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PURPOSE To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act. METHODS A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors. RESULTS Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg, 2 anthracycline chemotherapy, or chest radiation) were statistically significantly associated with increased hardship. CONCLUSION Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.

Adherence to cancer screening is important for cancer survivors because they are at high risk of subsequent cancer diagnoses or recurrence. We assessed adherence to breast, cervical, and colorectal cancer-(CRC)-screening guidelines and evaluated demographic disparities among a population-based sample of survivors.A representative sample of Utah survivors diagnosed from 2012-2018 with any reportable invasive cancer was selected from central cancer registry records for a survey about survivorship needs. We estimated the proportion of eligible survivors adhering to U.S. Preventive Services Task Force screening guidelines and calculated risk ratios and 95% confidence intervals. Analyses were age-adjusted and weighted to account for sample design and nonresponse.And 1421 survivors completed the survey (57.2% response rate). Screening adherence was 74.4% for breast, 69.4% for cervical, and 79.7% for CRC. Rural residents were more likely to adhere to breast cancer screening than urban residents (86.1% vs. 72.7%; adjusted RR = 1.19, CI = 1.05, 1.36). Higher educational attainment was associated with increased adherence to cervical and colorectal cancer screening. Younger age was associated with greater adherence to cervical cancer screening (p = 0.006) but lower adherence to CRC screening (p = 0.003). CRC screening adherence was lower among the uninsured and those without a primary care provider (45.6%) compared to those with a regular provider (83.0%; adjusted RR = 0.57, CI = 0.42, 0.79).Surveys based on samples from central cancer registries can provide population estimates to inform cancer control. Findings demonstrate work is needed to ensure all Utah cancer survivors obtain recommended cancer screenings. Efforts should focus particularly on increasing uptake of breast and cervical cancer screening and reducing demographic disparities in CRC screening.Despite high risk for subsequent cancer diagnosis, Utah cancer survivors are not all obtaining recommended breast, cervical, and colorectal cancer screenings. This presents a significant healthcare gap.

Background Primarily Spanish-speaking cancer patients and caregivers often experience non-congruence with healthcare providers about beliefs, values, and knowledge of cancer. Our goal was to describe how communication related to the diagnosis of cancer was influenced by culture and language among primarily Spanish-speaking caregivers of pediatric cancer patients. Methods Caregivers participated in three focus groups about their experiences with their child's diagnosis, communication issues, and understanding of their child's diagnosis and treatment plan. Focus groups were audio recorded, transcribed, and qualitatively analyzed using interpretive description. Results Three themes emerged: 1) Negative experiences and barriers during the cancer diagnosis and treatment, 2) Miscommunication and system complexity, and 3) Language barriers throughout the diagnostic process. Due to barriers and negative experiences, some caregivers reported that their child's diagnosis was delayed, that providers sometimes used dehumanizing language, and that they were confused about diagnostic testing and treatment. Conclusion Cultural and linguistic disparities in pediatric oncology must be systematically addressed at the provider, clinic, and system level. Practice implications High-quality cancer care delivered by oncologists and cancer care teams should include cultural humility when discussing the cancer diagnosis and prognosis.

There is limited information on how the COVID-19 pandemic has changed health behaviors among cancer patients. We examined changes in exercise behaviors since the pandemic and identified characteristics associated with these changes among cancer patients.Cancer patients (n = 1,210) completed a survey from August to September 2020 to assess COVID-19 pandemic-related changes in health behaviors and psychosocial factors. Patients were categorized into three groups: exercising less, exercising did not change, and exercising more. Patient characteristics were compared by exercise groups.One-third of the patients reported a decreased amount of regular exercise, while 10% reported exercising more during the pandemic. Patients who exercised less were more likely to be unemployed/retired and have poor health status and psychosocial stressors such as disruptions in daily life while less likely to be former smokers (all p 0.05). In contrast, patients who exercised more were younger, had stage IV diagnosis, and also reported disruptions in daily life (all p 0.05). Patients who were living in rural areas were also more likely not to experience changes in exercise habits (all p 0.05), although rural-urban status was not identified as a strong predictor.A significant proportion of cancer patients experienced changes in exercise habits, especially exercising less, during the first 6 months of the COVID-19 pandemic. Age, employment status, tumor stage, health status, smoking status, and psychosocial factors were associated with changes in exercise behaviors. Our results highlight the importance of promoting physical activity guidelines for cancer survivorship during the COVID-19 pandemic and may help improve the identification of cancer patients susceptible to exercising less.

PURPOSE The purpose of this report, commissioned by Teen Cancer America and performed by Deloitte Access Economics in 2021, was to estimate the total costs incurred by adolescent and young adults (AYAs) after cancer diagnosis in the United States (US) over their life course. METHODS The incidence of cancer in 2019 among AYAs age 15-39 years was estimated from the US Cancer Statistics Public Use Database, and relative survival was projected from the Surveillance, Epidemiology, and End Results Program. Cost domains included health system, productivity, and well-being costs. Components were estimated with published literature and pooled data from the Medical Expenditure Panel Survey from 2008 to 2012 and inflated to 2019 dollars. RESULTS The economic and human costs of cancer in AYAs are substantial—$23.5 billion overall, corresponding to $259,324 per person over the lifetime. The majority of costs are borne by AYA cancer survivors themselves in the form of lost productivity, loss of well-being, and loss of life. CONCLUSION These findings underscore the need to address the burden of cancer in AYAs through targeted programs for AYAs, such as financial navigation and health insurance literacy interventions, as well as local and national policy initiatives to address access to and enhanced coverage for clinical trials participation, fertility services, and survivorship care.

To determine how social media platform and cancer content is associated with the presence of social support in responses to young adult cancer caregivers' (YACC) posts.We retrospectively collected YACC's Facebook and/or Instagram posts and all responses from the first six months of caregiving.Eligible YACC were 18-39, caring for a cancer patient diagnosed 6 months-5 years prior, spoke English, and used social media weekly.Social media posts and responses were manually coded for five social support types, then transformed to depict the proportion of responses per post representing each type of support. Using mixed-effects models, we compared the distributions of responses with social support types by platform (Facebook vs. Instagram) and cancer content (no vs. yes).More responses contained emotional support on Instagram than Facebook (B = 0.25, Standard Error (SE)=0.09, p = 0.007). More responses with cancer content contained -validation support (B = 0.20, SE = 0.07, p = 0.002), but fewer contained emotional (B=-0.17, SE = 0.07, p = 0.02) and instrumental support (B=-0.06, SE = 0.02, p = 0.001) than posts without cancer content.Studying the responsiveness of social media followers by platform and cancer content provides a foundation for intervention development.Emphasizing the suitability of different social media platforms for particular support seeking behaviors is essential.

