Real-World Effectiveness of Human Papillomavirus Vaccination Against Cervical Cancer

Integrative literature review on human papillomavirus vaccination recommendations in national immunization programs in select areas in the Asia-Pacific region

There is limited literature on current human papillomavirus (HPV) vaccination in the Asia-Pacific region. This integrative literature review was conducted to describe HPV vaccination programs in Hong Kong, Indonesia, Japan, South Korea, Malaysia, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. Program descriptions, recommendations, f unding, and coverage data were extracted. Twenty-five citations were included. As of 2022, eight of the 10 areas of interest include HPV in their national immunization program (NIP) for school-aged girls; full implementation in Indonesia is expected in 2023 whereas Vietnam's NIP does not include HPV. Singapore also includes HPV vaccination for women (18-26 years). None of the HPV vaccination programs include males. In most areas (n = 7), programs include only one vaccine option. While female HPV NIPs are present in the Asia-Pacific region, opportunities remain to strengthen NIPs in broader populations (e.g., males, catch-up cohorts) to expand public health impact and provide gender equity in HPV vaccination.

Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination

Cervical cancer is the first cancer deemed amenable to elimination through prevention, and thus lessons from the epidemiology and prevention of this cancer type can provide information on strategies to manage other cancers. Infection with the human papillomavirus (HPV) causes virtually all cervical cancers, and an important proportion of oropharyngeal, anal and genital cancers. Whereas 20th century prevention efforts were dominated by cytology-based screening, the present and future of HPV-associated cancer prevention relies mostly on HPV vaccination and molecular screening tests. In this Review, we provide an overview of the epidemiology of HPV-associated cancers, their disease burden, how past and contemporary preventive interventions have shaped their incidence and mortality, and the potential for elimination. We particularly focus on the cofactors that could have the greatest effect on prevention efforts, such as parity and human immunodeficiency virus infection, as well as on social determinants of health. Given that the incidence of and mortality from HPV-associated cancers remain strongly associated with the socioeconomic status of individuals and the human development index of countries, elimination efforts are unlikely to succeed unless prevention efforts focus on health equity, with a commitment to both primary and secondary prevention.

Screening outcome of HPV-vaccinated women: Data from the Danish Trial23 cohort study

BACKGROUND

Danish women-who were HPV-vaccinated as girls-are now reaching an age where they are invited to cervical cancer screening. Because of their expected lower cervical cancer risk, we must reassess our screening strategies. We analyzed Danish HPV-vaccinated women's outcomes after the first screening test at age 23.

METHODS AND FINDINGS

Our study was embedded in Danish routine cytology-based screening. We conducted an observational study and included women born in 1994, offered the 4-valent HPV vaccine at age 14, and subsequently invited to screening at age 23. Cervical cytology was used for diagnostics and clinical management. Residual material was HPV tested with Cobas® 4800/6800. The most severe histology diagnosis within 795 days of screening was found through linkage with the Danish National Pathology Register. We calculated the number of women undergoing follow-up (repeated testing and/or colposcopy) per detected cervical intraepithelial neoplasia (CIN2+). A total of 6021 women were screened; 92% were HPV-vaccinated; 12% had abnormal cytology; 35% were high-risk HPV-positive, including 0.9% HPV16/18 positive, and 20% had follow-up. In women that were cytology-abnormal and HPV-positive (Cyt+/HPV+), 610 (98.5%) had been followed up, and 138 CIN2+ cases were diagnosed, resulting in 4.4 (95% CI 3.9-5.2) women undergoing follow-up per detected CIN2+. In contrast to recommendations, 182 (12.2%) cytology-normal and HPV-positive (Cyt-/HPV+) women were followed up within 795 days, and 8 CIN2+ cases were found, resulting in 22.8 (95% CI 13.3-59.3) women undergoing follow-up per detected CIN2+.

CONCLUSION

Overall, HPV prevalence was high in HPV-vaccinated women, but HPV16/18 had largely disappeared. In the large group of cytology-normal and HPV-positive women, 23 had been followed up per detected CIN2+ case. Our data indicated that primary HPV screening of young HPV-vaccinated women would require very effective triage methods to avoid an excessive follow-up burden.

TRIAL REGISTRATION

Trial registration number: NCT0304955.

Safety Assessment of Concurrent Vaccination with the HPV Vaccine and the COVID-19 Vaccine in Fujian Province, China: A Retrospective Study

During acute respiratory infections, women may concurrently receive human papillomavirus (HPV) and respiratory vaccines, as observed during the coronavirus disease 2019 (COVID-19) pandemic in China. However, few studies have assessed the safety of such concurrent administration, which could impact HPV vaccination schedules. This study analyzes the safety and optimal sequence of concurrent HPV and COVID-19 vaccinations. For this purpose, we surveyed women with both vaccines from January to October 2023 in Fujian Province, China. During this process, we collected vaccination history and adverse event (AE) data via telephone or interviews. Participants were grouped as Before, Concurrent, or After based on their vaccination sequence. A Chi-squared test, exact Fisher tests, and logistic regression were used to analyze the incidence of AEs and factors influencing vaccine safety. Overall, 1416 eligible participants were included. Although overall AE risk with the HPV vaccine was unaffected by vaccination sequence, individual AEs varied statistically between groups, including pain at the vaccination site (p < 0.001) and prolonged menstruation duration (p = 0.003). Based on the results, the optimal sequence would be to receive the HPV vaccine after the COVID-19 vaccine (After group). This insight may guide future emergency vaccination sequences for HPV and other respiratory infectious diseases.

Impact of human papillomavirus types on uterine cervical neoplasia

Human papillomavirus (HPV) is a major cause of cervical cancer. As the natural history of HPV-associated cervical lesions is HPV genotype-dependent, it is important to understand the characteristics of these genotypes and to manage them accordingly. Among high-risk HPVs, HPV16 and 18 are particularly aggressive, together accounting for 70% of HPV genotypes detected in cervical cancer. Other than HPV16 and 18, HPV31, 33, 35, 45, 52, and 58 are also at a high risk of progression to cervical intraepithelial neoplasia (CIN)3 or higher. Recent studies have shown that the natural history of HPV16, 18, 52, and 58, which are frequently detected in Japan, depends on the HPV genotype. For example, HPV16 tends to progress in a stepwise fashion from CIN1 to CIN3, while HPV52 and 58 are more likely to persist in the CIN1 to CIN2 state. Among the high-risk HPVs, HPV18 has some peculiar characteristics different from those of other high-risk HPV types; the detection rate in precancerous lesions is much lower than those of other high-risk HPVs, and it is frequently detected in highly malignant adenocarcinoma and small cell carcinoma. Recent findings demonstrate that HPV18 may be characterized by latent infection and carcinogenesis in stem cell-like cells. In this context, this review outlines the natural history of HPV-infected cervical lesions and the characteristics of each HPV genotype.

Invasive cervical cancer incidence following bivalent human papillomavirus vaccination: a population-based observational study of age at immunization, dose, and deprivation

BACKGROUND

High-risk human papillomavirus causes cervical cancer. Vaccines have been developed that significantly reduce the incidence of preinvasive and invasive disease. This population-based observational study used linked screening, immunization, and cancer registry data from Scotland to assess the influence of age, number of doses, and deprivation on the incidence of invasive disease following administration of the bivalent vaccine.

METHODS

Data for women born between January 1, 1988, and June 5, 1996, were extracted from the Scottish cervical cancer screening system in July 2020 and linked to cancer registry, immunization, and deprivation data. Incidence of invasive cervical cancer per 100 000 person-years and vaccine effectiveness were correlated with vaccination status, age at vaccination, and deprivation; Kaplan Meier curves were calculated.

RESULTS

No cases of invasive cancer were recorded in women immunized at 12 or 13 years of age irrespective of the number of doses. Women vaccinated at 14 to 22 years of age and given 3 doses of the bivalent vaccine showed a significant reduction in incidence compared with all unvaccinated women (3.2/100 000 [95% confidence interval (CI) = 2.1 to 4.6] vs 8.4 [95% CI = 7.2 to 9.6]). Unadjusted incidence was significantly higher in women from most deprived (Scottish Index of Multiple Deprivation 1) than least deprived (Scottish Index of Multiple Deprivation 5) areas (10.1/100 000 [95% CI = 7.8 to 12.8] vs 3.9 [95% CI = 2.6 to 5.7]). Women from the most deprived areas showed a significant reduction in incidence following 3 doses of vaccine (13.1/100 000 [95% CI = 9.95 to 16.9] vs 2.29 [95% CI = 0.62 to 5.86]).

CONCLUSION

Our findings confirm that the bivalent vaccine prevents the development of invasive cervical cancer and that even 1 or 2 doses 1 month apart confer benefit if given at 12-13 years of age. At older ages, 3 doses are required for statistically significant vaccine effectiveness. Women from more deprived areas benefit more from vaccination than those from less deprived areas.

