Echo L. Warner

Social well-being among adolescents and young adults with cancer: A systematic review.

A cancer diagnosis during adolescence or young adulthood may negatively influence social well‐being. The existing literature concerning the social well‐being of adolescents and young adults (AYAs) with cancer was reviewed to identify gaps in current research and highlight priority areas for future research.

Social well-being among adolescents and young adults with cancer

A cancer diagnosis during adolescence or young adulthood may negatively influence social well‐being. The existing literature concerning the social well‐being of adolescents and young adults (AYAs) with cancer was reviewed to identify gaps in current research and highlight priority areas for future research.

Geographic Factors and Human Papillomavirus (HPV) Vaccination Initiation among Adolescent Girls in the United States

Background: This study is among the first to explore geographic factors that may be associated with human papillomavirus (HPV) vaccine uptake in the United States. Methods: Data from the 2011 and 2012 National Immunization Survey-Teen for 20,565 female adolescents aged 13 to 17 years were analyzed to examine associations of HPV vaccine initiation (receipt of at least one dose) with ZIP code–level geographic factors. Logistic regression including individual and geographic factors was used to estimate the odds of HPV vaccine initiation. Results: Approximately 53% of girls initiated the HPV vaccine in both years. Girls in high poverty communities had higher HPV vaccine initiation compared with those in low poverty communities [61.1% vs. 52.4%; adjusted OR (AOR), 1.18; 95% confidence intervals (CI), 1.04–1.33]. Initiation was higher among girls in communities where the majority of the population was Hispanic (69.0% vs. 49.9%; AOR, 1.64; 95% CI, 1.43–1.87) or non-Hispanic mixed race (60.4% vs. 49.9%; AOR, 1.30; 95% CI, 1.17–1.44) compared with majority non-Hispanic white communities. Interactions between individual-level race/ethnicity and community racial–ethnic composition indicated significantly higher odds of initiation among Hispanic girls living in Hispanic communities compared with Hispanic girls living in predominantly non-Hispanic White (NHW) (AOR, 2.23; 95% CI, 1.87–2.65) or non-Hispanic Black (NHB) (AOR, 1.90; 95% CI, 1.20–3.04) communities, respectively. Conclusion: Initiation rates of HPV vaccination among teen girls were highest in the poorest communities and among Hispanics living in communities where the racial–ethnic composition was predominantly Hispanic or mixed race. Impact: Given low HPV vaccination rates in the United States, these results provide important evidence to inform public health interventions to increase HPV vaccination. Cancer Epidemiol Biomarkers Prev; 25(2); 309–17. ©2016 AACR.

Statewide analysis of missed opportunities for human papillomavirus vaccination using vaccine registry data.

BACKGROUND Human papillomavirus (HPV) vaccine 3-dose completion rates among adolescent females in the US are low. Missed opportunities impede HPV vaccination coverage. METHODS A population-based secondary data analysis of de-identified vaccination and demographic data from the Utah Statewide Immunization Information System (USIIS) was conducted. Records were included from 25,866 females ages 11-26 years at any time during 2008-2012 who received at least one of the following adolescent vaccinations documented in the USIIS: Tdap (Tetanus, Diphtheria, Pertussis), meningococcal, and/or influenza. A missed opportunity for HPV vaccination was defined as a clinical encounter where the patient received at least one adolescent vaccination, but not a HPV vaccine. RESULTS Of 47,665 eligible visits, there were 20,911 missed opportunities (43.87%). Age group, race/ethnicity, and rurality were significantly associated with missed opportunity (p<0.0001). In a multivariable mixed-effects logistic regression model that included ethnicity, location and age, as fixed effects and subject as a random effect, Hispanics were less likely to have a missed opportunity than whites OR 0.59 (95% CI: 0.52-0.66), small rural more likely to have a missed opportunity than urban youth OR 1.8 (95% CI: 1.5-2.2), and preteens more likely than teens OR 2.4 (95% CI: 2.2-2.7). CONCLUSION Missed clinical opportunities are a significant barrier to HPV vaccination among female adolescents. Interventions targeted at providers who serve patient groups with the highest missed opportunities are needed to achieve adequate protection from HPV-associated illnesses. IMPACT This is one of the first studies to utilize state immunization information system data to assess missed opportunities for HPV vaccination.Background Human papillomavirus (HPV) vaccine 3-dose completion rates among adolescent females in the US are low. Missed opportunities impede HPV vaccination coverage. Methods A population-based secondary data analysis of de-identified vaccination and demographic data from the Utah Statewide Immunization Information System (USIIS) was conducted. Records were included from 25,866 females ages 11–26 years at any time during 2008–2012 who received at least one of the following adolescent vaccinations documented in the USIIS: Tdap (Tetanus, Diphtheria, Pertussis), meningococcal, and/or influenza. A missed opportunity for HPV vaccination was defined as a clinical encounter where the patient received at least one adolescent vaccination, but not a HPV vaccine. Results Of 47,665 eligible visits, there were 20,911 missed opportunities (43.87%). Age group, race/ethnicity, and rurality were significantly associated with missed opportunity (p<0.0001). In a multivariable mixed-effects logistic regression model that included ethnicity, location and age, as fixed effects and subject as a random effect, Hispanics were less likely to have a missed opportunity than whites OR 0.59 (95% CI: 0.52–0.66), small rural more likely to have a missed opportunity than urban youth OR 1.8 (95% CI: 1.5–2.2), and preteens more likely than teens OR 2.4 (95% CI: 2.2–2.7). Conclusion Missed clinical opportunities are a significant barrier to HPV vaccination among female adolescents. Interventions targeted at providers who serve patient groups with the highest missed opportunities are needed to achieve adequate protection from HPV-associated illnesses. Impact This is one of the first studies to utilize state immunization information system data to assess missed opportunities for HPV vaccination.

