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Han S, Chen X, Li Z. Innate Immune Program in Formation of Tumor-Initiating Cells from Cells-of-Origin of Breast, Prostate, and Ovarian Cancers. Cancers (Basel) 2023; 15:cancers15030757. [PMID: 36765715 PMCID: PMC9913549 DOI: 10.3390/cancers15030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
Tumor-initiating cells (TICs), also known as cancer stem cells (CSCs), are cancer cells that can initiate a tumor, possess self-renewal capacity, and can contribute to tumor heterogeneity. TICs/CSCs are developed from their cells-of-origin. In breast, prostate, and ovarian cancers, progenitor cells for mammary alveolar cells, prostate luminal (secretory) cells, and fallopian tube secretory cells are the preferred cellular origins for their corresponding cancer types. These luminal progenitors (LPs) express common innate immune program (e.g., Toll-like receptor (TLR) signaling)-related genes. Microbes such as bacteria are now found in breast, prostate, and fallopian tube tissues and their corresponding cancer types, raising the possibility that their LPs may sense the presence of microbes and trigger their innate immune/TLR pathways, leading to an inflammatory microenvironment. Crosstalk between immune cells (e.g., macrophages) and affected epithelial cells (e.g., LPs) may eventually contribute to formation of TICs/CSCs from their corresponding LPs, in part via STAT3 and/or NFκB pathways. As such, TICs/CSCs can inherit expression of innate-immunity/TLR-pathway-related genes from their cells-of-origin; the innate immune program may also represent their unique vulnerability, which can be explored therapeutically (e.g., by enhancing immunotherapy via augmenting TLR signaling).
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Affiliation(s)
- Sen Han
- Division of Genetics, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Xueqing Chen
- Division of Genetics, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Zhe Li
- Division of Genetics, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-617-525-4740
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Brown M. Engaging Pattern Recognition Receptors in Solid Tumors to Generate Systemic Antitumor Immunity. Cancer Treat Res 2022; 183:91-129. [PMID: 35551657 DOI: 10.1007/978-3-030-96376-7_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Malignant tumors frequently exploit innate immunity to evade immune surveillance. The priming, function, and polarization of antitumor immunity fundamentally depends upon context provided by the innate immune system, particularly antigen presenting cells. Such context is determined in large part by sensing of pathogen specific and damage associated features by pathogen recognition receptors (PRRs). PRR activation induces the delivery of T cell priming cues (e.g. chemokines, co-stimulatory ligands, and cytokines) from antigen presenting cells, playing a decisive role in the cancer immunity cycle. Indeed, endogenous PRR activation within the tumor microenvironment (TME) has been shown to generate spontaneous antitumor T cell immunity, e.g., cGAS-STING mediated activation of antigen presenting cells after release of DNA from dying tumor cells. Thus, instigating intratumor PRR activation, particularly with the goal of generating Th1-promoting inflammation that stokes endogenous priming of antitumor CD8+ T cells, is a growing area of clinical investigation. This approach is analogous to in situ vaccination, ultimately providing a personalized antitumor response against relevant tumor associated antigens. Here I discuss clinical stage intratumor modalities that function via activation of PRRs. These approaches are being tested in various solid tumor contexts including melanoma, colorectal cancer, glioblastoma, head and neck squamous cell carcinoma, bladder cancer, and pancreatic cancer. Their mechanism (s) of action relative to other immunotherapy approaches (e.g., antigen-defined cancer vaccines, CAR T cells, dendritic cell vaccines, and immune checkpoint blockade), as well as their potential to complement these approaches are also discussed. Examples to be reviewed include TLR agonists, STING agonists, RIG-I agonists, and attenuated or engineered viruses and bacterium. I also review common key requirements for effective in situ immune activation, discuss differences between various strategies inclusive of mechanisms that may ultimately limit or preclude antitumor efficacy, and provide a summary of relevant clinical data.
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Affiliation(s)
- Michael Brown
- Department of Neurosurgery, Duke University, Durham, NC, USA.
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Das R, Langou S, Le TT, Prasad P, Lin F, Nguyen TD. Electrical Stimulation for Immune Modulation in Cancer Treatments. Front Bioeng Biotechnol 2022; 9:795300. [PMID: 35087799 PMCID: PMC8788921 DOI: 10.3389/fbioe.2021.795300] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/17/2021] [Indexed: 12/17/2022] Open
Abstract
Immunotherapy is becoming a very common treatment for cancer, using approaches like checkpoint inhibition, T cell transfer therapy, monoclonal antibodies and cancer vaccination. However, these approaches involve high doses of immune therapeutics with problematic side effects. A promising approach to reducing the dose of immunotherapeutic agents given to a cancer patient is to combine it with electrical stimulation, which can act in two ways; it can either modulate the immune system to produce the immune cytokines and agents in the patient's body or it can increase the cellular uptake of these immune agents via electroporation. Electrical stimulation in form of direct current has been shown to reduce tumor sizes in immune-competent mice while having no effect on tumor sizes in immune-deficient mice. Several studies have used nano-pulsed electrical stimulations to activate the immune system and drive it against tumor cells. This approach has been utilized for different types of cancers, like fibrosarcoma, hepatocellular carcinoma, human papillomavirus etc. Another common approach is to combine electrochemotherapy with immune modulation, either by inducing immunogenic cell death or injecting immunostimulants that increase the effectiveness of the treatments. Several therapies utilize electroporation to deliver immunostimulants (like genes encoded with cytokine producing sequences, cancer specific antigens or fragments of anti-tumor toxins) more effectively. Lastly, electrical stimulation of the vagus nerve can trigger production and activation of anti-tumor immune cells and immune reactions. Hence, the use of electrical stimulation to modulate the immune system in different ways can be a promising approach to treat cancer.
