Background:Pleural mesothelioma (PM) represents an uncommon and exceptionally lethal malignancy. The sarcomatoid subtype constitutes the rarest histological variant, traditionally linked to the worst prognosis, while the advantages of operative intervention remain inadequately established. In this study, we present findings from a cohort of 34 sequential cases with sarcomatoid mesothelioma managed at a specialized high-volume center employing pleurectomy decortication (PD) within a comprehensive therapeutic strategy. We aim to identify patients in this cohort who may benefit from a multimodality approach. Methods:All patients diagnosed with sarcomatoid mesothelioma between 2007 and 2019 who received PD at our facility were enrolled, and relevant medical, histopathological, and operative data collected. Survival curves generated through Kaplan-Meier methodology alongside log-rank testing enabled comparison of longevity outcomes, while Cox proportional hazards modeling facilitated examination of predictive variables. Results:The cohort included 31 male subjects (91.2%), 24 procedures performed on the right side (70.6%), with a median patient age of 71.5 years (range, 51-85 years). Preoperative treatment was administered to 8 individuals (24.2%), while 23 participants (67.7%) underwent intraoperative heated chemotherapy (IOHC). Macroscopic complete resection (MCR) was accomplished in 22 cases (64.7%). Mortality at 30 and 90 days post-surgery stood at 2.9% and 14.7%, respectively. The median overall survival for the entire cohort reached 7.4 months, extending to 20.1 months among those with forced expiratory volume in 1 second (FEV1) at or above 80% predicted. In multivariate analysis, preoperative FEV1 ≥80% was associated with prolonged overall survival [P=0.01; hazard ratio (HR) =0.54]. Conclusions:As expected, the median survival for most patients with sarcomatoid histology who undergo surgery is under one year. However, a small subset of patients with FEV1 ≥80% do quite well using the multimodality approach.

PURPOSE:Angiosarcoma and epithelioid hemangioendothelioma (EHE) are two rare vascular sarcomas with limited therapeutic options. Prior reports have shown sensitivity to microtubule-targeting agents in these histologies. We report the efficacy and safety of eribulin in these vascular sarcomas in a pooled analysis of two parallel phase 2 studies. PATIENTS AND METHODS:Patients more than age 18 years with metastatic or recurrent angiosarcoma or EHE were treated with eribulin (1.4 mg/m2 on days 1 and 8 of a 21-day cycle) until progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR) by RECIST 1.1. RESULTS:Twenty-nine patients were accrued to the study, with 25 (85%) having had prior taxane exposure. We observed an ORR of 17% for angiosarcomas, with 6 of 23 (26%) patients achieving disease stability for greater than 6 months, and an ORR of 33% (2/6) for EHE, with two of six continuing treatment for over 12 months. Five patients experienced a >1.3-fold time to progression ratio (TTP2/TTP1) on eribulin compared with the immediately prior therapy. Eribulin tolerability was consistent with published data. CONCLUSIONS:Eribulin showed clinical activity in this largely taxane-pretreated population. Future studies will be needed to confirm activity. See related commentary by Chen, p. 2130.

Background:Racial and socioeconomic disparities in lung cancer are well documented. Given the benefits of surgery and targeted therapies for early-stage disease, there is a need to increase screening participation of high-risk groups to improve survival. Yet, best practices for ascertaining which groups would benefit are lacking. The aims of this study were to demonstrate an association between zip code and stage at diagnosis of lung cancer as well as an association between zip code and age at diagnosis of lung cancer in Massachusetts patients. Methods:To identify such populations in Massachusetts, patients diagnosed with lung carcinoma from 2004 to 2020 were identified utilizing the Massachusetts Cancer Registry (n=72,559). Zip code-level demographic information, median household income, and percentage of residents without a high school diploma were obtained from census data. Geospatial analysis using ArcGISPro identified spatial trends in lung cancer incidence and patient characteristics. Results:Average age at diagnosis was 69.4 (±10.2) years old and the majority were White (95.9%) and female (53.8%). Many patients had distant (47.6%) spread at diagnosis, compared to regional (16.3%) or local disease (36.1%). Median household income and educational attainment were correlated with late-to-early-stage prevalence ratio for lung cancer (P<0.05). Higher proportions of Black residents in a zip code correlated with an increased rate of late-stage lung cancer cases in young patients (≤55 years; P<0.05) and further demonstrated geographic trends toward higher incidence of late-stage disease, lower educational attainment, and lower income. Conclusions:These results demonstrate the utility of geospatial analysis to detect trends in the incidence of late-stage lung cancer relating to race, age, education, and socioeconomic factors. Importantly, these results can direct location preferences for early intervention efforts including patient/provider education and mobile lung cancer screening clinics, particularly in neighborhoods with lower income and education levels (248/250).

