Cigarette smoking is an independent risk factor for cervical intraepithelial neoplasia in young women: a longitudinal study

The association between smoking and cervical human papillomavirus infection among women from indigenous communities in western Botswana

INTRODUCTION

Cervical cancer, a malignancy caused by infection with oncogenic human papillomavirus, disproportionally affects women from low resource settings. Persistence of human papillomavirus infection may mediate an association between tobacco use and cervical cancer. In limited resource settings, women from indigenous communities are often marginalized and do not benefit from evidence-based interventions to prevent tobacco use or cervical cancer due to the limited reach of mainstream healthcare services to these communities. This study determined the association between smoking and high-risk human papillomavirus infection among women from indigenous communities in western Botswana.

METHODS

A cross-sectional study of women in indigenous communities was conducted between June and October 2022. Demographic, clinical and self-reported smoking data were collected. Cervical cytology and HPV DNA testing for high-risk human papillomavirus genotypes were performed. Multilevel multivariable logistic regression models were fit to evaluate the association between smoking and high-risk human papillomavirus infection while adjusting for potential confounders.

RESULTS

A total of 171 participants with a median (interquartile range) age of 40 (31-50) years from three settlements and two villages were recruited for the study. Of these, 17% were current smokers, 32.8% were living with HIV and high-risk human papillomavirus DNA was detected in 32.8% of the cervical specimens. Women who were current smokers, were nearly twice as likely to have cervical high-risk human papillomavirus infection compared to non-smokers (Adjusted Odds Ratio (95% CI); 1.74(1.09, 2.79)) after controlling for confounders.

CONCLUSION

These data underscore the need for effective tobacco control to help mitigate cervical cancer risk in this setting. These findings can help inform decisions about targeted cervical cancer prevention and tobacco cessation interventions for women from indigenous communities.

Smoking Cessation by Cancer Treatment Status Among Cervical Cancer Survivors

INTRODUCTION

Continued smoking following a cancer diagnosis is associated with poorer cancer treatment outcomes and survival times. Little is known about how cancer treatment status at the time of tobacco treatment enrollment impacts long-term smoking cessation outcomes. Using data from a smoking cessation RCT, this study compared long-term cessation outcomes of women undergoing active treatment for cervical cancer at trial enrollment (n=40) to outcomes of women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) who were not undergoing active cancer treatment at enrollment (n=154).

METHODS

Participants (n=194) were randomized to Standard Treatment (ST) or ST plus a 6-session Motivation And Problem Solving (MAPS) telephone counseling protocol (data collected: 2017-2021; analyzed: 2023). Sociodemographic differences between participants undergoing (versus not undergoing) active cancer treatment at enrollment were examined. Significant covariates were included in a logistic regression analysis comparing the 2 groups' smoking cessation outcomes at 12 months, the end of the tobacco treatment period.

RESULTS

Participants in active cancer treatment at enrollment were significantly younger and less educated than those not in active cancer treatment. Race/ethnicity, relationship status, household income, nicotine dependence, and tobacco treatment condition did not vary by cancer treatment status. After adjusting for tobacco treatment condition, age, and education, being in active cancer treatment at the time of enrollment was associated with lower odds of abstinence at 12 months (5% vs 20%, aOR=0.22, 95% CI [0.05-0.998]).

CONCLUSIONS

Further research is necessary to identify and overcome barriers to abstinence among cancer survivors undergoing active treatment.

Aerobic vaginitis is associated with carbonic anhydrase IX in cervical intraepithelial neoplasia

The aim of this study was to analyze the association between vaginal microbiota, carbonic anhydrase IX (CAIX) and histological findings of cervical intraepithelial neoplasia (CIN). The study included 132 females, among them 66 were diagnosed with high-grade intraepithelial lesion (CIN2, CIN3, and cancer), 14 with low-grade disease, and 52 assigned to the control group. An interview focused on the behavior risk factors, together with vaginal fluid pH measurement, wet mount microscopy, detection of Chlamydia trachomatis, and Trichomonas vaginalis were performed. After colposcopy, high-grade abnormalities were detected via direct biopsies and treated with conization procedure. Conuses were immuno-stained with CAIX antibody. The histological findings were CIN1 (n = 14), and CIN2+ (included CIN2 (n = 10), CIN3 (n = 49), and cancer (n = 7; squamous cell carcinomas)). Prevalence of bacterial vaginosis (BV) was similar between the groups. Moderate or severe aerobic vaginitis (msAV) was diagnosed more often among CIN2+ (53.0%) than CIN1 (21.4%). Moderate or strong immunostaining of CAIX (msCAIX) was not detected among CIN1 cases. Thus, msAV was prevalent in CAIX non-stained group (p = 0.049) among CIN2 patients. Co-location of msAV and msCAIX was found in CIN3. Regression model revealed that msAV associated with high-grade cervical intraepithelial neoplasia independently from smoking and the number of partners.

Cervical cancer incidence, mortality, and burden in China: a time-trend analysis and comparison with England and India based on the global burden of disease study 2019

Background

Cervical cancer is the fourth highest incidence of malignancy in the world and a common cause of cancer death in women. We assessed the trends of incidence and mortality and disability-adjusted life year (DALY) in China, England and India from 1990 to 2030.

Method

Data were obtained from the Global Burden of Disease (GBD) database. We collected the number and rate of incidence, death and DALY from 1990 to 2019 and calculated the estimated annual percentage change (EAPC). Further analysis was carried out by ages and years. We also collected attributable risk factors to cervical cancer. Finally, we utilized the Bayesian Age-Period-Cohort (BAPC) model to forecast trends in the rate of age-standardized incidence (ASIR) and age-standardized death (ASDR) the for the next decade.

Result

Globally, the incidence of cervical cancer cases increased from 335,641.56 in 1990 to 565,540.89 in 2019. In 2019, the ASIR and ASDR of cervical cancer were higher than those of India but lower than those of England. Furthermore, unsafe sex and smoking emerge as prominent risk factors for cervical cancer. Over the next decade, ASIR and ASDR are expected to decline in China and England, while India's ASIR is still on an upward trend and ASDR is on a downward trend.

Conclusion

The epidemiological data of cervical cancer in these three countries reflects the influence of different stages of development and healthcare systems. Trends over the next decade suggest that China and India still face a huge burden of cervical cancer. When England has made significant progress, China and India need to take more measures to improve the prevention and control of cervical cancer.

Knowledge of cervical cancer screening among Omani women attending a university teaching hospital: a cross-sectional study

OBJECTIVES

To assess knowledge, attitudes, and practices regarding cervical cancer and Pap smear screening among Omani women attending a tertiary clinic in Muscat, Oman, and to establish correlations with selected sociodemographic factors.

METHODS

An observational, cross-sectional study was carried out among Omani women aged 18-50 years old attending the outpatient clinic of the Department of Obstetrics and Gynecology, Sultan Qaboos University Hospital, from October 2019 to February 2020. A validated Arabic-language questionnaire was utilized to collect data regarding the participants' sociodemographic characteristics, their knowledge of cervical cancer and related risk factors, and their knowledge, attitudes, and practices related to cervical cancer screening and Pap smear testing.

RESULTS

Of the 380 respondents, 86 and 55% had previously heard of cervical cancer and Pap smear testing, respectively; however, only 26% were knowledgeable concerning these topics. Knowledge scores were significantly associated with various sociodemographic factors, including marital status and a previous awareness of cervical cancer (odds ratio: > 1, p < 0.05). Only 21% had themselves previously undergone Pap smear testing; however, 75% reported being willing to undergo such screening in future.

CONCLUSIONS

Knowledge regarding cervical cancer-related risk factors and Pap smear screening was poor among a cohort of Omani women attending a tertiary clinic in Muscat, Oman. This may play a role in the increased frequency of cervical cancer cases observed in Oman over recent years. As such, a well-structured public education program is recommended to raise awareness of this issue.

Analysis of tobacco exposures and high-risk HPV infection in American women: National Health and Nutrition Examination Survey

Nicotine is a known toxin, but its relationship with cervicovaginal high-risk human papillomavirus (HR-HPV) infection is uncertain. This study aimed to investigate whether tobacco exposure is associated with elevated cervicovaginal HR-HPV infection in US women, and if the strength of this association varies with the degree of exposure. Cross-sectional data from the 2011-2016 National Health and Nutrition Examination Survey (NHANES), which included a nationally representative sample of US women, were used for the study. Out of 12436 women aged 18-59 who participated in the interview, 3833 were ultimately enrolled in this study. Weighted logistic regression was used to estimate the link between tobacco exposure and cervicovaginal HR-HPV infection. The mean age of participants was 38.6 (SD 12.1) years, and non-Hispanic White individuals accounted for 37.3% of the sample. Those with any tobacco exposure tended to be younger (mean age 37.7 [SD 12.4] years vs 40.3 [11.2] years), non-Hispanic Black (27.8% vs. 15.1%), lower educated (41.8% vs. 29.4%), and have lower family income (39.9% vs. 23.5%). After adjustment, the odds of having HR-HPV infection were 1.32 (95% CI, 1.09-1.59) for those exposed to tobacco, remaining significant in multiple sensitivity analyses and across subgroups. This study, based on a nationally representative sample from the United States, suggests that tobacco exposure is a risk factor for elevated HR-HPV infection in women, highlighting the need for further research into reducing this modifiable risk factor.