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Affiliation(s)
- Ritopa Das
- Department of Biomedical Engineering, University of Connecticut, Mansfield, CT, United States
| | - Sofia Langou
- Department of Physiology and Neurobiology, University of Connecticut, Mansfield, CT, United States
| | - Thinh T. Le
- Department of Mechanical Engineering, University of Connecticut, Mansfield, CT, United States
| | - Pooja Prasad
- Department of Cell and Molecular Biology, University of Connecticut, Mansfield, CT, United States
| | - Feng Lin
- Department of Mechanical Engineering, University of Connecticut, Mansfield, CT, United States
| | - Thanh D. Nguyen
- Department of Biomedical Engineering, University of Connecticut, Mansfield, CT, United States
- Department of Mechanical Engineering, University of Connecticut, Mansfield, CT, United States
- Institute of Materials Science, University of Connecticut, Mansfield, CT, United States
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Vacchelli E, Galluzzi L, Eggermont A, Fridman WH, Galon J, Sautès-Fridman C, Tartour E, Zitvogel L, Kroemer G. Trial watch: FDA-approved Toll-like receptor agonists for cancer therapy. Oncoimmunology 2021; 1:894-907. [PMID: 23162757 PMCID: PMC3489745 DOI: 10.4161/onci.20931] [Citation(s) in RCA: 168] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Toll-like receptors (TLRs) have first been characterized for their capacity to detect conserved microbial components like lipopolysaccharide (LPS) and double-stranded RNA, resulting in the elicitation of potent (innate) immune responses against invading pathogens. More recently, TLRs have also been shown to promote the activation of the cognate immune system against cancer cells. Today, only three TLR agonists are approved by FDA for use in humans: the bacillus Calmette-Guérin (BCG), monophosphoryl lipid A (MPL) and imiquimod. BCG (an attenuated strain of Mycobacterium bovis) is mainly used as a vaccine against tuberculosis, but also for the immunotherapy of in situ bladder carcinoma. MPL (derived from the LPS of Salmonella minnesota) is included in the formulation of Cervarix®, a vaccine against human papillomavirus-16 and -18. Imiquimod (a synthetic imidazoquinoline) is routinely employed for actinic keratosis, superficial basal cell carcinoma, and external genital warts (condylomata acuminata). In this Trial Watch, we will summarize the results of recently completed clinical trials and discuss the progress of ongoing studies that have evaluated/are evaluating FDA-approved TLR agonists as off-label medications for cancer therapy.
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Affiliation(s)
- Erika Vacchelli
- INSERM, U848; Villejuif, France ; Institut Gustave Roussy; Villejuif, France ; Université Paris-Sud/Paris XI; Paris, France
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Hunt JR, Kleindl PA, Moulder KR, Prisinzano TE, Forrest ML. Further exploration of the structure-activity relationship of imidazoquinolines; identification of potent C7-substituted imidazoquinolines. Bioorg Med Chem Lett 2019; 30:126788. [PMID: 31784317 DOI: 10.1016/j.bmcl.2019.126788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022]
Abstract
Small molecule agonists of TLR7/8, such as imidazoquinolines, are validated agonists for the treatment of cancer and for use in vaccine adjuvants. Imidazoquinolines have been extensively modified to understand the structure-activity relationship (SAR) at the N1- and C2-positions resulting in the clinical drug imiquimod, resiquimod, and several other highly potent analogues. However, the SAR of the aryl ring has not been fully elucidated in the literature. This initial study examines the SAR of C7-substituted imidazoquinolines. These compounds not only demonstrated that TLR7/8 tolerate changes at the C7-position but can increase potency and change their cytokine profiles. The most notable TLR7/8 agonists developed from this study 5, 8, and 14 which are up to 4-fold and 2-fold more active than resiquimod for TLR8 and/or TLR7, respectively, and up to 100-fold more active than the FDA approved imiquimod for TLR7.
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Affiliation(s)
- Jordan R Hunt
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS 66047, United States; Department of Medicinal Chemistry, University of Kansas, Lawrence, KS 66047, United States
| | - Peter A Kleindl
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS 66047, United States
| | - K Ryan Moulder
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS 66047, United States
| | - Thomas E Prisinzano
- Department of Medicinal Chemistry, University of Kansas, Lawrence, KS 66047, United States
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS 66047, United States.
