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Carvajal LJ, Herrero R, Angulo MM, Schussler J, Porras C, Ocampo R, Cortés B, Loría V, Castrillo H, Romero B, Barrientos G, Coronado K, Ávila C, Hildesheim A, Rodríguez AC, Jiménez SE, Kreimer AR, Sierra MS. Prevalencia y determinantes de la infección por virus de papiloma humano en mujeres jóvenes de Guanacaste y Puntarenas, Costa Rica, 2004-2005. Salud Publica Mex 2023; 65:253-264. [PMID: 38060880 DOI: 10.21149/14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/06/2023] [Indexed: 12/18/2023] Open
Abstract
OBJETIVO Estimar la prevalencia e identificar determinantes de la infección por el virus del papiloma humano (VPH) en mujeres jóvenes (18-25 años). Material y métodos. Se analizaron datos de 5 871 mujeres sexualmente activas a quienes se les realizó una entrevista y toma de muestras cervicouterinas para detección de VPH y citología durante la visita de reclutamiento del Ensayo de Vacunación contra VPH16/18 en Costa Rica. Se calculó la prevalencia total para cualquier tipo de VPH y tipos oncogénicos, no oncogénicos y específicos, con intervalos de confianza al 95% (IC95%). Se utilizó regresión logística múltiple paso-a-paso para identificar determinantes asociados con la infección. RESULTADOS La prevalencia total de VPH fue 50.0% (IC95% 48.8,51.3) y por tipos oncogénicos fue 33.8% (IC95% 32.6,35.0). El VPH-16 fue el tipo más prevalente (8.3%, IC95% 7.6,9.0). Los determinantes asociados con un alto riesgo de infección prevalente por VPH oncogénicos fueron no estar casada/unión libre, >1 compañero sexual, infección concomitante por Chlamydia trachomatis, y entre aquéllas con un único compañero sexual en su vida, un compañero con antecedente de múltiples compañeras sexuales. Conclusión. Se confirma la asociación de las infecciones por VPH oncogénicos con el comportamiento sexual de la mujer y se destacan los comportamientos del compañero sexual.
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Affiliation(s)
- Loretto J Carvajal
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health. Bethesda, Maryland, USA. Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Rolando Herrero
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - María M Angulo
- Área Rectora de Salud de Garabito, Ministerio de Salud. Jacó, Puntarenas, Costa Rica..
| | - John Schussler
- Information Management Services, Silver Spring. Maryland, USA,.
| | - Carolina Porras
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Rebeca Ocampo
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Bernal Cortés
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Viviana Loría
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Hariane Castrillo
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Byron Romero
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Gloriana Barrientos
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Karla Coronado
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Carlos Ávila
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA. San José, Costa Rica..
| | - Allan Hildesheim
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health. Bethesda, Maryland, USA..
| | | | | | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health. Bethesda, Maryland, USA..
| | - Mónica S Sierra
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health. Bethesda, Maryland, USA..
