Abstract
Purpose:
Childhood, adolescent, and young adult (CAYA) cancer survivors are at risk of HPV-related cancers, yet HPV vaccination remains lower than general population. The purpose of this study was to examine HPV vaccination initiation and completion among CAYA survivors and to assess the influence of sociodemographic and cancer-specific factors on vaccination.
Methods:
We used data from the St. Jude Lifetime Cohort, 5+ year cancer survivors, treated at St. Jude Children’s Research Hospital, eligible for HPV vaccination since 2006 (year of FDA licensure in the USA). Primary outcomes were HPV vaccination initiation and completion. HPV vaccination was assessed between 2011 to 2020. We performed descriptive statistics and evaluated associations using univariate and multivariable logistic regression analysis using SAS version 9.4.
Results:
We included 2907 CAYA survivors. HPV vaccination initiation was reported by 27.31% survivors. Among those who initiated, 71.16% survivors completed vaccination series. Female survivors compared to male survivors (OR, 2.58; 95% CI, 2.10-3.17), those age 27+ compared to 9-17 years (OR, 0.21; 95% CI,0.10-0.42), those with a college degree or higher compared to those with a high school degree (OR, 2.39; 95% CI, 1.40-4.06) and those with insurance compared to those without insurance (public, OR, 2.00; 95% CI, 1.22-3.28; private, OR, 2.26; 95% CI, 1.41-3.63) had higher vaccination initiation. Cancer diagnosed at later age (9-14 years, OR, 1.59; 95% CI, 1.20-2.09; 15-24 years, OR, 2.01; 95% CI, 1.40-2.90) had higher vaccination initiation than those diagnosed <9 years.
Conclusions:
HPV vaccination was low among survivors. We found differences in vaccination by age, sex, education, insurance coverage, and age at cancer diagnosis.
Implications for Cancer Survivors:
These findings provide evidence to guide the development of strategies for improving HPV vaccination and reducing the risk of HPV-related cancers among survivors.
Keywords: Childhood cancer survivors, Human papillomavirus, HPV vaccination, Cancer Prevention
INTRODUCTION
Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States (US) [1], causing nearly 40,000 new cancer cases annually in the USA [2, 3]. HPV causes cervical, oropharyngeal, anal, vaginal, and vulvar cancers in females and oropharyngeal, anal, and penile cancers in males [3, 4]. HPV vaccination prevents more than 90% of HPV-related cancers [4]. The Centers for Disease Control and Prevention (CDC) routinely recommends HPV vaccination for ages 9-26 years and for some individuals ages 27-45 years [5]. Despite the availability of the HPV vaccine in the U.S. since 2006, up-to-date HPV vaccination coverage in adolescents aged 13-17 years is 62.6%, far below the national Healthy People 2030 goal of 80% [6, 7]. Among HPV vaccine eligible populations, childhood, adolescent, and young adult cancer survivors remain an under immunized group for HPV vaccination [8].
Childhood, adolescent, and young adult (CAYA) cancer survivors have a higher risk of developing persistent HPV infections and new HPV-related cancers potentially due to the effects of cancer-directed therapy which often results in weakened immune systems [9-12]. Male and female cancer survivors are 2.5 and 1.4 times, respectively, more likely to develop HPV-related cancers than the general population [13]. However, these survivors are less likely to utilize cancer-related preventive measures including HPV vaccination [8, 14]. Evidence shows immunogenicity and safety of the HPV vaccination in cancer survivors, and the majority of HPV-related infections and cancers are preventable through HPV vaccination [15]. The Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (version 6.0) recommend a three-dose HPV vaccine series for cancer survivors, regardless of their age at first HPV vaccine dose, beginning 6 months after the completion of cancer-directed therapy [16]. However, the uptake of the HPV vaccine is significantly lower in cancer survivors compared to the general population (23.8% vs 40.5%, respectively) [8].
Some of the reasons for lower HPV vaccination in cancer survivors include vaccine hesitancy (i.e., delay in acceptance of HPV vaccine despite its availability) or refusal (i.e., decision not to get the vaccine), vaccine-related information deficits, safety concerns, family decision-making processes, and lack of healthcare provider recommendations [17, 18]. Research suggests that HPV vaccination recommendations from healthcare providers, especially oncology care providers, play the most promising role in HPV vaccine uptake in cancer survivors [19]. The close relationship cancer survivors and their families developed with the oncology care team during cancer treatment facilitates respect and trust; thus, they may be more receptive to adhere to health advice from their treating oncology healthcare providers who address concerns about the vaccine’s safety, clarify that it is not associated with cancer recurrence, and emphasize its role in preventing new HPV-related cancers [19, 20].
Cancer surveillance and long-term follow-up evaluations represent missed opportunities for discussion of HPV cancer prevention through vaccination that may be overlooked by oncology providers who defer immunizations to primary care providers after post-treatment immune recovery [21]. While prior studies have shown lower HPV vaccination rates among cancer survivors ages 9 to 26 years [8, 18, 22], our study adds novel insights by examining HPV vaccination across the age ranges who are eligible for HPV vaccination from ages 9 to 45 years, representing the entire age spectrum of individuals eligible for HPV vaccination. There is a need for detailed information to develop timely and targeted interventions improving HPV vaccination coverage among CAYA cancer survivors [23]. Thus, we examined HPV vaccination initiation and completion among CAYA cancer survivors and explored factors (sociodemographic and cancer-specific) that influenced HPV vaccination initiation and completion.
METHODS
Study design and participants
This study used data from the St. Jude Lifetime (SJLIFE) Cohort at St. Jude Children’s Research Hospital (SJCRH) in Memphis, Tennessee. SJLIFE is a retrospectively identified cohort of 5-year survivors of childhood cancer treated at SJCRH and prospectively followed for long-term outcomes. The details of SJLIFE have been previously described [24]. Briefly, SJLIFE is approved by the Institutional Review Board at SJCRH, and childhood cancer survivors are followed to collect their health information. Eligibility for participation in SJLIFE includes 5-year survival of childhood cancer diagnosed and followed at SJCRH between 1962 and 2012. In the present study, we employed a cross-sectional design including all age-eligible childhood cancer survivors enrolled in SJLIFE who were eligible for HPV vaccination (i.e., beginning in 2006 when HPV vaccine became available in the USA [25]), and enrolled in the SJLIFE. Several other studies have used a cross-sectional design using the data from the SJLIFE study [26, 27]. HPV vaccination status was assessed between March 29, 2011, to March 17, 2020. To maximize the capture of HPV vaccination initiation and completion, we systematically reviewed each survivor’s longitudinal SJLIFE survey records, starting with the most recent visit. If information regarding HPV vaccination status (initiation or completion) was missing or incomplete at the most recent visit, we retrospectively examined prior visits in sequence until vaccination data were available. This approach allowed us to prospectively leverage all available opportunities in the survivors’ records to ascertain HPV vaccination history as comprehensively as possible. We accounted for participants’ date of birth and their age at the time of the survey to determine their eligibility for HPV vaccination based on the guidelines over time. We also considered sex-specific timelines based on the guidelines. For females, the HPV vaccine was licensed and routinely recommended in 2006. For males, the quadrivalent HPV vaccine was licensed in 2009 and routinely recommended in 2011 [28]. According to the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP), HPV vaccination completion is defined as receipt of two doses for individuals who initiated vaccination before age 15 years and three doses for those who initiated vaccination at or after age 15 years. Furthermore, we applied participants’ eligibility based on the extended ACIP guidelines in 2018, which recommended HPV vaccination for individuals aged 9-45 years [29]. The analysis included all participants who had the opportunity to receive the HPV vaccine based on the timing of guideline availability. We excluded those cancer survivors enrolled in SJLIFE who did not complete the HPV vaccination surveys. The selection procedure for the participants is shown in Figure 1. We examined the potential difference between participants and eligible non-participants by sociodemographic factors, cancer diagnosis, and treatment variables (Supplemental Table 1).
