Purpose: In breast cancer, improved treatment approaches that reduce injury to lung tissue and early diagnosis and intervention for lung toxicity are increasingly important in survivorship. The aims of this study are to (1) compare lung tissue radiographic changes in women treated with conventional photon radiation therapy and those treated with proton therapy (PT), (2) assess the volume of lung irradiated to 5 Gy (V5) and 20 Gy (V20) by treatment modality, and (3) quantify the effects of V5, V20, time, and smoking history on the severity of tissue radiographic changes. Patients and Methods: A prospective observational study of female breast cancer patients was conducted to monitor postradiation subclinical lung tissue radiographic changes. Repeated follow-up x-ray computed tomography scans were acquired through 2 years after treatment. In-house software was used to quantify an internally normalized measure of pulmonary tissue density change over time from the computed tomography scans, emphasizing the 6- and 12 -month time points. Results: Compared with photon therapy, PT was associated with significantly lower lung V5 and V20. Lung V20 (but not V5) correlated significantly with increased subclinical lung tissue radiographic changes 6 months after treatment, and neither correlated with lung effects at 12 months. Significant lung tissue density changes were present in photon therapy patients at 6 and 12 months but not in PT patients. Significant lung tissue density change persisted at 12 months in ever -smokers but not in never -smokers. Conclusion: Patients treated with PT had significantly lower radiation exposure to the lungs and less statistically significant tissue density change, suggesting decreased injury and/or improved recovery compared to photon therapy. These findings motivate additional studies in larger, randomized, and more diverse cohorts to further investigate the contributions of treatment modality and smoking regarding the short- and long-term radiographic effects of radiation on lung tissue.

Purpose: Equitable inclusion of racial and ethnic participation in clinical trials is crucial to improving disparities in health care, especially for historically marginalized populations. Our study aims to describe the racial and ethnic demographics of patients enrolled in published phase 2 clinical trials involving proton therapy in the United States.Materials and Methods: Published manuscripts were identified in PubMed, Embase, World of Science, and Cochrane. Phase 2 trials evaluating proton therapy for US patients were included. For each article in the study, data were collected comprising authors, title, and publication year, and clinical trial numbers were verified. Additional data included tumor site, primary institution, sample size, reported race/ethnicity, and raw number/percentile of race/ethnicity. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used.Results: Overall, 970 titles were identified; 636 remained after duplicate screening, and 75 full-text articles were assessed. We identified 38 eligible manuscripts for inclusion comprising 2648 patients. Only 15 (39%) of the publications reported race/ethnicity. Of these, 8 (21%) and 10 (26%) documented Hispanic or Black trial participants, respectively; however, only 6 (16%) documented trial participation for both Hispanic and Black patients. Of the 1409 patients with a documented race/ethnicity, 89.0% (n = 1254) were non-Hispanic white, 5.3% (n = 75) were Black, and 2.2% (n = 31) were Hispanic. Other and unknown race/ethnicity comprised the remaining patients (3.5%; n = 49).Conclusion: We identified underreporting of demographic data in published phase 2 proton therapy trials, which unfortunately mirrored underreporting for cancer drug clinical trials. We also noted dramatic Black and Hispanic patient underrepresentation across the trials in which race and ethnicity are reported. Findings highlight the urgent need to identify and address barriers to proton therapy trials for Black and Hispanic patients ensuring clinical trials in radiation oncology are representative of the patients seen in clinical practice.

