61 Background: National Comprehensive Cancer Network recommends pneumococcal vaccination for adults 19 years and older with cancer. Currently at Massachusetts General Hospital (MGH) pneumococcal vaccination is not part of routine cancer care. A vaccination quality improvement project was developed to increase pneumococcal vaccination in lung cancer patients. The primary objective of this evaluation is to assess the impact of a multidisciplinary intervention to increase pneumococcal vaccination in patients with advanced lung cancer receiving intravenous anticancer therapy. Methods: Thoracic oncology clinic schedule and patient electronic medical records were reviewed prospectively from 01/01/2018 to 05/31/2018 by the clinical pharmacist to identify patients with advanced lung cancer eligible for vaccination. Patients list along with recommended vaccine type and schedule was emailed by the clinical pharmacist to clinical team (oncologist, nurse practitioner and practice nurses). Practice nurses obtained immunization records for patients with non-MGH primary care providers. A designated thoracic oncology nurse practitioner ordered appropriate vaccines. Vaccinations were administered by infusion nurse. Results: 50 patients were identified as eligible for vaccination: 7 patients had history of receiving prevnar 13, and 9 patients had history of pnemovax 23. 34 patients had no prior vaccination history. Through this intervention, 10 patients completed vaccination with both prevnar 13 and pnemovax 23. 15 patients received one of the two recommended vaccines. 22 patients refused vaccination, and 3 patients died before their next scheduled infusion visit. Conclusions: Pneumococcal vaccination is recommended for patients with cancer prior to initiation or three months after completion of immunosuppressive therapies. However, it is not always feasible to vaccinate patients prior to start of therapy as delays in cancer care can lead to disease related complications. Incorporating multidisciplinary intervention to identify patients with advanced lung cancer who are candidate for pneumococcal vaccination can improve the adherence to the guidelines.

71 Background: Annual influenza vaccination is recommended for individuals 6 months and older. Older adults are at high-risk of developing influenza and complications associated with the virus. However, < 50% of patients with cancer receive the influenza vaccine annually. In previous work at our institution, a quality improvement project identified that only 40% of adult patients initiating parenteral anticancer therapy between September and December 2017 were documented to have received the influenza vaccine. Therefore, a multidisciplinary student pharmacist-directed pilot intervention was developed to improve influenza vaccine documentation and administration rates, and we sought to investigate the impact of this intervention. Methods: All adult patients (≥65 years old) scheduled for parenteral anticancer therapy during November 2018 were screened for influenza vaccination documentation. Patients were identified by reviewing infusion center schedule. Under supervision of board-certified oncology pharmacists, two student pharmacists evaluated influenza vaccination documentation in the institution/network electronic medical record (EMR) and outside records. Patients with unknown vaccination history were identified for interview by pharmacy students. The student pharmacists collaborated with oncology nurses and clinicians to order and administer influenza vaccine to patients who agreed to vaccination. Influenza vaccination status was updated in the EMR following record reviews/interviews. Results: Student pharmacists screened 617 patient EMRs and interviewed 124 patients to verify vaccination status. Furthermore, 33 patients received influenza vaccination as a direct result of student pharmacist intervention. Overall, rate of influenza vaccination status documentation was 60.5%. Conclusions: Compared with historic data, we found promising results for a student pharmacist-directed pilot intervention, which demonstrated the potential to improve influenza vaccination status documentation and administration among older adults receiving parenteral anticancer therapy.

359 Background: National Comprehensive Cancer Network recommends intravenous (IV) iron therapy for management of cancer and chemotherapy induced anemia without mentioning agent preference. Currently at Dana-Farber Cancer Institute (DFCI), all IV iron formulations can be utilized in management of iron deficiency anemia. This study was performed to evaluate the utilization, efficacy, and safety of IV iron formulations in management of cancer and chemotherapy induced iron deficiency anemia in patients with gastrointestinal (GI) cancer. Methods: Retrospective chart review was performed on DFCI patients with GI cancer undergoing palliative or adjuvant chemotherapy who received ferric gluconate, ferumoxytol, or iron sucrose between January 2021 and January 2022. Patients were identified using electronic medical record reports. Data was collected on cancer diagnosis, chemotherapy regimen, total IV iron dose and frequency, infusion reactions, laboratory values including hemoglobin, mean corpuscular volume (MCV), and iron status parameters (serum iron, ferritin, transferrin, iron-binding capacity, transferrin saturation) at baseline and 4-6 weeks after the last dose. The primary outcome was to assess the utilization of different IV iron formulations. Secondary outcomes were efficacy defined as mean absolute change from baseline in Hemoglobin levels and safety defined as incidence of hypersensitivity reactions. Results: 102 patients were evaluated of which 61 received ferumoxytol, 36 ferric gluconate and 5 iron sucrose. All patients had baseline hemoglobin (≤11 g/dL) and MCV collected. 89 patients had baseline iron status parameters (serum iron, ferritin, transferrin, iron-binding capacity, transferrin saturation). Most patients (N = 70) had diagnosis of colorectal cancer and received chemotherapy every 2 weeks. All patients received recommend total dose of IV iron on days of chemotherapy which was outside the recommended schedule of the IV iron formulations. A gradual increase in Hemoglobin concentrations in patients treated with IV iron was observed. Conclusions: Ferumoxytol and Ferric Gluconate were the most utilized IV iron formulation at DFCI GI oncology patients. All patients received recommended IV iron dosing but did not follow the recommended schedule. All patients had hemoglobin and MCV checked before each IV iron therapy. IV iron therapy was well tolerated and effective in treatment of iron-deficiency anemia in patients with gastrointestinal cancer undergoing chemotherapy.[Table: see text]