A population-based study of childhood cancer survivors' body mass index.

Background. Population-based studies are needed to estimate the prevalence of underweight or overweight/obese childhood cancer survivors. Procedure. Adult survivors (diagnosed ≤20 years) were identified from the linked Utah Cancer Registry and Utah Population Database. We included survivors currently aged ≥20 years and ≥5 years from diagnosis (N = 1060), and a comparison cohort selected on birth year and sex (N = 5410). BMI was calculated from driver license data available from 2000 to 2010. Multivariable generalized linear regression models were used to calculate prevalence relative risks (RR) and 95% confidence intervals (95% CI) of BMI outcomes for survivors and the comparison cohort. Results. Average time since diagnosis was 18.5 years (SD = 7.8), and mean age at BMI for both groups was 30.5 (survivors SD = 7.7, comparison SD = 8.0). Considering all diagnoses, survivors were not at higher risk for being underweight or overweight/obese than the comparison. Male central nervous system tumor survivors were overweight (RR = 1.12, 95% CI 1.01–1.23) more often than the comparison. Female survivors, who were diagnosed at age 10 and under, had a 10% higher risk of being obese than survivors diagnosed at ages 16–20 (P < 0.05). Conclusion. While certain groups of childhood cancer survivors are at risk for being overweight/obese, in general they do not differ from population estimates.

Preventive health care among HIV positive women in a Utah HIV/AIDS clinic: a retrospective cohort study

BackgroundDespite evidence that HIV positive women may suffer higher rates of heart disease, diabetes, human papillomavirus infection, and some types of cancer, the provision of preventive health services to HIV positive women is unknown. Preventive health services recommended for such women include breast, colorectal and cervical cancer screening, sexually transmitted infection (STI) testing, vaccinations, and patient counseling on a number of issues including sexual behaviors.MethodsThis retrospective cohort study utilized medical record reviews of 192 HIV positive women who were patients at the University of Utah Infectious Diseases Clinic in 2009. Medical records were reviewed for all encounters during 2009 using a standardized data collection form; data were collected on patient demographics and a variety of preventive health services. Chi squared tests were used to assess receipt of preventive health services by demographic factors, and multivariable logistic regression was used to determine predictors of receiving select services.ResultsThe most commonly recorded preventive services included blood pressure screening, screening for Hepatitis A and B, Tetanus-Diphtheria-Pertussis vaccination, Pneumococcal pneumonia vaccination, substance abuse screening, and mental health screening. STI testing and safe sex counseling were documented in the medical records of only 37% and 33.9% of women, respectively. Documentation of cancer screening was also low, with cervical cancer screening documented for 56.8% of women, mammography for 65% (N = 26/40) of women, and colorectal cancer screening for 10% (N = 4/40) of women, where indicated. In multivariable models, women with private health insurance were less likely to have documented STI testing (OR 0.20; 95% CI 0.08 - 0.52), and, Hispanic women were less likely to have documented safe-sex counseling (OR 0.26; 95% CI 0.07 - 0.94).ConclusionsHIV/AIDS providers should focus on the needs of all women for preventive care services, including those with fewer socio-demographic risk factors (i.e., insured, stable housing etc.). In addition, failure to provide STI testing, cancer screening, or safe sex counseling to all patients represents a missed opportunity for provision of services that are important from both a clinical and public health perspective.

Statewide Vaccine Registry Data Indicate High Number of Missed Opportunities for the HPV Vaccine Among Eligible Girls

