12032 Background: Death with Dignity (DWD) legislation, which took effect in 2009 in Washington state, allows terminally ill patients (pts) to self-administer physician-prescribed, life-ending medication. Thoracic, head and neck cancer (THN) pts are among the top cancer types requesting DWD; however, data describing this group are limited. Methods: This retrospective chart review, conducted at Seattle Cancer Care Alliance/University of Washington and Fred Hutch, collected demographics, disease, treatment, support services and steps of the DWD process. We tested the association between disease characteristics of interest and DWD completion using Fisher’s Exact test. Results: Between Jan 2014 and October 2020, 498 pts inquired about DWD, and 108 (22%) were THN pts. Among THN pts, 51 (47%) only initiated the DWD request process, 35 (33%) only completed the DWD request process, and 22 (20%) completed the DWD request and self-administered the medication. Pts were white (n=90, 83%), male (n=64, 59%), primarily English speaking (n=103, 95%), nonreligious (n=69, 64%), single/divorced/non-partnered (n=55, 51%), and insured (n=103, 95%). Median age at request was 68 years (range 35-88). The table details THN DWD utilization. At time of DWD request, the median time from diagnosis was 14 months (range=0.2-242.7), and 62 (57%) had received ≥2 lines of therapy. Among 78 (72%) pts who received systemic therapy, 51 (65%) were ≥30 days from last therapy to time of death. Within 30 days prior to DWD request, 30 (28%), 25 (23%), and 7 (7%) pts saw social work, palliative care, and spiritual health respectively, and 35 (32%) were hospice-enrolled. Stage IV at diagnosis had higher rates of DWD medication use (p=0.05). There was no significant correlation between DWD medication use and primary site, ECOG score at request, insurance type, mental health diagnosis, use of depression/anxiety or pain medications, or hospice enrollment during DWD process. Conclusions: THN pts requesting DWD were predominantly white, nonreligious, insured males. Pts with advanced stage at diagnosis were more likely to use DWD medication. There was a higher proportion of DWD medication use with poorer performance status, and no association between use of depression/anxiety, pain medications, or utilization of supportive care services and DWD medication usage. Future research should investigate DWD utilization among THN pts in multiple centers and states to evaluate these patterns. [Table: see text]
153 Background: Immune checkpoint inhibitors (ICI) are now a therapeutic standard for recurrent/metastatic head and neck squamous cell cancer (R/M HNSCC). There is limited data on the impact of demographics and socioeconomic (SES) factors on outcomes in this population, and we sought to evaluate these in our single institution cohort. Methods: R/M HNSCC patients (pts) receiving ICI were retrospectively reviewed from an institutional database. SES factors included income, distance to center (dist), marital status, race, and insurance. Median household income by residence zip code was obtained from the US Census Bureau. Time to ICI initiation (TTI) was time from initial visit recommending ICI and first ICI dose. Opiate use was calculated using morphine equivalents prior to ICI initiation and either at best response or end of ICI if no response. Associations between SES factors with overall survival (OS) and TTI were assessed using Cox proportional hazards regression. Binary outcomes were assessed using logistic regression and included ER visits/unplanned hospitalizations (UH) and increase in opioid use. Analyses were adjusted for disease characteristics, smoking status, ECOG, and demographics. Results: Between 1/2012-12/2019, 152 pts received ICI; 124 (82%) were male, with median age of 64 years (range 23-90), and 103 (68%) were partnered/married. The most common races were 114 white (75%), 14 Asian (9%) and 6 Hispanic, any race (4%). Out of 149 (98%) insured pts, 27 (18%) were Medicaid and 69 (46%) Medicare. Median dist was 39 miles (Q1 21, Q3 100), and median income was $80,586 (Q1 $61,202, Q3 $103,059). The most common primary sites were oropharynx (36%), oral cavity (22%), and nasopharynx (7%); 29 (19%) had an ECOG ≥2. While on or within 100 days of ICI, 69 (45%) had ER visits, and 57 (38%) had UH. Increased dist was associated with improved OS (4th vs 1st quartile, p = 0.0002; HR 0.33; 95% CI [0.18,0.59]); we observed no other SES association with OS. Increased opioid use was associated with Medicaid/no insurance (p = 0.05; OR 2.89; 95% CI [1.02,8.77]). No SES association with TTI was found, although there was a nonsignificant trend of higher TTI with increasing dist. We saw no correlation with ER/UH and any SES variables. Conclusions: Among R/M HNSCC pts receiving ICI, insurance had an impact on opiate usage, suggesting more advance disease/higher burden of symptoms and indicating need for augmentation of supportive care in this group. Higher dist was associated with improved OS, even accounting for performance status, which may reflect increased resources in this group. Further studies should examine pt factors that may contribute to disparities in the setting of novel therapies for R/M HNSCC pts.