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Musa J. The Need for Societal Investment to Improve Cervical Cancer Outcomes in Nigeria: A commentary. Afr J Reprod Health 2017; 21:17-23. [PMID: 29624947 DOI: 10.29063/ajrh2017/v21i4.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Although cervical cancer is a preventable cancer with a well-known natural history, it remains a huge burden in developing countries of sub-Saharan Africa where organized cervical cancer screening services are lacking. Developed countries that have invested on providing organized screening programs have made substantial progress in reducing both incidence and mortality due to cervical cancer. Implementing evidence-based interventions such as human papillomavirus (HPV) vaccination of young girls, early detection and treatment of premalignant conditions of the cervix through conventional Pap cytology, HPV screening or visual aided inspection with acetic acid could significantly reduce incidence of new cases at population level. Societal investment for such preventive services and provision of effective treatment for those diagnosed at early stages will yield economic benefits in reducing premature deaths of women at the prime of their productive lives. From a societal perspective, this should be a priority area for national investment towards the achievement of sustainable development in Nigeria and similar settings in Africa.
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Lekoane BKM, Mashamba-Thompson TP, Ginindza TG. Mapping evidence on the distribution of human papillomavirus-related cancers in sub-Saharan Africa: scoping review protocol. Syst Rev 2017; 6:229. [PMID: 29149907 PMCID: PMC5693799 DOI: 10.1186/s13643-017-0623-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite the introduction of HPV vaccines, the incidence of HPV-related cancers (cervical, penile, anal, vulvar, vagina, head, and neck) in sub-Saharan Africa has been rising. The increasing incidence of these HPV-related cancers has been attributed to changes in lifestyle-related risk factors, most notably sexual behavior. The main objective of this study is to map evidence on the distribution of HIV-related cancers in sub-Saharan Africa (SSA). METHODS AND ANALYSIS We will conduct a scoping review to explore, describe, and map literature on the distribution of HPV-related cancers in sub-Saharan Africa. The primary search will include peer-reviewed and review articles. The list of references from included studies will also be searched. The search will be performed using EBSCOhost platform by searching the following databases within the platform: Academic search complete, health source: nursing/academic edition, CINAHL with full text, PubMed, Science Direct, Google scholar and World Health Organization (WHO) library databases, and gray literature. The researcher will search the articles using keywords, from the included studies; abstract and full articles will be screened by two independent reviewers. The screening will be guided by the inclusion and exclusion criteria. A thematic content analysis will be used to present the narrative account of the reviews, using NVivo version 10. DISCUSSION We anticipate finding relevant literature on the distribution of HPV-related cancers in sub-Saharan Africa. The study findings will help reveal research gaps to guide future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017062403.
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Affiliation(s)
- Bridget K M Lekoane
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Mazisi Kunene Road, Durban, 4041, South Africa
| | - Tivani P Mashamba-Thompson
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Mazisi Kunene Road, Durban, 4041, South Africa
| | - Themba G Ginindza
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Mazisi Kunene Road, Durban, 4041, South Africa.
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Baselga J, Bhardwaj N, Cantley LC, DeMatteo R, DuBois RN, Foti M, Gapstur SM, Hahn WC, Helman LJ, Jensen RA, Paskett ED, Lawrence TS, Lutzker SG, Szabo E. AACR Cancer Progress Report 2015. Clin Cancer Res 2015; 21:S1-128. [PMID: 26429991 PMCID: PMC5001568 DOI: 10.1158/1078-0432.ccr-15-1846] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Rosales-Mendoza S, Govea-Alonso DO. The potential of plants for the production and delivery of human papillomavirus vaccines. Expert Rev Vaccines 2015; 14:1031-41. [PMID: 25882610 DOI: 10.1586/14760584.2015.1037744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The available vaccines against human papillomavirus have some limitations such as low coverage due to their high cost, reduced immune coverage and the lack of therapeutic effects. Recombinant vaccines produced in plants (genetically engineered using stable or transient expression systems) offer the possibility to obtain low cost, efficacious and easy to administer vaccines. The status on the development of plant-based vaccines against human papillomavirus is analyzed and placed in perspective in this review. Some candidates have been characterized at a preclinical level with interesting outcomes. However, there is a need to perform the immunological characterization of several vaccine prototypes, especially through the oral administration route, as well as develop new candidates based on new chimeric designs intended to provide broader immunoprotection and therapeutic activity.
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Affiliation(s)
- Sergio Rosales-Mendoza
- Laboratorio de Biofarmacéuticos Recombinantes, Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, Av. Dr. Manuel Nava 6, SLP, 78210, México, USA
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10
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Abstract
Numerous reports have described Toll-like receptor (TLR) functions in myeloid cells such as dendritic cells (DCs) and macrophages, but relatively fewer studies have examined TLR responses in B lymphocytes. B cells express a wide variety of TLRs and are highly activated after TLR ligation, leading to enhancements in B cell survival, surface molecule expression, cytokine and antibody production, and antigen presentation. During an immune response, B cells can receive signals through TLRs as well as the B cell antigen receptor (BCR) and/or CD40. TLR ligation synergizes with signals through these receptors and augments both innate and adaptive immune functions of B lymphocytes. Additionally, targeting B cell TLRs may provide new therapies against certain types of cancer as well as autoimmune diseases. Here, we summarize TLR expression and contributions to both normal and pathogenic functions in mouse and human B cells.
