BACKGROUND AND OBJECTIVE:Trimodality therapy (TMT) is an accepted bladder-preserving option for selected patients with muscle-invasive bladder cancer (MIBC). Pembrolizumab has demonstrated activity in MIBC and may enhance the effects of chemotherapy and radiation. We evaluated the safety and efficacy of adding pembrolizumab to TMT. METHODS:In this multicenter phase 2 trial, patients with MIBC received one dose of pembrolizumab followed by maximal transurethral resection, then definitive bladder radiation with concurrent low-dose gemcitabine and pembrolizumab every 3 wk for three doses. The primary end point was 2-yr bladder-intact disease-free survival (BIDFS). Secondary end points included safety, metastasis-free survival (MFS), and overall survival (OS). KEY FINDINGS AND LIMITATIONS:Fifty-four patients were enrolled, including 48 in the efficacy cohort; 67% had clinical stage T2 disease. The 2-yr BIDFS was 60% (95% confidence interval [CI], 45-73). Two-yr MFS and OS were 81% (95% CI, 66-92) and 83% (95% CI, 69-91), respectively. Grade ≥3 treatment-related adverse events occurred in 25% of patients. Limitations include the single-arm design and modest sample size. CONCLUSIONS AND CLINICAL IMPLICATIONS:Pembrolizumab combined with gemcitabine-based chemoradiation was feasible and showed efficacy comparable to standard TMT. Ongoing phase 3 trials will further define its role in bladder preservation.

INTRODUCTION:Focal dose intensification strategies targeting the dominant intra-prostatic lesion (DIL) improve outcomes of patients with prostate cancer. The purpose was to determine whether the 6-month multiparametric (mp)MRI response of the DIL is associated with post-treatment prostate-specific antigen (PSA) kinetics after MRI linear accelerator (LINAC) guided stereotactic body radiotherapy (SBRT) with focal dose intensification. METHODS:Retrospective, single-center study including 72 patients with localized prostate cancer treated with MRI-LINAC SBRT with focal dose intensification and without androgen deprivation therapy. Patients were followed up at 6 months after SBRT with mpMRI and PSA. mpMRI complete response (CR) was defined as no residual lesion on diffusion-weighted imaging and dynamic contrast-enhanced MRI. This was correlated with PSA responses including PSA reduction (%), PSA reduction ≥ 50.0% (PSA50), and PSA ≤ 1.0 ng/mL. RESULTS:mpMRI CR was achieved in 37 patients (51.4%) at 6 months. Patients with mpMRI CR had greater PSA reduction (81.8% vs 66.1%, p < 0.001), and more commonly had PSA50 (100.0% vs 82.9%, p = 0.010) and PSA ≤ 1.0 ng/mL (45.9% vs 11.4%, p = 0.001) compared to those without mpMRI CR. In 10 patients without 6-month mpMRI CR but had further MRI follow-up (median 13 months), DILs either further decreased in size (30.0%) or resolved (70.0%). CONCLUSION:Initial 6-month mpMRI response correlates with PSA kinetics, which is associated with important clinical outcomes. mpMRI can be used for post-SBRT evaluation to gauge local tumor response of the DIL, where most recurrences occur.

OBJECTIVE:This study aimed to explore the demographic and clinical factors associated with delayed initiation of treatment for patients with cervical cancer treated with chemoradiation and brachytherapy and determine its impact on oncologic outcomes. METHODS:Patients with stage IB2 to IVA cervical cancer who were treated with definitive chemoradiation therapy and brachytherapy from 2009 to 2019 were included. Patients who initiated treatment within 8 weeks of diagnosis (early) were compared with those who initiated treatment after 8 weeks (delayed). Time intervals at each stage of care and reasons for delay were evaluated. Logistic regression was performed to identify factors associated with delayed treatment initiation. Cox regression analyzed factors associated with progression-free and overall survival. RESULTS:Of 122 patients, 76 (62%) initiated early treatment, with a median time to treatment of 35 days, and 46 (38%) underwent delayed treatment initiation, with 76 median days to treatment. Patients referred from the public hospital were more likely to experience delayed treatment than those referred from the private hospital (odds ratio 4.31, 95% confidence interval [CI] 1.31 to 14.07). Most delays were due to system factors (85%). Each 10-day increase in time to treatment initiation was associated with worsened overall survival (hazard ratio [HR] 1.07, 95% CI 1.01 to 1.13). Public hospital patients were more likely to experience delays but were less likely to present with advanced stage (29% vs 50%, p = .031) and had improved overall survival compared with patients referred from the private hospital (HR 0.37, 95% CI 0.16 to 0.87). CONCLUSIONS:Treatment initiation delays were associated with a decrement in survival. In this cohort, public hospital patients were more likely to have a favorable stage and improved survival than those from the private hospital but also were more likely to experience treatment initiation delays. Referral patterns and delays related to diagnostic workup were the most common factors contributing to delays in care establishment. Improving care coordination may ensure equitable access to timely staging and treatment. Further studies are needed to determine whether treatment initiation delays impact cancer outcomes.