1102 Background: ASCO recommends palliative care (PC) as an adjunct to the oncologic standard of care for patients with metastatic cancer. However, current evidence on PC utilization in patients with breast cancer and its relationship with area-level social determinants of health (SDoH) factors is limited. Therefore, we examined the associations between county-level factors and PC utilization among patients with metastatic breast cancer (mBC) in Florida. Methods: We extracted patient-level data (n = 23,539 patients diagnosed with mBC between 2012 and 2021) from the OneFlorida+ Data Trust and linked it to county-level data (67 Florida counties) from the AHRQ-SDoH Database. PC utilization since cancer diagnosis was identified using ICD-9 code V66.7 or ICD-10 code Z51.5. We assessed differences in PC utilization with county-level SDoH factors (e.g., poverty rate, transportation resource, provider supply, racial segregation) using bivariate analysis. Multivariable Poisson regression, including significant factors from bivariate analysis, was used to compare the PC utilization for the SDoH factors. Results: Our study population's overall prevalence of PC utilization was 16.1%. PC utilization was higher for patients with mBC residing in counties with a higher proportion of residents living in poverty and with a greater supply of advanced practice providers (APP: NP, PA), general surgeons, and nursing homes. Patients with mBC in counties with higher proportions of residents who identified as immigrants, with limited English proficiency, without personal transportation, and having higher racial segregation had lower PC utilization. In adjusted analysis, the supply of APP (coefficient:0.12) and nursing homes (coefficient:0.09) was associated with increased PC utilization. Conversely, racial segregation (White vs. non-White) was associated with decreased PC utilization (coefficient: -0.07). Conclusions: PC utilization among patients with mBC was associated with several SDoH at the county level. Notably, low PC utilization was associated with racial residential segregation and fewer APPs and nursing homes. Further research is needed to identify mediators in these relationships to improve PC effectiveness for patients with mBC in Florida.

Purpose: Patients with cancer are particularly vulnerable to coronavirus disease (COVID). Transportation barriers made travel to obtain medical care more difficult during the pandemic. Whether these factors led to changes in the distance traveled for radiotherapy and the coordinated location of radiation treatment is unknown.Materials and Methods: We analyzed patients across 60 cancer sites in the National Cancer Database from 2018 to 2020. Demographic and clinical variables were analyzed for changes in distance traveled for radiotherapy. We designated the facilities in the 99th percentile or above in terms of the proportion of patients who traveled more than 200 miles as “destination facilities.” We defined “coordinated care” as undergoing radiotherapy at the same facility where the cancer was diagnosed. Results: We evaluated 1,151,954 patients. There was a greater than 1% decrease in the proportion of patients treated in the Mid-Atlantic States. Mean distance traveled from place of residence to radiation treatment decreased from 28.6 to 25.9 miles, and the proportion traveling greater than 50 miles decreased from 7.7% to 7.1%. At “destination facilities,” the proportion traveling more than 200 miles decreased from 29.3% in 2018 to 24% in 2020. In comparison, at the other hospitals, the proportion traveling more than 200 miles decreased from 1.07% to 0.97%. In 2020, residing in a rural area resulted in a lower odds of having coordinated care (multivariable odds ratio = 0.89; 95% confidence interval, 0.83–0.95). Conclusion: The first year of the COVID pandemic measurably impacted the location of U.S. radiation therapy treatment.

The potential disparities in palliative care delivery for underrepresented minorities with breast cancer are not well known. We sought to determine whether race and ethnicity impact the receipt of palliative care for patients with metastatic breast cancer (MBC). We retrospectively reviewed the National Cancer Database for female patients diagnosed with stage IV breast cancer between 2010 and 2017 who received palliative care following diagnosis of MBC to assess the proportion of patients who received palliative care, including non–curative-intent local–regional or systemic therapy. Multivariable logistic regression analysis was performed to identify variables associated with receiving palliative care. 60,685 patients were diagnosed with de novo MBC. Of these, only 21.4