Novel Cancer Prevention Strategies in Individuals With Hereditary Cancer Syndromes: Focus on BRCA1, BRCA2, and Lynch Syndrome

Germline pathogenic variants (PVs) in the BRCA1 and BRCA2 genes confer elevated risks of breast, ovarian, and other cancers. Lynch syndrome (LS) is associated with increased risks of multiple cancer types including colorectal and uterine cancers. Current cancer risk mitigation strategies have focused on pharmacologic risk reduction, enhanced surveillance, and preventive surgeries. While these approaches can be effective, they stand to be improved on because of either limited efficacy or undesirable impact on quality of life. The current review summarizes ongoing investigational efforts in cancer risk prevention strategies for patients with germline PVs in BRCA1, BRCA2, or LS-associated genes. These efforts span radiation, surgery, and pharmacology including vaccine strategies. Understanding the molecular events involved in the premalignant to malignant transformation in high-risk individuals may ultimately contribute significantly to novel prevention strategies.

Predicting cervical cancer risk probabilities using advanced H20 AutoML and local interpretable model-agnostic explanation techniques

Background

Cancer is positioned as a major disease, particularly for middle-aged people, which remains a global concern that can develop in the form of abnormal growth of body cells at any place in the human body. Cervical cancer, often known as cervix cancer, is cancer present in the female cervix. In the area where the endocervix (upper two-thirds of the cervix) and ectocervix (lower third of the cervix) meet, the majority of cervical cancers begin. Despite an influx of people entering the healthcare industry, the demand for machine learning (ML) specialists has recently outpaced the supply. To close the gap, user-friendly applications, such as H2O, have made significant progress these days. However, traditional ML techniques handle each stage of the process separately; whereas H2O AutoML can automate a major portion of the ML workflow, such as automatic training and tuning of multiple models within a user-defined timeframe.

Methods

Thus, novel H2O AutoML with local interpretable model-agnostic explanations (LIME) techniques have been proposed in this research work that enhance the predictability of an ML model in a user-defined timeframe. We herein collected the cervical cancer dataset from the freely available Kaggle repository for our research work. The Stacked Ensembles approach, on the other hand, will automatically train H2O models to create a highly predictive ensemble model that will outperform the AutoML Leaderboard in most instances. The novelty of this research is aimed at training the best model using the AutoML technique that helps in reducing the human effort over traditional ML techniques in less amount of time. Additionally, LIME has been implemented over the H2O AutoML model, to uncover black boxes and to explain every individual prediction in our model. We have evaluated our model performance using the findprediction() function on three different idx values (i.e., 100, 120, and 150) to find the prediction probabilities of two classes for each feature. These experiments have been done in Lenovo core i7 NVidia GeForce 860M GPU laptop in Windows 10 operating system using Python 3.8.3 software on Jupyter 6.4.3 platform.

Results

The proposed model resulted in the prediction probabilities depending on the features as 87%, 95%, and 87% for class '0' and 13%, 5%, and 13% for class '1' when idx_value=100, 120, and 150 for the first case; 100% for class '0' and 0% for class '1', when idx_value= 10, 12, and 15 respectively. Additionally, a comparative analysis has been drawn where our proposed model outperforms previous results found in cervical cancer research.

Effect of the HPV vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England: population based observational study

OBJECTIVES

To replicate previous analyses on the effectiveness of the English human papillomavirus (HPV) vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia (CIN3) using 12 additional months of follow-up, and to investigate effectiveness across levels of socioeconomic deprivation.

DESIGN

Observational study.

SETTING

England, UK.

PARTICIPANTS

Women aged 20-64 years resident in England between January 2006 and June 2020 including 29 968 with a diagnosis of cervical cancer and 335 228 with a diagnosis of CIN3. In England, HPV vaccination was introduced nationally in 2008 and was offered routinely to girls aged 12-13 years, with catch-up campaigns during 2008-10 targeting older teenagers aged <19 years.

MAIN OUTCOME MEASURES

Incidence of invasive cervical cancer and CIN3.

RESULTS

In England, 29 968 women aged 20-64 years received a diagnosis of cervical cancer and 335 228 a diagnosis of CIN3 between 1 January 2006 and 30 June 2020. In the birth cohort of women offered vaccination routinely at age 12-13 years, adjusted age standardised incidence rates of cervical cancer and CIN3 in the additional 12 months of follow-up (1 July 2019 to 30 June 2020) were, respectively, 83.9% (95% confidence interval (CI) 63.8% to 92.8%) and 94.3% (92.6% to 95.7%) lower than in the reference cohort of women who were never offered HPV vaccination. By mid-2020, HPV vaccination had prevented an estimated 687 (95% CI 556 to 819) cervical cancers and 23 192 (22 163 to 24 220) CIN3s. The highest rates remained among women living in the most deprived areas, but the HPV vaccination programme had a large effect in all five levels of deprivation. In women offered catch-up vaccination, CIN3 rates decreased more in those from the least deprived areas than from the most deprived areas (reductions of 40.6% v 29.6% and 72.8% v 67.7% for women offered vaccination at age 16-18 and 14-16, respectively). The strong downward gradient in cervical cancer incidence from high to low deprivation in the reference unvaccinated group was no longer present among those offered the vaccine.

CONCLUSIONS

The high effectiveness of the national HPV vaccination programme previously seen in England continued during the additional 12 months of follow-up. HPV vaccination was associated with a substantially reduced incidence of cervical cancer and CIN3 across all five deprivation groups, especially in women offered routine vaccination.

Estimated Human Papillomavirus Vaccine Coverage Among Females 9-45 Years of Age - China, 2017-2022

What is already known on this topic?

There is a lack of comprehensive data on the coverage of the human papillomavirus (HPV) vaccine in China. The limited published literature hampers our ability to accurately assess the current situation.

What is added by this report?

This study aimed to determine the rates of HPV vaccine coverage based on data from the electronic vaccination registry reported to the China Immunization Information System between 2017 and 2022. While there was an increase in HPV vaccine coverage each year, the overall coverage remained below the optimal level.

What are the implications for public health practice?

This study presents evidence of low HPV vaccine coverage when administered outside of a national immunization program. Therefore, it is recommended that the HPV vaccine be included in the National Immunization Program in order to meet the 2030 WHO target of achieving 90% vaccination coverage for girls by the age of 15.

Prevalence of cervical human papillomavirus in kidney transplant recipients: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aims to investigate the prevalence of cervical high-risk human papillomavirus (hrHPV) among kidney transplant recipients (KTRs) and, furthermore to compare it to that in immunocompetent controls.

METHODS

A systematic literature search was conducted in PubMed, EMBASE, and Cochrane Library databases from January 2000 to February 2023, to identify studies investigating the prevalence of cervical hrHPV in KTRs. Pooled cervical hrHPV prevalences, odds ratios (ORs) comparing KTRs to controls and corresponding confidence intervals (CIs) were estimated using random effects logistic regression models. Heterogeneity between studies was assessed through the I2 statistic, and the significance was evaluated by the Cochrane's Q test.

RESULTS

Altogether, 16 studies covering >1200 KTRs were included. The prevalence of cervical hrHPV in KTRs was 27.7% (95% CI 21.3-35.1) with substantial interstudy heterogeneity. Stratification indicated a higher prevalence in recent years (2019-2023) and in Asia (39% (95% CI 11.2-61.4)). The prevalence of HPV16 and HPV18 in KTRs was 8.0% (95% CI 3.9-15.9) and 1.7% (95% CI 0.8-3.7), respectively. Comparing hrHPV prevalence in KTRs and controls based on six studies including >500 KTRs and 1000 controls, the OR for hrHPV was 2.0 (95% CI 1.1-3.6).

CONCLUSIONS

This meta-analysis establishes an increased cervical hrHPV prevalence in KTRs compared to controls. The increased risk may be associated with immunosuppressive therapy post-transplantation. Further research is needed to explore the potential benefits of HPV vaccination, including potential revaccination strategies in KTRs.

Long non-coding RNA NEAT1 promotes aerobic glycolysis and progression of cervical cancer through WNT/β-catenin/PDK1 axis

BACKGROUND

Cervical cancer is one of the most common gynecological cancers. Accumulated evidence shows that long non-coding RNAs (lncRNAs) play essential roles in cervical cancer occurrence and progression, but their specific functions and mechanisms remain to be further explored.

METHODS

The RT-qPCR assay was used to detect the expression of NEAT1 in cervical cancer tissues and cell lines. CCK-8, colony formation, flow cytometry, western blotting, and Transwell assays were used to evaluate the impact of NEAT1 on the malignant behavior of cervical cancer cells. Glucose consumption, lactate production, ATP levels, ROS levels, MMP levels, and the mRNA expressions of glycolysis-related genes and tricarboxylic acid cycle-related genes were detected to analyze the effect of NEAT1 on metabolism reprograming in cervical cancer cells. The expressions of PDK1, β-catenin and downstream molecules of the WNT/β-catenin signaling pathway in cervical cancer cells and tissues were detected by western blotting, RT-qPCR, immunofluorescence and immunohistochemistry assays.

