PurposeThe purpose of this study is to assess racial/ethnic differences in supportive care medication use over time among older adults with pancreatic adenocarcinoma.MethodsWe used the Surveillance, Epidemiology, End Results (SEER)-Medicare linked database to identify Medicare Part D beneficiaries who were diagnosed with distant or metastatic pancreatic adenocarcinoma from January 2008 to December 2019. We used modified Poisson regression to estimate the likelihood of using any nonopioid psychotropic medication, opioid pain medication, pancreatic enzyme replacement therapy (PERT), and supportive care medication (composite measure of aforementioned medications) over the entirety of the study period (2008-2020) and in 2-year increments.ResultsAmong the 29,266 beneficiaries included in this study, 12.4% were non-Hispanic Black and 12.4% were Hispanic. Compared to non-Hispanic White beneficiaries, non-Hispanic Black beneficiaries had a lower probability of any supportive care medication use from 2008-2009 (adjusted risk ratio (aRR) 0.83, 95% CL 0.77-0.90) to 2018-2019 (aRR 0.89, 95% CL 0.85-0.94). Findings were similar for any nonopioid psychotropic medication, opioid pain medication, and PERT. Inequities in any supportive care medication use narrowed from 2008-2009 (aRR 0.88, 95% CL 0.81-0.95) to 2018-2019 (aRR 0.98, 95% CL 0.93-1.02) for Hispanic beneficiaries. Although similar trends were observed for opioid pain medications, Hispanic beneficiaries had a lower probability of using any nonopioid psychotropic medication and PERT relative to their non-Hispanic White counterparts.ConclusionRacial/ethnic inequities in the use of many supportive care medications persisted over time. Policies and interventions targeting inequitable access to and use of supportive care medications are necessary to ensure pharmacoequity in cancer care.

BACKGROUND AND OBJECTIVE:The rs4680 single-nucleotide polymorphism (SNP) of the COMT gene leads to a reduction in dopamine clearance, resulting in better mood and a decrease in symptoms in noncancer populations, but its influence on quality of life (QOL) during cancer treatment is undefined. We hypothesized that in comparison to wildtype (WT) COMT, the rs4680 SNP is associated with better QOL among men with metastatic hormone-sensitive prostate cancer receiving androgen deprivation therapy ± docetaxel (ADT ± D). METHODS:In this post hoc analysis, we tested the association between COMT rs4680 status and Functional Assessment of Cancer Therapy-Prostate (overall QOL), Functional Assessment of Chronic Illness Therapy-Fatigue, and Brief Pain Inventory scores at baseline and at 3, 6, 9, and 12 mo using Fisher's exact test and the Wilcoxon rank-sum test. Blood samples for genotyping were collected before treatment initiation. KEY FINDINGS AND LIMITATIONS:COMT SNP data were available for 550/790 men. Across the overall cohort, 3-mo pain severity was lower for rs4680 versus WT COMT (0.5 vs 1.25; p = 0.04). In the ADT arm, rs4680 versus WT COMT was associated with better overall QOL at 6 mo (128.9 vs 118.5; p = 0.04), less pain at 3 mo (no pain: 70.4% vs 41.5%; p = 0.01), and less pain interference at 3 mo (no interference: 76% vs 51.3%; p = 0.03), 6 mo (75% vs 48.7%; p = 0.02), and 9 mo (83.3% vs 52%; p = 0.02), with similar fatigue scores. Patients in the ADT + D arm had similar QOL regardless of COMT status. CONCLUSIONS AND CLINICAL IMPLICATIONS:Patients with the COMT rs4680 SNP experienced less pain and better global QOL after starting ADT alone. This is the first study to show that inherited genetic traits may influence treatment tolerability in men with prostate cancer.

We present a case of a 65-year-old woman with a history of kidney and pancreas transplants for type 1 diabetes mellitus who presented with small bowel obstruction and was found to have a poorly differentiated small bowel adenocarcinoma with multifocal osseous and nodal metastases. Plasma-based next generation circulating tumor deoxyribonucleic acid (DNA) sequencing revealed mismatch repair deficiency and an exceptionally high tumor mutational burden (TMB) of 1069 mutations/megabase (mut/Mb). Initial management consisted of cytotoxic chemotherapy (FOLFOX; 5-fluorouracil, leucovorin, and oxaliplatin) given the urgent need for a clinical response. Following multidisciplinary discussion and shared decision-making, nivolumab was added with cycle 3 of FOLFOX. Transplant-related immunosuppression was adjusted, and pancreas and kidney transplant function were monitored closely. Potential organ rejection was monitored using donor-derived cell-free DNA. Immune-related adverse events were not observed. After 5 cycles of treatment (3 cycles involving nivolumab), she achieved a complete clinical, molecular, and radiographic response. There was minimal evidence of allograft rejection without signs of dysfunction. Treatment was discontinued and subsequent surveillance imaging suggested durable remission for at least 9 months following treatment cessation. This case highlights the importance of genomic testing and targeting actionable molecular alterations in patients with rare cancers, as well as the role of multidisciplinary care.

