International Survey of Secondary Thromboprophylaxis Practice Patterns in Pediatrics

Abstract Background/Aims: Despite the increase in clinicians identifying venous thromboembolism (VTE), we lack robust research to support clinical care guidelines. Although most children are at low risk for VTE recurrence, some have higher risks due to persistent prothrombotic risk factors. However, pediatric-specific guidance and expert consensus to recommend long-term anticoagulation in children is lacking. Understanding provider practices is a vital first step to addressing current limitations in pediatric guidelines for secondary thromboprophylaxis among such high-risk children. Methods: We performed an international survey of pediatric thrombosis physicians to approximate the number of children with persistent prothrombotic risk factors and characterize the contemporary practice patterns for the use of secondary thromboprophylaxis. Potential participants were identified using the membership registries of three of the primary pediatric thrombosis networks: Duration of Therapy for Thrombosis in children investigators, Children's Hospital Acquired Thrombosis consortium and the VENUS pediatric thrombosis subgroup. Surveys were disseminated December 2020 through January 2021 using Qualtrics (Provo, UT). Results: The survey was distributed electronically to 124 potential participants with 80 respondents. After exclusions, 61 complete surveys were evaluable. The majority of responders were from the United States, practicing more than 10 years at freestanding, academic pediatric hospitals with dedicated pediatric thrombosis programs. Providers were more likely to prescribe secondary thromboprophylaxis to adolescents and teenage patients as compared to infants and children. Respondents reported they were most likely to initiate chronic secondary thromboprophylaxis (therapeutic or low dose) in children with a potent thrombophilia (homozygous prothrombin or factor V Leiden mutations, protein C/S levels <20%, Antithrombin levels <30%), recurrent unprovoked VTE and in those with underlying inflammatory disorders (i.e., inflammatory bowel disease, systemic lupus erythematosus, sickle cell disease) and/or chronic indwelling central venous catheters. Conclusion: Our results show variation in practice patterns but less so in areas where we have more definitive guidelines. These findings highlight the need for a multi-center prospective cohort study to determine the impact of various risk factors on recurrence rates. This will inform the design of ultimate interventional studies aimed at safely decreasing the risk of recurrent VTE in children who have persistent prothrombotic risk factors upon completion of a conventional course of anticoagulation for provoked VTE. Disclosures Lebensburger: Novartis: Consultancy; Bio Products Laboratory: Consultancy. Goldenberg: Novartis: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Daiici: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Anthos: Membership on an entity's Board of Directors or advisory committees.

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Patterns and Growth of a Dedicated Pediatric Coagulation Consult Service in a Freestanding Children's Hospital

Blood ◽

10.1182/blood-2020-139686 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 33-34

Author(s):

Shannon L Carpenter ◽

Eryn Bilynsky ◽

Dena Wideman ◽

Kristina D'Agostino ◽

Lauren E Amos ◽

...

Keyword(s):

Intensive Care ◽

Board Of Directors ◽

Research Funding ◽

Tracking System ◽

Clinical Care ◽

Pediatric Hospital ◽

Consult Service ◽

Advisory Committees ◽

Prophylactic Anticoagulation ◽

The Impact

Introduction: At our freestanding pediatric hospital, a dedicated inpatient coagulation consult service has existed for 15 years. To our knowledge, this type of service is relatively unique in a pediatric hospital and provides an opportunity to objectively evaluate changes in coagulation consults in this patient population. Over the past decade, the increasing rate of thrombosis in hospitalized pediatric patients has been noted and more attention has been placed on preventing the occurrence of hospital-acquired venous thromboembolism. With concern over this increased incidence, more inpatients have been receiving prophylactic anticoagulation. Methods: This is a secondary use of existing clinical care data study, involving review of the patients receiving a consult from the inpatient coagulation consult service. Average daily census was documented via a clinical tracking system. Data collection ranged from May 2011 to May 2020. Since 2013, number of distinct new consults (not repeat patients), and indication for consult have also been documented. These data were analyzed for trends in average census number and indication for consult. Additionally, the service requesting the consult is also reported. Results: From May 2011 to May 2020, the average daily census for the coagulation consult service has increased from 4.5 to 34.4 patients. (Figure 1) The rate of consult request for prophylactic anticoagulation increased from 8 in 2013 to 82 in 2020, while thrombosis and bleeding referrals remained relatively stable. (Figure 2) Since 2013, the service with the most requests for prophylactic anticoagulation over the entire period was orthopedic surgery with 70, followed by the cardiovascular intensive care (31) and medical intensive care (28) units (ICU). There was an increase in the number of prophylactic anticoagulation consults from the ICUs over the course of the study. (Figure 3) In early 2020 a VTE risk stratification was instituted in the CVICU. Conclusions: In this single institution, retrospective study, we noted an increase in number of consults for the coagulation service overall, and a larger increase in requests for consults for prophylactic anticoagulation. Further studies should be done to determine whether this increase in use of prophylactic anticoagulation exists at other pediatric hospitals and the impact on subsequent VTE development. Disclosures Carpenter: CSL Behring: Research Funding; American Thrombosis and Hemostasis Network: Membership on an entity's Board of Directors or advisory committees; Genentech, Inc.: Honoraria; Kedrion: Honoraria; Novo Nordisk: Honoraria; Shire: Research Funding; Hemostasis & Thrombosis Research Society: Membership on an entity's Board of Directors or advisory committees; American Academy of Pediatrics: Other: PREP Heme/Onc editorial board.

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Risk of Mortality and Leukemic Transformation in Primary Myelofibrosis before and after Ruxolitinib Approval

Blood ◽

10.1182/blood-2020-134161 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 28-28

Author(s):

John William Thomas ◽

Mithun Vinod Shah ◽

Pankit Vachhani ◽

Omer Jamy ◽

Ronald S. Go ◽

...