A study on the correlation between the prognosis of HPV infection and lesion recurrence after cervical conization

Introduction

Persistent human papillomavirus infection is an important factor in the development of cervical cancer, which is usually a long process evolving from the development of squamous intraepithelial lesions (SIL), also referred to as cervical intraepithelial neoplasia (CIN). Local treatment of advanced squamous intraepithelial lesions, also regarded as High-Grade Squamous Intraepithelial Lesion, may be effective in preventing cancer.

Objective

To promptly identify high-risk patients with a tendency to recurrence.

Methods

We retrospectively analyzed the clinical data of 300 patients with high-grade squamous intraepithelial lesions of the cervix admitted to the Second Affiliated Hospital of Dalian Medical University from 2019 to 2020 to investigate the relationship between recurrence of cervical lesions and postoperative regression of HPV infection, as well as other related risk factors.

Results

We found that the HPV-negative rates were 81.81, 85.71, and 90.91% at 6, 12, and 24 months, respectively, and the average lesion recurrence rate was 8.16%, with a median time to recurrence of 14 months in patients undergoing CKC for HSIL. The risk of cervical squamous intraepithelial lesions was highest in patients with HPV16. Patients over 61 years of age had the lowest postoperative HPV-negative rate. The conversion rate was significantly lower in patients with multiple HPV genotypes than in those with single HPV infection (p < 0.05). The probability of recurrence was higher in patients with the same HPV infection genotype before and after surgery than in patients with different infection genotypes before and after surgery (p < 0.05).

Conclusion

Combined with the literature review, we believe that patients aged ≥50 years, with ≥3 pregnancies and births, a history of smoking, and consistent genotypes of preoperative and postoperative HPV infection in cervical conization have more HPV re-infection or persistent infection, and that these factors may be high-risk factors for lesion recurrence. For patients with possible potential high-risk factors, we need to carry out individualized follow-up and focused management, take timely and effective management measures, optimize the treatment plan, reduce the recurrence rate, prevent HSIL and cervical cancer, improve the quality of patient's survival, and improve the prognosis.

The salivary microbiota is altered in cervical dysplasia patients and influenced by conization

This study supports the correlation between the salivary microbiota and cervical dysplasia and suggests that smoking influences the salivary microbiota.

Enhancing long-term smoking abstinence among individuals with a history of cervical intraepithelial neoplasia or cervical cancer (Project ACCESS): protocol for a randomized clinical trial

BACKGROUND

The prevalence of smoking among cervical cancer survivors is high and evidence-based smoking cessation interventions are critically needed. This paper describes the study design, methods, and data analysis plans for a randomized clinical trial (RCT) designed to evaluate the efficacy of a novel, personally tailored SMS-delivered text-based digital treatment adjuvant designed to enhance the long-term efficacy of a "Motivation And Problem-Solving" (MAPS) approach for smoking cessation among individuals with a history of cervical intraepithelial neoplasia (CIN) or cervical cancer. MAPS is a phone counseling approach designed to facilitate long-term abstinence that comprises 6 counseling calls over 12 months. The current trial is evaluating the efficacy of MAPS+, which comprises all MAPS components plus a 24-month digital treatment adjuvant. This trial represents a logical extension of our previous RCT, which compared the efficacy of MAPS to a quitline control condition and found that MAPS resulted in greater than a 2-fold increase in smoking abstinence at 12 months (i.e., 26.4% vs. 11.9%). This treatment effect was no longer significant at 18 months, suggesting that efficacy dissipated as time from the end of treatment increased. The primary aim of the current trial is to compare the efficacy of MAPS + and ST in facilitating long-term abstinence.

METHODS

Individuals who smoke and have a history of cervical cancer or CIN (N = 340) are recruited throughout Florida and randomly assigned to Standard Treatment [ST] or MAPS+. ST participants are electronically connected with the Florida Quitline. MAPS + consists of 6 proactive MAPS-based counseling calls over 12 months plus the novel, personally tailored, text message-based treatment adjuvant delivered over 24 months. All participants receive 12 weeks of combination nicotine replacement therapy (patch and lozenge) and are followed for 24 months. Participant recruitment commenced in December 2022 and is ongoing.

DISCUSSION

This study builds on promising results from our recent trial which found that MAPS was associated with substantially higher abstinence from smoking at the end of the 12-month treatment period. Finding that this low-burden, personally tailored digital treatment adjuvant improves the long-term efficacy of MAPS would have important clinical and public health implications.

TRIAL REGISTRATION

Clinical Trials Registry NCT05645146; https://clinicaltrials.gov/ct2/show/NCT05645146 ; Registered on December 9, 2022.

Efficacy of a Smoking Cessation Intervention for Survivors of Cervical Intraepithelial Neoplasia or Cervical Cancer: A Randomized Controlled Trial

PURPOSE

Women who smoke and have a history of cervical intraepithelial neoplasia (CIN) or cervical cancer represent a vulnerable subgroup at elevated risk for recurrence, poorer cancer treatment outcomes, and decreased quality of life. The purpose of this study was to evaluate the long-term efficacy of Motivation And Problem Solving (MAPS), a novel treatment well-suited to meeting the smoking cessation needs of this population.

METHODS

Women who were with a history of CIN or cervical cancer, age 18 years and older, spoke English or Spanish, and reported current smoking (≥100 lifetime cigarettes plus any smoking in the past 30 days) were eligible. Participants (N = 202) were recruited in clinic in Oklahoma City and online nationally and randomly assigned to (1) standard treatment (ST) or (2) MAPS. ST consisted of repeated referrals to a tobacco cessation quitline, self-help materials, and combination nicotine replacement therapy (patch plus lozenge). MAPS comprised all ST components plus up to six proactive telephone counseling sessions over 12 months. Logistic regression and generalized estimating equations evaluated the intervention. The primary outcome was self-reported 7-day point prevalence abstinence from tobacco at 18 months, with abstinence at 3, 6, and 12 months and biochemically confirmed abstinence as secondary outcomes.

RESULTS

There was no significant effect for MAPS over ST at 18 months (14.2% v 12.9%, P = .79). However, there was a significant condition × assessment interaction (P = .015). Follow-up analyses found that MAPS (v ST) abstinence rates were significantly greater at 12 months (26.4% v 11.9%, P = .017; estimated OR, 2.60; 95% CI, 1.19 to 5.89).

CONCLUSION

MAPS led to a greater than two-fold increase in smoking abstinence among survivors of CIN and cervical cancer at 12 months. At 18 months, abstinence in MAPS declined to match the control condition and the treatment effect was no longer significant.

Polymorphisms of the interleukin-6 (IL-6) gene contribute to cervical cancer susceptibility in Bangladeshi women: A case-control study

Background and Aims

Cervical cancer is characterized by abnormal cell growth in the lining of cervix and it is the second major cause of cancer-related deaths among females in Bangladesh. Interleukin-6 (IL-6) is a multifunctional cytokine that has been heavily linked with cervical cancer. Our aim was to investigate the association of two promoter single-nucleotide polymorphisms (SNPs) of IL-6 (rs1800795 and rs1800797) with the susceptibility of cervical cancer in Bangladeshi women.

Methods

DNA was extracted from venous blood samples from cervical cancer patients (n = 126) and healthy controls (n = 120). Polymerase chain reaction-restriction fragment length polymorphism was used for genotyping of the selected SNPs. Logistic regression was performed to calculate the odds ratio (OR) with 95% confidence interval (CI) and p values.

Results

We found a significant association between rs1800795 and rs1800797 polymorphisms and cervical cancer. For, rs1800795 (G > C) the GC heterozygous genotype (OR = 2.80, 95% CI = 1.55-5.07, p = 0.0007) and CC mutant homozygous genotype (OR = 3.5, 95% CI = 1.29-9.51, p = 0.014) conferred an increased risk of cervical cancer. In case of rs1800797 (G > A) polymorphism, the AG heterozygous genotype (OR = 6.94, 95% CI = 3.76-12.81, p < 0.0001) and AA mutant homozygous genotype (OR = 3.88, 95% CI = 1.12-13.51, p = 0.0332) also exhibited an elevated risk of cervical cancer. Use of contraceptives was found as risk factor and patients who smoke were carriers of both the risk alleles and thus had an increased risk of cervical cancer.

Conclusion

Our findings suggest that polymorphism of rs1800795 and rs1800797 of the IL-6 gene play a significant role in cervical cancer susceptibility in Bangladeshi women.

Impact of smoking exposure on human papillomavirus clearance among Chinese women: A follow-up propensity score matching study

INTRODUCTION

Smoking has been proven to increase the risk of cervical cancer, but it is still controversial whether smoking reduces women's ability to clear human papillomavirus (HPV) infection. This study investigated the association between smoking behaviors during follow-up and clearance of HPV infection in women with HPV-positive and pathologically normal uterine cervix in China, using a propensity score matching (PSM) analysis.

METHODS

The present prospective study included data from women examined in the Gynecology Department of Shanghai General Hospital from January 2018 to June 2020. Twenty patients who smoked throughout follow-up were selected and matched with 60 patients using the 1:3 PSM method on age, marital status, and whether infected with high-risk HPV (HR-HPV). At each visit, smoking and sexual behaviors were collected. The Kaplan-Meier method and a Cox proportional hazard regression model were used to evaluate the probability of clearing HPV infection within a 2-year follow-up.