OBJECTIVES:To assess differences in risk factors for uterine cancer (UC) mortality, differences in five-year overall survival across clinical and demographic characteristics, and independent predictors of mortality among Black and White patients. SAMPLE & SETTING:Patients treated between January 1, 2002, and December 31, 2022, at a specialized urban cancer center in the northeastern United States. METHODS & VARIABLES:This study used a retrospective analysis of data from an internal registry. Differences in overall survival across age, race, education, area income, stage, grade, and histology were compared using Kaplan-Meier curves. Survival was compared across characteristics using pairwise log-rank tests, followed by a Cox proportional hazards regression model to identify predictors of mortality. RESULTS:Among 4,891 patients, 262 self-identified as African American or Black. Compared to non-Hispanic White patients, Black patients were more likely to experience risk factors for UC mortality. Kaplan-Meier curves suggested reduced survival in patients with fewer resources. In the adjusted model, older age, advanced disease, higher tumor grade, and not having graduated from high school were associated with a greater likelihood of mortality. IMPLICATIONS FOR NURSING:Socioeconomic factors may contribute to racial disparities in UC survival. Earlier diagnosis and enhanced patient support may address modifiable risk factors for UC mortality.

PURPOSE:Methylthioadenosine phosphorylase (MTAP) is deleted in 13% of NSCLC, and MTAP two-copy deleted (MTAPdel) cancer cells are vulnerable to protein arginine methyltransferase 5 inhibitors being examined in trials. Outcomes for MTAPdel NSCLC are poorly characterized. EXPERIMENTAL DESIGN:Patients with advanced MTAPdel and MTAPwt NSCLC who underwent large panel, tissue-based, NGS at a single center and received systemic therapy and from 10/2016-3/2024, were included in this retrospective study. Treatments of interest included platinum doublet + anti-PD-(L)1 therapy, anti-PD-(L)1 monotherapy, and docetaxel-based chemotherapy. Baseline characteristics, PFS, and OS were compared between cohorts. RESULTS:Compared to the MTAPwt cohort (n=307), the MTAPdel cohort (n=93) had more female patients (65.6% vs. 51.5%, p=0.018), less of a smoking history (33.3% vs. 49.0% >30 pack-years, p=0.008), more stage IV disease at diagnosis (78.8% vs. 60.9%, p=0.002), lower PD-L1 TPS (37.9% vs. 24.3% TPS <1%, p=0.017), and lower tumor mutational burden (median 7.6 vs. 9.9 mutations/Mb, p=0.012). Patients with MTAPdel (vs. MTAPwt) NSCLC had shorter PFS on anti-PD-(L)1 monotherapy (HR 1.70 [95% CI 1.02-2.82], p=0.040) and platinum doublet + anti-PD-(L)1 therapy (HR 1.89 [95% CI 1.20-2.97], p=0.006) when controlling for histology, age, smoking pack-years, PD-L1 TPS, targetable co-mutations, and treatment line. OS was similar between MTAPdel and MTAPwt cohorts across regimens. CONCLUSIONS:MTAPdel NSCLC has more features of aggressive disease, including CNS metastasis, and associates with PD-L1 TPS <1%. Compared to patients with MTAPwt NSCLC, patients with MTAPdel NSCLC have worse outcomes to anti-PD-(L)1-based therapies. Effective therapies targeting MTAPdel NSCLC are needed.

