Abstracts of the 2023 Canadian Association of Medical Oncologists Annual Scientific Meeting

On behalf of the Canadian Association of Medical Oncologists, we are pleased to present the abstracts of the 2023 Annual Scientific Meeting. The CAMO Annual Scientific Meeting (ASM) took place on 27 April 2023 in an in-person event in Toronto, ON. Thirty-two (32) abstracts were selected for presentation as oral presentations, in-person poster presentations, and virtual poster presentations. Awards for the top four (4) abstracts were presented during the ASM; they have been marked as “Award Recipient”. We congratulate all presenters on their research work and contribution.

The benefit of adjuvant bisphosphonates (BPs) in patients receiving contemporary systemic therapy remains uncertain. Therefore, we performed this meta-analysis to determine the absolute and relative benefits of adjuvant BPs on DFS and OS in patients with early-stage breast cancer in contemporary trials.

Methods
Using references from the American Society of Clinical Oncology guidelines on the use of adjuvant BPs (2017 and 2022), we selected randomized trials that recruited patients exclusively after 2000 and extracted the 5-year DFS and OS in the BP and control group arm along with associated hazard ratios (HRs). DFS and OS data were weighed by the study sample size. The HRs for DFS and OS were pooled in a meta-analysis using generic inverse variance and random effects modelling. A meta-regression comprising linear regression weighted by sample size (mixed effects) was performed to explore the association between disease-and treatment-related factors and the absolute differences in the benefit resulting from BPs.

Conclusions
Compared with the data reported by the Early Breast Cancer Trialist's Collaborative Group, the benefit from adjuvant BPs is lower in more recent clinical trials, especially in patients receiving contemporary chemotherapy. The balance between benefits and risks of adjuvant BPs should be considered in individual patients.

Objective
To identify the rates of adherence to guideline-recommended surgery and adjuvant chemotherapy treatment for early-stage (IB to IIIA) non-small cell lung cancer (NSCLC) patients in Ontario.

Methods
A retrospective population-based study using linked administrative data through ICES was completed that included all adult patients (age of 18 years or older) that were diagnosed with stage IB to IIIA (AJCC 7th edition) NSCLC from 2010 to 2020 in Ontario. The rates of surgery and chemotherapy completion were calculated using available OHIP (Ontario Health Insurance Plan) billing codes. A logistic regression was also completed to assess any predictors for adherence to the guideline-recommended treatments.

Conclusions
In our population-based study, less than half of the patients with early-stage (IB-IIIA) NSCLC underwent surgical resection and chemotherapy. These low rates are concerning and are likely leading to sub-optimal outcomes. Furthermore, in the context of increasing the number of neoadjuvant and adjuvant clinical trials involving early-stage NSCLC patients, the real-world outcomes may be drastically different from the trial outcomes if there is poor adherence to guidelines in the real world. Our data suggest a need for quality improvement strategies to identify and improve treatment adherence for patients with early-stage NSCLC.

Oral Presentation The Impact of COVID-19 On The Wellness and Resilience of The Canadian Medical Oncology Workforce: A Canadian Association of Medical Oncologists Survey
Lauren Jones 1 , Bruce Colwell 2 , Desiree Hao 3 , Stephen Welch 4 , Alexi Campbell 5 and Sharlene Gill 1 1.
Medical Oncology, BC Cancer, University of British Columbia, Vancouver, BC 2.
Medical Oncology, London Regional Cancer Program, London, ON 5.
Canadian Association of Medical Oncologists, Ottawa, ON

Background
The COVID-19 (C19) pandemic has presented professional and personal challenges. The Canadian Association of Medical Oncologists (CAMO) has been examining the effects of C19 on the workforce to understand the impact of the pandemic on the medical oncology (MO) community. This survey examines how C19 has impacted the workforce with a focus on wellness and resilience; it also assesses the impact that C19 may have on the MO workforce capacity going forward.

Methods
An English-language, multiple-choice survey was distributed by email to MO members who were identified through CAMO and the Royal College of Physicians and Surgeons directory in March 2022.

Results
The response rate was 32% (n = 151/477). The respondents were 59% female, where 88% worked in comprehensive cancer centers and 64% had been in practice for > 10 years. Physical (60%) and mental (60%) wellness were reported as the biggest personal challenges. Of the respondents, 47% were dissatisfied or very dissatisfied with their current work-life balance, and 83% indicated that their workload had increased since the beginning of C19. Of the respondents, 56% were considering retiring or reducing total working hours or full-time equivalent (FTE) in the next 5 years, and 35% had considered leaving the MO community entirely. Career length > 10 years and age > 40 years were associated with considering leaving MO (p = 0.01 and p = 0.03, respectively). Career length > 10 years was associated with the consideration of reducing total working hours or current FTE within the next 5 years (p = 0.045) (Table 1).

Conclusions
This survey corresponds with the transition of the C19 pandemic towards becoming endemic. There are concerns that correspond to physician wellness, workload escalation, and job dissatisfaction. One-third of respondents were considering leaving MO practice, which was associated with > 10 years of practice, suggesting the potential loss of the senior, experienced workforce. With the escalating demand for MO services due to rising cancer prevalence and treatment complexity, the proactive implementation of wellness, retention, and workload modification strategies are needed to ensure the stability of the Canadian MO workforce.

