of transient dysarthria as an isolated adverse effect associated with FOLFIRINOX.

CASE REPORT: A 45-year-old woman with stage 3 pancreatic adenocarcinoma was being treated with neoadjuvant FOLFIRINOX. She developed severe dysarthria and generalized weakness after completing Day 1 of her second cycle. Upon ED evaluation, she was given methylprednisolone and diphenhydramine with complete resolution of symptoms. At 3rd cycle, intravenous atropine was given prior to irinotecan infusion. Eight hours after initiation of the infusion, she developed slowed speech and dysarthria. Her vitals remained stable. On physical exam, she was drowsy and had slowed mentation, with slow and slurred speech. No other focal deficits were identified. Her symptoms resolved on follow up evaluation.

DISCUSSION: Acute cholinergic syndrome is a wellknown side effect associated with irinotecan containing chemotherapy regimens such as FOLFIRINOX. Symptoms include diarrhea, flushing, hypersalivation, lacrimation, abdominal cramping, diaphoresis, visual disturbances, bradycardia and shortness of breath. Self-limiting recurrent dysarthria is a rare adverse effect associated with both irinotecan and oxaliplatin. The exact mechanism contributing to dysarthria is unknown. According to Matsuoka et al, irinotecan is thought to bind to the active site of acetylcholinesterase, resulting in an increased cholinergic response. It is known that among the brainstem nuclei, hypoglossal nerve carries the highest density of cholinergic receptors. Hence irinotecan may cause overstimulation of hypoglossal nerve leading to dysarthria. Oxaliplatin is known to potentiate the cholinergic effects of irinotecan by causing neuronal hyperexcitation. Hence infusion of oxaliplatin prior to irinotecan may make dysarthria more prominent. Infusing irinotecan before oxaliplatin is shown to minimize dysarthria. Atropine is known to work well in preventing acute cholinergic syndrome but has shown mixed results in treating dysarthria. It is reassuring that irinotecan-induced dysarthria is self-limiting, but an increased awareness among physicians is needed so that this adverse effect is not misdiagnosed as a stroke.

BACKGROUND: Waldenström macroglobulinemia (WM) is a rare, incurable non-Hodgkin Lymphoma. There is limited real-world evidence on WM treatment among US Veterans.

OBJECTIVE: This retrospective observational study aims to evaluate the real-world treatment patterns and associated outcomes among patients with WM in the Veteran Health Administration (VHA) population.

METHODS: Adults who had ≥2 visits with WM diagnosis codes and ≥1 WM treatment were identified in VHA database (2014-2018). Index date was defined as the first date of WM treatment. Patients included were newly diagnosed, initiating treatment, and enrolled continuously for 6 months prior to and ≥60 days following index date. Treatment regimens were categorized as: rituximab monotherapy, ibrutinib-based, chemotherapybased, proteasome inhibitor-based and other regimens. Healthcare resource utilization examined included hospitalization and length-of-stay (LOS). Total costs were calculated as sum of inpatient, outpatient and pharmacy costs per-patient-per-month (PPPM).

RESULTS: Prevalence and incidence of WM among Veterans ranged from 11.4-12.8 cases, and 0.4-1.6 cases per 100,000 persons, respectively. A total of 255 patients (median age: 72 years, 84% white, mean Charlson comorbidity index score: 1.1) received 1st line (mean duration: 289 days); 96 (38%) patients received 2nd line (mean duration: 267 days); and 34 (13%) received 3rd line therapy (mean duration: 253 days). Treatment pattern for each line of therapy were as follows, 1st line: ibrutinib-based (30%), chemotherapy- based (25%), rituximab monotherapy (25%), proteasome inhibitor-based (14%), and other (5%); 2nd line: chemotherapy-based (27%), ibrutinib-based (24%), rituximab monotherapy (23%), proteasome inhibitor- based (15%), and other (9%); 3rd line: ibrutinib- based (41%), rituximab monotherapy (32%), chemotherapy-based (18%), proteasome inhibitorbased (6%), and other (3%). The overall hospitalization rate was 29% with an average LOS of 12 days. Approximately 21% (LOS: 10.9 days), 18% (LOS: 6.9 days), and 24% (LOS: 7.3 days) of patients had a hospitalization, respectively, during 1st, 2nd, and 3rd line therapy. Average total PPPM costs overall were $13,007, and $13,154, $12,550, and $25,813 during 1st, 2nd, and 3rd line therapy, respectively.

BACKGROUND: Waldenström macroglobulinemia (WM) is a rare, incurable non-Hodgkin Lymphoma. There is limited real-world evidence on WM treatment among US Veterans.

OBJECTIVE: This retrospective observational study aims to evaluate the real-world treatment patterns and associated outcomes among patients with WM in the Veteran Health Administration (VHA) population.