12120 Background: Persistent inequities in the care for patients with metastatic breast cancer (mBC) were recognized by ASCO and, in partnership with Pfizer, awarded our team a grant to understand and address them in people of color. Florida has a higher age-adjusted percentage of breast cancer in females and a higher mortality rate in those under the age of 65 compared to the United States. The racial disparity in mortality is further magnified among female patients with mBC. Therefore, we sought to characterize the prevalence and trends of palliative care utilization and clinical trial participation (CTP) among Floridians with mBC and quantify the associated factors. Methods: Using the OneFlorida+ Data Trust, a repository of patient-level electronic health records of ~17 million Floridians seen in public and private health care systems, including those enrolled in Medicaid, we obtained demographics of mBC patients, including sex, age, race, and ethnicity, insurance type, zip-code based socioeconomic status, Charlson comorbidity index (CCI) and rural/urban residence. CPT codes were obtained for palliative care services between the date of mBC diagnosis and death, including pain management, psychology, psychiatry, nutrition, and advanced care planning. Our analysis included the Cochran-Armitage trend test and bivariate analysis to correlate patient characteristics to palliative care receipt and CTP. Results: In Florida, 25,225 individuals (1.5% men and 98.5% women) were diagnosed with mBC between 2012 and 2021; 49.3% were under age 60. 19.5% of this cohort received palliative care at a median time of 10.1 months (IQR 2.1 – 27.1) from the initial diagnosis of mBC. The median survival was 13.6 months (IQR 3.4 – 31.6). On multivariable analysis, significant variables (p < 0.001) associated with increased palliative care utilization were Non-Hispanic Black, self-pay/uninsured and Medicaid insured, and a CCI of 5+. Only 3% of the study cohort had advanced care planning. There was a declining trend in CTP among patients with mBC, from 13.9% in 2012 to 7.9% in 2021. Among those participating in clinical trials, 80.2% did not receive palliative care. Variables associated with higher CTP (p < 0.001) were younger age (18-49), Asian and Hispanic race/ethnicity, the highest quartile of median household income and education level, private insurance, metropolitan residence, and CCI of 0. Further, there was a trend towards more prolonged survival among those enrolled in clinical trials. Conclusions: This robust statewide assessment highlights that less than 20% of patients with mBC receive palliative care, and its receipt is exclusive of CTP. We identified significant racial and socioeconomic disparities in CTP. Educational interventions with palliative care trained navigators, partnerships with providers on palliative care benefits, and state policy support are needed.

Purpose: Obtaining prior authorization (PA) before treatment is becoming increasingly burdensome in oncology, especially in radiation oncology. Here, we describe the impact of a strategic novel operational PA redesign to shorten authorization time and to improve patient access to cancer care at a large United States academic proton therapy center. We ask whether such a redesign may be replicable and adoptable across oncology centers.Materials and Methods: Our PA redesign strategy was based on a 3-tiered approach. Specifically, we (1) held payors accountable to legally backed timelines, (2) leveraged expertise on insurance policies and practices, and (3) updated the submission, appeal writing, and planning procedures for PA. Metrics were compared at the following 3 time points: 6 months before, at phase-in, and at 6 months after intervention.Results: In analyzing the impact of improving PA access to care, the percentage of approvals for commercial proton beam therapy improved by an absolute 30.6% postintervention (P , .001). The proportion of commercially insured patients treated with proton beam therapy also increased by 6.2%, and the number of new starts rose by 11.7 patients/mo. Overall patient census increased by 13 patients/d. Median authorization time was 1 week, and 90% of surveyed providers reported reduced PA burden and improved patient care.Conclusion: This is the first validated, comprehensive operational strategy to improve access to cancer therapy while reducing the burden of PA. This novel approach may be helpful for addressing barriers to PA in medical and surgical oncology because the redesign is predicated on laws that regulate PA across disciplines.