Purpose of review The most common definitive treatment for muscle-invasive bladder cancer (MIBC) is radical cystectomy. However, removing the bladder and surrounding organs poses risks of morbidity that can reduce quality of life, and raises the risk of death. Treatment strategies that preserve the organs can manage the local tumor and mitigate the risk of distant metastasis. Recent data have demonstrated promising outcomes in several bladder-preservation strategies. Recent findings Bladder preservation with trimodality therapy (TMT), combining maximal transurethral resection of the bladder tumor, chemotherapy, and radiotherapy (RT), was often reserved for nonsurgical candidates for radical cystectomy. Recent meta-analyses show that outcomes of TMT and radical cystectomy are similar. More recent bladder-preservation approaches include combining targeted RT (MRI) and immune checkpoint inhibitors (ICIs), ICIs and chemotherapy, and selecting patients based on genomic biomarkers and clinical response to systemic therapies. These are all promising strategies that may circumvent the need for radical cystectomy. Summary MIBC is an aggressive disease with a high rate of systemic progression. Current management includes neoadjuvant cisplatin-based chemotherapy and radical cystectomy with lymph node dissection. Novel alternative strategies, including TMT approaches, combinations with RT, chemotherapy, and/or ICIs, and genomic biomarkers, are in development to further advance bladder-preservation options for patients with MIBC.

Background and purpose: Radiation dose prescriptions are foundational for optimizing treatment efficacy and limiting treatment-related toxicity. We sought to assess the lack of standardization of SBRT dose pre-scriptions across institutions. Materials & Methods: Dosimetric data from 1298 patients from 9 academic institutions treated with IMRT and VMAT were collected. Dose parameters D100, D98, D95, D50, and D2 were used to assess dosimetric variability.Results: Disease sites included lung (48.3 %) followed by liver (29.7 %), prostate (7.5 %), spine (6.8 %), brain (4.1 %), and pancreas (2.5 %). The PTV volume in lung varied widely with bimodality into two main groups (22.0-28.7 cm3) and (48.0-67.1 cm3). A hot spot ranging from 120-150 % was noted in nearly half of the patients, with significant variation across institutions. A D50 >= 110 % was found in nearly half of the insti-tutions. There was significant dosimetric variation across institutions.Conclusions: The SBRT prescriptions in the literature or in treatment guidelines currently lack nuance and hence there is significant variation in dose prescriptions across academic institutions. These findings add greater importance to the identification of dose parameters associated with improved clinical outcome comparisons as we move towards more hypofractionated treatments. There is a need for standardized reporting to help institutions in adapting treatment protocols based on the outcome of clinical trials. Dosimetric parameters are subsequently needed for uniformity and thereby standardizing planning guidelines to maximize efficacy, mitigate toxicity, and reduce treatment disparities are urgently needed.(c) 2023 Elsevier B.V. All rights reserved. Radiotherapy and Oncology 182 (2023) 109571