RESULTS

A total of 80 patients were included in the study, all of whom were infected with at least one HR-HPV type at baseline. Current smokers had a lower likelihood of clearing the HPV infection than current non-smokers, after adjusting for a history of sexually transmitted diseases (STD), HPV infection status, and sexual behaviors during follow-up (AHR=0.478; 95% CI: 0.239-0.958, p=0.037). Additionally, longer duration, higher frequency and larger doses of smoking correlated with the lower clearance possibility of HPV infection (p for trend=0.029, 0.022 and 0.026, respectively).

CONCLUSIONS

This study showed that the use of tobacco throughout follow-up could increase the risk of a persistent HPV infection, this risk being higher for smokers with heavier tobacco consumption. Our results should alert HPV-positive women to reiterate the advice to cut-back on or stop smoking.

Proteases and HPV-Induced Carcinogenesis

Simple Summary

Human papillomavirus (HPV) infection is a sexually transmitted disease with high prevalence worldwide. Although most HPV infections do not lead to cancer, some HPV types are correlated with the majority of cervical cancers, and with some anogenital and oropharyngeal cancers. Moreover, enzymes known as proteases play an essential role in the pathogenic process in HPV-induced carcinogenesis. This review highlights the role of proteases and recent epidemiological data regarding HPV-dependent carcinogenesis.

Abstract

Persistent infection with Human papillomavirus (HPV) is the main etiologic factor for pre-malignant and malignant cervical lesions. Moreover, HPV is also associated with oropharynx and other anogenital carcinomas. Cancer-causing HPV viruses classified as group 1 carcinogens include 12 HPV types, with HPV 16 and 18 being the most prevalent. High-risk HPVs express two oncoproteins, E6 and E7, the products of which are responsible for the inhibition of p53 and pRB proteins, respectively, in human keratinocytes and cellular immortalization. p53 and pRB are pleiotropic proteins that regulate the activity of several signaling pathways and gene expression. Among the important factors that are augmented in HPV-mediated carcinogenesis, proteases not only control processes involved in cellular carcinogenesis but also control the microenvironment. For instance, genetic polymorphisms of matrix metalloproteinase 1 (MMP-1) are associated with carcinoma invasiveness. Similarly, the serine protease inhibitors hepatocyte growth factor activator inhibitor-1 (HAI-1) and -2 (HAI-2) have been identified as prognostic markers for HPV-dependent cervical carcinomas. This review highlights the most crucial mechanisms involved in HPV-dependent carcinogenesis, and includes a section on the proteolytic cascades that are important for the progression of this disease and their impact on patient health, treatment, and survival.

Current Status of Human Papillomavirus Infection and Cervical Cancer in the Philippines

Cervical cancer is estimated to cause 341,831 deaths each year, with 9 of 10 deaths occurring in developing countries. Over the past decade, there has been a significant increase in cervical cancer incidence among women in the Philippines. Persistent infection with high-risk human papillomavirus (HPV) is the well-established necessary cause of cervical cancer. Based on limited studies conducted in the Philippines, the prevalence of infection with any HPV genotype was 93.8% for cervical squamous cell carcinoma and 90.9% for cervical adenocarcinomas. HPV types 16 and 18 were the most common HPV genotypes among Filipino patients with cervical cancer. On the other hand, the incidence of HPV infection among Filipino women with normal cervices was 9.2%. The World Health Organization has launched a global agenda of eliminating HPV infection by 2030. One of its key milestones is to vaccinate 90% of girls with the HPV vaccine by 15 years. However, the HPV vaccination rate among Filipino women remains to be unsatisfactory. HPV vaccination has only been included in the Philippine Department of Health's community-based National Immunization Program in 2015. Despite these efforts, the Philippines currently ranks last on HPV program coverage among low-middle income countries, with coverage of only 23% of the target female population for the first dose and 5% for the final dose. The principal reason for the non-acceptance of HPV vaccines was the perceived high cost of vaccination. The low utilization of available cervical cancer screening tests such as Pap smear and visual inspection with acetic acid hampered the Philippines' control and prevention of HPV infection and cervical cancer. Among those diagnosed with cervical cancer in the Philippines, only an estimated 50% to 60% receive some form of treatment. To this end, we summarize the burden of HPV infection and cervical cancer on Filipinos and the risk factors associated with the disease. We present the current screening, diagnostics, treatment, and prevention of HPV-related diseases in the Philippines. Lastly, we also propose solutions on how each building block in health systems can be improved to eliminate HPV infection and reduce the burden of cervical cancer in the Philippines.

A micro-Raman spectroscopy study of inflammatory condition of human cervix: Probing of Tissues and blood plasma samples

The present study explores the application of the micro-Raman spectroscopy technique to discriminate normal and cervicitis condition from cervical malignancy by analyzing the Raman signatures of tissues and plasma samples of the same subjects. The Raman peaks from tissue samples at 1026 cm^-1,1298 cm^-1 and 1243 cm^-1 are attributed to glycogen, fatty acids and collagen and are found to be reliable signatures capable of identifying cervicitis and normal condition from cervical cancer. The Raman signatures from plasma samples belonging to carbohydrates (578 cm^-1), lipids (1059 cm^-1) and nucleic acids (1077 cm^-1,1341 cm^-1 and 1357 cm^-1) are quite useful to classify various stages of cervix at par with tissue based diagnosis. The PCA-SVM based classification of the spectral data indicates the potential of Raman spectroscopy based liquid biopsy to rule out false diagnosis of cervicitis as cervical malignancy.

The effectiveness of smoking cessation interventions for socio-economically disadvantaged women: a systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis assessed the effectiveness of smoking cessation interventions among women smokers in low socio-economic status (SES) groups or women living in disadvantaged areas who are historically underserved by smoking cessation services.

METHODS

A systematic literature search was conducted using MEDLINE (OVID), EMBASE, Cochrane, CINAHL, PsychINFO and Web of Science databases. Eligibility criteria included randomised controlled trials of any smoking cessation intervention among women in low SES groups or living in socio-economically disadvantaged areas. A random effects meta-analysis assessed effectiveness of interventions on smoking cessation. Risk of bias was assessed with the Cochrane Risk of Bias tool. The GRADE approach established certainty of evidence.

RESULTS

A total of 396 studies were screened for eligibility and 11 (6153 female participants) were included. Seven studies targeted women-only. 5/11 tested a form of face-to-face support. A pooled effect size was estimated in 10/11 studies. At end of treatment, two-thirds more low SES women who received a smoking cessation intervention were more likely to stop smoking than women in control groups (risk ratio (RR) 1.68, 95% CI 1.36-2.08, I²= 34%). The effect was reduced but remained significant when longest available follow-up periods were pooled (RR 1.23, 95% CI 1.04-1.48, I² = 0%). There was moderate-to-high risk of bias in most studies. Certainty of evidence was low.

CONCLUSIONS

Behavioural and behavioural + pharmacotherapy interventions for smoking cessation targeting women in low SES groups or women living in areas of disadvantage were effective in the short term. However, longer follow-up periods indicated reduced effectiveness. Future studies to explore ways to prevent smoking relapse in this population are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42019130160.

Evaluation of the Efficacy of a Smoking Cessation Intervention for Cervical Cancer Survivors and Women With High-Grade Cervical Dysplasia: Protocol for a Randomized Controlled Trial

BACKGROUND

The prevalence of smoking among cervical cancer survivors is strikingly high, yet no smoking cessation interventions to date have specifically targeted this population. This paper describes the study design, methods, and data analysis plans for a randomized clinical trial designed to evaluate the efficacy of a theoretically and empirically based Motivation And Problem Solving (MAPS) approach for promoting and facilitating smoking cessation among cervical cancer survivors. MAPS is a comprehensive, dynamic, and holistic intervention that incorporates empirically supported cognitive behavioral and social cognitive theory-based treatment strategies within an overarching motivational framework. MAPS is designed to be appropriate for all smokers regardless of their motivation to change and views motivation as dynamically fluctuating from moment to moment throughout the behavior change process.

OBJECTIVE

This 2-group randomized controlled trial compares the efficacy of standard treatment to MAPS in facilitating smoking cessation among women with a history of high-grade cervical dysplasia or cervical cancer.

METHODS

Participants (N=202) are current smokers with a history of high-grade cervical dysplasia or cervical cancer recruited nationally and randomly assigned to one of two treatment conditions: (1) standard treatment (ST) or (2) MAPS. ST consists of repeated letters referring participants to their state's tobacco cessation quitline, standard self-help materials, and free nicotine replacement therapy when ready to quit. MAPS has all ST components along with 6 proactive telephone counseling sessions delivered over 12 months. The primary outcome is abstinence from tobacco at 18 months. Secondary outcomes include abstinence over time across all assessment points, abstinence at other individual assessment time points, quit attempts, cigarettes per day, and use of state quitlines. Hypothesized treatment mechanisms and cost-effectiveness will also be evaluated.

RESULTS

This study was approved by the institutional review boards at the University of Texas MD Anderson Cancer Center, the University of Oklahoma Health Sciences Center, and Moffitt Cancer Center. Participant enrollment concluded at Moffitt Cancer Center in January 2020, and follow-up data collection was completed in July 2021. Data analysis is ongoing.