Figure 1.
Consort diagram for childhood, adolescent, and young adult cancer survivors
Variables
The primary outcome variables were HPV vaccination initiation and completion. HPV vaccination initiation was defined as receiving at least one dose of HPV vaccine. HPV vaccination completion was defined as receiving all the recommended doses of HPV vaccine. When we started this study, HPV vaccination completion in the COG guidelines, versions 3.0 to 5.0 released before 2023, was in accordance with the Advisory Committee on Immunization Practices (ACIP) guidelines recommending (1) two doses of the HPV vaccine before 15th birthday or (2) three doses on or after 15th birthday and for individuals with immunocompromising conditions [5]. In October 2023, the COG long-term follow-up guideline (version 6.0) changed their recommendations to the three-dose HPV vaccine series for CAYA cancer survivors, regardless of their age at first HPV vaccine dose, beginning 6 months after the completion of cancer-directed therapy [16]. Since our survey data collection ended in 2020, we examined HPV vaccination completion using the COG guidelines, versions 3.0 to 5.0, released before 2023. The SJLIFE survey asked the following HPV vaccination questions for both males and females: “Have you ever received the HPV shot or vaccine?”, “How old were you when you received the first dose of the HPV vaccine?”, and “How many shots of the HPV vaccine did you receive?” We used the first question about ever receiving the HPV shot or vaccine to determine HPV vaccination initiation. Then, we used all three questions to determine HPV vaccination completion. We also assessed sociodemographic factors at the time of vaccination survey to evaluate associations with vaccine initiation and completion including age, sex, race, ethnicity, education, household income, insurance coverage, geographic location, and cancer-specific factors (e.g., age at primary cancer diagnosis, fear of cancer recurrence, recommendation from healthcare providers, types of cancer diagnosis, mode of cancer treatment).
Statistical methods
Using data from SJLIFE, we performed descriptive analyses and evaluated association analyses using univariate and multivariable regression analysis using SAS version 9.4 [30]. Descriptive statistics helped to compare the distribution of various characteristic variables in cancer survivors. Table 1 shows the characteristics of the participants, and Table 2 shows descriptive statistics information on HPV vaccination initiation and completion among the cancer survivors assessed using a chi-square test. To explore the association between various factors and HPV vaccination initiation and completion, we applied a univariate logistic regression model to calculate the odds ratio (OR) and 95% confidence interval (CI). We further conducted multivariable analysis by including the variables (sociodemographic and cancer-specific) with p-value <=0.1 from the univariate analysis and conducted a backward selection method to select the most important exposures/covariates in the model. We calculated the adjusted OR and 95% CI. The p-value of <0.05 determined a significant influence of various factors on HPV vaccination initiation and completion in cancer survivors.
Table 1.
Characteristic variables of childhood, adolescent, and young adult cancer survivors
| Characteristics | Cancer survivors (N=2907) |
|---|---|
| n (%) | |
| Age [Mean (SD)] (years) at survey | 25.39 (8.83) |
| [Median (Range)] (years) | 25 (9-47) |
| Age (years) | |
| 9-17 | 621 (21.36) |
| 18-26 | 996 (34.26) |
| 27 and above | 1290 (44.38) |
| Sex | |
| Male | 1393 (47.92) |
| Female | 1514 (52.08) |
| Race/Ethnicity | |
| White, Non-Hispanic | 2202 (75.75) |
| Black, Non-Hispanic | 458 (15.76) |
| Hispanic | 159 (5.47) |
| Others | 88 (3.03) |
| Education* | |
| High school or below | 362 (23.37) |
| Some post-high school | 403 (26.02) |
| College degree or higher | 698 (45.06) |
| Other | 48 (3.10) |
| Missing | 38 (2.45) |
| Household income, $US | |
| <$20,000 | 448 (15.41) |
| $20,000 to $59,999 | 939 (32.30) |
| ≥$60,000 | 1127 (38.77) |
| Don’t know | 290 (9.98) |
| Missing | 103 (3.54) |
| Insurance | |
| Public | 768 (26.42) |
| Private | 1737 (59.75) |
| Uninsured | 292 (10.04) |
| Other | 58 (2.00) |
| Missing | 52 (1.79) |
| Location at survey (By regions) | |
| Northeast | 60 (2.06) |
| Midwest | 474 (16.31) |
| South | 2184 (75.13) |
| West | 122 (4.20) |
| Other | 67 (2.30) |
| Cancer-specific variables | |
| Age at diagnosis, years (Mean± SD) | 7.23 (5.59) |
| Median (Range) | 6 (0-24) |
| Age at diagnosis (years) | |
| 0-8 | 1835 (63.12) |
| 9-14 | 642 (22.08) |
| 15-24 | 430 (14.79) |
| Difference between age at diagnosis and age at HPV vaccination, years ( Mean± SD) | 18.17 (8.43) |
| Median (Range) | 16 (5-45) |
| Fear of cancer recurrence | |
| Agree | 607 (20.88) |
| Disagree | 1101 (37.87) |
| Neutral | 501 (17.23) |
| Missing | 698 (24.01) |
| Recommendation from healthcare provider | |
| Yes | 1479 (50.88) |
| No | 536 (18.44) |
| Not sure | 399 (13.73) |
| Missing | 493 (16.96) |
| Cancer diagnosis | |
| CNS tumor | 579 (19.92) |
| Non-CNS solid tumor | 965 (33.20) |
| Leukemia | 950 (32.68) |
| Lymphoma | 356 (12.25) |
| Other | 57 (1.96) |
| Mode of cancer treatment | |
| Any Chemotherapy | |
| Yes | 2384 (82.01) |
| No | 523 (17.99) |
| Vinca Alkaloid | |
| Yes | 1881 (64.71) |
| No | 1026 (35.29) |
| Alkylators | |
| Yes | 1634 (56.21) |
| No | 1260 (43.34) |
| Missing | 13 (0.45) |
| Radiation therapy | |
| Any radiation | |
| Yes | 1264 (43.48) |
| No | 1643 (56.52) |
| Brain radiation | |
| Yes | 643 (22.12) |
| No | 2179 (74.96) |
| Missing | 85 (2.92) |
| Any chest radiation | |
| Yes | 579 (19.92) |
| No | 2244 (77.19) |
| Missing | 84 (2.89) |
| Any abdominal radiation | |
| Yes | 543 (18.68) |
| No | 2281 (78.47) |
| Missing | 83 (2.86) |
| Any pelvic radiation | |
| Yes | 498 (17.13) |
| No | 2325 (79.98) |
| Missing | 84 (2.89) |
| Surgery | |
| Any surgery | |
| Yes | 2822 (97.08) |
| No | 85 (2.92) |
| Brain surgery | |
| Yes | 599 (20.61) |
| No | 2308 (79.39) |
| Pelvic surgery | |
| Yes | 436 (15.00) |
| No | 2471 (85.00) |
Note: SJLIFE is St. Jude Lifetime (SJLIFE) Cohort
Education participants age >=25 years; under cancer diagnosis, “other” includes other carcinoma, non-malignnacy requiring cytotoxic therapy because of clinically aggressive behavior, and other malignancies with less common histology.