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Sierra MS, Tsang SH, Hu S, Porras C, Herrero R, Kreimer AR, Schussler J, Boland J, Wagner S, Cortes B, Rodríguez AC, Quint W, van Doorn LJ, Schiffman M, Sampson JN, Hildesheim A. Risk Factors for Non-Human Papillomavirus (HPV) Type 16/18 Cervical Infections and Associated Lesions Among HPV DNA-Negative Women Vaccinated Against HPV-16/18 in the Costa Rica Vaccine Trial. J Infect Dis 2021; 224:503-516. [PMID: 33326576 PMCID: PMC8496490 DOI: 10.1093/infdis/jiaa768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/11/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Factors that lead human papillomavirus (HPV) infections to persist and progress to cancer are not fully understood. We evaluated co-factors for acquisition, persistence, and progression of non-HPV-16/18 infections among HPV-vaccinated women. METHODS We analyzed 2153 women aged 18-25 years randomized to the HPV-vaccine arm of the Costa Rica HPV Vaccine Trial. Women were HPV DNA negative for all types at baseline and followed for approximately 11 years. Generalized estimating equation methods were used to account for correlated observations. Time-dependent factors evaluated were age, sexual behavior, marital status, hormonally related factors, number of full-term pregnancies (FTPs), smoking behavior, and baseline body mass index. RESULTS A total of 1777 incident oncogenic non-HPV-16/18 infections were detected in 12 292 visits (average, 0.14 infections/visit). Age and sexual behavior-related variables were associated with oncogenic non-HPV-16/18 acquisition. Twenty-six percent of incident infections persisted for ≥1 year. None of the factors evaluated were statistically associated with persistence of oncogenic non-HPV-16/18 infections. Risk of progression to Cervical Intraepithelial Neoplasia grade 2 or worst (CIN2+) increased with increasing age (P for trend = .001), injectable contraceptive use (relative risk, 2.61 [95% confidence interval, 1.19-5.73] ever vs never), and increasing FTPs (P for trend = .034). CONCLUSIONS In a cohort of HPV-16/18-vaccinated women, age and sexual behavior variables are associated with acquisition of oncogenic non-HPV-16/18 infections; no notable factors are associated with persistence of acquired infections; and age, parity, and hormonally related exposures are associated with progression to CIN2+.
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Affiliation(s)
- Mónica S Sierra
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
| | - Sabrina H Tsang
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
| | - Shangying Hu
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
| | - Carolina Porras
- Agencia Costarricense de Investigaciones Biomédicas,
formerly Proyecto Epidemiológico Guanacaste, Fundación
INCIENSA, San José, Costa
Rica
| | - Rolando Herrero
- Agencia Costarricense de Investigaciones Biomédicas,
formerly Proyecto Epidemiológico Guanacaste, Fundación
INCIENSA, San José, Costa
Rica
- Prevention and Implementation Group, International Agency
for Research on Cancer, Lyon, France
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
| | - John Schussler
- Information Management Services, Silver
Spring, Maryland, USA
| | - Joseph Boland
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
- Cancer Genomics Research Laboratory, Frederick National
Laboratory for Cancer Research, Leidos Biomedical Research Inc,
Frederick, Maryland, USA
| | - Sarah Wagner
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
- Cancer Genomics Research Laboratory, Frederick National
Laboratory for Cancer Research, Leidos Biomedical Research Inc,
Frederick, Maryland, USA
| | - Bernal Cortes
- Agencia Costarricense de Investigaciones Biomédicas,
formerly Proyecto Epidemiológico Guanacaste, Fundación
INCIENSA, San José, Costa
Rica
| | | | - Wim Quint
- DDL Diagnostic Laboratory, Rijswijk,
The Netherlands
| | | | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
| | - Joshua N Sampson
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
| | - Allan Hildesheim
- Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Maryland, USA