CONCLUSIONS

This study will yield crucial information regarding the efficacy and cost-effectiveness of a MAPS approach for smoking cessation tailored to the specific needs of women with a history of high-grade cervical dysplasia or cervical cancer. Findings indicating that MAPS has substantially greater efficacy than existing evidence-based tobacco cessation treatments would have tremendous public health significance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02157610; https://clinicaltrials.gov/ct2/show/NCT02157610.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34502.

Cervical cytopathological changes in pregnancy: An experience from a low resource setting

Background:

Cervical cancer is the leading cause of death among women in developing countries. It is preventable through effective cervical cancer screening program. However, in Nigeria, screening programs are opportunistic and coverage is insufficient to make an impact.

Aim:

This study assessed the cervical cytopathological changes among pregnant women at booking using liquid-based cytology (LBC) in Aminu Kano Teaching Hospital (AKTH).

Methodology:

This was a cross-sectional study that was carried out at the antenatal Clinic of AKTH, Kano, Nigeria. A total of 161 pregnant women who fulfilled the criteria and gave their consent were recruited into the study using systematic sampling technique at booking for antenatal care. LBC was employed using standard procedure and samples sent to histopathology department for analysis. Pro forma developed for the study was used to obtain the socio-demographic and reproductive characteristics of the women and the risk factors for abnormal cervical cytology.

Results:

Out of the 161 pregnant women that had cervical cytology screening using LBC on their first prenatal visit during the study, 22 had abnormal cervical cytology, giving a prevalence rate of 13.7%. Out of this, six (27.3%) were atypical squamous cells of undetermined significance, 3 (13.6%) were Atypical Squamous Cells, Cannot Rule Out HSIL (ASC-H), 11 (50.0%) were low-grade Squamous Intraepithelial Lesions while 2 (9.1%) were high grade squamous intraepithelial lesions. Negative smears were seen in 104 women (64.6%). Inflammatory and other conditions of the cervix which are technically negative smears made up the remaining 21.7%. There was a statistically significant association between cervical cytology results and advanced age (P < 0.01), increasing number of lifetime sexual partners since coitarche (P < 0.01), high parity (P < 0.01), absent previous Pap test (P < 0.027), previous history of sexually transmitted infections (P < 0.040), and positive HIV status (P < 0.001). Following binary logistic regression, advanced maternal age, increasing number of sexual partners, high parity, and positive HIV status stood out to be independent predictors of premalignant lesions of the cervix in pregnancy in this study.

Conclusion:

Advanced maternal age, increasing number of sexual partners, high parity, and positive HIV status stood out to be independent predictors of premalignant lesions of the cervix in the study. Routine cervical cytology screening using LBC should be offered to all antenatal clients in our setting to increase coverage and detection rate of preinvasive lesions of the cervix, and/or pregnant women with increased risk of abnormal cervical cytology from this study.

Efficacy and safety of photodynamic therapy mediated by 5-aminolevulinic acid for the treatment of cervical intraepithelial neoplasia 2: A single-center, prospective, cohort study

BACKGROUND

Photodynamic therapy (PDT) mediated by 5-aminolevulinic acid (5-ALA) is a minimally-invasive treatment for cervical intraepithelial neoplasia (CIN). The present study was carried out to investigate the effect of 5-ALA-PDT on CIN2 and the factors influencing outcome of 5-ALA-PDT.

METHODS

Patients diagnosed as CIN2 who met the inclusion criteria were enrolled in this study sequentially from January 2019 to April 2020. Patients were treated by PDT or cryotherapy according to their intentions. The primary endpoint was pathological regression. The secondary endpoint was HPV clearance. Affecting factors of the efficacy of PDT and adverse events were also assessed during treatment.

RESULTS

A total of 210 patients were enrolled, including 97 patients in PDT group and 101 patients in cryotherapy group, with 12 patients excluded. There was no statistical difference in population characteristics. The pathological regression rate in PDT group was 92.0% (80/87), compared with 81.4% (79/97) in cryotherapy group (P < 0.05). The HPV clearance rate was 64.4% (56/87) in PDT group and 57.8% (56/97) in cryotherapy group (P = 0.36). The main side effects of PDT were abdominal pain (24.1%, 21/87) and increased vaginal secretions (23.0%, 20/87). On univariate analysis, the risk for lesions persisting at 6 months after PDT was increased by recurrent genital tract inflammation (P = 0.004), smoking or passive smoking (P = 0.020), and multicentric lesions (P = 0.020).

CONCLUSION

PDT can be a safe and efficient treatment for CIN2. Risk factors for persisting HSIL after PDT include recurrent genital tract inflammation, smoking or passive smoking, and multicentric lesions.

Is smoking an independent risk factor for developing cervical intra-epithelial neoplasia and cervical cancer? A systematic review and meta-analysis

Introduction: Cervical cancer is the fourth most common form of cancer among women. Smoking tobacco seems to be a risk factor for the development of cervical intra-epithelial neoplasia (CIN) and cervical cancer, but the exact role of smoking in the process of cervical carcinogenesis is not known. The aim of this study is to investigate the relationship between smoking and the development of CIN and cervical cancer. Areas covered: We searched Embase, Medline, Cochrane Central, Web of Science, and Google Scholar for studies on smoking and CIN and cervical cancer, published between 2009 and 2018. The following were the outcomes: CIN3 alone, CIN2 and CIN3 combined, CIN2+, CIN3+, and cervical cancer alone. We included 49 studies in our review and 45 in our meta-analyses. Expert opinion: Based on the available evidence it can be - cautiously - concluded that smoking increases the risk of cervical abnormalities. However, the high risk of bias indicates that for future studies, it will be important to adjust for relevant predictors, to separate CIN from cervical cancer as outcome measures, and to report research methods in detail.

Aerobic Vaginitis-Underestimated Risk Factor for Cervical Intraepithelial Neoplasia

The aim of this study is to analyse the association between vaginal microbiota and the histological finding of CIN. From July 2016 until June 2017, we included 110 consecutive patients with abnormal cervical cytology results referred for colposcopy to Riga East Clinical University Hospital Outpatient department in the study group. 118 women without cervical pathology were chosen as controls. Certified colposcopists performed interviews, gynaecological examinations and colposcopies for all participants. Material from the upper vaginal fornix was taken for pH measurement and wet-mount microscopy. Cervical biopsy samples were taken from all subjects in the study group and in case of a visual suspicion for CIN in the control group. Cervical pathology was more often associated with smoking (34.6% vs. 11.0%, p < 0.0001), low education level (47.2% vs. 25.5%, p = 0.001), increased vaginal pH (48.2% vs. 25.4%, p < 0.0001), abnormal vaginal microbiota (50% vs. 31.4%, p = 0.004) and moderate to severe aerobic vaginitis (msAV) (13.6% vs. 5.9%, p = 0.049) compared to controls. The most important independent risk factors associated with CIN2+ were smoking (OR 3.04 (95% CI 1.37–6.76), p = 0.006) and msAV (OR 3.18 (95% CI 1.13–8.93), p = 0.028). Bacterial vaginosis (BV) was found more often in CIN1 patients (8/31, 25.8%, p = 0.009) compared with healthy controls (8/118, 6.8%), or CIN2+ cases (8/79, 10.1%). In the current study msAV and smoking were the most significant factors in the development of CIN in HPV-infected women, especially high grade CIN. We suggest that AV changes are probably more important than the presence of BV in the pathogenesis of CIN and progression to cervix cancer and should not be ignored during the evaluation of the vaginal microbiota.

Incidence and mortality from cervical cancer and other malignancies after treatment of cervical intraepithelial neoplasia: a systematic review and meta-analysis of the literature

BACKGROUND

Although local treatments for cervical intraepithelial neoplasia (CIN) are highly effective, it has been reported that treated women remain at increased risk of cervical and other cancers. Our aim is to explore the risk of developing or dying from cervical cancer and other human papillomavirus (HPV)- and non-HPV-related malignancies after CIN treatment and infer its magnitude compared with the general population.

MATERIALS AND METHODS

Design: Systematic review and meta-analysis. Eligibility criteria: Studies with registry-based follow-up reporting cancer incidence or mortality after CIN treatment.

DATA SYNTHESIS

Summary effects were estimated using random-effects models.

OUTCOMES

Incidence rate of cervical cancer among women treated for CIN (per 100 000 woman-years). Relative risk (RR) of cervical cancer, other HPV-related anogenital tract cancer (vagina, vulva, anus), any cancer, and mortality, for women treated for CIN versus the general population.

RESULTS

Twenty-seven studies were eligible. The incidence rate for cervical cancer after CIN treatment was 39 per 100 000 woman-years (95% confidence interval 22-69). The RR of cervical cancer was elevated compared with the general population (3.30, 2.57-4.24; P < 0.001). The RR was higher for women more than 50 years old and remained elevated for at least 20 years after treatment. The RR of vaginal (10.84, 5.58-21.10; P < 0.001), vulvar (3.34, 2.39-4.67; P < 0.001), and anal cancer (5.11, 2.73-9.55; P < 0.001) was also higher. Mortality from cervical/vaginal cancer was elevated, but our estimate was more uncertain (RR 5.04, 0.69-36.94; P = 0.073).

CONCLUSIONS

Women treated for CIN have a considerably higher risk to be later diagnosed with cervical and other HPV-related cancers compared with the general population. The higher risk of cervical cancer lasts for at least 20 years after treatment and is higher for women more than 50 years of age. Prolonged follow-up beyond the last screening round may be warranted for previously treated women.

