Etiology of cervical cancer: current concepts

Cigarette smoking is associated with an altered vaginal tract metabolomic profile

Cigarette smoking has been associated with both the diagnosis of bacterial vaginosis (BV) and a vaginal microbiota lacking protective Lactobacillus spp. As the mechanism linking smoking with vaginal microbiota and BV is unclear, we sought to compare the vaginal metabolomes of smokers and non-smokers (17 smokers/19 non-smokers). Metabolomic profiles were determined by gas and liquid chromatography mass spectrometry in a cross-sectional study. Analysis of the 16S rRNA gene populations revealed samples clustered into three community state types (CSTs) ---- CST-I (L. crispatus-dominated), CST-III (L. iners-dominated) or CST-IV (low-Lactobacillus). We identified 607 metabolites, including 12 that differed significantly (q-value < 0.05) between smokers and non-smokers. Nicotine, and the breakdown metabolites cotinine and hydroxycotinine were substantially higher in smokers, as expected. Among women categorized to CST-IV, biogenic amines, including agmatine, cadaverine, putrescine, tryptamine and tyramine were substantially higher in smokers, while dipeptides were lower in smokers. These biogenic amines are known to affect the virulence of infective pathogens and contribute to vaginal malodor. Our data suggest that cigarette smoking is associated with differences in important vaginal metabolites, and women who smoke, and particularly women who are also depauperate for Lactobacillus spp., may have increased susceptibilities to urogenital infections and increased malodor.

Epidemiology and pathophysiology of malignancy in common variable immunodeficiency?

Common variable immunodeficiency (CVID) is a diagnostic category of primary immunodeficiency (PID) which may present with heterogeneous disorders including recurrent infections, autoimmunity, granulomatous diseases, lymphoid and other types of malignancies. Generally, the incidence of malignancy in CVID patients is around 1.5-20.7% and usually occurs during the 4th-6th decade of life. Non-Hodgkin lymphoma is the most frequent malignancy, followed by epithelial tumours of stomach, breast, bladder and cervix. The exact pathological mechanisms for cancer development in CVID are not fully determined; however, several mechanisms including impaired genetic stability, genetic predisposition, immune dysregulation, impaired clearance of oncogenic viruses and bacterial infections, and iatrogenic causes have been proposed to contribute to the high susceptibility of these patients to malignancies.

Risk Factors for Cervical Cancer and CIN3 in Jewish Women in Israel - Two Case Control Studies

PURPOSE

The aim of the study was to identify risk and protective factors/markers for cervical cancer and cervical intraepithelial neoplasia 3 (CIN3) in Israeli Jewish women in order to settle the discrepancy of low incidence rate of cervical cancer and relatively high incidence rate of CIN3.

MATERIALS AND METHODS

We conducted two case control studies, which examined the association between potential risk and protective factors/markers for cervical cancer or CIN3 using self administered detailed questionnaires.

RESULTS

For studying cervical cancer, 40 cases and 40 matched controls were interviewed. In the univariable and multivariable analyses older age, depression or anxiety and ever smoking seemed to act as independent risk factors/markers, while older age at first intercourse was protective. For studying CIN3, 99 cases and 79 controls were interviewed. Multivariable analysis has demonstrated that being born in Israel, depression or anxiety and ever smoking were independent risk factors/markers for CIN3.

CONCLUSIONS

The risk factors/markers studied, that were associated with cervical cancer or CIN3 among Jewish women in Israel, are similar to those reported in other parts of the world, and do not explain the observed discrepancy of high in-situ cervical cancer rates and low invasive cervical cancer incidence in Israel.

Lack of Associations between TNF-αPolymorphisms and Cervical Cancer in Thai women

The risk of developing cervical cancer in women infected with human papillomavirus (HPV) may be influenced by an individual's genetic susceptibility. Published data linking single nucleotide polymorphisms (SNPs) in the tumor necrosis factor-alpha (TNF-?) promoter region at positions -308G>A (rs1800629) and -238G>A (rs361525) to cervical cancer risk have been inconclusive. In this study, we examined 251 cervical specimens and classified them into two groups according to their cytological findings: 121 cancer cases and 130 controls (low-grade squamous intraepithelial lesion and normal cytology). All specimens were typed by PCR and sequencing for TNF-αpromoter -308G>A (rs1800629) and -238G>A (rs361525). The genotype distribution of SNPs in either rs1800629 or rs361525 did not significantly demonstrate higher frequency in the cancer group (p=0.621 and p=0.68, respectively). Based on these results, neither the TNF-αpromoter -308G>A (rs1800629) nor the -238G>A (rs361525) polymorphism presents a major risk factor for cervical cancer among Thai women. Larger studies are necessary to elucidate possible genetic mechanisms influencing cervical cancer development.