Table 2.
HPV vaccination initiation and completion among childhood, adolescent, and young adult cancer survivors
| Characteristics | HPV vaccination initiation | HPV vaccination completion* |
|---|---|---|
| Cancer survivors (n=794, 27.31%) |
Cancer survivors (n=565, 71.16%) |
|
| n (%) | n (%) | |
| Age (years) at survey | ||
| 9-17 | 276 (34.76) | 197 (34.87) |
| 18-26 | 382 (48.11) | 277 (49.03) |
| 27 and above | 136 (17.13) | 91 (16.11) |
| Sex | ||
| Male | 269 (33.88) | 182 (32.21) |
| Female | 525 (66.12) | 383 (67.79) |
| Race/Ethnicity | ||
| White, Non-Hispanic | 589 (74.18) | 427 (75.58) |
| Black, Non-Hispanic | 117 (14.74) | 73 (12.92) |
| Hispanic | 51 (6.42) | 40 (7.08) |
| Others | 37 (4.66) | 25 (4.42) |
| Education | ||
| High school or below | 24 (11.01) | 16 (10.88) |
| Some post-high school | 40 (18.35) | 23 (15.65) |
| College degree or higher | 139 (63.76) | 97 (65.99) |
| Other | 6 (2.75) | 5 (3.40) |
| Missing | 9 (4.13) | 6 (4.08) |
| Household income, $US | ||
| <$20,000 | 106 (13.35) | 72 (12.74) |
| $20,000 to $59,999 | 245 (30.86) | 175 (30.97) |
| ≥$60,000 | 338 (42.57) | 245 (43.36) |
| Don’t know | 85 (10.71) | 59 (10.44) |
| Missing | 20 (2.52) | 14 (2.48) |
| Insurance | ||
| Public | 215 (27.08) | 150 (26.55) |
| Private | 516 (64.99) | 372 (65.84) |
| Uninsured | 33 (4.16) | 20 (3.54) |
| Other | 21 (2.64) | 16 (2.83) |
| Missing | 9 (1.13) | 7 (1.24) |
| Location (By regions) | ||
| Northeast | 26 (3.27) | 20 (3.54) |
| Midwest | 132 (16.62) | 100 (17.70) |
| South | 585 (73.68) | 405 (71.68) |
| West | 37 (4.66) | 29 (5.13) |
| Other | 14 (1.76) | 11 (1.95) |
| Cancer-specific variables | ||
| Age at diagnosis, years (Mean± SD) | 6.78 (5.29) | 6.87 (5.37) |
| [Median (Range)] | 5 (0-24) | 5 (0-24) |
| Age at diagnosis | ||
| 0-8 | 530 (66.75) | 375 (66.37) |
| 9-14 | 171 (21.54) | 120 (21.24) |
| 15-24 | 93 (11.71) | 70 (12.39) |
| Fear of cancer recurrence | ||
| Agree | 162 (20.40) | 123 (21.77) |
| Disagree | 236 (29.72) | 153 (27.08) |
| Neutral | 94 (11.84) | 70 (12.39) |
| Missing | 302 (38.04) | 219 (38.76) |
| Recommendation from healthcare provider | ||
| Yes | 467 (58.82) | 343 (60.71) |
| No | 155 (19.52) | 103 (18.23) |
| Not sure | 95 (11.96) | 67 (11.86) |
| Missing | 77 (9.70) | 52 (9.20) |
| Cancer diagnosis | ||
| CNS tumor | 152 (19.14) | 106 (18.76) |
| Non-CNS solid tumor | 274 (34.51) | 195 (34.51) |
| Leukemia | 268 (33.75) | 196 (34.69) |
| Lymphoma | 77 (9.70) | 51 (9.03) |
| Other | 23 (2.90) | 17 (3.01) |
| Mode of cancer treatment | ||
| Any Chemotherapy | ||
| Yes | 640 (80.60) | 461 (81.59) |
| No | 154 (19.40) | 104 (18.41) |
| Vinca Alkaloid | ||
| Yes | 500 (62.97) | 351 (62.12) |
| No | 294 (37.03) | 214 (37.88) |
| Alkylators | ||
| Yes | 432 (54.41) | 312 (55.22) |
| No | 361 (45.47) | 252 (44.60) |
| Missing | 1 (0.13) | 1 (0.18) |
| Radiation therapy | ||
| Any radiation | ||
| Yes | 279 (35.14) | 193 (34.16) |
| No | 515 (64.86) | 372 (65.84) |
| Brain radiation | ||
| Yes | 136 (17.13) | 93 (16.46) |
| No | 635 (79.97) | 454 (80.35) |
| Missing | 23 (2.90) | 18 (3.19) |
| Any chest radiation | ||
| Yes | 122 (15.37) | 82 (14.51) |
| No | 650 (81.86) | 466 (82.48) |
| Missing | 22 (2.77) | 17 (3.01) |
| Any abdominal radiation | ||
| Yes | 117 (14.74) | 78 (13.81) |
| No | 655 (82.49) | 470 (83.19) |
| Missing | 22 (2.77) | 17 (3.01) |
| Any pelvic radiation | ||
| Yes | 102 (12.85) | 68 (12.04) |
| No | 670 (84.38) | 480 (84.96) |
| Missing | 22 (2.77) | 17 (3.01) |
| Surgery | ||
| Any surgery | ||
| Yes | 785 (98.87) | 560 (99.12) |
| No | 9 (1.13) | 5 (0.88) |
| Brain surgery | ||
| Yes | 161 (20.28) | 110 (19.47) |
| No | 633 (79.72) | 455 (80.53) |
| Pelvic surgery | ||
| Yes | 73 (9.19) | 49 (8.67) |
| No | 721 (90.81) | 516 (91.33) |
Note: HPV is Human papillomavirus
HPV vaccination completion: following the Children’s Oncology Group guidelines, versions 3.0 to 5.0.