The purpose of this study was to evaluate the impact of age and race on female patients with non-small cell lung cancer (NSCLC) and identify factors posing a greater risk to overall survival (OS). A retrospective analysis of the Southern Community Cohort Study database was conducted of female patients diagnosed with NSCLC from 2004 to 2018. Patients were stratified into Black versus white groups and by age: < 55 years and ≥ 55 years. Fisher’s exact test was used to compare categorical variables and Wilcoxon rank sum for numerical variables. Hazard ratios were calculated to assess risk on OS for both races. Black female patients, more often than white female patients, were diagnosed with pathologic stage IV (43.2

While most gastrointestinal stromal tumors are driven by oncogenic mutations in KIT or PDGFRA, 10-15% exhibit functional loss of the succinate dehydrogenase (SDH) complex and genome-wide DNA hypermethylation. Excess methylation in SDH-deficient gastrointestinal stromal tumors disrupts genomic insulators, inducing aberrant expression of oncogenic ligands FGF3, FGF4, and activating an autocrine signaling loop mediated through FGFR1. We conducted a phase 2 trial of pan-fibroblast growth factor receptor inhibitor rogaratinib in patients with sarcoma and report here on the cohort of patients with advanced SDH-deficient GIST. The primary objective was to estimate objective response rate. Secondary objectives were to estimate progression-free survival (PFS) and assess safety and tolerability. Exploratory objectives were to evaluate serial measurements of FGF3 and FGF4 and fibroblast growth factor receptors in serial biopsies, to perform whole-exome sequencing in serial biopsies and to explore rogaratinib exposure with pharmacodynamic effects. Twenty-four patients received rogaratinib and ten experienced partial responses for an objective response rate of 41.7%. Median PFS was 31.0 months (95% confidence interval 20.2-not reached), and 1-year PFS was 77.4% (95% confidence interval 61.7-97.1). Toxicities were manageable and included hyperphosphatemia, fatigue and diarrhea. Elevations in phosphorous were seen across the cohort, consistent with target engagement of FGFR1. Whole-exome and next-generation sequencing revealed alterations in the SDH subunit coding genes (SDHx) as expected. This trial illustrates a successful demonstration of targeted cancer therapy predicated on an epigenetic mechanism of oncogene activation. Clinicaltrials.gov identifier: NCT04595747 .

OBJECTIVES:To assess the feasibility, safety and preliminary efficacy of psilocybin-assisted therapy (PAT) for demoralisation in terminally ill patients receiving home hospice care. METHODS:In this open-label pilot trial, 4607 home hospice patients at a large community hospice were screened over 22 months; 66 were approached, 15 enrolled and 10 received psilocybin. Participants completed two home-based preparation sessions, a single 25 mg oral psilocybin session at an inpatient hospice facility, and two home-based integration sessions. Feasibility was assessed through recruitment, retention and acceptability. Safety was evaluated via adverse event monitoring, and preliminary efficacy was assessed using changes in demoralisation scores and other psychosocial measures. RESULTS:The intervention was well tolerated, with no serious adverse events attributed to psilocybin. At week 3, demoralisation scores significantly decreased (mean reduction: 8.8 points, p=0.0196), despite ongoing clinical decline. Grief- and peace-related themes were prominent during psilocybin sessions. While six participants rated the treatment favourably on the Reaction to Research Participation Questionnaire global evaluation factor, three rated neutral on one or more items, suggesting that the emotional intensity and demands of the intervention may influence acceptability. CONCLUSION:This study provides initial evidence that PAT can be feasibly and safely integrated into hospice care for terminally ill patients. Further research is needed to optimise delivery and further assess therapeutic potential.