PURPOSE Patients with cancer experience high rates of morbidity and unplanned health care utilization and may benefit from new models of care. We evaluated an adult oncology hospital at home program's rate of unplanned hospitalizations and health care costs and secondarily, emergency department (ED) use, length of hospital stays, and intensive care unit (ICU) admissions during the 30 days after enrollment. METHODS We conducted a prospective, nonrandomized, real-world cohort comparison of 367 hospitalized patients with cancer—169 patients consecutively admitted after hospital discharge to Huntsman at Home (HH), a hospital-at-home program, compared with 198 usual care patients concurrently identified at hospital discharge. All patients met clinical criteria for HH admission, but those in usual care lived outside the HH service area. Primary outcomes were the number of unplanned hospitalizations and costs during the 30 days after enrollment. Secondary outcomes included length of hospital stays, ICU admissions, and ED visits during the 30 days after enrollment. RESULTS Groups were comparable except that more women received HH care. In propensity-weighted analyses, the odds of unplanned hospitalizations was reduced in the HH group by 55% (odds ratio, 0.45, 95% CI, 0.29 to 0.70; P < .001) and health care costs were 47% lower (mean cost ratio, 0.53; 95% CI, 0.39 to 0.72; P < .001) over the 30-day period. Secondary outcomes also favored HH. Total hospital stay days were reduced by 1.1 days ( P = .004) and ED visits were reduced by 45% (odds ratio, 0.55; 95% CI, 0.33 to 0.92; P = .022). There was no evidence of a difference in ICU admissions ( P = .972). CONCLUSION This oncology hospital at home program shows initial promise as a model for oncology care that may lower unplanned health care utilization and health care costs.

Background Medical financial burden includes material, behavioral, and psychological hardship and has been underinvestigated among adult survivors of childhood cancer. Methods A survey from 698 survivors and 210 siblings from the Childhood Cancer Survivor Study was analyzed. The intensity of financial hardship was estimated across 3 domains: 1) material, including conditions that arise from medical expenses; 2) behavioral, including coping behaviors to manage medical expenses; and 3) psychological hardship resulting from worries about medical expenses and insurance, as measured by the number of instances of each type of financial hardship (0, 1-2, and ≥3 instances). Multivariable logistic regressions were conducted to examine the clinical and sociodemographic predictors of experiencing financial hardship (0-2 vs ≥3 instances). Results The intensity of financial hardship did not significantly differ between survivors and siblings. Survivors reported more instances of material hardship than siblings (1-2 instances: 27.2% of survivors vs 22.6% of siblings; ≥3 instances: 15.9% of survivors vs 11.4% siblings; overall P = .03). In multivariable regressions, insurance was protective against all domains of financial hardship (behavioral odds ratio [OR], 0.12; 95% confidence interval [CI], 0.06-0.22; material OR, 0.37; 95% CI, 0.19-0.71; psychological OR, 0.10; 95% CI, 0.05-0.21). Survivors who were older at diagnosis, female, and with chronic health conditions generally had higher levels of hardship. Brain radiation and alkylating agents were associated with higher levels of hardship. Conclusions Material, behavioral, and psychological financial burden among survivors of childhood cancer is common.

Cancer survivors are at higher risk of developing HPV-associated cancers later in life, yet their HPV vaccination rates remain lower than the general population. Improving HPV vaccination uptake among survivors is essential to preventing second malignancies. We interviewed HPV vaccine eligible adolescent and young adult (AYA) cancer survivors (18-26 years) and caregivers of HPV vaccine eligible childhood cancer survivors approaching the AYA age range (9-17 years) about their HPV vaccine experiences and preferences as informed by the HPV Vaccination Roundtable Best Practices. Interviews (N = 20) were recorded, transcribed, and analyzed using interpretive description. Of AYA survivors (n = 10), 50% had received at least one HPV vaccine dose. Of caregivers (n = 10), 30% reported their child had received at least one HPV vaccine dose. Three distinct categories emerged including (1) HPV vaccine knowledge, (2) HPV vaccination recommendation preferences, and (3) HPV vaccination reminder preferences. The first two categories were oncology focused. Participants lacked knowledge regarding HPV vaccine safety and applicability due to their complex cancer history. Most participants strongly preferred that their oncologist provide an HPV vaccine recommendation. The third category was mixed, with some participants preferring oncology-based HPV vaccine reminders while others preferred primary care-based reminders. Almost all participants preferred digital reminders (e.g., text messages). Our results suggest that oncologists play an essential role in recommending the HPV vaccine and providing information to assist survivors and caregivers with vaccine decision-making. Additionally, HPV vaccination uptake among pediatric and childhood and AYA survivors could be improved through the use of tailored, electronically delivered vaccine reminders.

Purpose: Describe associations between changes in employment during the COVID-19 pandemic and financial toxicity among adolescent and young adult (AYA) cancer patients and survivors. Methods: Eligible individuals were diagnosed between 15-39 years of age, currently age ≥18, and recruited through the Huntsman-Intermountain Adolescent and Young Adult Cancer Care Program. We sent the survey to N=709. Survey questions included demographics, employment, and the 11-item COmprehensive Score for financial Toxicity (COST) which captures financial toxicity in the last four weeks. COST is scored from 0 to 44 with lower scores indicating greater financial toxicity. Scores were dichotomized as high (0-21) or low (22-44). Changes in employment since March 2020 were categorized as no change, increase in hours, and decrease in hours/lost job. We calculated descriptive statistics and fit a multivariable logistic regression to examine the association between employment change and financial toxicity controlling for current age, gender, and treatment status. Results: Of 280 respondents (39.5% participation), 198 (70.7%) were employed prior to the pandemic and were thus included in analyses. Employed individuals were a mean of 29.4 years of age (range 18-58), 64.3% were female, and 50.5% had received cancer treatment since March 2020. Nearly a third (31.3%) had lost their job or reported reduced hours; 50.3% reported high financial toxicity. Among those previously employed, participants who lost their job or had their hours reduced had nearly six times the odds of high financial toxicity than those who reported no change in hours (Odds Ratio [OR]=5.8, 95% Confidence Interval [CI]: 2.6-12.9). In the same model, the odds of reporting high financial toxicity was over twice as high among females than males (OR=2.3, 95% CI: 1.2-4.5). Treatment status and age were not significant. Conclusions: Employment changes during the COVID-19 pandemic resulted in increased financial toxicity among a population already susceptible to high financial hardship. Societal gender inequity appears to be mirrored in participants’ financial toxicity during the pandemic. Employment interventions for patients and survivors of AYA cancers who have experienced job loss or reduction in work hours during the pandemic are needed and may particularly benefit females. Citation Format: Austin Waters, Heydon Kaddas, Karely Mann, Perla L. Vaca Lopez, Echo L. Warner, Joemy Ramsay, Judy Ou, Nicole Ray, Tomoko Tsukamoto, Douglas B. Fair, Joseph M. Letourneau, Mark A. Lewis, David A. Gill, Lauri Linder, Anne C. Kirchhoff. Adolescent and young adult cancer patient and survivor employment changes during COVID-19 are associated with financial toxicity [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr S10-03.

