Factors associated with parental human papillomavirus vaccination intentions among adolescents from socioeconomically advantaged versus deprived households: a nationwide, cross-sectional survey.

Background: In the USA, HPV vaccine coverage is substantially lower among adolescents from high-income households compared to their low-income counterparts. We examined and compared the factors associated with parental HPV vaccination intentions between socioeconomically divergent groups. Methods: Data from unvaccinated and not fully HPV-vaccinated adolescents from the 2017-2021 National Immunization Survey (NIS)-Teen were analyzed. Socioeconomically advantaged vs. deprived groups were identified based on dichotomized income (material capital) and education (social capital). Parental intent to initiate and complete the HPV vaccine series was compared using bivariable analysis and the factors associated with lacking intent were identified. Findings: The 2017-2021 NIS-Teen included a total of 212,643 participants; the final analytical sample consisted of 105,958 adolescents (an estimated 10.3 million adolescents) who were unvaccinated or not fully vaccinated. In the advantaged group, 64.7% of parents of unvaccinated adolescents (equating to 2.4 million US adolescents) had no intention to initiate the HPV vaccine compared to 40.9% of parents in the deprived group (equating to 0.2 million adolescents) (P < 0.0001; S > 13.29). The most frequent reason for lacking intent in the advantaged group was 'safety concerns' (25.5%). In the deprived group, 'lack of knowledge', 'not recommended', and 'not needed' were common reasons (nearly 15% each). Lack of intent to complete the HPV vaccine series was higher in the advantaged group (43.9%; 1.1 million adolescents) compared to the deprived group (25.2%; 0.08 million adolescents) (P < 0.0001; S > 13.29). More than half in the advantaged group (58.4%) and over a third (37.1%) in the deprived group cited 'already up to date' as the main reason for not completing the HPV vaccine series. Interpretation: Lack of intent to initiate and complete the HPV vaccination series, particularly among socioeconomically advantaged parents is a significant barrier to achieving the national goal in the USA. Funding: The US National Institute on Minority Health and Health Disparities, the National Center for Advancing Translational Sciences, MUSC Hollings Cancer Center Seed funding, and the US National Cancer Institutes.

Interventions addressing health-related social needs among patients with cancer.

Health-related social needs are prevalent among cancer patients; associated with substantial negative health consequences; and drive pervasive inequities in cancer incidence, severity, treatment choices and decisions, and outcomes. To address the lack of clinical trial evidence to guide health-related social needs interventions among cancer patients, the National Cancer Institute Cancer Care Delivery Research Steering Committee convened experts to participate in a clinical trials planning meeting with the goal of designing studies to screen for and address health-related social needs among cancer patients. In this commentary, we discuss the rationale for, and challenges of, designing and testing health-related social needs interventions in alignment with the National Academy of Sciences, Engineering, and Medicine 5As framework. Evidence for food, housing, utilities, interpersonal safety, and transportation health-related social needs interventions is analyzed. Evidence regarding health-related social needs and delivery of health-related social needs interventions differs in maturity and applicability to cancer context, with transportation problems having the most maturity and interpersonal safety the least. We offer practical recommendations for health-related social needs interventions among cancer patients and the caregivers, families, and friends who support their health-related social needs. Cross-cutting (ie, health-related social needs agnostic) recommendations include leveraging navigation (eg, people, technology) to identify, refer, and deliver health-related social needs interventions; addressing health-related social needs through multilevel interventions; and recognizing that health-related social needs are states, not traits, that fluctuate over time. Health-related social needs-specific interventions are recommended, and pros and cons of addressing more than one health-related social needs concurrently are characterized. Considerations for collaborating with community partners are highlighted. The need for careful planning, strong partners, and funding is stressed. Finally, we outline a future research agenda to address evidence gaps.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do.

Purpose of review: To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings: Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary: Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

Tobacco use and cancer-related symptom burden: Analysis of the US Population Assessment of Tobacco and Health Study.