Keyword(s):

Board Of Directors ◽

Myeloproliferative Neoplasms ◽

Primary Myelofibrosis ◽

Hematologic Malignancies ◽

The United States ◽

Symptom Improvement ◽

Advisory Committees ◽

Study Results ◽

Significant Difference ◽

The Impact

Background: Primary myelofibrosis (PMF) has the worst prognosis of the classical BCR-ABL1 negative myeloproliferative neoplasms, with a median overall survival of six years. Factors affecting survival include age, symptom burden, cytopenias, mutation profile, and development of second malignancies including transformation to acute myeloid leukemia (AML). Ruxolitinib, a selective JAK1 and JAK2 inhibitor, was granted approval by the United States (US) Food and Drug Administration for treatment of intermediate and high-risk PMF in November 2011 based on reduction in spleen volume and demonstration of symptom improvement. The impact of ruxolitinib on PMF survival is unknown. In this study, we aimed to evaluate whether there has been a change in survival and patterns of second primary malignancies (SPMs) including AML transformation among PMF population in US after ruxolitinib approval. Methods: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-18 survival and Multiple Primary Standardized Incidence Ratio (MP-SIR) registries, we conducted a retrospective study with patients diagnosed with PMF between the years of 2007 and 2016. We divided these patients into two five-year cohorts, pre-ruxolitinib approval (2007-2011) and post-ruxolitinib approval (2012-2016), and compared relative survival rates (RSRs) and standardized incidence ratios (SIRs) of SPMs between the cohorts. SIRs were calculated as the ratio of observed to expected malignancy cases over the specified time periods. Median follow-up duration was five years for each cohort. RSRs and SIRs were compared between cohorts using two-proportion Z-tests. Results: We included 2164 patients diagnosed with PMF between 2007 and 2016 with data available in the SEER-18 survival and MP-SIR registries. Of these, 1051 (49%) patients were included in the pre-ruxolitinib cohort and 1113 (51%) patients were included in the post-ruxolitinib cohort. There was no significant difference in the four-year RSRs between the pre-ruxolitinib and post-ruxolitinib cohorts (55% vs. 56%, p = 0.719). A higher proportion of SPMs occurred in the post-ruxolitinib cohort when compared with the pre-ruxolitinib cohort (60% vs. 40%, p < 0.001). Hematologic malignancies comprised a majority of all SPMs (AML 39% and non-Hodgkin lymphoma 16%). A higher incidence of AML transformation occurred in the post-ruxolitinib cohort when compared with the pre-ruxolitinib cohort (SIR 121.48 vs. 72.22, p = 0.037). Non-hematologic malignancies were also more common in the post-ruxolitinib cohort when compared with the pre-ruxolitinib cohort (SIR 1.09 vs. 0.94, p < 0.001). The most common non-hematologic malignancies were cancers of the respiratory tract, urinary tract, and prostate gland, though their SIRs were not significant in either cohort. Conclusions: Our study results suggest that despite improvements in prognostication and the approval of ruxolitinib, the prognosis of PMF remains poor in the US. These results may be due to low uptake of ruxolitinib in practice or a lack of benefit from the drug itself. Additionally, for reasons that are unclear, SPM incidence has increased in the five years following the approval of this drug. Further studies should be conducted to determine the cause of these findings. Figure Disclosures Shah: Dren Bio: Consultancy. Vachhani:astellas: Speakers Bureau; agios, blueprint medicines, jazz pharmaceuticals, daiichi sankyo: Membership on an entity's Board of Directors or advisory committees; incyte: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

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High Incidence of Bleeding Found with Direct Oral Anticoagulant Use in Myeloproliferative Neoplasm Patients

Blood ◽

10.1182/blood-2021-148941 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3632-3632

Author(s):

Chi-Joan How ◽

Charlotte McIlwaine Story ◽

Siyang Ren ◽

Donna S. Neuberg ◽

Rachel P. Rosovsky ◽

...

Keyword(s):