Supplementary Data: Tables S1-S2; Figures S1-S4

4509 Background: Trimodality therapy (TMT) is a standard treatment option for MIUC. We previously reported an early analysis of a phase II study of pembro added to standard TMT with maximal transurethral resection of bladder tumor (TURBT), hypofractionated RT and twice weekly gem (ASCO 2021). Herein we present updated follow up safety and efficacy results. Methods: In this multicenter phase 2 trial, patients (pts) with clinical T2-T4aN0M0 MIUC who were ineligible fpr or declined radical cystectomy, had ECOG PS 0/1 and eGFR≥30 cc/min were enrolled. Pts received pembro 200 mg IV x 1 followed by maximal TURBT and then whole bladder RT (52 Gy/20 fx) with twice weekly gem 27 mg/m2 and pembro Q3 wks x 3 treatments. Response was assessed every 12 weeks post-RT with CT/MRI, tumor bed biopsy and cytology. The primary endpoint was 2-yr bladder-intact disease-free survival (BIDFS; first of MIUC, regional or distant metastases, cystectomy or death). Our study had 85% power to detect a 20% absolute improvement in 2-yr BIDFS rate over 60% historical rate (Mak JCO 2014). Key secondary endpoints included safety, 12-week pathologic complete response (CR) rate, metastases-free survival (MFS) and overall survival (OS). Results: Between 5/2016 and 6/2022, 54 pts (median age 74 years, 72% male, 83% Caucasian; clinical stage: 74% T2, 22% T3 and 4% T4) were enrolled at 5 institutions. PD-L1 status was available in 43 pts, and 21 pts (49%) had modified proportion score≥10. Forty-six (88%) pts completed all therapy. 1/54 (2%), 3/54 (6%), and 4/54 (7%) discontinued RT/Gem, Gem or Pembro, respectively, most commonly due to toxicity. 6 pts (11%) underwent salvage cystectomies. As of 6/2022, with a median FU of 23 months (1.6- 62.7) there were 12 (22%) tumor recurrences (3 MIUC, 5 locoregional, 4 distant). 4 pts (7%) had non-muscle invasive only recurrences. The efficacy outcomes are shown. 10 pts died during the study period (18%; 3 from disease progression, 1 from treatment toxicity and 6 from unrelated/unknown causes). There were no new safety signals in our updated analysis: 13 pts (24%) experienced 17 AEs that were Grade 3 or greater (cytopenias [n=7], colitis [n=5], cystitis [n=2], polyneuropathy, fatigue, hypokalemia [n=1, each]). Grade 3 or greater immune-related AEs included 2 pts with colitis, 1 pt with polyneuropathy and 1 pt with Grade 5 colonic perforation. Conclusions: TMT combined with pembro was well tolerated and continues to show promising early outcomes data. A large phase 3 trial is underway to further explore this treatment. Clinical trial information: NCT02621151 . [Table: see text]

Purpose Locally advanced cervical cancer was defined by an international consensus panel as a high priority malignancy during the COVID-19 pandemic, recommending prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID). Materials and Methods This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/1/2019 to 12/31/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT in 1/2019-12/2019, and peri-COVID was defined by initiation in 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05. Results Thirty-one pts were included, with 18 patients undergoing treatment pre-COVID and 13 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, four pts had delayed initiation to treatment >100 days: two related to fertility, and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3 cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts except one completed CRT with RT: 25 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710). Conclusions Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in dosimetric treatment parameters pre- and peri-COVID. Delays in treatment initiation of treatment initiation were seen in 30% of pts in the peri-COVID period, suggesting that patients may have had increased barriers to access care. More follow-up is needed to determine how the Covid pandemic impacted cervical cancer outcome measures.

ObjectivesTo investigate the efficacy and safety of lung stereotactic body radiation therapy (SBRT) for non-small cell lung cancer (NSCLC) including oligorecurrent and oligoprogressive disease.MethodsSingle-institution retrospective analysis of 60 NSCLC patients with 62 discrete lesions treated with SBRT between 2008 and 2017. Patients were stratified into three groups, including early stage, locally recurrent, and oligoprogressive disease. Group 1 included early stage local disease with no prior local therapy. Group 2 included locally recurrent disease after local treatment of a primary lesion, and group 3 included regional or well-controlled distant metastatic disease receiving SBRT for a treatment naive lung lesion (oligoprogressive disease). Patient/tumor characteristics and adverse effects were recorded. Local failure free survival (LFFS), progression free survival (PFS), and overall survival (OS) were estimated using the Kaplan Meier method.ResultsAt median follow-up of 34 months, 67% of the study population remained alive. The estimated 3-year LFFS for group 1, group 2, and group 3 patients was 95% (95% CI: 86%-100%), 82%(62% - 100%), and 83% (58-100%), respectively. The estimated 3-year PFS was 59% (42-83%), 40% (21%-78%), and 33% (12%-95%), and the estimated 3-year OS was 58% (41-82%), 60% (37-96%), and 58% (31-100%)), respectively for each group. When adjusted for age and size of lesion, no significant difference in OS, LFFS, and PFS emerged between groups (p > 0.05). No patients experienced grade 3 to 5 toxicity. Eighteen patients (29%) experienced grade 1 to 2 toxicity. The most common toxicities reported were cough and fatigue.ConclusionsOur data demonstrates control rates in group 1 patients comparable to historical controls. Our study also reveals comparable clinical results for SBRT in the treatment of NSCLC by demonstrating similar rates of LFFS and OS in group 2 and group 3 patients with locally recurrent and treatment naïve lung lesion with well-controlled distant metastatic disease.

