- Email: [email protected]
Human Papillomavirus Vaccination in Female Pediatric Cancer Survivors
Original Study Human Papillomavirus Vaccination in Female Pediatric Cancer Survivors Lindsey Hoffman DO, MS *, M. Fatih Okcu MD, MPH, ZoAnn E. Dreyer MD, Hilary Suzawa MD, Rosalind Bryant PhD, RN-CS, PNP, Amy B. Middleman MD, MPH, MSEd Department of Pediatrics, Baylor College of Medicine, Houston, Texas
a b s t r a c t Study Objective: Survivors of childhood malignancy may be at increased risk for HPV infection for biological and cognitive/behavioral reasons. HPV vaccination is currently recommended for females 11-12 years old with catch up vaccination up to age 26 years. The objective of this cross-sectional study was to determine the prevalence of HPV vaccination among female pediatric cancer survivors, age 11-18 years, at Texas Children's Hospital. Study Design, Setting, and Participants: A 42-question survey was distributed to parents/guardians of 172 long-term cancer survivors from August-November of 2010. Data were analyzed using frequencies, t-tests, and chi-square analyses. Main Outcome Measures: Prevalence of HPV vaccination (intention and completion). Results: Sixty-six persons (38%) responded. The median current age of survivors was 14 years. Most were white/non-Hispanic (48%) or white/Hispanic (37%). Seventy-one percent had discussed HPV vaccination with a healthcare provider. The overall rate of HPV vaccination ($ 1 dose) was 32%, including 5% of those age 11-12 years (n 5 1 of 21), 36% of those age 13-17 years (n 5 13 of 36), and 78% of those age 18 years (n 5 7 of 9). Of those whose children had not been immunized, 36% intended to do so in the future. Factors associated with HPV vaccination included age $13 years, report of sexual activity, and report of having discussed HPV vaccination with a healthcare provider. Conclusion: The rate of HPV vaccination among female pediatric cancer survivors is not appreciably different than that seen in the general population. Key Words: Human papillomavirus, Vaccine, Cancer, Pediatric
Introduction
Methods
Human papillomavirus (HPV) is the most common sexually transmitted infection, reaching a lifetime prevalence of almost 80% in sexually active women.1 Persistence of HPV in patients with chronic immunosuppression, such as those with HIV infection and those who have undergone solid organ transplant, leads to increased morbidity and mortality from HPV-related diseases.2 HPV-related secondary malignancy in cancer survivors has been detailed most extensively in adult patients who have undergone hematopoietic stem cell transplantation2; similar data in pediatric survivors are very limited. Factors that may contribute to increased risk for and morbidity from HPV in children and adolescents who survive malignancy include immunosuppression secondary to disease state or treatment regimen, cognitive-behavioral risk factors, and demographic factors.1 HPV vaccination is currently recommended for female adolescents age 11 through 12 years old, with catch-up vaccination through age 26 years. The primary aim of this study was to determine the prevalence of HPV vaccination (intention and initiation) among female pediatric cancer survivors, age 11-18 years, at a large children's hospital in Texas.
A 42-question survey was distributed to parents/guardians of female pediatric cancer survivors (defined as $ 5 years from diagnosis and $ 2 years off therapy), age 11-18 years, at Texas Children's Hospital from August to November of 2010. Of 186 potential participants, 14 had inaccurate contact information, rendering them ineligible. Questionnaires were provided in English and Spanish to the remaining 172 potential participants. Informed consent was inferred by return of a completed questionnaire. This study was approved by the Institutional Review Board at Baylor College of Medicine. Our primary dependent variable was prevalence of HPV vaccination (intention and completion). Independent variables included type of cancer and cancer therapy, utilization of medical care, education history, sexual history, demographic information including religion, HPV knowledge, and beliefs about HPV vaccination. Descriptive statistics were calculated for all variables, and 2-sample t-test, Fisher exact test, and chi-square analyses were used to determine the association of independent variables to vaccination status and intention to vaccinate. Analyses comparing independent variables against intention and completion of vaccination did not vary significantly from comparisons of vaccination status alone. For ease of reporting, only results comparing ‘vaccinated’ versus ‘not vaccinated’ are noted. Analyses did not include those who were ‘not sure’ of their vaccination status (n 5 6; 9%). A 2-sided P-value !.05 was considered statistically significant. Data were analyzed using SPSS version 18.0 (SPSS Inc, Chicago, IL).