RESULTS

This study investigated the role and possible molecular mechanism of lncRNA nuclear paraspeckle assembly transcript 1 (NEAT1) in cervical cancer. Our results showed that NEAT1 was highly expressed in cervical cancer tissues and cell lines. Downregulation of NEAT1 inhibited the proliferation, migration, invasion and glycolysis of cervical cancer cells, while overexpression of NEAT1 led to the opposite effects. Mechanistically, NEAT1 upregulated pyruvate dehydrogenase kinase (PDK1) through the WNT/β-catenin signaling pathway, which enhanced glycolysis and then facilitated cervical cancer metastasis. Furthermore, NEAT1 maintained the protein stability of β-catenin but did not affect its mRNA level. We also excluded the direct binding of NEAT1 to the β-catenin protein via RNA pull-down assay. The suppressive impact of NEAT1 knockdown on cell proliferation, invasion, and migration was rescued by β-catenin overexpression. The WNT inhibitor iCRT3 attenuated the carcinogenic effect induced by NEAT1 overexpression.

CONCLUSION

In summary, these findings indicated that NEAT1 may contribute to the progression of cervical cancer by activating the WNT/β-catenin/PDK1 signaling axis.

Risk of progression of cervical intraepithelial neoplasia grade 2 in human papillomavirus-vaccinated and unvaccinated women: a population-based cohort study

BACKGROUND

Many countries have implemented active surveillance (ie, leaving the lesion untreated) as an option among younger women with cervical intraepithelial neoplasia grade 2 because regression rates are high and excisional treatment increases the risk for preterm birth in subsequent pregnancies. However, early identification of women at increased risk for progression to cervical intraepithelial neoplasia grade 3 or worse is important to ensure timely treatment. Because women who have received a human papillomavirus vaccine have a lower risk for cervical cancer, they may have a lower risk for progression of untreated cervical intraepithelial neoplasia grade 2 to cervical intraepithelial neoplasia grade 3 or worse.

OBJECTIVE

This study aimed to investigate if women who received a human papillomavirus vaccine and who are undergoing active surveillance for cervical intraepithelial neoplasia grade 2 are less likely to progress to cervical intraepithelial neoplasia grade 3 or worse when compared with women who did not receive the vaccine.

STUDY DESIGN

We conducted a population-based cohort study in Denmark using data from national health registers. We identified all women aged 18 to 40 years who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 from January 1, 2007, to December 31, 2020. Women with a previous record of cervical intraepithelial neoplasia grade 2 or worse, hysterectomy, or a loop electrosurgical excision procedure were excluded. Exposure was defined as having received ≥1 dose of a human papillomavirus vaccine at least 1 year before the cervical intraepithelial neoplasia grade 2 diagnosis. We used cumulative incidence functions to estimate the risk for progression to cervical intraepithelial neoplasia grade 3 or worse within 28 months using hysterectomy, emigration, and death as competing events. We used modified Poisson regression to calculate crude and adjusted relative risks of progression during the 28-month surveillance period. Results were stratified by age at vaccination and adjusted for index cytology, disposable income, and educational level.

RESULTS

The study population consisted of 7904 women of whom 3867 (48.9%) were vaccinated at least 1 year before a diagnosis of cervical intraepithelial neoplasia grade 2. At the time of cervical intraepithelial neoplasia grade 2 diagnosis, women who were vaccinated were younger (median age, 25 years; interquartile range, 23-27 years) than those who were not (median age, 29 years; interquartile range, 25-33 years). The 28-month cumulative risk for cervical intraepithelial neoplasia grade 3 or worse was significantly lower among women who were vaccinated before the age of 15 years (22.9%; 95% confidence interval, 19.8-26.1) and between the ages of 15 and 20 years (31.5%; 95% confidence interval, 28.8-34.3) when compared with women who were not vaccinated (37.6%; 95% confidence interval, 36.1-39.1). Thus, when compared with women who were not vaccinated, those who were vaccinated before the age of 15 years had a 35% lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse (adjusted relative risk, 0.65; 95% confidence interval, 0.57-0.75), whereas women who were vaccinated between the ages of 15 and 20 years had a 14% lower risk (adjusted relative risk, 0.86; 95% confidence interval, 0.79-0.95). For women who were vaccinated after the age of 20 years, the risk was comparable with that among women who were not vaccinated (adjusted relative risk, 1.02; 95% confidence interval, 0.96-1.09).

CONCLUSION

Women who were vaccinated and who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 had a lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse during 28 months of follow-up when compared with women who were not vaccinated but only if the vaccine was administered by the age of 20 years. These findings may suggest that the human papillomavirus vaccination status can be used for risk stratification in clinical management of cervical intraepithelial neoplasia grade 2.

Human Papillomavirus and Its Association With Cervical Cancer: A Review

The human papillomavirus (HPV) belongs to the Papillomavirus family and is considered a non-enveloped virus. HPV affects individuals by causing both benign and malignant lesions. We aim to define HPV and its important characteristics, explain the relation between HPVs and cervical cancer, review its prevalence among Saudi women and their awareness of screening and prevention of cervical cancer, and focus on the importance of HPV vaccination. The persistence of HPV infection is the most important risk factor for the development of cervical cancer. HPVs cannot be cultured, and the identification of the virus is dependent on a variety of techniques, including immunology, serology, and molecular biology. Cervical cancer is the fourth most prevalent form of cancer in women worldwide, while it is considered the 12th type of cancer that affects Saudi women. Unfortunately, many studies have shown a lack of awareness regarding HPV infection, screening, and vaccination among the Saudi population in general, as well as among Saudi healthcare professionals. The HPV vaccine has a potent role in preventing people from getting infected with the virus, despite some previous clinical trials assessing the outcomes of therapeutic HPV vaccinations showing unsatisfactory results. While there is no doubt about the benefits of vaccines and their role in reducing the incidence of HPV infectious diseases, there are discrepancies in the evaluation of the safety of the HPV vaccine. In conclusion, HPV is an essential etiology of cervical cancer, and the expansion of public awareness about protective methods and threat factors associated with HPV infection is highly important.

Advances and challenges in cancer immunoprevention and immune interception

Invasive cancers typically evade immune surveillance through profound local and systemic immunosuppression, preventing their elimination or control. Targeting immune interventions to prevent or intercept premalignant lesions, before significant immune dysregulation has occurred, may be a more successful strategy. The field of cancer immune interception and prevention is nascent, and the scientific community has been slow to embrace this potentially most rational approach to reducing the global burden of cancer. This may change due to recent promising advances in cancer immunoprevention including the use of vaccines for the prevention of viral cancers, the use of cancer-associated antigen vaccines in the setting of precancers, and the development of cancer-preventative vaccines for high-risk individuals who are healthy but carry cancer-associated heritable genetic mutations. Furthermore, there is increasing recognition of the importance of cancer prevention and interception by national cancer organizations. The National Cancer Institute (NCI) recently released the National Cancer Plan, which includes cancer prevention among the top priorities of the institute. The NCI's Division of Cancer Prevention has been introducing new funding opportunities for scientists with an interest in the field of cancer prevention: The Cancer Prevention-Interception Targeted Agent Discovery Program and The Cancer Immunoprevention Network. Moreover, the Human Tumor Atlas Network is spearheading the development of a precancer atlas to better understand the biology of pre-invasive changes, including the tissue microenvironment and the underlying genetics that drive carcinogenesis. These data will inform the development of novel immunoprevention/immuno-interception strategies. International cancer foundations have also started recognizing immunoprevention and immune interception with the American Association for Cancer Research, Cancer Research UK and the Society for Immunotherapy of Cancer each implementing programming focused on this area. This review will present recent advances, opportunities, and challenges in the emerging field of cancer immune prevention and immune interception.

Prevalence of Human Papillomavirus (HPV) and HPV Type Distribution in Penile Samples in Young Men in Denmark: Results 10 Years After Implementation of a Girls-Only HPV Vaccination Program

BACKGROUND

In Denmark, a girls-only human papillomavirus (HPV) vaccination program was initiated in 2008-2009. The study aim was to assess the HPV prevalence and type distribution in younger men prior to HPV vaccination in men.

METHODS

The study population was younger men who attended information days regarding military service. At random days (2019-2020), 280 men were included. We collected questionnaire data regarding risk factors for HPV infection and a penile swab for HPV testing. We compared results in this study with those from a previous study of young men (2006-2007).

RESULTS

The majority of participants (94%) were 18-20 years old. The median number of lifetime sexual partners was 4. Altogether, 130 men (46.4%) were HPV positive. No infections with HPV types 6, 11, 16, 18, 31, and 45 were detected. The most frequent type was HPV-51 (detected in 11.1%). Comparison showed that the odds of high-risk HPV type infection were higher in 2019-2020 (prevalence odds ratio [POR], 1.7 [95% confidence interval {CI}, 1.1-2.7]) compared with 2006-2007. In contrast, the odds were lower (POR, 0.3 [95% CI, .1-.6]) for HPV types targeted by the 9-valent HPV vaccine.

CONCLUSIONS

The multicohort girls-only vaccination program has to a large degree protected young men against the HPV types included in the licensed vaccines. This does not speak against gender-neutral vaccination as the HPV prevalence is still high, although consisting largely of less carcinogenic HPV types.