Health insurance literacy interventions may reduce financial burden and its effects on cancer patients and their caregivers. However, little is known about the health insurance literacy levels of head and neck cancer (HNC) patients and their caregivers. We assessed the feasibility of screening for health insurance literacy in a pilot study and described the health insurance literacy levels of HNC patients and their caregivers.We administered a survey that assessed demographics and subjective and objective health insurance literacy to HNC patients and their caregivers. Subjective health insurance literacy was measured through the Health Insurance Literacy Measure (score range: 0-84). Objective health insurance literacy was measured through correct answers to a previously developed 10-question knowledge test. Due to a small sample size, inferential statistics were not used; we instead descriptively reported findings.The pilot included 48 HNC patients and 13 caregivers. About 44.4% of patients and 30.8% of caregivers demonstrated low health insurance literacy (HILM ≤60). On the 10-item knowledge test, patients had an average of 6.8 (SD: 2.3) correct responses and caregivers had 7.8 (SD: 1.1) correct responses. Calculating out-of-pocket costs for out-of-network services was challenging; only 9.5% of patients and 0% of caregivers answered correctly.Additional outreach strategies may be needed to supplement screening for health insurance literacy. Areas of focus for interventions include improving understanding of how to calculate financial responsibility for health care services and filing an appeal for health insurance claim denial.IV.

BackgroundIn the United States, the cost of cancer treatment can lead to severe financial burden for cancer survivors. The economic impacts of the COVID-19 pandemic compound cancer survivors’ financial challenges. Financial burden may be particularly challenging for lesbian, gay, bisexual, transgender, queer, intersex, asexual and other sexual and gender minority (LGBTQIA+) survivors. LGBTQIA+ survivors who are adolescent and young adults (AYA) may face elevated financial burden due to multiple, intersecting identities.MethodsAn explanatory sequential mixed methods design was applied, beginning with a survey of AYA cancer survivors in the Mountain West region of the United States. Survey measures included demographics, COVID-19 impacts, the COmprehensive Score for financial Toxicity (COST), Perceived Stress Scale-4 (PSS-4), and PROMIS anxiety and depression scales. Two-way t-tests were used to analyze differences in outcomes between LGBTQIA+ and non-LGBTQIA+ AYAs. All LGBTQIA+ survey participants were invited to complete an interview, and those who agreed participated in descriptive interviews about financial burden due to cancer, COVID-19, and LGBTQIA+ identity. Interviews were audio recorded, transcribed, and analyzed using Dedoose.ResultsSurvey participants (N=325) were LGBTQIA+ (n=29, 8.9%), primarily female (n= 197, 60.6%), non-Hispanic White (n= 267, 82.2%), and received treatment during COVID-19 (n= 174, 54.0%). LGBTQIA+ interview participants (n=9, 100%) identified as a sexual minority and (n=2, 22.2%) identified as a gender minority. Most were non-Hispanic White (n=6, 66.7%) and had received treatment during COVID-19 (n=7, 77.8%). Statistical analyses revealed that LGBTQIA+ AYAs reported significantly worse COST scores than non-LGBTQIA+ AYAs (p=0.002). LGBTQIA+ AYAs also reported significantly higher PSS-4 (p=0.001), PROMIS anxiety (p=0.002) and depression scores (pConclusionsLGBTQIA+ AYA survivors reported substantial financial burden and psychological distress exacerbated by cancer, the COVID-19 pandemic, and LGBTQIA+ stigma. Given their multiple intersecting identities and potential for marginalization, LGBTQIA+ AYA survivors deserve prioritization in research to reduce financial burden and poor mental health.

African American cancer survivors disproportionately experience financial difficulties after cancer. Decreased work participation (going from being employed full time to part time or from employed to not employed) can contribute to financial hardship after cancer but employment outcomes among African American cancer survivors have not been well described. This study estimates the prevalence of work changes and identifies factors associated with decreased work participation among African American cancer survivors. We analyzed data from 916 African American breast, colorectal, lung, and prostate cancer survivors who participated in the Detroit Research on Cancer Survivors (ROCS) cohort and were employed before their cancer diagnosis. Modified Poisson models estimated prevalence ratios of decreased work participation and work changes, including changes to hours, duties, or schedules, between diagnosis and ROCS enrollment controlling for sociodemographic and cancer‐related factors. Nearly half of employed survivors made changes to their schedules, duties, or hours worked due to cancer and 34.6% took at least one month off of work, including 18% who took at least one month of unpaid time off. More survivors employed full time (vs. part time) at diagnosis were on disability at ROCS enrollment (18.7% vs. 12.6%, P, Nearly half of employed African American cancer survivors decreased work participation (went from full time to part time or employed to not employed) after cancer diagnosis. Taking unpaid (but not paid) time off and changing work hours, duties, and/or schedules were associated with decreased work participation.

Background: Air pollution is a carcinogen and causes pulmonary and cardiac complications. We examined the association of fine particulate matter pollution (PM2.5) and mortality from cancer and all causes among pediatric, adolescent, and young adult (AYA) patients with cancer in Utah, a state with considerable variation in PM2.5. Methods: We followed 2,444 pediatric (diagnosed ages 0–14) and 13,459 AYA (diagnosed ages 15–39) patients diagnosed in 1986–2015 from diagnosis to 5 and 10 years postdiagnosis, death, or emigration. We measured average monthly PM2.5 by ZIP code during follow-up. Separate pediatric and AYA multivariable Cox models estimated the association of PM2.5 and mortality. Among AYAs, we examined effect modification of PM2.5 and mortality by stage while controlling for cancer type. Results: Increases in PM2.5 per 5 μg/m3 were associated with cancer mortality in pediatric lymphomas and central nervous system (CNS) tumors at both time points, and all cause mortality in lymphoid leukemias [HR5-year = 1.32 (1.02–1.71)]. Among AYAs, PM2.5 per 5 μg/m3 was associated with cancer mortality in CNS tumors and carcinomas at both time points, and all cause mortality for all AYA cancer types [HR5-year = 1.06 (1.01–1.13)]. PM2.5 ≥12 μg/m3 was associated with cancer mortality among breast [HR5-year = 1.50 (1.29–1.74); HR10-year = 1.30 (1.13–1.50)] and colorectal cancers [HR5-year = 1.74 (1.29–2.35); HR10-year = 1.67 (1.20–2.31)] at both time points. Effect modification by stage was significant, with local tumors at highest risk. Conclusions: PM2.5 was associated with mortality in pediatric and AYA patients with specific cancers. Impact: Limiting PM2.5 exposure may be important for young cancer patients with certain cancers. See all articles in this CEBP Focus section, “Environmental Carcinogenesis: Pathways to Prevention.”

Objective To describe how young adult cancer caregivers (YACC) use social media for social support during a cancer experience. Methods Eligible YACC were 18 to 39 years, used Facebook and/or Instagram at least once per week, and cared for an adult cancer patient diagnosed 6 months to 5 years prior (N = 34). Recruitment of a cross-sectional sample occurred through oncology clinics in Utah and online advertising by caregiving and cancer organizations from September 2017 to June 2018. Semi-structured telephone interviews were recorded, transcribed, iteratively coded, and qualitatively analyzed, yielding four categories concerning how YACC use social media. Results Caregivers were most commonly spouses aged 29 years on average (range 21-38); cancer patients were 37 years (range 19-76). Analysis yielded four distinct yet related categories: Category 1: Posting about cancer on social media often begins as a strategy for YACC to efficiently provide updates about the cancer patient. Category 2: Caregivers who actively post on social media experience a variety of different functional social supports to which they otherwise would not have access. Category 3: Posting about cancer online presents an opportunity for negative consequences. Category 4: Potential for negative consequences influences how some caregivers use social media. Conclusions Supportive services, including social media-based supports, are needed for YACC in formats that are convenient for them as they balance their caretaking duties with their daily lives.