Risk Factors ◽

Board Of Directors ◽

Median Duration ◽

Cumulative Incidence ◽

Research Funding ◽

Practice Patterns ◽

Recurrent Thrombosis ◽

Advisory Committees ◽

Bleeding Rate ◽

Vein Thrombosis

Abstract BACKGROUND: Patients with myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) are at increased risk of arterial (ATE) and venous thromboembolism (VTE). There are no clear guidelines regarding selection of anticoagulation (AC) in MPN patients. Direct oral anticoagulants (DOACs) are increasingly used in the general population to treat a variety of conditions including VTE, ATE, and atrial fibrillation (AF). Data on the safety and efficacy of DOACs in MPNs limited. We conducted a multi-center, retrospective analysis of DOAC use in MPN patients to characterize real-world practice patterns and evaluate thrombosis and bleeding risks. METHODS: We retrospectively analyzed 133 MPN patients prescribed DOACs across the Massachusetts General Brigham / Dana Farber Harvard Cancer Center system from 1995 to 2020. Patients were identified using ICD-9 and 10 codes in the electronic medical record. Patient and treatment characteristics were described with summary statistics. We calculated cumulative incidence functions of VTE and ATE, and major and clinically relevant non-major bleeding (CRNMB) by ISTH criteria, using death on DOAC as a competing risk. A Gray's test was used to compare cumulative incidence between groups. Analysis of risk factors associated with bleeding/thrombosis was carried out by univariate and multivariable Fine-Gray models. RESULTS: Baseline characteristics are displayed in Table 1. Seventy-five (56.4%) MPN patients were prescribed DOAC for VTE, 46 (34.6%) for AF, 7 (5.3%) for stroke, and 5 for other ATE (3.8%). The median age at DOAC initiation was 71; the AF population was significantly older than patients with VTE (75 vs 59, p<0.001). Fifty-seven percent of patients (N = 76) had a diagnosis of PV, with 89% (N = 118) of patients carrying a JAK2 driver mutation. Apixaban was the most commonly prescribed DOAC (N = 83, 62.4%). Nearly half (N = 59, 45%) of patients had a prior VTE/ATE at DOAC initiation, and 23% (N = 31) of patients were switched from warfarin. Among the VTE-treated patients, 43% of events were deep vein thrombosis (N = 39), 31% (N = 28) were pulmonary embolism, 21% (N = 19) were splanchnic vein thrombosis (SVT), and 4.4% (N=4) were other VTE. Table 2 displays practice patterns of DOAC use in MPN patients. The median duration of AC was 37.0 months for all patients, with no difference (p=0.01) between patients treated for AF (42.3 months) and VTE (37.0 months). Twenty-one percent of VTE-treated patients completed a finite course of AC of 6 months median duration. Fifteen percent (N = 11) of VTE-treated and 4.3% (N = 2) of AF patients had reduction to prophylactic dosing. Fifty percent (N = 66) of patients took aspirin and AC concurrently; 83% (N = 110) of patients took cytoreduction with AC. After a median follow-up of 37 months, we found 12 thrombotic (7 arterial, 3 venous, 2 TIPS occlusions) and 28 bleeding (6 major with 4 contributing to patient death, 2 CRNMB) events on DOAC. The estimated 1-year cumulative incidence of thrombosis and bleeding on DOAC was 5.5% (1.5%-9.5%) and 12.3% (6.4%-18.2%), respectively (Figure 1). Thrombosis and bleeding rates were not significantly different between patients treated for VTE versus AF. Prior history of thrombosis and use of dabigatran or edoxaban were significantly associated with increased thrombosis on both univariate and multivariable analysis (p<0.05). Age ≤ 65 also emerged as a risk factor for recurrent thrombosis in multivariate analysis (p=0.04). Use of dabigatran or edoxaban trended toward increased bleeding, but otherwise we found no significant risk factors for bleeding at α=0.05 level, including concomitant aspirin use. DISCUSSION: DOACs are increasingly prescribed in MPN patients for a wide range of indications, with heterogeneity in practice patterns. In our cohort, 1-year thrombosis and bleeding incidence rates on DOAC were 5.5% and 12.3%, respectively. While our 5.5% thrombosis rate is similar to recurrent thrombosis rates reported in MPN patients on DOACs and VKA, our 12.3% bleeding rate appears much higher. This may be related to the complexity of patients seen at our tertiary referral center. The higher-than-expected bleeding rate found in our study indicates the continued need for rigorous evaluation of DOACs in this population, with the gold standard being randomized controlled trials comparing DOAC with warfarin. Figure 1 Figure 1. Disclosures Neuberg: Madrigal Pharmaceuticals: Other: Stock ownership; Pharmacyclics: Research Funding. Rosovsky: Janssen: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Inari: Consultancy, Membership on an entity's Board of Directors or advisory committees; Dova: Consultancy, Membership on an entity's Board of Directors or advisory committees. Hobbs: Bayer: Research Funding; Merck: Research Funding; AbbVie.: Consultancy; Celgene/Bristol Myers Squibb: Consultancy; Novartis: Consultancy; Incyte Corporation: Research Funding; Constellation Pharmaceuticals: Consultancy, Research Funding. Connors: Abbott: Consultancy; Bristol-Myers Squibb: Honoraria; takeda: Honoraria; Alnylam: Consultancy; Pfizer: Honoraria; CSL Behring: Research Funding.

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Body Mass Index and Survival of Patients with Lymphoma

Blood ◽

10.1182/blood-2020-139402 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 2-3

Author(s):

Dai Chihara ◽

Melissa C. Larson ◽

Dennis P. Robinson ◽

Carrie A. Thompson ◽

Matthew J. Maurer ◽

...

Keyword(s):

Body Mass Index ◽

At Risk ◽

Board Of Directors ◽

Body Mass ◽

Research Funding ◽

B Cell Lymphoma ◽

The United States ◽

Advisory Committees ◽

The Impact

Background: Obesity is increasing worldwide, with the highest prevalence in the United States. High or low body mass index (BMI) is a well-established risk factor for increased all-cause mortality and also has been associated with cancer-specific mortality. However, the impact of BMI on survival following diagnosis with lymphoma currently remains controversial. We leveraged a prospective cohort of lymphoma patients to assess the relationship of BMI two years prior to diagnosis (BMI-2), at diagnosis (BMI-dx), and three-years post-diagnosis (BMI+3) with lymphoma-specific survival (LSS) as the primary endpoint and with event-free survival (EFS) and overall survival (OS) as secondary endpoints. Patient and Method: Patients were prospectively enrolled at lymphoma diagnosis to the SPORE Molecular Epidemiology Resource (MER) cohort at Mayo Clinic and University of Iowa from 2002-2015. BMI-2 and BMI+3 were self-reported in patient questionnaires, while BMI-dx was extracted from the medical chart. Patients with extreme BMI (BMI <14 and BMI ≥50) were excluded from the analysis. BMI change from BMI-2 to BMI-dx and from BMI-dx to BMI+3 was categorized as no change (-5% to 5%), decrease (>-5%), and increase (>+5%). Person-time at risk was assessed from lymphoma diagnosis until death or last follow-up, except for analyses of BMI change from BMI-dx to BMI+3, which started person-time at risk when the 3-year (+/- 6 months) follow-up questionnaire was returned. Cause of death was assigned by a study clinician. For all lymphoma patients combined and in the most common subtypes, we evaluated the association of BMI at each time point and change in BMI with EFS, LSS, and OS using hazard ratios (HRs) and 95% confidence intervals (CI) from multivariable adjusted Cox models. Results: A total of 4,009 lymphoma patients (including 670 diffuse large B-cell lymphoma [DLBCL], 689 follicular lymphoma [FL] and 1018 chronic lymphocytic leukemia/small lymphocytic lymphoma [CLL/SLL] and 1,632 others) with data on BMI-dx were included. Among them, 2,955 patients had BMI-2 and 2,004 had BMI+3 and were evaluable for change in BMI. The median age of all patients at diagnosis was 61 years (range 18-92 years), and 94% of patients had ECOG performance status <2. At the time of diagnosis, 28% were normal weight (BMI 18.5-25), 1% were underweight (BMI <18.5), 39% were overweight (BMI 25-30) and 32% were obese (BMI ≥30). With a median follow-up of 108 months from diagnosis (IQR 83-143 months), 1320 deaths were observed, 48% of which were due to lymphoma. Patients with FL who were obese at BMI-2 had significantly shorter LSS (HR: 3.02, 95%CI: 1.43-6.41, p=0.004). Associations between obesity at BMI-2 and LSS were not evident for DLBCL (HR: 1.04, 95%CI: 0.62-1.76, p=0.879) or CLL/SLL (HR: 1.10, 95%CI: 0.71-1.70, p=0.668) (Table). BMI-dx was not associated with LSS in any lymphoma patients, except that DLBCL patients who were underweight at BMI-dx (n=10) experienced shorter LSS (HR: 3.52, 95%CI: 1.22-10.1, p=0.020). This correlated significantly with presence of B symptoms (p=0.004) and may signify aggressive disease. Across all subtypes, >5% decrease in BMI from BMI-2 to BMI-dx was associated with significantly shorter LSS in patients with (HR: 2.02, 95%CI: 1.65-2.48, p<0.001). However, only for FL patients, >5% increase in BMI from BMI-dx to BMI+3 also was associated with significantly shorter LSS in subsequent years (HR: 3.74, 95%CI: 1.30-10.8, p=0.014). The associations reported for LSS generally were similar for EFS and OS. Conclusions: FL patients with obesity prior to diagnosis or who experienced increasing BMI after the diagnosis had significantly shorter LSS. The impact of weight control after the diagnosis of FL patient outcomes warrants investigation. Figure Disclosures Maurer: Celgene / BMS: Research Funding; Kite: Membership on an entity's Board of Directors or advisory committees; Morphosys: Membership on an entity's Board of Directors or advisory committees; Nanostring: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees. Flowers:Leukemia and Lymphoma Society: Membership on an entity's Board of Directors or advisory committees; Denovo Biopharma: Consultancy; Celgene: Consultancy, Research Funding; BeiGene: Consultancy; Kite: Research Funding; Bayer: Consultancy; Eastern Cooperative Oncology Group: Research Funding; Cancer Prevention and Research Institute of Texas: Research Funding; National Cancer Institute: Research Funding; AbbVie: Consultancy, Research Funding; V Foundation: Research Funding; TG Therapeutics: Research Funding; Burroughs Wellcome Fund: Research Funding; Millennium/Takeda: Consultancy, Research Funding; Acerta: Research Funding; Spectrum: Consultancy; Pharmacyclics/Janssen: Consultancy; Karyopharm: Consultancy; OptumRx: Consultancy; Gilead: Consultancy, Research Funding; Genentech, Inc./F. Hoffmann-La Roche Ltd: Consultancy, Research Funding. Cerhan:NanoString: Research Funding; BMS/Celgene: Research Funding.