In this hypothesis-generating retrospective cohort study, patients with oligoprogressive malignancy treated with SBRT have similar freedom from new systemic therapy to patients with oligometastatic malignancy, strengthening the rationale for treating oligoprogressive malignancy with SBRT.

Our ICVBT survey tool is designed to screen for "at-risk" patients, and provide a pathway for open dialogue between patients and physicians to potentially reduce undue harm during this important, yet sensitive treatment. To the best of our knowledge, this is the first such ICVBT survey tool to assess for a history of sexual trauma, and include SOGI and gender-inclusive questions. This adaptation has allowed our team to approach patients in a sensitive manner inclusive of their identity and prior experiences. Preliminary data is being collected and will be presented at the conference.

We built an interactive web-based dashboard to enable general users' easy access to de-identified clinical data stored within the institutional big data platform. Additional data sources, including external molecular data can be connected to the dashboard allowing for future integration.

Objective: Neoadjuvant chemoradiation (NA-CRT), followed by resection of high-risk soft tissue sarcoma (STS), may offer good disease control and toxicity outcomes. We report on a single institution's modern NA-CRT experience. Materials and Methods: Delay to surgical resection, resection margin status, extent of necrosis, tumor cell viability, presence of hyalinization, positron emission tomography (PET)/computed tomography data, and treatment toxicities were collected. Using the Kaplan-Meier survival analysis, 5-year overall survival, disease-free survival, distant metastasis-free survival, and local control (LC) were estimated. Clinicopathologic features and PET/computed tomography avidity changes were assessed for their potential predictive impact using the log-rank test. Results: From 2011 to 2018, 37 consecutive cases of localized high-risk STS were identified. Twenty-nine patients underwent ifosfamide-based NA-CRT to a median dose of 50 Gy before en bloc resection. At a median follow-up of 40.3 months, estimated 5-year overall survival was 86.1%, disease-free survival 70.2%, distant metastasis-free survival 75.2%, and LC 86.7%. Following NA-CRT, a median reduction of 54.7% was observed in tumor PET avidity; once resected, median tumor necrosis of 60.0% with no viable tumor cells was detected in 13.8% of the cases. Posttreatment resection margins were negative in all patients, with 27.6% having a margin of <= 1 mm. Delays of over 6 weeks following the end of radiation treatment to surgical resection occurred in 20.7% cases and was suggestive of inferior LC (92.8% vs. 68.6%, P=0.025). Conclusions: This single-institution series of NA-CRT demonstrates favorable disease control. Delay in surgical resection was associated with inferior LC, a finding that deserves further evaluation in a larger cohort.

Objective: We aimed to explore the disparities associated with the delay of initiating chemoradiation therapy (CRT) and brachytherapy (BT) beyond the recommended 8 weeks for patients with cervical cancer and the effect on outcomes.

Intracavitary brachytherapy (ICBT) is an essential component of definitive chemoradiation for localized cervical cancer. This procedure is complex, and even in the hands of experts, complications arise. The most notable complication is perforation of the tandem through a friable cervix/vagina or uterine wall. Historical rates of perforation have been reported to be 2 – 15% without routine image guidance, such as intra-operative ultrasound (IOUS). However, with IOUS guidance, perforation rates have been reported to range from 0 - 6%, although up to 30% has been reported in high risk patients. Notably, IOUS use has also been shown to reduce time required for applicator insertion, reduce complications, and improve overall cost savings. Despite current practice guidelines recommending IOUS, widespread adoption and data regarding the benefit of IOUS remains limited. Here, we examine the impact of IOUS in reducing complications during tandem applicator placement at our urban institution, with a high-risk patient population with more advanced disease than those described in currently published literature. With IRB approval, data was collected on patients with cervical cancer treated with EBRT followed by ICBT (1-2 insertions) between 1/1/13 and 2/4/20. All insertions were performed under anesthesia by a gynecologic and radiation oncologist team. Applicators used included tandem & ovoids, tandem & ring, and tandem & split ring. Prior to 2015, IOUS was inconsistently used for ICBT. However, on 1/7/15, based upon root cause analysis, our institution initiated a policy requiring IOUS guidance for tandem insertions to improve applicator positioning and reduce complications, particularly perforations. The rate of intraoperative complication (IOC) was calculated in two ways – 1. the percentage of patients with complications, 2. the percentage of complications per attempted ICBT insertion. Categorical comparisons were completed using a one-tailed Fisher's exact test. 195 tandem insertions were performed for 99 patients treated with ICBT between 1/1/13 and 2/4/20. There was a 70.6% relative risk reduction (95% CI: 0.0989 – 0.8909, p = 0.03) in the number of IOC for a given patient from 23.1% (6 of 26) to 6.8% (5 of 73) after the 1/7/15 implementation of IOUS. When analyzing attempted insertions, the rate of IOC dropped from 11.5% (6 of 52) of attempted insertions to 3.5% (5 of 143) (95% CI: 0.0966 – 0.9509, p = 0.04). All patients who had a perforation were treated with prophylactic antibiotics: no patient required hospitalization or had significant complications. Our results demonstrate that consistent IOUS use has the potential to reduce ICBT complications, especially in high-risk, anatomically complicated patients. Additional investigations focused on disease outcomes and cost effectiveness of the procedure will be important to better understand and further advance widespread implementation of IOUS for ICBT.