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Porras C, Tsang SH, Herrero R, Guillén D, Darragh TM, Stoler MH, Hildesheim A, Wagner S, Boland J, Lowy DR, Schiller JT, Schiffman M, Schussler J, Gail MH, Quint W, Ocampo R, Morales J, Rodríguez AC, Hu S, Sampson JN, Kreimer AR. Efficacy of the bivalent HPV vaccine against HPV 16/18-associated precancer: long-term follow-up results from the Costa Rica Vaccine Trial. Lancet Oncol 2020; 21:1643-1652. [PMID: 33271093 PMCID: PMC8724969 DOI: 10.1016/s1470-2045(20)30524-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Oncogenic human papillomavirus (HPV) infections cause most cases of cervical cancer. Here, we report long-term follow-up results for the Costa Rica Vaccine Trial (publicly funded and initiated before licensure of the HPV vaccines), with the aim of assessing the efficacy of the bivalent HPV vaccine for preventing HPV 16/18-associated cervical intraepithelial neoplasia grade 2 or worse (CIN2+). METHODS Women aged 18-25 years were enrolled in a randomised, double-blind, controlled trial in Costa Rica, between June 28, 2004, and Dec 21, 2005, designed to assess the efficacy of a bivalent vaccine for the prevention of infection with HPV 16/18 and associated precancerous lesions at the cervix. Participants were randomly assigned (1:1) to receive an HPV 16/18 AS04-adjuvanted vaccine or control hepatitis A vaccine. Vaccines were administered intramuscularly in three 0·5 mL doses at 0, 1, and 6 months and participants were followed up annually for 4 years. After the blinded phase, women in the HPV vaccine group were invited to enrol in the long-term follow-up study, which extended follow-up for 7 additional years. The control group received HPV vaccine and was replaced with a new unvaccinated control group. Women were followed up every 2 years until year 11. Investigators and patients were aware of treatment allocation for the follow-up phase. At each visit, clinicians collected cervical cells from sexually active women for cytology and HPV testing. Women with abnormal cytology were referred to colposcopy, biopsy, and treatment as needed. Women with negative results at the last screening visit (year 11) exited the long-term follow-up study. The analytical cohort for vaccine efficacy included women who were HPV 16/18 DNA-negative at vaccination. The primary outcome of this analysis was defined as histopathologically confirmed CIN2+ or cervical intraepithelial neoplasia grade 3 or worse associated with HPV 16/18 cervical infection detected at colposcopy referral. We calculated vaccine efficacy by year and cumulatively. This long-term follow-up study is registered with ClinicalTrials.gov, NCT00867464. FINDINGS 7466 women were enrolled in the Costa Rica Vaccine Trial; 3727 received the HPV vaccine and 3739 received the control vaccine. Between March 30, 2009, and July 5, 2012, 2635 women in the HPV vaccine group and 2836 women in the new unvaccinated control group were enrolled in the long-term follow-up study. 2635 women in the HPV vaccine group and 2677 women in the control group were included in the analysis cohort for years 0-4, and 2073 women from the HPV vaccine group and 2530 women from the new unvaccinated control group were included in the analysis cohort for years 7-11. Median follow-up time for the HPV group was 11·1 years (IQR 9·1-11·7), 4·6 years (4·3-5·3) for the original control group, and 6·2 years (5·5-6·9) for the new unvaccinated control group. At year 11, vaccine efficacy against incident HPV 16/18-associated CIN2+ was 100% (95% CI 89·2-100·0); 34 (1·5%) of 2233 unvaccinated women had a CIN2+ outcome compared with none of 1913 women in the HPV group. Cumulative vaccine efficacy against HPV 16/18-associated CIN2+ over the 11-year period was 97·4% (95% CI 88·0-99·6). Similar protection was observed against HPV 16/18-associated CIN3-specifically at year 11, vaccine efficacy was 100% (95% CI 78·8-100·0) and cumulative vaccine efficacy was 94·9% (73·7-99·4). During the long-term follow-up, no serious adverse events occurred that were deemed related to the HPV vaccine. The most common grade 3 or worse serious adverse events were pregnancy, puerperium, and perinatal conditions (in 255 [10%] of 2530 women in the unvaccinated control group and 201 [10%] of 2073 women in the HPV vaccine group). Four women in the unvaccinated control group and three in the HPV vaccine group died; no deaths were deemed to be related to the HPV vaccine. INTERPRETATION The bivalent HPV vaccine has high efficacy against HPV 16/18-associated precancer for more than a decade after initial vaccination, supporting the notion that invasive cervical cancer is preventable. FUNDING US National Cancer Institute.
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Affiliation(s)
- Carolina Porras
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica.