BACKGROUND: Understanding the relationship between tobacco use and symptom burden may inform tobacco treatment interventions tailored to the needs of individuals with cancer. METHODS: The study included 1409 adult cancer survivors from Wave 5 of the US Food and Drug Administration Population Assessment of Tobacco and Health (PATH) Study. A multivariate analysis of variance controlling for age, sex, and race/ethnicity assessed the association of cigarette smoking and vaping on cancer-related symptom burden (fatigue, pain, emotional problems) and quality of life (QoL). Generalized linear mixed models controlling for the same factors were used to assess associations among symptom burden, QoL, and quit-smoking intentions, quit-smoking likelihood, and past 12-month smoking quit attempts. RESULTS: Weighted rates of current cigarette smoking and vaping were 14.21% and 2.88%, respectively. Current smoking was associated with greater fatigue (p < .0001; partial η 2  = .02), pain (p < .0001; partial η 2  = .08), emotional problems (p < .0001; partial η 2  = .02), and worse QoL (p < .0001; partial η 2  = .08). Current vaping was associated with greater fatigue (p = .001; partial η 2  = .008), pain (p = .009; partial η 2  = .005), and emotional problems (p = .04; partial η 2  = .003), but not worse QoL (p = .17). Higher cancer symptom burden was not associated with reduced interest in quitting, likelihood of quitting, or odds of past year quit attempts (p > .05 for each). CONCLUSIONS: Among adults with cancer, current smoking and vaping were associated with greater symptom burden. Survivors' interest in and intentions to quit smoking were not related to symptom burden. Future research should examine the role of tobacco cessation in improving symptom burden and QoL.

Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016.

PURPOSE: The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected. METHODS: The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months. RESULTS: A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states. CONCLUSION: Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.

The Affordable Care Act and suicide incidence among adults with cancer.

BACKGROUND: Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. METHODS: We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. RESULTS: We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. CONCLUSIONS: We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.

Quantifying Total and Out-of-Pocket Costs Associated With Head and Neck Cancer Survivorship.

Importance: Oncologic treatment is costly to the health care system and to individuals, but patients with head and neck cancer (HNC) also have long-term care needs after treatment. Survivors of HNC require specific consideration given their rapidly growing numbers. This subpopulation of cancer survivors often experiences long-term treatment-associated morbidity. Objective: To describe the total and out-of-pocket (OOP) costs associated with HNC survivorship and the risk factors for financial toxicity among this population. Design, Setting, and Participants: This was a retrospective review and economic evaluation of a cohort of US adults with a diagnosis of HNC from 2006 to 2018. The study used data the from IBM MarketScan Commercial Claims Database. Data were analyzed from November 2020 to June 2022. Exposures: Treatment for HNC. Main Outcomes and Measures: Total and OOP medical costs were assessed monthly and reported relative to the date of HNC diagnosis. The primary outcome was the difference between a patient's mean monthly survivorship costs (13-60 months after diagnosis) and mean monthly baseline costs (7-12 months before diagnosis). Univariate and multivariable linear regression models were created for total and OOP costs to generate coefficient estimates with 95% CIs. Results: The study cohort of this economic evaluation included 19 098 patients with HNC (median [range] age, 56 [18-64] years; 14 144 [74.1%] men and 4954 [25.9%] women; race and ethnicity were not considered). Throughout the survivorship period, median total and OOP costs were $372 per month and $31 per month higher than baseline costs, respectively, with variation in expenses by demographic information, health plan type, and oncologic variables. In the multivariable model, greater total and OOP excess survivorship costs were associated with female sex ($343/mo; 95% CI, $126 to $560 and $9/mo; 95% CI, $4 to $14). Highest and lowest total excess survivorship costs associated with cancer site were seen for hypopharyngeal ($1908/mo; 95% CI, $1102 to $2714) and oropharyngeal cancers (-$703/mo; 95% CI, -$967 to -$439) vs oral cavity cancers. Compared with surgery or radiation therapy alone, multimodal treatment was generally associated with excess OOP survivorship costs. Conclusions and Relevance: The findings of this retrospective economic evaluation review suggest that the costs of HNC survivorship remain persistently elevated above baseline costs for at least 5 years after diagnosis. High survivorship costs were associated with female sex, hypopharyngeal tumors, and treatment with multimodal therapy. Practitioners should seek to minimize costs for these patients at higher-risk of financial toxicity after treatment and work to provide directed supportive services.