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Affiliation(s)
- Claire M Buchta
- Graduate Program in Immunology, University of Iowa, Iowa City, IA, 52242, USA
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11
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Vaccination anti-HPV : évaluation de la couverture vaccinale et des facteurs qui l’influencent chez les lycéennes et étudiantes de la région PACA. ACTA ACUST UNITED AC 2015; 44:126-35. [DOI: 10.1016/j.jgyn.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/09/2014] [Accepted: 02/14/2014] [Indexed: 11/20/2022]
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Tabatabai MA, Kengwoung-Keumo JJ, Eby WM, Bae S, Guemmegne JT, Manne U, Fouad M, Partridge EE, Singh KP. Disparities in cervical cancer mortality rates as determined by the longitudinal hyperbolastic mixed-effects type II model. PLoS One 2014; 9:e107242. [PMID: 25226583 PMCID: PMC4167327 DOI: 10.1371/journal.pone.0107242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/01/2014] [Indexed: 12/29/2022] Open
Abstract
Background The main purpose of this study was to model and analyze the dynamics of cervical cancer mortality rates for African American (Black) and White women residing in 13 states located in the eastern half of the United States of America from 1975 through 2010. Methods The cervical cancer mortality rates of the Surveillance, Epidemiology, and End Results (SEER) were used to model and analyze the dynamics of cervical cancer mortality. A longitudinal hyperbolastic mixed-effects type II model was used to model the cervical cancer mortality data and SAS PROC NLMIXED and Mathematica were utilized to perform the computations. Results Despite decreasing trends in cervical cancer mortality rates for both races, racial disparities in mortality rates still exist. In all 13 states, Black women had higher mortality rates at all times. The degree of disparities and pace of decline in mortality rates over time differed among these states. Determining the paces of decline over 36 years showed that Tennessee had the most rapid decline in cervical cancer mortality for Black women, and Mississippi had the most rapid decline for White Women. In contrast, slow declines in cervical cancer mortality were noted for Black women in Florida and for White women in Maryland. Conclusions In all 13 states, cervical cancer mortality rates for both racial groups have fallen. Disparities in the pace of decline in mortality rates in these states may be due to differences in the rates of screening for cervical cancers. Of note, the gap in cervical cancer mortality rates between Black women and White women is narrowing.
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Affiliation(s)
- Mohammad A. Tabatabai
- School of Graduate Studies and Research, Meharry Medical College, Nashville, Tennessee, United States of America
| | | | - Wayne M. Eby
- Department of Mathematics, New Jersey City University, Jersey City, New Jersey, United States of America
| | - Sejong Bae
- Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Juliette T. Guemmegne
- Department of Economics, University of New Mexico, Albuquerque, New Mexico, United States of America
| | - Upender Manne
- Department of Pathology and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Mona Fouad
- Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Edward E. Partridge
- Department of Obstetrics & Gynecology and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Karan P. Singh
- Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail:
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Zhao S, Zhang Y, Zhang Q, Wang F, Zhang D. Toll-like receptors and prostate cancer. Front Immunol 2014; 5:352. [PMID: 25101092 PMCID: PMC4107957 DOI: 10.3389/fimmu.2014.00352] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/09/2014] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the second leading cause of cancer-related death in men after lung cancer. Immune responses clearly play a critical role in the tumorigenesis and in the efficacy of radiation therapy and chemotherapy in prostate cancer; however, the underlying molecular mechanisms are still poorly understood. Toll-like receptors (TLRs) are a well-known family of pattern recognition receptors that play a key role in host immune system. Recent studies demonstrate that there are links between TLRs and cancer; however, the function and biological importance of TLRs in prostate cancer seems complex. To elucidate the role of TLRs and innate immunity in prostate cancer might provide us with a better understanding of the molecular mechanisms of this disease. Moreover, utilizing the agonists or antagonists of TLRs might represent a promising new strategy against prostate cancer. In this review, we summarize recent advances on the studies of association between TLR signaling and prostate cancer, TLR polymorphisms and prostate cancer risk, and provide some insights about TLRs as potential targets for prostate cancer immunotherapy.