Effectiveness of catch-up and routine program of the 9-valent vaccine on cervical cancer risk reduction in Japan

In 2013, the national human papillomavirus (HPV) immunization program began. However, in June 2013, Japan's Ministry of Health, Labor and Welfare (MHLW) announced a "temporary" suspension of its recommendation for the human papillomavirus vaccine. Finally, in November 2021, the MHLW ended its suspension of the recommendation of the HPV vaccine. To address the 9-year gap in HPV vaccinations the suspension had caused, the MHLW conducted a program of catch-up vaccinations from April 2022 to March 2025. Finally, in April 2023, the 9-valent HPV vaccine was approved for both the routine and catch-up vaccination programs in Japan. In this study, we investigated the potential effects of the introduction of the 9-valent vaccine on the increased risk of cervical cancer in females born after fiscal year (FY) 2000. We estimated the lifetime relative risk of cervical cancer incidence and death using the improved routine and catch-up vaccination rates after the recent resumption of the governmental recommendation for women and girls to have the HPV vaccination. These relative risks were calculated using a lifetime risk of 1.000 for cervical cancer incidence and death for females born in FY 1993. We predicted that even if a 90% vaccination rate were to be achieved by FY 2024 with the 9-valent vaccine among women born between FY 2000 and FY 2005, the risk would remain higher than for the vaccination generation. Therefore, for women born between FY 2000 and FY 2005, it will be necessary to significantly improve the cervical cancer screening rate to compensate for this increased risk.

Human papillomavirus vaccination and anal high-grade precancerous lesions and cancer-a real-world effectiveness study

BACKGROUND

Human papillomavirus (HPV) vaccination has shown high efficacy against anal HPV infection and lesions in clinical trials, and the HPV prevalence and type distribution in anal precancers and cancer predict a high preventable potential for HPV vaccination. However, the real-world effectiveness of HPV vaccination against anal high-grade lesions and cancer is yet to be shown.

METHODS

We investigated HPV vaccine effectiveness against anal high-grade squamous intraepithelial lesion (HSIL) or worse in a nationwide cohort including all Danish women aged 17-32 years during October 2006 to December 2021 (n = 968 881). HPV vaccinations and first occurrence of anal HSIL or worse were retrieved from nationwide registries. Women were considered vaccinated after first dose and classified by age at vaccination. Using Cox regression, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for anal HSIL or worse according to vaccination status.

RESULTS

During follow-up, the number of incident histological anal HSIL or worse cases was 37 in unvaccinated women, and less than 5 and 26 in women vaccinated at ages younger than 17 years and 17-32 years, respectively. The overall number of cancers was less than 5. Compared with unvaccinated women, the risk of histological anal HSIL or worse was reduced for women vaccinated at age younger than 17 years (HR = 0.30, 95% CI = 0.10 to 0.87). For women vaccinated at age 17-32 years, the hazard rate of anal HSIL or worse was 1.21 (95% CI = 0.73 to 2.03).

CONCLUSION

This is the first study to demonstrate that HPV vaccination at a younger age is associated with substantially reduced risk of anal HSIL or worse in the general population.

Vaccination Effectiveness against Human Papillomavirus in Kazakhstan

OBJECTIVE

The purpose was to determine the effectiveness of human papillomavirus immunization and its impact on cervical cancer development in Kazakhstan.

METHODS

The current research is a case-control study with two groups: a main group and a control group. A total of 725 subjects participated in the research.

RESULTS

The association between vaccination and cervical cancer development was calculated both for the two groups as a whole and for individual patients, who were selected based on criteria of residence, presence of immunodeficiency or chronic cardiac or renal pathology, as well as analysis of age at which the vaccine dose was received. There was a statistically significant association between the absence of the human papillomavirus vaccine and the risk of cervical cancer in all groups. When considering the entire cohort, the chance of finding a risk factor (lack of vaccination) was almost 7 times higher in the main group than in the control group. Thus, an association between vaccination and cervical cancer risk was found in each of the pairs of subjects.

CONCLUSION

The effectiveness of vaccination in preventing cervical cancer was not observed in patients who were vaccinated after 18 years of age, while most patients in the control group were vaccinated in their teens. The practical significance of the research is not only to further study the problem of human papillomavirus (HPV) vaccination in Kazakhstan but also to popularize HPV immunization to prevent cervical cancer (CC).

Barriers and facilitators to the HPV vaccine: a multicenter qualitative study of French general practitioners

BACKGROUND

In France, human papillomavirus (HPV) vaccination coverage is low, with 30.7% of 17-year-old girls having received a complete HPV vaccination schedule in 2020.

AIM

To determine the perspective and behaviors of general practitioners (GPs) regarding HPV vaccination with their patients and if a reluctance is observed.

DESIGN AND SETTING

A qualitative study based on semi-directed individual interviews was conducted between December 2019 and December 2020. A representative sample of GPs with various profiles were included in 4 French regions.

METHOD

A purposive sampling was used and interviews were continued until data saturation was reached. The analysis was based on the grounded theory.

RESULTS

Twenty-six GPs aged 29-66 years were interviewed. The measures taken by the French health authorities (lowering the target age, reimbursing the vaccine, extending the target population to boys) were perceived as facilitators. The reported barriers were organizational, due to low attendance of adolescents, and relational, mainly due to parental vaccine hesitancy. Physicians had to deal with fears about the perceived risks and concerns about sexuality conveyed by HPV vaccination and linked to the socio-cultural characteristics of the families. Physicians developed strategies, including scientific knowledge mobilization, empowerment of families by promoting health through prevention, repetition of the vaccination proposals, personal experience and relationship. Different practices were identified according to three GP typologies: effective, convinced but unpersuasive, and reluctant physicians.

CONCLUSION

Based on these results, specific interventions, including communication techniques, especially for hesitant or unpersuasive physicians, are needed to enable GPs to become more effective.

Implementing interventions to start HPV vaccination at age 9: Using the evidence we have

Human papillomavirus (HPV) vaccination is routinely recommended for adolescents aged 11 or 12 years but can begin at age 9. On-time HPV vaccination by the thirteenth birthday has proven to be effective in preventing HPV cancer and pre-cancer. However, HPV coverage rates continue to lag behind other routinely recommended vaccinations for adolescents. A promising approach to improving coverage is to start HPV vaccination at age 9. This approach has been endorsed by the American Academy of Pediatrics and the American Cancer Society. Benefits of this approach include increased time to complete vaccination series by the thirteenth birthday, additional spacing of recommended vaccines, and a more concentrated focus on cancer prevention messaging. While promising, little is known about how and if existing evidence-based interventions and approaches can be used to promote starting HPV vaccination at age 9. Implementation science frameworks offer scientific direction in how to adapt current and develop new interventions to promote starting HPV vaccination at age 9 and accelerate dissemination and prevent HPV cancers.

Human papillomavirus (HPV) vaccines in adults: Learnings from long-term follow-up of quadrivalent HPV vaccine clinical trials

The risk for acquiring human papillomavirus (HPV) infections and associated diseases is lifelong. An important part of prophylactic HPV vaccine development is durable protection against infection and disease. With comprehensive long-term follow-up (LTFU) in adolescents, men, and women, the quadrivalent HPV (qHPV) vaccine demonstrated durable effectiveness, immunogenicity, and safety, with almost no breakthrough disease. Those who received a placebo during initial trials were offered the qHPV vaccine at study conclusion and continued to be followed in LTFU extensions. In this catch-up vaccination group, LTFU demonstrated protection even in individuals with current or prior HPV infection after approximately 3 years. The initial efficacy and durable long-term effectiveness of the qHPV vaccine have already translated to a real-world reduction in cancer and cancer precursors. To date, there is no evidence of waning protection; evidence suggests that vaccination ultimately provides strong protection against future disease, with effective prophylaxis even among those with past infections.

Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningococcal vaccination on timely completion of the HPV vaccine series

To explore the impact on timely series completion of initiating the HPV vaccine series prior to other vaccines in the adolescent platform (Tdap or meningococcal vacccines), we created a cohort of children aged 9 in 2015 who were continuously enrolled through the age of 13 (2019) from a national administrative database of employee-sponsored insurance in the United States (MarketScan). Logistic regressions were used to predict the odds of HPV vaccine series completion among those who started the series prior to, concurrent with, or after receiving Tdap or meningococcal vaccination. The cohort included 100,857 eligible children. Compared with adolescents who received their HPV and Tdap or HPV and meningococcal vaccinations concurrently, those who received HPV prior to other vaccines had higher completion (aOR = 1.38 for Tdap, aOR 1.62 for meningococcal), while those who received their HPV vaccination after other vaccines had lower odds of HPV vaccine series completion (aOR = 0.68 for Tdap, aOR = 0.62 for meningococcal). Other factors associated with series completion included female sex, residing in an urban (vs. rural) area, residing in the Northeast, and receiving primary care from a pediatrician (vs. family medicine physician). These data indicate that beginning the HPV vaccine series prior to the adolescent platform may improve on-time series completion.