METHODS: Adults who had ≥2 visits with WM diagnosis codes and ≥1 WM treatment were identified in VHA database (2014-2018). Index date was defined as the first date of WM treatment. Patients included were newly diagnosed, initiating treatment, and enrolled continuously for 6 months prior to and ≥60 days following index date. Treatment regimens were categorized as: rituximab monotherapy, ibrutinib-based, chemotherapybased, proteasome inhibitor-based and other regimens. Healthcare resource utilization examined included hospitalization and length-of-stay (LOS). Total costs were calculated as sum of inpatient, outpatient and pharmacy costs per-patient-per-month (PPPM).

RESULTS: Prevalence and incidence of WM among Veterans ranged from 11.4-12.8 cases, and 0.4-1.6 cases per 100,000 persons, respectively. A total of 255 patients (median age: 72 years, 84% white, mean Charlson comorbidity index score: 1.1) received 1st line (mean duration: 289 days); 96 (38%) patients received 2nd line (mean duration: 267 days); and 34 (13%) received 3rd line therapy (mean duration: 253 days). Treatment pattern for each line of therapy were as follows, 1st line: ibrutinib-based (30%), chemotherapy- based (25%), rituximab monotherapy (25%), proteasome inhibitor-based (14%), and other (5%); 2nd line: chemotherapy-based (27%), ibrutinib-based (24%), rituximab monotherapy (23%), proteasome inhibitor- based (15%), and other (9%); 3rd line: ibrutinib- based (41%), rituximab monotherapy (32%), chemotherapy-based (18%), proteasome inhibitorbased (6%), and other (3%). The overall hospitalization rate was 29% with an average LOS of 12 days. Approximately 21% (LOS: 10.9 days), 18% (LOS: 6.9 days), and 24% (LOS: 7.3 days) of patients had a hospitalization, respectively, during 1st, 2nd, and 3rd line therapy. Average total PPPM costs overall were $13,007, and $13,154, $12,550, and $25,813 during 1st, 2nd, and 3rd line therapy, respectively.

BACKGROUND: Waldenström macroglobulinemia (WM) is a rare, incurable non-Hodgkin Lymphoma. There is limited real-world evidence on WM treatment among US Veterans.

OBJECTIVE: This retrospective observational study aims to evaluate the real-world treatment patterns and associated outcomes among patients with WM in the Veteran Health Administration (VHA) population.

METHODS: Adults who had ≥2 visits with WM diagnosis codes and ≥1 WM treatment were identified in VHA database (2014-2018). Index date was defined as the first date of WM treatment. Patients included were newly diagnosed, initiating treatment, and enrolled continuously for 6 months prior to and ≥60 days following index date. Treatment regimens were categorized as: rituximab monotherapy, ibrutinib-based, chemotherapybased, proteasome inhibitor-based and other regimens. Healthcare resource utilization examined included hospitalization and length-of-stay (LOS). Total costs were calculated as sum of inpatient, outpatient and pharmacy costs per-patient-per-month (PPPM).

RESULTS: Prevalence and incidence of WM among Veterans ranged from 11.4-12.8 cases, and 0.4-1.6 cases per 100,000 persons, respectively. A total of 255 patients (median age: 72 years, 84% white, mean Charlson comorbidity index score: 1.1) received 1st line (mean duration: 289 days); 96 (38%) patients received 2nd line (mean duration: 267 days); and 34 (13%) received 3rd line therapy (mean duration: 253 days). Treatment pattern for each line of therapy were as follows, 1st line: ibrutinib-based (30%), chemotherapy- based (25%), rituximab monotherapy (25%), proteasome inhibitor-based (14%), and other (5%); 2nd line: chemotherapy-based (27%), ibrutinib-based (24%), rituximab monotherapy (23%), proteasome inhibitor- based (15%), and other (9%); 3rd line: ibrutinib- based (41%), rituximab monotherapy (32%), chemotherapy-based (18%), proteasome inhibitorbased (6%), and other (3%). The overall hospitalization rate was 29% with an average LOS of 12 days. Approximately 21% (LOS: 10.9 days), 18% (LOS: 6.9 days), and 24% (LOS: 7.3 days) of patients had a hospitalization, respectively, during 1st, 2nd, and 3rd line therapy. Average total PPPM costs overall were $13,007, and $13,154, $12,550, and $25,813 during 1st, 2nd, and 3rd line therapy, respectively.

BACKGROUND: Diffuse large B cell lymphoma (DLBCL) is curable in most patients, however this high cure rate is mostly reserved for those who achieve a complete remission with first line treatment. In patients who have relapsed/refractory disease the cure rate is significantly lower. There are limited studies that have previously investigated the rate of clinical trial discussion and enrollment among DLBCL patients. Our aim, as part of a larger study, was to determine the rate of clinical trial enrollment for patients diagnosed with DLBCL at the Veterans Health Administration system (VHA), a population that traditionally experiences poorer outcomes when compared to the community and academic centers.

METHODS: We performed a retrospective chart review of patients diagnosed with DLBCL in the VHA nationwide from 01/01/2011 to 12/31/2017. Patients treated outside of the VHA and patients with primary DLBCL of the CNS were excluded. During our inclusion period, we randomly selected patients and evaluated the number of patients that engaged in discussions with their providers about clinical trials and the number of patients that eventually enrolled in trials.

