Objective. Animal data suggest that cocaine has an immunosuppressive effect, but no human studies have been conducted to assess the relation of cocaine use with human papillomavirus (HPV) infection, the viral cause of cervical cancer. Since both cocaine use and HPV infection are common among HIV-positive women, we sought to determine whether use of cocaine and/or crack influences the natural history of HPV among women with or at high risk of HIV. Methods. Women enrolled in the Women's Interagency HIV Study (2278 HIV-seropositive and 826 high-risk seronegative women) were examined every six months for up to 9.5 years with Pap smear, collection of cervicovaginal lavage (CVL) samples, and detailed questionnaires regarding health and behavior, including use of crack and cocaine (crack/cocaine). CVLs were tested for HPV DNA by PCR, with genotyping for over forty HPV types. Results. In multivariate logistic regression models, censoring women treated for cervical neoplasia, crack/cocaine use within the last six months was associated with prevalent detection of oncogenic HPV DNA (odds ratio [OR] = 1.30 (1.09–1.55)), and with oncogenic HPV-positive squamous intraepithelial lesions (SIL) (OR = 1.70 (1.27–2.27)), following adjustment for age, race, HIV-serostatus, and CD4+ T-cell count, the number of sexual partners in the past six months, and smoking. In multivariate Cox models crack/cocaine use was also associated with a trend that approached significance in regard to incident detection of oncogenic HPV-positive SIL , and while the rate of oncogenic HPV clearance was not related to cocaine use, the clearance of any SIL was significantly lower in those with versus those without recent crack/cocaine use . Conclusions. Cocaine use is associated with an increased risk of detection of both prevalent and incident oncogenic HPV infection, as well as an increased risk of HPV-positive SIL over time.  Human papillomavirus (HPV) infectionsof women, though common, typically resolve. Persistence of oncogenic HPV isnecessary for the development of cervical precancer and invasive cervicalcancer (ICC). The incident detection and persistence of HPV infections andrelated lesions have been shown by us –4, and oCocaine use is also common amongHIV-infected women , 10 and Any disruption to host defensesattributable to cocaine, in conjunction with those associated withHIV-infection per se, could increase the incidence and/or duration of oncogenicHPV infection. That in turn could contribute to an enhanced risk of cervicalneoplasia to which HIV-infected women are demonstrably prone . AdditioThe Women'sInteragency HIV Study (WIHS) is a prospective study of the natural history ofHIV infection in women that initially enrolled HIV-seropositive and at riskseronegative women participants at six clinical sites  between October 1994 and November1995. A subsequent recruiting cycleoccurred in 2002. The recruitment methods and data collection procedures forWIHS have previously been described [Therewere a total of 3768 subjects in WIHS. We excluded 16 subjects who had HIVseroconverted during follow-up, and 253 subjects who did not have a cervixpresent at baseline. Thus 3499 women were included. We censored all the visits afterhysterectomy. The current analysis includeswomen recruited in 1994/1995 and additional women recruited in 2002. The initialrecruits were tested for HPV infection during visit 1 through visit 15, and themore recent recruits were tested for HPV infection during their baseline visit(V15 or V16) through visit 19.Eighty-nine (9.7%) of the 915 HIV-seronegative women and 306 (11.8%) ofthe 2584 seropositive women did not have HPV DNA test results available andwere excluded from analysis. Comparisons were made between HPV carriagepatterns (defined below) of women who did or did not acknowledge cocaine use.μL of each cell digest was used in reactionscontaining 10 mM Tris-HCL, 50 mM KCL, 4 mM MgCl2, 200 μM of eachdeoxyribonucleotide triphosphate, 2.5 U Taq DNA polymerase, 0.5 μM of eachprimer. There were 40 amplification cycles . Amplified material was thendetected using filters individually hybridized with biotinylated type-specificoligonucleotide probes for multiple HPV types including HPV 6, 11, 16, 18, 26,31, 32, 33, 35, 39, 40, 45, 51, 52, 53, 54 (AE9), 55, 56, 58, 59, 61, 62, 66,67, 68, 69, 70, 71 (AE8), 72, 73 (PAP238A), 81 (AE7), 83(PAP291), 82v(AE2), 84 (PAP155), 85 (AE5), and 89 (AE6), asdescribed in [Thelaboratory technique for HPV assessments have been described in detailelsewhere . HPV DNA2, 73 PAP8A, 81  using the 1991 Bethesda System criteriafor cytologic diagnosis . All smeT-cellsubsets were determined by immunofluorescence using flow cytometry inlaboratories participating in the AIDS Clinical Trials Quality AssuranceProgram. Plasma HIV RNA levels weremeasured using a nucleic acid sequence-based amplification (NASBA) technique with a lower threshold of detection of 4000copies/ml .