Background
To mitigate the risks of chemotherapy-associated neutropenia, during the COVID-19 pandemic, all genitourinary (GU) cancer patients that were treated with chemotherapy at the Princess Margaret Cancer Centre (PMCC) were offered primary prophylaxis with GCSF. We hypothesized that these reduced the rates of febrile neutropenia, hospitalizations, and healthcare costs and improved the overall outcomes compared with GU cancer patients treated with chemotherapy without GCSF in the 2 years prior to the pandemic.

Methods
We performed a retrospective review of GU cancer patients receiving curative or palliative intent chemotherapy and with or without primary GCSF prophylaxis between Jan 2018 and June 2022.
During chemotherapy, the median white blood cell levels were higher in the GCSF group compared with the non-GCSF group (14.1 × 10 × 9/L vs. 2.90 × 10 × 9/L, p < 0.0001); neutropenia rates were markedly lower (2% vs. 93%, p = < 0.0001). Hospital admission rates were significantly lower in G-CSF users compared with non-users (19% vs. 69%, p < 0.0001). A symptomatic disease progression of 13% was the leading cause of admission in the G-CSF group. Infectious causes such as UTI, pneumonia, COVID-19, and sepsis were seen in 12% of the G-CSF group compared with 31% in the non-users. G-CSF was well tolerated, with just 0.97% discontinuing G-CSF.

Conclusions
During the COVID-19 pandemic, primary prophylactic G-CSF use in GU cancer patients undergoing chemotherapy significantly lowered the rates of both febrile neutropenia and hospitalizations; this could be a cost-effective strategy in this patient population that warrants further study.

Objective
To evaluate the use of bone-targeted agents (BTAs) and its relationship with palliative bone radiation as a measure of skeletal-related events (SREs) in patients with metastatic castration-resistant prostate cancer (mCRPC).

Conclusions
Patients receiving contemporary prostate cancer treatments still suffer from a significant burden of skeletal-related events, and the majority only started BTA treatment after first having an SRE. Our results highlight an opportunity to improve outcomes by emphasizing the early introduction of BTAs in mCRPC patients who are being started on LPT.
Department of Internal Medicine, Edmonton, AB 2.
Cross Cancer Institute, Edmonton, AB

Objective
Emerging evidence indicates that anemia may confer an immunosuppressive state, including for patients with cancer. We hypothesized that the presence of anemia may negatively impact the efficacy of immunotherapy. We tested for associations between peripheral blood cell counts (hemoglobin, leukocyte, neutrophil, lymphocyte, and platelet counts) and the response to immunotherapy as measured by overall survival (OS) and objective response rate (ORR).

Methods
A retrospective cohort study was conducted on Albertan patients > 18 years old with unresectable or metastatic melanoma diagnosed between January 2008 and December 2017 and who were treated with at least one dose of immunotherapy. The data were extracted from the Alberta Cancer Registry. Retrospective chart reviews were completed for the laboratory data and radiological findings. Tests for associations between peripheral blood counts (hemoglobin, leukocyte, neutrophil, lymphocyte, and platelet counts) and OS/ORR were performed. The analyses were adjusted for confounders, including age, sex, toxicity, Charlson Comorbidity Index, transfusion history, tumor location, and treatment regimen.

Conclusions
In our analysis, OS was proportionally diminished with the degree of anemia, but thrombocytopenia was not; this suggests that our observation has immunological significance. Anemia and lymphopenia, but not abnormal platelet counts, were associated with reduced OS among metastatic melanoma patients. Only anemia was associated with a reduced ORR. Our analysis is limited by its retrospective nature but suggests that anemia may negatively impact immunotherapy treatment outcomes. More study is required to delineate possible immunologic mechanisms to explain our findings.

Objective
Given the availability of central nervous system (CNS)-penetrant systemic therapies that target the androgen receptor (AR), we evaluated the expression of the AR "target" in breast cancer brain metastases (BrMs).

Methods
An established, retrospective cohort of 57 patients with metastatic breast cancer who underwent surgery for BrMs at the Sunnybrook Odette Cancer Centre (SOCC) between 1999 and 2013 was studied. AR expression in BrM samples was assessed in triplicate using immunohistochemistry (IHC). AR-positive status was defined as nuclear AR expression ≥ 10% in tumor-infiltrating cells as a percentage of tumor area using the SP107 antibody.

Conclusions
AR is expressed in the majority of breast cancer BrMs and represents a promising therapeutic target.

Informative Tools to Optimize Neoadjuvant Therapy in Er-Positive, Her2-Negative Breast Cancers
Lidiya Luzhna, Stephen Chia, Mehrnoosh Pauls and Nathalie Levasseur BC Cancer Vancouver, Vancouver, BC

Background
Neoadjuvant therapy (NAT) in HR+/HER2-tumors is often disputable. While the role of Oncotype DX has been well established in adjuvant settings, its clinical utility and potential implementation for the prediction of NAT benefit requires further study.