BACKGROUND:Lung adenocarcinomas presenting as mixed ground-glass nodules (GGNs) are commonly treated by sublobar resection with favorable survival, but the optimal margin remains unclear. METHODS:We retrospectively reviewed patients with cT1 (≤3 cm) GGNs who underwent curative sublobar resection (January 2012-December 2020) and had invasive adenocarcinoma confirmed. Patients with uncertain/positive margins or positive lymph nodes were excluded. Margin distance was pathologically defined as the shortest distance from tumor edge to resection margin. Cox proportional hazards regression, Kaplan-Meier, and competing-risk analysis were used to assess the relationship between the margin-to-tumor diameter ratio (MTR) and margin-to-solid component ratio (MSR) and locoregional recurrence-free survival (LRFS). Optimal cutoffs for LRFS prediction were identified using recursive classification tree analysis. RESULTS:Among 208 patients (median follow-up, 64 months), median tumor, solid component, and margin sizes were 18.0, 6.25, and 12.0 mm, respectively. Recursive partitioning identified MTR as most predictive, with an optimal cutoff of ∼0.174. MTR and MSR were the top influential predictors and strongly correlated through a second-degree polynomial model. Patients with MTR ≥0.2 had significantly improved LRFS compared with those with MTR <0.2 (log-rank P = .0026) and reduced recurrence (subdistribution hazard ratio, 0.203; 95% CI, 0.067-0.619; P = .005). In multivariable Cox regression, MTR ≥0.2 remained an independent predictor of improved LRFS (hazard ratio, 0.15; 95% CI, 0.04-0.51; P = .003). CONCLUSIONS:For sublobar resection of invasive lung adenocarcinoma as mixed GGNs, a margin distance of >0.2 times the tumor diameter is clinically significant to optimize local control.

BACKGROUND:Little is known about large language model (LLM) performance on palliative care (PC)-related knowledge-based tasks. We evaluated two LLMs in answering PC-related test questions and explaining their answer choice rationale. METHODS:LLMs were prompted to answer 25 randomly selected questions from the Fast Facts Quiz and provide their answer choice rationale. Three PC educators ranked and rated LLM-generated answer choice explanations versus the test's answer key explanations. Linear fixed-effect models evaluated reviewer ranking, and ordinal logistic regression evaluated reviewer ratings of quality, suitability, accuracy, relevance, and comprehensiveness. RESULTS:Both LLMs answered 96% of selected questions correctly. Reviewers rated LLM-generated explanations more highly than Fast Facts Quiz explanations. Five themes emerged from reviewer comments: perceived inaccuracies, clarity of writing, educational value, linguistic style, and miscellaneous. CONCLUSIONS:LLMs demonstrated high answer choice accuracy and generated preferable answer explanations when compared to the Fast Facts Quiz answer key.

Rationale and Objectives Accurate clinical staging in pleural mesothelioma (PM) is limited by the subjectivity of conventional imaging assessment, which introduces inter- and intraobserver variability. Tumor volume, pleural thickness and diaphragmatic thickness measurements individually prognostic — offer objective, quantifiable surrogates for locoregional tumor burden. We evaluated these Magnetic Resonance Imaging (MRI)-derived metrics to develop a reproducible quantitative clinical T-classification strategy for PM that offers objective, reproducible surrogates for tumor burden with reduced interobserver variability compared to qualitative MRI staging. Materials and Methods Patients referred for surgical evaluation of PM between 2009 and 2014 who underwent MRI using an IRB-approved protocol were included. For survival analyses, only patients with complete data and uniform treatment were analyzed. Quantitative measures included MR-derived tumor volume (VolMR), summed unidimensional pleural thickness (Psum) and Fissural and diaphragmatic thickness (Ptotal= Psum+Fmax+Dtotal) Optimal categorical thresholds were derived by survival-based optimization using the log-rank statistic, implemented via Classification and Regression Trees (CART) with 20-fold cross-validation. Predictive accuracy was assessed using univariable Cox models and C-statistics, and survival curves were generated using Kaplan-Meier estimates. Continuous variable Cox models were also constructed for VolMR and Ptotal. Analyses were stratified by surgical modality to assess robustness. Results Of 695 patients evaluated, 377 had eligible MR imaging. Median age was 68 years; 77% were male and 60% had epithelioid tumors. Clinical Tumor Node Metastasis staging was concordant with pathology in 52.5%, understaged in 33%, and overstaged in 14% of patients. Among evaluated metrics, diaphragmatic thickness (C-statistic = 0.5996) and total pleural thickness (0.5868) demonstrated the highest predictive accuracy. Survival curves showed strong stratification using Ptotal and VolMR. Head-to-head comparison with AJCC 8th edition qualitative T staging (C-statistic 0.6022) showed that Ptotal-based categories (C=0.6217) and VolMR-based categories (C=0.6364) provided superior survival stratification. Conclusion Quantitative MR-derived Ptotal and VolMR improve upon qualitative T category in PM by offering objective, reproducible surrogates for tumor burden with strong prognostic stratification when appropriate cut points are applied. These metrics could support future Tumor Node Metastasis refinements and individualized treatment planning.