Inherited alterations of TGF beta signaling components in Appalachian cervical cancers

PURPOSE

This study examined targeted genomic variants of transforming growth factor beta (TGFB) signaling in Appalachian women. Appalachian women with cervical cancer were compared to healthy Appalachian counterparts to determine whether these polymorphic alleles were over-represented within this high-risk cancer population, and whether lifestyle or environmental factors modified the aggregate genetic risk in these Appalachian women.

METHODS

Appalachian women's survey data and blood samples from the Community Awareness, Resources, and Education (CARE) CARE I and CARE II studies (n = 163 invasive cervical cancer cases, 842 controls) were used to assess gene-environment interactions and cancer risk. Polymorphic allele frequencies and socio-behavioral demographic measurements were compared using t tests and χ2 tests. Multivariable logistic regression was used to evaluate interaction effects between genomic variance and demographic, behavioral, and environmental characteristics.

RESULTS

Several alleles demonstrated significant interaction with smoking (TP53 rs1042522, TGFB1 rs1800469), alcohol consumption (NQO1 rs1800566), and sexual intercourse before the age of 18 (TGFBR1 rs11466445, TGFBR1 rs7034462, TGFBR1 rs11568785). Interestingly, we noted a significant interaction between "Appalachian self-identity" variables and NQO1 rs1800566. Multivariable logistic regression of cancer status in an over-dominant TGFB1 rs1800469/TGFBR1 rs11568785 model demonstrated a 3.03-fold reduction in cervical cancer odds. Similar decreased odds (2.78-fold) were observed in an over-dominant TGFB1 rs1800469/TGFBR1 rs7034462 model in subjects who had no sexual intercourse before age 18.

CONCLUSIONS

This study reports novel associations between common low-penetrance alleles in the TGFB signaling cascade and modified risk of cervical cancer in Appalachian women. Furthermore, our unexpected findings associating Appalachian identity and NQO1 rs1800566 suggests that the complex environmental exposures that contribute to Appalachian self-identity in Appalachian cervical cancer patients represent an emerging avenue of scientific exploration.

Association between secondhand smoke exposure and abnormal cervical cytology: A one-to-one matched case-control study

INTRODUCTION

The aim was to evaluate the association between secondhand smoke (SHS) exposure and abnormal cervical cytology among Chinese adult women.

METHODS

A one-to-one matched case-control study was conducted with outpatients of the First Hospital of Jilin University between October 2013 to September 2016. In all, 228 cytologic confirmed new cases of abnormal cervical cytology and the equivalent number of age and ethnic matched controls were interviewed about SHS exposure and related factors.

RESULTS

Although 78.3% of all the participants had been exposed to SHS (78.1% subjects vs 78.5% controls), there were no statistical significance of cervical cytological abnormalities and SHS exposure status (never, former, current exposure), exposure intensity in cigarettes per day (none, 1–9, 10–19, and ≥20), SHS exposure duration in years (none, 1–9, 10–19, and ≥20) and the Brinkman Index (BI) (none, 1–99, 100–399, ≥400) between the two groups. The univariate analysis results showed that there were statistical differences between subjects and controls in marital status, sexual frequency in past year, number of sexual partners, age at first intercourse, age at first delivery. The stratified Cox regression model only showed that the age at first sexual intercourse was associated with the cervical cytological abnormalities (OR=1.206, 95% CI: 1.104–1.319).

CONCLUSIONS

Studies on the association between SHS exposure and cervical lesions have been equivocal. In this study, the SHS exposure could not be detected as an independent risk factor of abnormal cervical cytology among Chinese adult women.

Tobacco Use and Prevalence of Human Papillomavirus in Self-Collected Cervicovaginal Swabs Between 2009 and 2014

OBJECTIVE

To evaluate relationships between an objective biomarker of current tobacco exposure and high-risk genital human papillomavirus (HPV) prevalence among adult women in the United States.

METHODS

We performed a retrospective analysis of adult women (aged 18-59 years) using three consecutive 2-year cycles (2009-2014) from the cross-sectional National Health and Nutrition Examination Surveys. Women who provided self-collected cervicovaginal swabs and serum were included. Human papillomavirus genotyping was conducted on cervicovaginal samples with a Linear Array HPV assay. Cotinine, a major metabolite of nicotine, was assayed from serum to provide a biomarker of recent tobacco exposure. Participants were stratified into three levels of tobacco exposure (nonsmokers, secondhand smoke exposure, and smokers) based on serum cotinine concentration levels using previously published ethnic-specific cut points. Weighted percentages are provided to account for unequal selection probabilities among participants and adjustments for nonresponse.

RESULTS

Among the 5,158 women analyzed, 2,778 were classified as nonsmokers (57.1%, 95% CI 54.5-59.6%), 1,109 classified as having secondhand smoke exposure (18.4%, 95% CI 16.5-20.3%), and 1,271 classified as smokers (24.6%, 95% CI 22.8-26.5%) using serum cotinine concentration levels. Prevalence of HPV infection differed between nicotine exposure groups (P<.001): 441 smokers (32.1%, 95% CI 29.6-34.7%), 322 women with secondhand smoke exposure (26.1%, 95% CI 22.7-29.7%), and 451 nonsmokers (15.1%, 95% CI 13.3-17.1%) had a high-risk genital HPV infection. Controlling for demographics and number of lifetime sexual partners, the risks compared with nonsmokers for infection with a high-risk HPV genotype for smokers (adjusted odds ratio [OR] 1.7, 95% CI 1.4-22) and secondhand smokers (adjusted OR 1.4, 95% CI 1.1-1.8) are similarly increased (P<.001).

CONCLUSION

In this large cross-sectional, population-based study, we show a relationship between an objective biomarker of current tobacco use and genital HPV infection. Cigarette smoking and exposure to secondhand smoke are associated with increased odds of infection with high-risk genital HPV independent of lifetime number of sexual partners.

A retrospective study of smoking cessation intervention among university students

This retrospective study investigated the effect of smoking cessation intervention (SCI) among university students in China.Around 192 eligible smokers among university students were included, and were assigned to an intervention group (n = 100), and a control group (n = 92). All included subjects in both groups were recommended to increase fruits and vegetables consumptions. Additionally, participants in the intervention group also underwent SCI therapy for a total of 4 weeks. The outcome measurements consisted of a number of students quit smoking, daily cigarettes, quit attempts, mean days of smoking in the past 30 days, and also stage of change.After 4-week treatment, SCI neither can decrease the number of students quit smoking (P = .21), daily cigarettes (P = .21), quit attempts (P = .07), and mean days of smoking in past 30 days (P = .77), nor can enhance the stage of change (precontemplation, P = .18; contemplation, P = .59; preparation, P = .46).The results of this study showed that after 4-week therapy, SCI may be ineffective for smokers among university students in Chinese.

Smoking and subsequent human papillomavirus infection: a mediation analysis

PURPOSE

Smoking is an established risk factor for a human papillomavirus (HPV) infection advancing to cervical precancer and cancer, but its role earlier in the natural history is less clear. Smoking is inversely associated with possessing HPV antibodies from a past infection suggesting that smoking may influence acquiring subsequent infections.

METHODS

In a cohort of 1976 U.S. women, we evaluate whether reduced antibodies to HPV-16 is a mechanism for smoking's role on acquiring a subsequent HPV-16 infection, through the analytic technique of causal mediation analysis. We posit a causal model and estimate two counterfactually defined effects: a smoking impaired antibody-mediated indirect effect and a nonmediated direct effect representing all other potential mechanisms of smoking.

RESULTS

Compared to never smokers, current smokers had increased odds of HPV-16 infection by the antibody-mediated indirect effect (odds ratio [OR] = 1.29; 95% confidence interval [CI]: 1.11, 1.73); the estimated direct effect was very imprecise (OR = 0.57; 95% CI, 0.26-1.13). We observed a stronger estimated indirect effect among women who smoked at least half a pack of cigarettes daily (OR = 1.61, 95% CI, 1.27-2.15) than among women who smoked less than that threshold (OR = 1.09; 95% CI, 0.94-1.44).

CONCLUSIONS

This is the first study to directly test the mechanism underlying smoking as an HPV cofactor. The results support current smoking as a risk factor earlier in the natural history of HPV and are consistent with the hypothesis that smoking increases the risk of a subsequent infection by reducing immunity.

Incidence Trends of Cervical Cancer in Adolescents and Young Adults: Brazilian Population Based Data

PURPOSE

High incidence rates for cervical cancer in adolescents and young adults (AYAs: 15-29 years) make this the most common carcinoma in Brazil. Our aim was to analyze the incidence trends for cervical cancer (CC) and in situ neoplasia (IsN) among this age group.

METHODS

Incidence data were extracted from 21 Brazilian population-based cancer registries (PBCRs). Tumors with behavior code/3 (malignant) were classified as CC. Tumors with behavior code/2 were classified as IsN. Age-adjusted and age-specific incidence rates were calculated for individuals aged 15-19 years, 20-24 years, and 25-29 years. Incidence trends were evaluated by joinpoint regression analyses.