Association of age with survival in older patients with cutaneous melanoma treated with immune checkpoint inhibitors.

INTRODUCTION: Several types of immune checkpoint inhibitors (ICIs) are approved to treat advanced melanoma, but their effectiveness has not been compared in older patients treated outside of a clinical trial. Moreover, evidence suggests that a patient's response to ICI therapy may vary by age and type of ICI. The purpose of this study was to compare survival by ICI type in older patients with melanoma and to investigate treatment effect modification by age. MATERIALS AND METHODS: Using the SEER-Medicare database, we identified patients with cutaneous melanoma (2012-2015) treated with an ICI (CTLA-4, PD-1, or combination CTLA-4 + PD-1 inhibitors). Cox proportional hazards regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for ICI types. We used an interaction term and stratified models to test for treatment effect modification by age. RESULTS: Of the 1435 patients included in our analysis, 790 (55.1%) received CTLA-4 inhibitors, 512 (35.7%) received PD-1 inhibitors, and 133 (9.3%) were treated with combination ICIs. Median survival ranged from 13.4 months (95%CI: 10.7-16.3) for CTLA-4 inhibitors to 23.5 months (95%CI: 16.2-30.0) for combination ICIs. In multivariable models, the risk of death was lower with PD-1 inhibitors compared to CTLA-4 inhibitors (HR = 0.78, 95%CI: 0.68-0.89). An age*ICI type interaction term was significant (p < 0.001), and survival gains were greater the older age group (≥80) compared to the younger group (65-79). DISCUSSION: In a population-based setting, we identified important differences in survival by ICI type in older patients with melanoma treated with ICIs, with prolonged survival associated with PD-1 inhibitors compared to CTLA-4 inhibitors.

Early Medicaid Expansion and Cancer Mortality.

BACKGROUND: Although Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates. METHODS: We obtained county-level data from the National Center for Health Statistics for adults aged 20-64 years who died from cancer from 2007 to 2009 (preexpansion) and 2012 to 2016 (postexpansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs nonexpansion states through a difference-in-differences analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed. RESULTS: In adjusted difference-in-differences analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100 000 in early expansion vs nonexpansion states, which translates to an estimated decrease of 5276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (-0.18 deaths per 100 000, 95% confidence interval = -0.32 to -0.05) in states that expanded Medicaid by 2014 compared with nonexpansion states. CONCLUSIONS: Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.

Association of Medicaid Expansion Under the Affordable Care Act With Stage at Diagnosis and Time to Treatment Initiation for Patients With Head and Neck Squamous Cell Carcinoma.