8634 Background: With the recent approvals of the FLAURA2 and MARIPOSA regimens in EGFR -mutant non-small cell lung cancer (NSCLC), identifying clinicogenomic features predictive of suboptimal outcomes with first-line osimertinib monotherapy is critical in guiding upfront treatment selections. Methods: This is a multicenter retrospective study enrolling patients (pts) with advanced NSCLC harboring common EGFR mutations (exon 19 deletions [ex19del], L858R) treated with first-line osimertinib monotherapy across 13 centers (Clinical cohort). Comprehensive baseline genomic data on tumor tissue were available for DFCI and MSKCC (Genomic cohort). The association of clinicogenomic features with real-world progression-free survival (rwPFS) was investigated. Time-dependent discrimination for very-early progression (rwPFS < 6 months) was evaluated using Receiver Operating Characteristic (ROC) curve-based Area Under the Curve (AUC). Variable importance was assessed by delta (Δ) AUC after covariate exclusion. Moreover, very-early progression was analyzed with a Cox model censored at 6 months, reporting adjusted hazard ratios (aHR). Results: A total of 1488 pts were enrolled in the clinical cohort; at median follow-up of 43.3 months, median rwPFS was 16.3 months (95%CI 15.3-17.4), median overall survival was 36.7 months (95%CI 34.8-39.4). The strongest predictor of very-early rwPFS in a multivariable model, including, age, sex, EGFR mutations, PD-L1 tumor proportion score (TPS), concurrent TP53 mutations, metastatic sites (brain, bone, liver), performance status, was PD-L1 TPS (aHR 2.75 for ≥50% versus 0%, p < 0.0001), with the largest decrease in the AUC when excluded from the model (ΔAUC = 0.17). Looking at genomic features in the genomic cohort, at median follow up of 38.2 months, loss-of-function mutations in KMT2D (HR 7.1, p < 0.001), TP53 (HR 1.4, p = 0.01), RB1 (HR 1.7, p = 0.01), RBM10 (HR 1.6, p = 0.01), CREBBP (HR 2.7, p = 0.02), ATM (HR 2.1, p = 0.04 ), predicted shorter rwPFS. Next, we investigated the role of concurrent tumor suppressor gene ( TSG ) alterations beyond TP53 , including in this cathegory those with a p < 0.1 for rwPFS and mutated in at least 5 cases (RBM10, CREBBP, ATM, RB1, KMT2D, TSC2, PTEN). TSG MUT had shorter rwPFS compared to TSG WT (aHR 1.5, p = 0.01), specifically in L858R subgroup (aHR 1.7, p = 0.02), while TP53 MUT had shorter rwPFS compared to TP53 WT in ex19del only (aHR 1.7, p = 0.01). Combining TP53 with TSG, pts with TP53 MUT plus at least one TSG MUT and pts with TP53 WT -TSG MUT had shorter rwPFS compared to TP53 WT -TSG WT and TP53 MUT -TSG WT (10.8, 13.1, 21.9, 18.1 months, respectively, p = 0.004). In the genomic cohort, PD-L1 TPS was the strongest predictor of very-early rwPFS (ΔAUC = 0.16), followed by TP53 combined with TSG (ΔAUC = 0.08). Conclusions: In this multicenter real-world cohort, baseline PD-L1 and TP53 combined with TSG predict very-early progression to first-line Osimertinib.