Association of single nucleotide polymorphisms in tumor necrosis factor-alpha with cervical cancer susceptibility

Tumor necrosis factor-alpha (TNF-α) polymorphisms have been reported to play an important role in the development of cervical cancer. But the results remain inconclusive. We performed this study to provide a comprehensive assessment of the association by means of a meta-analysis in which all published studies were included. The studies investigating the associations between cervical cancer risk and TNF-α polymorphisms were identified through PubMed, Embase, CNKI, and Chinese BioMedical Literature Database. OR and 95% CI (odds ratio and 95% confidence interval) were calculated using either the fixed or random effects model to assess the associations. We eventually included eighteen case-control studies of SNP -308 G>A and nine studies of SNP -238 G>A. Meta-analysis of the former polymorphism suggested significantly increased risk of cervical cancer associated with the A allele (OR 1.19, 95% CI 1.02-1.38). Subgroup analysis according to ethnicity showed similar results in Caucasians (A vs. G: OR 1.25, 95% CI 1.02-1.54; AA vs. GG: OR 1.47, 95% CI 1.04-2.08; AA vs. GA+GG: OR 1.47, 95% CI 1.04-2.08). For SNP -238 G>A, a protective association was observed in overall comparisons (A vs. G: OR 0.64, 95% CI 0.51-0.80; AA+GA vs. GG: OR 0.62, 95% CI 0.49-0.79) and subgroup analysis of Caucasians (A vs. G: OR 0.67, 95% CI 0.53-0.83; AA+GA vs. GG: OR 0.65, 95% CI 0.51-0.82). Our meta-analysis indicates that TNF-α polymorphisms may confer susceptibility to cervical cancer in an ethic-specific fashion.

Evaluation of microbial enzymes in normal and abnormal cervicovaginal fluids of cervical dysplasia: a case control study

The aim of the present study was to evaluate the role of microbial enzymes in normal and abnormal cervicovaginal fluids of cervical dysplasia. The cervicovaginal infections were evaluated through the estimation of microbial enzymes in patients with and without abnormal cervical cytology like bacterial and fungal infections. The patients were categorized based on infection caused by organism and stages of dysplasia. The pH, Whiff test, and Pap smear tests were conducted for normal and abnormal cervical swabs based on standard protocols. Microbial enzymes include mucinase, sialidases, and proteases of the cervical swabs and are estimated according to standard methods. The results of abnormal cervical cytological smears showed increased pH and the presence of amines with different levels of Pap smear test. Increased levels of microbial enzymes were observed in patients with abnormal cytology than normal cytology. Three microbial enzymes mucinase, sialidase, and protease were significantly (P < 0.01) more elevated in patients with bacterial infections (8.97 ± 0.64, 10.39 ± 0.28, 8.12 ± 0.64) than without dysplasia (2.02 ± 0.8, 1.98 ± 0.3, 1.96 ± 0.8). The results reinforce that the microbial infection seems to be more prone to cervical dysplasia and may act as risk-factor for the development of cervical cancer along with HPV infection.

Predictors of Pap Test Use Among Women Living on the Hopi Reservation

Between July and December 1993, the Hopi Department of Health Services, in collaboration with the Arizona Cancer Center (AZCC), conducted a population-based study of cervical cancer risk factors, screening practices, and predictors of Pap test utilization among American Indian women age 18 years and older living on the Hopi reservation in northern Arizona. This survey, entitled the Healthy Hopi Women's Study, involved a stratified random sample of households from each of the 11 Hopi villages. The final study sample was 559 completed face-to-face interviews. This article reports on unpublished findings of the survey and discusses how the Hopi utilized the study's findings to develop a Centers for Disease Control and Prevention (CDC)-funded breast and cervical cancer program.

