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Purpose Childhood cancer survivors are at higher risk of human papillomavirus (HPV)‐related second cancers than adolescents without cancer, yet their HPV vaccination uptake is lower. Using a statewide sample, we evaluated whether survivors are at higher risk of missed opportunities for concomitant HPV vaccination. Methods From statewide healthcare data, we identified encounters where vaccines were received. Concomitant HPV vaccine missed opportunities were defined as a vaccine encounter where the HPV vaccine was not administered, although eligibility criteria were met. From these encounters, our sample included 327 survivors identified from the Utah Cancer Registry, diagnosed 2000–2016 at ages 0–9, and a birth year and sex‐matched sample without cancer from the general population (n = 1,911). Mixed‐effects Poisson regression estimated the rate of concomitant missed opportunities per vaccine encounter and 95% confidence intervals by vaccine encounter type (all vaccines, flu shot only, or adolescent/catch‐up) from 2013 to 2016. Results Survivors had more concomitant HPV vaccine missed opportunities than the population sample (70.0% vs. 59.0%). On average, survivors were 12% more likely to have missed opportunities at vaccine encounters and 4% more likely at flu shot only encounters. The predicted excess risk of concomitant missed opportunities for survivors ranged from 0.5 per10 vaccine encounters to 1.1 per10 vaccine encounters. Higher parental education, rurality, younger first vaccine age, and chemotherapy were associated with missed opportunities. Conclusions Childhood cancer survivors have more missed opportunities for concomitant HPV vaccination than a population sample. As flu shots should be administered annually, providers have a regular opportunity to recommend and deliver the HPV vaccine to survivors.

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.

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.

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.

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]

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.

Purpose: To describe adolescent and young adult (AYA) cancer patients’ and survivors’ experiences with telehealth during the COVID-19 pandemic. Methods: Eligible participants were identified through the Huntsman Intermountain Adolescent and Young Adult Cancer Care Program, which provides age-specific programming and patient navigation to AYA cancer patients and survivors in Utah and surrounding Mountain West states. Participants were emailed an online survey if they were currently age 18 or older and had been diagnosed with cancer between the ages of 15-39 years. We applied descriptive statistics to summarize demographics, comfortability with technology, access to reliable internet connection, and perceived quality of care while using telehealth. Results: AYAs (N=280) were an average of 29.4 years old at survey (range 18-58); 65.2% were female and 82.4% non-Hispanic white. Over half (54.2%) had received cancer treatment since March 2020. All participants reported owning a computer, tablet, and/or smart phone they could use for telehealth appointments. The majority (93.5%) reported almost always or always having a reliable internet connection. AYAs felt most comfortable having a telehealth appointment in their own home (96.4%); only 12.5% felt comfortable using telehealth at work. Since March 2020, (N=183) 65.4% had a health care visit moved to a telehealth platform due to COVID-19. Of those who recently moved to telehealth, 60.1% had an oncology visit, 33.9% had a primary care visit, and 31.1% had a mental health visit. Additionally over one-third (35.2%) reported the quality of their medical care had decreased since moving to telehealth. This was most commonly due to 1) troubles with audio, video, or connecting through telehealth platforms; 2) telehealth visits feeling impersonal; and 3) feeling that providers more easily dismissed or did not fully address their symptoms. Conclusions: Although AYAs are digital natives, over one-third of AYAs feel the quality of their medical care has decreased since moving to telehealth for COVID-19. Further research should explore medical provider training in using telehealth systems and encourage telehealth practices that help AYAs feel more supported and understood. Citation Format: Karely Mann, Austin R. Waters, Perla L. Vaca Lopez, Echo L. Warner, Judy Ou, Heydon Kaddas, Joemy Ramsay, Nicole Ray, Tomoko Tsukamoto, Douglas B. Fair, Joseph M. Letourneau, Mark A. Lewis, David Gill, Lauri Linder, Anne C. Kirchhoff. Telehealth experiences of adolescent and young adult cancer patients and survivors during the COVID-19 pandemic [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 S06-04.