BACKGROUND:Demoralization is common in palliative psycho-oncology settings. Although its relationship with other psycho-existential conditions has been scrutinized, its co-occurrence with adjustment disorder, as measured by the Adjustment Disorder New Module-20 (ADNM-20), remains unexamined. AIM:Estimate frequency and co-occurrence of demoralization and adjustment disorder symptom domains among palliative outpatients and examine sociodemographic and psycho-existential factors. METHODS:A single-site, cross-sectional survey at an academic cancer center used self-reported web-based screening questionnaires. Analyses included descriptive statistics, association tests, and hierarchical logistic regression models. RESULTS:Moderate-to-severe demoralization symptoms occurred in 43.3% (90% CI: 36.9-49.7) of the 164 outpatients. Among these, co-occurrence with high-risk adjustment disorder symptoms reached 77.6% (90% CI: 69.5-85.8) versus 54.9% (90% CI: 45.2-64.6) for moderate-to-severe depression symptoms (p < 0.001). High-risk adjustment disorder was also frequent (44.1%, 90% CI: 34.4-53.8.3) and, along with moderate-to-severe depression (OR 7.23 and 8.67, p < 0.01), was independently associated with moderate-to-severe demoralization. CONCLUSIONS:Approximately half of oncology outpatients screened positive for demoralization or adjustment disorder, with substantial co-occurrence reflecting their conceptually defined shared disruption of adaptive capacities. Demoralization demonstrates incomplete overlap at the symptom-domain level and appears to capture a distinct existential dimension of distress. This pattern supports consideration of routine screening and further empirical evaluation of its potential diagnostic positioning. Clinician-administered longitudinal studies incorporating item-level analyses are warranted to clarify temporal relationships, refine discriminant validity, and further evaluate demoralization as a distinct diagnostic entity. Such work may enhance recognition of existential suffering and inform targeted integrative interventions.

Objective: Despite curative resection, recurrence remains a clinically relevant problem in patients with early-stage non–small cell lung cancer (NSCLC). Although several high-risk features have been individually associated with adverse outcomes, their cumulative prognostic influence remains unclear. Methods: Patients with NSCLC undergoing curative-intent resection between 2017 and 2024 were identified from a prospective institutional database. Inclusion criteria were solid tumors with size <4 cm, pN0 disease, and R0 resection with documented spread through air spaces status. High-risk features included nonanatomic resection, poorly/undifferentiated grade, lymphovascular invasion (LVI), visceral pleural invasion (VPI), incomplete lymphadenectomy (<3N2 and <1N1 stations), and spread through air spaces positivity. Cox proportional hazards modeling was used to quantify the association of high-risk features and 5-year recurrence-free survival, and a nomogram was constructed to estimate cumulative recurrence risk. Results: Of the 497 patients included, anatomic resection was performed in 268 (53.9%) patients and complete lymphadenectomy was achieved in 126 (25.4%). Over a median 30-month follow-up (interquartile range, 13-49 months), 50 patients (10.1%) developed recurrence. LVI (hazard ratio [HR], 3.7; 95% CI, 2-7; P < .001), VPI (HR, 2.8; 95% CI, 1.5-5.2; P = .002), poorly/undifferentiated tumor (HR, 1.8; 95% CI, 0.99-3.3; P = .05), resection margin distance (HR, 0.7; 95% CI, 0.5-0.9; P = .01), and incomplete lymphadenectomy (HR, 2.7; 95% CI, 1-7.1; P = .05) were significantly associated with recurrence. The final nomogram demonstrated good discrimination for estimated 5-year recurrence risk, with a concordance index of 0.82. Conclusions: A multifactorial nomogram integrating high-risk pathologic features to estimate recurrence risk in early-stage NSCLC was developed. This model suggests that recurrence risk in early-stage NSCLC may be driven by the cumulative burden of high-risk surgical and pathologic features rather than isolated factors, providing a clinically applicable framework for postoperative risk stratification. External validation and integration into clinical decision-making frameworks are warranted.