Sexually transmitted Human Papillomavirus type variations resulting in high grade cervical dysplasia in North-East North Dakota and North-West Minnesota

Background

A review of Pap smear diagnoses from a reference laboratory in Grand Forks, North Dakota over a 3-year period (07/00 to 10/03) revealed a two-fold higher rate of high grade squamous intraepithelial lesion in a community in northwest Minnesota (Roseau, 0.486%) than in northeast North Dakota (Grand Forks, 0.249%), in spite of both having similar rates of low-grade squamous intraepithelial lesion (1.33% vs.1.30% respectively)

Objectives

To identify the different types of HPV present in patient populations showing high-grade dysplasia in Grand Forks, ND and Roseau, MN.

Study design

Formaldehyde-fixed paraffin-embedded cervical tissue samples were analyzed using polymerase chain reaction (PCR) to detect the presence of HPV type 16, 18 and 31.

Results

Our studies showed that 41 % of samples from Roseau were triply infected with HPV serotypes 16, 18 and 31 in comparison to 12 % from Grand Forks.

Conclusion

Due to the small sample size we were unable to prove the study to be statistically significant. However, our results suggest that the presence of HPV 16, 18 and 31 in triply infected samples may be the cause of the higher percentage of high-grade dysplasia in Roseau, MN when compared to Grand Forks, ND.

Changes of neoplasm concentration with geographical co-ordinates

We investigated the regional differences in diversity--from another respect concentration--of causes of cancer mortality in England and Wales. Statistical analyses of published mortality data were done, using the jackknifed estimate of the Shannon index, for each region, sex and age group and year of death. In males diversity of cancer death causes is secularly increasing whilst it is decreasing in females. Latitude was negatively associated with diversity in male 45+ year age groups and longitude negatively associated with diversity in male 65+ age groups. Although, there were some significant associations in the female groups, there was no general trend across age groups as found in males. These trends remained after accounting for regional variation in past smoking behaviour. We suggest that the observed patterns may be related to prior occupational exposures and non-identified environmental and socioeconomical factors. It is concluded that techniques drawn from population ecology have a potential value in epidemiological studies of human disease. Ecological methods by themselves are likely to be of value in hypothesis generation rather than hypothesis testing.

Epidemiology of AIDS-related malignancies an international perspective

Patients with HIV infection are at increased risk for developing Kaposi's sarcoma, non-Hodgkin's lymphoma, and several other cancers. The relative risks for the most common epithelial cancers in the general population--lung, breast, colon/rectum, stomach, liver, and prostate--are not increased substantially in people with AIDS, however. Accumulating data suggest that HIV-infected patients also are at increased risk for developing Hodgkin's lymphoma, cervical carcinoma in situ (CIS), other anogenital neoplasms (invasive cancer and CIS), leiomyosarcoma, and conjunctival squamous cell carcinoma. There is inconclusive evidence, however, with regard to HIV infection being associated with invasive cervical cancer, testicular seminoma, or hepatocellular carcinoma. Notably, other viral infections have been implicated in the etiology of many of these conditions. The introduction of highly active antiretroviral therapy (HAART) has decreased the incidence of AIDS-associated cancers in Western countries, but less than 1% of AIDS patients are receiving HAART in the HIV epicenter of sub-Saharan Africa. Further therapeutic advances that extend survival with HIV infection with varying reconstitution of immune competence may lead to additional alterations in cancer risk.

Second neoplasms after megavoltage radiation for pediatric tumors

BACKGROUND

Because ionizing radiation is a known carcinogen, diligent long-term follow-up in children exposed to therapeutic radiation is required. The authors updated an earlier study on the nature and risk of second neoplasms (SN) in patients treated with megavoltage radiotherapy as children.

METHODS

The authors followed 446 children who were treated for a primary malignancy with megavoltage radiotherapy between January 16, 1954 and December 31, 1980. These children survived a minimum of 5 years. The nature and incidence of SNs were evaluated in this population. Patients with bilateral retinoblastoma or neurofibromatosis were excluded from the study due to their large genetically based predisposition for developing an SN.

