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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.

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.”

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.

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]

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.

Purpose: We studied the influence of oncology and primary care provider (PCP) recommendations on caregiver intentions to restart vaccines (e.g., catch-up or boosters) after cancer treatment. Methods: We surveyed primary caregivers ages 18 or older with a child who had completed cancer treatment 3–36 months prior (N=145) about demographics, child’s vaccination status, and healthcare factors (e.g., provider recommendations, barriers, preferences for vaccination). We compared these factors by caregiver’s intention to restart vaccines (“vaccine intention” vs. “no intent to vaccinate”) using bivariate and multivariable analyses. Results: Caregivers were primarily ages 30–39 years (54.9%), mothers (80.6%), college graduates (44.4%), Non-Hispanic (89.2%), and married (88.2%). Overall, 34.5% of caregivers did not know which vaccines their child needed. However, 65.5% of caregivers reported vaccine intention. Fewer caregivers with no intention to vaccinate believed vaccinating their child helps protect others (85.4% vs. 99.0%, p

Background: Adolescents and young adults (AYA, age 15–39 years) with cancer may be at elevated risk for late morbidity following their cancer treatment, but few studies have quantified the excess burden of severe disease in this population. Using population-based data from Utah, we examined the risk of inpatient hospitalizations among AYA cancer survivors compared with their siblings and the general population. Methods: Survivors of AYA cancer who were ≥2 years from diagnosis and diagnosed from 1994 to 2015 (N = 6,330), their siblings (N = 12,924), and an age- and sex-matched comparison cohort (N = 18,171) were identified using the Utah Population Database (UPDB). Hospitalizations from 1996 to 2017 were identified from statewide discharge records in the UPDB. We estimated multivariable-adjusted hazard ratios (HR) for first hospitalization and rate ratios (RR) for total hospitalizations for survivors relative to the matched comparison cohort and siblings. Results: Overall, the risk of a first hospitalization was higher among AYA cancer survivors than the matched population-based cohort [HR = 1.93; 95% confidence interval (CI), 1.81–2.06]. Risk was most elevated for survivors of leukemia (HR = 4.76), central nervous system tumors (HR = 3.45), colorectal cancers (HR = 2.83), non-Hodgkin lymphoma (HR = 2.76), and breast cancer (HR = 2.37). The rate of total hospitalizations was also increased among survivors relative to the comparison cohort (RR = 2.05; 95% CI, 1.95–2.14). Patterns were generally similar in analyses comparing survivors to their siblings. Conclusions: AYA cancer survivors have a higher burden of inpatient hospitalization than their siblings and the general population. Impact: Results indicate the importance of long-term, risk-based follow-up care to prevent and treat severe morbidities after cancer treatment.

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.

Background: Adolescent and young adult (AYA) cancer patients commonly report health insurance concerns and financial burden that emerge due to their cancer treatment. AYAs often have limited experience with health care prior to their cancer diagnosis, which may limit their understanding of health insurance concepts and affect their medical costs. As part of the development of an insurance navigation program, we conducted an evaluation of health insurance experiences, expectations, and literacy among a sample of AYA cancer patients. Methods: Eligible participants were 18-39 years of age with cancer, and currently insured. Participants were recruited in-person and online through a statewide AYA cancer navigation program in Utah. We selected the sample stratified on current age (18-25 and 26-39 years). Participants completed a brief survey and a semi-structured interview. We summarized demographic factors and the Health Insurance Literacy Measure (HILM), a continuous measure ranging from 0-84. The HILM score was examined by age (18-25 vs. 26-39 years) and insurance policy holder (yes vs. no) using t-tests. The semi-structured interviews were recorded, transcribed, and analyzed. Two cycles of inductive coding were applied to open-ended questions regarding health insurance knowledge, areas of confusion, their coverage expectations, and their experiences with medical costs. Results: Of AYA participants, N=13 were 18-25 and N=11 were 26-29 years; participants were female (58%) and Non-Hispanic White (79%), and most had completed at least had some college (92%). Less than half of participants were policy holders for their health insurance (41.7%). Mean HILM score was 55.63 (SD=10.06). There were no differences in the HILM measure by age or policy holder status. Three emergent qualitative themes included: 1) Lack of insurance knowledge affected experiences throughout treatment. While some AYAs understood the basics of their insurance coverage, most were unaware of the specifics of their plan, including how their coverage impacted their out-of-pocket costs. 2) Unclear expectations of health insurance. Most AYA participants were unsure what their health insurance should cover, but at the same time, were surprised about the lack of coverage and high costs. 3) Difficulties navigating coverage and the complexity of the health care system. Most AYAs reported struggled with handling insurance coverage issues, particularly when appeals were necessary to have their health care covered. Conclusions: AYAs with cancer report difficulty navigating the complexities of health insurance and lack understanding about what services their insurance should cover. Education focusing on insurance concepts (e.g., cost-sharing mechanisms such as deductibles) and areas where out-of-pocket costs could be managed (e.g., appeals process, in- vs. out-of-network services) could help AYA cancer patients make more informed health insurance decisions during their cancer treatment. Citation Format: Anne C. Kirchhoff, Karely Mann, Austin R. Waters, Echo L. Warner, Perla Vaca Lopez, Heydon K. Kaddas, Nicole Ray, Tomoko Tsukamoto, Doug Fair, Mark Lewis, Giselle K Perez, Elyse R. Park. Addressing gaps in health insurance literacy among adolescent and young adult cancer patients [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr IA21.

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.

Timely vaccination after childhood cancer treatment is vital for protecting against vaccine-preventable diseases during survivorship. However, caregiver intention for restarting vaccinations, such as getting catch-up or booster vaccines, after cancer treatment is unknown. Methods: We surveyed primary caregivers ages 18 or older with a child who had completed cancer treatment in the prior 3–24 months (N = 129; participation rate = 60.3%). Participants were asked about demographics, their child's vaccination status, and healthcare factors (e.g., provider recommendations, barriers). We examined the influence of whether the oncology care team recommended catch-up or booster vaccines on caregiver intention to restart vaccines using multivariable generalized linear models. Vaccine barriers were examined by intention in chi- square tests. Results: Caregivers were primarily aged 30–49 years (82.0%), mothers (81.2%), college graduates (44.8%), married (89.1%), and Non-Hispanic (90.3%). In total, 67% of caregivers intended to restart vaccines for their child and 49.6% reported that they had a discussion with the cancer care team about catch-up or booster vaccines. Caregivers who discussed vaccines with their child's cancer care team were much more likely to report intention to restart vaccination (Relative Risk (RR) = 1.82, 95% CI 1.37–2.45). The most common barrier to restarting vaccines after cancer was not knowing which vaccines to get, which was common across both groups (intend to restart = 31% vs. did not intend = 40.5%, P = 0.29). Of caregivers, 93.1% who intended to restart vaccines felt vaccines were safe compared to 79.5% of those who did not (P = 0.02). Conclusions: Caregivers of childhood cancer survivors need guidance for restarting vaccinations after cancer treatment, including information on safety and which vaccines their child needs. Provider recommendations positively influence caregiver's intention to restart vaccines. Clinical guidelines are needed to support providers in making tailored vaccination recommendations after cancer treatment.