RESULTS
Characteristics of the study participants
A total of 2907 cancer survivors were included in the study (Table 1). The participation rate for cancer survivors is 52.56% (Fig. 1). The median age at the time of the survey for cancer survivors was 25 years (IQR, 9-47 years). Among the total participants, 52.08% were female cancer survivors. Most participants were White, Non-Hispanic (75.75%), followed by Black, non-Hispanic (15.76%). Many participants had a college degree or higher (45.06%), a household income of ≥$60,000 (38.77%), and private insurance coverage (59.75%). Most participants were from the South region of the USA (75.13%), followed by the Midwest (16.31%). Regarding cancer-specific factors, the median age at primary cancer diagnosis was 6 years (IQR, 0-24 years), with the most common diagnoses including non-central nervous system (CNS) solid tumors (33.20%) followed by leukemia (32.68%) (Table 1). Participant and non-participant cancer survivors differed by sociodemographic factors (such as, age, sex, race/ethnicity, income, and insurance coverage) and cancer-specific factors (such as age at cancer diagnosis and mode of cancer treatment) as shown in Supplemental Table 1.
Regarding HPV vaccination, 27.31% of cancer survivors reported HPV vaccination initiation (Table 2). Among those who initiated HPV vaccination, 71.16% of cancer survivors completed the vaccination (Table 2). Most participants who initiated and completed HPV vaccination were aged 18-26 years (vaccination initiation, 48.11% and vaccination completion, 49.03%), female (vaccination initiation, 66.12% and vaccination completion, 67.79%), White, Non-Hispanic (vaccination initiation, 74.18% and vaccination completion, 75.58%), had college degree or higher (vaccination initiation, 63.76% and vaccination completion, 65.99%) and had private insurance coverage (vaccination initiation, cancer survivors, 64.99%; vaccination completion, cancer survivors, 65.84% (Table 2). The details of the findings from the univariate logistic regression analysis related to HPV vaccination initiation and completion by various sociodemographic, diagnosis, and treatment categories are shown in Table 3.
Table 3.
Univariate relationship between sociodemographic and cancer-related factors and HPV vaccination initiation and completion among childhood, adolescent, and young adult cancer survivors
| Characteristics | HPV vaccination initiation |
HPV vaccination completion* |
||
|---|---|---|---|---|
| Cancer survivors | Cancer survivors | |||
| OR (95% CI) | P-value | OR (95% CI) | P-value | |
| Age (years) at survey | ||||
| 9-17 | Ref | Ref | ||
| 18-26 | 0.78 (0.64, 0.95) | 0.015 | 1.06 (0.75, 1.49) | 0.749 |
| 27 and above | 0.15 (0.12, 0.19) | <0.0001 | 0.81 (0.52, 1.26) | 0.353 |
| Sex | ||||
| Male | Ref | Ref | ||
| Female | 2.22 (1.87, 2.63) | <0.0001 | 1.29 (0.94, 1.76) | 0.120 |
| Race/Ethnicity | ||||
| White, Non-Hispanic | Ref | Ref | ||
| Black, Non-Hispanic | 0.94 (0.75, 1.18) | 0.596 | 0.63 (0.42, 0.95) | 0.029 |
| Hispanic | 1.29 (0.92, 1.83) | 0.145 | 1.38 (0.69, 2.75) | 0.362 |
| Others | 1.99 (1.29, 3.07) | 0.002 | 0.79 (0.39, 1.61) | 0.517 |
| Education | ||||
| High school or below | Ref | Ref | ||
| Some post-high school | 1.55 (0.92, 2.63) | 0.103 | 0.68 (0.24, 1.94) | 0.468 |
| College degree or higher | 3.50 (2.22, 5.51) | <0.0001 | 1.16 (0.46, 2.91) | 0.760 |
| Other | 2.01 (0.78, 5.20) | 0.150 | 2.50 (0.25, 25.15) | 0.437 |
| Household income, $US | ||||
| <$20,000 | Ref | Ref | ||
| $20,000 to $59,999 | 1.14 (0.88, 1.48) | 0.330 | 1.18 (0.72, 1.93) | 0.509 |
| ≥$60,000 | 1.38 (1.07, 1.78) | 0.012 | 1.24 (0.78, 2.00) | 0.365 |
| Insurance | ||||
| Uninsured | Ref | Ref | ||
| Public | 3.05 (2.06, 4.53) | <0.0001 | 1.50 (0.70, 3.20) | 0.293 |
| Private | 3.32 (2.28, 4.83) | <0.0001 | 1.68 (0.81, 3.47) | 0.161 |
| Other | 4.45 (2.33, 8.50) | <0.0001 | 2.08 (0.61, 7.07) | 0.241 |
| Location at survey (By regions) | ||||
| South | Ref | Ref | ||
| Midwest | 1.06 (0.85, 1.32) | 0.637 | 1.39 (0.90, 2.15) | 0.139 |
| Northeast | 2.09 (1.24, 3.52) | 0.005 | 1.48 (0.59, 3.75) | 0.407 |
| West | 1.19 (0.80, 1.77) | 0.392 | 1.61 (0.72, 3.59) | 0.244 |
| Other | 0.72 (0.40, 1.31) | 0.285 | 1.63 (0.45, 5.91) | 0.458 |
| Cancer-specific variables | ||||
| Age at diagnosis (years) | ||||
| 0-8 | Ref | Ref | ||
| 9-14 | 0.89 (0.73, 1.09) | 0.277 | 0.97 (0.67, 1.42) | 0.885 |
| 15-24 | 0.68 (0.53, 0.87) | 0.003 | 1.26 (0.76, 2.09) | 0.375 |
| Fear of cancer recurrence | ||||
| Disagree | Ref | Ref | ||
| Agree | 1.33 (1.06, 1.68) | 0.014 | 1.71 (1.09, 2.68) | 0.019 |
| Neutral | 0.85 (0.65, 1.11) | 0.220 | 1.58 (0.93, 2.70) | 0.093 |
| Recommendation from healthcare provider | ||||
| No | Ref | Ref | ||
| Yes | 1.13 (0.91, 1.40) | 0.254 | 1.40 (0.94, 2.07) | 0.095 |
| Not sure | 0.77 (0.57, 1.03) | 0.081 | 1.21 (0.70, 2.10) | 0.503 |
| Cancer diagnosis | ||||
| CNS tumor | Ref | Ref | ||
| Non-CNS solid tumor | 1.11 (0.88, 1.41) | 0.362 | 1.07 (0.69, 1.65) | 0.756 |
| Leukemia | 1.10 (0.88, 1.39) | 0.405 | 1.18 (0.76, 1.83) | 0.457 |
| Lymphoma | 0.78 (0.57, 1.06) | 0.111 | 0.85 (0.47, 1.53) | 0.590 |
| Other | 1.90 (1.09, 3.33) | 0.025 | 1.23 (0.46, 3.32) | 0.683 |
| Mode of cancer treatment | ||||
| Any Chemotherapy | ||||
| Yes | 0.88 (0.71, 1.08) | 0.227 | 1.24 (0.85, 1.81) | 0.269 |
| No | Ref | Ref | ||
| Vinca Alkaloid | ||||
| Yes | 0.90 (0.76, 1.06) | 0.186 | 0.88 (0.64, 1.21) | 0.437 |
| No | Ref | Ref | ||
| Alkylators | ||||
| Yes | 0.90 (0.76, 1.06) | 0.186 | 1.13 (0.83, 1.53) | 0.455 |
| No | Ref | Ref | ||
| Radiation therapy | ||||
| Any radiation | ||||
| Yes | 0.62 (0.52, 0.74) | <0.0001 | 0.86 (0.63, 1.19) | 0.364 |
| No | Ref | Ref | ||
| Brain radiation | ||||
| Yes | 0.65 (0.53, 0.81) | <0.0001 | 0.86 (0.58, 1.29) | 0.468 |
| No | Ref | Ref | ||
| Any chest radiation | ||||
| Yes | 0.66 (0.53, 0.82) | 0.0002 | 0.81 (0.54, 1.23) | 0.318 |
| No | Ref | Ref | ||
| Any abdominal radiation | ||||
| Yes | 0.68 (0.55, 0.85) | 0.0008 | 0.79 (0.52, 1.20) | 0.265 |
| No | Ref | Ref | ||
| Any pelvic radiation | ||||
| Yes | 0.64 (0.50, 0.81) | 0.0002 | 0.79 (0.51, 1.24) | 0.303 |
| No | Ref | Ref | ||
| Surgery | ||||
| Any surgery | ||||
| Yes | 3.25 (1.62, 6.52) | 0.0009 | 1.99 (0.53, 7.48) | 0.308 |
| No | Ref | Ref | ||
| Brain surgery | ||||
| Yes | 0.97 (0.79, 1.19) | 0.789 | 0.84 (0.58, 1.23) | 0.374 |