RESULTS

The Kaplan-Meier actuarial survival rate was 80% (95% confidence interval [CI] 74-85%) at 30 years for all patients. Thirty-seven (8.3%) patients developed SNs, most of which occurred within the original radiation treatment field, 3.8-31.8 years (median, 15.5 years) after radiotherapy. The cumulative risk of developing an SN was 13% (95% CI 9-19%) at 30 years and the standardized incidence ratio for the development of any SN was 5.2 (95% CI 3.4-7.6%). The most common SNs were breast carcinoma (n = 8), skin carcinoma (five basal cell carcinomas, two malignant melanomas, and one dermatosarcoma), and meningiomas (n = 6). All eight breast carcinomas occurred after the treatment of childhood Hodgkin disease. Of the 37 patients with SNs, 12 died of either the SN (n = 10) or of recurrent disease (n = 2). Risk factors associated with developing a SN included initial diagnosis of Hodgkin disease (P = 0.0003), female gender (P = 0.008), and an initial diagnosis of acute lymphoblastic leukemia (P = 0.02).

CONCLUSIONS

Patients in the radiation-treated cohort experienced increased mortality, were at an increased risk of developing an SN, and should undergo increased medical surveillance as adults. The cumulative probability of developing an SN has increased substantially at 30 years, largely due to an increase in follow-up time. In addition, the cumulative probability curve does not show evidence of plateau after increased duration of follow-up. Finally, the emergence of secondary breast carcinoma in the current study was not noted in the previous analysis.

Prognostic factors associated with the clinical outcome of cervical intraepithelial neoplasia: a cohort study in Japan

One hundred and eighty-five Japanese women with cervical intraepithelial neoplasia (CIN) were enrolled in this follow-up study. On the basis of the prevalence of human papillomavirus (HPV) DNA in Japanese cervical cancer patients, HPV types were categorized into three groups as follows: (1) high risk (types 16, 18, 33, 52, and 58), (2) intermediate risk (types 31, 35, 39, 51, 56, 59, 68, and 70), (3) low risk (type 6, 30, 42, 53, 54, 55, 66 and unclassified types). High-risk HPV infection was a risk factor for progression of the disease. The regression rate in the HPV negative group was higher (83.3%) than those in the HPV positive groups, but the differences in regression were no longer significant after adjustment for age and CIN grade. It is also noted that a lower cytomegalovirus IgG level and a smaller number of past pregnancies might be associated with the regression of CIN lesions.

Reducing death from cervical cancer examining the prevention paradigms

The prevention of morbidity and mortality from cervical cancer will hinge upon our understanding of the epidemiology, the molecular basis, and natural history of the disease and its associated precursors. This article serves as an introduction and presents our current challenge to prevent or find all women at risk, and alter the course of disease to effect a regression or a cure.

Cervical cancer risk as a predictor of Pap smear use in rural North Carolina

Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer-related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross-sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk-appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High-risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low-risk status was the absence of all factors. A high-risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low-risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk-appropriate screening guidelines. Low-risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.

HPV subtype analysis in lower genital tract neoplasms of female renal transplant recipients

OBJECTIVE

Immunocompromised patients, such as female renal transplant recipients, have an increased incidence of neoplasms involving the lower genital tract (i.e., cervix, vagina, vulva). The relationship between lower genital tract neoplasms and human papillomavirus (HPV) infection has been established and high-risk oncogenic subtypes have been identified (HPV 16, 18, 45, and 56). The purpose of this study is to evaluate HPV subtypes present in lower genital tract neoplasms of post renal transplant women and compare HPV subtypes found in these patients with immunocompetent patients having similar neoplasms and normal immunocompetent controls.

METHODS

Twenty specimens from lower genital tract neoplasms of 16 renal transplant patients, 13 specimens from 13 immunocompetent patients with similar histology, and 13 patients with normal lower genital tract histology were analyzed for the presence of HPV using polymerase chain reaction. HPV primers including the L1 (late) region consensus primers and primers specific for the HPV E6 (early) region for subtypes 6, 11, 16, and 18 were amplified with DNA from the above patient samples.

RESULTS

Overall, HPV was detected in 21/46 specimens tested. Thirteen of the HPV-positive specimens were from transplant patients, and 8 were from immunocompetent patients (5 immunocompetent with disease and 3 normal patients). This difference in the total number of HPV-positive cases was statistically significant between the transplant and immunocompetent group (P = 0.02). Although no difference in HPV 6 and/or 11 was detected between the two groups, HPV subtypes 16 and/or 18 approached statistical significant difference (P = 0.06).