Essential Oils in Cervical Cancer: Narrative Review on Current Insights and Future Prospects

Cervical cancer is a prevalent and often devastating disease affecting women worldwide. Traditional treatment modalities such as surgery, chemotherapy, and radiation therapy have significantly improved survival rates, but they are often accompanied by side effects and challenges that can impact a patient's quality of life. In recent years, the integration of essential oils into the management of cervical cancer has gained attention. This review provides an in-depth exploration of the role of various essential oils in cervical cancer, offering insights into their potential benefits and the existing body of research. The review also delves into future directions and challenges in this emerging field, emphasizing promising research areas and advanced delivery systems. The encapsulation of essential oils with solid lipid nanoparticles, nanoemulsification of essential oils, or the combination of essential oils with conventional treatments showed promising results by increasing the anticancer properties of essential oils. As the use of essential oils in cervical cancer treatment or management evolves, this review aims to provide a comprehensive perspective, balancing the potential of these natural remedies with the challenges and considerations that need to be addressed.

Fighting cervical cancer in Africa: a cross-sectional study on prevalence and risk factors for precancerous lesions in rural Uganda

OBJECTIVE

To identify risk factors for precancerous cervical lesions and factors associated with treatment delay among women in the rural Busoga Region, Uganda.

STUDY DESIGN

A retrospective cross-sectional study from a regional cervical cancer screening program and from cervical cancer patients enrolled in a region-wide palliative care program.

METHODS

Logistic regression analysis was conducted to assess risk factors for screening positive for precancerous lesions. In a separate analysis, factors associated with treatment delay were assessed among women enrolled in the palliative care program.

RESULTS

Three thousand nine hundred forty-six women were included from the screening program and 334 from the palliative care program. In total, 7.6% of screening participants had precancerous lesions. Within Busoga Region, the highest positivity rate was found in Bugweri and Namayingo Districts. Abnormal vaginal bleeding (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI] 1.15-2.21; p = 0.005) and older age at first menstrual period (aOR 1.08; 95% CI 1.01-1.16; p = 0.03) were associated with having a precancerous lesion. Among palliative care patients, a history of previous contact with the health care system was associated with a delay in enrolment (≥12 months from first symptom presentation until commencement in palliative care; aOR 5.23; 95% CI 1.16-36.54; p = 0.047).

CONCLUSIONS

The results underline an unmet need for broad-scale cervical cancer screening focusing on all women in the reproductive age. Abnormal bleeding was the only substantial risk factor for precancerous lesions, indicating that specific algorithms to identify high-risk populations may not be applicable in this population. Increased awareness, resources, and funding are still necessary to achieve global cervical cancer elimination.

Clinical course of cervical intraepithelial neoplasia grade 2: a population-based cohort study

BACKGROUND

Cervical intraepithelial neoplasia grade 2 has historically been the threshold for surgical excision, but because of high regression rates, many countries are transitioning to active surveillance. However, estimates for regression rates are based on small studies with heterogeneous definitions of regression and progression.

OBJECTIVE

This study aimed to describe regression and progression rates of cervical intraepithelial neoplasia grade 2 using nationwide healthcare registry data.

STUDY DESIGN

This was a nationwide population-based cohort study on women aged 18 to 40 years who had undergone active surveillance for cervical intraepithelial neoplasia grade 2 in Denmark from 1998 to 2020. This study excluded women with a previous record of cervical intraepithelial neoplasia grade 2 or worse or surgical excision. Cumulative incidence functions were used to estimate the rates of regression and progression at 6, 12, 18, and 24 months after diagnosis. In addition, a modified Poisson regression was used to estimate the crude and adjusted relative risks of progression within 24 months stratified by index cytology and age.

RESULTS

During the study period, 11,056 women underwent active surveillance, 6767 of whom regressed and 3580 of whom progressed within 24 months. This corresponded to regression rates of 62.9% (95% confidence interval, 61.9-63.8) and progression rates of 33.3% (95% confidence interval, 32.4-34.2) at 24 months of follow-up. Most women regressed (90%) or progressed (90%) within the first 12 months. Women with high-grade index cytology had a higher risk of progression than women with normal index cytology (adjusted relative, 1.58; 95% confidence interval, 1.43-1.76), whereas there was no difference in the risk of progression between women aged 30 and 40 years and women aged 23 to 29 years (adjusted relative risk, 0.98; 95% confidence interval, 0.88-1.10).

CONCLUSION

The observed high regression rates of cervical intraepithelial neoplasia grade 2 supported the transition in clinical management from surgical excision to active surveillance, particularly among women with low-grade or normal index cytology.

Human papillomavirus vaccine impact on invasive cervical cancer in Japan: Preliminary results from cancer statistics and the MINT study

The first prophylactic vaccine against human papillomavirus (HPV) 16 and HPV18 was licensed in Japan in 2009. HPV vaccine effectiveness against high-grade cervical lesions has been demonstrated among young Japanese women, but evidence of its effects on invasive cervical cancer (ICC) is lacking. Using data from two different cancer registries, we compared recent trends of new ICC cases by age group using Poisson regression analysis. We also analyzed time trends in HPV16/18 prevalence among 1414 Japanese women aged <40 years newly diagnosed with ICC in the past decade. Based on the population-based cancer registry, the incidence of ICC among young women aged 20-29 years showed a significant decline from 3.6 to 2.8 per 100 000 women-years during 2016-2019, but no similar decline was observed for older age groups (p < 0.01). Similarly, using data from the gynecological cancer registry of the Japan Society of Obstetrics and Gynecology, the annual number of ICCs among women aged 20-29 years also decreased from 256 cases to 135 cases during 2011-2020 (p < 0.0001). Furthermore, a declining trend in HPV16/18 prevalence in ICC was observed only among women aged 20-29 years during 2017-2022 (90.5%-64.7%, p = 0.05; Cochran-Armitage trend test). This is the first report to suggest population-level effects of HPV vaccination on ICC in Japan. Although the declining trend in HPV16/18 prevalence among young women with ICC supports a causal linkage between vaccination and results from cancer registries, further studies are warranted to confirm that our findings are attributable to vaccination.

Understanding cervical cancer at single-cell resolution

Cervical cancer is now the fourth most prevalent malignancy in women worldwide, representing a tremendous burden of cancer. The heterogeneity of complex tumor ecosystem impacts tumorigenesis, malignant progression, and response to treatment; thus, a thorough understanding of the tumor ecosystem is vital for enhancing the prognosis of patients with cervical cancer. The rapid development and widespread use of single-cell sequencing have generated a new paradigm of cancer research, providing a comprehensive and in-depth understanding of cancers. In this review, we give an overview of the recent advances made by leveraging single-cell sequencing studies in the dissection of cervical cancer ecosystem heterogeneity. We highlight the evolution of the cervical cancer ecosystem during tumor initiation, progression, and treatment. High-resolution dissection of cervical cancer at the single-cell level has the potential to drive the development of targeted therapies and enable the realization of personalized medicine.

Ten-Year Follow-up of 9-Valent Human Papillomavirus Vaccine: Immunogenicity, Effectiveness, and Safety

BACKGROUND AND OBJECTIVES

The 9-valent human papillomavirus (9vHPV) vaccine Phase III immunogenicity study in 9- to 15-year-old boys and girls was extended to assess immunogenicity and effectiveness through 10 years after the last vaccine dose (NCT00943722).

METHODS

Boys (n = 301) and girls (n = 971) who received three 9vHPV vaccine doses in the base study (day 1, months 2 and 6) enrolled in the extension. Serum was collected through month 126 for antibody assessments by competitive Luminex immunoassay and immunoglobulin G-Luminex immunoassay. For effectiveness analysis starting at age 16 years, genital swabs were collected (to assess HPV DNA by polymerase chain reaction) and external genital examinations conducted every 6 months. Primary analyses were conducted in per-protocol populations.

RESULTS

Geometric mean antibody titers peaked around month 7, decreased sharply between months 7 and 12, then gradually through month 126. Seropositivity rates remained ≥81% by competitive Luminex immunoassay and ≥95% by immunoglobin G-Luminex immunoassay at month 126 for each 9vHPV vaccine type. After up to 11.0 (median 10.0) years of follow-up postdose 3, there were no cases of HPV6/11/16/18/31/33/45/52/58-related high-grade intraepithelial neoplasia or condyloma in males or females. Incidence rates of HPV6/11/16/18/31/33/45/52/58-related 6-month persistent infection in males and females were low (54.6 and 52.4 per 10000 person-years, respectively) and within ranges expected in vaccinated cohorts, based on previous human papillomavirus vaccine efficacy trials.

CONCLUSIONS

The 9vHPV vaccine demonstrated sustained immunogenicity and effectiveness through ∼10 years post 3 doses of 9vHPV vaccination of boys and girls aged 9 to 15 years.

Manipulating TGF-β signaling to optimize immunotherapy for cervical cancer

Cervical cancer is a serious threat to women's health globally. Therefore, identifying key molecules associated with cervical cancer progression is essential for drug development, disease monitoring, and precision therapy. Recently, TGF-β (transforming growth factor-beta) has been identified as a promising target for cervical cancer treatment. For advanced cervical cancer, TGF-β participates in tumor development by improving metastasis, stemness, drug resistance, and immune evasion. Accumulating evidence demonstrates that TGF-β blockade effectively improves the therapeutic effects, especially immunotherapy. Currently, agents targeting TGF-β and immune checkpoints such as PD-L1 have been developed and tested in clinical studies. These bispecific antibodies might have the potential as therapeutic agents for cervical cancer treatment in the future.