Background For adolescent and young adult (AYA) cancer patients aged 18 to 39 years, health insurance literacy is crucial for an effective use of the health care system. AYAs often face high out-of-pocket costs or have unmet health care needs due to costs. Improving health insurance literacy could help AYAs obtain appropriate and affordable health care. This protocol illustrates a randomized controlled trial testing a virtual health insurance education intervention among AYA patients. Methods This is a two-arm multisite randomized controlled trial. A total of 80 AYAs diagnosed with cancer in the Mountain West region will be allocated to either usual navigation care or tailored health insurance education intervention with a patient navigator that includes usual care. All participants will complete a baseline and follow-up survey 5 months apart. The primary outcomes are feasibility (number enrolled and number of sessions completed) and acceptability (5-point scale on survey measuring satisfaction of the intervention). The secondary outcomes are preliminary efficacy measured by the Health Insurance Literacy Measure and the COmprehensive Score for financial Toxicity. Discussion This trial makes a timely contribution to test the feasibility and acceptability of a virtual AYA-centered health insurance education program. Trial registration ClinicalTrials.gov NCT04448678. Registered on June 26, 2020

Survivors of adolescent and young adult (AYA) cancer are susceptible to severe COVID-19 outcomes due to their cancer history. Drivers of COVID-19 vaccine hesitancy and willingness are largely unexplored among AYA cancer survivors.We surveyed survivors of AYA cancer from October 2020-February 2021 who received services through an AYA cancer care program. Survey measures included vaccine hesitancy on a five-point Likert scale and an open-ended question on vaccine intent. Open-ended responses were content analyzed through two cycles of structured coding. Quantitative vaccine intent and qualitative drivers of intent were integrated during data analysis.Of participants who responded to the open-ended vaccine intent question (N = 300), 39.0% reported COVID-19 vaccine hesitancy. Qualitative content analysis resulted in N = 517 codes and seven content categories. The most common content category associated with hesitancy included COVID-19 vaccine development, approval, and efficacy (34.5%; p value ≤ 0.001), as well as content areas including presence of misinformation about COVID-19 in the response (4.8%; p value = 0.04), the desire for more information about COVID-19/COVID-19 vaccine (6.0%; p value ≤ 0.001), and reference to political influence on participants' intent to get the vaccine (2.5%; p value = 0.005). The most common category associated with vaccine willingness was personal perceptions of COVID-19 vaccination including protecting oneself and others (36.6% of codes; p value ≤ 0.001), followed by pro-vaccine beliefs (8.3%; p value ≤ 0.001) and trust in science (3.9%; p value ≤ 0.001).Common drivers of COVID-19 vaccine hesitancy among survivors of AYA cancer include concern about vaccine side effects and approval process, and misinformation. Cancer survivors COVID-19 vaccine uptake could be improved by focusing communication on drivers of willingness, motivational interviewing, and physician recommendations.

The COVID-19 pandemic has disrupted many facets of life. We evaluated pandemic-related health care experiences, COVID-19 prevention behaviors and measures, health behaviors, and psychosocial outcomes among rural and urban cancer patients.Among 1,472 adult cancer patients, who visited Huntsman Cancer Institute in the past 4 years and completed a COVID-19 survey (August-September 2020), we assessed the impact of the pandemic on medical appointments, prevention/health behaviors, and psychosocial factors, stratified by urbanicity.Mean age was 61 years, with 52% female, 97% non-Hispanic White, and 27% were residing in rural areas. Rural versus urban patients were more likely to be older, not employed, uninsured, former/current smokers, consume alcohol, and have pandemic-related changes/cancellations in surgery appointments (all P.05). Changes/cancellations in other health care access (eg, doctor's visits) were also common, particularly among urban patients. Urban versus rural patients were more likely to socially distance, use masks and hand sanitizer, and experience changes in exercise habits and in their daily lives (all P.05). Less social interaction and financial stress were common among cancer patients but did not differ by urbanicity.These findings suggest that the COVID-19 pandemic had a substantial impact on cancer patients, with several challenges specific to rural patients. This comprehensive study provides unique insights into the first 6 months of COVID-19 pandemic-related experiences and continuity of care among rural and urban cancer patients predominantly from Utah. Further research is needed to better characterize the pandemic's short- and long-term effects on rural and urban cancer patients and appropriate interventions.

Background: Subsequent malignant neoplasms (SMN) are a leading cause of premature mortality among adolescent and young adult (AYA) cancer survivors, who have unique health needs. Human Papillomavirus-related second cancers (HPV-SMN) are generally preventable through screenings and vaccination. We identified disparities in HPV-SMN among AYA survivors by demographics and first cancer therapy, and examined temporal trends in incidence of HPV-SMN. Methods: We identified diagnoses of any HPV-SMN, oropharyngeal-SMN, and cervical-SMN among AYA survivors in the SEER 9 1976-2015 registries starting two months after the first cancer. Standardized incidence ratios (SIR) compared risk between AYA survivors and general population. We used Fine and Gray competing risk models to estimate hazard ratios (HR) of therapy on risk for HPV-SMN while controlling for cancer site and demographic confounders. Age-period-cohort (APC) models identified temporal trends in HPV-SMN incidence. Results: Of 374,408 survivors diagnosed with a first primary cancer ages 15-44, a total of 1,369 had an HPV-SMN occurring on average five years after the first cancer. Compared to the general population, AYA survivors had increased risks of 70% for any HPV-SMN (95%CI=1.61-1.79) and 117% for oropharyngeal-SMN (95%CI=2.00-2.35). Cervical-SMN risk was generally lower in survivors (SIR=0.85, 95%=CI 0.76-0.95). Hispanic AYA survivors had a significant increase in cervical-SMN relative to the general population (SIR=1.46, 95%CI=1.01-2.06). AYAs who were uninsured or on Medicaid at diagnosis had significant increases in HPV-SMN risk relative to the general populations (Uninsured SIR=5.23, 95%CI=2.26-10.31; Medicaid SIR=5.95, 95%CI=4.07-8.40). AYAs first diagnosed with Kaposi sarcoma, leukemia, Hodgkin, and Non-Hodgkin lymphoma had increased risk for HPV-SMN relative to the general population. Among survivors with HPV-related first primary cancers, radiation was associated with increased risk for HPV-SMN (HR=1.35, 95%CI-1.03-1.77). Among survivors whose first primary cancer was not HPV-related, chemotherapy was associated with increased risk for HPV-SMN (HR=1.20, 95%CI=1.00-1.44) but the general effect of treatment was not significant (p=0.16). In APC models, incidence of oropharyngeal-SMN significantly declined over time. Conclusion and Impact: While the overall risk is low, AYA survivors are at higher risk for HPV-SMNs than the general population, largely driven by oropharyngeal-SMN. Hispanic survivors are the only group at higher risk for cervical-SMN than the general population suggesting a need to improve their cervical cancer screening. Uninsured/Medicaid AYA survivors also face higher HPV-SMN risks. Improving access to screening and HPV vaccination is needed to reduce the burden of HPV-SMN in AYA survivors. Citation Format: Judy Y. Ou, Natalie Bennion, Kellee Parker, Douglas Fair, Heidi A. Hanson, Deanna Kepka, Echo L. Warner, Joemy M. Ramsay, Heydon K. Kaddas, Anne C. Kirchhoff. Risk factors, trends, and disparities in HPV-associated subsequent malignant neoplasms among adolescent and young adult cancer survivors. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5763.