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Hematuria Is Not a Risk Factor for the Hypertension of Hemophilia

Blood ◽

10.1182/blood.v126.23.2301.2301 ◽

2015 ◽

Vol 126 (23) ◽

pp. 2301-2301

Author(s):

Haowei (Linda) Sun ◽

Ming Yang ◽

Afrah S Sait ◽

Annette Von Drygalski ◽

Shannon Jackson

Keyword(s):

Risk Factors ◽

Blood Pressure ◽

Renal Insufficiency ◽

Board Of Directors ◽

Univariate Analysis ◽

Multivariate Logistic Regression Analysis ◽

Severe Hemophilia ◽

Advisory Committees ◽

Tract Infections ◽

The Impact

Abstract Introduction: Advances in hemophilia care have led to improved life expectancy and a cohort at risk for age-related comorbidities such as hypertension and cardiovascular diseases. Several studies have shown an increased prevalence of hypertension in patients with hemophilia compared to age-matched general population. However, causes of the increased prevalence of hypertension in patients with hemophilia are unclear. Hemophilia-specific risk factors such as renal bleeding or micro-bleeding may be implicated, but data are limited and conflicting regarding the association between hematuria, renal insufficiency and hypertension. In this two-centre prospective cohort study, we aim to assess the prevalence of gross or microscopic hematuria detected on routine surveillance urinalysis and microscopy, and determine the impact of hematuria on blood pressure and renal function. Methods: 135 adult males with mild-severe hemophilia A and B followed by the British Columbia Adult Bleeding Disorders Program (n=56) and the University of California, San Diego Hemophilia Treatment Center (n=79) were included. Screening urinalysis/microscopy were performed in all patients during routine clinic visits. Hematuria was defined as either a self-reported history of gross hematuria, or > 3 red blood cells per high-power field on urine microscopy in the absence of urinary tract infections. Hypertension was defined as systolic blood pressure (SBP) ≥140mmHg or diastolic blood pressure (DBP) ≥90mmHg on ≥2 occasions, or use of anti-hypertensive medications. Univariate and multivariate logistic regression analysis were used to examine the significance of hematuria and other potential hypertension risk factors. Results: The prevalence of hypertension was 44% in this population, 71% of whom were on anti-hypertensives, of whom 43% achieved blood pressure control (SBP <140 mmHg, and DBP <90mmHg) at last clinic visit. The median age was 42 years (IQR 30-57 years). On univariate analysis, patients with hypertension tended to be older (median age 56 years vs 35 years, P<0.001), had a higher prevalence of diabetes (17% vs 1%, P=0.001), dyslipidemia (35% vs 11%, P<0.001), and obesity (BMI >30; 32% vs 13%, P=0.012) compared to patients without hypertension. Despite the high prevalence of hematuria (34%), chronic kidney disease was rare (2%). On multivariate analysis, only age remains as a significant predictor of hypertension. Hematuria was associated with neither hypertension nor renal insufficiency and was not more prevalent in severe hemophilia. Conclusion: Hypertension was prevalent in our cohort of patients with hemophilia, but not optimally controlled. Hematuria was prevalent, not associated with a diagnosis of hypertension or renal dysfunction, and could not explain the hypertension while renal disease was rare. Larger prospective studies are needed to better elucidate the risk factors and mechanisms for increased prevalence of hypertension in the hemophilia population. Disclosures Sun: Baxter: Other: AHCDC/Baxter fellowship training award. Von Drygalski:Baxalta: Consultancy, Honoraria, Speakers Bureau; Pfizer: Consultancy, Honoraria, Speakers Bureau; Biogen: Consultancy, Honoraria, Speakers Bureau; CSL Behring: Consultancy, Honoraria, Speakers Bureau; Novo Nordisk: Consultancy, Honoraria, Speakers Bureau; Grifols: Consultancy, Honoraria, Speakers Bureau; Hematherix LLC: Membership on an entity's Board of Directors or advisory committees. Jackson:Biogen: Honoraria, Speakers Bureau; Baxalta: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bayer: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees.