e24073 Background: Understanding the experience of individuals with cancer (pts) who utilize Medical Aid in Dying (MAID) is important given growing access and limited research in the U.S. Methods: Chart review from January 1, 2014-October 1, 2020, of all pts who inquired (but did not initiate completion of all legal requirements), initiated (but did not complete all legal requirements to obtain access to the medications), or completed all legal requirements and could have had access to medications (whether or not they were obtained or used) at Seattle Cancer Care Alliance/University of Washington. Chi-square tests were used to compare differences in pt characteristics between the inquired/initiated versus completed group. Results: Of 498 total pts, 116 (23.3%) inquired, 127 (25.5%) initiated, and 255 (51.2%) completed the MAID process, of which, 45.9% (117/255) were known to have used the medications. At time of first inquiry (FI), mean age was 66 years (standard deviation [SD] = 11.9)/median 67.3/range 22-94; 206 (41.4%) were female; and 40 (8.0%) were non-white, while 11 (2.2%) were Hispanic/Latino and 14 (2.8%) were non-English speaking. At FI, 292 (58.6%) pts were married or had a significant other; 152 (30.5%) had a religious affiliation; 23 (4.6%) were uninsured; and 282 (56.6%) had Medicare. Mean months from the original cancer diagnosis and FI was 36.5 (SD = 50.3, range 0.1-366.1). 461 (92.6%) pts had solid/central nervous system (CNS) tumors, of which 231 (46.4%) had presented with metastatic disease. At FI, 84 (16.9%) were currently hospitalized; in total, 236 (47.4%) pts had been hospitalized within the 3 months prior to FI. A total of 71.9% (358/498) had not yet initiated hospice at FI; 51.8% (258/498) had evidence of advance care planning (ACP), including 41.5% (107/258) with a Physician Order for Life Sustaining Treatment on file. Overall, 152 (30.5%) and 166 (33.3%) of pts had seen social work or palliative care in the 30 days prior to FI, while 62 (12.4%) had met with a spiritual health clinician. Statistically significant differences were found between those who inquired/initiated versus completed with the following pt characteristics: non-white (ꭓ2= 6.596, p = .010); Medicaid versus all other insured (ꭓ2= 9.489, p = .002); those hospitalized at FI (ꭓ2= 6.101, p = .014); and those without evidence of ACP (ꭓ2= 17.090, p < .001). Pts with a hematologic malignancy (HM, n = 37/498, 7.4%) were less likely to complete the MAID process compared to pts with solid/CNS tumors (ꭓ2= 7.378, p = .007); 43.2% (16/37) of HM pts did not complete due to rapid decline. Conclusions: Less than half of pts who initially inquired about MAID completed the process. Recent hospitalizations and evidence of ACP were relatively common compared to current utilization of hospice or prior use of supportive care services. Future research should investigate why non-white pts, those with Medicaid and those with HM may be less likely to complete the MAID process.