RESULTS

The median incidence rate of CC for AYA in Brazil was 3.63 per 100,000, with the highest rate observed in Recife (27.50 per 100,000). Significant increase in incidence for CC was identified in two PBCRs, with decreased rates for three PBCRs. The median incidence rate of IsN was 16.78 per 100,000 and was highest in Roraima (93.37 per 100,000). Increased incidence rates for IsN were identified in six PBCRs, with significant decreases in two PBCRs.

CONCLUSION

The incidence rate for CC among AYA in Brazil is high and warrants intervention in terms of both prevention and control.

Role of active and passive smoking in high-risk human papillomavirus infection and cervical intraepithelial neoplasia grade 2 or worse

Objective

We performed a pooled analysis to examine cigarette smoking and household passive smoke exposure in relation to the risk of human papillomavirus (HPV) infection and cervical intraepithelial neoplasia grade 2+ (CIN2+).

Methods

Data were pooled from 12 cross-sectional studies for cervical cancer screenings from 10 provinces of China in 1999–2007. A total of 16,422 women were analyzed, along with 2,392 high-risk-HPV (hr-HPV) positive women and 381 CIN2+ cases. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models controlling for sexual and non-sexual confounding factors.

Results

There was an excess risk between active smoking and hr-HPV infection and CIN2+. Adjusted OR for ever smokers vs. never smokers was 1.45 (95% CI=1.10–1.91), for hr-HPV infection and 1.89 (95% CI=1.03–3.44), for CIN2+. Passive smoking had a slightly increased risk on the hr-HPV infection with adjusted OR 1.11 (1.00–1.24), but no statistical association was observed between passive smoke exposure and CIN2+. Compared with the neither active nor passive smokers, both active and passive smokers had a 1.57-fold (95% CI=1.14–2.15) increased risk of HPV infection and a 1.99-fold (95% CI=1.02–3.88) risk of CIN2+.

Conclusion

Our large multi-center cross-sectional study found active smoking could increase the risk of overall hr-HPV infection and CIN2+ adjusted by passive smoking and other factors. Passive smoking mildly increased the risk of HPV infection but not the CIN2+. An interaction existed between passive tobacco exposure and active smoking for hr-HPV infection and the CIN2+.

Nicotine and Tobacco as Substances of Abuse in Children and Adolescents

Nicotine is the primary pharmacologic component of tobacco, and users of tobacco products seek out its effects. The highly addictive nature of nicotine is responsible for its widespread use and difficulty with quitting. This technical report focuses on nicotine and discusses the stages of use in progression to dependence on nicotine-containing products; the physiologic characteristics, neurobiology, metabolism, pharmacogenetics, and health effects of nicotine; and acute nicotine toxicity. Finally, some newer approaches to cessation are noted.

Genetic polymorphisms of glutathione S transferase and cervical intraepithelial neoplasia

Aim: The present study aim to analyze the relationship between GST M/T genotypes of glutathione S-transferases and cervical intraepithelial neoplasia.

Materials and Methods: A prospective case-control study has been designed including 69 cases with different degrees of cervical dysplasia and 107 controls. All patients had been examined colposcopically. For every patient both cervical and blood specimen have been obtained. The peripheral blood was used for GST M/T genotyping. The statistical analysis was performed using OR and chi-square at a level of significance inferior to 0.05.

Results: No statistically significant differences had been found between cases and controls for GST T-/M- geno-type (T-/M-, χ2=0.03, p= 0.8610) and T+/M+ χ2=0.65, p = 0.4197. Patients with in situ carcinoma had significant GST genotype association for T-/M+ genotype (OR=4.66, CI 95% [0.6528,24.9725], χ2=4.6, p=0.0314) and for T+/M- genotype (OR=0.12, CI 95% [0.0027,0.9465], χ2=0.05, p=0.0219).

Conclusion: The combination of GST genotypes can be included in a predictive score for patients with cervical carcinoma.

Progression of HPV infection to detectable cervical lesions or clearance in adult women: Analysis of the control arm of the VIVIANE study

The control arm of the phase III VIVIANE (Human PapillomaVIrus: Vaccine Immunogenicity ANd Efficacy; NCT00294047) study in women >25 years was studied to assess risk of progression from cervical HPV infection to detectable cervical intraepithelial neoplasia (CIN). The risk of detecting CIN associated with the same HPV type as the reference infection was analysed using Kaplan–Meier and multivariable Cox models. Infections were categorised depending upon persistence as 6‐month persistent infection (6MPI) or infection of any duration. The 4‐year interim analysis included 2,838 women, of whom 1,073 (37.8%) experienced 2,615 infections of any duration and 708 (24.9%) experienced 1,130 6MPIs. Infection with oncogenic HPV types significantly increased the risk of detecting CIN grade 2 or greater (CIN2+) versus non‐oncogenic types. For 6MPI, the highest risk was associated with HPV‐33 (hazard ratio [HR]: 31.9 [8.3–122.2, p < 0.0001]). The next highest risk was with HPV‐16 (21.1 [6.3–70.0], p < 0.0001). Similar findings were seen for infections of any duration. Significant risk was also observed for HPV‐18, HPV‐31, and HPV‐45. Concomitant HPV infection or CIN grade 1 or greater associated with a different oncogenic HPV type increased risk. Most women (79.3%) with an HPV infection at baseline cleared detectable infections of any duration, and 69.9% cleared a 6MPI. The risk of progression of HPV infection to CIN2+ in women >25 years in this study was similar to that in women 15–25 years in PATRICIA.

What's New?

Which HPV infections lead to cancer in women over 25 years? Most cervical cancer follows persistent oncogenic HPV infection, but most HPV infections clear naturally. Thus, to best predict patient outcomes, it's imperative to understand how HPV infections progress to CINs. This study confirmed that in women over 25 years, persistent infection with HPV‐33 or HPV‐16 meant the greatest chance of developing a CIN—the same as was found in women 15–25 years, in an earlier analysis.

What factors are important in smoking cessation and relapse in women from deprived communities? A qualitative study in Southeast England

OBJECTIVES

Women are relatively more susceptible to smoking-related diseases and find it more difficult to quit; however, little research exists on factors associated with smoking cessation and relapse in women. We examined attitudes towards and perceptions of factors associated with smoking cessation and relapse in women from deprived communities.

STUDY DESIGN

Qualitative interview study.

METHODS

Participants included eleven women, smokers and ex-smokers, from disadvantaged communities in East Sussex, England, who had used the National Health Service (NHS) stop smoking service. Data were collected through a focus group and semi-structured interviews, and subjected to thematic analysis.

RESULTS

Participants opined that it is more difficult for women to quit smoking than men. Women felt that postcessation weight gain was inevitable and acted as a barrier to quitting. Hormonal fluctuations during the menstrual cycle and greater levels of stress were perceived as obstacles to quitting and reasons for relapse. Conversely, the women cited effects of smoking on physical appearance, oral hygiene and guilt about exposing children to passive smoke as powerful motivators to quit; and highlighted the impact of public health campaigns that focused on these factors. Views diverged on whether quitting with someone close to you is a help or hindrance. Other themes including alcohol intake, daily routine and being in the presence of smokers emerged as situational triggers of relapse.

CONCLUSIONS

Interventions that address women's concerns related to postcessation weight gain, hormonal fluctuations during the menstrual cycle and stress may aid with smoking cessation and reduce relapse. Public health campaigns should consider the impact of smoking on physical appearance and the effect of passive smoke on children.

Intervention study for smoking cessation in Spanish college students: pragmatic randomized controlled trial

AIM

To evaluate the effectiveness of a nurse intervention aimed at helping college student smokers quit smoking.

DESIGN

Single-blind, pragmatic randomized controlled trial which compares a multi-component intervention, tailored specifically to college students, with a brief advice session with a 6-month follow-up.

SETTINGS

This study was conducted at the University of Navarra, Spain.

PARTICIPANTS

A total of 255 college student smokers (age range = 18-24 years) were randomized to an intervention group (n = 133) or to a control group (n = 122).

INTERVENTION

A multi-component intervention based on the Theory of Triadic Influence of Flay was developed. The intervention consisted of a 50-minute motivational interview conducted by a nurse and online self-help material. The follow-up included a reinforcing e-mail and group therapy.

MEASUREMENTS

The primary outcome was self-reported abstinence, with biochemical verification at 6 months. The secondary outcomes consisted of the mean number of cigarettes smoked per day, self-reported attempts to quit smoking and stage of change at 6 months.

FINDINGS

At the 6-month follow-up, the smoking cessation incidence was 21.1% in the intervention group compared with 6.6% in the control group (difference = 14.5 confidence interval = 6.1-22.8; relative risk = 3.41, 95% confidence interval = 1.62-7.20). The difference in the mean number of cigarettes at 6 months was significantly different (difference = -2.2, confidence interval = -3.6 to -0.9).

CONCLUSIONS

A multi-component intervention tailored to college students and managed by a nurse is effective in increasing smoking cessation among college students.

Development of a risk index for prediction of abnormal pap test results in Serbia

BACKGROUND

Serbia is one of the countries with highest incidence and mortality rates for cervical cancer in Central and South Eastern Europe. Introducing a risk index could provide a powerful means for targeting groups at high likelihood of having an abnormal cervical smear and increase efficiency of screening. The aim of the present study was to create and assess validity ofa index for prediction of an abnormal Pap test result.