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Affiliation(s)
- Shu Zhao
- Institute of Biosciences and Technology, Texas A&M University Health Science Center , Houston, TX , USA ; Department of Medical Oncology, Affiliated Tumor Hospital of Harbin Medical University , Harbin , China
| | - Yifan Zhang
- Institute of Biosciences and Technology, Texas A&M University Health Science Center , Houston, TX , USA
| | - Qingyuan Zhang
- Department of Medical Oncology, Affiliated Tumor Hospital of Harbin Medical University , Harbin , China
| | - Fen Wang
- Institute of Biosciences and Technology, Texas A&M University Health Science Center , Houston, TX , USA
| | - Dekai Zhang
- Institute of Biosciences and Technology, Texas A&M University Health Science Center , Houston, TX , USA
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Hoque ME, Ghuman S, Hal GV. Human Papillomavirus vaccination acceptability among female university students in South Africa. Asian Pac J Cancer Prev 2014; 14:4865-9. [PMID: 24083760 DOI: 10.7314/apjcp.2013.14.8.4865] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objectives of this present study were to assess the awareness of cervical cancer and its risk factors among female undergraduates in South Africa, and to determine the their level of acceptability of Human Papillomavirus (HPV) vaccination. MATERIALS AND METHODS This cross-sectional study was conducted in March 2013 among 440 full time undergraduate female students. RESULTS Of those students who never had sex (n=163), 96 (58.9%) had ever heard of cervical cancer and only 12 students (12.5%) knew that HPV causes cervical cancer. More than a third (35.4%) of the students correctly said that sexual intercourse before age of 18 years is a risk factor for cervical cancer and 55.2% of the students knew about the Pap smear test which is used for screening cervical cancer. The majority (77.3%) were willing to accept HPV vaccination. Results revealed that students who knew about the Pap smear test, and were aware that having multiple sex partners, sexual intercourse before the age of 18 years, smoking and having contracted any STDs are risk factors for cervical cancer were more likely to accept HPV vaccination compared to other groups. CONCLUSIONS The general knowledge of South African female university students about cervical cancer is not sufficient but they have positive attitudes toward getting vaccinated with the HPV vaccine.
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Affiliation(s)
- Muhammad Ehsanul Hoque
- Graduate School of Business and Leadership, University of KwaZulu-Natal, South Africa, E-mail : ,
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Guo C, Manjili MH, Subjeck JR, Sarkar D, Fisher PB, Wang XY. Therapeutic cancer vaccines: past, present, and future. Adv Cancer Res 2014; 119:421-75. [PMID: 23870514 DOI: 10.1016/b978-0-12-407190-2.00007-1] [Citation(s) in RCA: 361] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Therapeutic vaccines represent a viable option for active immunotherapy of cancers that aim to treat late stage disease by using a patient's own immune system. The promising results from clinical trials recently led to the approval of the first therapeutic cancer vaccine by the U.S. Food and Drug Administration. This major breakthrough not only provides a new treatment modality for cancer management but also paves the way for rationally designing and optimizing future vaccines with improved anticancer efficacy. Numerous vaccine strategies are currently being evaluated both preclinically and clinically. This review discusses therapeutic cancer vaccines from diverse platforms or targets as well as the preclinical and clinical studies employing these therapeutic vaccines. We also consider tumor-induced immune suppression that hinders the potency of therapeutic vaccines, and potential strategies to counteract these mechanisms for generating more robust and durable antitumor immune responses.
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Affiliation(s)
- Chunqing Guo
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Association between maternal preventive care utilization and adolescent vaccination: it's not just about Pap testing. J Pediatr Adolesc Gynecol 2014; 27:29-36. [PMID: 24315716 DOI: 10.1016/j.jpag.2013.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/22/2013] [Accepted: 08/23/2013] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE To examine the association between maternal preventive care utilization and human papillomavirus (HPV) vaccine uptake by their adolescent daughters. DESIGN A cross-sectional study using immunization records from administrative claims and the state health department's immunization information system from June 2006 through May 2011. PARTICIPANTS Commercially-insured Michigan females aged 13-17 in May 2011 and their mothers. Mothers were identified using relationship information on the insurance contract. MAIN OUTCOME MEASURES Using logistic regression, we investigated whether initiating and/or completing the HPV vaccine series were associated with maternal preventive care utilization (Papaniculou testing, mammograms, primary care office visits) independently and using a combined maternal preventive care utilization index. RESULTS Among 38,604 mother-daughter pairs, 36% of daughters initiated and 22% completed the HPV vaccine series. Maternal utilization of each recommended service was modestly associated with both daughter's initiation and completion of the HPV vaccine. Effect estimates for receipt of Papaniculou test on vaccine initiation (OR = 1.07, 95% CI = 1.06-1.08) were not any higher than for mammograms (OR = 1.10, 95% CI = 1.08-1.11) or primary care office visits (OR = 1.07, 95% CI = 1.06-1.09). Using a maternal preventive care utilization index, vaccine uptake increased with an increasing number of received services. CONCLUSIONS Maternal receipt of recommended preventive care, which may reflect general attitudes toward prevention, is as or more predictive of daughter's vaccination status than cervical cancer screening alone. Engaging women in broad routine preventive care practices may have additional positive effects on adolescent HPV vaccination beyond those achieved through cervical cancer prevention efforts alone.