249 Background: Many patients diagnosed with cancer own pets, yet information addressing pet care during cancer treatment is both rare and inconsistent in content. The resultant gap of knowledge and need for resources is not well understood. Cancer Care (a national non-profit providing emotional and practical support services) created a survey to assess pet owner perspectives with the goal of implementing patient-informed solutions. Methods: A mixed methods approach was utilized including an original 11-question online survey sent to 8434 patients with cancer known to own pets in August 2021. The survey asked about pets in the home and pet care knowledge and needs. A focus group of 10 patients was selected from the 84 who volunteered and included 6 females, 4 males, age range 41-68, from a variety of race/ethnicities. This research was funded through a grant from Amie’s Place Foundation. Results: 328 responses were collected in the 10 days of survey administration. The most common pets in the home were dogs (77%) and cats (45%) with a minority (2-5%) reporting other pets. The vast majority (98%) reported that their pets were extremely or very important in their recovery from cancer treatment. Prior to cancer diagnosis, most were involved in feeding (89%), taking pets to the veterinarian (80%), grooming (70%), walking (68%), administering pet meds (56%), and cleaning soiled pet items (47%). After cancer diagnosis, many relied on help from their spouse/partner (41%), children (33%), friends (14%); 15% noted that they didn’t have anyone else to help with their pets. Over half (55%) had safety concerns regarding pet care since their cancer diagnosis. Of the 77% with questions about caring for their pet, the 3 most common concerns were: how to care for their pets when feeling unwell (58%), infections from their pets (47%), and impact of their cancer treatment on pets (36%). Places from which respondents wanted information included CancerCare.org (66%), their veterinarian’s office (32%), or the treating cancer center (25%). Information was best received online (56%), or via printed materials (46%), and downloadable fact sheets (24%). The focus group findings confirmed the emotional support and companionship that pets provided (“ When I was at my lowest point, my dog kept me up and going.”) but highlighted the need for additional assistance for pet care needs and information from their care team (“ Cancer patients don’t have a clear direction on where to go for resources on how to take care of your pet.”). Conclusions: While almost all surveyed pet owners with cancer highly value the emotional support their pet provides and state it helped them recover from cancer treatment, there is a clear need for improved information dissemination regarding patient and pet safety during the patient’s cancer treatment. Accurate and accessible information would benefit patients with cancer and fill an unmet need.

75 Background: Receiving palliative care (PC) is associated with improving quality of life in patients with cancer. Despite its clinical benefits, limited data is available regarding PC utilization among the metastatic breast cancer population. Examining the trends and current patterns of PC provide an opportunity for improved effective implementation of PC in management of patients with breast cancer. Methods: SEER-Medicare linked data was queried to identify patients with metastatic breast cancer aged > 65 years between 2006 and 2017. PC utilization since diagnosis was identified using ICD-9 code V66.7 or ICD-10 Z51.5. Descriptive statistics were used to summarize patient characteristics by the receipt of PC. Multivariable logistic regression was estimated to identify predictors of PC use. Trends in PC utilization were then compared by patient race/ethnicity, residential region, and census poverty rate. Results: Of 11,245 patients with metastatic breast cancer diagnosed between 2006 and 2017 (median survival, 17.9 months), 1,756 (15.6%) received PC (median time from diagnosis to PC, 18.5 months). During the study period, PC use increased significantly from 2.5% in 2006-2007 to 28.1% in 2016-2017 (P trend <.001). Patients with metastatic breast cancer who received PC were more likely to be younger (20.6% among 65-69 years old vs. 11.9% among 80+), living in the West census region (17.2% vs. 14.1% in South), urban areas (16.8% vs. 8.2% in rural), and low poverty rate (16.1% with < 5% poverty level vs. 12.9% with > 20%) (P all <.05). There was no significant difference observed by race or ethnicity (P >.05). Conclusions: There was a significant increase in PC utilization among patients with metastatic breast cancer aged > 65 years between 2006 and 2017. However, its utilization rate remains suboptimal, with geographic, age and income disparities in PC use.