β-globingene—see Laboratory Methods). We defined “incidentdetection” of HPV as detection of an HPV type that was not found at baseline orat any other earlier visit in a given woman. The term “incident detection” isused instead of “incidence” to reflect the fact that it is impossible todistinguish newly acquired HPV infection and reactivation of previouslyacquired latent HPV infection in a population with many years of sexualactivity, regardless of the HIV status of that population. Persistence of HPVinfection was defined as the time to clearance of a specific HPV type, and wefurther distinguished in our analysis between the persistence of HPV detectedprevalently at baseline and those first detected incidentally at a subsequentvisit (see below). Clearance itself was defined as either a single negative ortwo negative type-specific HPV results at sequential visits. The findings weresimilar using either approach for defining clearance, and herein we present theresults of clearance using the former definition.Cocaineused in the last six months was examined both as a binary outcome (use/nouse), and as an ordinal variable (no use/less than once a month/once amonth—once a week/2–6 times a week/once a day ormore). Consistent with prior studies  the prevThebaseline characteristics of cocaine users and nonusers in this study wereexamined, and the distributions for selected parameters compared using standardPearson chi-square tests for categorical data, or by theCochran-Mantel-Haenszel tests when examining trends in ordinal data. Thesevariables were also evaluated as potential confounders in the multivariableanalyses described below.Theassociation of cocaine use with prevalent HPV DNA detection was measured in multivariate logistic regression models that incorporatedgeneralized estimating equations (GEE) to adjust the standard errors forrepeated measures , and assuming an independent correlation structure. In previous papers,we have shown that the results in this dataset are unaltered by using other possiblecorrelation structures , 27, andTreatmentof abnormal cervical cytology can introduce a bias into analysis of HPVinfection, since treatment can alter the underlying mucosa; either increasinginfection  or decreasing infection . Censoring women at the time of cervical treatment iscommonly employed to address this bias and was used in the analyses reportedherein. Adjusting for therapy is an alternate approach that was also used, butas the results were in the same direction and of similar magnitude to thosefound with censoring they are not presented. Other time-dependent covariates included in our multivariate models were CD4+ T-cell count, recent sexual behavior, smoking status, and age group.Ethnicity was adjusted as a time-independent variable.Coxproportional-hazard regression models  were usePrevalent SIL and its association with cocaine use was assessed using similarmultivariate logistic regression models incorporating GEE, as described above,to control repeatedobservations over time. The associations of cocaine use and incident detectionof SILs were assessed using multivariate Cox models.This analysis included data from 2584 HIV-seropositive and 915HIV-seronegative women. The median follow-up time among those recruited during1994-1995 was 10 years and for those recruited during 2002 was 3 years; a totalof 20 849 person years of observation among HIV-seropositive and 6385 among HIV-seronegative womenwere included in this analysis. At baseline 16.1% of participants reported useof crack within the prior 6 months, 11.5% had used cocaine, and 6.9% had usedboth. The prevalence of HPV in the cohort was34.4%. Although we initially analyzed the effects of cocaine use on HPVinfection separately from the effects of crack use, no significant (orotherwise notable) differences were observed (data not shown). Therefore, wecombined these data, and herein report a comparison of the prevalence,incidence and time to clearance of HPV among women who used either cocaine orcrack (crack/cocaine use) to that among women who used neither drug.Prevalent detection ofoncogenic HPV was significantly more common among women who reportedcrack/cocaine use during the prior 6 months , than woIncident detection ofoncogenic HPV was increased among crack/cocaine users, although therelationship did not reach significance at traditional values . Crack/cClearance of oncogenic HPV infection was not associated with crack/cocaine use during the prior 6 months . SimilarSimilar analyses wereperformed for alcohol and heroin use. No association was found between eitherdrugs  and any of the outcomes of interest .In this prospective study ofHIV-infected and HIV-uninfected women, we observed increased risk of oncogenicand nononcogenic HPV infection in those with crack/cocaine use but not in thosewith