The authors indicate no conflict of interest. * Address correspondence to: Lindsey Hoffman, DO, MS, 7420 East 22nd Ave, Denver, CO 80207; Phone: (720) 425-3761; Fax: (832) 825-9302 E-mail address: [email protected] (L. Hoffman).
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2012.05.004
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L. Hoffman et al. / J Pediatr Adolesc Gynecol 25 (2012) 305e307
5 (8%) chose to have their children immunized for reasons including the following: “original cancer caused by a virus” (child diagnosed with Hodgkin lymphoma), “am cautious about what is ahead”, and “we want to prevent any other cancer if possible”. The average knowledge score did not differ significantly among those who had been vaccinated (5.5, SD 2.46) or had not been vaccinated (5.1, SD 2.88).
Results
Sixty-six of 172 potential participants (38%) returned a completed questionnaire. Patient characteristics are listed in Table 1. The overall rate of HPV vaccination was 32% (n 5 21 of 66). Vaccination was significantly associated with age $13 years (P 5 .002) (Table 2), report of sexual activity (P 5 .001), and parental report of discussion about HPV vaccination with a healthcare provider (P 5 .003). Neither cancer diagnosis nor treatment was associated with HPV vaccination status. Eight study participants (12%) reported that their child's cancer diagnosis affected their decision regarding HPV vaccination; 3 (5%) declined vaccination, citing hesitancy about vaccine safety and side effects, and
Discussion
Morbidity and mortality from HPV-related disease are disproportionately high among immunosuppressed individuals. Though long-term sequelae of HPV infection in survivors of childhood cancer have not been fully
Table 1 Characteristics of Respondents Based on HPV Vaccination Status Characteristics
Frequency N (%)
Current Age (years) 11e12 13e17 18 Age at Diagnosis (years) #5 6 to 10 11 to 13 Cancer Diagnosis Leukemia Hodgkin lymphoma Non-Hodgkin lymphoma Brain/spine tumor Kidney tumor Neuroblastoma Soft tissue sarcoma Other Cancer Therapy Chemotherapy Radiation Surgery HSCT Household Income # $19,999 $20,000 or above Insurance Coverage Medicaid Private Insurance Race White/Non-Hispanic White/Hispanic Black Asian Other Religion Catholic Protestant Jewish Buddhist/Hindu Other Not religious Seen PCP in last year Yes No Discussed HPV vaccine with provider Yes No Sexual Activity Yes No Cancer diagnosis affected vaccine decision Yes No
Vaccinated (n 5 21) Mean (SD)
N (%)
15.9 (2.0) 21 (32) 36 (55) 9 (14)
.002 16 (41) 20 (51.2) 2 (5.1)
3.6 (3.2) 13 (61.9) 6 (28.5) 2 (9.5)
P-value
N (%)
13.6 (2.2) 1 (4.8) 13 (61.9) 7 (33.3)
4.9 (3.8) 41 (62) 16 (24) 3 (5)
Not Vaccinated (n 5 39) Mean (SD)
.372 29 (74.3) 8 (20.5) 1 (2.6) .753
31 3 6 6 9 4 2 5
(47) (5) (9) (9) (14) (6) (3) (8)
60 22 25 2
(91) (33) (38) (3)
9 2 2 2 3
(42.8) (9.5) (9.5) (9.5) (14.2) 0 1 (4.7) 2 (9.5)
20 1 3 3 4 4 1 3
(51.2) (2.5) (7.7) (7.7) (10.2) (10.2) (2.5) (7.7)
19 (91) 7 (33) 10 (48) 0
35 12 12 2
(90) (31) (31) (5)
12 (18) 53 (80)
1 (4.8) 20 (95.2)
10 (26.3) 28 (73.7)
19 (29) 46 (70)
4 (19) 18 (9)
10 (26) 24 (62)
31 23 6 3 2
(47) (35) (9) (5) (3)
14 (66.7) 6 (28.6) 0 0 1 (4.8)
15 15 5 2 1
(39.5) (39.5) (13.2) (5.3) (4.8)
24 33 1 1 3 3
(36) (50) (2) (2) (5) (5)
8 (38.1) 12 (57.1) 0 0 0 1 (4.8)
16 16 1 1 3 1
(42.1) (42.1) (2.6) (2.6) (7.9) (2.6)
59 (89) 6 (9)
19 (90.4) 2 (9.6)
36 (92.3) 3 (7.7)
47 (71) 14 (21)
21 (100) 0
23 (59) 13 (33.3)
5 (8) 59 (89)
5 (23.8) 15 (71.4)
0 38 (97.4)
8 (12) 47 (71)
5 (23.8) 18 (85.7)
3 (7.7) 29 (74.3)
.928 .839 .196 .291 .042
.495 .088 .163
.602
.807
.003
.001
.230
L. Hoffman et al. / J Pediatr Adolesc Gynecol 25 (2012) 305e307 Table 2 Intention and Completion of HPV Vaccination Based on Age Age Group
$ 1 Injection N (%)
3 Injections N (%)
Intend to Vaccinate N (%)
11-12 13-17 18
1/21 (5) 13/36 (39) 7/9 (78)
0 7/36 (19) 5/9 (56)
5/21 (24) 9/36 (25) 0