We examined whether financial burdens occurring during the COVID-19 pandemic impacted healthcare utilization among survivors of adolescent and young adult cancers.We surveyed survivors enrolled in a patient navigation program to obtain self-reports of delayed/skipped cancer care or other care, changes to medication obtainment, and changes to medication use since the COVID-19 pandemic began. Reported financial burdens were defined as financial toxicity in the past 4 weeks (COmprehensive Score for financial Toxicity [COST] ≤ median 21) and material hardships (range = 4-11) since March 2020. Adjusted logistic regression models calculated associations and effect modification by gender.Survivors (n = 341) were mostly female (61.3%) and non-Hispanic White (83.3%). Nearly 20% delayed/skipped cancer care, 35.2% delayed/skipped other care, 19.1% changed medication obtainment, and 12.6% changed medication use. Greater material hardships were associated with delayed/skipped cancer care (odds ratio (OR) = 3.13, 95% CI = 1.44-6.81) and other care (OR = 2.17, 95% CI = 1.18-3.98), and changed medication obtainment (OR = 2.72, 95% CI = 1.43-5.18) or use (OR = 4.49, 95% CI = 2.05-9.80). Financial toxicity was associated with delayed/skipped other care (OR = 2.53, 95% CI = 1.31-4.89) and changed medication obtainment (OR = 1.96, 95% CI = 1.01-3.83) and medication use (OR = 3.73, 95% CI = 1.59-8.73). The association of material hardships and any changes in healthcare utilization was greater among female compared to male survivors.Financial burdens experienced during the pandemic impeded survivors' ability to utilize necessary healthcare, with worse impacts among female survivors.Delayed or skipped healthcare may lead to an increased cancer mortality or severity of therapy-related conditions. Providing resources that enable survivors experiencing financial burdens to continue critical cancer and preventive care during the COVID-19 pandemic is a priority.

Despite efforts to increase participation of adolescents and young adults (AYAs; 15-39 years) in cancer clinical trials (CTs), enrollment remains very low. Even when provided access to CTs, AYAs are less likely to participate than children and older adults. A better understanding of oncologist- and AYA survivor-reported barriers, facilitators, and potential areas for CT enrollment improvement is needed.From December 2019 to August 2020, we conducted 43 semi-structured interviews with oncologists (n = 17) and AYA cancer survivors (n = 26) who were offered and/or participated in CTs at cancer centers in California and Utah. Thematic analyses were used to interpret the findings.Oncologists identified a lack of available CTs, strict eligibility criteria, lack of awareness of open CTs, and poor communication between pediatric and adult oncologists as major barriers to enrollment. AYA cancer survivors identified financial and psychosocial barriers, and a poor understanding of what a CT means and its potential benefits as barriers to enrollment. Areas for improvement identified by oncologists and AYAs include educational, financial, and psychosocial support to AYAs. Oncologists also emphasized the need to increase CT availability, improve awareness of open CTs, and better communication between both pediatric and adult oncologists and oncologists and AYAs.For AYAs with cancer, a lack of CT eligibility and physician awareness of open CTs likely factor into their lower CT enrollment. Potential strategies to improve AYA enrollment in CTs require comprehensive collaboration between pediatric and adult institutions, as well as educational, psychosocial, and financial support to AYAs.

ImportanceAlthough access to pediatric cancer care has implications for use of such care and patient outcomes, little is known about the geographic accessibility of pediatric cancer care and how it may vary by population characteristics across the continental US.ObjectiveTo estimate the travel time to pediatric cancer care settings in the continental US, identify potential disparities among subgroups of children and adolescents and young adults (AYAs), and identify areas needing improved access to pediatric cancer care.Design, Setting, and ParticipantsThis cross-sectional study collected data from August 1 to December 1, 2021. Pediatric oncologists’ service locations in 2021 served as the pediatric cancer care settings, data for which were scraped from 2 websites containing information about health professionals. Demographic characteristics for younger children and AYAs aged 0 to 21 years were obtained from the 2015 to 2019 American Community Survey 5-year estimates. Data were analyzed from January 1 to April 31, 2022.Main Outcomes and MeasuresThe main outcome was the travel time from geographic centroids of zip code tabulation areas to the nearest pediatric oncologist. The median (IQR) travel times for each demographic subgroup were estimated. Per capita pediatric oncologist supply was calculated by dividing the total number of pediatric oncologists for each state or US Census division by its population.ResultsOf the 90 498 890 children and AYAs included in the study, 63.6% were estimated to travel less than 30 minutes and 19.7% to travel between 30 and 60 minutes (for a total of 83.3%) to the nearest pediatric oncologist. Median (IQR) travel times were longest for the American Indian or Alaska Native pediatric population (46 [16-104] minutes) and residents of rural areas (95 [68-135] minutes), areas with high deprivation levels (36 [13-72] minutes), and the South (24 [13-47] minutes) and Midwest (22 [11-51] minutes) compared with the general population of children and AYAs. The pediatric oncologist supply was lowest in Wyoming (0 oncologists per 100 000 pediatric population) and highest in Washington, DC (53.3 oncologists per 100 000 pediatric population). Pediatric oncologist supply across Census divisions was lowest in the Mountain division (3.3 oncologists per 100 000 pediatric population) and highest in the New England division (8.1 oncologists per 100 000 pediatric population).Conclusions and RelevanceResults of this study showed that most children and AYAs in the continental US had adequate access to pediatric cancer care, although disparities existed among racial and ethnic groups and residents in rural areas, areas with high deprivation levels, and some Southern and Midwestern states. Reducing these disparities may require innovative approaches, such as expanding the capabilities of local facilities and creating partnerships with adult oncology centers and primary care physicians.