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Szarewski A. Cervarix®: a bivalent vaccine against HPV types 16 and 18, with cross-protection against other high-risk HPV types. Expert Rev Vaccines 2014; 11:645-57. [DOI: 10.1586/erv.12.42] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Jeannot E, Wyler CA, Meynard A, Kaiser B, Sudre P, Alvarin J, Chastonay P. Facteurs associés à la vaccination HPV chez les jeunes filles de 13 à 14ans dans le canton de Genève, Suisse. Rev Epidemiol Sante Publique 2013; 61:513-8. [DOI: 10.1016/j.respe.2013.07.683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 04/04/2013] [Accepted: 07/16/2013] [Indexed: 11/15/2022] Open
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Wang JW, Roden RBS. Virus-like particles for the prevention of human papillomavirus-associated malignancies. Expert Rev Vaccines 2013; 12:129-41. [PMID: 23414405 DOI: 10.1586/erv.12.151] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
As compared with peptide- or protein-based vaccines, naked DNA vectors and even traditional attenuated or inactivated virus vaccines, virus-like particles (VLPs) are an attractive vaccine platform, as they offer a combination of safety, ease of production and both high-density B-cell epitope display and intracellular presentation of T-cell epitopes that induce potent humoral and cellular immune responses, respectively. Indeed, HPV vaccines based on VLP production by recombinant expression of major capsid antigen L1 in yeast (Gardasil(®), Merck & Co., NJ, USA) or insect cells (Cervarix(®), GlaxoSmithKline, London, UK) have been licensed for the prevention of cervical and anogenital infection and disease associated with the genotypes targeted by each vaccine. However, these HPV vaccines have not been demonstrated as effective to treat existing infections, and efforts to develop a therapeutic HPV vaccine continue. Furthermore, current HPV L1-VLP vaccines provide type-restricted protection, requiring highly multivalent formulations to broaden coverage to the dozen or more oncogenic HPV genotypes. This raises the complexity and cost of vaccine production. The lack of access to screening and high disease burden in developing countries has spurred efforts to develop second-generation HPV vaccines that are more affordable, induce wider protective coverage and offer therapeutic coverage against HPV-associated malignancies. Given the previous success with L1-VLP-based vaccines against HPV, VLPs have been also adopted as platforms for many second-generation HPV and non-HPV vaccine candidates with both prophylactic and therapeutic intent. In this article, the authors examine the progress and challenges of these efforts, with a focus on how they inform VLP vaccine design.
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Affiliation(s)
- Joshua W Wang
- Department of Pathology, The Johns Hopkins University, Baltimore, MD 21287-0014, USA
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Piana A, Sotgiu G, Cocuzza C, Musumeci R, Marras V, Pischedda S, Deidda S, Muresu E, Castiglia P. High HPV-51 prevalence in invasive cervical cancers: results of a pre-immunization survey in North Sardinia, Italy. PLoS One 2013; 8:e63395. [PMID: 23717420 PMCID: PMC3661560 DOI: 10.1371/journal.pone.0063395] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 03/30/2013] [Indexed: 11/19/2022] Open
Abstract
Background Human Papilloma virus (HPV) is recognized as the etiological agent of benign and malignant ano-genital lesions. The most prevalent genotypes associated with cervical carcinoma are HPV-16 and -18 worldwide. However, recent studies have emphasized the role of other genotypes, such as HPV-51, in the pathogenesis of cervical dysplasia. The aim of the study was to estimate the burden of HPV-51 infection in invasive cervical malignant lesions in Northern Sardinia, Italy. Methods/Principal Findings An observational, retrospective, prevalence, mono-center study was carried out to evaluate the presence of HPV genotypes in tissues biopsies of cervical lesions (CIN-1, CIN-2, CIN-3 and invasive carcinoma) gathered from 1996 to 2009. Biological samples were collected from women admitted consecutively to a tertiary university hospital situated in Sassari, Italy. Molecular methods were used to identify 28 oncogenic HPV types. A total of 155 formalin-fixed and paraffin-embedded cervical tissue samples were analyzed. Approximately half of the cervical lesions were classified as invasive carcinoma. HPV-DNA was detected in 71% of the samples, with a higher frequency (100%) in those categorized as invasive neoplasia. Mono- or co-infections were demonstrated in 45.8% and 25.8% of the cervical samples, respectively. Overall, the most prevalent HPV types were -16 (49%) and -51 (19.4%), with an increased frequency of detection associated with the severity of the cervical lesions. Conclusions/Significance This survey highlights for the first time the relevant role of HPV-51 infection in the pathogenesis of invasive cervical cancer prior to the introduction of a vaccination program. Although a selection bias could have influenced the results, other recent studies have described the impact of HPV-51. This remarkable epidemiological element should be carefully evaluated, particularly in the view of opting for preventive vaccines, whose cross-protection patterns determine their efficacy in protecting against infection from HPV types that are not included in the vaccine itself.