This study investigates the rate of missed opportunities for the HPV vaccine among eligible girls using statewide vaccine registry data. Methods: Using data from the Utah Statewide Immunization Information System (USIIS) from 2008–2012 for approximately 55,000 girls ages 11–18, we assessed the frequency of missed opportunities (receipt of other recommended vaccinations such as TDap, MCV4, and/or flu and not the HPV vaccine) among eligible female patients for the HPV vaccine. USIIS is a free, confidential, web-based information system that contains immunization histories for Utah residents of all ages. Records of all persons born in Utah since 1998 are in USIIS. USIIS is designed to help enrolled healthcare providers track immunization records for patient care by consolidating immunizations from enrolled providers into one centralized record. Vaccine administration from 86% of healthcare providers in Utah is reported to USIIS. USIIS data used for the study include date of birth, age, gender, ethnicity and race, zip code, and date and type of vaccine received. Descriptive statistics and chi- square tests were used to assess rate of missed opportunities for the HPV vaccine and associated demographic factors. Results: Approximately 65% of preteens (ages 11–12; N = 2,593) and 32% of female teens (ages 13–18; N = 4,937) had a missed opportunity for the HPV vaccine between years 2008–2012 in Utah (P < 0.001). Race and ethnicity related to rates of missed opportunities for the HPV vaccine among all girls ages 11–18 (Whites = 36%, N = 2,454; Hispanics = 21%, N = 254) (P < 0.001). Rural and urban locations were also associated with rates of missed opportunities for the HPV vaccine (urban = 31%, N = 4,448; large rural town = 42%, N = 202) (P < 0.001). Conclusions: For more than eight years, a vaccine to prevent cervical and other HPV-related cancers has been available, yet receipt of the 3-dose HPV vaccine in the United States is far below national goals for girls (33% vs. 80%; actual vs. target). Using statewide vaccine registry data, our study demonstrates that administering the HPV vaccine when providing other recommended adolescent vaccinations may dramatically improve rates of HPV vaccination among girls in a state with low HPV vaccine uptake. In addition, targeting rural communities and non-Hispanic White patients may further reduce missed opportunities.

Supplemental Security Income and Social Security Disability Insurance Coverage Among Long-term Childhood Cancer Survivors

Supplemental security income (SSI) and social security disability insurance (DI) are federal programs that provide disability benefits. We report on SSI/DI enrollment in a random sample of adult, long-term survivors of childhood cancer (n = 698) vs a comparison group without cancer (n = 210) from the Childhood Cancer Survivor Study who completed a health insurance survey. A total of 13.5% and 10.0% of survivors had ever been enrolled on SSI or DI, respectively, compared with 2.6% and 5.4% of the comparison group. Cranial radiation doses of 25 Gy or more were associated with a higher risk of current SSI (relative risk [RR] = 3.93, 95% confidence interval [CI] = 2.05 to 7.56) and DI (RR = 3.65, 95% CI = 1.65 to 8.06) enrollment. Survivors with severe/life-threatening conditions were more often enrolled on SSI (RR = 3.77, 95% CI = 2.04 to 6.96) and DI (RR = 2.73, 95% CI = 1.45 to 5.14) compared with those with mild/moderate or no health conditions. Further research is needed on disability-related financial challenges after childhood cancer.

Health Care Concerns of Rural Childhood Cancer Survivors

Background. Geographic isolation may limit health care access due to burdens of time, cost and travel distance. We explored rural childhood cancer survivors’ experiences and concerns about accessing affordable, quality care. Methods. In-depth, semi-structured telephone interviews were conducted with 17 rural adult survivors recruited from the Utah Cancer Registry. Interviews were recorded, transcribed, and content analyzed with NVivo 9 by two coders (kappa = 0.93). Results. Two primary themes emerged: (1) concerns about health care quality and (2) geographic and insurance issues. Within these main themes, we identified salient sub-themes: quality of primary care, patient-provider trust, specialty care access, travel burdens, and financial and insurance concerns. Conclusions. Rural childhood cancer survivors have concerns about local health care services, but are willing to travel several hours to receive care. Partnerships between local primary care and cancer specialty providers via telemedicine that incorporate survivor care plans could improve risk-based care for rural survivors.

“Job Lock” Among Long-term Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

Importance Childhood cancer survivors may be reluctant to make changes in their employment because of access to health insurance. Objective To examine the prevalence of “job lock” (staying at a job to keep work-related health insurance) in a sample drawn from an established, multi-institutional cohort of full-time employed childhood cancer survivors compared with a random sample of siblings and to explore factors associated with job lock among cancer survivors. Design, Setting, and Participants Cross-sectional survey of full-time employed adult survivors of childhood cancer and a random sample of siblings derived from a cohort of 25 US pediatric oncology centers. Exposures Data collection included sociodemographic factors, insurance coverage, chronic medical conditions, and treatment. Main Outcomes and Measures Self-report of job lock and factors associated with job lock. Results Among the 522 participants, 394 were cancer survivors (54.5% male) and 128 were siblings (51.5% male). Job lock was reported by 23.2% (95% CI, 18.9%-28.1%) of survivors, compared with 16.9% (95% CI, 11.1%-25.0%) of siblings (P = .16). Job lock was more common among survivors reporting previous health insurance denial (relative risk [RR], 1.60; 95% CI, 1.03-2.52) and problems paying medical bills (RR, 2.43; 95% CI, 1.56-3.80). Among survivors, being female (RR, 1.70; 95% CI, 1.11-2.59; P = .01) and having a severe, disabling, or life-threatening health condition (RR, 1.72; 95% CI, 1.09-2.69; P = .02) were associated with job lock. Conclusions and Relevance Job lock is common among long-term childhood cancer survivors who are employed full-time. A survivor’s decision to remain employed at a job in order to maintain health insurance coverage may affect career trajectory, diminish potential earning power, and ultimately impact quality of life.