Sexual behaviors and human papillomavirus vaccine non-initiation among young adult cancer survivors



Young adult cancer survivors are at risk for subsequent human papillomavirus (HPV)-related malignancies. High-risk sexual behavior increases risk for HPV acquisition; HPV vaccination protects against infection. We aimed to determine the prevalence of sexual behaviors, factors related to high-risk sexual behaviors, and the relationship between sexual behaviors and HPV vaccine non-initiation among survivors.


Survivors at comprehensive cancer centers, aged 18–26 years and 1–5 years post-treatment, reported sexual behaviors and HPV vaccine initiation (i.e., ≥ 1 dose). Multivariable logistic regression was performed to calculate odds ratios (OR) and 95% confidence intervals (95%CI) for factors associated with high-risk sexual behaviors (age at first intercourse < 16 years, ≥ 3 lifetime sexual partners, or condom use ≤ 50% of the time) and to explore the relationship between sexual behaviors and vaccine non-initiation.


Of the 312 participants (48.1% female, median age at cancer diagnosis 17.2 years and at survey 20.9 years), sexual intercourse was reported by 63.1%. Of those reporting intercourse, 74.6% reported high-risk sexual behavior. Factors related to high-risk sexual behavior included currently dating/partnered (OR = 4.39, 95%CI 2.5–7.7, P < 0.001) and perceived susceptibility to HPV (OR = 1.76, 95%CI 1.3-2.5, P < 0.001). Most survivors (75.3%) reported HPV vaccine non-initiation; sexual behaviors were not associated with vaccine non-initiation (P = 0.4).


Many survivors participate in high-risk sexual behaviors, yet HPV vaccine initiation rates are low. Factors related to high-risk sexual behaviors can inform interventions to reduce risk for HPV acquisition among survivors.

Implications for Cancer Survivors

Cancer survivors participate in sexual behaviors that increase risk for HPV acquisition and would benefit from vaccination.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12–9.

    CAS  Article  Google Scholar 

  2. 2.

    Viens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, et al. Human papillomavirus-associated cancers - United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65:661–6.

    Article  Google Scholar 

  3. 3.

    Lewis RM, Markowitz LE, Gargano JW, Steinau M, Unger ER. Prevalence of genital human papillomavirus among sexually experienced males and females aged 14-59 years, United States, 2013-2014. J Infect Dis. 2018;217:869–77.

    Article  Google Scholar 

  4. 4.

    Miller KD, Nogueira L, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019;69:363–85.

    Article  Google Scholar 

  5. 5.

    Bhatia S, Louie AD, Bhatia R, O’Donnell MR, Fung H, Kashyap A, et al. Solid cancers after bone marrow transplantation. J Clin Oncol. 2001;19:464–71.

    CAS  Article  Google Scholar 

  6. 6.

    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:e70349.

    CAS  Article  Google Scholar 

  7. 7.

    Leigh IM, Buchanan JA, Harwood CA, et al. Role of human papillomaviruses in cutaneous and oral manifestations of immunosuppression. J Acquir Immune Defic Syndr. 1999;21(Suppl 1):S49–57.

    PubMed  Google Scholar 

  8. 8.

    Petry KU, Scheffel D, Bode U, Gabrysiak T, Köchel H, Kupsch E, et al. Cellular immunodeficiency enhances the progression of human papillomavirus-associated cervical lesions. Int J Cancer. 1994;57:836–40.

    CAS  Article  Google Scholar 

  9. 9.

    Pierce Campbell CM, Lin HY, Fulp W, Papenfuss MR, Salmerón JJ, Quiterio MM, et al. Consistent condom use reduces the genital human papillomavirus burden among high-risk men: the HPV infection in men study. J Infect Dis. 2013;208:373–84.

    CAS  Article  Google Scholar 

  10. 10.

    Panatto D, Amicizia D, Trucchi C, Casabona F, Lai PL, Bonanni P, et al. Sexual behaviour and risk factors for the acquisition of human papillomavirus infections in young people in Italy: suggestions for future vaccination policies. BMC Public Health. 2012;12:623.

    Article  Google Scholar 

  11. 11.

    Remschmidt C, Fesenfeld M, Kaufmann AM, Deleré Y. Sexual behavior and factors associated with young age at first intercourse and HPV vaccine uptake among young women in Germany: implications for HPV vaccination policies. BMC Public Health. 2014;14:1248.

    Article  Google Scholar 

  12. 12.

    Frederick NN, Recklitis CJ, Blackmon JE, Bober S. Sexual dysfunction in young adult survivors of childhood cancer. Pediatr Blood Cancer. 2016;63:1622–8.