| No | Ref | Ref | ||
| Pelvic surgery | ||||
| Yes | 0.49 (0.37, 0.64) | <0.0001 | 0.81 (0.49, 1.36) | 0.425 |
| No | Ref | Ref |
Note: OR is odds ratio; CI is confidence interval; HPV is human papillomavirus
HPV vaccination completion: following the Children’s Oncology Group guidelines, versions 3.0 to 5.0.
The findings from the multivariable analysis showing various factors (sociodemographic and cancer-specific) and HPV vaccination initiation and completion in cancer survivors are shown in Table 4. The multivariable results showed that female cancer survivors were more likely to report HPV vaccination initiation (OR, 2.58; 95% CI, 2.10-3.17) and completion (OR, 1.45; 95% CI, 1.01, 2.08). Compared to the cancer survivors aged 9-17 years, those aged 27 years and above were significantly less likely to initiate HPV vaccination (cancer survivors: OR, 0.21; 95% CI, 0.10-0.42). Cancer survivors with a college degree or higher (OR, 2.39; 95% CI, 1.40-4.06) compared to those with high school or below, and those with insurance coverage (public, OR, 2.00; 95% CI, 1.22-3.28; private, OR, 2.26; 95% CI, 1.41-3.63) compared to uninsured, were significantly more likely to report HPV vaccination initiation. The odds of HPV vaccination completion were higher among cancer survivors with insurance coverage; however, the results were not statistically significant. Compared to the participants from the South, the participants from the Northeast had higher odds of HPV vaccination initiation (OR, 1.98; 95% CI, 1.01-3.87). Regarding cancer-specific variables, compared to cancer survivors diagnosed at aged 0-8 years, cancer survivors diagnosed at aged 9-14 years (OR: 1.59; 95% CI, 1.20-2.09) and 15-24 years (OR, 2.01; 95% CI, 1.40-2.90) were more likely to report HPV vaccination initiation. Regarding cancer treatment, there was no significant association between cancer treatment categories and HPV vaccination initiation (all p > 0.05). Those who endorsed fear of cancer recurrence were more likely to initiate HPV vaccination, although the finding was not statistically significant (OR, 1.33; 95% CI, 0.99-1.78), compared to those who disagreed. However, fear of cancer recurrence was significantly associated with higher odds of HPV vaccination completion (OR, 1.73; 95% CI, 1.04-2.89). Furthermore, those who reported that they received recommendation from a health care professional were more likely to initiate and complete HPV vaccination series; however, the findings were not significant (Table 4).
Table 4.
Multivariable relationship between sociodemographic and cancer-related factors and HPV vaccination among childhood, adolescent, and young adult cancer survivors
| Characteristics | HPV vaccination initiation |
HPV vaccination completion |
||
|---|---|---|---|---|
| OR (95% CI) | P-value | OR (95% CI) | P-value | |
| Age (years) at survey | ||||
| 9-17 | Ref | Ref | ||
| 18-26 | 1.02 (0.57 ,1.84 ) | 0.944 | 1.94 (0.72, 5.22) | 0.193 |
| 27 and above | 0.21 (0.10 , 0.42 ) | <0.0001 | 1.95 (0.59, 6.38) | 0.271 |
| Sex | ||||
| Male | Ref | Ref | ||
| Female | 2.58 (2.10, 3.17) | <0.0001 | 1.45 (1.01, 2.08) | 0.042 |
| Race/Ethnicity | ||||
| White, Non-Hispanic | Ref | Ref | ||
| Black, Non-Hispanic | 1.03 (0.76, 1.40) | 0.837 | 0.63 (0.39, 1.02) | 0.062 |
| Hispanic | 1.26 (0.80, 1.98 ) | 0.317 | 1.11 (0.50, 2.48) | 0.798 |
| Others | 1.52 (0.90, 2.55) | 0.114 | 0.62 (0.29, 1.32) | 0.214 |
| Education | ||||
| High school or below | Ref | Ref | ||
| Some post-high school | 1.07 (0.58 , 1.97) | 0.821 | 0.86 (0.26, 2.83) | 0.805 |
| College degree or higher | 2.39 (1.40, 4.06) | 0.001 | 1.03 (0.37, 2.91) | 0.951 |
| Other | 2.49 (0.88, 7.02) | 0.084 | 2.02 (0.18, 22.33) | 0.567 |
| Insurance | ||||
| Uninsured | Ref | Ref | ||
| Public | 2.00 (1.22, 3.28 ) | 0.006 | 1.21 (0.49, 3.04) | 0.679 |
| Private | 2.26 (1.41, 3.63 ) | 0.0007 | 1.10 (0.46, 2.63) | 0.830 |
| Other | 3.00 (1.36, 6.60) | 0.006 | 1.53 (0.40, 5.82) | 0.536 |
| Location (By regions) | ||||
| South | Ref | Ref | ||
| Midwest | 1.02 (0.77, 1.34 ) | 0.907 | 1.37 (0.85, 2.21) | 0.193 |
| Northeast | 1.98 (1.01, 3.87) | 0.046 | 1.47 (0.52, 4.20) | 0.468 |
| West | 1.21 (0.75, 1.97) | 0.437 | 1.66 (0.69, 4.01) | 0.259 |
| Other | 0.87 (0.40, 1.90) | 0.729 | 1.62 (0.30, 8.74) | 0.576 |
| Age at cancer diagnosis (years) | ||||
| 0-8 | Ref | Ref | ||
| 9-14 | 1.59 (1.20, 2.09) | 0.001 | 1.20 (0.76, 1.91) | 0.439 |
| 15-24 | 2.01 (1.40, 2.90 ) | 0.0002 | 1.40 (0.73, 2.70) | 0.315 |
| Recommendation from healthcare provider | ||||
| No | Ref | Ref | ||
| Yes | 1.05 (0.82, 1.35) | 0.684 | 1.39 (0.91, 2.10) | 0.125 |
| Not sure | 0.65 (0.46, 0.91) | 0.012 | 1.24 (0.70, 2.20) | 0.455 |
| Fear of cancer recurrence | ||||
| Disagree | Ref | Ref | ||
| Agree | 1.33 (0.99, 1.78) | 0.060 | 1.73 (1.04, 2.89) | 0.037 |
| Neutral | 0.86 (0.62, 1.20) | 0.376 | 1.51 (0.84, 2.72) | 0.171 |
| Mode of cancer treatment | ||||
| Brain radiation | ||||
| Yes | 1.09 (0.81, 1.47) | 0.560 | ||
| No | Ref | |||
| Any chest radiation | ||||
| Yes | 0.83 (0.56, 1.23) | 0.351 | ||
| No | Ref | |||
| Any abdominal radiation | ||||
| Yes | 0.80 (0.46, 1.38) | 0.419 | ||
| No | Ref | |||
| Any pelvic radiation | ||||
| Yes | 0.78 (0.45, 1.36) | 0.388 | ||
| No | Ref | |||
| Pelvic surgery | ||||
| Yes | 0.86 (0.62, 1.19) | 0.351 | ||
| No | Ref |
Note: OR is adjusted odds ratio; Initiation: adjusted for age, sex, race, education, insurance, location, age of cancer diagnosis, recommendation from healthcare provider, fear of cancer recurrence and mode of cancer treatment (brain radiation, chest radiation, abdominal radiation, pelvic radiation, and pelvic surgery); Completion (following Children’s Oncology Group (COG) guidelines, versions 3.0 to 5.0): adjusted for age, sex, race, education, insurance, location, age of cancer diagnosis, recommendation from healthcare provider, fear of cancer recurrence.
DISCUSSION