elucidated, immune dysfunction at various stages of malignancy and associated with cancer treatment likely confer increased risk for HPV disease. This cross-sectional study revealed that 32% of cancer survivors, including 36% of those 13-17 years old, had received at least 1 dose of HPV vaccine. For comparison, the National Immunization Survey-Teen reported that 44.3% of females aged 13-17 years had received at least 1 dose of HPV vaccine in 2009.3 Although this study represents only a small sample, it is concerning that the prevalence of HPV vaccination among the potentially more vulnerable survivor population is not higher. In contrast to Advisory Committee on Immunization Practices recommendations to initiate HPV vaccination in females age 11-12 years, cancer survivors $ 13 years old were significantly more likely than their younger counterparts to have begun the HPV vaccine series. These data are consistent with other studies which indicate that for a variety of reasons, HPV vaccination is often initiated after the recommended age.4 Because an estimated 61% of high school students have had sex by the 12th grade, including nearly 6% who initiate sexual activity before age 13 years,5 and because HPV is often acquired within months of the first sexual encounter, this finding indicates an important area for improvement in reducing the prevalence of HPV among pediatric cancer survivors. Nearly 8% of parents/guardians in this study reported knowledge of sexual activity by their child, which correlated significantly with the child having received at least 1 dose of HPV vaccine. Factors influencing sexual behavior in pediatric cancer survivors may be different from those seen among their peers, including the possibility of delayed social development as a consequence of their cancer diagnosis and treatment. van Dijk et al concluded that among a cohort of 60 childhood cancer survivors, those age 25 years or older had less sexual experience than their agematched peers.6 Other data, however, suggest that survivors may be at higher risk for acquiring sexually transmitted infections because of riskier sexual practices. Zebrack et al found that survivors who perceived themselves as infertile as a consequence of their cancer treatment reported using contraception less often and engaging in more sexual experimentation.7 Also, up to 40% of childhood cancer survivors suffer treatment-related neuro-cognitive deficit, most commonly affecting concentration and attention.1 In the general population, attention deficit disorder and attention deficit/hyperactivity disorder (ADD/ADHD) has been associated with early age of sexual debut and an
307
increasing number of sexual partners, both of which increase lifetime risk of acquiring HPV. The incidence of ADD/ADHD in this study was 5%, too low to determine any significant associations. Physician recommendation has been strongly linked to parent/patient decision to obtain many vaccines, including the HPV vaccine.4 In our study, parents/guardians of survivors who had discussed HPV vaccination with a healthcare provider were more likely to have their child vaccinated, emphasizing the importance of provider input. Another potentially important factor in the decision to obtain HPV vaccination among parents of cancer survivors is ‘perceived risk’, which has been correlated positively with HPV vaccination in the general population and may hold even greater influence in pediatric survivors. Data from the Childhood Cancer Survivor Study indicate that ‘perceived vulnerability’ among families of survivors affects medical decisions and survivors' overall interaction with the medical community.8 In this study, 8 parents/guardians (12%) reported that their child's history of cancer affected their decision regarding HPV vaccination, 5 in favor of and 3 against vaccination. Though this finding did not reach the level of statistical significance, it is important to recognize that survivors and families may relate their personal or family cancer history with the decision to obtain or refuse this ‘cancer preventing’ vaccination. Despite its limitations, which include small sample size and low response rate, this study preserves its relevance as the first to quantify and describe factors associated with HPV vaccination among female survivors of childhood cancer. Data from this study indicate that the prevalence of HPV vaccination among survivors is similar to that seen in the general population, emphasizing the need to more aggressively screen and immunize this particularly vulnerable population. Future directions include recruiting greater participation by including survivors at multiple