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Affiliation(s)
- Andrea Piana
- Department of Biomedical Sciences, Hygiene and Preventive Medicine Unit, University of Sassari – AOU Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Department of Biomedical Sciences, Hygiene and Preventive Medicine Unit, University of Sassari – AOU Sassari, Sassari, Italy
| | - Clementina Cocuzza
- Department of Surgery and Interdisciplinary Medicine, University of Milano Bicocca, Milan, Italy
| | - Rosario Musumeci
- Department of Surgery and Interdisciplinary Medicine, University of Milano Bicocca, Milan, Italy
| | - Vincenzo Marras
- Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Stefania Pischedda
- Department of Biomedical Sciences, Hygiene and Preventive Medicine Unit, University of Sassari – AOU Sassari, Sassari, Italy
| | - Silvia Deidda
- Department of Biomedical Sciences, Hygiene and Preventive Medicine Unit, University of Sassari – AOU Sassari, Sassari, Italy
| | - Elena Muresu
- Department of Biomedical Sciences, Hygiene and Preventive Medicine Unit, University of Sassari – AOU Sassari, Sassari, Italy
| | - Paolo Castiglia
- Department of Biomedical Sciences, Hygiene and Preventive Medicine Unit, University of Sassari – AOU Sassari, Sassari, Italy
- * E-mail:
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Belhadj H, Rasanathan JJK, Denny L, Broutet N. Sexual and reproductive health and HIV services: integrating HIV/AIDS and cervical cancer prevention and control. Int J Gynaecol Obstet 2013; 121 Suppl 1:S29-34. [PMID: 23477703 DOI: 10.1016/j.ijgo.2013.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
People living with HIV are at an increased risk of acquiring HPV and of developing evolutive cervical cancers (women) and penile and anal cancers (men). Low-cost screening-visual inspection with acetic acid, HPV DNA diagnostics and primary care level treatment, cryotherapy for cervical intraepithelial neoplasia (CIN 2), and primary prevention through HPV vaccination of girls aged 9-13 years-makes the goal of eliminating cervical cancer possible in the long term. Integration of cervical cancer screening and treatment into a sexual and reproductive health service package raises programmatic questions and calls for a continuum of care. The latter is only possible when adequate cytopathology skills and treatment for advanced cancer conditions are available. The present paper highlights the role of member societies of the International Federation of Gynecology and Obstetrics (FIGO) in developing the base for an integrated package that responds to women's sexual and reproductive health needs.
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Hopkins TG, Wood N. Female human papillomavirus (HPV) vaccination: global uptake and the impact of attitudes. Vaccine 2013; 31:1673-9. [PMID: 23375978 DOI: 10.1016/j.vaccine.2013.01.028] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/09/2013] [Accepted: 01/15/2013] [Indexed: 01/27/2023]
Abstract
Human papillomavirus (HPV) is the causative agent in cervical cancer and has been implicated in a range of other malignancies. Preventative vaccines are now internationally available and provide high levels of protection from common viral strains. The introduction of a comprehensive vaccination programme (except 'program' in computers) could prevent over 60% of current cervical cancer cases, but this is dependent on such programmes achieving a high level of coverage. In this review, we summarise the current trends in female HPV vaccination coverage throughout the world, and place it in the context of available research on attitudes towards vaccination amongst the public and health professionals. Where countries have the resources for mass vaccination programmes, uptake has varied. School-based opt-out programmes consistently achieve highest coverage, whilst countries and regions without systematic vaccination schemes have low coverage. In all countries, the success of vaccination programmes is dependent on the support of the public and healthcare professionals. Whilst public acceptance is dependent on multiple factors, it has repeatedly been shown that recommendation by a health professional, particularly clinicians, is key to vaccine uptake. Worryingly, it appears that a proportion of clinicians still have significant reservations about promoting vaccination, particularly for younger age groups. A commitment now, to fully educating both the public and clinicians, has the potential to make a dramatic future impact.
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Affiliation(s)
- Tom Glass Hopkins
- Institute of Reproductive and Developmental Biology, Imperial College, London, UK.
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Álvarez-Argüelles ME, Melón S, Junquera ML, Boga JA, Villa L, Pérez-Castro S, de Oña M. Human papillomavirus infection in a male population attending a sexually transmitted infection service. PLoS One 2013; 8:e54375. [PMID: 23372715 PMCID: PMC3553085 DOI: 10.1371/journal.pone.0054375] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 12/11/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Human Papillomavirus (HPV) infection in men may produce cancer and other major disorders. Men play an important role in the transmission of the virus and act as a reservoir. The aim of this study was to determine the HPV-genotypes and their prevalence in a group of men attending a Sexually Transmitted Infection service. PATIENTS AND SAMPLES: Between July 2002 and June 2011, 1392 balanopreputial, 435 urethral, 123 anal, and 67 condyloma lesions from 1551 men with a mean age of 35.8±11.3 years old (range: 17-87) were collected for HPV-DNA testing. METHODS A fragment of the L1-gene and a fragment of the E6/E7-genes were amplified by PCR. Positive samples were typed by hybridization. RESULTS The HPV genome was detected in 36.9% (486/1318) balanopreputial and in 24.9% (101/405) urethral (p<0.0001) swabs from 38.1% (538) of 1469 men. Co-infections were present in 5.4% (80/1469) of cases. HPV was found in 43.9% (373/850) of men younger than 35 vs. 31.7% (187/589) of men aged >35. HPV was found in 59.4% (104) of 165 men with lesions (macroscopic or positive peniscopy), and in 22.8% (61/267) without clinical alterations. HPV was also detected in 71.4% (40/56) men with condylomata and in 58.7% (64/109) of men with positive peniscopy. CONCLUSIONS HPV prevalence in men was high and decreased with age. HPV was found more frequently in balanopreputial than in urethral swabs. There was a low rate of co-infections. Low-risk HPV vaccine genotypes were the most recurrent especially in younger. Although HPV has been associated with clinical alterations, it was also found in men without any clinical presentation. Inclusion of men in the national HPV vaccination program may reduce their burden of HPV-related disease and reduce transmission of the virus to non-vaccinated women.