65 Background: Adolescent and young adult (AYA) cancer patients (15-39 years of age) often report health insurance concerns and financial toxicity due to their life-saving treatment. AYAs often have limited experience with healthcare prior to their diagnosis, which may limit their understanding of health insurance concepts, coverage, and costs. To describe AYA health insurance experiences, expectations, and literacy, we conducted semi-structured interviews with AYA cancer patients and survivors. Methods: Eligible participants were 18-39 years, diagnosed with cancer, and insured. Participants were recruited through an AYA cancer navigation program in Utah from 10/2019-03/2020. Participants were purposively sampled to achieve equal age strata (18-25 vs. 26-39), as patients under 26 often remain on their parents policy. Individual interviews were recorded, transcribed, and analyzed. Inductive qualitative analysis was conducted to describe their experiences with and understanding of their insurance. We calculated descriptive statistics of demographics and the Health Insurance Literacy Measure (HILM), a continuous measure ranging from 0-84 (higher scores indicate higher comfortability and literacy). Associations of age (18-25 vs. 26-39) and policy holder (yes vs. no) with HILM score were evaluated with t-tests. Results: AYAs (N = 24) were nearly even by gender, female (58%), primarily heterosexual (92%), Non-Hispanic White (79%), and had at least some college (92%). Less than half of participants were policy holders (41.7%). Three themes emerged from analysis: 1) Lack of knowledge and experiential learning throughout treatment, 2) Unclear expectations of health insurance, and 3) Difficulties navigating coverage and the complex systems. Most AYAs were unaware of the specifics of their coverage and how their insurance plan impacted their costs. Most AYAs were surprised at the lack of coverage and high costs they encountered during treatment. Most AYAs experienced substantial difficulty navigating coverage issues, particularly the appeals process. The mean HILM score was 55.63 (SD = 10.06), no differences by age group or policy holder status. Conclusions: AYAs with cancer report substantial difficulty navigating the complex health insurance system and demonstrate low levels of health insurance literacy. Health insurance education focusing on insurance concepts (e.g., cost-sharing mechanisms) may help AYAs better manage costs and enable them to make informed health insurance decisions despite being at higher risk for financial toxicity.

83 Background: Cancer patients in the United States often experience distress surrounding out of pocket costs from treatment. Adolescents and young adults (AYA) are more likely to be underinsured, skip care due to cost, go into debt, and file for bankruptcy after a cancer diagnosis than patients diagnosed at older ages. We conducted semi-structured interviews with AYA cancer patients and survivors to evaluate their experiences with health insurance, cancer costs and use of crowdfunding. Methods: Eligible participants were ages 18-39, diagnosed with cancer, and currently insured. Recruitment occurred largely through patient navigators at two large cancer centers from October 2019 to March 2020. Data was collected via individual semi-structured telephone interviews, which were analyzed for content. Questions were asked pertaining to crowdfunding platforms, fundraisers, satisfaction with current health insurance policy, and cost conversations with their cancer care team. Interviews were analyzed applying two rounds of thematic content analysis. Summary statistics were calculated for demographics. Results: Twenty-four interviews were completed, with more than half of participants being female (58%), most participants being Non-Hispanic White (79%), mean age at 26.5, and currently receiving cancer treatment (79%). Three themes emerged about AYAs’ experience with treatment costs and health insurance: 1) Even with insurance, cancer care was unexpectedly expensive and burdensome on financial wellbeing; 2) Conversations about cost with cancer care teams were brief and rare and 3) Crowdfunding platforms, fundraisers or financial grants were often used as financial safety nets, and did not cover all out of pocket costs. More than half of participants expressed interest in having cost conversations with their oncologist, nurse or social worker. All participants expressed a need for education on managing cancer costs and a particular interest in educational information on appeals and out of pocket costs. Conclusions: AYAs with cancer report unexpected costs and are interested in discussing this with their cancer care team. AYAs often receive money from fundraisers, financial grants or crowdfunding platforms to assist with the expenses of treatment. Discussions between cancer care teams and AYA patients about health insurance policies and cost saving mechanisms may help reduce out of pocket costs and reliance on external financial mechanisms.