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Impact of Sociodemographic and Clinical Factors on the Survival of Patients with Acute Myeloid Leukemia: A Multicenter Experience in Colombia, on Behalf of Acho's Renehoc-Pethema Investigators

Blood ◽

10.1182/blood-2021-150930 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3374-3374

Author(s):

Claudia Lucia Sossa ◽

Virginia Abello ◽

Angela María Peña ◽

Luis Antonio Salazar ◽

Guillermo Quintero Vega ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Board Of Directors ◽

Myeloid Leukemia ◽

Research Funding ◽

The United States ◽

Advisory Board ◽

Clinical Factors ◽

Advisory Committees ◽

The Impact ◽

Acute Myeloid

Abstract Introduction: Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults, accounting for almost 80 percent of the cases. Incidence of AML increases with age and it ranges from 3 to 5 cases per 100,000 persons in the United States. Advances in treatment have led to significant improvements in outcomes for younger patients, while prognosis in the elderly remains poor. There are different sociodemographic and clinical factors that have an impact on survival such as type of leukemia (secondary vs novo), low socioeconomic status, age, gender, health regimen, co-morbidities and performance status Objective: The aim of the study was to describe the impact of sociodemographic and clinical factors on survival of patients with AML in 11 health institutions from Colombia, from 2009 to June 2021. Methods: Population based on RENEHOC (online platform) and PETHEMA (Spanish Program for Hematology Treatments). Kaplan-Meier analysis was used to assess overall survival (OS) and Relapse-Free Survival global (RFS) of the different evaluated factors. Results: A total of 463 patients were included. The median age at diagnosis was 61 years (range, 19-90) and 50.5% were female. According to the FAB classification, 95 (26.6%), 84 (23.6%), and 53 (14.9%) of patients were classified as M2, M0 and M1, respectively. The cytogenetic risk was applied for 227 patients (57%), 135 (59.5%) were intermediate and 78 (34.4%) were high-risk. Secondary AML were 73 (18.2%) and these cases evolved from hematological malignancies in 38 cases (80.8%), the most common were myelodysplastic syndrome (n=16; 34%) and chronic myeloid leukemia (n=7; 50%). For induction therapy, 232 (59.7%) patients received 7+3 (cytarabine/idarubicin), 47 (11.7%) received Azacitidine (AZA) and 23 (5.7%) received FLUGA (Fludarabine/cytarabine low doses). Complete remission (CR) after induction was achieved in 53% of patients, 12% had partial remission, 20.3% had primary refractory AML. Twelve percent died during induction. The most common consolidation regimen was high dose cytarabine (HiDAC), 143 (35,6%) and 36 (9%) of patients received 1 and 2 cycles respectively. Seventy-two (51%) patients that achieved a CR relapsed, and 46 (69.7%) received second line therapy. The most common treatment was FLAG-IDA (27%), followed by best supportive care (23.8%). The response rate was 40% (CR:31.1%/PR:8.9%) with 16 (36.6%) patients being refractory to treatment. Five (11.1%) died during salvage therapy. Thirty-eight (21%) patients had a hematopoietic stem cell transplantation (HCT), 35 (92%) had allogeneic HCT and 3 (8%) autologous HCT, respectively. The median and 5-year OS for the whole population was 19 months and 27.6% (95%CI,19.7- 36.0). The median and 5-year RFS was 14 months and 21.8% (95%CI, 15.2 - 29.2), respectively (Figure 1). Sociodemographic and clinical factors such as age, ECOG PS, co-morbidies (Hypertension, diabetes, and chronic heart failure), AML subtype and leukocytosis at diagnosis were prognostic (Table 1). Conclusion: This is the first multicenter report analyzing real world data from AML patients in Colombia. Results confirm the impact of clinical factors: age, ECOG, secondary LMA on OS and RFS. Challenges includes low alloHSCT rate and low access to complete cytogenetic and molecular classification at diagnosis. Figure 1 Figure 1. Disclosures Sossa: Amgen: Research Funding. Abello: Dr Reddy's: Research Funding; Janssen: Honoraria; Amgen: Honoraria. Peña: Amgen: Research Funding. Salazar: Amgen: Research Funding. Sandoval-Sus: SeaGen, Janssen, MassiveBio, TG: Other: Advisory Board; BMS: Other: Advisory Board, Speakers Bureau. Montesinos: Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Agios: Consultancy; Tolero Pharmaceutical: Consultancy; AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Glycomimetics: Consultancy; Astellas Pharma, Inc.: Consultancy, Honoraria, Other: Advisory board, Research Funding, Speakers Bureau; Forma Therapeutics: Consultancy; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Incyte: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sanofi: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Teva: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Stemline/Menarini: Consultancy.

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Survival Implications of Opioid Use after Blood and Marrow Transplantation

Blood ◽

10.1182/blood-2020-134463 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 2-3

Author(s):

Noha N. Soror ◽

Ashleigh Keiter ◽

Qiuhong Zhao ◽

Julianna Roddy ◽

Sam Penza ◽

...

Keyword(s):