| | - Sabrina H Tsang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Rolando Herrero
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica; Early Detection and Prevention Section, International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Diego Guillén
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica
| | | | - Mark H Stoler
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Allan Hildesheim
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Sarah Wagner
- Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Frederick, MD, USA
| | - Joseph Boland
- Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Frederick, MD, USA
| | - Douglas R Lowy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - John T Schiller
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | | | - Mitchell H Gail
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Wim Quint
- DDL Diagnostic Laboratory, Rijswijk, Netherlands
| | - Rebeca Ocampo
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica
| | - Jorge Morales
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica
| | | | - Shangying Hu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Joshua N Sampson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
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Mulet M, Sánchez D, Rodríguez AC, Nogales B, Bosch R, Busquets A, Gomila M, Lalucat J, García-Valdés E. Pseudomonas gallaeciensis sp. nov., isolated from crude-oil-contaminated intertidal sand samples after the Prestige oil spill. Syst Appl Microbiol 2018; 41:340-347. [DOI: 10.1016/j.syapm.2018.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 03/26/2018] [Accepted: 03/30/2018] [Indexed: 10/17/2022]
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Sánchez D, Mulet M, Rodríguez AC, David Z, Lalucat J, García-Valdés E. Pseudomonas aestusnigri sp. nov., isolated from crude oil-contaminated intertidal sand samples after the Prestige oil spill. Syst Appl Microbiol 2014; 37:89-94. [DOI: 10.1016/j.syapm.2013.09.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 09/05/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
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Herrero R, Wacholder S, Rodríguez AC, Solomon D, González P, Kreimer AR, Porras C, Schussler J, Jiménez S, Sherman ME, Quint W, Schiller JT, Lowy DR, Schiffman M, Hildesheim A. Prevention of persistent human papillomavirus infection by an HPV16/18 vaccine: a community-based randomized clinical trial in Guanacaste, Costa Rica. Cancer Discov 2011; 1:408-19. [PMID: 22586631 PMCID: PMC3354733 DOI: 10.1158/2159-8290.cd-11-0131] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Target groups for human papillomavirus (HPV) vaccination are controversial. We evaluated vaccine efficacy (VE) against 1-year persistent infection, stratified by age and sexual behavior, among young women in Costa Rica. We randomized 7,466 healthy women 18 to 25 years of age to HPV16/18 or hepatitis A vaccine (follow-up, 50.4 months). According-to-protocol (ATP) cohorts included compliant HPV-negative women; intention-to-treat (ITT) included all randomized women. ATP VE was 90.9% (95% CI, 82.0-95.9) against HPV16/18 infections, 44.5% against HPV31/33/45 (95% CI, 17.5-63.1), and 12.4% (95% CI, -3.2 to 25.6) against any oncogenic infection. Overall ITT VE against HPV16/18 infections was 49.0%, but ATP and ITT VE almost reached 100% in year 4 of follow-up. ATP efficacy against HPV16/18 was similar by age, but ITT VE was greatest among youngest women (68.9% among those 18-19 years of age; 21.8% among those 24-25 years of age) and 79.8% among virgins. Among previously unexposed women, vaccination is highly efficacious against HPV16/18 and partially against HPV31/33/45. Vaccination is most effective in women and girls before they initiate sexual activity, with programmatic and individual decision implications.
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Affiliation(s)
- Rolando Herrero
- Proyecto Epidemiológico Guanacaste, Fundación Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud, San José, Costa Rica.
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Porras C, Wentzensen N, Rodríguez AC, Morales J, Burk RD, Alfaro M, Hutchinson M, Herrero R, Hildesheim A, Sherman ME, Wacholder S, Solomon D, Schiffman M. Switch from cytology-based to human papillomavirus test-based cervical screening: implications for colposcopy. Int J Cancer 2011; 130:1879-87. [PMID: 21607948 DOI: 10.1002/ijc.26194] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 03/25/2011] [Accepted: 04/07/2011] [Indexed: 02/06/2023]
Abstract
Human papillomavirus (HPV) testing is more sensitive than cytology; some cervical cancer prevention programs will switch from cytology to carcinogenic HPV test-based screening. The objective of our study is to evaluate the clinical implications of a switch to HPV test-based screening on performance and workload of colposcopy. Women in the population-based, 7-year Guanacaste cohort study were screened at enrollment using cytology. We also took another specimen for HPV DNA testing and collected magnified cervical photographic images (cervigrams). A final case diagnosis (≥cervical intraepithelial neoplasia [CIN] grade 3, CIN2, <CIN2) was assigned at exit. Using the cervigram as a surrogate of colposcopy impression, we evaluated the impact of changing screening method from cytology to carcinogenic HPV testing on the distribution of enrollment colposcopic impression and on the predictive values of positive and negative colposcopic impressions for the cumulative 7-year detection of ≥CIN2 and ≥CIN3. A program based on immediate colposcopic referral after positive HPV would immediately identify as high risk more of the cumulative ≥CIN2 cases than conventional cytology, because of an increased number of referrals. However, the proportion of women that would have visible lesions at referral to colposcopy and the sensitivity versus specificity trade-off of the colposcopic impressions would be similar to programs using cytology (≥ atypical squamous cells of unknown significance [ASCUS]) for referral. The major concern with switching from cytology to more sensitive HPV screening is management of the many HPV-positive women, including those with still nonvisible ≥CIN2 lesions. Our data support the need for a nonvisual diagnostic method to guide management and treatment of HPV-positive women.