Importance: Medicaid expansions as part of the Patient Protection and Affordable Care Act (ACA) are associated with decreases in the percentage of uninsured patients who have received a new diagnosis of cancer. Little is known about the association of Medicaid expansions with stage at diagnosis and time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC). Objective: To determine the association of Medicaid expansions as part of the ACA with stage at diagnosis and TTI for patients with HNSCC. Design, Setting, and Participants: A retrospective cohort study was conducted at Commission on Cancer-accredited facilities among 90 789 patients identified from the National Cancer Database aged 18 to 64 years with HNSCC that was diagnosed during the period from January 1, 2010, to December 31, 2016. Statistical analysis was conducted from February 18 to November 8, 2019. Main Outcomes and Measures: Outcome measures included health insurance coverage, stage at diagnosis, and TTI. Absolute percentage change in health insurance coverage, crude and adjusted difference in differences (DD) in absolute percentage change in coverage, stage at diagnosis, and TTI before (2010-2013) and after (2014-2016) ACA implementation were calculated for Medicaid expansion and nonexpansion states. Results: Of the 90 789 nonelderly adults with newly diagnosed HNSCC (mean [SD] age, 54.7 [7.0] years), 70 907 (78.1%) were men, 72 911 (80.3%) were non-Hispanic white, 52 142 (57.4%) were between 55 and 64 years of age, and 54 940 (60.5%) resided in states with an ACA Medicaid expansion. Compared with nonexpansion states, the percentage of patients with HNSCC with Medicaid increased more in expansion states after the implementation of the ACA (adjusted DD, 4.6 percentage points [95% CI, 3.7-5.4 percentage points]). The percentage of patients with localized disease (American Joint Committee on Cancer stage I-II) at diagnosis increased in expansion states compared with nonexpansion states for the overall cohort (adjusted DD, 2.3 percentage points [95% CI, 1.1-3.5 percentage points]) and for the subset of patients with nonoropharyngeal HNSCC (adjusted DD, 3.4 percentage points [95% CI, 1.5-5.2 percentage points]). The mean TTI did not differ between expansion and nonexpansion states for the cohort (adjusted DD, -12.7 percentage points [95% CI, -27.4 to 4.2 percentage points]) but improved for patients with nonoropharyngeal HNSCC (adjusted DD, -26.5 percentage points [95% CI, -49.6 to -3.4 percentage points]). Conclusions and Relevance: This study suggests that Medicaid expansions were associated with a greater increase in the percentage of patients with HNSCC with Medicaid coverage, an increase in the percentage of patients with localized disease at diagnosis for the overall cohort of patients with HNSCC, and improved TTI for patients with nonoropharyngeal HNSCC.

Evaluation of a survivorship needs assessment planning tool for head and neck cancer survivor-caregiver dyads.

PURPOSE: The objectives of this study were to test the acceptability and feasibility of a survivorship needs assessment planning (SNAP) tool for head and neck cancer (HNC) survivors and caregivers, evaluate short-term changes in psychosocial outcomes after completing the SNAP session, and develop strategies for system refinement. METHODS: We used a prospective one-group design and mixed methods with HNC survivors and caregivers (N = 25 dyads). Participants completed baseline and 6-week surveys before and after completing a SNAP clinic visit to assess psychosocial outcomes and acceptability. Intervention sessions included tablet-based needs assessments driving tailored care plans. Dyads' open-ended feedback and clinician interviews (N = 12) evaluated acceptability and feasibility. RESULTS: SNAP data collection time burden and technology challenges were minimal, and care plans included messages (M = 19), educational materials (M = 13), and referrals (M = 4.5; 86% behavioral medicine, 77% nutrition, 65% physical therapy). Participants reported high satisfaction with the session and care plan, highlighting the key strengths of pulling complex medical information together and the focus on caregiver well-being, with multiple suggestions to facilitate clinic workflow. Depression and unmet needs decreased and survivorship knowledge increased significantly in survivors and caregivers (p < .05) over the 6-week period. CONCLUSIONS: The SNAP tool is an innovative technology-based survivor-centered strategy to assess and manage needs in HNC survivors and caregivers. Results support its acceptability and ability to address dyads' needs; the tool merits further testing in a clinical trial. IMPLICATIONS FOR CANCER SURVIVORS: Technology-enabled care planning may be a productive way to assess and address HNC dyads' dynamic needs after treatment.

Association of the Anterolateral Thigh Osteomyocutaneous Flap With Femur Structural Integrity and Assessment of Prophylactic Fixation.