United States ◽

Board Of Directors ◽

Research Funding ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Use ◽

Advisory Committees ◽

Impact On Survival ◽

The Impact

B ackground Premature death from opioid-related causes imposes an enormous public health burden across the United States. Between 2001 and 2016, the number of opioid-related deaths in the United States increased by 345%, from 9489 to 42 245 deaths (33.3 to 130.7 deaths per million population. Moreover, opioids may have immunosuppressive properties independent of their psychotropic effects; opioid use has been associated with increased invasive pneumococcal disease in a nested case-control study of 1233 Medicaid patients from Tennessee. In liver transplant recipients, opioid use disorder has been associated with increased mortality after transplant. The impact of opioid use disorder on patients receiving blood and marrow transplant (BMT) remains to be defined. Methods We performed a retrospective analysis of all consecutive adult patients who had BMT (autologous and allogeneic) from 1/1/2008 through 1/1/2018 at the James Comprehensive Cancer Center. Overall survival (OS) was measured from the date of transplant to the date of death, censoring at date of last follow up if alive. Progression free survival (PFS) was measured from the date of transplant to the date of disease progression or the date of death, whichever occurred first, censoring at last follow up if no event. OS and PFS were estimated by the Kaplan-Meier method and compared using the log-rank test. Opioid use (OU) was defined as a binary yes/no variable if an opioid was prescribed upon discharge from the hospital after BMT. The impact of OU, along with other patient, disease, and BMT related factors, on PFS/OS, was analyzed using Cox regression method. Results A total of 1585 patients were included in the analysis (Table 1). The median age at BMT was 58 (range=18-79) years; 59% were males; 60% had autologous transplants; and 58% were prescribed opioids upon discharge from the hospital. OU was significantly more in patients who were younger, have had allogeneic transplant, reduced intensity conditioning, had acute myeloid leukemia (AML), or higher BMT comorbidity index (CMI). On univariable analysis, OU was not associated with cumulative incidence of relapse (CIR) or PFS however it was associated with inferior OS; hazard ratio (HR)=1.25, 95% CI: 1.06-1.49; p=0.01 (Figure-1). There were no differences in CIR, PFS, or OS when autologous and allogeneic transplants were analyzed separately. Upon multivariable analysis of OS, OU lost statistical significance after controlling for age, diagnosis, type of transplant, intensity of conditioning regimen, CMI, and disease risk index (DRE). Of interest, OU independently predicted for superior OS at 100 days and 365 days post-BMT; HR=0.29, 95% CI 0.16-0.50 (p=<.0001) and HR=0.47, 95% CI 0.32-0.69 (p<0.001); respectively. Conclusion: Our results suggest that opioid use (OU) may have a long term negative impact on survival in BMT patients. The apparently protective effects of OU early on after BMT is elusive but may be possibly related immunomodulatory effects of opioids. A major limitation of our study is that OU is analyzed at a single time point at hospital discharge after BMT. We plan to undertake a more detailed analysis of ongoing OU after discharge and its impact on survival outcomes after BMT. Disclosures Brammer: Celgene Corporation: Research Funding; Seattle Genetics, Inc.: Speakers Bureau. Efebera:Celgene: Research Funding; Ohio State University: Current Employment; Pharmacyclics: Research Funding; Takeda: Honoraria, Speakers Bureau. Mims:Abbvie: Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Other: Data Safety Monitoring Board; Syndax Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Kura Oncology: Membership on an entity's Board of Directors or advisory committees; Leukemia and Lymphoma Society: Other: Senior Medical Director for Beat AML Study; Agios: Consultancy; Novartis: Speakers Bureau. Chaudhry:Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees. Bumma:Sanofi: Speakers Bureau; Amgen: Speakers Bureau. Khan:Amgen: Consultancy; Janssen: Consultancy. Devarakonda:Janssen: Consultancy. Jaglowski:Novartis: Consultancy, Research Funding; CRISPR: Consultancy; Juno: Consultancy; Kite, a Gilead Company: Consultancy, Research Funding. William:Kyowa Kirin: Consultancy, Honoraria; Merck: Research Funding; Seattle Genetics: Research Funding; Incyte: Research Funding; Guidepoint Global: Consultancy; Dova: Research Funding; Celgene: Consultancy, Honoraria.

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Results from the Displace Consortium: Practice Patterns on the Use of Transcranial Doppler Screening for Risk of Stroke in Children with Sickle Cell Anemia

Blood ◽

10.1182/blood-2018-99-116709 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4697-4697

Author(s):

Shannon Phillips ◽

Martina Mueller ◽

Alyssa M Schlenz ◽

Cathy Melvin ◽

Robert J. Adams ◽

...

Keyword(s):

Board Of Directors ◽

Sickle Cell ◽

Cerebral Artery ◽

Sickle Cell Anemia ◽

Transcranial Doppler ◽

Research Funding ◽

Practice Patterns ◽

The United States ◽

Care Providers ◽

Advisory Committees

Abstract Introduction: Stroke is one of the most devastating complications of sickle cell anemia (SCA). The STOP (Stroke Prevention Trial in Sickle Cell Anemia) protocol has been adopted by National Heart Lung and Blood Institute (NHLBI) as the guideline for stroke screening using transcranial Doppler ultrasound (TCD) and prevention with chronic red cell transfusion therapy (CRCT). Evidence from the STOP I/II studies indicates the protocol is highly effective, yet wide scale implementation has not been achieved. The DISPLACE (Dissemination and Implementation Looking at the Care Environment) project is a multicenter, NHLBI funded consortium of 28 sites across the United States whose purpose is to identify barriers to the implementation of the STOP protocol and test novel methods for overcoming barriers. The purpose of this study was to use data on practice patterns to evaluate current measurement and practice standards at DISPLACE consortia sites. This abstract presents reported TCD screening and CRCT practices. Methods: A practice patterns survey was sent to the principal investigator (PI) for each DISPLACE site via RedCap ©. PIs were hematology/oncology specialty care providers for children with SCA. Sites represent urban and rural regions, large and small academic institutions, and community-based institutions. The survey was developed by the study investigators; questions were predominantly in a multiple-choice format. Items pertaining to TCD screening included: screening technique (including type of TCD); screening frequency; follow-up for abnormal, conditional, and inadequate results; standard value ranges. Results: All 28 PIs completed the survey. About half of the respondents were female (53.5%). Most identified as White (77.8%), followed by Asian (11.1%) and Black or African American (7.4%). Two identified as Hispanic or Latino (7.4%). Slightly more sites reported using standard TCD (57.1%) versus imaging TCD (TCDi) (42.9%). To calculate the time-averaged mean of the maximum (TAMM) velocities and characterize TCD results, nearly all sites use the middle cerebral artery (96.4%); a majority also use the anterior cerebral artery and/or the terminal internal cerebral artery or distal internal cerebral artery (71.4%). Fewer sites use the posterior cerebral artery (35.7%) or the basilar artery (14.3%). In 7.1% of sites, the radiologist determines which vessels to use during the exam. TCD screening is ordered for children with SCA annually in 92.9% of sites and every 6 months in 7.1% of sites. When TCD screening indicates abnormal TAMM velocities, 85.7% of sites initiate CRCT, 7.1% initiate hydroxyurea (HU) therapy, and 3.6% initiate both HU and CRCT. For additional evaluation, an MRI/MRA is obtained at 64.3% of sites. For high conditional results, the most common action is to initiate HU (67.9%). Other responses include obtaining an MRI/MRA (46.4%) and/or repeating the TCD in 2-4 weeks (25.0%), 6-8 weeks (35.7%), or 12-16 weeks (7.1%). Results deemed inadequate led to repeating the TCD in 2-12 weeks (57.1%) or in one year (3.6%), obtaining an MRI/MRA (57.1%), beginning HU therapy (7.1%), or no repeat TCD or change in management (3.6%). Actions for low conditional results include repeating the TCD (71.4%), obtaining an MRI/MRA (32.3%), and/or initiating HU therapy (57.1%). Surprisingly, sites use different TAMM ranges to characterize the normal/abnormal findings (Table 1). Conclusions: Nearly all DISPLACE sites order TCD screening annually, as recommended in the guidelines, with some ordering screening more frequently. A few sites did not report initiation of CRCT per STOP protocol for abnormal TCD results; however, over half of the sites reported following up with an MRI/MRA, which may suggest evaluating for vasculopathy prior to CRCT. Some sites reported beginning HU therapy for abnormal results; this may reflect consideration of patients for whom CRCT is not possible, but data were not collected for confirmation. Interestingly, results suggest a reliance on MRI/MRA since sites commonly reported ordering neuroradiology studies for abnormal, conditional, and inadequate TCD results. This may suggest an unclear pathway for children with borderline TCD results, and an area for future study. While reported value ranges closely approximated those in the STOP protocol, results indicate sites conducting screening with TCDi may use more conservative values than the validated protocol. Disclosures Phillips: NHLBI: Research Funding. Mueller:NHLBI: Research Funding. Schlenz:NHLBI: Research Funding. Melvin:NHLBI: Research Funding. Adams:NHLBI: Research Funding. Kanter:AstraZeneca: Membership on an entity's Board of Directors or advisory committees; bluebird bio: Membership on an entity's Board of Directors or advisory committees, Research Funding; Global Blood Therapeutics: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sancilio: Research Funding; NHLBI: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding; Apopharma: Research Funding; ASH: Membership on an entity's Board of Directors or advisory committees.