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Affiliation(s)
- Carolina Porras
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
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Castle PE, Rodríguez AC, Burk RD, Herrero R, Hildesheim A, Solomon D, Sherman ME, Jeronimo J, Alfaro M, Morales J, Guillén D, Hutchinson ML, Wacholder S, Schiffman M. Neither one-time negative screening tests nor negative colposcopy provides absolute reassurance against cervical cancer. Int J Cancer 2009; 125:1649-56. [PMID: 19569231 DOI: 10.1002/ijc.24525] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A population sample of 10,049 women living in Guanacaste, Costa Rica, was recruited into a natural history of human papillomavirus (HPV) and cervical neoplasia study in 1993-1994. At the enrollment visit, we applied multiple state-of-the-art cervical cancer screening methods to detect prevalent cervical cancer and to prevent subsequent cervical cancers by the timely detection and treatment of precancerous lesions. Women were screened at enrollment with 3 kinds of cytology (often reviewed by more than one pathologist), visual inspection and cervicography. Any positive screening test led to colposcopic referral and biopsy and/or excisional treatment of CIN2 or worse. We retrospectively tested stored specimens with an early HPV test (hybrid capture tube test) and for >40 HPV genotypes using a research PCR assay. We followed women typically 5-7 years and some up to 11 years. Nonetheless, 16 cases of invasive cervical cancer were diagnosed during follow-up. Six cancer cases were failures at enrollment to detect abnormalities by cytology screening; 3 of the 6 were also negative at enrollment by sensitive HPV DNA testing. Seven cancers represent failures of colposcopy to diagnose cancer or a precancerous lesion in screen-positive women. Finally, 3 cases arose despite attempted excisional treatment of precancerous lesions. Based on this evidence, we suggest that no current secondary cervical cancer prevention technologies applied once in a previously under-screened population is likely to be 100% efficacious in preventing incident diagnoses of invasive cervical cancer.
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Affiliation(s)
- Philip E Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, MD 20892-7234, USA.
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Herrero R, Hildesheim A, Rodríguez AC, Wacholder S, Bratti C, Solomon D, González P, Porras C, Jiménez S, Guillen D, Morales J, Alfaro M, Cyr J, Morrisey K, Estrada Y, Cortés B, Morera LA, Freer E, Schussler J, Schiller J, Lowy D, Schiffman M. Rationale and design of a community-based double-blind randomized clinical trial of an HPV 16 and 18 vaccine in Guanacaste, Costa Rica. Vaccine 2008; 26:4795-808. [PMID: 18640170 PMCID: PMC2652516 DOI: 10.1016/j.vaccine.2008.07.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Revised: 06/20/2008] [Accepted: 07/01/2008] [Indexed: 02/08/2023]
Abstract
We report the rationale, design, methods and details of participation of a community-based, double-blind, randomized clinical trial of an HPV 16 and 18 vaccine conducted in two provinces of Costa Rica to investigate the efficacy and population impact of the vaccine in the prevention of cervical cancer precursors. More than 24,000 women between 18 and 25 years of age were invited to participate and pre-screened for eligibility, with recruitment of 7466 women (30% of those pre-screened, 59% of those eligible) who were randomized to receive 3 doses of the HPV vaccine or hepatitis A vaccine as control. A complex protocol of data and specimen collection was applied, including an interview, pelvic exam for sexually active women, blood for serology and cell-mediated immunity, cervical secretions for local immunity and cells for HPV, Chlamydia trachomatis and gonorrhea testing. Eighty percent of the women received three doses, 12.4% two doses and 7.4% one dose. At visits, compliance with data and specimen collection was close to 100%. Baseline characteristics and age-specific prevalence of HPV and cervical neoplasia are reported. Overall prevalence of HPV was high (50%), with 8.3% of women having HPV 16 and 3.2% HPV 18. LSIL was detected in 12.7% of women at baseline and HSIL in 1.9%. Prevalence of Chlamydia was 14.2%. There was very good agreement in HPV detection between clinician-collected and self- collected specimens (89.4% agreement for all types, kappa 0.59). Follow up will continue with yearly or more frequent examinations for at least 4 years for each participant.