Purpose
This ongoing study aims to report the feasibility of Oncotype DX testing on core biopsy specimens prior to NAT in patients with operable HR+/HER2-breast cancer. The effect of the recurrence score (RS) on systemic treatment recommendations and its correlation to dynamic markers of proliferation and NAT response will be evaluated.

Methods
Participants with clinical T2-T4 and/or node-positive HR+/HER2-breast cancer had Oncotype DX testing conducted prior to NAT. The clinico-pathological information, treatment regimens, and clinical, radiologic, and pathological responses were recorded.

Results
Of the 48 patients with HR+/HER2-breast cancer that were referred to BC Cancer Vancouver for consideration of NAT between September 2021 and January 2023, 26 were eligible and enrolled in the study. The success rate of Oncotype DX testing on core biopsy samples was 96%. The mean turnaround time from patient consent to RS report was 19 calendar days. Approximately 32% of tumors had an RS equal or higher than 26, while 4% of tumors had a score less than 10. Nearly 25% of neoadjuvant treatment recommendations were changed based on the RS. Overall, 33% of patients received neoadjuvant chemotherapy, 54% received neoadjuvant endocrine treatment, and 12.5% proceeded with upfront surgery.

Conclusions
The success rate of Oncotype DX testing on core biopsy samples was excellent. There were multiple factors that influenced trial enrollment, highlighting the low uptake and equipoise of NAT use in HR+/HER2-tumors. The Oncotype DX testing resulted in a change in the systemic treatment plan in 25% of patients. Analyses are ongoing to correlate the RS to NAT response, dynamic Ki-67 changes, and breast MRI changes.

Background
The presence of circulating tumor DNA (ctDNA) is prognostic in solid tumors that are treated with curative intent. Studies have evaluated ctDNA at specific 'landmark' timepoints or over numerous 'surveillance' timepoints. However, variable results have led to uncertainty about the clinical validity of this tool.

Methods
A search of MEDLINE (host: PubMed) identified studies evaluating ctDNA monitoring after curative intent therapy in solid tumors. The odds ratios (OR) for clinical and/or radiologic recurrence at both landmark and surveillance time points for each study were calculated and pooled in a meta-analysis using the Peto method. The pooled sensitivity and specificity as weighted by an individual study inverse variance method were estimated; meta-regression utilizing linear regression weighted by inverse variance was performed to explore the associations between patient and tumor characteristics and the OR for disease recurrence.

Results
Of the 39 studies identified; 30 (1924 patients) and 24 studies (1516 patients) reported on landmark and surveillance time points, respectively. The pooled OR for recurrence at the landmark was 15.47 (95% CI 11.84-20.22); at the surveillance point, it was 31.0 (95% CI 23.9-40.2). The pooled sensitivity for ctDNA at the landmark and surveillance analyses were 58.3% and 82.2%, respectively. The corresponding specificities were 92% and 94.1%. There was lower prognostic accuracy with the use of tumor agnostic panels. Adjuvant chemotherapy negatively impacted specificity in the landmark setting. Longer time to landmark analysis, higher number of surveillance blood draws, and a history of smoking were associated with higher prognostic accuracy.

Conclusions
Although ctDNA at both landmark and surveillance time points shows high prognostic accuracy for relapse in patients with solid tumors treated with curative intent, it has low sensitivity, borderline high specificity, and thus modest discriminatory accuracy, especially for landmark analyses. Adequately designed clinical trials with appropriate testing strategies and assay parameters are required to demonstrate clinical utility.
We conducted a systematic review and meta-analysis to assess the role of immune checkpoint inhibitors (ICIs) in the treatment of extended-stage small cell lung cancer (ES-SCLC).
The MEDLINE (PubMed), EMBASE, and Cochrane Library databases were queried between January 2010 and March 2022, and conference proceedings between 2018 and 2022 were searched for randomized clinical trials assessing ICIs (combined with chemotherapy or as single agents), compared with chemotherapy, in patients with ES-SCLC. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Secondary endpoints included objective response rate (ORR) and grade 3 or higher adverse events (AEs). Pooled hazard ratios (HRs) for OS and PFS were meta-analyzed using the generic inverse variance method, and random-effect models were used to compute pooled estimates. Subgroup analyses compared the survival by line of therapy, sex, age, and ECOG status.
A total of 5325 patients from 10 trials were included. Compared with chemotherapy, ICI-based treatment decreased the risk of death by 19% (HR 0.81, 95% confidence interval (CI) 0.76-0.86). The OS benefit was observed regardless of age, sex, or ECOG status, but was only observed in patients treated in the first-line setting. Similarly, ICI-based therapy decreased the risk of disease progression by 20% (HR 0.80, 95% CI 0.68-0.94), and the PFS benefit was restricted to first-line treatment with a detrimental effect occurring in the second-line setting. The ORR was also improved with ICIs (odds ratio (OR) 0.80, 95% CI 0.65-0.97) with an increase in grade 3 or higher diarrhea (OR 3.63, 95% CI 1.46-9.02).
In conclusion, ICIs conferred efficacy benefits (OS, PFS, and ORR) and an acceptable safety profile in the treatment of patients with ES-SCLC in the first-line setting; they should not be used in the second-line setting as single agents. Valid biomarkers that predict the long-term benefits are needed to further improve outcomes.