institutions and long term follow-up to determine the incidence of HPV vaccination in survivors over time, with particular focus on the influence of primary care provider and subspecialist recommendation of the HPV vaccine. References 1. Klosky JL, Gamble HL, Spunt SL, et al: Human papillomavirus vaccination in survivors of childhood cancer. Cancer 2009; 115:5627 2. Malouf MA, Hopkins PM, Singleton L, et al: Sexual health issues after lung transplantation: importance of cervical screening. J Heart Lung Transplant 2004; 23:894 3. Centers for Disease Control and Prevention (CDC): National, state, and local area vaccination coverage among adolescents age 13-17 yearsdUnited States, 2009. MMWR Morb Mortal Wkly Rep 2010; 59(32):1018 4. Guerry SL, De Rosa CJ, Markowitz LE, et al: Human papillomavirus vaccine initiation among adolescent girls in high-risk communities. Vaccine 2011; 29:2235 5. Eaton DK, Kann L, Kinchen S, et al: Youth risk behavior surveillanceeUnited States, 2009. MMWR Surveill Summ 2010; 59:1 6. van Dijk EM, van Dulmen-den Broeder E, Kaspers GJ, et al: Psychosexual functioning of childhood cancer survivors. Psychooncology 2008; 17:506 7. Zebrack BJ, Casillas J, Nohr L, et al: Fertility issues for young adult survivors of childhood cancer. Psychooncology 2004; 13:689 8. Yeazel MW, Oeffinger KC, Gurney JG, et al: The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Cancer 2004; 100:631
a b s t r a c t Study Objective: Survivors of childhood malignancy may be at increased risk for HPV infection for biological and cognitive/behavioral reasons. HPV vaccination is currently recommended for females 11-12 years old with catch up vaccination up to age 26 years. The objective of this cross-sectional study was to determine the prevalence of HPV vaccination among female pediatric cancer survivors, age 11-18 years, at Texas Children's Hospital. Study Design, Setting, and Participants: A 42-question survey was distributed to parents/guardians of 172 long-term cancer survivors from August-November of 2010. Data were analyzed using frequencies, t-tests, and chi-square analyses. Main Outcome Measures: Prevalence of HPV vaccination (intention and completion). Results: Sixty-six persons (38%) responded. The median current age of survivors was 14 years. Most were white/non-Hispanic (48%) or white/Hispanic (37%). Seventy-one percent had discussed HPV vaccination with a healthcare provider. The overall rate of HPV vaccination ($ 1 dose) was 32%, including 5% of those age 11-12 years (n 5 1 of 21), 36% of those age 13-17 years (n 5 13 of 36), and 78% of those age 18 years (n 5 7 of 9). Of those whose children had not been immunized, 36% intended to do so in the future. Factors associated with HPV vaccination included age $13 years, report of sexual activity, and report of having discussed HPV vaccination with a healthcare provider. Conclusion: The rate of HPV vaccination among female pediatric cancer survivors is not appreciably different than that seen in the general population. Key Words: Human papillomavirus, Vaccine, Cancer, Pediatric
Introduction
Methods
Human papillomavirus (HPV) is the most common sexually transmitted infection, reaching a lifetime prevalence of almost 80% in sexually active women.1 Persistence of HPV in patients with chronic immunosuppression, such as those with HIV infection and those who have undergone solid organ transplant, leads to increased morbidity and mortality from HPV-related diseases.2 HPV-related secondary malignancy in cancer survivors has been detailed most extensively in adult patients who have undergone hematopoietic stem cell transplantation2; similar data in pediatric survivors are very limited. Factors that may contribute to increased risk for and morbidity from HPV in children and adolescents who survive malignancy include immunosuppression secondary to disease state or treatment regimen, cognitive-behavioral risk factors, and demographic factors.1 HPV vaccination is currently recommended for female adolescents age 11 through 12 years old, with catch-up vaccination through age 26 years. The primary aim of this study was to determine the prevalence of HPV vaccination (intention and initiation) among female pediatric cancer survivors, age 11-18 years, at a large children's hospital in Texas.