Currently, there are no publicly-available estimates of indoor radon concentration at scales smaller than the county. Radon-hazard potential soil maps that reflect underlying geologic factors can be created at small geographic scale and linked to residential and census data. We determined the association between residential radon tests and high radon-hazard potential soil at the residential and block group levels using a large Utah-based dataset. We also identified characteristics of block groups with limited tests in the dataset.We geocoded a dataset of residential radon tests obtained from 2001 to 2017 by a statewide educational program. We linked each location to maps of radon-hazard potential soil, the Environmental Protection Agency's (EPA) county radon zones. We also calculated the number of tests conducted in each block group and linked block groups to demographic data from the 2020 United States census. Log-linear and logistic models identified the association between residential home test results and 1) radon-hazard potential soil of each residence, 2) percent of residences on high radon-hazard potential soils in block groups, and 3) EPA's radon zones. We compared demographic characteristics among block groups with ≥5 or5 residential tests in our dataset.Approximately 42% of homes in the dataset tested ≥4 pCi/L. We found significant positive associations for residential radon test results with 1) residential location on high radon-hazard potential soil and 2) block groups with0% of residences on high radon-hazard potential soil. EPA radon zones were not associated with residential test results. Block groups with5 tests had higher than the statewide median percentage of Hispanic residents (OR = 2.46, 95% CI = 1.89-3.21) and were located in rural counties.Radon-hazard potential soil has a significant association with residential home radon tests. More efforts are needed to improve radon testing in block groups that are rural and have greater percentages of racial minorities.

Many caregivers take paid and/or unpaid time off work, change from full-time to part-time, or leave the workforce. We hypothesized that cancer survivor-reported material hardship (e.g., loans, bankruptcy), behavioral hardship (e.g., skipping care/medication due to cost), and job lock (i.e., staying at a job for fear of losing insurance) would be associated with caregiver employment changes.Adult cancer survivors (N = 627) were surveyed through the Utah Cancer Registry in 2018-2019, and reported whether their caregiver had changed employment because of their cancer (yes, no). Material hardship was measured by 9 items which we categorized by the number of instances reported (0, 1-2, and ≥ 3). Two items represented both behavioral hardship (not seeing doctor/did not take medication because of cost) and survivor/spouse job lock. Odds ratios (OR) were estimated using survey-weighted logistic regression to examine the association of caregiver employment changes with material and behavioral hardship and job lock, adjusting for cancer and sociodemographic factors.There were 183 (29.2%) survivors reporting their caregiver had an employment change. Survivors with ≥ 3 material hardships (OR = 3.13, 95%CI 1.68-5.83), who skipped doctor appointments (OR = 2.88, 95%CI 1.42-5.83), and reported job lock (OR = 2.05, 95%CI 1.24-3.39) and spousal job lock (OR = 2.19, 95%CI 1.17-4.11) had higher odds of caregiver employment changes than those without these hardships.Caregiver employment changes that occur because of a cancer diagnosis are indicative of financial hardship.Engaging community and hospital support for maintenance of stable caregiver employment and insurance coverage during cancer may lessen survivors' financial hardship.

Introduction. It is estimated that 50% of vaccines produced annu- ally are wasted because effectivity is dependent on protein structure and heat exposure disrupts the intermolecular interactions that maintain this structure. Since 90% of vaccines require a temperature- controlled supply chain, it is necessary to create a cold chain system to minimize vaccine waste. We have developed a more sustainable technology via the adsorption of Invasion Plasmid Antigen D (IpaD) onto mesoporous silica gels, improving the thermal stability of pro- tein-based therapeutics. Methods.xThe solution depletion method using UV-Vis was uti- lized to study the adsorption of IpaD onto silica gels. The silica-IpaD complex is heated above the denaturing temperature of the protein and then the IpaD is removed using N,N-Dimethyldodecylamine N-oxide (LDAO) and their secondary structure is tested using cir- cular dichroism (CD). Results. Pore diameter, pore volume and surface area were charac- terized for seven different silica gels. Silica gels designated as 6389, 6378, and 6375 had an adsorption percentage above 95% at pore volumes of 2.2, 2.8 and 3.8 cm3 mg-1, respectively. CD analyses con- firmed that the adsorbed IpaD after the heat treatment displayed a similar “W” shape CD signal as the native IpaD, indicating the con- servation of α-helices. In contrast, the unprotected IpaD after being exposed to high temperature shows a flat CD signal, demonstrating the loss of secondary structure. Conclusion. We have successfully increased the thermo-tolerance for IpaD using mesoporous silica and continue to further optimize mesoporous silica’s physiochemical properties to improve adsorption and desorption yields.

The HPV vaccine is an important vaccine for childhood cancer survivors because of their risks of second cancers, yet few survivors receive it. We examined HPV vaccine knowledge among caregivers of childhood cancer survivors, whether their child had received the vaccine, and their intentions to vaccinate. Eligible participants were caregivers (mostly parents) whose child finished cancer treatment at Primary Children’s Hospital in Salt Lake City, Utah 3 to 36 months prior to the start of the study (N = 145). Additional analyses were done among caregivers whose child was age-eligible for the HPV vaccine (ages 11 and up; N = 61). We ran descriptive statistics and fit multivariable generalized linear models to identify factors associated with intention to vaccinate and HPV vaccination uptake. Among caregivers whose child had not yet gotten the HPV vaccine, approximately 30% stated they were not likely to get the vaccine for their child and the most commonly cited reason was not enough information (25.2%). Provider discussion about vaccines and side effects (relative risk (RR) = 1.85, 95% CI 1.16–2.94), along with recommendations regarding vaccines after cancer treatment (RR = 1.35, 95% CI 1.06–1.72), led to greater caregiver intention to get the HPV vaccine for their child with cancer. Approximately 40% of age-eligible survivors had gotten at least one dose of the HPV vaccine. Our findings demonstrate a need for oncology-focused interventions to educate families of childhood cancer survivors about the importance of the HPV vaccine after cancer therapy.

218 Background: Adolescents and young adults (AYAs; ages 18-39) with cancer report worries about costs and feeling uninformed about their insurance, which may impair their ability to navigate the health care system, use their insurance, and manage costs. We conducted a pilot randomized controlled trial (RCT) to assess a virtually delivered health insurance navigation intervention (“CHAT”) to improve health insurance literacy (HIL) and knowledge, increase awareness of insurance protections in the Affordable Care Act (ACA), and reduce financial toxicity and stress. Methods: CHAT is a 4-session program delivered by a patient navigator. Session content included learning about insurance, navigating your plan, insurance-related laws, & managing care costs. Eligible participants had access to a wireless device, were within their first year of cancer diagnosis, and were treated at oncology sites from the University of Utah Healthcare and Intermountain Healthcare systems. We assessed feasibility and preliminary efficacy of CHAT compared to usual navigation care, including HIL (9 items on confidence using insurance), insurance knowledge (13 items on terms such as deductible & copay), ACA protections (8 items), Perceived Stress Scale (PSS; 4 items), and COmprehensive Score for financial Toxicity (COST; 11 items) using t-tests. Results: From November 2020 to January 2022, 86 AYAs enrolled (46.2% approached consented); 68.6% were female, 72.1% white, 18.6% Hispanic, 34.9% age 18-25, 65.1% age 26-39, 83.7% had private insurance, and 10.5% public. Mean baseline HIL scores were 22.6 (range = 9-33, SD = 5.5). At baseline, 65.1% of participants were unaware of the ACA provision allowing appeals for coverage denials. 64.4% of intervention participants completed all 4 sessions; 86.0% completed the 5-month follow-up survey with data collection ongoing (74/86). At follow-up, compared to usual navigation care, CHAT participants had improvements in HIL, knowledge of insurance, and knowledge of ACA provisions (Table). While PSS improved more for CHAT than usual care, COST did not differ. Conclusions: Results support the feasibility and preliminary efficacy of CHAT with related improvements in HIL and knowledge of the ACA. Clinical trial information: NCT04448678. [Table: see text]