Uninsured cervical cancer (CC) patients often experience delays in treatment initiation and other barriers that result in worse outcome. Our center treats patients (pts) with CC with definitive chemoradiation therapy (CRT) referred from both a public (PbH) and private (PrH) hospital in an inner city setting by the same team of physicians. We sought out to determine whether hospital referral or insurance status impacts disease-free (DFS) and overall survival (OS). An IRB approved retrospective review was conducted for pts with CC treated with definitive CRT: external beam pelvic RT and chemotherapy followed by intracavitary brachytherapy (BT) boost (median 7 Gy x 4 fractions) delivered via two insertions of intracavitary BT two weeks apart with image-guided CT/MR target delineation. We evaluated age, stage, PbH versus PrH, time from diagnosis to treatment (TTT) and insurance status: uninsured (UI), Medicare/Medicaid (MM) or private insurance (PR). Disease free survival (DFS) and overall survival (OS) were analyzed with the Kaplan-Meier method. Multivariate Cox hazards analysis was run to identify the effects of covariates, using R v3.5.1. Between 7/2009 and 9/2017, 106 pts were diagnosed with FIGO stage IA(1), IB(22), IIA(10), IIB(46), IIIA(3), IIIB(24) and IVA(2) CC. Median age was 54 years (y) (range 28-83). At median follow-up of 32.2 months (3.8-110.2), locoregional control (LC) was 80.2%. 5-y DFS and OS was 62.4% and 84.2%. PbH pts were diagnosed at a younger median age of 52.4y (28.1-77.7) compared to 59.8y (30-83) at PrH (P=0.03). PbH vs PrH pts were more likely to present at earlier stages I/II (79% vs 56%), than stages III/IV (21% vs 44%, P=0.04), and have better outcomes: PbH vs PrH DFS was 65.0% vs 54.5% (P=0.1), while OS was 89.3% vs 54.9% (P=0.01). PbH pts were more likely to be UI or have MM and less likely to have PR insurance compared to PrH pts (P<0.001):31 PbH pts were UI (38.3%), 43 had MM (53.1%) and 7 had PR (8.6%) while 11 PrH pts had MM (44%) and 14 had PR (56%). There was no association between insurance status and stage at time of diagnosis (P=0.343). DFS was 67.4% for UI, 67.1% for MM and 43.7% for PR pts (P=0.073). UI pts had significantly better OS: 100% for UI, compared with 85.7% for MM, and 50.8% for PR (P<0.001). Median TTT was 47d (range 0-464d) and was significantly longer in pts referred from a PbH vs PrH (mean 65.1d vs 33.5d, P=0.0017) but TTT was not significantly different by insurance status: 55d for UI, 48.5d for MM and 36d for PR (ANOVA P=0.09). TTT was not associated with either DFS (P=0.45) or OS (P=0.45). Although patients referred from public hospital had a longer delay in the time from diagnosis to treatment they did not exhibit worse outcomes. Additionally, uninsured patients did not have worse outcomes compared with patients with Medicare, Medicaid or private insurance likely because treatment was provided by the same centralized multidisciplinary team for all patients.