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Affiliation(s)
- Rolando Herrero
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Allan Hildesheim
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, USA
| | - Ana C Rodríguez
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, USA
| | - Sholom Wacholder
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, USA
| | | | - Diane Solomon
- Division of Cancer Prevention and Control, National Cancer Institute, USA
| | - Paula González
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Carolina Porras
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Silvia Jiménez
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Diego Guillen
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Jorge Morales
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Mario Alfaro
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Jean Cyr
- Information Management Systems (IMS), Rockville MD USA
| | | | - Yenory Estrada
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Bernal Cortés
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Lidia Ana Morera
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, Costa Rica
| | - Enrique Freer
- Centro de Investigación en Estructuras Microscópicas (CIEMIC), University of Costa Rica
| | | | - John Schiller
- Center for Cancer Research, National Cancer Institute, USA
| | - Douglas Lowy
- Center for Cancer Research, National Cancer Institute, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, USA
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10
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Castle PE, Jeronimo J, Schiffman M, Herrero R, Rodríguez AC, Bratti MC, Hildesheim A, Wacholder S, Long LR, Neve L, Pfeiffer R, Burk RD. Age-Related Changes of the Cervix Influence Human Papillomavirus Type Distribution. Cancer Res 2006; 66:1218-24. [PMID: 16424061 DOI: 10.1158/0008-5472.can-05-3066] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Approximately 15 human papillomavirus (HPV) types cause virtually all cervical cancer whereas other HPV types are unrelated to cancer. We were interested in whether some noncarcinogenic types differ from carcinogenic in their affinity for the cervical transformation zone, where nearly all HPV-induced cancers occur. To examine this possibility, we tested cervical specimens from 8,374 women without cervical precancer and cancer participating in a population-based study in Guanacaste for >40 HPV types using PCR. We compared age-group specific prevalences of HPV types of the alpha9 species, which are mainly carcinogenic and include HPV16, to the genetically distinct types of the alpha3/alpha15 species (e.g., HPV71), which are noncarcinogenic and common in vaginal specimens from hysterectomized women. We related HPV detection of each group to the location of the junction between the squamous epithelium of the ectocervix and vagina and the columnar epithelium of the endocervical canal. Models evaluated the independent effects of amount of exposed columnar epithelium (ectopy) and age on the presence of alpha9 or alpha3/alpha15 types. Prevalence of alpha9 types (7.6%) peaked in the youngest women, declined in middle-aged women, and then increased slightly in older women. By contrast, prevalence of alpha3/alpha15 types (7.6%) tended to remain invariant or to increase with increasing age. Detection of alpha9 infections increased (P(trend) < 0.0005) but alpha3/alpha15 infections decreased (P(trend) < 0.0005) with increasing exposure of the columnar epithelia. Older age and decreasing cervical ectopy were independently positively associated with having an alpha3/alpha15 infection compared with having an alpha9 infection. These patterns need to be confirmed in other studies and populations. We suggest that these genetically distinct groups of HPV types may differ in tissue preferences, which may contribute to their differences in carcinogenic potential.