A 42-question survey was distributed to parents/guardians of female pediatric cancer survivors (defined as $ 5 years from diagnosis and $ 2 years off therapy), age 11-18 years, at Texas Children's Hospital from August to November of 2010. Of 186 potential participants, 14 had inaccurate contact information, rendering them ineligible. Questionnaires were provided in English and Spanish to the remaining 172 potential participants. Informed consent was inferred by return of a completed questionnaire. This study was approved by the Institutional Review Board at Baylor College of Medicine. Our primary dependent variable was prevalence of HPV vaccination (intention and completion). Independent variables included type of cancer and cancer therapy, utilization of medical care, education history, sexual history, demographic information including religion, HPV knowledge, and beliefs about HPV vaccination. Descriptive statistics were calculated for all variables, and 2-sample t-test, Fisher exact test, and chi-square analyses were used to determine the association of independent variables to vaccination status and intention to vaccinate. Analyses comparing independent variables against intention and completion of vaccination did not vary significantly from comparisons of vaccination status alone. For ease of reporting, only results comparing ‘vaccinated’ versus ‘not vaccinated’ are noted. Analyses did not include those who were ‘not sure’ of their vaccination status (n 5 6; 9%). A 2-sided P-value !.05 was considered statistically significant. Data were analyzed using SPSS version 18.0 (SPSS Inc, Chicago, IL).
The authors indicate no conflict of interest. * Address correspondence to: Lindsey Hoffman, DO, MS, 7420 East 22nd Ave, Denver, CO 80207; Phone: (720) 425-3761; Fax: (832) 825-9302 E-mail address: [email protected] (L. Hoffman).
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2012.05.004
306
L. Hoffman et al. / J Pediatr Adolesc Gynecol 25 (2012) 305e307
5 (8%) chose to have their children immunized for reasons including the following: “original cancer caused by a virus” (child diagnosed with Hodgkin lymphoma), “am cautious about what is ahead”, and “we want to prevent any other cancer if possible”. The average knowledge score did not differ significantly among those who had been vaccinated (5.5, SD 2.46) or had not been vaccinated (5.1, SD 2.88).
Results
Sixty-six of 172 potential participants (38%) returned a completed questionnaire. Patient characteristics are listed in Table 1. The overall rate of HPV vaccination was 32% (n 5 21 of 66). Vaccination was significantly associated with age $13 years (P 5 .002) (Table 2), report of sexual activity (P 5 .001), and parental report of discussion about HPV vaccination with a healthcare provider (P 5 .003). Neither cancer diagnosis nor treatment was associated with HPV vaccination status. Eight study participants (12%) reported that their child's cancer diagnosis affected their decision regarding HPV vaccination; 3 (5%) declined vaccination, citing hesitancy about vaccine safety and side effects, and
Discussion
Morbidity and mortality from HPV-related disease are disproportionately high among immunosuppressed individuals. Though long-term sequelae of HPV infection in survivors of childhood cancer have not been fully
Table 1 Characteristics of Respondents Based on HPV Vaccination Status Characteristics
Frequency N (%)
Current Age (years) 11e12 13e17 18 Age at Diagnosis (years) #5 6 to 10 11 to 13 Cancer Diagnosis Leukemia Hodgkin lymphoma Non-Hodgkin lymphoma Brain/spine tumor Kidney tumor Neuroblastoma Soft tissue sarcoma Other Cancer Therapy Chemotherapy Radiation Surgery HSCT Household Income # $19,999 $20,000 or above Insurance Coverage Medicaid Private Insurance Race White/Non-Hispanic White/Hispanic Black Asian Other Religion Catholic Protestant Jewish Buddhist/Hindu Other Not religious Seen PCP in last year Yes No Discussed HPV vaccine with provider Yes No Sexual Activity Yes No Cancer diagnosis affected vaccine decision Yes No