2655 Background: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of cancer with significantly improved outcomes, but these agents have a unique spectrum of toxicities known as immune-related adverse events (irAEs). The recommended treatment for non-endocrine toxicities is steroid based. However, a subset of patients (pts) is steroid-refractory and requires second-line immunosuppression. There is very little evidence regarding this population. In this retrospective study we report the 1) incidence 2) type of treatment used 3) natural history and 4) potential predictors of steroid-refractory irAE at a major academic medical center. Methods: The Research Patient Database Registry at Mass General Brigham was used to identify pts treated with an ICI from 1/5/2017 to 6/1/2019. Pharmaceutical records identified a subset of the cohort received a second-line immunosuppressive agent within a 15-month period after ICI. For pts with steroid-refractory irAE additional information was collected: demographics, ICI regimen, type/#/and severity of irAE, clinical characteristics, # of admissions, length of stay (LOS), amount and duration of steroid therapy, second line immunosuppression type, treatment discontinuation rates, response, and outcome of re-challenge. Multivariate logistic regressions were used to predict risk of refractory toxicity and study the association of different variables (age, sex, race, marital status, cancer and ICI types) with refractory toxicities. Results: We identified 61 pts (1.4%) with steroid-refractory irAEs (48 colitis, 4 myocarditis, 6 pneumonitis, 3 neurologic) out of the total ICI cohort (N=4,325). 60.7% received ICI monotherapy. 24.6% received ICI in the adjuvant setting. Median length of steroid duration was 68 days with max of 1135 days. Despite use of second line immunosuppression, 25.8% of pts were never able to discontinue steroids. Majority of pts (72.1%) had at least one hospitalization with median LOS of 7.5 days. 93.4% of pts permanently discontinued the ICI responsible for the irAE. Thirteen pts (21.3%) were later re-challenged with ICI and 7 (53.8%) of these developed a subsequent irAE. Anti-CTLA-4 therapy was associated with a 10-fold risk of refractory toxicity compared to PD-1 (p<.05). Best tumor response was complete response in 21.3% and partial response in 26.2%. Among different cancer types, melanoma was most strongly associated with refractory events (OR 2.97 in comparison to thoracic malignancy). Conclusions: Refractory toxicity is uncommon but leads to high rates of ICI discontinuation, frequent hospitalizations, and a long duration of illness with exposure to prolonged and high-doses of steroids. There is an urgent need for further investigation into predictive factors for steroid-refractory toxicity given that ICI is being used more frequently and in earlier lines of treatment.

27 Background: According to NCCN, ASCO, and Multinational Association of Supportive Care in Cancer (MASCC) guidelines, palonosetron in combination with dexamethasone is the preferred 5-HT3 antagonist for use with moderately-emetogenic chemotherapy (MEC). NCCN gives all 5-HT3 antagonists a category one recommendation. Currently at the Massachusetts General Hospital (MGH), ondansetron is the 5-HT3 antagonist of choice due to its significant cost advantage and flexibility in dosing. Palonosetron is currently restricted to use in the second-line setting at MGH based on limitations of the evidence currently available supporting its preferred use. The primary objective of this study is to assess antiemetic utilization in patients receiving FOLFOX +/- bevacizumab(B) in an outpatient infusion unit and measure palonosetron and NK-1 antagonist usage. Methods: A retrospective review was conducted of all outpatient chemotherapy orders for FOLFOX +/- B for a six month period from 11/13-4/14. Prophylactic antiemetic use was evaluated over that time period. Data was captured using electronic MARs, prescription records, and drug utilization reports. Results: 184 patients were identified; 858 FOLFOX +/- B treatments were administered during the study period. For emesis prophylaxis, 74.5% received the MGH standard ondansetron and dexamethasone, 10.3% received palonosetron, 9.8% received an NK-1 antagonist, and 5.4% received a combination of palonosetron plus NK-1 antagonist. Mean patient age was 60.8 years; 59.8% of patients were male; 63.6% had a diagnosis of colorectal cancer; 42.9% had metastatic disease. Conclusions: The majority of patients receiving FOLFOX +/- B were well managed on ondansetron and dexamethasone and did not require the use of more costly antiemetics. However 25.5% of patients required alternative/additional antiemetics, suggesting further investigation to determine which patients could benefit from these therapies up-front may be prudent. Study data support continued use of palonosetron as a second line therapy. Larger, pharmacoeconomic comparison studies are necessary to justify frontline use of palonsetron.