This study examined HPV vaccination initiation and completion among CAYA cancer survivors and explored sociodemographic and cancer-specific factors influencing HPV vaccination among these cancer survivors. Our findings showed low HPV vaccination initiation and completion among cancer survivors, which is below the national Healthy People 2030 goal of 80% [7]. Further, we identified significant differences in HPV vaccination by age, sex, education level, insurance coverage, and age at cancer diagnosis among cancer survivors. Lower HPV vaccination coverage among cancer survivors is concerning, as these cancer survivors are at an elevated risk for developing HPV-related new cancers in adulthood [13, 31]. Our findings of low HPV vaccination coverage among cancer survivors are similar with those from previous studies of pediatric and young adult cancer survivors [8, 32]. However, prior studies focused only on participants aged 9 to 26 years before the updated HPV vaccination guidelines by the CDC’s ACIP in 2018 [29]. Furthermore, we identified differences in HPV vaccination based on various sociodemographic factors and cancer-specific factors.
Among sociodemographic factors, we found significant differences in HPV vaccination by sex, age, educational attainment, and insurance coverage. Female cancer survivors were more likely to initiate and complete the HPV vaccination series compared to their male counterparts. These findings align with previous studies that focused on HPV vaccination among childhood cancer survivors [22, 33]. A similar trend, where females are more likely to receive the HPV vaccination than males, is also shown in studies focusing on general populations [6]. The lower vaccination rates observed among males highlight an important opportunity for targeted interventions to improve HPV vaccination uptake in this group. Consistent educational efforts for male survivors and their caregivers may help to increase HPV vaccination coverage. Further, we found differences in HPV vaccination by age group, with older age groups being less likely to initiate HPV vaccination compared to the cancer survivors in younger age groups. These findings suggest significantly higher chances of missed opportunities for HPV vaccination during young adulthood among cancer survivors [21]. Higher missed opportunities among young cancer survivors could potentially be due to fewer HPV vaccines being offered to CAYA cancer survivors after completing the cancer-directed therapy [34]. Additionally, after the completion of cancer directed therapy, these cancer survivors transition care to local primary care providers or pediatricians in their community who might be less aware of the importance of HPV vaccination among cancer survivors [35, 36] as well as lack information about HPV vaccination guidelines specific to these vulnerable populations [19]. Findings from these studies emphasize the need for better collaboration between oncology health care providers and primary care providers, as well as consistent vaccination efforts tailored to the specific age group of cancer survivors. The challenges faced by cancer survivors may differ as they age, and cancer survivors in higher age groups might require slightly different intervention approaches compared to those in lower age groups.
Factors such as higher educational attainment and insurance coverage were positively associated with HPV vaccination initiation. This shows that higher educational attainment is more likely to increase the awareness of benefits of HPV vaccine and greater engagement with preventive healthcare, including timely initiation of HPV vaccination. Similarly, having health insurance coverage is more likely to increase access to healthcare services. However, these factors were not significantly associated with HPV vaccination completion. This could potentially be due to the lower sample size for HPV vaccination completion. Furthermore, the findings showed cancer survivors from the Northeast region were significantly more likely to initiate the HPV vaccination. The higher trend of HPV vaccination from the Northeast region aligns with trends in the general population. For example, Rhode Island, which is in the Northeast region, has the highest HPV vaccination coverage in the USA [6].
Regarding cancer specific factors, age at cancer diagnosis influenced HPV vaccination initiation. Cancer survivors whose primary cancer diagnosis occurred at an older age (aged 15-24 years) were more likely to initiate HPV vaccination than those diagnosed before age 9. This could potentially be due to greater awareness of HPV vaccination among cancer survivors who are older at diagnosis who might be more motivated to be involved in health prevention behaviors and improve their health outcomes. Additionally, the caregivers of cancer survivors could perceive vaccination as more relevant for older adolescents and young adults. In line with previous studies, cancer survivors who reported receiving the recommendation from healthcare providers had higher odds of HPV vaccination initiation [32, 37]. However, the findings from our study were not significant, possibly because healthcare providers’ advice focused generally on behaviors to reduce the risk of future cancers, rather than specifically on HPV vaccination. In the future, conducting primary data collection, including specific HPV vaccination recommendations from healthcare providers as well as timing of recommendation, is important to improve understanding of effective health messages to motivate HPV vaccine initiation and completion among CAYA cancer survivors and their caregivers. Previous studies have shown that recommendations from oncology care providers after cancer treatment help increase caregivers’ intention to have their child receive the HPV vaccine to prevent them from future HPV-related cancers [38, 39]. These data support that receiving HPV vaccine-related information from trusted sources help reduce misconceptions and concerns about potential side effects [40]. Our findings also highlight the need for more tailored strategies to improve HPV vaccine uptake, particularly among cancer survivors aged 27 and above, for whom the HPV vaccination guidelines recommend shared clinical decision-making after discussing with the health care provider. Increasing provider awareness, implementing EMR prompts, and survivor-focused outreach may improve HPV vaccine uptake among this higher age group of childhood cancer survivors. Furthermore, underutilization of primary care for cancer survivors’ follow-up care may limit opportunities for provider recommendation for HPV vaccination. Enhancing survivorship care co-ordination, including HPV vaccination, between oncology and primary care providers would be important for improving HPV vaccination coverage among CAYA cancer survivors.