Assessment of Tumor-Infiltrating Lymphocytes as A Prognostic Factor In Patients with Objective
To determine whether tumor-infiltrating lymphocytes (TILs) impact prognosis in patients treated with immunotherapy for advanced melanoma.

Methods
This retrospective study involved 204 patients with metastatic melanoma who received single-agent, palliative-intent PD-1 inhibitors between January 2012 and December 2021 at the Cancer Centre of Southeastern Ontario (CCSEO) and London Regional Cancer Program (LRCP). TILs were assessed in the pathology specimen prior to immunotherapy initiation. TIL status was defined as 'brisk', 'non-brisk/absence', or 'unknown'. The Primary study outcome was overall survival (OS).

Conclusions
Our study demonstrated a non-significant improved OS trend favoring 'brisk' over 'non-brisk/absence' or 'unknown' TIL statuses in advanced melanoma patients on immunotherapy. However, our study was limited by its small sample size and relatively large 'unknown' TIL group. If validated in future larger, multi-center studies, TILs may become part of standard of care pathology reporting, given its inexpensive and benefit of not requiring an additional invasive procedure.

Poster Presentation
An Examination of the Determinants and Outcomes of Acute Immune Checkpoint Inhibitor (Ici) Pneumonitis in Patients with Locally Advanced Non-Small Cell Lung Can-
Internal Medicine Residency Program, University of Calgary, Calgary, AB 2.
Cancer Care Alberta, University of Alberta, AB 3.
Tom Baker Cancer Center, Department of Oncology, University of Calgary, AB

Background
Consolidation durvalumab following chemoradiotherapy has improved survival outcomes in patients with LA-NSCLC. However, ICI pneumonitis is a serious complication that can have life-threatening outcomes, necessitating ICI discontinuation. Understanding the factors that drive the risk of pneumonitis can inform patient selection and treatment monitoring. The objective of this study was to characterize the risk factors and outcomes of ICI pneumonitis in NSCLC patients treated with consolidation durvalumab therapy in real-world practices.

Methods
Using the Alberta Immunotherapy Database, we retrospectively evaluated all NSCLC patients who received durvalumab in Alberta, Canada, from Jan/18 to Dec/21. Pneumonitis cases were identified based on radiographic changes and oncologists' clinical assessments. We examined the incidence and predictive values of severe pneumonitis, with the secondary outcomes of overall survival (OS) and time-to-treatment failure (TTF). Exploratory multivariate analyses were performed to identify the predictive values for developing severe pneumonitis.

Results
Out of 189 patients, most were ECOG 0-1 (91%) and partial response from chemoradiation (85%) prior to durvalumab. The results showed that 49% of patients received a full year of therapy (n = 93). Median TTF = 11.2 months; median OS = 19.7 months with 1-year OS = 64% (n = 121). Median treatment duration = 62 days with a median follow-up duration of 613 days. Durvalumab was discontinued in 23% of patients due to any toxicity. It was found that 26% (n = 49) of patients developed any grade of pneumonitis, and 9% (n = 17) of patients had ≥ grade 3 pneumonitis. With respect to deaths, 13% (n = 9) were attributed to pneumonitis. Corticosteroids were administered to 86% of the patients with pneumonitis (n = 42). Male sex and a pre-existing autoimmune condition were associated with ≥ grade 3 pneumonitis.

Conclusions
We report a risk of pneumonitis that is comparable to prior retrospective studies and the PACIFIC study, but a higher incidence of corticosteroid use. This is the first Canadian real-world study to date that has explored clinical factors associated with ICI pneumonitis post-durvalumab therapy in NSCLC, which may help guide future patient selection for the safe completion of consolidation immunotherapy.

Introduction
To characterize the sequence of PRRT and chemotherapy at two Canadian pNET treatment centers, as distinguished by the availability of PRRT.

Methods
This is a multicenter retrospective cohort study involving the Ottawa Hospital Cancer Centre (TOHCC; PRRT non-treatment center (PRRT-NTC)) and London Regional Cancer Centre (LRCC; PRRT treatment center (PRRT-TC). Patients with histologically confirmed pNETs between January 2010 and June 2021 over the age of 18 years (n = 226) with metastatic disease (n = 177) were included. Demographic, clinical, and cancer treatments were collected. Descriptive statistics were used to evaluate the sequence of systemic therapy.

Discussion
Early data from United States centers may suggest an association with temozolomide prior to PRRT and the development of myelodysplasia and leukemia. In this large real-world sample, sequencing of chemotherapy and PRRT showed center-to-center variation, with metastatic pNET patients treated at a PRRT-TC being more likely to receive chemotherapy, including temozolomide, prior to PRRT. This may be explained in part by referral/practice patterns and PRRT availability. These findings suggest an opportunity to evaluate and optimize the sequence of systemic therapy with the increasing availability of PRRT in Canada.

Objective
To evaluate the cumulative incidence of radiotherapy for brain metastases (BrMs) among patients diagnosed with breast cancer (BC) in Ontario.