Vaccinated (n 5 21) Mean (SD)
N (%)
15.9 (2.0) 21 (32) 36 (55) 9 (14)
.002 16 (41) 20 (51.2) 2 (5.1)
3.6 (3.2) 13 (61.9) 6 (28.5) 2 (9.5)
P-value
N (%)
13.6 (2.2) 1 (4.8) 13 (61.9) 7 (33.3)
4.9 (3.8) 41 (62) 16 (24) 3 (5)
Not Vaccinated (n 5 39) Mean (SD)
.372 29 (74.3) 8 (20.5) 1 (2.6) .753
31 3 6 6 9 4 2 5
(47) (5) (9) (9) (14) (6) (3) (8)
60 22 25 2
(91) (33) (38) (3)
9 2 2 2 3
(42.8) (9.5) (9.5) (9.5) (14.2) 0 1 (4.7) 2 (9.5)
20 1 3 3 4 4 1 3
(51.2) (2.5) (7.7) (7.7) (10.2) (10.2) (2.5) (7.7)
19 (91) 7 (33) 10 (48) 0
35 12 12 2
(90) (31) (31) (5)
12 (18) 53 (80)
1 (4.8) 20 (95.2)
10 (26.3) 28 (73.7)
19 (29) 46 (70)
4 (19) 18 (9)
10 (26) 24 (62)
31 23 6 3 2
(47) (35) (9) (5) (3)
14 (66.7) 6 (28.6) 0 0 1 (4.8)
15 15 5 2 1
(39.5) (39.5) (13.2) (5.3) (4.8)
24 33 1 1 3 3
(36) (50) (2) (2) (5) (5)
8 (38.1) 12 (57.1) 0 0 0 1 (4.8)
16 16 1 1 3 1
(42.1) (42.1) (2.6) (2.6) (7.9) (2.6)
59 (89) 6 (9)
19 (90.4) 2 (9.6)
36 (92.3) 3 (7.7)
47 (71) 14 (21)
21 (100) 0
23 (59) 13 (33.3)
5 (8) 59 (89)
5 (23.8) 15 (71.4)
0 38 (97.4)
8 (12) 47 (71)
5 (23.8) 18 (85.7)
3 (7.7) 29 (74.3)
.928 .839 .196 .291 .042
.495 .088 .163
.602
.807
.003
.001
.230
L. Hoffman et al. / J Pediatr Adolesc Gynecol 25 (2012) 305e307 Table 2 Intention and Completion of HPV Vaccination Based on Age Age Group
$ 1 Injection N (%)
3 Injections N (%)
Intend to Vaccinate N (%)
11-12 13-17 18
1/21 (5) 13/36 (39) 7/9 (78)
0 7/36 (19) 5/9 (56)
5/21 (24) 9/36 (25) 0
elucidated, immune dysfunction at various stages of malignancy and associated with cancer treatment likely confer increased risk for HPV disease. This cross-sectional study revealed that 32% of cancer survivors, including 36% of those 13-17 years old, had received at least 1 dose of HPV vaccine. For comparison, the National Immunization Survey-Teen reported that 44.3% of females aged 13-17 years had received at least 1 dose of HPV vaccine in 2009.3 Although this study represents only a small sample, it is concerning that the prevalence of HPV vaccination among the potentially more vulnerable survivor population is not higher. In contrast to Advisory Committee on Immunization Practices recommendations to initiate HPV vaccination in females age 11-12 years, cancer survivors $ 13 years old were significantly more likely than their younger counterparts to have begun the HPV vaccine series. These data are consistent with other studies which indicate that for a variety of reasons, HPV vaccination is often initiated after the recommended age.4 Because an estimated 61% of high school students have had sex by the 12th grade, including nearly 6% who initiate sexual activity before age 13 years,5 and because HPV is often acquired within months of the first sexual encounter, this finding indicates an important area for improvement in reducing the prevalence of HPV among pediatric cancer survivors. Nearly 8% of parents/guardians in this study reported knowledge of sexual activity by their child, which correlated significantly with the child having received at least 1 dose of HPV vaccine. Factors influencing sexual behavior in pediatric cancer survivors may be different from those seen among their peers, including the possibility of delayed social development as a consequence of their cancer diagnosis and treatment. van Dijk et al concluded that among a cohort of 60 childhood cancer survivors, those age 25 years or older had less sexual experience than their agematched peers.6 Other data, however, suggest that survivors may be at higher risk for acquiring sexually transmitted infections because of riskier sexual practices. Zebrack et al found that survivors who perceived themselves as infertile as a consequence of their cancer treatment reported using contraception less often and engaging in more sexual experimentation.7 Also, up to 40% of childhood cancer survivors suffer treatment-related neuro-cognitive deficit, most commonly affecting concentration and attention.1 In the general population, attention deficit disorder and attention deficit/hyperactivity disorder (ADD/ADHD) has been associated with early age of sexual debut and an