CONCLUSIONS

High-risk oncogenic HPV subtypes 16 and/or 18 were found at a higher rate in transplant patients compared with their immunocompetent counterparts. The combination of immunocompromise and increased HPV 16 and/or 18 positivity may place these patients at increased risk for aggressive lower genital tract neoplastic progression.

Receipt of preventive health care services by lesbians

BACKGROUND

We measured receipt of age-appropriate preventive health services by lesbians and assessed whether provider and individual characteristics, including disclosure of sexual orientation, are independently associated with receipt of these services.

METHODS

A questionnaire was printed in a national biweekly gay, lesbian, and bisexual news magazine, and self-identified lesbians living in all U. S. states (N =6935) responded to the survey. Main outcome variables were receipt of a Pap smear within the preceding 1 and 2 years and, for women aged > or= 50, receipt of a mammogram within the past 1 and 2 years.

RESULTS

Fifty-four percent had Pap smears within 1 year and 71% within 2 years, with increasing rates among older and more educated respondents. Seventy percent of respondents aged > or = 50 had a mammogram in the past year, and 83% within 2 years; rates did not vary significantly controlling for education. Sixty percent had disclosed their sexual orientation to their regular health care provider. Controlling for patient and provider characteristics, disclosure was independently associated with receipt of Pap smears, but not mammograms.

CONCLUSIONS

It is important for providers to identify their lesbian patients' unmet needs for preventive health care. Additionally, it is important for providers to provide complete and appropriate preventive health care for their lesbian patients. Further research is needed to determine why lesbians are not receiving Pap smears at the recommended rate and whether this disparity is reflective of aspects of cervical cancer screening or indicates a more general problem with access to health care including receipt of preventive services.

Increased telomerase activity and decreased telomere length in genital condylomata acuminata

Our objective was to find a possible correlation between telomerase activity, mean telomere length and human papillomavirus (HPV) presence and type in genital condylomata acuminata. Fifteen biopsies from women with genital condylomata acuminata and nine control tissue samples were tested for telomerase activity, mean telomere length, and HPV presence and type. All condylomata exhibited telomerase activity, compared to 78% of the control samples. The mean telomere length of condylomata was significantly (P<0.002) shorter compared to telomere length in control tissue samples. All condylomata lesions were infected with HPV types 6/11, and more than half had additional infection with HPV 16/18. Mixed HPV 6/11 with 16/18 infection correlated with shorter telomeres than presence of HPV 6/11 alone in the lesions (4.68 +/- 0.44 kb vs 4.97 +/- 0.57 kb). None of the control tissue samples showed presence of HPV DNA. Telomerase activity may be a marker of proliferation rather than malignancy, whereas the mean telomere length could better serve as a marker for the progression of HPV lesions toward malignancy.

'With the best of reasons': cervical cancer prevention policy and the suppression of sexual risk factor information

Cervical cancer is a very common but largely preventable cancer. Despite considerable medical knowledge of risk and even causal factors, possible social-behavioural strategies for the primary prevention of cervical cancer have rarely been explored as a viable addition to cervical screening. We examine key policy documents and interview 18 key informants on cervical cancer prevention in New Zealand. Using a discourse analytic approach we identify and discuss two discourses (which we have labelled 'protectionism' and 'right to know') which inform positions on whether or not women should be provided with information regarding sexual risk factors for cervical cancer. Cervical cancer prevention policy in New Zealand, which largely reflects a protectionist discourse, suppresses sexual risk factor information and focuses exclusively on cervical screening. The right to know discourse informs an alternative position, which contends that women have a right to be informed about risk factors. We discuss these positions in relation to questions about women's rights, the principle of informed choice, and attempts to judge what is in women's 'best interests.'

Human papillomavirus infection and other risk factors for cervical intraepithelial neoplasia in Japan

Various risk factors were investigated in 167 cervical intra-epithelial neoplasia (CIN) case and control pairs in Japan. CIN cases showed evidence of nine known risk factors including smoking and sexual behaviour. However, after adjustment for papillomavirus infection, the highest determinant, the only remaining risk factors were: being married, early age at first pregnancy and multiparity.