MATERIALS AND METHODS

The study population was drawn from patients attending Departments for Women's Health in two primary health care centers in Serbia. Out of 525 respondents 350 were randomly selected and data obtained from them were used as the index creation dataset. Data obtained from the remaining 175 were used as an index validation data set.

RESULTS

Age at first intercourse under 18, more than 4 sexual partners, history of STD and multiparity were attributed statistical weights 16, 15, 14 and 13, respectively. The distribution of index scores in index-creation data set showed that most respondents had a score 0 (54.9%). In the index-creation dataset mean index score was 10.3 (SD-13.8), and in the validation dataset the mean was 9.1 (SD=13.2).

CONCLUSIONS

The advantage of such scoring system is that it is simple, consisting of only four elements, so it could be applied to identify women with high risk for cervical cancer that would be referred for further examination.

Excisional treatments of the cervix and effect on subsequent fertility: a retrospective cohort study

OBJECTIVE

Concerns exist regarding the impact of excisional treatments for cervical intraepithelial neoplasia (CIN) on subsequent pregnancy outcome yet few studies have addressed fertility following surgery.

STUDY DESIGN

Retrospective cohort study. Set in the colposcopy service of National Maternity Hospital. A postal questionnaire was sent to 3590 women of reproductive age who attended colposcopy from 2001 to 2007; 1795 of these had at least one excisional treatment (surgical group) and 1795 had no treatment (non-surgical group). Records were reviewed to confirm the clinical details and volume of tissue excised. The main outcome measures were pregnancy and fertility rates as well as time to conception correlated with volume of tissue excised. Students' t-test, Mann-Whitney U-test, spearman correlation and Kruskal-Wallis tests were used during the analysis.

RESULTS

1355 Women (37.7%) responded. 537 Women had no treatment and 818 had at least one excision. A subsequent pregnancy was reported in 730 women (434 surgical and 296 non-surgical groups). No difference was detected between the groups in the reported pregnancy rates (p=0.56), the time to conception (p=0.37) or fertility problems (p=0.89). The volume of the excision did not affect fertility rates or time to conception. There were fewer pregnancies in women following a cold knife cone or more than one LLETZ treatment-significant surgery, (p=0.004) but no difference in their reported time to conception (p=0.54).

CONCLUSIONS

One excisional treatment for CIN does not appear to affect subsequent fertility. Our study showed no delay in conception and no increased risk of problems conceiving in this group, even when controlling for the volume and depth of tissue removed. Women should be reassured by these results. Further work is required to evaluate the effect of cold knife cone biopsy and repeated LLETZ procedures on subsequent fertility.

Women's attitude toward smoking: effect of a community-based intervention on smoking-related social norms

BACKGROUND

Smoking has long been discouraged in Iranian women. However, in recent years, more women have started smoking. This study aimed to investigate the role of women's attitude towards smoking on smoking prevalence in women in the context of a community-based intervention program.

METHODS

Participants were samples of the third and fifth evaluation stages of the 'Isfahan Healthy Heart Program', which is a comprehensive community-based intervention program for noncommunicable disease prevention and control. A total of 3112 and 4794 women were investigated in 2004 and 2007, respectively. Intervention and reference groups were assessed for smoking habits and attitude towards smoking. T test and chi-square test were used to compare the parameters between the intervention and the reference groups.

RESULTS

Negative attitude towards smoking increased significantly in the intervention and the reference groups from 2004 to 2007 (P = 0.0001). Negative attitude towards smoking in women decreased significantly in the intervention group (P = 0.0001), whereas it increased significantly in the reference group (P = 0.0001). However, smoking prevalence showed a significant decrease in women in the intervention group, from 2.5 to 1% (P < 0.0001) and a nonsignificant decrease in the reference group.

CONCLUSION

A change in social norms towards acceptability of smoking for women can be overcome by effective strategies that discourage the population from smoking.

Prevalence and risk factors for cervical neoplasia: a cervical cancer screening program in Beijing

Background

Cervical cancer is the second most common cancer and cause of cancer-related death for women worldwide. The aims of this study were to investigate the prevalence of cervical neoplasia and examine factors associated with high-grade cervical squamous intraepithelial lesions (HSIL) among women taking part in a cervical cancer screening program in Beijing.

Methods

Women aged 25–65 years were screened using the ThinPrep cytologic test and gynecologic examination. Univariate and multivariate logistic regressions were conducted to investigate factors associated with HSIL.

Results

Among 728,704 women screened, the prevalence of cervical intraepithelial neoplasia (CIN) I, II, III was 50.2, 34.0, and 36.4 per 100,000, respectively. Prevalence of cervical cancer was 12.2 per 100,000. Risk factors for HSIL included being in age group of 46–55 years (adjusted odds ratio [aOR] = 1.15, 95% CI: 1.07–1.44, compared with the 25–35 age group), bleeding after intercourse (aOR = 2.08, 95% CI: 1.40–3.10), and presence of trichomonas vaginalis infection (aOR = 2.62, 95% CI: 1.35–5.07), cervical inflammation (aOR = 4.22, 95% CI: 3.39–5.26), and genital warts (aOR = 3.89, 95% CI: 2.54–7.70). High education level (college and above compared with junior middle school or lower) was found to be protective (aOR = 0.79, 95% CI: 0.37–0.90).

Conclusions

The prevalence of cervical neoplasia is relatively high in Beijing. Women aged 46–55 years, those with a lower education level, those reporting bleeding after intercourse, and those affected by Trichomonas vaginalis infection, cervical inflammation and genital warts are at higher risk for HSIL. Particular efforts should be made to ensure these women are included in cervical cancer screening programs.

Tobacco exposure results in increased E6 and E7 oncogene expression, DNA damage and mutation rates in cells maintaining episomal human papillomavirus 16 genomes

High-risk human papillomavirus (HR-HPV) infections are necessary but insufficient agents of cervical and other epithelial cancers. Epidemiological studies support a causal, but ill-defined, relationship between tobacco smoking and cervical malignancies. In this study, we used mainstream tobacco smoke condensate (MSTS-C) treatments of cervical cell lines that maintain either episomal or integrated HPV16 or HPV31 genomes to model tobacco smoke exposure to the cervical epithelium of the smoker. MSTS-C exposure caused a dose-dependent increase in viral genome replication and correspondingly higher early gene transcription in cells with episomal HPV genomes. However, MSTS-C exposure in cells with integrated HR-HPV genomes had no effect on genome copy number or early gene transcription. In cells with episomal HPV genomes, the MSTS-C-induced increases in E6 oncogene transcription led to decreased p53 protein levels and activity. As expected from loss of p53 activity in tobacco-exposed cells, DNA strand breaks were significantly higher but apoptosis was minimal compared with cells containing integrated viral genomes. Furthermore, DNA mutation frequencies were higher in surviving cells with HPV episomes. These findings provide increased understanding of tobacco smoke exposure risk in HPV infection and indicate tobacco smoking acts more directly to alter HR-HPV oncogene expression in cells that maintain episomal viral genomes. This suggests a more prominent role for tobacco smoke in earlier stages of HPV-related cancer progression.

Evaluation of HPV infection and smoking status impacts on cell proliferation in epithelial layers of cervical neoplasia

Accurate cervical intra-epithelial neoplasia (CIN) lesion grading is needed for effective patient management. We applied computer-assisted scanning and analytic approaches to immuno-stained CIN lesion sections to more accurately delineate disease states and decipher cell proliferation impacts from HPV and smoking within individual epithelial layers. A patient cohort undergoing cervical screening was identified (n = 196) and biopsies of varying disease grades and with intact basement membranes and epithelial layers were obtained (n = 261). Specimens were sectioned, stained (Mib1), and scanned using a high-resolution imaging system. We achieved semi-automated delineation of proliferation status and epithelial cell layers using Otsu segmentation, manual image review, Voronoi tessellation, and immuno-staining. Data were interrogated against known status for HPV infection, smoking, and disease grade. We observed increased cell proliferation and decreased epithelial thickness with increased disease grade (when analyzing the epithelium at full thickness). Analysis within individual cell layers showed a ≥50% increase in cell proliferation for CIN2 vs. CIN1 lesions in higher epithelial layers (with minimal differences seen in basal/parabasal layers). Higher rates of proliferation for HPV-positive vs. -negative cases were seen in epithelial layers beyond the basal/parabasal layers in normal and CIN1 tissues. Comparing smokers vs. non-smokers, we observed increased cell proliferation in parabasal (low and high grade lesions) and basal layers (high grade only). In sum, we report CIN grade-specific differences in cell proliferation within individual epithelial layers. We also show HPV and smoking impacts on cell layer-specific proliferation. Our findings yield insight into CIN progression biology and demonstrate that rigorous, semi-automated imaging of histopathological specimens may be applied to improve disease grading accuracy.

