Need Most cancers are diagnosed in adults; however, many cancer risk behaviors are patterned early in life. Because of this, and because visits to a physician become increasingly infrequent as children and adolescents become young and middle-aged adults, there is growing recognition of the essential role of pediatric providers in addressing lifelong cancer prevention in children and adolescents. In particular, pediatric providers can play an important role in tobacco prevention and HPV vaccination. In the case of tobacco prevention, screening and counseling from a healthcare provider (including specific focus on electronic nicotine delivery systems, or e-cigarettes) is an evidence-based inte...

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Need Most cancers are diagnosed in adults; however, many cancer risk behaviors are patterned early in life. Because of this, and because visits to a physician become increasingly infrequent as children and adolescents become young and middle-aged adults, there is growing recognition of the essential role of pediatric providers in addressing lifelong cancer prevention in children and adolescents. In particular, pediatric providers can play an important role in tobacco prevention and HPV vaccination. In the case of tobacco prevention, screening and counseling from a healthcare provider (including specific focus on electronic nicotine delivery systems, or e-cigarettes) is an evidence-based intervention to reduce the risk of smoking initiation. In the case of HPV vaccination, the single most important factor influencing parents’ decision to initiate the HPV vaccine series for their children is a strong recommendation from a healthcare provider. There is much need for HPV vaccine and tobacco prevention services in Harris County, Texas. Harris County, the third most populous county in the U.S., has one of the highest uninsured rates in the nation. The incidence of HPV-associated cervical cancer is 30% higher in Harris County compared to the U.S. Despite the vaccines’ potential to prevent cervical and other HPV-associated cancers (i.e., oropharyngeal, anal, penile, vaginal, and vulvar), vaccine coverage remains far below the Health People 2020 goal of 80% completion. Tobacco use is associated with multiple cancers, most notoriously lung cancer. Lung cancer is the leading cause of cancer-related mortality in Harris County, as it is in the rest of Texas and the U.S. However, lung cancer incidence among racial/ethnic minorities (particularly non-Hispanic blacks) is higher in Harris County compared to both Texas and U.S. Nationally, tobacco use is reported by 19.6% and 5.6% of U.S. high- and middle- school students, respectively. The high prevalence is exacerbated by the sharp rise in e-cigarette use, which increased 14-fold between 2011 and 2018 and by a dramatic 78% in the single year between 2017 and 2018. The e-cigarette epidemic threatens to set back decades of public health progress against tobacco use in youth. Overall Project Strategy We currently have a CPRIT prevention services grant to implement and evaluate a comprehensive HPV vaccine program within a large, urban safety net health system in Harris County, Texas. In the proposed continuation/expansion project, we will leverage the infrastructure and strategies of our current HPV vaccine program to expand the role of pediatric providers in cancer prevention, specifically by integrating evidence-based tobacco prevention services. We will also integrate additional strategies to address program sustainability and target health-system barriers that currently impede achievement of the Healthy People 2020 goal of 80% HPV vaccine series completion. Finally, we will expand our reach within Harris County’s medically underserved population by partnering with additional clinics that serve this population. Our proposed project utilizes multi-level, evidence-based strategies, specifically electronic medical record modifications; provider training and practice facilitation; patient and parent education; patient tracking, reminder/recall, and navigation; and care coordination. Specifically, we will work with pediatric providers and clinical staff to ensure that all age-eligible pediatric patients and parents receive a strong HPV vaccine recommendation; receive reminder/recalls and navigation to ensure completion of the full vaccine series; are screened for and counseled against tobacco use (including e-cigarettes and other tobacco products); and are referred for cessation assistance as needed. Specific Goals The overarching goal of the expansion program is to increase pediatric provider-delivered cancer prevention services, specifically HPV vaccination and tobacco prevention, in a network of safety net clinics that serve the medically underserved. Our specific goals are: 1) To increase the proportion of pediatric patients who complete the HPV vaccine series. 2) To increase the proportion of pediatric patients who receive comprehensive tobacco prevention clinical services. Significance and Impact The proposed project will significantly increase the proportion of adolescent patients within a network of safety net clinics who are protected by the HPV vaccine against HPV-associated cancers. It will also dramatically improve tobacco prevention efforts by expanding screening, counseling, and referral to e-cigarettes and other tobacco products that increase children and adolescent’s risk of using combustible tobacco products in the future. Finally, it will establish a comprehensive model that can be used in other healthcare systems to engage pediatric providers in cancer prevention.

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