    Article  Google Scholar 

  13. 13.

    Ford JS, Kawashima T, Whitton J, Leisenring W, Laverdière C, Stovall M, et al. Psychosexual functioning among adult female survivors of childhood cancer: a report from the childhood cancer survivor study. J Clin Oncol. 2014;32:3126–36.

    Article  Google Scholar 

  14. 14.

    Klosky JL, Howell CR, Li Z, Foster RH, Mertens AC, Robison LL, et al. Risky health behavior among adolescents in the childhood cancer survivor study cohort. J Pediatr Psychol. 2012;37:634–46.

    Article  Google Scholar 

  15. 15.

    Robertson EG, Sansom-Daly UM, Wakefield CE, Ellis SJ, McGill BC, Doolan EL, et al. Sexual and romantic relationships: experiences of adolescent and young adult cancer survivors. J Adolesc Young Adult Oncol. 2016;5:286–91.

    Article  Google Scholar 

  16. 16.

    Centers for disease control and prevention: HPV cancers are preventable, 2019

  17. 17.

    Klosky J, Hudson MM, Chen Y, et al. Human papillomavirus vaccination rates in young cancer survivors. J Clin Oncol. 2017;35:3582–90.

    Article  Google Scholar 

  18. 18.

    Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and sexual behavior among adolescent and young women. Am J Prev Med. 2012;42:44–52.

    Article  Google Scholar 

  19. 19.

    Bednarczyk RA, Birkhead GS, Morse DL, Doleyres H, McNutt LA. Human papillomavirus vaccine uptake and barriers: association with perceived risk, actual risk and race/ethnicity among female students at a New York State university, 2010. Vaccine. 2011;29:3138–43.

    Article  Google Scholar 

  20. 20.

    Bernat DH, Gerend MA, Chevallier K, Zimmerman MA, Bauermeister JA. Characteristics associated with initiation of the human papillomavirus vaccine among a national sample of male and female young adults. J Adolesc Health. 2013;53:630–6.

    Article  Google Scholar 

  21. 21.

    Kazak AE, Hocking MC, Ittenbach RF, Meadows AT, Hobbie W, DeRosa BW, et al. A revision of the intensity of treatment rating scale: classifying the intensity of pediatric cancer treatment. Pediatr Blood Cancer. 2012;59:96–9.

    Article  Google Scholar 

  22. 22.

    Cox DS, Cox AD, Sturm L, Zimet G. Behavioral interventions to increase HPV vaccination acceptability among mothers of young girls. Health Psychol. 2010;29:29–39.

    Article  Google Scholar 

  23. 23.

    Brabin L, Roberts SA, Farzaneh F, et al. Future acceptance of adolescent human papillomavirus vaccination: a survey of parental attitudes. Vaccine. 2006;24:3087–94.

    Article  Google Scholar 

  24. 24.

    Klosky J, Russell KM, Canavera KE, et al. Risk factors for non-initiation of the human papillomavirus vaccine among adolescent survivors of childhood cancer. Cancer Prev Res. 2013;6:1101–10.

    Article  Google Scholar 

  25. 25.

    Miller KS, Kotchick BA, Dorsey S, et al. Family communication about sex: what are parents saying and are their adolescents listening? Fam Plan Perspect. 1998;30:218–22, 235.

    CAS  Article  Google Scholar 

  26. 26.

    Abma JC, Martinez GM. Sexual activity and contraceptive use among teenagers in the United States, 2011-2015. Natl Health Stat Rep. 2017;104:1–23.

  27. 27.

    Petersen JL, Hyde JS. Gender differences in sexual attitudes and behaviors: a review of meta-analytic results and large datasets. J Sex Res. 2011;48:149–65.

    Article  Google Scholar 

  28. 28.

    Copen CE. Condom use during sexual intercourse among women and men aged 15-44 in the United States: 2011-2015 National Survey of Family Growth. Natl Health Stat Rep. 2017;105:1–18.

  29. 29.

    National Center for Health Statistics: Key statistics from the national survey of family growth, Center for Disease Control and Prevention, 2017

  30. 30.

    Matser A, Heiligenberg M, Geskus R, Heijman T, Low N, Kretzschmar M, et al. The importance of partnership factors and individual factors associated with absent or inconsistent condom use in heterosexuals: a cross-sectional study. Sex Transm Infect. 2014;90:325–31.

    Article  Google Scholar 

  31. 31.

    Roberts ME, Gerrard M, Reimer R, Gibbons FX. Mother-daughter communication and human papillomavirus vaccine uptake by college students. Pediatrics. 2010;125:982–9.