15 Background: We previously demonstrated that Huntsman at Home (HH), a novel oncology hospital at home program, was associated with reduced healthcare utilization and costs. HH was also linked to shorter hospital stays and fewer emergency room (ER) visits. In this study, we sought to understand the impact of HH in specific patient subgroups. Methods: We compared outcomes among 169 patients consecutively admitted to HH against 198 usual care patients. Five dichotomous subgroups were created based upon patient a) sex b) age c) area level median income d) Charlson Comorbidity Index (CCI), and e) current use of systemic therapy (ST). Outcomes included 30-day costs, unplanned hospitalizations (UH), length of hospital stays, and ER visits. HH and usual care were compared via inverse propensity weighted regression models. Treatment propensities were estimated via random forests based on age, race, stage, cancer site, presence of metastases, CCI, and area level median income.Results: The between group difference favoring HH achieved statistical significance (p < 0.05) for at least two out of the four outcomes in each subgroup except for patients with higher comorbid illnesses. While HH participants did not always experience statistically better outcomes than usual care, none of the outcomes examined favored usual care for any subgroup. Sex. Female and male HH patients experienced fewer UH and lower costs than usual care. Male HH patients also had shorter hospital stays and fewer ED visits. Age. When stratifying age at 65 years, older HH patients experienced fewer days in the hospital and fewer UH. Younger HH patients had lower costs, and fewer UH and ED visits. Area level Income. All outcomes were better for high and low income HH patients compared to usual care except for ED visits among those with low income. CCI. Among those with a low CCI score, all four outcomes were better among HH patients. In contrast, differences between groups with higher comorbid illness did not achieve statistical significance for any outcome. Systemic Therapy. HH participants on ST experienced shorter hospital stays and fewer UH compared to usual care. Among those not on ST, HH patients experienced lower costs, and fewer UH and ED admissions. Conclusions: In this exploratory analysis, we found that the utilization and cost benefit associated with HH was robust, favoring better outcomes in each subgroup including lower 30-day costs, shorter hospital length of stay and fewer unplanned hospitalizations or ER visits. While medically complex patients may not receive similar benefit from HH as other subgroups, no outcomes favored patients managed by usual care. Taken together, this suggests that health care utilization and cost reductions associated with HH occur across multiple subgroups, but patients with high comorbidity may require additional intervention to realize lower utilization and costs.

Health insurance literacy is crucial for navigating the US healthcare system. Low health insurance literacy may be especially concerning for adolescent and young adult (AYA) cancer survivors. To describe AYAs' health insurance literacy, we conducted semi-structured interviews with AYA survivors, on and off of treatment.We interviewed 24 AYA cancer survivors (aged 18-39 years) between November 2019 and March 2020. Interviews were recorded, transcribed, and quality-checked. Using two cycles of structured coding, we explored AYAs' health insurance literacy and examined thematic differences by policy holder status and age.AYAs were 58.3% female, 79.2% non-Hispanic White, 91.7% heterosexual, and 62.5% receiving cancer treatment. Most participants had employer-sponsored health insurance (87.5%), and 41.7% were their own policy holder. Four themes emerged; in the first theme, most AYAs described beginning their cancer treatment with little to no understanding of their health insurance. This led to the three subsequent themes in which AYAs reported: unclear expectations of what their insurance would cover and their out-of-pocket costs; learning about insurance and costs by trial and error; and how their health insurance literacy negatively impacted their ability to navigate the healthcare system.Our findings, while requiring confirmation in larger samples and in other health systems, suggest that the health insurance literacy needed to navigate insurance and cancer care is low among US AYA survivors and may have health and financial implications. As the burden of navigating insurance is often put on patients, health insurance education is an important supportive service for AYA survivors on and off of treatment.

The study objective was to identify sociodemographic and coronavirus disease 2019 (COVID-19) factors that are associated with COVID-19 vaccine hesitancy among adolescent and young adult (AYA) cancer survivors. Eligible participants were 18 years or older and were diagnosed with cancer as an AYA (ages 15-39 years) and received services through an AYA cancer program. A total of 342 participants completed a cross-sectional survey. Our primary outcome—COVID-19 vaccine hesitancy—was surveyed as a 5-point Likert scale and operationalized as a binary outcome (agree vs hesitant). A large proportion of participants reported COVID-19 vaccine hesitancy (37.1%). In the multivariable regression, female survivors (odds ratio = 1.81, 95% confidence interval = 1.10 to 2.98) and survivors with a high school education or less (odds ratio = 3.15, 95% confidence interval = 1.41 to 7.04) reported higher odds of vaccine hesitancy compared with their male or college graduate or higher counterparts. COVID-19 vaccine hesitancy persists among AYA survivors despite their recommended priority vaccination status and higher chances of severe COVID-19 outcomes.

10051 Background: Chronic health conditions are prevalent among adult survivors of childhood cancer. The impact of health on maintaining full-time (FT) employment, a common indicator of socioeconomic independence, has not been studied in this population. Methods: Self-reported employment status (FT, part-time [PT], unemployed [any reason], not in labor force) was assessed at two timepoints (2002-04 [T1] and 2015-16 [T2]) in adult (≥25y old) survivors of childhood cancer diagnosed between 1970-86. Sex-stratified Poisson regression, adjusted for race and ages at diagnosis and T2, was used to study associations between timing and severity of chronic health conditions (graded per the CTCAE v4.03) and transitions from FT to PT or unemployed. Results: Survivors employed FT at T1 (males=1712, median age [min-max]: 34y [25-53]; females=1337, 33y [25-53]) who reported employment status at T2 were included. At T2 (median time from T1 11.5y [9.4-13.8]), 83% males and 70% females remained employed FT, but 4% and 10% transitioned to PT, and 11% and 12% to unemployed (additional 2% and 8% left the labor force), respectively. Male and female survivors with grade 2 or 3-4 neurologic conditions acquired before T1 or between T1-T2 were at a higher risk of moving from FT to PT or unemployed compared to those with grade 0-1 conditions. Males and females with grade 3-4 respiratory conditions prior to T1 and cardiac and musculoskeletal conditions acquired between T1-T2 were also at higher risk for moving to PT or unemployed (Table). Additional predictors for males included grade 2 vision (before T1 RR 2.3, 95% CI 1.5-3.3; between T1-T2 RR 1.7, 95% CI 1.1-2.7) and endocrine (before T1 RR 1.4, 95% CI 1.1-1.9; between T1-T2 RR 1.7, 95% CI 1.3-2.3) conditions. Conclusions: A substantial portion of adult survivors of childhood cancer with health conditions of varying severity leave FT employment. Increased awareness of all stakeholders may facilitate access to clinical counseling and occupational provisions for flexible and supportive work accommodations to reduce work-related barriers for childhood cancer survivors. [Table: see text]