58 Background: Prior to ARPIs, chemotherapy was used to treat mCSPC. Recently, intensifying mCSPC treatment with a triplet combination of chemotherapy, ARPI and androgen deprivation therapy (ADT) has been a recommended approach. Few recent studies explore time burden and costs associated with chemotherapy-containing regimens (CCR) relative to non-chemotherapy containing regimens (NCR). This study compared the additive burden of docetaxel to ADT and ARPI combination by assessing the number of days needed to manage prostate cancer (PC) care and healthcare costs among patients with mCSPC receiving CCR or NCR in the US. Methods: Clinical data from community urology practices (PPS Analytics) linked with the Komodo Research Database (1/1/2016-12/31/2023) were used to identify patients initiating a CCR or NCR. The index date was earliest of ARPI or docetaxel initiation. Patients were followed from index until earliest of 12 months, ARPI discontinuation, start of new ARPI, chemotherapy initiation (NCR cohort only), or end of insurance/data availability. Outcomes reported per-patient-per-month (PPPM) included time spent managing mCSPC (total days with PC-related resource utilization [inpatient admissions, outpatient, emergency room, and other PC-related visits]) or PC management care (imaging, biopsy, chemotherapy management [iron/blood transfusions, erythropoiesis-stimulating agents, granulocyte colony-stimulating factor], testing), and all-cause and PC-related healthcare costs ($2023 US dollars). Cohorts were balanced on baseline covariates using overlap weighting. Outcomes were compared using weighted multivariable Poisson and linear regression models. Results: A total of 126 CCR and 837 NCR patients were identified (mean age 64.7 years, 52.6% White, 14.4% Black, and 33.7% had visceral metastasis in both cohorts). Patients were followed for a mean of 6.3 (CCR) and 6.8 (NCR) months. For the CCR cohort, a mean of 4.0 docetaxel infusions were observed per patient (mean time 22.0 days between infusions). The CCR cohort spent a mean of 4.1 days PPPM managing mCSPC, compared to 3.3 days PPPM in the NCR cohort (rate ratio: 1.18; 95% confidence interval [CI]; 1.03, 1.34). Mean all-cause medical and pharmacy costs were $17,833 PPPM in the CCR cohort and $11,527 PPPM in the NCR cohort (weighted adjusted cost difference [CD]: $6,184; 95% CI: 3,515, 8,517). Mean all-cause medical costs were $6,592 PPPM in the CCR cohort and $4,240 PPPM in the NCR cohort (CD [95% CI]: $2,060 [865, 3,369]). Conclusions: In this real world study, patients initiating a CCR experienced greater time toxicity managing mCSPC and higher healthcare costs than those initiating an NCR. Counseling expressing these differences in burden should be included in decision-making conversations when selecting treatment for mCSPC.

Paragangliomas are extra-adrenal neuroendocrine neoplasms (NENs), and those arising in the gallbladder are exceedingly rare. Pathogenic variants in the succinate dehydrogenase (SDH) complex are well-established drivers of paragangliomas and pheochromocytomas, and have also been implicated in epithelial neuroendocrine tumors (NETs). We report a 50-year-old woman with a likely pathogenic succinate dehydrogenase subunit B (SDHB) germline variant (p.D118Y, c.352G>T), who underwent surveillance imaging due to a family history of malignant carotid paraganglioma. Magnetic resonance imaging revealed a 2.5-cm retroperitoneal mass adjacent to the duodenum and pancreatic head, consistent on biopsy with a well-differentiated, low-grade NET showing loss of SDHB expression. Endoscopic evaluation incidentally identified a 1.2-cm enhancing nodule on the hepatic surface of the gallbladder wall. 64Cu-DOTATATE positron emission tomography/computed tomography (PET/CT) showed somatostatin receptor-positive uptake in both lesions. The patient underwent cholecystectomy with liver wedge resection and excision of the periduodenal mass. Histologic examination revealed two distinct tumors: a gallbladder paraganglioma showing a Zellballen pattern, positive for synaptophysin and chromogranin but negative for cytokeratin, and a periduodenal well-differentiated NET positive for cytokeratin AE1/AE3, synaptophysin, and chromogranin. Both lesions demonstrated complete loss of SDHB immunoreactivity, confirming cross-lineage SDH deficiency. The concurrent absence of SDHB expression in both tumors provides compelling phenotypic evidence supporting the pathogenicity of the germline SDHB variant, and reinforces the biologic coherence of the genotype-phenotype correlation. The postoperative course was uneventful, and follow-up imaging at eight months showed no recurrence. This unique case of synchronous SDHB-deficient gallbladder paraganglioma and periduodenal NET illustrates cross-lineage tumorigenesis within a single germline background and emphasizes the value of SDH immunohistochemistry and genotype-guided surveillance.