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Examining the Clinical Features and Underlying Cardiovascular Risk Among Patients with Polycythemia Vera in the REVEAL Study

Blood ◽

10.1182/blood.v128.22.1934.1934 ◽

2016 ◽

Vol 128 (22) ◽

pp. 1934-1934 ◽

Cited By ~ 1

Author(s):

Brady L. Stein ◽

Ahmad Naim ◽

Michael R. Grunwald ◽

Alison R. Moliterno ◽

Stephen T. Oh ◽

...

Keyword(s):

Risk Factors ◽

Board Of Directors ◽

Research Funding ◽

Clinical Characteristics ◽

The United States ◽

Employment Equity ◽

Advisory Committees ◽

Reveal Study ◽

History Of ◽

Equity Ownership

Abstract Background:Patients with polycythemia vera (PV) often present with a broad range of clinical characteristics that may contribute to increased risks of cardiovascular (CV) morbidity and mortality, including thrombotic events (TE). Limited contemporary real-world data have been reported about the clinical burden of PV and treatment patterns in the United States. The ongoing REVEAL study collects data on disease burden, clinical management, patient-reported outcomes, and healthcare resource utilization for patients with PV in the United States. This analysis reports clinical characteristics, including underlying CV risk factors, for patients enrolled in the REVEAL study as of April 28, 2016. Methods: REVEAL is a multicenter, nonrandomized, prospective, observational study enrolling patients ≥18 years of age with a PV diagnosis who are actively managed in an academic or community setting. For this analysis, data regarding PV disease and diagnosis, clinical characteristics, and treatment patterns were collected at enrollment during usual-care visits and were based on physician assessment, electronic medical records, and local laboratory values. Ten-year CV risk factors selected for this analysis were adapted from the Framingham Heart Study for CV diseases. Results: At data cutoff, 2307 patients were available for this analysis. Mean (SD) age was 66.3 (12.2) years, 54.4% were male, 89.9% were white, 62.7% had at least some college education, and 51.1% were retired. Approximately 6% of patients had a family history of PV, primarily in parents (35.1%) and siblings (33.8%). A history of second malignancies was reported for 344 patients (14.9%). The majority of patients (84.6%) were diagnosed with PV based on an abnormal blood test alone or in combination with a bone marrow test. Among patients who were diagnosed with a mutational test (n=1078), 95.2% were diagnosed via an abnormal JAK2V617F test result. Abnormal hemoglobin (57.3%), hematocrit (55.4%), or both (47.5%) were among the most common blood values assessed for PV diagnosis. At diagnosis, 58.5% of patients were classified with high-risk PV (age ≥60 years or history of a TE); this percentage increased to 77.3% at REVEAL enrollment. The average (SD) disease duration from diagnosis to enrollment was 5.8 (6.1) years. At enrollment, 91.5% of patients were under active management for PV (phlebotomy ± aspirin, 34.0%; hydroxyurea ± aspirin, 27.0%; and phlebotomy + hydroxyurea ± aspirin, 23.2%). Underlying CV risk factors that were either diagnosed or treated in 86.0% of enrolled patients included hypertension (66.5%), history of smoking (46.2%), current smoking at enrollment (10.9%), obesity (34.2%), hyperlipidemia (27.4%), and diabetes (14.8%). At enrollment, 431 (18.7%) patients reported having ≥1 TE, including 181 patients who had a TE between PV diagnosis and enrollment. Venous and arterial TEs were reported in 11.1% and 8.6% of patients, respectively. Most commonly reported venous TEs were deep vein thrombosis (5.9%) and pulmonary embolism (2.5%); most common arterial TEs were cerebrovascular arterial thrombosis including transient ischemic attack (5.1%) and acute myocardial infarction (1.7%). Increased rates of TEs were observed among patients with hyperlipidemia (23.6%) and hypertension (21.0%; Table 1), compared with patients who did not have any risk factors (10.5%). Conclusion: A large proportion of patients in the REVEAL study had 1 or more underlying CV risks, including age, hypertension, smoking, obesity, hyperlipidemia, and diabetes, which may contribute to the risk of thrombosis. Longitudinal data from REVEAL will provide a better understanding of how these factors affect CV outcomes over time. Disclosures Stein: Incyte Corporation: Membership on an entity's Board of Directors or advisory committees, Research Funding. Naim:Incyte Corporation: Employment, Equity Ownership. Grunwald:Janssen: Research Funding; Forma Therapeutics: Research Funding; Medtronic: Equity Ownership; Alexion: Membership on an entity's Board of Directors or advisory committees; Ariad: Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding; Incyte Corporation: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Oh:Incyte Corporation: Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Research Funding; CTI: Research Funding. Paranagama:Incyte Corporation: Employment, Equity Ownership. Cordaro:Incyte Corporation: Employment, Equity Ownership. Sun:Incyte Corporation: Employment, Equity Ownership. Parasuraman:Incyte Corporation: Employment, Equity Ownership. Boccia:Celgene: Consultancy, Honoraria, Speakers Bureau; Amgen/Onyx: Consultancy, Honoraria, Speakers Bureau; Gilead: Speakers Bureau; Genentech: Consultancy, Honoraria, Speakers Bureau; Eisai: Consultancy, Honoraria, Speakers Bureau. Mesa:Ariad: Consultancy; CTI: Research Funding; Gilead: Research Funding; Galena: Consultancy; Novartis: Consultancy; Promedior: Research Funding; Celgene: Research Funding; Incyte Corporation: Research Funding.