Methods
We conducted an Ontario-wide, retrospective, observational cohort study using the ICES database to assess treatment patterns and outcomes of patients with BC who received radiotherapy for BrMs between January 2009 and December 2018.
The primary endpoint was the cumulative incidence of radiotherapy for BrMs accounting for the competing risk of death. The data were censored if patients were alive on the same therapy at the last available follow-up with the last cut-off date being 31 March 2019. Kaplan-Meier analyses were performed for the time-to-event endpoints and were compared using the log-rank test. The cumulative incidence of radiotherapy for BrMs from the diagnosis of BC was calculated using the cumulative incidence function while accounting for the competing risk of death using a competing risk analysis. Multivariable regression models were used to account for confounding variables.

Results
A total of 88,111 patients with BC were identified; of these patients, 85.2% had a stage I-III disease and 4.6% had a stage IV disease at diagnosis. In the overall population, 2.4% (n = 2120) received radiotherapy for BrMs; this proportion was highest among patients with a de novo stage IV disease (14%, n = 549). Out of the patients with BrMs, 82% (n = 1738) were treated using whole brain radiotherapy (WBRT) while 18% (n = 382) were treated using stereotactic radiation (SRS). Patients treated using SRS had a longer median OS compared with those treated using WBRT (9.3 months vs. 4.6 months, p < 0.0001) with a lower 30-day mortality (5.2% vs. 15.5%, p < 0.001) after adjustment for confounding variables.

Conclusions
Approximately one in seven patients with metastatic BC will require radiotherapy for BrMs. Given that women treated for BC BrMs using SRS had better outcomes, the use of SRS should be encouraged when clinically indicated.

Multidisciplinary Rectal Cancer Rounds-Characterization of Delays to Oncological Consultation and Treatment among Patients scheduled For Clinical Discussions; Quality Improvement Analysis
Joanna Mycek 1 , Mark Freeman 2 , Richard Lee-Ying 2 and Hyea Min Yoon 3 1.
Department of Medicine, University of Calgary, Alberta, Canada 2.
Department of Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada 3.
Department of Surgery, University of Calgary, Alberta, Canada

Objective
Since September 2020, the Tom Baker Cancer Centre (TBCC) has embedded weekly multidisciplinary rounds reviews of all non-metastatic rectal cancer cases to determine optimal management before formal consultations. However, this extra step could lead to delays in management.

Methods
We reviewed all non-metastatic rectal cancer referrals from January 2019 to December 2021 and compared the time from clinical diagnosis to first TBCC consultation (either a medical or radiation oncologist) and time to first rectal cancer treatment with those reviewed in rounds and those that were not.

Discussion
This convenience sample demonstrates no statistically significant delays between diagnosis and first oncological consultation or treatment among patients that were scheduled for mandatory multidisciplinary rounds discussions. These findings provide reassurance that adding steps to improve the quality of rectal cancer management does not have a worrisome impact on time to consultation or treatment.
Ontario Institute for Cancer Research, Ontario

Objective
To assess the rate of multisystem immune-related adverse events (irAEs) for patients who received ipilimumab and nivolumab for cancer treatment.

Method
A retrospective cohort review was completed that included all cancer patients seen at Juravinski Cancer Centre who received at least one dose of ipilimumab and nivolumab from 1 January 2018 to 31 May 2022. The patient characteristics, cancer types, and number and types of irAEs were recorded. Multivariate logistic regressions were also completed by comparing those who experienced multisystem irAEs, single irAE, and no irAE.

Results
A total of 123 patients were included in this study. The median age was 59 years, with 69% of patients being male. A total of 72 out of 123 patients (59%) had melanoma, 50 out of 123 (41%) had renal cell carcinoma (RCC), and 1 out of 123 (1%) had breast cancer. At least one irAE was observed in 72% of patients, and most irAEs occurred during the combination phase (89% of first irAE, 59% of second irAE, 75% of third irAE, and 50% of fourth irAE). Multisystem irAEs were observed in 40% of the overall cohort. The most common irAE type was dermatitis (22%), followed by colitis (19%), hepatitis (17%), and thyroiditis (15%). It was found that 30 out of 89 patients (34%) who experienced irAE(s) required hospitalization for treatment of irAE(s).

Conclusions
From our single-center cohort study, there appeared to be a higher than previously quoted percentage of patients who experienced irAEs after receiving ipilimumab and nivolumab, with the majority of them developing multisystem irAEs. Many patients experienced debilitating associated symptoms and hospital admissions that were related to irAEs. It is important for both the counselling and consent of patients, and for patient education, to discuss the possibility of multiple irAEs prior to dual immunotherapy initiation.

Improving the Frequency and Documentation of Goals of Care Conversations by Medical Oncologists at the Ottawa Hospital
Julian Surujballi and Joanna Gotfrit The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada

Objective
This quality improvement project aims to assess and improve the rates of goals of care discussion (GOCD) documentation using an electronic documentation template for medical oncologists and nurses at The Ottawa Hospital Cancer Centre.

Methods
The primary intervention was in the form of the creation and distribution of a documentation template in the Epic electronic health record. The secondary intervention was in the form of education sessions for medical oncologists and nurses regarding holding GOCDs and using the template.
The rate of documented GOCDs within 60 days of consultation to medical oncology was assessed through a retrospective chart review. The rates of GOCDs were assessed for seven days before and after the education sessions. The results were assessed based on the treatment intent and by an individual oncologist. A survey assessing barriers to GOCDs was administered to medical oncologists after the evaluation period.