We describe a case of the first successful treatment of platinum refractory clear cell ovarian cancer with secondary cytoreductive surgery and placement of Calypso transponders to facilitate post-operative volumetric arc radiation therapy. In the setting of both primary and recurrent disease, patients with clear cell ovarian cancer are less responsive to standard chemotherapy and those treated with radiation therapy may have improved outcomes compared to the use of other treatment modalities. Volumetric arc radiation therapy with implantable transponders is feasible, and allows for the targeted treatment of sites of metastatic disease while limiting toxicity to surrounding structures and can be considered for patients with recurrent ovarian cancer and oligometastatic disease.

AbstractPurpose:Previous studies indicate that the benefit of therapy depends on patients' risk for cancer recurrence relative to noncancer mortality (ω ratio). We sought to test the hypothesis that patients with head and neck cancer (HNC) with a higher ω ratio selectively benefit from intensive therapy.Experimental Design:We analyzed 2,688 patients with stage III–IVB HNC undergoing primary radiotherapy (RT) with or without systemic therapy on three phase III trials (RTOG 9003, RTOG 0129, and RTOG 0522). We used generalized competing event regression to stratify patients according to ω ratio and compared the effectiveness of intensive therapy as a function of predicted ω ratio (i.e., ω score). Intensive therapy was defined as treatment on an experimental arm with altered fractionation and/or multiagent concurrent systemic therapy. A nomogram was developed to predict patients' ω score on the basis of tumor, demographic, and health factors. Analysis was by intention to treat.Results:Decreasing age, improved performance status, higher body mass index, node-positive status, P16-negative status, and oral cavity primary predicted a higher ω ratio. Patients with ω score ≥0.80 were more likely to benefit from intensive treatment [5-year overall survival (OS), 70.0% vs. 56.6%; HR of 0.73, 95% confidence interval (CI): 0.57–0.94; P = 0.016] than those with ω score <0.80 (5-year OS, 46.7% vs. 45.3%; HR of 1.02, 95% CI: 0.92-1.14; P = 0.69; P = 0.019 for interaction). In contrast, the effectiveness of intensive therapy did not depend on risk of progression.Conclusions:Patients with HNC with a higher ω score selectively benefit from intensive treatment. A nomogram was developed to help select patients for intensive therapy.

e17018 Background: In the US, cervical cancer (CC) disproportionately impacts minorities and women with insufficient access to care. In our department, patients (pts) with advanced CC referred from a public hospital (PbH) and a private hospital (PrH) are treated with the same integrated team of physicians. We sought to determine whether referral source affects outcome post definitive chemoradiation (CRT) and brachytherapy (BT) for CC pts. Methods: An IRB approved retrospective review was conducted for pts diagnosed with CC and treated with definitive CRT. All pts were treated with external beam RT and chemotherapy followed by intracavitary BT boost (median 7 Gy x 4 fractions) delivered via two insertions of intracavitary BT two weeks apart with image-guided CT/MR delineation. Disease free survival (DFS) and overall survival (OS) were analyzed with the Kaplan-Meier method. Multivariate Cox hazards analysis was run to identify the effects of covariates, using R v3.5.1. Results: Between 7/2009 and 9/2017, 106 pts were diagnosed with FIGO stage IA(1), IB(22), IIA(10), IIB(46), IIIA(3), IIIB(24) and IVA(2) CC. 81 (76.4%) pts were diagnosed and received chemotherapy and operative insertion at PbH, 25 (23.6%) at PrH. Median age was 54 years (y), range (28-83). At median follow-up of 32.2 months (3.8-110.2), local control was 82%. 5-y DFS and OS was 62.4% and 84.2%. 19.8% pts were diagnosed at age 65 or greater. PbH pts were diagnosed at a younger median age of 52.4y (28.1-77.7) compared to 59.8y (30-83) at PrH (P = 0.03). PbH vs PrH pts were more likely to present at earlier stages I/II (79% vs 56%), than stages III/IV (21% vs 44%), p = 0.04 and have better outcomes; PbH vs PrH DFS was 65.0% vs 54.5% (P = 0.1), while OS was 89.3% vs 54.9% (P = 0.01). In Cox multivariate analysis, only stage at diagnosis was a significant independent predictor of survival (P = 0.006). Conclusions: Our data suggests that patients referred from a public hospital do not have worse outcomes when treated by a centralized multidisciplinary team. PrH pts presented at older age, more advanced stage and had worse OS than PbH pts. Twenty percent of pts diagnosed with advanced CC were above age 65, highlighting the need for continued screening.