Background Patients with chronic critical illness experience prolonged mechanical ventilation, severe symptoms, poor quality of life, and low survival. Guidelines recommend that clinicians discuss goals of care with seriously ill patients and their surrogate decision-makers, but this process is understudied during chronic critical illness, when treatment burdens are high and long-term outcomes are poor. Research Question How do clinicians from varied professions perceive barriers to discussions about goals of care during chronic critical illness? Study Design and Methods We conducted a cross-sectional survey of chronic critical illness clinicians at two academic ventilator facilities, assessing perceptions of barriers to goals-of-care communication. We used Likert scale and multiple-choice responses, with statistical analysis by signed rank, proportion, and marginal homogeneity tests. Results Clinicians (N=274) from 11 professions (including nursing, medicine, respiratory therapy, rehabilitation therapy, social work) completed the survey (response rate, 78.5%). The most commonly selected reasons for delaying goals-of-care discussions included challenges with patient or surrogate processing of prognosis (55% of respondents), explicit requests to not discuss goals of care (47%), clinician prognostic uncertainty (42%), and prior clarity of goals of care (40%). Clinicians contrasted their own low expectations for patient recovery (median response, “unlikely”) with perceived high expectations of patients (median, “likely,” P < 0.001). In contrast to shared responsibility across professions for symptom management (i.e. nursing, medicine, rehabilitation therapy, social work, chaplaincy), perceived responsibility for initiating goals-of-care discussions was primarily limited to physicians and nurse practitioners (P < 0.001 by test of proportions). Interpretation In this two-site cross-sectional survey, clinicians identified distinct challenges to goals-of-care communication during chronic critical illness – including challenges processing information, discordant expectations, and differential clinician responsibilities for initiating these discussions. These provide unique and targeted opportunities to improve communication and care during chronic critical illness.

Black patients present with non-small-cell lung cancer (NSCLC) at younger ages, and Black race has been shown to be a poor prognostic factor. Data reporting NSCLC cases in the National Cancer Database (NCDB) from 2000 to 2020 was evaluated in 3 categories: 18 to 44(A), 45 to 49(B) and 50-90 years(C). Insurance status, distance from the treating hospital, median household income and proportion of the residents without a high school diploma (HSD) were used as surrogates for socioeconomic factors. Despite being geographically closer to hospitals and being more commonly seen at academic centers, Black patients under 50 years with NSCLC presented more frequently with stage IV disease and are more commonly from disadvantaged settings compared to their White counterparts. This suggests that earlier screening of Black patients may help to address the observed delays in presentation. Background: Black patients present with non-small-cell lung cancer (NSCLC) at younger ages, and Black race is a poor prognostic factor. We aimed to identify specific socioeconomic factors that may contribute to these disparities. Methods: The National Cancer Database (NCDB) was queried for NSCLC cases (2000-2020). Patients were grouped into 3 categories: 18 to 44(A), 45 to 49(B) and 50 to 90 years(C). Demographics, tumor characteristics, survival, insurance status, distance from the treating hospital, median household income, and proportion of residents without a high school diploma (HSD) were compared. Results: There were 1,703,062 patients, 77,107 of whom were under 50-years-old. Compared to White patients, more Black patients in A and B presented at stage IV (A: 39.7% vs. 35%; B: 40.9% vs. 35%), had higher 90-day mortality (A: 2.7% vs. 2.2%; B: 4% vs. 2.7%) and were uninsured (A: 14.2% vs. 9.6%; B: 14.8% vs. 10.2%). Additionally, more Black patients in A (38.2% vs. 18.2%) and B (42% vs. 18%) were from regions with fewer high school graduates and where the median income was in the lowest quartile (A: 45.2% vs. 18.3%; B: 48.8% vs. 19.4%). Black patients lived closer to treating hospitals and were more often seen at academic centers. Despite this, Black patients under 50 years presented more frequently with stage IV disease and were commonly from disadvantaged settings compared to White patients. Conclusions: Interventions on social determinants such as education and income might address some of the disparities surrounding NSCLC in young Black patients.