Purpose: Combined modality therapy with multiagent chemotherapy and radiation therapy is a standard treatment option for aggressive mediastinal non-Hodgkin lymphomas (AMNHLs); however, concerns regarding acute and late radiation toxicities have fueled an effort to use systemic therapy alone. The use of proton therapy (PT) is a promising treatment option, but there are still limited data regarding clinical outcomes with this treatment modality. In this Particle Therapy Cooperative Group lymphoma subcommittee collaboration, we report outcomes of patients with AMNHL treated with pencil-beam scanning PT or double-scatter PT after chemotherapy. Methods and Materials: This was a multi-institutional retrospective observational cohort study of patients with AMNHL treated with PT following chemotherapy between 2011 and 2021. Progression-free survival (PFS), local recurrence–free survival (LRFS), and overall survival (OS) rates were estimated with the Kaplan-Meier method. PT toxicity was graded by the Common Terminology Criteria for Adverse Events version 5.0. A 2-tailed paired t test was used for dosimetric comparisons. Results: Twenty-nine patients were identified. With a median follow-up time of 4.2 years (range, 0.2-8.9 years), the estimated 5-year PFS for all patients was 93%, 5-year LRFS was 96%, and estimated 5-year OS was 87%. Maximum acute grade 1 (G1) toxicities occurred in 18 patients, and 7 patients had maximum G2 toxicities. No G3+ radiation-related toxicities were observed. Average mean lung dose and lung V20 Gy were lower for patients treated with pencil-beam scanning PT compared with double-scatter PT (P = .016 and .006, respectively), while patients with lower mediastinal disease had higher doses for all evaluated dosimetric heart parameters. Conclusions: PT after chemotherapy for patients with AMNHL resulted in excellent outcomes with respect to 5-year PFS, LRFS, and OS without high-grade toxicities. Future work with larger sample sizes is warranted to further elucidate the role of PT in the treatment of AMNHL.

Purpose:Radiation-associated angiosarcoma (RAAS) is a rare complication among patients treated with radiation therapy for breast cancer. Hyperfractionated-accelerated reirradiation (HART) improves local control after surgery. Proton therapy may further improve the therapeutic ratio by mitigating potential toxicity. Materials and Methods:Six patients enrolled in a prospective registry with localized RAAS received HART with proton therapy between 2015 and 2021. HART was delivered twice or thrice daily in fraction sizes of 1.5 or 1.0 Gy, respectively. All patients received 45 Gy to a large elective volume followed by boosts to a median dose of 65 (range, 60-75) Gy. Toxicity was recorded prospectively by using the Common Terminology Criteria for Adverse Events, version 4.0. Results:The median follow-up duration was 1.5 (range, 0.25-2.9) years. The median age at RAAS diagnosis was 73 (range, 60-83) years with a median latency of 8.9 (range, 5-14) years between radiation therapy completion and RAAS diagnosis. The median mean heart dose was 2.2 (range, 0.1-4.96) Gy. HART was delivered postoperatively (n = 1), preoperatively (n = 3), preoperatively for local recurrence after initial management with mastectomy (n = 1), and as definitive treatment (n = 1). All patients had local control of disease throughout follow-up. Three of 4 patients treated preoperatively had a pathologic complete response. The patient treated definitively had a complete metabolic response on her posttreatment PET/CT (positron emission tomography-computed tomography) scan. Two patients developed distant metastatic disease despite local control and died of their disease. Acute grade 3 toxicity occurred in 3 patients: 2 patients undergoing preoperative HART experienced wound dehiscence and 1 postoperatively developed grade 3 wound infection, which resolved. Conclusion:HART with proton therapy appears effective for local control of RAAS with a high rate of pathologic complete response and no local recurrences to date. However, vigilant surveillance for distant metastasis should occur. Toxicity is comparable to that in photon/electron series. Proton therapy for RAAS may maximize normal tissue sparing in this large-volume reirradiation setting.

Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach (LYMPHA) is a technique used to prevent BCRL at the time of axillary lymph node dissection (ALND). We report the 5-year experience of a breast surgeon trained in LYMPHA and investigate the outcomes of patients who underwent LYMPHA following ALND for treatment of cT1–4N1–3M0 breast cancer. A retrospective review of patients with cT1–4N1–3M0 breast cancer was performed in patients who underwent ALND with and without LYMPHA. Diagnosis of BCRL was made by certified lymphedema therapists. Descriptive statistics and lymphedema surveillance data were analyzed using results of Fisher’s exact or Wilcoxon rank-sum tests. Logistic regression and propensity matching were performed to assess the reduction of BCRL occurrence following LYMPHA. In a 5-year period, 132 patients met inclusion criteria with 76 patients undergoing LYMPHA at the time of ALND and 56 patients undergoing ALND alone. Patients who underwent LYMPHA at the time of ALND were significantly less likely to develop BCRL than those who underwent ALND alone (p = 0.045). Risk factors associated with BCRL development were increased patient age (p = 0.007), body mass index (BMI) (p = 0.003), and, in patients undergoing LYMPHA, number of positive nodes (p = 0.026). LYMPHA may be successfully employed by breast surgeons trained in lymphatic–venous anastomosis at the time of ALND. While research efforts should continue to focus on prevention and surveillance of BCRL, LYMPHA remains an option to reduce BCRL and improve patient quality of life.