Purpose Absence of cortical alignment in wedge-shaped and multifragmentary fractures (Fx) results in decreased fixation stability. The aim of this study was to compare the outcome using 2.0- vs. 3.5-mm screws for open reduction and internal fixation (ORIF) in dislocated, wedge-shaped or fragmentary midshaft clavicle fractures. Materials and methods Patients suffering from AO/OTA 15 2.A-C midshaft clavicle fractures were operatively treated between 2008 and 2018. 2.0- or 3.5-mm cortical screws were used to restore anatomic alignment in dislocated, wedge-shaped and fragmentary clavicle fractures. Data of radiologic outcome were collected until fracture consolidation was identified. Results 80 consecutive patients with a mean age of 44.5 ± 16.3 years, who were operatively treated for dislocated midshaft clavicle fractures were enrolled. 40 patients were treated using 2.0-mm and 40 patients using routine 3.5-mm cortical screws, respectively. Time to fracture consolidation was 12.8 ± 7.8 months. No mal- or non-unions occurred during routine follow-up until 18 months postoperatively. Conclusion Restoring anatomic alignment in wedge or fragmentary clavicle fractures can ultimately be addressed using cortical screw augmentation. Both groups showed comparable results with respect to fracture reduction, fixation and stability as well as time to consolidation of the fracture, while the 2.0-mm screw diameter was associated with easier handling of small Fx fragments.

Approximately half of all vaccines produced annually are wasted because effectivity is dependent on protein structure and heat exposure disrupts the intermolecular interactions needed to maintain the structure. Thus, most vaccines require a temperature-controlled supply chain to minimize waste. A more sustainable technology was developed via the adsorption of invasion plasmid antigen D (IpaD) onto mesoporous silica, improving the thermal stability of this protein-based therapeutic. Seven silicas were characterized to determine the effects of pore diameter, pore volume, and surface area on protein adsorption. The silica-IpaD complex was then heated above the IpaD denaturing temperature and N,N-dimethyldodecylamine N-oxide was used to remove IpaD from the silica. Circular dichroism confirmed that the adsorbed IpaD after the heat treatment maintained a native secondary structure rich in α-helix content. In contrast, the unprotected IpaD after heat treatment lost its secondary structure. Isotherms using Langmuir, Freundlich, and Temkin models demonstrated that the adsorption of IpaD onto silicas is best fit by the Langmuir model. If pores are less than 15 nm, adsorption is negligible. If the pores are between 15 and 25 nm, then monolayer coverage is achieved and IpaD is protected from thermal denaturing. If pores are larger than 25 nm, the adsorption is a multilayer coverage and it is easier to remove the protein from the silica because of a less-developed hydrogen bond network. This case study provides strong evidence that IpaD is thermally stabilized via adsorption on mesoporous silica with the proper range of pore sizes.

Background Emerging research suggests that survivors of childhood and adolescent cancers are at risk for morbidity and mortality associated with air pollutants. However, caregiver perceptions of the effects of air pollution are unknown. Thus, to address this gap we described caregivers’ perceptions of air pollution’s impact on general population health and specifically on childhood cancer survivors, and caregivers’ air pollution information-seeking and exposure reduction behaviors. Methods Participants were Utah residents, ≥18 years, and caregiver of a childhood cancer survivor who had completed treatment. Semi-structured interviews were conducted with caregivers to describe their perspectives on air quality, how air pollution impacts health (general population and survivor health), and their information seeking and exposure reduction behaviors. Interviews were recorded, transcribed, and analyzed through two rounds of structured coding. Results Caregivers (N = 13) were non-Hispanic white and primarily females (92.3%) between 30 and 49 years old (46.2%). Most families lived within the Wasatch Front (69.2%), the main metropolitan of Utah. Two categories emerged pertaining to caregiver’s perceptions of air pollution: 1) Limited awareness about the health effects of air pollution, and 2) Unsuccessful information seeking and minimal exposure reduction behaviors. All caregivers held negative perceptions of air pollution in Utah, but most were unaware of how pollution affects health. While some families limited air pollution exposure by avoiding outdoor activity or physically leaving the region, few practiced survivor-specific exposure reduction. Nearly half of caregivers worried about potential effects of air pollution on survivor health and wanted more information. Conclusions Despite negative perceptions of air pollution, caregivers were divided on whether air pollution could impact survivor health. Few caregivers engaged in exposure reduction for their cancer survivor. As air pollution levels increase in the U.S., continued research on this topic is essential to managing cancer survivor respiratory and cardiovascular health.

Background The objective of this study was to describe young adult cancer caregivers' exposure to cancer misinformation on social media. Methods Eligible participants were 18 to 39 years old, used social media weekly, and cared for an adult patient with cancer diagnosed 6 months to 5 years before (N = 21). Recruitment occurred from August 2017 to June 2018 in person at oncology clinics and online. Semistructured telephone interviews were recorded and analyzed with grounded theory methods through 2 rounds of coding (κ = 0.88). Results Caregivers were on average 29.1 years old, female (76.2%), non-Hispanic White (90.5%), college educated (57.1%), and caring for a spouse/partner (47.6%). Caregivers were exposed to a variety of cancer misinformation topics; some felt uncertain in their caregiving ability when confronted with cancer misinformation. Caregivers crosschecked online sources and consulted trusted individuals (eg, family, friends, and health care providers) to determine the quality of cancer-related information and manage cancer misinformation. Conclusions Cancer misinformation on social media may influence caregiving behaviors and decision making. Whether caregivers correctly and consistently identify cancer misinformation on social media is unknown. Supporting digital literacy to mitigate cancer misinformation on social media may improve young cancer caregivers' access to credible cancer information. Lay summary Cancer misinformation on social media affects young adult cancer caregivers' perceptions of their social support network. Caregivers differ in how they evaluate cancer information for quality and in how this information influences their health behaviors and caregiving decisions.

To explore how family/friend young adult cancer caregivers (YACC) used social media for social support in a cross-sectional retrospective mixed-methods study. Eligible YACC were recruited online and in-person from September 2017 to June 2018, were 18–39 years, used social media weekly, and cared for an adult cancer patient diagnosed 6 months–5 years prior (N = 34). Social media posts were randomly sampled, and content analyzed for five types of social support (emotional, informational, validation, companionship, instrumental). Generalized linear models were fit to estimate changes in the prevalence of social support in posts over the 6-month period following diagnosis. The investigators analyzed N = 2090 social media posts, 26.9% made by YACC, and 73.1% by followers; 36.8% were cancer-related. The most common type of social support for YACC on social media was emotional (63.3%), followed by informational (27.7%), validation (15.3%), companionship (5.7%), and instrumental (1.3%). When controlling for platform (e.g., Instagram), the odds of posts containing emotional support decreased significantly over the first 6 months of caregiving (adjusted odds ratio [aOR]: 0.90, 95%CI 0.85–0.94), while informational (aOR: 1.15, 95%CI 1.09–1.21) and companionship (aOR: 1.12, 95%CI 1.02–1.24) support increased. YACC and their followers share emotional and informational support on social media. Next steps should determine how social media may improve (e.g., social support) or hinder (e.g., misinformation) cancer caregiving throughout survivorship. Caregivers and patients should be aware of possible fluctuations in social media support after diagnosis and the utility of using social media for different types of social support.