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Collongues N, Durand-Dubief F, Lebrun-Frenay C, Audoin B, Ayrignac X, Bensa C, Bigaut K, Bourre B, Carra-Dallière C, Ciron J, Defer G, Kwiatkowski A, Leray E, Maillart E, Marignier R, Mathey G, Morel N, Thouvenot E, Zéphir H, Boucher J, Boutière C, Branger P, Da Silva A, Demortière S, Guillaume M, Hebant B, Januel E, Kerbrat A, Manchon E, Moisset X, Montcuquet A, Pierret C, Pique J, Poupart J, Prunis C, Roux T, Schmitt P, Androdias G, Cohen M. Cancer and multiple sclerosis: 2023 recommendations from the French Multiple Sclerosis Society. Mult Scler 2024; 30:899-924. [PMID: 38357870 DOI: 10.1177/13524585231223880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Epidemiological data reveal that 45% of persons with multiple sclerosis (PwMS) in France are more than 50 years. This population more than 50 is more susceptible to cancer, and this risk may be increased by frequent use of immunosuppressive drugs. Consequently, concerns have arisen about the potential increased risk of cancer in PwMS and how patients should be screened and managed in terms of cancer risk. OBJECTIVE To develop evidence-based recommendations to manage the coexistence of cancer and multiple sclerosis (MS). METHODS The French Group for Recommendations in MS collected articles from PubMed and university databases covering the period January 1975 through June 2022. The RAND/UCLA method was employed to achieve formal consensus. MS experts comprehensively reviewed the full-text articles and developed the initial recommendations. A group of multidisciplinary health care specialists then validated the final proposal. RESULTS Five key questions were addressed, encompassing various topics such as cancer screening before or after initiating a disease-modifying therapy (DMT), appropriate management of MS in the context of cancer, recommended follow-up for cancer in patients receiving a DMT, and the potential reintroduction of a DMT after initial cancer treatment. A strong consensus was reached for all 31 recommendations. CONCLUSION These recommendations propose a strategic approach to managing cancer risk in PwMS.
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Affiliation(s)
- Nicolas Collongues
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
- Center for Clinical Investigation, INSERM U1434, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
- Department of Pharmacology, Addictology, Toxicology, and Therapeutics, Strasbourg University, Strasbourg, France
| | - Françoise Durand-Dubief
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Christine Lebrun-Frenay
- Department of Neurology, CHU Nice, Nice, France
- Université Côte d'Azur, UMR2CA-URRIS, Nice, France
| | - Bertrand Audoin
- Department of Neurology, CRMBM, APHM, Aix-Marseille University, Marseille, France
| | - Xavier Ayrignac
- Department of Neurology, Montpellier University Hospital, Montpellier, France
- University of Montpellier, Montpellier, France
- INM, INSERM, Montpellier, France
| | - Caroline Bensa
- Department of Neurology, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kévin Bigaut
- Department of Neurology, University Hospital of Strasbourg, Strasbourg, France
- Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, INSERM U1119, Strasbourg, France
| | | | | | - Jonathan Ciron
- CHU de Toulouse, CRC-SEP, Department of Neurology, Toulouse, France
- Université Toulouse III, Infinity, INSERM UMR1291-CNRS UMR5051, Toulouse, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
| | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic University, Lille Catholic Hospitals, Lille, France
| | - Emmanuelle Leray
- Université de Rennes, EHESP, CNRS, INSERM, ARENES-UMR 6051, RSMS-U1309, Rennes, France
| | | | - Romain Marignier
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Nathalie Morel
- Service de Neurologie, Centre Hospitalier Annecy Genevois, Epagny-Metz-Tessy, France
| | - Eric Thouvenot
- Service de Neurologie, CHU de Nîmes, Nîmes, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Hélène Zéphir
- University of Lille, INSERM U1172, CHU de Lille, Lille, France
| | - Julie Boucher
- Department of Neurology, CHU de Lille, Lille, France
| | - Clémence Boutière
- Department of Neurology, University Hospital of Marseille, Marseille, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Angélique Da Silva
- Breast Cancer Unit, Centre François Baclesse, Institut Normand du Sein, Caen, France
| | - Sarah Demortière
- Department of Neurology, CRMBM, APHM, Aix-Marseille University, Marseille, France
| | | | | | - Edouard Januel
- Sorbonne Université, Paris, France/Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
- Département de Neurologie, Hôpital Pitié Salpêtrière, AP-HP, Paris, France
| | - Anne Kerbrat
- Service de Neurologie, CHU de Rennes, France
- EMPENN U1228, INSERM-INRIA, Rennes, France
| | - Eric Manchon
- Service de Neurologie, Centre Hospitalier de Gonesse, Gonesse, France
| | - Xavier Moisset
- Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM, Neuro-Dol, Clermont-Ferrand, France
| | | | - Chloé Pierret
- Université de Rennes, EHESP, CNRS, INSERM, ARENES-UMR 6051, RSMS U-1309, Rennes, France