Potential population-level effectiveness of one-dose HPV vaccination in low-income and middle-income countries: a mathematical modelling analysis

BACKGROUND

Given the accumulating evidence that one-dose vaccination could provide high and sustained protection against human papillomavirus (HPV) infection and related diseases, we examined the population-level effectiveness and efficiency of one-dose HPV vaccination of girls compared with two-dose vaccination, using mathematical modelling.

METHODS

In this mathematical modelling study, we used HPV-ADVISE LMIC, an individual-based transmission-dynamic model independently calibrated to four epidemiologically diverse low-income and middle-income countries (LMICs; India, Nigeria, Uganda, and Viet Nam). We parameterised and calibrated the model using sexual behaviour and epidemiological data identified from international population-based datasets and the literature. All base-case vaccination scenarios start in 2023 with the nonavalent vaccine and assumed 80% vaccination coverage with one or two doses. We assumed that two doses of vaccine provide 100% efficacy against vaccine-type infections and a lifelong duration of protection. We examined a non-inferior vaccination scenario for one dose compared with two doses, pessimistic scenarios of lower one-dose vaccine efficacy (85%) or a shorter duration of protection (ie, 20 or 30 years), and the effectiveness of a mitigation scenario in which schedules would switch from one dose to two doses. We also did sensitivity analyses by varying vaccination coverage. We used three outcomes: the relative reduction in cervical cancer incidence, the number of cervical cancers averted, and the number of vaccine doses needed to prevent one cervical cancer.

FINDINGS

Assuming non-inferior vaccine characteristics for one dose compared with two doses, the model projections show that two-dose or one-dose routine vaccination of girls aged 9 years (with a multi-age cohort vaccination of girls aged 10-14 years) would avert 12·0 million (80% UI 9·5-14·5) cervical cancers in India, 4·7 million (3·4-5·8) in Nigeria, 2·3 million (1·9-2·6) in Uganda, and 0·4 million (0·2-0·5) in Viet Nam over 100 years. Under pessimistic assumptions of lower one-dose efficacy (85%) or a shorter duration of protection (ie, 30 years), one-dose routine vaccination would avert 69% (61-80) to 94% (92-96) of the cervical cancers averted with two-dose routine vaccination. However, when assuming a duration of protection of 20 years, one-dose routine vaccination would avert substantially fewer cervical cancers (ie, 35% [26-44] to 69% [65-71] of the cervical cancers averted with two-dose routine vaccination). A switch from one-dose to two-dose routine vaccination of girls aged 9 years, with a one-dose catch-up of girls aged 10-14 years, 5 years after the start of the vaccination programme, could mitigate potential losses in cervical cancer prevention from a short one-dose duration of protection (averting 92% [83-98] to 99% [97-100]) of the cervical cancers averted with two-dose routine vaccination). One-dose routine vaccination would result in fewer doses needed to prevent one cervical cancer than two-dose routine vaccination, even if the duration of protection is as low as 20 years. Finally, for countries with two-dose routine vaccination, adding one-dose multi-age cohort vaccination in the first year would provide similar benefits as a two-dose multi-age cohort vaccination, and would be more efficient even under the pessimistic assumptions of lower one-dose vaccine efficacy or duration of protection.

INTERPRETATION

One-dose routine vaccination could avert most of the cervical cancers averted with two-dose vaccination while being more efficient, provided the duration of one-dose protection is greater than 20-30 years (depending on the LMIC). The doses saved by introducing one-dose routine vaccination could offer the opportunity to vaccinate girls before they age out of the vaccination window of 9-14 years and, potentially, to vaccinate boys or older age groups.

FUNDING

Fonds de recherche du Québec-Santé, Digital Research Alliance of Canada, Bill & Melinda Gates Foundation.

Exploring HPV vaccine knowledge, attitudes, barriers and information sources among parents, health professionals and teachers in Kazakhstan: a mixed-methods study protocol

INTRODUCTION

Human papillomavirus (HPV) is a prevalent sexually transmitted infection linked to certain types of malignant neoplasms, notably cervical cancer (CC). In Kazakhstan, a high prevalence of high oncogenic HPV types (HR-HPV) has been observed, and CC ranks as the second most common malignancy among women with a crude incidence rate of 18.3 cases per 100 000 women. The HPV vaccine, developed as the primary prevention measure against HPV infection, including the most prevalent HR-HPV, received approval from the WHO in 2009. In 2014, Kazakhstan initiated HPV vaccination as a pilot project in four sub-national regions; however, it was later in 2017 discontinued due to widespread parental refusal influenced by negative media reports. This study aims to examine knowledge, attitudes, information sources, barriers to HPV vaccination and factors associated with HPV vaccination hesitancy among different target groups in Kazakhstan prior to the HPV vaccine re-launch announced by the Ministry of Health.

METHODS AND ANALYSIS

This mixed-method-designed research comprises quantitative and qualitative components. Data on HPV awareness, attitudes towards HPV vaccination and sources of information will be collected through an online survey administered by parents and legal guardians, health professionals, and schoolteachers in the Republic of Kazakhstan between January 2023 and January 2024. Additionally, qualitative data on Kazakhstani parental beliefs and attitudes toward HPV vaccination will be collected through online focus group discussions.

ETHICS AND DISSEMINATION OF RESULTS

The study has been approved by the local ethics committee at the Kazakhstan Medical University "Higher School of Public Health" (KMU "KSPH") (No. 138 of 31.05.2021). The results will be reported in publications, at conferences among researchers and healthcare and school education professionals in Kazakhstan, and internationally.

Mechanisms underlying the effects, and clinical applications, of oral microbiota in lung cancer: current challenges and prospects

The oral cavity contains a site-specific microbiota that interacts with host cells to regulate many physiological processes in the human body. Emerging evidence has suggested that changes in the oral microbiota can increase the risk of lung cancer (LC), and the oral microbiota is also altered in patients with LC. Human and animal studies have shown that oral microecological disorders and/or specific oral bacteria may play an active role in the occurrence and development of LC through direct and/or indirect mechanisms. These studies support the potential of oral microbiota in the clinical treatment of LC. Oral microbiota may therefore be used in the prevention and treatment of LC and to improve the side effects of anticancer therapy by regulating the balance of the oral microbiome. Specific oral microbiota in LC may also be used as screening or predictive biomarkers. This review summarizes the main findings in research on oral microbiome-related LC and discusses current challenges and future research directions.

Quadrivalent HPV vaccine effectiveness against anogenital warts: A registry-based study of 2,2 million individuals

BACKGROUND

In 2009, Norway initiated routine quadrivalent HPV (qHPV) vaccination for girls at 12-13 years of age to protect against virus types causing cervical cancer, HPV16/18, and HPV6/11 which cause anogenital warts (AGW). We wanted to investigate qHPV vaccine effectiveness (VE) against AGW in females before and after first AGW episode and to assess the impact of female vaccination in males.

MATERIALS AND METHODS

QHPV vaccination and AGW episodes were collected for the time period 2006-2016 for birth cohorts 1975-2003. Cox models were applied to age at first, as well as at second AGW episode. Finally, we estimated the impact of the female vaccination program on unvaccinated males.

RESULTS

The VE against the first episode of AGW was strongly dependent on vaccination age, with hazard ratios (HRs) compared to unvaccinated individuals of 0.2, 0.2, 0.3, 0.5, 1.0, 1.3, and 2.7, for age groups of ⩽13, 14-15, 16-17, 18-19, 20-24, 25-29, and 30+ years at first vaccination, respectively. Among women who had suffered a first episode of AGW, subsequent qHPV vaccination did not protect against a second episode, with HRs of 0.8, 1.0, and 1.4, for age groups of ⩽17, 18-24, and 25+ years at first vaccination. A gradually decreasing AGW risk was seen in unvaccinated male cohorts neighboring the first routinely vaccinated female 1997 cohort.

CONCLUSIONS

When administered before 14 years of age, qHPV vaccination reduced the probability of AGW about fivefold. The effect decreased sharply with vaccination age, and was not significant among women vaccinated after age 20 years. QHPV administered after the first AGW episode did not protect against a second AGW episode. Herd effects were indicated in unvaccinated males, as we observed a gradual decrease in AGW rates from the 1993 male birth cohort and onwards.