Importance: The chimeric anterolateral thigh osteomyocutaneous (ALTO) free flap is a recently described microvascular option for head and neck osseous defects associated with complex soft-tissue requirements. To date, the association of ALTO flap harvest with femur structural integrity and the need for routine prophylactic fixation following harvest has been incompletely described. Objective: To investigate the association of ALTO flap harvest, with and without prophylactic fixation, on femur structural integrity as measured by 4-point bend and torsional biomechanical testing. Design and Setting: At a research laboratory, 24 synthetic fourth-generation composite femurs with validated biomechanical properties underwent 10-cm-long, 30% circumferential osteotomies at the proximal middle third of the femur; 6 femurs served as controls. Osteotomized femurs with and without fixation underwent torsional and 4-point bend biomechanical testing. Femur fixation consisted of intramedullary nail and distal interlock screw placement. Main Outcomes and Measures: Force and torque to fracture (expressed in kilonewtons [kN] and Newton meters [N∙m], respectively) were compared between controls, osteotomized femurs without fixation, and osteotomized femurs with fixation. Additional outcome measures included femur stiffness and fracture patterns. Results: On posterior to anterior (PA) 4-point bend testing, force to fracture of osteotomized femurs was 22% of controls (mean difference, 8.3 kN; 95% CI, 6.6-10.0 kN). On torsional testing the torque to fracture of osteotomized femurs was 12% of controls (mean difference, 351.1 N∙m; 95% CI, 307.1-395.1 N∙m). Following fixation there was a 67% improvement in PA force to fracture and a 37% improvement in torque to fracture. However, osteotomized femurs with fixation continued to have a reduced PA force to fracture at 37% of controls (mean difference, 6.8 kN; 95% CI, 4.5-9.2 kN) and torque to fracture at 16% of controls (mean difference, 333.7 N∙m; 95% CI, 306.8-360.6 N∙m). On torsional testing, all osteotomized femurs developed similar spiral fractures through a corner of the distal osteotomy site. This fracture pattern changed after prophylactic fixation with femurs developing nondisplaced fractures through the proximal osteotomy site. There were no underlying hardware failures during testing of osteotomized femurs with fixation. Conclusions and Relevance: Anterolateral thigh osteomyocutaneous flap harvest results in significant changes in the structural integrity of the femur. Postoperative stabilization should be strongly considered, with future research directed at investigating the clinical significance of residual biomechanical changes following femur fixation.

Adherence to National Comprehensive Cancer Network guidelines for time to initiation of postoperative radiation therapy for patients with head and neck cancer.

BACKGROUND: Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. The objective of this study was to determine the rate and predictors of care that does not adhere to National Comprehensive Cancer Network guidelines regarding commencing postoperative radiation therapy (PORT) within 6 weeks of surgery for patients with head and neck squamous cell carcinoma (HNSCC). METHODS: The National Cancer Data Base was reviewed from 2006 to 2014, and patients with HNSCC who underwent curative-intent surgery followed by PORT were identified. Multivariable logistic regression analysis was used to determine the factors associated with nonadherence to guidelines regarding the timing of initiating PORT. RESULTS: In total, 47,273 patients were included in the study. 55.7% of patients (26,340/47,273) failed to commence PORT within 6 week of surgery. The percentage of patients who failed to initiate PORT within 6 week of surgery increased over time. On multivariable analysis, the factors associated with failure to initiate timely, guideline-adherent PORT included black race, public insurance [Medicare, Medicaid] or uninsured status, lower levels of education, increased severity of comorbidity, increased postoperative length of stay, 30-day unplanned hospital readmission, treatment at an academic medical center, and the receipt of surgery and PORT at different facilities. CONCLUSIONS: Over 50% of patients with HNSCC who undergo surgery and PORT receive care that does not adhere to National Comprehensive Cancer Network guidelines with regard to initiating PORT within 6 weeks of surgery. Sociodemographic, oncologic, treatment, and hospital factors are all associated with failure to receive guideline-directed care and should be explored in future studies. Cancer 2017;123:2651-60. © 2017 American Cancer Society.