The major strength of this study is the large SJLIFE sample size. Children visit SJCRH from local, state-wide, national, and international locations for pediatric cancer treatment, resulting in a diverse participant which enhances the generalizability of the study findings. We comprehensively explored both HPV vaccination initiation and completion among CAYA cancer survivors and factors influencing HPV vaccination. However, there are some limitations. First, the cross-sectional design limits us in establishing the temporal relationship between identified factors and HPV vaccination coverage among cancer survivors. Longitudinal studies would be appropriate to explore how changes over time affect the HPV vaccination coverage. This study was cross-sectional, and therefore, temporal relationships, such as the timing of doses in relation to outcomes, could not be assessed. Second, participants self-reported information regarding HPV vaccination initiation and completion, which might have introduced recall bias. Third, variability in cancer treatment protocols across time periods might have influenced HPV vaccination coverage. Fourth, interactions between variables were not evaluated; therefore, the potentially complex relationships among these variables may not be fully captured in our analyses. Despite these limitations, our study provides critical insights into the factors influencing HPV vaccination among childhood cancer survivors. This study further provides evidence to inform targeted interventions that address both sociodemographic and cancer-specific barriers to improve HPV vaccination initiation and completion among these vulnerable populations.
In conclusion, this study identified significant differences in HPV vaccination coverage by sociodemographic factors and cancer-specific factors, including age, sex, education, insurance coverage, and age at cancer diagnosis. HPV vaccination initiation and completion were significantly higher among females compared to males in both the childhood cancer survivor. Cancer survivors with higher age groups were less likely to initiate HPV vaccination. Cancer survivors with college or higher education and insurance coverage were more likely to initiate HPV vaccination. Additionally, cancer survivors diagnosed with primary cancer at older ages were more likely to report HPV vaccination initiation than those diagnosed before age nine. This study provides valuable insights into the sociodemographic and cancer-specific factors influencing HPV vaccination coverage among cancer survivors. Findings will help to guide the development of targeted strategies that address both sociodemographic and cancer-specific factors to improve HPV vaccination initiation and completion among cancer survivors following their cancer-directed therapy and reduce the burden of HPV-related infections and cancers in adulthood.
Supplementary Material
Funding
The St. Jude Lifetime (SJLIFE) Cohort Study is funded by the grant from the National Cancer Institute [U01 CA195547]. Additionally, this work was supported by the American Lebanese and Syrian Associated Charities (ALSAC) of St. Jude Children’s Research Hospital.
Footnotes
Ethics approval
This study used the data from the St. Jude Lifetime Cohort Study which is approved by the Institutional Review Board at St. Jude Children’s Research Hospital, Memphis, Tennessee.
Competing interests
The authors declare no competing interests.
Conflicts of Interest: The authors declare no conflicts of interest.
Data availability
The St. Jude Lifetime Cohort Study (SJLIFE) data are publicly available on the St. Jude Survivorship Portal within the St. Jude Cloud at https://viz.stjude.cloud/cancer-survivorship/visualization/st-jude-survivorship-portal~18. The data generated in this study will be available upon reasonable request.
References
- 1.Centers for Disease Control and Prevention. Sexually transmitted infections: about genital HPV infection. 2025. https://www.cdc.gov/sti/about/about-genital-hpv-infection.html. Accessed 12 Aug 2025.
- 2.Centers for Disease Control and Prevention. Cancers linked with HPV each year. 2025. https://www.cdc.gov/cancer/hpv/cases.html. Accessed 16 Dec 2025.
- 3.American Cancer Society. Cancers linked with HPV. 2024. https://www.cancer.org/cancer/risk-prevention/hpv/hpv-and-cancer-info.html. Accessed 17 Aug 2025.
- 4.Centers for Disease Control and Prevention. Human Papillomavirus (HPV): cancers caused by HPV. 2025. https://www.cdc.gov/hpv/about/cancers-caused-by-hpv.html. Accessed 12 Aug 2025.
- 5.Centers for Disease Control and Prevention. HPV vaccine recommendations. 2024. https://www.cdc.gov/hpv/hcp/vaccination-considerations/index.html. Accessed 12 Aug 2025.
- 6.Pingali C. Vaccination coverage among adolescents aged 13–17 years—national immunization survey–teen, United States, 2022. MMWR Morb and Mortal Wkly Rep. 2023. 10.15585/mmwr.mm7234a3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Healthy People 2030. Increase the proportion of adolescents who get recommended doses of the HPV vaccine — IID-08. (n.d). https://health.gov/healthypeople/objectives-and-data/browse-objectives/vaccination/increase-proportion-adolescents-who-get-recommended-doses-hpv-vaccine-iid-08/data. Accessed 17 Aug 2025.