Prevention and control of HPV and HPV-related cancers in France: the evolving landscape and the way forward - a meeting report

Misinformation regarding HPV vaccine safety and benefits has resulted in low coverage within the eligible French population. HPV vaccination is safe and efficacious in preventing HPV infections in adolescents. However, reaching optimal coverage in countries such as France is challenging due to misinformation, among other factors. Moreover, disparities exist in cervical cancer screening programs. To support the government health promotion policy aimed at improving prevention and control of HPV-related cancers in France, the Human Papillomavirus Prevention and Control Board (HPV-PCB), in collaboration with local experts, held a meeting in Annecy, France (December 2021).HPV-PCB is an independent, multidisciplinary board of international experts that disseminates relevant information on HPV to a broad array of stakeholders and provides guidance on strategic, technical and policy issues in the implementation of HPV control programs.After a one-and-a-half-day meeting, participants concluded that multi-pronged strategies are required to expand vaccination coverage and screening. Vaccine acceptance could be improved by: 1) strenghtening existing trust in clinicians by continuous training of current and upcoming/pre-service healthcare professionals (HCPs), 2) improving health literacy among adolescents and the public through school and social media platforms, and 3) providing full reimbursement of the gender-neutral HPV vaccine, as a strong signal that this vaccination is essential.The discussions on HPV infections control focused on the need to: 1) encourage HCPs to facilitate patient data collection to support performance assessment of the national cervical cancer screening program, 2) advance the transition from cytology to HPV-based screening, 3) improve cancer prevention training and awareness for all HCPs involved in screening, including midwives, 4) identifying patient barriers to invitation acceptance, and 5) promoting urine or vaginal self-sampling screening techniques to improve acceptability, while establishing appropriate follow-up strategies for HPV-positive women. This report covers some critical findings, key challenges, and future steps to improve the status of HPV prevention and control measures in the country.

Human papillomavirus vaccine effectiveness by age at vaccination: A systematic review

Human papillomavirus (HPV) vaccines work by preventing infections prior to natural exposure. Thus, it is likely more effective at younger ages, and it is important to understand how effectiveness might be diminished when administered at older ages. We conducted a systematic review of HPV vaccine effectiveness studies published between 2007 and 2022 that included an analysis of effectiveness against vaccine-type HPV infections, anogenital warts, cervical abnormalities and cervical cancer by age at vaccine initiation or completion. Searching multiple databases, 21 studies were included and results were summarized descriptively. Seventeen studies found the highest vaccine effectiveness in the youngest age group. Vaccine effectiveness estimates for younger adolescents ages 9-14 years ranged from approximately 74% to 93% and from 12% to 90% for adolescents ages 15-18 years. These results demonstrate that the HPV vaccine is most effective against HPV-related disease outcomes when given at younger ages, emphasizing the importance of on-time vaccination.

A questionnaire survey on the prevention of HPV infection among females and males who came of age in Japan under various scenarios of HPV vaccine recommendation

The Japanese Ministry of Health, Labor and Welfare (MHLW) temporarily suspended recommendation for HPV vaccinations for girls in June 2013. It resumed its recommendation in November 2021. To compensate for eight years of lost overage, a 'catch-up HPV vaccination' program began in April 2022. To determine intervention needs in regards to HPV vaccine hesitancy, from October 13 2021 to April 31 2022, we surveyed 12-28 year-old vaccine-eligible males and females (281 males, 583 females). We investigated the gender and 'vaccine generational' differences in attitudes, perceptions, and future intentions regarding HPV vaccination. Two generations were defined by the vaccine recommendation environment they grew up in. The 'vaccine generation' was born in FY 1994-1999; the 'vaccine-suspension generation' born in FY 2000-2009. Knowledge regarding the HPV vaccine correlated significantly with being female, of the vaccination generation, a medical student, and having received the COVID-19 vaccine. There was a significant 'generational' difference in terms of approval of the MHLW's recommendation resumption. The attitudes, perceptions, and future intentions of Japan's two generation groups are unique and should be dealt with accordingly. HPV vaccination promotion should consider the strong gender differences we identified. As an extension of the anti-cervical cancer program, HPV vaccinations for boys should begin immediately. Our study of their unique outlooks will contribute to the discussion surrounding that implementation.

Advances in immunotherapy for gynecological malignancies

To date, surgery, chemotherapy and radiotherapy are mainly used to treat or remove gynecological malignancies. However, these approaches have their limitations when facing complicated female diseases such as advanced cervical and endometrial cancer (EC), chemotherapy-resistant gestational trophoblastic neoplasia and platinum-resistant ovarian cancer. Instead, immunotherapy, as an alternative, could significantly improve prognosis of those patients receiving traditional treatments, with better antitumor activities and possibly less cellular toxicities. Its' development is still not fast enough to meet the current clinical needs. More preclinical studies and larger-scale clinical trials are required. This review aims to introduce the landscape and up-to-date status of immunotherapy against gynecological malignancies, with a discussion of the challenges and future direction.

Anal Cancer and Anal Intraepithelial Neoplasia Risk among Patients Treated for HPV-Related Gynecological Diseases-A Systematic Review

BACKGROUND

The most important causative agent of neoplasms in the anogenital area is the human papillomavirus (HPV). Due to the anatomical proximity of the genital and anus area and the ease with which HPV infection is transmitted, it seems that patients after the treatment of HPV-related gynecological diseases may have an increased risk of developing a second HPV-related neoplasm anal cancer. The aim of this study was to determine the risk of anal intraepithelial neoplasia (AIN) and anal cancer (AC) among patients after the treatment of HPV-related gynecological diseases.

METHODS

We conducted a comprehensive review of the available literature from multiple databases. The study was performed following Cochrane Reviewers' Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Moreover, we assessed the quality of each study using QUADAS-2.

RESULTS

Twenty-five studies were included in the final analysis. Patients after the treatment of HPV-related gynecological diseases have a significantly higher risk of AC (mean standardized incidence ratio (SIR) = 5.387, mean incidence risk (IR) = 0.096%, mean IR per 100,000 person-years = 10.37) and AIN (mean IR = 23.683%) compared to the population risk.

CONCLUSIONS

patients with HPV-related gynecological diseases should constitute a group for which an appropriate primary and secondary screening for AC should be introduced.

Age-specific and genotype-specific carcinogenic human papillomavirus prevalence in a country with a high cervical cancer burden: results of a cross-sectional study in Estonia

OBJECTIVES

To describe age-specific and type-specific carcinogenic human papillomavirus (HPV) prevalence prior to large-scale effect of HPV vaccines in Estonia and to analyse the risk factors associated with carcinogenic HPV.

DESIGN

Cross-sectional study using self-administered questionnaire and self-collected vaginal swabs for detection of HPV infection.

SETTING

Estonian Biobank database.

PARTICIPANTS

Stratified random sample of women aged 30-33, 57-60 and 67-70 years living in one of the three largest counties in Estonia. Of 3065 women approached, 1347 (43.9%) returned questionnaires and specimens for HPV DNA detection.

OUTCOME MEASURES

HPV prevalence and fully adjusted ORs with 95% CIs for risk factors.

RESULTS

HPV prevalence was highest among women aged 30-33 years (18.7%; 95% CI 15.8 to 21.9) followed by those aged 67-70 years (16.7%; 95% CI 12.4 to 22.0) and 57-60 years (10.2%; 95% CI 7.8 to 13.3). HPV16 and HPV56 were the most common among women aged 30-33 years (both 4.0%; 95% CI 2.7 to 5.9), and HPV68 was the most common among women aged 57-60 years (2.8%; 95% CI 1.5 to 4.7) and 67-70 years (6.4%; 95% CI 3.6 to 10.4). Vaccination with nonavalent vaccine would have halved the carcinogenic HPV prevalence among women aged 30-33 years. The odds of infection with carcinogenic HPV were higher among women with six or more sexual partners among younger (OR 2.99; 95% CI 1.54 to 5.81) and older (OR 3.80; 95% CI 1.25 to 11.55) women and lower (OR 0.35; 95% CI 0.17 to 0.72) among younger married women.

CONCLUSIONS

This study demonstrated U-shaped age-specific genotype profile of carcinogenic HPV prevalence, indicating that public health providers should focus on developing exit strategies for the cervical cancer screening programme in Estonia with a possible extension of HPV testing beyond the current screening age of 65 years. Generalisability of the findings of this study may be affected by the low response rate.

Endemic, epidemic and pandemic infections: the roles of natural and acquired herd immunity

PURPOSE OF REVIEW

This review summarizes the general concepts of innate and acquired immunity, including vaccine use and hesitancy, as they relate to reduction of the global burden of highly communicable infectious diseases.

RECENT FINDINGS

Vaccination to increase herd immunity remains the cornerstone of disease prevention worldwide yet global vaccination goals are not being met. Modern obstacles to vaccine acceptance include hesitancy, reduced altruistic intentions, impact of COVID-19, distrust of science and governmental agencies as well as recent geopolitical and environmental disasters. Together, such barriers have negatively impacted immunization rates worldwide, resulting in epidemics and pandemics of serious life-threatening infections from vaccine-preventable diseases, especially those affecting children. In addition, pathogens thought to be controlled or eradicated are reemerging with new genetic traits, making them more able to evade natural and acquired immunity, including that induced by available vaccines. Lastly, many serious and widespread infectious diseases await development and utilization of efficacious vaccines.

SUMMARY

The global burden of communicable diseases remains high, necessitating continued pathogen surveillance as well as vaccine development, deployment and continued efficacy testing. Equally important is the need to educate aggressively the people and their leaders on the benefits of vaccination to the individual, local community and the human population as a whole.

Human Papillomavirus: Oral Lesions and Vaccination

Human papillomavirus (HPV) is associated with benign and malignant lesions in various locations, such as the skin and oral and genital mucosa [...]