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Affiliation(s)
- Philip E Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute/NIH, 6120 Executive Boulevard, Bethesda, MD 20892-7234, USA.
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11
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Bratti MC, Rodríguez AC, Schiffman M, Hildesheim A, Morales J, Alfaro M, Guillén D, Hutchinson M, Sherman ME, Eklund C, Schussler J, Buckland J, Morera LA, Cárdenas F, Barrantes M, Pérez E, Cox TJ, Burk RD, Herrero R. Description of a seven-year prospective study of human papillomavirus infection and cervical neoplasia among 10000 women in Guanacaste, Costa Rica,. Rev Panam Salud Publica 2004; 15:75-89. [PMID: 15030652 DOI: 10.1590/s1020-49892004000200002] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The Guanacaste study ("Guanacaste Project," or GP), was designed to investigate the role of human papillomavirus (HPV) infection and its cofactors in the development of cervical neoplasia and to evaluate new cervical cancer screening technologies. The follow-up phase of the GP was designed to study why a small proportion of women infected with HPV develop cervical intraepithelial neoplasia grade 2 (CIN 2), CIN 3, or cancer (these three together are globally referred to as > or = CIN 2, that is, CIN 2 or worse). The purpose of this article is to describe this prospective study in detail and to present the preliminary findings regarding the incidence of cervical neoplasia. METHODS A cohort of 10 049 randomly selected women from 18 to 97 years old from Guanacaste, a province in northwestern Costa Rica, was intensively screened in 1993-1994 and then followed up for seven years after being enrolled. A questionnaire for demographic and risk factors was administered, and a pelvic examination was performed on sexually active women at each follow-up visit in order to obtain samples for screening tests and for research purposes. The final diagnosis given at the end of the enrollment phase categorized women into several groups according to the perceived risk of their developing either high-grade precursors of cancer or cancer. These groups were followed up at different intervals according to the risk of developing > or = CIN 2. The most active follow-up (every 6-12 months) was concentrated on the women most likely to develop >or = CIN 2, based on cytology (n = 492). The remainder of the cohort was followed either annually (n = 2 574) or after five to seven years of passive follow-up (n = 3 926). All women with possibly severe lesions detected by any technique were referred to colposcopy for further evaluation and treatment, and they were also censored from the study. Lesions >or = CIN 2 served as both the censoring outcome and our surrogate for cancer risk. RESULTS Participation during follow-up was high (near 90%). Suspected > or = CIN 2 by any screening technique censored 4.6% of women. Most of the women censored because of suspected > or = CIN 2 came from the large group perceived at entry as being at low risk of developing > or = CIN 2, but the greatest rates of progression to > or = CIN 2 were observed among women perceived at entry to be at highest risk of > or = CIN 2, based on their cytology, virology, or sexual behavior. CONCLUSIONS The GP is the largest population-based longitudinal cohort for the study of HPV and cervical neoplasia in the world, and its results will hopefully let us soon plan future worldwide prevention strategies. Research projects such as this one require the long-term commitment of a large multidisciplinary team and ample financial resources. The intensive effort and expertise applied in all aspects of this study were key factors in its success as a model of cooperative, interdisciplinary cancer research in Latin America. Quality control played an important role at all times during the study and made it possible to adapt new diagnostic and screening technology to Guanacaste. The systematic follow-up of a population-based group of close to 10 000 women in Guanacaste should permit careful, time-dependent evaluation of factors postulated to be linked to the development of cervical cancer as well as the evaluation of clinical markers of disease progression. The study results that have already been published have validated sensitive screening techniques and have also promoted the use of more affordable screening techniques in resource-poor, developing countries. The GP has also contributed to building knowledge for the search for vaccines against HPV as part of the effort to develop an effective tool to reduce the incidence and mortality of cervical cancer worldwide.