296 Background: Immune checkpoint inhibitors (ICI) are approved for recurrent and/or metastatic squamous head and neck cancers (R/M HNSCC). Landmark trials have shown stable or improved patient (pt) reported quality of life outcomes. It is unclear how these translate into gastrostomy (G) and tracheostomy (T) dependence, opioid use, or ER/unplanned hospitalizations (UH) in an unselected population. We sought to explore these in our large single institution cohort. Methods: We reviewed R/M HNSCC pts receiving ICI at a tertiary referral NCI designated cancer center. Outcomes were assessed between the first dose of ICI and 100 days after the last dose of ICI. Overall survival (OS) was estimated via Kaplan-Meier estimation. Differences between groups were assessed via log-rank testing procedure and adjusted for age, tumor characteristics, and smoking status. Results: Between 1/2012 and 12/2019, we treated 152 pts with ICI, mostly male (n = 142, 82%), partnered/married (n = 103, 68%), with median age 64 years (range 23 – 90). The most common primary sites were oropharynx (n = 55, 36%) and oral cavity (n = 33, 22%). 50 (35%) had ≥2 lines of prior systemic therapy and 29 (19%) had an ECOG ≥2. The most common pt races were white (n = 114, 75%), Asian (n = 14, 9%), and Hispanic, any race (n = 6, 4%). 83 (55%) and 23 (15%) had history of smoking and heavy alcohol use respectively. Median duration of ICI therapy was 95 days (range 1-1720). Prior to ICI, 49 (32%) had G, 17 (11%) had T, and 15 (10%) had both. While on ICI, 6 (4%) had G placed, and 1 (1%) had a G removed; 1 (1%) had T placed, and 2 (1%) had T removed. 69 (45%) had ER visits and 57 (38%) had UH; 11 (7%) were directly related to ICI adverse effects. Prior to ICI, 104 (68%) were on opiates; requirements increased in 58 (41%) pts and decreased in 17 (12%) pts. Pre-existing G prior to ICI had worse OS on log-rank testing, but significance was lost when adjusted for variables. Pre-existing T prior to ICI (p = 0.001, HR 3.08, 95% Cl [1.56,6.08]), and pts with increasing opiate requirements on ICI (p value = 0.0007, HR 2.13, 95% Cl [1.38,3.28]) had worse OS. Conclusions: In our cohort, ICI did not change G or T usage. Pre-existing T and increasing opiate use were also associated with worse survival. Our data supports augmentation of palliative care and advanced care planning in the R/M HNSCC population.
e21196 Background: Treatment after front line osimertinib (osi) for epidermal growth factor receptor (EGFR) mutated advanced non-small cell lung cancer (NSCLC) remains a clinical challenge. Interval chemotherapy after osi may eradicate clones responsible for EGFR tyrosine kinase (TKI) resistance, which may re-sensitize the tumor to EGFR inhibition. We describe outcomes of metastatic EGFR NSCLC patients who undergo osi rechallenge. Methods: NSCLC patients with confirmed EGFR mutation were retrospectively reviewed from a single institutional database from 1/2010-12/2022. We identified patients who received osi after interval therapy following initial osi progression. Patient characteristics and tumor type were collected via chart review. Response was determined using RECIST 1.1. Results: Seventeen patients with osi rechallenge after initial progression were identified. Median age at time of osi rechallenge was 62 yrs (range 42-73). Patients were predominantly female (n = 11, 65%), white (n = 9, 53%) and Asian (n = 8, 47%), never smokers (n = 13, 77%). Patients had either del19 mutation (n = 10, 59%) or L858R mutation (n = 7, 41%). Twelve patients (71%) received a 1st or 2nd generation EGFR TKI (erlotinib n = 10, afatinib n = 2) prior to initial osi; eight patients (47%) had confirmed T790M mutation. Eight patients (47%) had CNS metastases prior to osi rechallenge. Twelve patients (71%) had ECOG 0-1 at time of rechallenge. Patients had a median of 4 (range 2-5) lines of therapy prior to osi rechallenge. Median time between initial osi discontinuation and osi rechallenge was 13.8 months (range 3.2-50.7). In the interim, 17 patients (100%) received chemotherapy, 2 (12%) received immunotherapy monotherapy, 3 (18%) received antibody drug conjugate, and 1 (6%) received TKI. Sixteen patients had follow-up restaging CT scans; 1 died before restaging imaging was obtained. Two patients achieved partial response (PR) (13%), and 6 patients had stable disease (SD) as the best response (38%). Median duration of initial osi was 13.9 months (range 1.9-26.4), and median duration of osi rechallenge was 3.6 months (range 1.0-10.3). Patients who had PR/SD were on osi for 7.5 months (range 2.7-10.3). Ten (59%) patients received osi rechallenge for at least 3 months duration, and 6 (35%) received osi rechallenge for at least 6 months duration. Conclusions: Osi rechallenge is a potential option for advanced EGFR NSCLC patients to obtain disease control at later lines of therapy. Further research is needed to characterize mechanisms of targeted therapy resistance and better select patients who can benefit from EGFR TKI re-exposure.
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