Smoking as a major risk factor for cervical cancer and pre-cancer: results from the EPIC cohort

A total of 308,036 women were selected from the European Prospective Investigation into Cancer and Nutrition (EPIC) study to evaluate the association between tobacco smoking and the risk of cervical intraepithelial neoplasia of grade 3 (CIN3)/carcinoma in situ (CIS) and invasive cervical cancer (ICC). At baseline, participants completed a questionnaire and provided blood samples. During a mean follow-up time of 9 years, 261 ICC cases and 804 CIN3/CIS cases were reported. In a nested case-control study, the baseline sera from 609 cases and 1,218 matched controls were tested for L1 antibodies against HPV types 11, 16, 18, 31, 33, 35, 45, 52, 58, and antibodies against Chlamydia trachomatis (CT), and Human Herpes Virus 2 (HHV-2). Cervical samples were not available for HPV-DNA analysis in this study. Multivariate analyses were used to estimate associations between smoking and risk of CIN3/CIS and ICC in the cohort and the case-control studies. In the cohort analyses smoking status, duration and intensity showed a two-fold increased risk of CIN3/CIS and ICC, while time since quitting was associated with a two-fold reduced risk. In the nested case-control study, consistent associations were observed after adjustment for HPV, CT and HHV-2 serostatus, in both HPV seronegative and seropositive women. Results from this large prospective study confirm the role of tobacco smoking as an important risk factor for both CIN3/CIS and ICC, even after taking into account HPV exposure as determined by HPV serology. The strong beneficial effect of quitting smoking is an important finding that will further support public health policies for smoking cessation.

Cytokine profile in cervical mucosa of Japanese patients with cervical intraepithelial neoplasia

BACKGROUND

Immune responses in the uterine cervix are considered to play an important role in persistent human papillomavirus (HPV) infection and carcinogenesis, but many aspects of the mechanism are still unclear. The goal of this study was to measure cytokines to analyze immune responses in patients with cervical intraepithelial neoplasia (CIN).

MATERIALS AND METHODS

The levels of 17 cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, G-CSF, GM-CSF, INF-γ, MCP-1, MIP-1β, and TNFα) in cervical mucus were simultaneously measured using a multiplex immunoassay in 52 high-grade squamous intraepithelial lesion (HSIL) cases and overproduction of IL-1β, IL-8, and MIP-1β was identified. The levels of these 3 cytokines were measured in 130 patients with or without CIN lesions using enzyme-linked immunosorbent assay. The associations of the cytokine levels with the cytology, infecting HPV type, and status of cigarette smoking were investigated.

RESULTS

IL-1β and IL-8 levels were associated with the cytology, and these levels were higher in HSIL cases than in NILM (negative for intraepithelial lesion and malignancy) and LSIL (low-grade squamous intraepithelial lesion) cases (P = 0.005, P = 0.001, respectively). The MIP-1β level was significantly lower in smokers (P = 0.018) and high-risk (HR)-HPV-infected patients (P = 0.021).

CONCLUSIONS

Enhanced expression of IL-1β and IL-8 indicates that Th2 inflammatory responses become stronger in the local uterine cervical region with the progression of CIN lesions, and a decrease in the MIP-1β level may be advantageous for immunoescape of HPV. Cigarette smoking may further facilitate persistent HPV infection.

Women and Smoking: The Effect of Gender on the Epidemiology, Health Effects, and Cessation of Smoking

Smoking is still the leading cause of premature morbidity and mortality. This paper examines new research on gender differences and the epidemiology of smoking, smoking-related morbidity and mortality, and factors that affect smoking cessation. The rate of decline in the prevalence of smoking has been slowing, especially among adolescent girls. New research suggests that, compared with men, women may be more susceptible to smoking-related morbidity and mortality. Gender-related barriers to smoking cessation include weight gain, sex hormones, and mood. Furthermore, the sensory aspects of smoking may have more of an effect on smoking treatment for women than for men. We discuss new studies that examine smoking-cessation interventions that may be particularly beneficial for women, including exercise (as an adjunct intervention), very low nicotine content cigarettes, and a variety of pharmacotherapy. Further research is needed to identify and target the gender-specific needs of smokers.

Is cancer risk still reduced if you give up smoking in later life?

SUMMARY This report summarizes the experimental and epidemiological evidence examining the ability of smoking cessation to influence cancer risk reduction in later life. Available evidence suggests that smoking cessation even in later years can significantly reduce mortality and yield risk reductions for many cancers including lung, oral, head and neck, and stomach cancer, among others. More research is necessary to accurately quantify the degree of cancer risk reduction for particular age groups and to calculate the minimum time of cessation necessary to produce a significant benefit for the patient. Smoking cessation is the only approach that has been shown to effectively reduce the risk of many cancers on a mass scale. Considering this, we recommend that healthcare providers communicate these benefits to patients at every opportunity and reinforce the notion that it is never too late to quit smoking.

Alcohol consumption and viral load are synergistically associated with CIN1

Purpose

We investigated the association between alcohol consumption and risk of cervical intraepithelial neoplasia (CIN) and cervical cancer, and determined whether these associations were modified by human papillomavirus (HPV) viral load in high-risk HPV-positive women participating in the Korean HPV cohort study (KHPV).

Methods

Among the women recruited in the KHPV (n = 1,243) from March 2006 to December 2009, we analyzed normal cytology (n = 581) as control group, CIN1 (n = 299), CIN2/3 (n = 161), or cervical cancer (n = 202). Multinomial logistic analysis was performed to estimate multivariate-adjusted odds ratios (OR).

Results

Alcohol drinkers had an increased risk of CIN1 (OR = 2.18, 95% CI 1.22–3.89) compared with non-drinkers after adjusting for potential confounders. Subjects with more frequent alcohol consumption had a higher risk of CIN1 (p for linear trend <0.0001). Higher ethanol consumption was associated with an increased risk of CIN1 (p for linear trend = 0.0001). We also observed a synergistic effect between HPV viral load and alcohol consumption: drinkers with a high HPV viral load (≥100 RLU/PC) were associated with a significantly increased risk of CIN1 (OR = 19.1; 95% CI, 6.60–55.3, interaction p<0.001). There were no associations between alcohol drinking and CIN2/3 or cervical cancer.

Conclusions

HPV viral load and alcohol was associated with the risk of CIN1 among high-risk HPV-positive women. This is the first demonstration that alcohol is an independent and combined risk factor of CIN1.

Smoking and genital human papilloma virus infection in women attending cervical cancer screening in Greece

AIM: To investigate whether smoking is associated with human papilloma virus (HPV) infection.

METHODS: HPV infection is considered to be a necessary condition for cervical cancer development. The study population included 1291 women, aged 25-55 years, attending cervical cancer screening. All women had a Papanicolaou (Pap) test, with liquid-based cytology (Thinprep^®), an HPV-DNA test and an evaluation of smoking habits. The COBAS^® 4800 system was used for HPV-DNA testing, enabling identification of the following high-risk HPV (hrHPV)-types: each of HPVs 16 and 18 separately, and HPVs 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 as a cocktail. The evaluation of smoking habits was assessed using the smoking intensity index (SII), a variable formed as the product of cigarettes consumed per day by the days (years × 365) that a woman was a smoker, divided by 1000.

RESULTS: There were 136 smokers among 238 women tested positive for hrHPV-types (HPVs 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and/or 68), and 463 smokers among 1053 hrHPV-negative women (OR = 1.7, P < 0.001). This association was attributed to the youngest age group of women, aged 25-34 years (OR = 2.3, P < 0.001), while there was no association in other age groups. The intensity of smoking (increasing SII) showed no statistically significant association with hrHPV infection. Cervical infection with HPV 16 and/or HPV 18 was also not associated with age or smoking habits. Finally, no association was found between Pap test status and smoking habits or smoking intensity.

CONCLUSION: Smoking appears to be associated with hrHPV infection of the uterine cervix, particularly in younger women. Further studies should investigate whether this association is based on causality and evaluate the role of other possible co-factors.

Association of TAP gene polymorphisms and risk of cervical intraepithelial neoplasia

BACKGROUND

Transporter associated with antigen processing (TAP) is responsible for peptide loading onto class I major histocompatibility complex (MHC-I) molecules. TAP seems to facilitate the detection of HPV by MHC-I molecules and contributes to successful eradication of HPV. TAP polymorphisms could have an important impact on the course of HPV infection.

OBJECTIVE

The aim of this study is to evaluate the association between five TAP gene polymorphisms and the risk of CIN. Methods. This case-control study investigated five common TAP polymorphisms in TAP1 (1341 and 2254) and TAP2 (1135, 1693, and 1993) in 616 women with CIN and 206 controls. Associations between gene polymorphisms and risk of CIN were analysed by univariate and multivariable models. The combined effect of the five TAP gene polymorphisms on the risk for CIN was investigated by haplotype analysis.

RESULTS

No significant difference in genotype distribution of the five TAP polymorphisms was observed in women with CIN and controls. Haplotype analysis revealed that women with haplotype mut-wt-wt-wt-wt (TAP polymorphisms t1135-t1341-t1693-t1993-t2254) had a significantly lower risk for CIN, compared to women with the haplotype wt-wt-wt-wt-wt (P = 0.006; OR 0.5 [0.35-0.84]).

CONCLUSION

Identification of this haplotype combination could be used to identify women, less susceptible for development of CIN following HPV infection.

Human papillomavirus: what every provider should know

Persistence of human papillomavirus (HPV) infection is necessary for the development of cervical cancer. Additionally, infection with HPV is implicated in the majority of cases of other genital tract malignancies including vulvar, penile, and vaginal cancer. HPV testing and vaccination are a routine part of obstetrical/gynecological clinical practice. With an enhanced public awareness of HPV infections, many patients turn to their obstetricians/gynecologists with questions about transmission, testing, and prevention. In this review, we will discuss the biology of HPV, epidemiology of disease, methods and indications for testing, and vaccination strategies.