Background We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers’ end‐of‐life (EOL) quality metrics among minority and white decedents to explore center‐attributable sources of EOL disparities. Methods We conducted a retrospective cohort study of Medicare beneficiaries with poor‐prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients’ EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk‐adjusted metrics of EOL quality (hospice admission ≤3 days before death; chemotherapy last 14 days of life; ≥2 emergency department (ED) visits; intensive care unit (ICU) admission; or life‐sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers. Results Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life‐sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within‐center correlation for minority and white metrics (0.61‐0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life‐sustaining treatments (P < .01). Conclusion EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority‐serving centers had worse performance on many metrics.

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Background: There are limited data and conflicting guideline recommendations regarding the role of neuroimaging in the pretreatment evaluation of non-small cell lung cancer (NSCLC). Methods: We performed a retrospective, pragmatic cohort study of patients with NSCLC diagnosed between January 1 and December 31, 2015. Eligible patients were identified from an institutional tumor registry. We collected all records of pretreatment neuroimaging within 12 weeks of diagnosis, including CT head (CT) and MRI brain (MRI). We abstracted the indication for neuroimaging, presence of central neurologic symptoms and cancer stage (with and without neuroimaging findings) from the tumor registry and the electronic health record. Results: We identified 216 evaluable patients with newly diagnosed NSCLC. 157 of 216 patients (72.7%) underwent neuroimaging as part of initial staging, and 41 (26%) were found to have brain metastases. Of 43 patients with central neurologic symptoms at the time of neuroimaging, 28 (67%) had brain metastasis. In patients without central neurologic symptoms, brain metastases were discovered in 0 of 33 patients with clinical stage I or II, 4 of 36 (11%) with clinical stage III and 9 of 45 (20%) with clinical stage IV disease. Conclusions: In patients with early stage NSCLC (i.e. clinical stage I and II) without central neurologic symptoms, brain metastases are unlikely. The continued use of neuroimaging in the pretreatment evaluation of clinical stage I patients without central neurologic symptoms is not needed.

PURPOSE: We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS: We performed content analysis of outpatient oncology encounters at two US National Cancer Institute–designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS: Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION: In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.

PURPOSE: We aimed to increase Serious Illness Conversations (SIC) from a baseline of, at or near, zero to 25% of eligible patients by December 31, 2020. METHODS: We assembled an interdisciplinary team inclusive of a family partner and used the Model for Improvement as our quality improvement framework. The team developed a SMART Aim, key driver diagram, and SIC workflow. Standardized screening for SIC eligibility was implemented using the 2-year surprise question. Team members were trained in SIC communication skills by a trained facilitator and received ongoing coaching in quality improvement. We performed Plan-Do-Study-Act cycles and used audit-feedback data in weekly team meetings to inform iterative Plan-Do-Study-Act cycles. The primary outcome was the percent of eligible patients with documented SIC. RESULTS: Over 18 months, three clinics identified 63 eligible patients; of these, 32 (51%) were diagnosed with head and neck cancer and 31 (49%) with sarcoma. The SIC increased from a baseline near zero to 43 of 63 (70%) patients demonstrating three shifts in the median (95% CI). Conversations were interdisciplinary with 25 (57%) by oncology MD, six (14%) by advanced practice registered nurse, and 13 (30%) by specialty palliative care. We targeted four key drivers: (1) standardized work, (2) engaged interdisciplinary team, (3) engaged patients and families, and (4) system-level support. CONCLUSION: Our approach was successful in its documentation of end points and required resource investment (training and time) to embed into team workflows. Future work will evaluate scaling the approach across multiple clinics, the patient experience, and outcomes of care associated with oncology clinician–led SIC.

TPS11582 Background: Chondrosarcomas (CS) are the third most common type of primary bone cancer after myeloma and osteosarcoma. Conventional CS represent 85–90% of all cases and are typically treated with surgical resection. However, there are no approved systemic treatment options for patients with unresectable or metastatic conventional CS, and outcomes remain poor. INBRX-109 is a precision-engineered, tetravalent death receptor 5 (DR5) agonist antibody designed to overcome the limitations of earlier-generation agonists and exploit the tumor-specific cell death induced by DR5 activation. DR5 is one of two pro-apoptotic receptors for the trimeric tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). Early clinical activity of INBRX-109 was observed in an ongoing phase 1 trial and warrants further investigation. INBRX-109 has been granted an FDA fast-track designation for conventional CS. Methods: This is a multicenter, randomized, blinded, placebo-controlled phase 2 study in patients with unresectable or metastatic conventional CS, measurable disease by RECIST 1.1, and radiologic disease progression within 6 months prior to screening. Any number of prior lines of therapy are allowed, except for prior DR5 agonists. Patients must be ≥18 years of age and have an ECOG performance status of 0/1 and have archival or fresh tissue available. Approximately 201 patients will be randomized (2:1) to INBRX-109 (3 mg/kg intravenously, every 21 days) or placebo, stratified by histologic grade (Grade 1/2 vs 3), isocitrate dehydrogenase (IDH)1 R132/IDH2 R172 status (wildtype vs mutation), and line of systemic therapy (none vs prior). Treatment will continue until disease progression/unacceptable toxicity. Patients treated with a placebo will have the option to cross over to INBRX-109 upon disease progression. The primary endpoint is progression-free survival (PFS) by independent radiology review. Secondary endpoints are overall survival, PFS by investigator assessment, quality of life, overall response rate, duration of response, disease control rate, safety, pharmacokinetics, and immunogenicity. Adverse events will be recorded and graded by NCI CTCAE Version 5.0. Median PFS of 7.0 months is projected for INBRX-109 and 4.0 months for placebo (corresponding hazard ratio of 0.571); INBRX-109 will be declared superior if the 1-sided p-value from the stratified log-rank test is <0.025. More than 50 sites are planned across the US/Europe. The study is actively enrolling. Clinical trial information: NCT04950075.

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