Lower genital tract intraepithelial neoplasia in HIV-infected women: guidelines for evaluation and management

Human immunodeficiency virus (HIV) and human papillomavirus (HPV) are both sexually transmitted viruses with many risk factors in common. Studies have found that HIV-seropositive women are at least five times as likely to be infected with HPV as seronegative controls. In immunocompromised HIV-seropositive women, the risk of cervical intraepithelial neoplasia (CIN) is almost as high as in women with squamous intraepithelial lesions on their Pap smear. Some studies have shown the false-negative rate of cervical cytology in HIV-seropositive women to be very high, although others have shown it to be comparable with the rate in seronegative controls. However, given the prevalence of CIN in this population, even a "normal" false-negative rate may result in many missed CIN lesions. Among HIV-seropositive women and especially among those who are immunocompromised, CIN is more likely to progress and recur after treatment. Recurrence rates may reach 87 percent 36 months after treatment in markedly immunosuppressed women. Cryotherapy is especially ineffective in these patients. Vulvar condyloma and vulvar intraepithelial neoplasia (VIN) are much more prevalent in HIV-seropositive women and especially in those who are markedly immunosuppressed or who have been immunosuppressed for a prolonged period of time. It is recommended that all HIV-seropositive women undergo periodic evaluation at intervals no less than every 6 months. Immunocompromised women should be followed with cytology and colposcopy of the cervix and vulva, although those with normal immune systems may be followed with cytology alone. Because the rates of recurrence and progression are so high after treatment of these women, they should be followed with colposcopy and cytology every 6 months. New approaches to treatment need to be explored in this population.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will understand the association between the immune suppression of HIV and HPV-related diseases, be familiar with the treatment options for the HIV-seropositive woman with cervical intraepithelial neoplasia (CIN), understand the natural history of CIN in the patient with HIV-seropositivity, and become aware of the appropriate surveillance of the HIV-seropositive woman treated for CIN.

High prevalence of cervical intra-epithelial neoplasia in women treated for pelvic inflammatory disease

Because human papillomavirus (HPV) is sexually transmitted, as are pelvic inflammatory disease (PID) agents, the authors investigated whether cervical intra-epithelial neoplasia (CIN) are more frequent in women under treatment for PID. The study involved 298 patients hospitalized for PID, in whom CIN were investigated by smears and colposcopy. CIN were diagnosed in 42 patients, i.e. in 14% of patients: 21 low-grade CIN and 21 high-grade CIN, including one case of early-stage microinvasion. These figures are to be compared to the 0.5-4% of pre-cancerous lesions found in the general population. Screening smears are frequently inaccurate and direct colposcopy appeared preferable. No clinical study of this type has been published before, but certain authors have mentioned a high CIN incidence in patients with PID histories or followed up in sexually transmitted disease centers. These results show that CIN are more frequent in patients treated for PID; CIN should be investigated systematically in this population.

Exploring the possibility of sexual-behavioural primary prevention interventions for cervical cancer

Consistent causal and risk factors for cervical cancer indicate that primary prevention may be beneficial for cervical cancer prevention. However, social or behavioural primary prevention strategies are seldom discussed in the prevention literature. This paper uses thematic analyses of interviews with key informants involved with cervical cancer prevention policy development in New Zealand to explore the possibility of sexual-behavioural primary prevention. While many informants perceived primary prevention to be important, others were cautiously accepting or opposed to it. Many concerns were raised that highlighting a preventable (sexually transmitted) causal factor might lead to blame and stigma around cervical cancer and reduce participation in cervical screening. Much of the support for primary prevention depended on it being conducted (indirectly) in the context of young people's sexual health education. Positions on primary prevention appeared to be informed by common presumptions about what happens in the 'real world' and the commonality of human papilloma virus in the general population. We contend that the possible health benefits from sexual-behavioural strategies for cervical cancer primary prevention need further exploration.

Cigarette smoking and bone healing: implications in foot and ankle surgery

Despite the known health risks associated with cigarettes, millions of Americans continue to smoke. Much has been reported on the adverse effects of cigarette smoke on wound healing. Recent experimental work and clinical observation have demonstrated the risk of impaired bone healing associated with cigarette smoking. The authors review the biological aspects of bone healing and analyze how the chemical components of cigarette smoke affect the bone healing process. Laboratory and clinical data are also reviewed. Cessation of cigarette smoking before foot and ankle surgery is recommended by the authors.