Trends in research related to vaccine and cancer prevention from 1992 to 2022: A 30-years bibliometric analysis

Vaccines may play an important role in cancer prevention. This bibliometric study in the field of vaccine and cancer prevention is designed to evaluate key research advances, identify existing deficiencies, and provide reference for future investigations. A total of 2916 original articles published in English from 1992 to 2022 were extracted from the Web of Science core collection. America (1,277) and the National Cancer Institute (82) were the most productive country and institution in this field, respectively. Vaccine was not only the most co-cited journal but also the most influential. Garland SM was the most prolific author, and Bosch FX was the most influential co-cited author. The keywords "cervical cancer" had the highest frequency. "Nanovaccines," "vaccine acceptance" and "coverage" were the new research hotspots in this field. Currently, although an increasing number of publications involve vaccine and cancer prevention studies, most of them are related to cervical cancer, and few other cancers, suggesting the need to investigate other cancer prevention vaccines. The promising research hotspots, such as nanovaccines, vaccine acceptance, and vaccine coverage should be the focus of investigation. The study provides the current status and trends in clinical research on vaccine and cancer prevention, enabling researchers to identify hotspots and explore new study directions. In the future, vaccines are expected to play a key role in multiple cancer prevention.

The Burden of Cervical Conization in Privately Insured Young and Mid-Adult Women in the United States

In 2019, the United States (US) Advisory Committee on Immunization Practices (ACIP) recommended that healthcare providers engage in shared clinical decision making for adults aged 27-45 who may benefit from HPV vaccination. However, it is difficult to assess these benefits as there is a lack of data on HPV burden on young and mid-adult women. This analysis estimates the incidence of conization and the burden associated with treating pre-cancerous states related to HPV with a loop electrosurgical excision procedure (LEEP) or a cold knife conization (CKC) among commercially insured women aged 18-45. This retrospective cohort study used the IBM MarketScan commercial claims encounter database for women aged 18-45 treated with conization. We assessed the annual incidence of conization (2016-2019) and adjusted the two-year health care costs post-conization using a multivariable Generalized Linear Model (GLM)-accounting for follow-up time and other characteristics-stratified by the age groups, namely 18-26 and 27-45. The inclusion criteria were met by 6735 women, with a mean age of 33.9 years (SD = 6.2). Conization incidence was lowest for women aged 18-26 (41/100,000 to 62/100,000 women-years) and highest for women aged 31-35 (243/100,000 to 269/100,000). The GLM-adjusted, all-cause healthcare costs per patient per year were USD 7279 and USD 9249 in the 18-26 and 27-45 age groups, respectively. The adjusted costs for disease-specific care were USD 3609 and USD 4557 for women ages 18-26 and 27-45, respectively. The burden of conization and the associated costs were significant, indicating a potential healthcare benefit of HPV vaccination among young and middle-aged women.

Incidence of cervical precancerous lesions and cervical cancer in Denmark from 2000 to 2019: Population impact of multi-cohort vaccination against human papillomavirus infection

In Denmark, vaccination against human papillomavirus (HPV) has been implemented in the children's vaccination program (January 2009) and in multiple catch-up cohorts (October 2008 in girls 13-15 years and in August 2012 in women up to 27 years). In the present study we estimate incidence of cervical intraepithelial neoplasia grade 3 (CIN3), adenocarcinoma in situ (AIS), squamous cell carcinoma (SCC) and adenocarcinoma (AC) during 2000-2019. All cases of CIN3 and AIS were identified from the nationwide Pathology Data Bank, while SCC and AC were identified from the Danish Cancer Registry. We calculated age-standardized incidence rates and estimated annual percentage change (EAPC) with corresponding 95% confidence interval (CI) for the periods before vaccination implementation (2000-2005), early after implementation of childhood HPV vaccination and the first catch-up vaccination program (2006-2012), and after implementation of the second catch-up program (2013-2019). For CIN3 and AIS, age-specific incidence rates and EAPCs were calculated. An increasing age-standardized incidence was observed before introduction of HPV vaccination (2000-2005) for CIN3 [EAPC_CIN3 : 3.0 (95% CI 1.7 to 4.3)] and AIS [EAPC_AIS : 3.5 (95% CI 0.7 to 6.4)]. In the most recent period (2013-2019), following implementation of the second catch-up program, a decrease was observed for both CIN3 [EAPC_CIN3 : -6.5 (95% CI -8.3 to -4.8)], AIS [EAPC_AIS : -8.7 (95% CI -12.3 to -5.1)] and for SCC [EAPC_SCC : -3.9 (95% CI -7.5 to -0.2)]. In this study we document a decrease in the incidence of CIN3, AIS and SCC in the period after implementation of multi-cohort HPV vaccination in Denmark.

Highlights into historical and current immune interventions for cancer

Immunotherapy is an additional pillar when combined with traditional standards of care such as chemotherapy, radiotherapy, and surgery for cancer patients. It has revolutionized cancer treatment and rejuvenated the field of tumor immunology. Several types of immunotherapies, including adoptive cellular therapy (ACT) and checkpoint inhibitors (CPIs), can induce durable clinical responses. However, their efficacies vary, and only subsets of cancer patients benefit from their use. In this review, we address three goals: to provide insight into the history of these approaches, broaden our understanding of immune interventions, and discuss current and future approaches. We highlight how cancer immunotherapy has evolved and discuss how personalization of immune intervention may address present limitations. Cancer immunotherapy is considered a recent medical achievement and in 2013 was selected as the "Breakthrough of the Year" by Science. While the breadth of immunotherapeutics has been rapidly expanding, to include the use of chimeric antigen receptor (CAR) T-cell therapy and immune checkpoint inhibitor (ICI) therapy, immunotherapy dates back over 3000 years. The expansive history of immunotherapy, and related observations, have resulted in several approved immune therapeutics beyond the recent emphasis on CAR-T and ICI therapies. In addition to other classical forms of immune intervention, including human papillomavirus (HPV), hepatitis B, and the Mycobacterium bovis Bacillus Calmette-Guérin (BCG) tuberculosis vaccines, immunotherapies have had a broad and durable impact on cancer therapy and prevention. One classic example of immunotherapy was identified in 1976 with the use of intravesical administration of BCG in patients with bladder cancer; resulting in a 70 % eradication rate and is now standard of care. However, a greater impact from the use of immunotherapy is documented by the prevention of HPV infections that are responsible for 98 % of cervical cancer cases. In 2020, the World Health Organization (WHO) estimated that 341,831 women died from cervical cancer [1]. However, administration of a single dose of a bivalent HPV vaccine was shown to be 97.5 % effective in preventing HPV infections. These vaccines not only prevent cervical squamous cell carcinoma and adenocarcinoma, but also oropharyngeal, anal, vulvar, vaginal, and penile squamous cell carcinomas. The breadth, response and durability of these vaccines can be contrasted with CAR-T-cell therapies, which have significant barriers to their widespread use including logistics, manufacturing limitations, toxicity concerns, financial burden and lasting remissions observed in only 30 to 40 % of responding patients. Another, recent immunotherapy focus are ICIs. ICIs are a class of antibodies that can increase the immune responses against cancer cells in patients. However, ICIs are only effective against tumors with a high mutational burden and are associated with a broad spectrum of toxicities requiring interruption of administration and/or administration corticosteroids; both of which limit immune therapy. In summary, immune therapeutics have a broad impact worldwide, utilizing numerous mechanisms of action and when considered in their totality are more effective against a broader range of tumors than initially considered. These new cancer interventions have tremendous potential notability when multiple mechanisms of immune intervention are combined as well as with standard of care modalities.

Knowledge, attitudes and acceptance toward Human papillomavirus (HPV) vaccination: Perspectives of Muslim women and men

OBJECTIVES

Human papillomavirus (HPV) infection is the leading risk factor for the development of anogenital cancers. Most Arab countries lack both HPV education and national HPV vaccination programs. The objective of this study was to assess knowledge, attitudes, and acceptance toward HPV vaccination in men and women from Oman, a country in the Middle Eastern North Africa region.

METHODS

This cross-sectional quantitative study used convenience sampling to recruit male and female participants, aged 18 years and above from all 11 governorates of Oman to complete a validated self-administered questionnaire online in the Arabic language. The questionnaire comprised five sections, with a total of 32 questions. The questionnaire, including Arabic and English versions, was content validated and piloted.

RESULTS

A total of 1403 participants, including 952 parents and 369 healthcare providers, completed the survey. The results showed a lack of knowledge regarding HPV infection and vaccines, including among healthcare providers. Less than a quarter of the participants had heard of HPV infection, with digital sources of information being the most common. Factors such as being a woman or a healthcare provider or completing higher levels of education were independently and significantly positively association with HPV awareness (p < 0.001). The majority of the participants lacked vaccine safety knowledge, had concerns about the vaccine's side effects, and sought reassurance of its protection against HPV infection (62%, 71.5%, and 84.6%, respectively). Nevertheless, nearly two-thirds of the participants agreed to take the HPV vaccine, with support for both boys and girls being vaccinated. There was almost universal agreement among the participants regarding the need for parental and adolescent HPV educational programs.

CONCLUSION

Omani women and men showed a high level of acceptance and favorable attitude toward HPV vaccination. The study findings support future efforts to implement school and public-level HPV education and a national HPV vaccination program in Oman.