307
increasing number of sexual partners, both of which increase lifetime risk of acquiring HPV. The incidence of ADD/ADHD in this study was 5%, too low to determine any significant associations. Physician recommendation has been strongly linked to parent/patient decision to obtain many vaccines, including the HPV vaccine.4 In our study, parents/guardians of survivors who had discussed HPV vaccination with a healthcare provider were more likely to have their child vaccinated, emphasizing the importance of provider input. Another potentially important factor in the decision to obtain HPV vaccination among parents of cancer survivors is ‘perceived risk’, which has been correlated positively with HPV vaccination in the general population and may hold even greater influence in pediatric survivors. Data from the Childhood Cancer Survivor Study indicate that ‘perceived vulnerability’ among families of survivors affects medical decisions and survivors' overall interaction with the medical community.8 In this study, 8 parents/guardians (12%) reported that their child's history of cancer affected their decision regarding HPV vaccination, 5 in favor of and 3 against vaccination. Though this finding did not reach the level of statistical significance, it is important to recognize that survivors and families may relate their personal or family cancer history with the decision to obtain or refuse this ‘cancer preventing’ vaccination. Despite its limitations, which include small sample size and low response rate, this study preserves its relevance as the first to quantify and describe factors associated with HPV vaccination among female survivors of childhood cancer. Data from this study indicate that the prevalence of HPV vaccination among survivors is similar to that seen in the general population, emphasizing the need to more aggressively screen and immunize this particularly vulnerable population. Future directions include recruiting greater participation by including survivors at multiple institutions and long term follow-up to determine the incidence of HPV vaccination in survivors over time, with particular focus on the influence of primary care provider and subspecialist recommendation of the HPV vaccine. References 1. Klosky JL, Gamble HL, Spunt SL, et al: Human papillomavirus vaccination in survivors of childhood cancer. Cancer 2009; 115:5627 2. Malouf MA, Hopkins PM, Singleton L, et al: Sexual health issues after lung transplantation: importance of cervical screening. J Heart Lung Transplant 2004; 23:894 3. Centers for Disease Control and Prevention (CDC): National, state, and local area vaccination coverage among adolescents age 13-17 yearsdUnited States, 2009. MMWR Morb Mortal Wkly Rep 2010; 59(32):1018 4. Guerry SL, De Rosa CJ, Markowitz LE, et al: Human papillomavirus vaccine initiation among adolescent girls in high-risk communities. Vaccine 2011; 29:2235 5. Eaton DK, Kann L, Kinchen S, et al: Youth risk behavior surveillanceeUnited States, 2009. MMWR Surveill Summ 2010; 59:1 6. van Dijk EM, van Dulmen-den Broeder E, Kaspers GJ, et al: Psychosexual functioning of childhood cancer survivors. Psychooncology 2008; 17:506 7. Zebrack BJ, Casillas J, Nohr L, et al: Fertility issues for young adult survivors of childhood cancer. Psychooncology 2004; 13:689 8. Yeazel MW, Oeffinger KC, Gurney JG, et al: The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Cancer 2004; 100:631