Results
During the assessment period, 88 and 111 charts were reviewed before and after the intervention, respectively. The rates of documented GOCDs in the overall population were not significantly different before and after the intervention ( The barrier survey response rate was 42.3% (n = 11). The top barriers that were identified were being unaware of the template (n = 4) and forgetting to use the template (n = 3).

Conclusions
Creating a documentation template and providing education did not significantly increase the rates of documented GOCDs among medical oncologists at The Ottawa Hospital. Future directions include further education and engaging in patient GOCDs outside of clinic visits.
Division of Medical Oncology, BC Cancer Agency, Vancouver, BC 2.
BC Cancer Research Institute, Vancouver, BC 3.
Gynecological Cancer Outcomes Unit, BC Cancer Agency Vancouver, BC 4.
Division of Gynecological Oncology, BC Cancer Agency Vancouver, BC

Background
Management of advanced ovarian cancer requires a multidisciplinary team. The community oncology network (CON) in British Columbia (BC) connects local health centers with the BC cancer agency, enabling patients to receive cancer care that is close to home. The CON is defined by a Tiers of Service framework, ranging from tier 1 (primary care) to 6 (subspecialized province-wide consultations). We aim to identify whether patients undergoing treatment for advanced ovarian cancer at tier 3/4 CON centers received the same care compared with those at tier 5/6 centers.

Methods
Patients with advanced, high-grade serous ovarian cancer diagnosed from 1 January 2017 to 30 June 2019 were identified. A total of 30 patients from tier 3/4 CON centers and 30 patients from tier 5/6 centers with follow-up data were selected. Information on the diagnostic and treatment details was collected and analyzed.

Results
It was found that 20% of patients from tier 3/4 CON centers had cytology only for diagnosis compared with 33.3% of patients from tier 5/6 centers. The results showed that 70% of patients from tier 3/4 centers received pre-operative chemotherapy (POC) and 63.3% of patients from tier 5/6 centers received POC. For both tier 3/4 and tier 5/6 centers, most patients (83.3%) had a surgical consultation with a gynecological oncologist and 70% had debulking surgery. The median number of cycles of POC received by patients prior to surgical debulking was five among tier 3/4 CON patients and four among those from tier 5/6 centers. It was discovered that 60% of patients treated in tier 3/4 and 63.3% from tier 5/6 centers received adjuvant chemotherapy. The referral rates to the Hereditary Cancer Program was high (81.7%) among patients from both groups.

Conclusions
In the pre-COVID era, BC patients with advanced ovarian cancer that were treated at tier 3/4 CON centers received care that was similar to those treated at tier 5/6 centers. Tier 3/4 patients received more cycles of POC, possibly reflecting a delay in coordinating surgical care.

Results
We received 14 responses from UGME leadership, 29 from medical students and 17 from family physicians. UGME leaders from 13 of 17 Canadian institutions and medical students from 8 of 17 Canadian institutions responded. Overall, 13 (45%) medical students did not feel prepared for cancer care. Students felt the least prepared for managing survivorship and complications of active cancer/cancer therapies, which were allotted at < 5 h as reported by 10 (71.4%) people from UGME leadership. More than 50% of family physicians reported undergraduate and residency training as below average or unsatisfactory. Family physicians identified cancer screening, survivorship, and communication as the most relevant competencies to their practice.

Conclusions
Despite cancer being the leading cause of death in Canada, medical graduates do not feel prepared for cancer care. These results identify the survivorship and management of cancer and cancer treatment complications as areas of deficiency that would benefit from more comprehensive teaching and exposure in UGME training.

Virtual Poster Presentation
Locally Advanced Rectal Cancer Referrals at the Ottawa Hospital Cancer Centre: An Audit Victor Lo and Joanna Gotfrit Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario

Objective
Locally advanced rectal cancer patients require multidisciplinary care for treatment planning. We determined the proportion of patients who had all necessary consultations and investigations prior to their medical oncology consultation, and we planned to assess the logistical, system, and clinical factors that may be associated with increased time from diagnosis to treatment initiation.

Methods
We conducted a retrospective chart review of adult patients that were referred to The Ottawa Hospital Cancer Centre with locally advanced rectal adenocarcinoma as observed in a consultation performed by a surgical, medical, and radiation oncologist between January 2019 and December 2022.

Conclusions
Many patients did not have a surgical oncology opinion at the time of the medical oncology consultation, and almost half of all patients required additional appointments with medical oncology prior to treatment initiation. Future analysis aims to determine whether the initial treatment approach, order of specialist consultations, availability of staging investigations at time of medical oncology consultation, and need for presentation at MCCs are associated with increased time-to-treatment initiation.