| | - Julie Pique
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Julien Poupart
- Department of Neurology and U995-LIRIC-Lille Inflammation Research International Center, INSERM, University of Lille, CHU Lille, Lille, France
| | - Chloé Prunis
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Thomas Roux
- Hôpital La Pitié-Salpêtrière, Service de Neurologie, Paris, France
- CRC-SEP Paris. Centre des maladies inflammatoires rares du cerveau et de la moelle de l'enfant et de l'adulte (Mircem)
| | | | - Géraldine Androdias
- Service de Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Bron, France
- Clinique de la Sauvegarde-Ramsay Santé, Lyon, France
| | - Mikael Cohen
- Department of Neurology, CHU Nice, Nice, France/Université Côte d'Azur, UMR2CA-URRIS, Nice, France
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Bridge F, Brotherton J, Stankovich J, Sanfilippo PG, Skibina OG, Buzzard K, Kalincik T, Nguyen AL, Guo K, Monif M, Wrede CD, Rath L, Taylor L, Butzkueven H, Jokubaitis VG, Van Der Walt A. Risk of Cervical Abnormalities for Women With Multiple Sclerosis Treated With Moderate-Efficacy and High-Efficacy Disease-Modifying Therapies. Neurology 2024; 102:e208059. [PMID: 38306594 DOI: 10.1212/wnl.0000000000208059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/27/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of immunomodulatory therapies on the risk of cervical pre-cancer and invasive cancer development is important for the health and safety of women with multiple sclerosis (wwMS). We investigate the risk of cervical abnormalities in wwMS treated with disease-modifying therapies (DMTs). METHODS This is a multicenter cohort study with data collected from 1998 to 2019 in Victoria, Australia. Data linkage was performed using matching records from the MSBase Registry, the National Human Papillomavirus (HPV) Vaccination Program Register, and the Victorian Cervical Cytology Register. The primary outcome was the detection of any type of cervical abnormality as determined by cytology or histology. Survival methods were used to assess the time to cervical abnormality detection on cervical screening tests (CSTs). Crude and adjusted Cox proportional hazards models were used to determine time to and magnitude of association of DMTs with the risk of cervical abnormality. In a sensitivity analysis, we constructed standardized survival curves averaged over the same set of covariates to determine the commensurate population-average (marginal) causal effects. RESULTS We included 248 wwMS. The incidence of abnormal CSTs was lower (p < 0.001) for women not exposed to moderate-high-efficacy therapy (10.2 per 1,000 patient-years [95% confidence interval (CI) 5.5-14.9]), compared with those exposed (36.6 per 1,000 patient-years [95% CI 21.7-51.6]). Exposure to higher efficacy treatment was associated with a 3.79-fold increased hazard (95% CI 2.02-7.08, p < 0.001) of developing a cervical abnormality relative to those not exposed. When adjusted for vaccination status, smoking, hormonal contraceptive use, and socioeconomic status, the risk remained elevated at 3.79 (95% CI 1.99-7.21, p < 0.001). Marginal hazard ratios declined over time, ranging from 3.90 (95% CI 2.09-7.27) at 20 years of age to 2.06 (95% CI 1.14-3.73) at 70 years of age. DISCUSSION A greater than three-and-a-half-fold increased risk of cervical abnormalities was found after exposure to moderate-high-efficacy DMTs. This risk persisted despite adjusting for HPV vaccination status, hormonal contraception use, smoking, and socioeconomic status. If confirmed in future studies, we would advocate for wwMS exposed to moderate-high-efficacy DMTs to be treated in line with immune-deficient paradigm in cervical screening and HPV vaccination programs. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that highly active MS therapy compared with less active therapy increases the risk of developing cervical abnormalities among women with MS.
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Affiliation(s)
- Francesca Bridge
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Julia Brotherton
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Jim Stankovich
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Paul G Sanfilippo
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Olga G Skibina
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Katherine Buzzard
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Tomas Kalincik
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Ai-Lan Nguyen
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Kylie Guo
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Mastura Monif
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - C David Wrede
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Louise Rath
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Lisa Taylor
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Helmut Butzkueven
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Vilija G Jokubaitis
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Anneke Van Der Walt
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
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