Increasing HPV Vaccination Coverage Among Adolescent and Young Adult (AYA) Cancer Survivors: A Multilevel Intervention
Abstract
Among long-term (>5 years) adolescent and young adult cancer survivors, secondary cancers are a leading cause of early death. Specifically, adolescent and young adult cancer survivors are 2.8 times more likely to develop a secondary human papillomavirus (HPV)-associated malignancy, including anal, cervical, oropharyngeal, penile, vaginal, and vulvar cancers. Thus, National Comprehensive Cancer Network Adolescent and Young Adult Oncology guidelines recommend 3 doses of HPV vaccine for male and female adolescent and young adult cancer survivors 9-26 years of age. Despite these recommendations, studies from our group and others show HPV vaccination coverage among adolescent and young adult cancer survivors is even lower than that among the general population at approximately 24%. Using the Fogg Behavior Model as a theoretic guide (achieving a desired behavior is dependent on motivation, ability, and a trigger), we propose a patient-level randomized controlled trial of a game-based mobile educational app intervention coupled with oncologist- and clinic-level quality improvement interventions to increase HPV vaccination coverage (initiation and 3-dose completion) to prevent secondary malignancy among adolescent and young adult cancer survivors. Advancements in childhood cancer treatments have resulted in 84% of children and adolescents diagnosed with cancer surviving >5 years. While risk of dying from the original malignancy is significantly decreased, the treatments used to induce this “permanent survival” increase the risk of other long-term health risks. Almost all individuals are infected with HPV during their lifetime, but the immunosuppressive regimens used for cancer treatment increase the risk of persistent HPV infection and thus cancer. Further, although secondary prevention in the form of screening and treatment of pre-cancerous lesions of the cervix, anus, and lower genital tract exist, these treatments due not cure the underlying HPV, and thus cancer survivors are at high risk of recurrent disease, requiring multiple treatments resulting in decreased quality of life due to anxiety, anatomic disfigurement, and/or sexual dysfunction. Additionally, secondary prevention is only effective for those who have healthcare access to screening and treatment, and secondary prevention methods do not currently exist for oropharyngeal cancer, currently the most prevalent HPV-associated cancer. We propose implementation of a training program for oncologists and clinic staff in an adolescent and young adult survivorship clinic to trigger vaccination through a strong and presumptive recommendation, which has been shown to be the strongest predictor for HPV vaccination uptake in primary care clinics. Secondly, we propose developing a clinic workflow incorporating the electronic health record, clinic staff and clinic pharmacist to routinely administer the HPV vaccine in the survivorship clinic to improve ability to access the vaccine, and electronic health record-generated reminders to trigger subsequent doses. These interventions will be implemented via a quality improvement initiative, as it was deemed unethical to randomize patients to a study arm without these interventions due to evidence of efficacy in the primary care setting. Lastly, we propose a randomized controlled clinical trial to test a game-based educational app to increase motivation to vaccinate pre-clinic visit, and app-based messaging to trigger subsequent doses with links to locations where the HPV vaccine can be administered to increase ability to complete the vaccine series. Lastly, we will test the effect of motivation through electronic rewards and competition with other anonymous app users. The primary endpoints of this study are HPV vaccination initiation and 3-dose completion. The study is not powered to measure a decrease in cervical and anogenital tract dysplasia (pre-cancerous lesions) or cancer, but increase in HPV vaccination coverage is anticipated
Document Details
- Document Type
- DoD Grant Award
- Publication Date
- Dec 05, 2021
- Source ID
- W81XWH2110347
Entities
People
- Deanna Teoh
Organizations
- United States Army
- University of Minnesota