Eligibility and Workload Impact of Introduction of Adjuvant Nivolumab in Patients with Resected Esophageal and Gastroesophageal Junction (ESO/GEJ) Cancer
Tae Hoon Lee 1 and Sharlene Gill 1,2 1.
Department of Medicine, University of British Columbia, Vancouver, British Columbia 2.
BC Cancer, Vancouver, British Columbia

Objectives
The CheckMate (CM) 577 study demonstrated the benefit of 12 months of additional therapy with adjuvant nivolumab in patients with pathologic residual disease following neoadjuvant chemoradiation for ESO/GEJ cancer. Nivolumab is now funded in BC as per the GIAJNIV protocol. This BC Cancer retrospective study reviews the real-world eligibility and potential resource implications that are associated with the therapy.

Methods
An REB-approved chart review was conducted for patients who underwent CROSS chemoradiation at BC Cancer from January 2016 to December 2020. Patient eligibility was determined by the identification of at least ypT1 or ypN1, which was assessed as per the CM577 and GIAJNIV criteria. The resource impact of nivolumab was assessed by projecting the number of MD visits, chemotherapy visits, and anticipated G3/4 serious toxicity events as per the CM577 study.

Results
A total of 677 patients were identified: 63% were esophageal and 37% were GEJ, with 74% having adenocarcinoma and 25% having squamous cell carcinoma histology. A total of 460 patients underwent resection, with 365 patients (79%) having pathologic residual disease. By the CM577 criteria, n = 249 (68%) were eligible for adjuvant nivolumab, while n = 321 (88%) were eligible as per the GIAJNIV criteria. In BC, with conservative assumptions, this translates into an estimated 60 patients/year being eligible for adjuvant nivolumab, resulting in 768 additional new chemotherapy visits and a potentially equal number of MD visits, which translates into 254 additional MD work hours annually. Based on a 34% G3/4 toxicity rate, an estimated 20 patients/year would result in a serious toxicity event that requires medical intervention.

Conclusions
Adjuvant nivolumab is an important new treatment option for patients with resected ESO/GEJ cancer. Our findings suggest that most patients (88%) with resected ESO/GEJ cancer and residual disease would be eligible for 12 months of adjuvant nivolumab. In addition to treatments costs, the additional oncologist workload impact should be considered in the provincial implementation of therapies for new indications.

Background
Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer in Canada. However, to date, few real-world reports exist on the treatment of refractory locally advanced (non-metastatic cSCC no longer amenable to surgical intervention or radiation therapy) or metastatic cSCC using cemiplimab. The objective of this study was to characterize the demographic and clinical outcomes of these patients in a real-world setting.

Methods
A retrospective analysis was performed on adult patients with refractory locally advanced (LA) and metastatic cSCC that was treated using cemiplimab at the London Regional Cancer Program in Ontario, Canada. The patient demographics and treatment characteristics were reported, as well as the Kaplan-Meier estimates of progression-free survival (PFS) and overall survival (OS).

Results
Forty patients were included in this study. A total of 15 (38%) had an LA disease at the time of cemiplimab treatment, and 25 (62%) had a metastatic disease. The median treatment duration was 5.2 months (IQR 1.6 months-10.3 months). The Kaplan-Meier analysis revealed that the median OS was not reached (NR) for LA patients but was 10 months (95% CI 3.25 months-NR) for metastatic patients. The median PFS was 25.3 months (95% CI 7.29 months-NR) for LA patients and 7.1 months (95% CI 3.02 months-NR) for metastatic patients. The estimated probability of OS at 12 months for all patients was 58.6% (95% CI 43.2%-79.4%), and the estimated probability of PFS at 12 months was 45.3% (95% CI 30.4%-67.5%). Reasons for treatment discontinuation were death from any cause (44%), disease progression (22%), cemiplimab side effects (4%), and other causes (30%; comorbidities, treatment breaks).

Discussion
The estimated 12-month OS and PFS values were lower than the corresponding pivotal phase I and II clinical trials. However, the toxicity was tolerable, and no deaths were attributable to cemiplimab. Thus, cemiplimab is a safe and effective therapy in patients with refractory locally advanced and metastatic cSCC disease.

Background
With the emergence of new systemic therapies, there has been a substantial change in the treatment of HCC. The aim of this study was to assess the real-world data regarding treatment patterns and outcomes in Canadian HCC patients with an intermediate (BCLC-B) and advanced (BCLC-C) stage disease who received systemic treatments.

Methods
All BCLC-B and BCLC-C HCC patients who received at least one dose of systemic therapy between 1 January 2008 and 31 December 2020 in Alberta, Canada, were included. The patient characteristics, treatment patterns, overall survival (OS), progression-free survival (PFS), clinician-assessed response rates (RR), and reasons for treatment discontinuation were retrospectively analyzed across both BCLC stages.

Results
Of total 321 patients included, 33 (10%) were BCLC-B and 288 (90%) were BCLC-C. The demographic and clinical characteristics were as follows for the BCLC-B and BCLC-C groups, respectively: The median age was 65 and 63 years; out of the two groups, 91% and 80% were male, and 9% and 20% were of East Asian ethnicity; most patients were ECOG 0-1 (94% and 85%) and Child-Pugh A (82% and 85%); in both groups, 97% were albuminbilirubin (ALBI) grade 1 or 2 before the start of first-line treatment; common causes of liver disease were hepatitis C (33% and 42%), alcohol (36% and 25%), and hepatitis B (15% and 24%); prior treatments included TACE (34% and 30%), TARE (6% and 8%), liver resection (24% and 17%), and SBRT (15% and 4%). Table 1 outlines the systemic treatments received and the outcomes by BCLC stage. The median follow-up was 13.5 months and 10 months for the BCLC-B and BCLC-C groups, respectively. The median treatment duration of systemic therapy for all patients was 4 months.