- 8.Klosky JL, Hudson MM, Chen Y, Connelly JA, Wasilewski-Masker K, Sun C-L, et al. Human papillomavirus vaccination rates in young cancer survivors. J Clin Oncol. 2017;35(31):3582. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Ojha RP, Jackson BE, Tota JE, Offutt-Powell TN, Hudson MM, Gurney JG. Younger age distribution of cervical cancer incidence among survivors of pediatric and young adult cancers. Gynecol Oncol. 2014;134(2):309–13. [DOI] [PubMed] [Google Scholar]
- 10.Guilcher GM, Rivard L, Huang JT, Wright NA, Anderson L, Eissa H, et al. Immune function in childhood cancer survivors: a Children's Oncology Group review. Lancet Child Adolesc Health. 2021;5(4):284–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Teepen JC, Kremer L, Ronckers CM, Van Leeuwen FE, Hauptmann M, Dulmen-Den Broeder V, et al. Long-term risk of subsequent malignant neoplasms after treatment of childhood cancer in the DCOG LATER study cohort: role of chemotherapy. J Clin Oncol. 2017;35(20):2288–98. [DOI] [PubMed] [Google Scholar]
- 12.Ou JY, Bennion N, Parker K, Fair D, Hanson HA, Kepka D, et al. Risk Factors and Trends for HPV-Associated Subsequent Malignant Neoplasms among Adolescent and Young Adult Cancer Survivors. Cancer Epidemiol Biomarkers Prev. 2023;32(5):625–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ojha RP, Tota JE, Offutt-Powell TN, Klosky JL, Minniear TD, Jackson BE, et al. Human papillomavirus-associated subsequent malignancies among long-term survivors of pediatric and young adult cancers. PloS One. 2013;8(8):e70349. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Yeazel MW, Oeffinger KC, Gurney JG, Mertens AC, Hudson MM, Emmons KM, et al. The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Cancer. 2004;100(3):631–40. [DOI] [PubMed] [Google Scholar]
- 15.Landier W, Bhatia S, Wong FL, York JM, Flynn JS, Henneberg HM, et al. Immunogenicity and safety of the human papillomavirus vaccine in young survivors of cancer in the USA: a single-arm, open-label, phase 2, non-inferiority trial. The Lancet Child Adolesc Health. 2022;6(1):38–48. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Children's Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers - Version 6.0. 2023. http://www.survivorshipguidelines.org/. Accessed 21 Aug 2025. [DOI] [PMC free article] [PubMed]
- 17.Cherven B, Klosky JL, Keith KE, Hudson MM, Bhatia S, Landier W. Reasons for refusal of the human papillomavirus vaccine among young cancer survivors. Cancer. 2023;129(4):614–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.York JM, Klosky JL, Chen Y, Connelly JA, Wasilewski-Masker K, Giuliano AR, et al. Patient-level factors associated with lack of health care provider recommendation for the human papillomavirus vaccine among young Cancer survivors. J Clin Oncol. 2020;38(25):2892. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Waters AR, Mann K, Vaca Lopez PL, Kepka D, Wu YP, Kirchhoff AC. HPV vaccine experiences and preferences among young adult cancer survivors and caregivers of childhood cancer survivors. J Cancer Educ. 2021:1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Ramsay JM, Mann K, Kaul S, Zamora ER, Smits-Seemann RR, Kirchhoff AC. Follow-up care provider preferences of adolescent and young adult cancer survivors. J Adolesc Young Adult Oncol. 2018;7(2):204–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ramsay JM, Kaddas HK, Ou JY, Kepka D, Kirchhoff AC. Missed opportunities for concomitant HPV vaccination among childhood cancer survivors. Cancer Med. 2022;11(4):1181–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Garcia M, McGillicuddy C, Rodriguez EM, Attwood K, Schweitzer J, Coley S, et al. Human papillomavirus vaccination uptake among childhood cancer survivors in Western New York. Pediatr Blood Cancer. 2022;69(11):e29962. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Brandt HM, Kepka D, Kirchhoff AC, Daniel CL, Bhatt NS. Human papillomavirus (HPV) vaccination is cancer prevention for childhood cancer survivors. Wiley Online Library; 2022. p. 237–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Howell CR, Bjornard KL, Ness KK, Alberts N, Armstrong GT, Bhakta N, et al. Cohort profile: the St. Jude Lifetime Cohort Study (SJLIFE) for paediatric cancer survivors. Int J Epidemiol. 2021;50(1):39–49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.American Cancer Society. HPV Vaccines. 2024. https://www.cancer.org/cancer/risk-prevention/hpv/hpv-vaccines.html. Accessed 18 Sep 2025.
- 26.Zhang FF, Hudson MM, Huang IC, Bhakta N, Ness KK, Brinkman TM, et al. Lifestyle factors and health-related quality of life in adult survivors of childhood cancer: a report from the St. Jude Lifetime Cohort Study. Cancer. 2018;124(19):3918–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Tonning Olsson I, Alberts NM, Li C, Ehrhardt MJ, Mulrooney DA, Liu W, et al. Pain and functional outcomes in adult survivors of childhood cancer: a report from the St. Jude Lifetime Cohort study. Cancer. 2021;127(10):1679–89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Markowitz LE, Dunne EF, Saraiya M, Chesson HW, Curtis CR, Gee J, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(Rr-05):1–30. [PubMed] [Google Scholar]
- 29.Meites E. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019. 10.15585/mmwr.mm6832a3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Delwiche LD, Slaughter SJ. The little SAS book: a primer. 6th ed. Cary, NC: SAS institute Inc; 2019. [Google Scholar]
- 31.Henderson TO, Fowler BW, Hamann HA, Nathan PC, Whitton J, Leisenring WM, et al. Subsequent malignant neoplasms in the Childhood Cancer Survivor Study: Occurrence of cancer types in which human papillomavirus is an established etiologic risk factor. Cancer. 2022;128(2):373–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Klosky JL, Favaro B, Peck KR, Simmons JL, Russell KM, Green DM, et al. Prevalence and predictors of human papillomavirus (HPV) vaccination among young women surviving childhood cancer. J Cancer Surviv. 2016;10:449–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Castellino SM, Allen KE, Pleasant K, Keyes G, Poehling KA, Tooze JA. Suboptimal uptake of human papillomavirus (HPV) vaccine in survivors of childhood and adolescent and young adult (AYA) cancer. J Cancer Surviv. 2019;13:730–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Kacew AJ, Jacobson S, Sheade J, Patel AA, Hlubocky FJ, Lee NK, et al. Provider-level barriers to human papillomavirus vaccination in survivors of childhood and young adult cancers. J Adolesc Young Adult Oncol. 2022;11(3):284–9. [DOI] [PubMed] [Google Scholar]
- 35.Hofstetter AM, Lappetito L, Stockwell MS, Rosenthal SL. Human papillomavirus vaccination of adolescents with chronic medical conditions: a national survey of pediatric subspecialists. J Pediatr Adolesc Gynecol. 2017;30(1):88–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Miller ME, Rahim MQ, Coven SL, Jacob SA, Zimet GD, Meagher CG, et al. Pediatric hematology and oncology physician and nurse practitioner views of the HPV vaccine and barriers to administration. Hum Vaccin Immunother. 2023;19(2):2224089. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Klosky JL, Russell KM, Simmons JL, Foster RH, Peck K, Green DM, et al. Medical and sociodemographic factors associated with human papillomavirus (HPV) vaccination adherence among female survivors of childhood cancer. Pediatr Blood Cancer. 2015;62(9):1630–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Kirchhoff AC, Mann K, Warner EL, Kaddas HK, Fair D, Fluchel M, et al. HPV vaccination knowledge, intentions, and practices among caregivers of childhood cancer survivors. Hum Vaccin Immunother. 2019;15(7-8):1767–75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Warner EL, Vaca Lopez PL, Kepka D, Mann K, Kaddas HK, Fair D, et al. Influence of provider recommendations to restart vaccines after childhood cancer on caregiver intention to vaccinate. J Cancer Surviv. 2020;14:757–67. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Rahim MQ, Jacob SA, Coven SL, Miller M, Meagher CG, Lozano G, et al. Identifying barriers to HPV vaccination for patients with sickle cell disease and childhood cancer survivors. J Pediatr Hematol Oncol. 2023;45(8):e940–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The St. Jude Lifetime Cohort Study (SJLIFE) data are publicly available on the St. Jude Survivorship Portal within the St. Jude Cloud at https://viz.stjude.cloud/cancer-survivorship/visualization/st-jude-survivorship-portal~18. The data generated in this study will be available upon reasonable request.