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Cohen R, Vié Le Sage F, Weil-Olivier C, Romain O, Hau I, Guérin N, Thiebault G, Virey B, Bakhache P, Dommergues MA, Gaudelus J. [Plea for advancement of the age of vaccination against human papillomavirus in France: Position of the Pediatric Infections Pathology Group (GPIP) and the French Association of Ambulatory Pediatrics (AFPA)]. Arch Pediatr 2012. [PMID: 23178137 DOI: 10.1016/s0929-693x(12)71289-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vaccination against human papillomavirus (HPV) is recommended in France at 14 years. The Groupe de Pathologie Infectieuse Pédiatrique de la Société Française de Pédiatrie takes a clear position for advancement of age of vaccination at 11-12 years based on the following arguments: (i) data on the long-term persistence of protective antibodies are reassuring; (ii) these vaccines can be co-administered with vaccines recommended in the current immunization schedule at this age; (iii) actually, nearly 20% of adolescents have had sexual intercourse when the vaccination schedule is finished; (iv) vaccination beyond 14 years increases the risk of occurrence of coincidental autoimmune diseases; (v) the immunogenicity of vaccines against HPV is better when they are administered before age 15; (vi) finally, especially by reducing the number of injections from 3 to 2, the immunization at 11-12 years could improve immunization coverage which is insufficient nowadays.
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Affiliation(s)
- R Cohen
- Centre Hospitalier intercommunal de Créteil, 40, avenue de Verdun, 94010 Créteil cedex, France.
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Bartolini RM, Winkler JL, Penny ME, LaMontagne DS. Parental acceptance of HPV vaccine in Peru: a decision framework. PLoS One 2012; 7:e48017. [PMID: 23144719 PMCID: PMC3483308 DOI: 10.1371/journal.pone.0048017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 09/20/2012] [Indexed: 12/02/2022] Open
Abstract
Objective and Method Cervical cancer is the third most common cancer affecting women worldwide and it is an important cause of death, especially in developing countries. Cervical cancer is caused by human papillomavirus (HPV) and can be prevented by HPV vaccine. The challenge is to expand vaccine availability to countries where it is most needed. In 2008 Peru’s Ministry of Health implemented a demonstration project involving 5th grade girls in primary schools in the Piura region. We designed and conducted a qualitative study of the decision-making process among parents of girls, and developed a conceptual model describing the process of HPV vaccine acceptance. Results We found a nonlinear HPV decision-making process that evolved over time. Initially, the vaccine’s newness, the requirement of written consent, and provision of information were important. If information was sufficient and provided by credible sources, many parents accepted the vaccine. Later, after obtaining additional information from teachers, health personnel, and other trusted sources, more parents accepted vaccination. An understanding of the issues surrounding the vaccine developed, parents overcome fears and rumors, and engaged in family negotiations–including hearing the girl’s voice in the decision-making process. The concept of prevention (cancer as danger, future health, and trust in vaccines) combined with pragmatic factors (no cost, available at school) and the credibility of the offer (information in the media, recommendation of respected authority figure) were central to motivations that led parents to decide to vaccinate their daughters. A lack of confidence in the health system was the primary inhibitor of vaccine acceptance. Conclusions Health personnel and teachers are credible sources of information and can provide important support to HPV vaccination campaigns.
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Affiliation(s)
| | | | - Mary E. Penny
- Instituto de Investigación Nutricional, La Molina, Lima, Peru
| | - D. Scott LaMontagne
- PATH, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Harborview Medical Center, Seattle, Washington, United States of America
- * E-mail:
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Poljak M. Prophylactic human papillomavirus vaccination and primary prevention of cervical cancer: issues and challenges. Clin Microbiol Infect 2012; 18 Suppl 5:64-9. [DOI: 10.1111/j.1469-0691.2012.03946.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Binagwaho A, Wagner CM, Gatera M, Karema C, Nutt CT, Ngabo F. Achieving high coverage in Rwanda's national human papillomavirus vaccination programme. Bull World Health Organ 2012; 90:623-8. [PMID: 22893746 DOI: 10.2471/blt.11.097253] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 02/15/2012] [Accepted: 02/28/2012] [Indexed: 02/08/2023] Open
Abstract
PROBLEM Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275,000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years. APPROACH In 2011, Rwanda's Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a "public-private community partnership" to ensure effective and equitable delivery. LOCAL SETTING Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12-23 months receive all basic immunizations recommended by the World Health Organization. RELEVANT CHANGES In 2011, Rwanda's HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose. LESSONS LEARNT Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda's strong vaccination system and human resources framework. Following the GAVI Alliance's decision to begin financing HPV vaccination, Rwanda's example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context.
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Austin RM, Zhao C. Type 1 and type 2 cervical carcinomas: some cervical cancers are more difficult to prevent with screening. Cytopathology 2012; 23:6-12. [DOI: 10.1111/j.1365-2303.2011.00955.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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