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Affiliation(s)
- M Concepción Bratti
- FUCODOCSA (Costa Rican Foundation for Training in Health Sciences), Proyecto Epidemiológico Guanacaste, San José, Costa Rica
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12
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Rodríguez AC, Castle PE, Smith JS, Bratti C, Hildesheim A, Schiffman M, Viscidi R, Burk RD, Ashley RL, Castellsagué X, Herrero R. A population based study of herpes simplex virus 2 seroprevalence in rural Costa Rica. Sex Transm Infect 2004; 79:460-5. [PMID: 14663121 PMCID: PMC1744764 DOI: 10.1136/sti.79.6.460] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine seroprevalence and determinants of herpes simplex virus 2 (HSV-2) seropositivity, in a random sample of a population based cohort of 10 049 women of Guanacaste, Costa Rica, using a highly sensitive and specific serological assay. METHODS Seroprevalence was determined by a type specific HSV-2 ELISA assay in an age stratified random sample of 1100 women. Univariate and multivariate logistic regression was used to calculate odds ratios and 95% confidence intervals for risk factors of seropositivity. RESULTS Overall age adjusted HSV-2 seroprevalence was 38.5% (95% CI, 37.5 to 39.5), and it was strongly associated with increasing age (p(Trend<0.0001)), both among monogamous women and women with multiple sexual partners. A greater number of lifetime sexual partners increased the risk of seropositivity, with a 28.2% (95% CI, 24.4 to 32.2) seroprevalence among monogamous women and 75% (95% CI, 65.6 to 83.0) seroprevalence for those with four or more partners (OR = 7.6 95% CI, 4.7 to 12.4 p(Trend<0.0001)). Barrier contraceptive use was negatively associated with HSV-2 seropositivity (OR 0.54, 95% CI, 0.31 to 0.94). Women with antibodies against HPV 16, 18, or 31 were 1.6 times more likely to be HSV-2 seropositive (OR 1.6, 95% CI, 1.2 to 2.1). CONCLUSIONS HSV-2 infection is highly endemic in Guanacaste, even among lifetime monogamous women, suggesting a role of male behaviour in the transmission of the infection. Until vaccination against HSV-2 is available, education to prevent high risk sexual behaviour and the use of condoms appear as preventive measures against HSV-2.
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Affiliation(s)
- A C Rodríguez
- Guanacaste Project, Costa Rica Foundation for Health Sciences, San José, Costa Rica
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Wesseling C, Antich D, Hogstedt C, Rodríguez AC, Ahlbom A. Geographical differences of cancer incidence in Costa Rica in relation to environmental and occupational pesticide exposure. Int J Epidemiol 1999; 28:365-74. [PMID: 10405835 DOI: 10.1093/ije/28.3.365] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study describes geographical differences in cancer incidence in Costa Rica, and investigates if some of these differences may be related to pesticides. METHODS Data were combined from the cancer registry (1981-1993), the 1984 population census, the 1984 agricultural census, and a national pesticide data set. The 81 counties of Costa Rica were the units for the ecological analyses. Adjacent counties were grouped into 14 regions (3 urban and 11 rural) with relatively similar socioeconomic characteristics. County indices for population density and agricultural variables were constructed and categorized. Differences across regions and categories were assessed by comparing observed numbers of incident cases to expected values derived from national rates. Within the tertile of most rural counties, rate ratios between categories of high and low pesticide use were calculated. RESULTS In urban regions, excesses were observed for lung, colorectal, breast, uterus, ovary, prostate, testis, kidney, and bladder cancers; and in rural regions for gastric, cervical, penile, and skin cancers. Skin cancers (lip, melanoma, non-melanocytic skin and penile cancer) occurred in excess in coffee growing areas with extensive use of paraquat and lead arsenate. In the most rural subset, heavy pesticide use was associated with an increase of cancer incidence overall and at a considerable number of specific sites, including lung cancer (relative risk [RR] 2.0 for men and 2.6 for women) and all female hormone-related cancers (RR between 1.3 and 1.8). CONCLUSIONS Regions and populations at high risk for specific cancers were identified. Several hypotheses for associations between pesticides and cancer emerged. The findings call for studies at the individual level.
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Affiliation(s)
- C Wesseling
- Central American Institute of Studies on Toxic Substances, Universidad Nacional, Heredia, Costa Rica
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