    Article  Google Scholar 

  32. 32.

    McBride ML, Lorenzi MF, Page J, Broemeling AM, Spinelli JJ, Goddard K, et al. Patterns of physician follow-up among young cancer survivors: report of the Childhood, Adolescent, and Young Adult Cancer Survivors (CAYACS) research program. Can Fam Physician. 2011;57:e482–90.

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    Frederick NN, Revette A, Michaud A, Bober SL. A qualitative study of sexual and reproductive health communication with adolescent and young adult oncology patients. Pediatr Blood Cancer. 2019;66:e27673.

    Article  Google Scholar 

  34. 34.

    Copen CE, Chandra A, Febo-Vazquez I. Sexual behavior, sexual attraction, and sexual orientation among adults aged 18-44 in the United States: data from the 2011-2013 National Survey of Family Growth. Natl Health Stat Rep. 2016;88:1–14.

  35. 35.

    Bober SL, Zhou ES, Chen B, Manley PE, Kenney LB, Recklitis CJ. Sexual function in childhood cancer survivors: a report from Project REACH. J Sex Med. 2013;10:2084–93.

    Article  Google Scholar 

  36. 36.

    Thomas R, Higgins L, Ding L, Widdice LE, Chandler E, Kahn JA. Factors associated with HPV vaccine initiation, vaccine completion, and accuracy of self-reported vaccination status among 13- to 26-year-old men. Am J Mens Health. 2018;12:819–27.

    Article  Google Scholar 

  37. 37.

    Oliveira CR, Avni-Singer L, Badaro G, Sullivan EL, Sheth SS, Shapiro ED, et al. Feasibility and accuracy of a computer-assisted self-interviewing instrument to ascertain prior immunization with human papillomavirus vaccine by self-report: cross-sectional analysis. JMIR Med Inform. 2020;8:e16487.

    Article  Google Scholar 

  38. 38.

    Rolnick SJ, Parker ED, Nordin JD, Hedblom BD, Wei F, Kerby T, et al. Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors? Vaccine. 2013;31:3928–35.

    CAS  Article  Google Scholar 

Download references


This work was supported by the National Cancer Institute (R01CA166559—MPIs-Landier & Klosky) and supported in part by the Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp (MISP #40083; PI-Landier), and the American Lebanese Syrian Associated Charities (ALSAC) support of the Consortium for Pediatric Intervention Research. Dr. Cherven received support from the Robert Wood Johnson Future of Nursing Scholars (RWJF 72509) program and the American Cancer Society Doctoral Scholarship in Cancer Nursing (17-078-01-SCN). The opinions expressed in this paper are those of the authors and do not necessarily represent those of the study sponsors.

Author information




Conception and Design: Brooke Cherven, James L. Klosky, Karen Heaton, Gwendolyn Childs, Smita Bhatia, Wendy Landier.

Financial Support: James L. Klosky, Wendy Landier, Brooke Cherven

Administrative Support: James L. Klosky, Smita Bhatia, Leslie L. Robison, Wendy Landier

Provision of Study Materials or Patients: James L. Klosky, Jocelyn M. York, Jessica S. Flynn, James A. Connelly, Karen Wasilewski-Masker, Leslie L. Robison, Melissa M. Hudson, Smita Bhatia, Wendy Landier

Collection and Assembly of Data: James L. Klosky, Jocelyn M. York, Jessica S. Flynn, James A. Connelly, Karen Wasilewski-Masker, Wendy Landier

Data Analysis and Interpretation: Brooke Cherven, James L. Klosky, Yanjun Chen, Karen Heaton, Gwendolyn Childs, F. Lennie Wong, Smita Bhatia, Wendy Landier

Manuscript Writing: All authors

Final Approval of Manuscript: All authors

Accountable for All Aspects of the Work: All authors

Corresponding author

Correspondence to Wendy Landier.

Ethics declarations

Ethics approval

The study was approved by the Institutional Review Board at the study coordinating center (University of Alabama at Birmingham) and at each participating site (City of Hope, St. Jude Children’s Research Hospital, University of Michigan, and Emory University/Children’s Healthcare of Atlanta). The study was performed in line with the principles of the Declaration of Helsinki. Young adult participants provided written informed consent in their preferred language.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information


(DOCX 56 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cherven, B., Klosky, J.L., Chen, Y. et al. Sexual behaviors and human papillomavirus vaccine non-initiation among young adult cancer survivors. J Cancer Surviv (2021).

Download citation


  • Cancer survivor
  • Human papillomavirus
  • HPV vaccine
  • Sexual behavior