Effect of smoking on the clinical progression of HIV-1 infection

Cigarette smoking as a risk factor in progression of HIV-1 disease was investigated in the Multicenter AIDS Cohort Study of homosexual men. Longitudinal data for T-cell subsets, HIV-related clinical symptoms, smoking behavior, and AIDS medication use were collected semiannually from 2,499 HIV-1-seropositive men for up to 9 years. Survival methods, including Kaplan-Meier analysis and multivariate Cox regression models, were used to assess the effect of cigarette smoking on development of Pneumocystis carinii pneumonia (PCP), AIDS, death, and self-reported oral thrush. After adjustment for CD4+ lymphocyte count and use of antiretroviral and anti-PCP medications, smoking was not significantly associated with progression to PCP, AIDS, or death in either the HIV-seroprevalent or-seroincident cohort members. Among men who had baseline CD4+ cell counts > 200/microliter, smoking was associated with a 40% increase in the hazard of oral thrush (p < or = 0.01). These data indicate that cigarette smoking does not have a major effect on the progression of HIV-1 infection to AIDS or death but may affect the incidence of oral thrush.

p53 expression in carcinoma of the cervix

AIM

To assess overexpression of the proposed tumour suppressor gene product p53 using the mouse monoclonal antibody DO-7 in the three main subtypes of carcinoma of the uterine cervix and to evaluate its value as a prognostic indicator.

METHODS

Eighty two cases of FIGO Stage IB/IIA uterine cervical carcinoma were studied retrospectively. The tumours had been previously typed into adenocarcinomas, squamous carcinomas and adenosquamous carcinomas after the tissue had been fixed in formalin and embedded in paraffin wax. p53 protein expression was assessed using a standard immunohistochemical technique and the findings were correlated with tumour type, lymph node status and clinical outcome.

RESULTS

In total, the p53 gene product was overexpressed in 17.1% (14/82) of all carcinomas and also in areas of cervical intraepithelial neoplasia grade III adjacent to invasive squamous carcinoma. Where present, the normal epithelium was uniformly negative. No association was found between p53 overexpression and tumour subtype, lymph node status or clinical outcome.

CONCLUSIONS

It seems unlikely that p53 analysis will be of value in determining prognosis in carcinoma of the uterine cervix.

Up-regulation of hormone response of human papillomavirus type 16 expression and increased DNA-protein binding by consensus mutations of viral glucocorticoid response elements

Human papillomaviruses (HPVs) and steroid hormones are linked to the development of cervical cancer. Studies from our laboratory and others showed that the steroid glucocorticoid and progesterone hormones activated the expression of HPV type 16. This activation was attributed to the specific interaction of the glucocorticoid receptor (GR) with the three glucocorticoid response elements (GREs) in the HPV16 regulatory region. In the present study, we first examined the glucocorticoid response mediated through the GREs, using GRE consensus (GREc) mutations and expression assays from a heterologous basal promoter. Both single and triple HPV16 GREc constructs increased expression in the presence of the dexamethasone glucocorticoid in HeLa cervical carcinoma cells and primary baby rat kidney epithelial cells, in comparison with the triple wild-type GREs. Further, the hormone increased significantly the expression of the viral E6-E7 oncogene mRNA from intact HPV in primary human ectocervical cells in in situ hybridization assays. Three in vitro assays of DNA-protein interaction with oligonucleotides and HeLa cell extracts showed a higher binding of protein to two of the HPV16 GREcs than to the wild-type GREs. This applied especially to the GRE containing an overlapping NF1 half site, that also had a greater differential induction by dexamethasone of expression in vivo. The NF1 site was mutated in the GREc that also was bound by unique, lower-mobility complexes in electrophoretic mobility shift assays. UV-crosslinking assays confirmed the increased binding and showed binding by a 96-kDa protein, probably the GR. Our results show an important role of glucocorticoids in HPV16 expression. The direct action through the HPV16 GREs is suggested to be mediated by the hormone-activated GR in association with other factors.