Conclusions
Although this study was not powered for a formal comparison, the systemic treatment patterns and outcomes of BCLC-B and C HCC patients seemed comparable, with a possible trend towards better PFS and OS in BCLC-B patients.

Objective
Inpatient medical oncology units face growing capacity pressures as systemic therapy becomes increasingly complex. This quality improvement initiative assesses adherence to local admission criteria for the inpatient medical oncology ward at The Ottawa Hospital.

Methods
In phase 1, medical oncology inpatient admissions during January 2020 were retrospectively assessed for adherence to local admission guidelines. The reasons for admission were additionally reviewed by two medical oncologists to assess if cases were most appropriately primarily cared for by a medical oncologist versus another specialist.
In phase 2, on-call personnel were asked to log and rate the appropriateness of all referrals from the emergency department from February to November 2020.

Results
In phase 1, 80% of admissions were referred through the emergency department and 20% from direct admissions or transfers. We report that 59% of admissions were adherent to the referral guidelines, 26% were non-adherent, and 15% were unclear. When assessed by medical oncologists, 63% of admissions were thought to be appropriate, 14% were best cared for by another specialist, and 23% required collaborative care.

Conclusions
There exists an opportunity for the optimization of medical oncology inpatient service utilization, although results are confounded by competing inpatient pressures that are caused by the COVID-19 pandemic. With medical oncology being a primarily outpatient specialty, reserving the oncology inpatient unit for patients that require specialized oncology care could allow for resources to be diverted to the outpatient setting. As oncology care becomes more complex, a multidisciplinary approach to inpatient cancer care may be required.
Regularly scheduled follow-up was important to monitor for local recurrence, distant recurrence, manage the side effects of treatment, and to provide psychological support. Most patients were satisfied with their follow-up frequency (satisfaction score 8.26/10) and would worry more about their cancer if there were no visits (n = 225/247,91%). Patients felt that regular follow-up would detect recurrent cancer earlier (n = 214/255, 96%) and would help them live longer (n = 218/249, 88%). While most patients felt that their medical oncologist was the most suited for providing follow-up, 55% of patients felt comfortable being followed by their family physician. The COVID-19 pandemic reduced the number of in-person breast examinations for 54% of patients (n = 63/117). Many patients were concerned that this would lead to a later detection of local (n = 29/63, 46%) and distant recurrence (n = 25/63, 40%).

Conclusions
Despite evidence showing little impact on in-person assessment and the move to virtual care on the detection of recurrence, patients continue to place importance on regularly scheduled in-person follow-ups.

6.
Department of Medicine, University of Ottawa, Ottawa, ON

Objective
To determine the treatment patterns of pNET patients managed at the LRCP and TOHCC.

Methods
This is a multicenter retrospective cohort study involving LRCP and TOHCC. Patients with histologically confirmed pNETs between January 2010 -June 2021 over the age 18 were included. Demographic, clinical and cancer treatments were collected. Descriptive analysis was performed on the data collected to identify the local and systemic therapies used.

Results
In total 192 pNET patients' charts were reviewed, 40% treated at LRCP; 42% female. Most common pNET locations were the pancreatic head (34% ) and tail (45%) of the pancreas. 53% presented with stage IV disease and 21% with stage II. 28% were grade 1, 36% grade 2, and 8% grade 3 with the remainder either being unknown or having no pathology performed for the disease.
Local treatments included surgery for the primary tumour in 56% of patients, with 40% having curative intent (Table 1). Surgery for metastasis occurred in 16% of patients and 63% of surgeries were in the liver. Local regional ablative treatments were used in 16%, 99% of ablations targeted metastases, and radiation was used in 15% of patients. The percentage of patients treated with systemic therapy included: 34% octreotide, 30% lanreotide, 30% chemotherapy, 29% PRRT, and 22% targeted therapy. The majority of patients undergoing systemic therapy had established metastases and progressive disease prior to treatment.

Conclusions
In this real-world database, 53% of patients present with non-curative disease and 15% of pNETs undergo metasetecomy, while embolization is not a common modality used. The most common systemic treatment used was somatostatin analogues followed by chemotherapy, PRRT and targeted therapy. This is one of the first cross centre, patient-level, Ontario databases that report the common treatment modalities used for pNETs. Further analysis will assess how treatments choices vary according to tumour grade. Radiation Therapy 15 93% of treatments were done with non-curative intent. 100% had progressive disease and 93% had metastases at start.

Virtual Poster Presentation
A Retrospective Analysis of the Diagnosis of Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs) at the Ottawa Hospital Cancer Centre (TOHCC) and the Impact of COVID-19 on Diagnosis Background Treatment (tx) options for metastatic prostate cancer (mPC) have significantly advanced. We evaluated the real-world prescribing patterns and outcomes of new therapeutics.