Demand exists for a convenient, user-friendly mobile platform integrating updated, clinically relevant information for busy radiation oncology residents and practitioners. We developed 1ONC as a free, comprehensive and easily accessible mobile and web-based app (application) to address this unmet need. The primary objective for our project is improve the design and functionality of 1ONC by analyzing user engagement and feedback.

Patients with recurrent breast cancer to chest wall, who had previous irradiation, are difficult to manage and have limited options. Several reports described the use of photon therapy, hyperthermia, and brachytherapy. This is a case report of a 72-year-old female with Stage IIIA (pT3N1M0) invasive ductal carcinoma of the right breast status post modified radical mastectomy. The patient developed recurrence to the chest wall and one internal mammary lymph node one year later. She received 3-D conformal photon radiation therapy for this recurrence. Two years later, she had progression of the recurrence at the right chest wall and axillary and internal mammary lymph nodes. She was treated with intensity modulated proton therapy (IMPT) for a total of 6600 cGy in 33 fractions. However, four months later, she was found to have biopsy-proven isolated metastatic disease at her right bicep, which was again treated with IMPT for a dose of 6000 cGy in 20 fractions. Proton beam therapy was used in this case to spare dose to the brachial plexus, heart and lung while optimally irradiating the recurrent tumors. At last follow up, the patient is alive and has been disease free for 39 months. This report describes the technique and dosimetry for this unique case, which also reviewed recent series of re-irradiation using proton beam.

PURPOSE: The purpose of this study is to compare the predicted rate of local control and bladder and rectum toxicity rates for image-guided adaptive brachytherapy plans using a tandem and ovoid (T/O) applicator versus using a simulated hybrid intracavitary/interstitial tandem and ring applicator with needles (T/R + N) for patients with locally advanced cervical cancer (LACC). METHODS AND MATERIALS: Patients with >= FIGO Stage IIB locally advanced cervical cancer treated with T/O from a single institution were included. Simulated treatment plans were created with a T/R + N applicator for the best high-risk clinical target volume (CTV) coverage and minimal dose to organs at risk. Three-year local control rate was estimated using published dose-volume effect relationships. Next, the high-risk CTV EQD2 D90 of T/R + N plans were calculated, and bladder and rectum toxicity rates were estimated. Analysis was performed in subpatient groups defined based on tumor volume and ratio of maximal and minimal tumor radii (RR) that reflects tumor shape asymmetry. RESULTS: Improvements in predicted local control rate for the T/R + N were 0.8, 4.1, 1.6, and 3.9% for groups with tumor volume <35 cc, >= 35 cc, RR < 2.0, and >= 2.0, respectively, with the latter three being statistically significant. Predicted reductions in Grade 2-4 toxicity rates of bladder and rectum were significant in all groups except bladder toxicity in tumor volume < 35 cc, when T/R + N plans were normalized to the same CTV coverage as the T/O plans. Comparing unnormalized T/R + N plans and T/O plans, predicted toxicity reductions were significant in all groups except rectum toxicity in RR >= 2.0. Predicted reduction of toxicity rate was larger for patients with large tumor or large tumor RR, although some reductions were relatively small. CONCLUSIONS: Cases with large tumor (volume >= 35 cc) or large tumor asymmetry (RR >= 2.0) would probably benefit more from the use of hybrid applicators. (c) 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.