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Association between the Leukemia Mortality-to-Incidence Ratio and State Geographic Healthcare Disparities in the United States

Blood ◽

10.1182/blood-2021-151798 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3066-3066

Author(s):

Mina Abdelmalek ◽

Yu-Che Lee ◽

Mazen Jizzini ◽

Ko-Yun Chang ◽

Yi Lee ◽

...

Keyword(s):

United States ◽

Board Of Directors ◽

Incidence Rate ◽

Clinical Care ◽

The United States ◽

Advisory Board ◽

State Health ◽

Advisory Committees ◽

Potential Association ◽

The Us

Abstract INTRODUCTION : Leukemia is the seventh leading cause of cancer death in the United States (US) in 2021. The Mortality Incidence Rate Ratio, also known as Mortality-to-Incidence Ratio (MIR), is calculated by dividing the mortality rate by the incidence rate for selected cancers and population. The MIR provides a population-based indicator of cancer survival which has previously been used to assess healthcare disparities among different countries. Here weevaluated the potential association between leukemia MIR and state-based health disparities in the US. METHODS: Leukemia (AML, CML, ALL, CLL and other leukemias) MIRs for 2008-2017 were obtained from United States Cancer Statistics (USCS) database provided by the Centers for Disease Control and Prevention (CDC). America's Health Rankings (AHR), a partnership of the United Health Foundation and the American Public Health Association, evaluates the nation's health on a state-by-state basis by using weighted measures in 5 different categories (25% for Behaviors, 22.5% for Community & Environment, 12.5% for Policy, 15% for Clinical Care, and 25% for Outcomes). AHR then determines state health rankings and reflects state health disparities based on these specific factors. Here we analyzed the potential association between leukemia MIRs and state health rankings by linear regression. RESULTS: From 2008 to 2017, a total of 489,037 people were diagnosed with leukemia and 231,069 people died from leukemia in the US. The 10-year average of age-adjusted incidence rate and mortality rate were 14.2 and 6.7 per 100,000 population respectively. The average MIR between all states was calculated to be 0.470. As seen in Table 1, the lowest MIR (best survival) was found in Florida (0.374), New York (0.391), and New Jersey (0.412) with AHR 34, 19 and 11 respectively. The highest MIR (worst survival) was found in Mississippi (0.579), Wyoming (0.570), and Ohio (0.569) with AHR 50, 24 and 37 respectively. According to AHR, over the last decade, the states with the highest health rankings were reported in Vermont (No. 1), Hawaii (No. 2), and Massachusetts (No. 3) with MIR 0.508, 0.439 and 0.502 respectively. The states with the lowest health rankings were reported in Arkansas (No. 48), Louisiana (No. 49), and Mississippi (No. 50) with MIR 0.559, 0.503 and 0.579 respectively. In our analysis, states with better health rankings were significantly associated with lower MIRs (R 2=0.232, P<0.001), as seen in Figure 1. CONCLUSIONS: There is a remarkable geographic difference in leukemia MIRs in the US between 2008-2017. Leukemia MIR was significantly associated with state health rankings reported by the AHR. Although the quality of clinical care for leukemia patients remains to be an important predictor of mortality, our findings suggest that other aggregate determinants of health, including social, economic, and community and physical environment may also play a vital role in influencing leukemia survival. More in-depth analysis of these data focusing on specific leukemia subtypes as well as other factors (race, gender, age) may be helpful in identifying and addressing other non-medical issues negativity impacting on leukemia outcomes in different geographical regions in the United States. Figure 1 Figure 1. Disclosures Wang: Kura Oncology: Consultancy, Honoraria, Other: Advisory board, steering committee, Speakers Bureau; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Stemline Therapeutics: Consultancy, Honoraria, Other: Advisory board, Speakers Bureau; Kite Pharmaceuticals: Consultancy, Honoraria, Other: Advisory Board; Takeda: Consultancy, Honoraria, Other: Advisory board; Pfizer: Consultancy, Honoraria, Other: Advisory Board, Speakers Bureau; Novartis: Consultancy, Honoraria, Other: Advisory Board; Mana Therapeutics: Consultancy, Honoraria; BMS/Celgene: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Consultancy, Honoraria, Other: Advisory Board; Jazz Pharmaceuticals: Consultancy, Honoraria, Other: Advisory Board; DAVA Oncology: Consultancy, Speakers Bureau; Rafael Pharmaceuticals: Other: Data safety monitoring committee; Gilead: Consultancy, Honoraria, Other: Advisory board; Daiichi Sankyo: Consultancy, Honoraria, Other: Advisory board; PTC Therapeutics: Consultancy, Honoraria, Other: Advisory board; Genentech: Consultancy; MacroGenics: Consultancy.

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