51 Background: Inequities in cancer care delivery can profoundly affect access to high-quality treatments and patient outcomes. Supportive care medication use is important for preserving quality of life in older adults with metastatic pancreatic ductal adenocarcinoma (PDAC). Whether there are differences in supportive care medication use by race and sex is unknown. Our objectives were to assess the racial/ethnic and biological sex inequities in use of treatments for pain, depression, and pancreatic insufficiency-related treatments (PERT) among older adults with PDAC. Methods: We used the Surveillance, Epidemiology, and End Results-Medicare linked database, to identify Medicare beneficiaries aged 65 and older diagnosed with metastatic PDAC from January 2008 to December 2019. We included those continuously enrolled in Medicare prescription drug benefits in the 6 months before and month of diagnosis. Any use of opioid pain medications, antidepressants, and PERT was identified from diagnosis to the end of the study period (at death, disenrollment, or 12 months). Multivariable regression was used to compare supportive care medications use by racial/ethnic and biological sex groups. Results: There were 29,509 individuals in our sample, with12.9% Black patients, 3.9% Hispanic patients, and 83.2% White patients. The mean age was 76.5 (SD: 7.4) years. Mean follow-up time was 135.4 (SD:117.7) days overall, with the shortest follow-up among Black patients 124 (SD:111.1) days and longest for White patients 137.5 (SD: 118.8) days. Antidepressants were used by 23.8%, opioids by 60.3%, and PERT by 12.4% overall. Within race groups there were limited differences in medication use by sex. However, we observed differences in supportive care treatment use by race and ethnicity. Specifically, relative to White individuals, those who identified as Black were 20% less likely (adjusted risk ratio [aRR]: 0.8, 95% CI:0.74-0.85) to receive antidepressants, 14% less likely to receive opioids (aRR: 0.86, 95% CI:0.84-0.89), and 41% less likely to receive PERT (aRR: 0.59, 95% CI:0.53-0.65). Similar patterns were observed for patients of Hispanic ethnicity, with those individuals being 12% less likely (adjusted risk ratio[aRR]: 0.88, 95% CI:0.89-0.98) to receive antidepressants, 9% less likely to receive opioids (aRR: 0.91, 95% CI:0.87-0.96), and 42% less likely to receive PERT (aRR: 0.58, 95% CI:0.47-0.70). Conclusions: Our preliminary data showed differences in the uptake of supportive care drugs among Black and Hispanic patients relative to White patients. Specifically, these individuals were less likely to start opioid pain medications, antidepressants, and pancreatic enzyme replacement therapy compared to their White counterparts. These findings highlight potential gaps in treatment use that may better support patients facing life-limiting illnesses.

696 Background: PERT is an important but costly and inconsistently used supportive care medication in PC. We sought to characterize patterns of PERT use among U.S. insured patients with PC. Methods: We conducted a retrospective observational analysis of patients with a primary diagnosis of pancreatic adenocarcinoma in the IBM MarketScan national claims database between 2013-2019. We identified pharmacy claims for PERT (Creon, Pancreaze, Pertzye, Viokace, and Zenpep) and classified patients as PERT-users (≥ 1 PERT prescription [Rx]) and non-PERT users. We used descriptive statistics for clinical, demographics, and costs. Multiple logistic regression identified predictors of PERT use. Kaplan-Meier method assessed time from PC diagnosis to first PERT Rx. Results: Of 19,866 patients with PC (median age 62 years, 49% women), 6,918 (35%) were PERT-users. The median follow-up was 11 months (PERT users: 14 months, non-PERT users: 9 months). Overall, 43% of patients received no cancer-directed treatment. PERT-users were more likely to have a history of pancreatitis (acute, odds ratio [OR] = 1.9; chronic, OR = 3.6), and received chemotherapy (OR = 1.2), surgery (OR = 2.3), and radiation (OR = 1.4). Among all PERT-users, the median time from PC diagnosis to first fill was 1.9 months (95% CI: 1.8,2.0). The median time from surgery to first fill was 1.6 months (95% CI: 1.4,1.7). The median number of PERT Rxs was 4; 22% of PERT-users received 1 Rx. A median of 150 days of PERT was supplied across all Rxs per patient. The median (IQR) cost of each PERT Rx was $25 ($0- $50). PERT accounted for 16% of all drug out-of-pocket costs (OOPC) (excluding systemic outpatient cancer-directed treatment), and 7% of all healthcare OOPC. Patients with PERT had significantly higher monthly OOPC on Rxs but lower on all other services, including inpatient and outpatient services (all p < 0.0001). Overall, PERT-users had significantly lower per-patient per-month (PPPM) OOPC vs non-PERT users ($469, vs $520, p < 0.0001). They also had fewer PPPM outpatient (0.7 vs 1.2, p < 0.0001) and ER (0.4 vs 0.5, p < 0.0001) visits. Conclusions: In this national study of insured U.S. adults with PC, only one-third received PERT. Of those receiving PERT, approximately a fifth received just a single Rx. PERT users, despite higher OOP drug spending had reduced overall OOP costs and fewer healthcare visits. These data highlight the need to explore non cost-related reasons for lack of and ways to standardize PERT use.