RESULTS: In total, 721 patients met our inclusion criteria. Median age was 67 and the majority of patients were white (74.5%), male (96.8%), had an ECOG of 2 (83.7%) and presented with advanced stage disease (stage IV: 40.3% and stage III: 26.5%). Of all the patients included in our study 3.7% engaged in discussion about clinical trials and amongst relapsed/ refractory patients (N=182), 12.6% engaged in discussion. The rate of clinical trial enrollment was 1.8% in all patients and 6% in relapsed/refractory patients.

CONCLUSION: Our results show a low rate of 1.8% of DLBCL patients enrolling in clinical trials. These rates are improved but remain low at 6% in relapsed/ refractory patients with only 12.6 % of all relapsed/refractory patients engaging in discussions with their provider about clinical trials, despite NCCN’s recommendation for clinical trial consideration in this subset of DLBCL patients. These results are concerning and show a need to identify and understand the barriers to enrollment in this population in addition to the implementation of mitigation practices.

BACKGROUND: Diffuse large B cell lymphoma (DLBCL) is curable in most patients, however this high cure rate is mostly reserved for those who achieve a complete remission with first line treatment. In patients who have relapsed/refractory disease the cure rate is significantly lower. There are limited studies that have previously investigated the rate of clinical trial discussion and enrollment among DLBCL patients. Our aim, as part of a larger study, was to determine the rate of clinical trial enrollment for patients diagnosed with DLBCL at the Veterans Health Administration system (VHA), a population that traditionally experiences poorer outcomes when compared to the community and academic centers.

METHODS: We performed a retrospective chart review of patients diagnosed with DLBCL in the VHA nationwide from 01/01/2011 to 12/31/2017. Patients treated outside of the VHA and patients with primary DLBCL of the CNS were excluded. During our inclusion period, we randomly selected patients and evaluated the number of patients that engaged in discussions with their providers about clinical trials and the number of patients that eventually enrolled in trials.

RESULTS: In total, 721 patients met our inclusion criteria. Median age was 67 and the majority of patients were white (74.5%), male (96.8%), had an ECOG of 2 (83.7%) and presented with advanced stage disease (stage IV: 40.3% and stage III: 26.5%). Of all the patients included in our study 3.7% engaged in discussion about clinical trials and amongst relapsed/ refractory patients (N=182), 12.6% engaged in discussion. The rate of clinical trial enrollment was 1.8% in all patients and 6% in relapsed/refractory patients.

CONCLUSION: Our results show a low rate of 1.8% of DLBCL patients enrolling in clinical trials. These rates are improved but remain low at 6% in relapsed/ refractory patients with only 12.6 % of all relapsed/refractory patients engaging in discussions with their provider about clinical trials, despite NCCN’s recommendation for clinical trial consideration in this subset of DLBCL patients. These results are concerning and show a need to identify and understand the barriers to enrollment in this population in addition to the implementation of mitigation practices.

BACKGROUND: Diffuse large B cell lymphoma (DLBCL) is curable in most patients, however this high cure rate is mostly reserved for those who achieve a complete remission with first line treatment. In patients who have relapsed/refractory disease the cure rate is significantly lower. There are limited studies that have previously investigated the rate of clinical trial discussion and enrollment among DLBCL patients. Our aim, as part of a larger study, was to determine the rate of clinical trial enrollment for patients diagnosed with DLBCL at the Veterans Health Administration system (VHA), a population that traditionally experiences poorer outcomes when compared to the community and academic centers.

METHODS: We performed a retrospective chart review of patients diagnosed with DLBCL in the VHA nationwide from 01/01/2011 to 12/31/2017. Patients treated outside of the VHA and patients with primary DLBCL of the CNS were excluded. During our inclusion period, we randomly selected patients and evaluated the number of patients that engaged in discussions with their providers about clinical trials and the number of patients that eventually enrolled in trials.

RESULTS: In total, 721 patients met our inclusion criteria. Median age was 67 and the majority of patients were white (74.5%), male (96.8%), had an ECOG of 2 (83.7%) and presented with advanced stage disease (stage IV: 40.3% and stage III: 26.5%). Of all the patients included in our study 3.7% engaged in discussion about clinical trials and amongst relapsed/ refractory patients (N=182), 12.6% engaged in discussion. The rate of clinical trial enrollment was 1.8% in all patients and 6% in relapsed/refractory patients.

CONCLUSION: Our results show a low rate of 1.8% of DLBCL patients enrolling in clinical trials. These rates are improved but remain low at 6% in relapsed/ refractory patients with only 12.6 % of all relapsed/refractory patients engaging in discussions with their provider about clinical trials, despite NCCN’s recommendation for clinical trial consideration in this subset of DLBCL patients. These results are concerning and show a need to identify and understand the barriers to enrollment in this population in addition to the implementation of mitigation practices.