heroin or alcohol use, consistent with our a priori hypothesis. If correct, the data suggest that the immunologic effects of cocaine, previously reported primarily in animal models, may have relevance to humans.Shen and colleagues, evaluating amouse model in which cocaine was injected intraperitoneally found that allimmune parameters, other than lymphocyte transformation of thesplenic or the peripheral blood lymphocytes, were suppressed . OtheriThese data suggestthat response to HPV infection might be altered by cocaine. While HIV-infectedwomen are already at immunologic jeopardy and prone to numerous coinfections,the relationship between cocaine use and HPV, one of the most common sexuallytransmitted infections, has not, to our knowledge, been the focus of priorresearch. While we and others have considered drug use as a covariate in studies of HPV infections, those studieshave often not looked specifically at cocaine or crack, controlled for otherfactors, or used drug use as a primary focus of analysis . Our datThisstudy had several limitations. The finding of increased detection of HPV amongwomen acknowledging cocaine or crack use could reflect either an immunologicphenomenon or a behavioral one  despite ourefforts to controlthis in our analyses. However, we did not find a similar relationship betweenHPV and the use of other drugs that might also be markers of risk taking. Ourfailure to detect a consistent biologic gradient in cocaine's effect  suggests that caution must be exercised in interpretation of results and that further work is warranted toconfirm and potentially extend these findings.An additional limitation to this studyis our inability to provide biologic measures of drug exposure. We note,however, that the same study personnel performed repeated interviews over thecourse of the study and formed a close rapport with the WIHS participants.Further, we have previously observed a close correlation of acknowledged druguse and reliable surrogates . More importantly, it is most likely thatmisclassification would have been in the direction of understating the frequencyof drug use, which would most likely have biased our results toward thenull. A final concern is that, since wehave previously shown that HAART use can modify the course of HPV disease , it is pIn summary, our data suggestan association of crack/cocaine use with increased prevalence, incidence, anddelayed time to clearance of oncogenic HPV among HIV-infected women and womenat risk of HIV. These data lend support to animal studies suggesting a linkbetween cocaine use and predilection to infections and add to the litany ofreasons for making drug treatment a component of the care of HIV-infectedindividuals.


High-risk human papillomavirus testing or combined screening revealed a much higher sensitivity, at the cost of a small decrease in specificity, and a higher negative predictive value for the detection of lesions ⩾CIN3 till the next screening round (5 years) than cytology alone.We prospectively evaluated the 5-year predictive values of adding high-risk human papillomavirus (hrHPV) testing to cytology for the detection of ⩾cervical intraepithelial neoplasia (CIN)3 lesions in a population-based cohort of 2810 women. At baseline, nine (0.3%) women had prevalent lesions ⩾CIN3, all being hrHPV positive. After 5 years of follow-up, four (6.5%) of the 62 hrHPV-positive women with normal cytology developed lesions ⩾CIN3,  Cervical screening by cytology is known to yield a substantial proportion of both false-positive and false-negative smears. Since infection with high-risk human papillomavirus (hrHPV) is considered to be the cause of cervical carcinoma, it has been suggested that adding hrHPV testing to cervical screening might improve screening in terms of reducing false-positive and false-negative smears  was enrolled from March 1995 till October 1998 by 60 general practitioners in the small district of Amstelveen, The Netherlands. In all, 194 women were excluded because of abnormal cervical cytology and/or histology during 2 years preceding the intake, 159 women because of a negative Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of cytology, cytology and hrHPV testing combined, and hrHPV testing, for the detection of prevalent and incident lesions ⩾CIN3 were computed using two by two tables. Results are presented as percentages with 95% confidence intervals (95% CI). To determine whether any gain in test performance from the addition of the second test (hrHPV testing) was greater than that expected if the second test offered no diagnostic information, expected performance characteristics for cytology combined with a random test having the similar prevalence as hrHPV were computed .Of 2810 women for analysis at baseline, 2687 (95.6%) women had normal cytology, of whom 77 (2.9%) had a positive hrHPV test. Among 111 (4.0%) women with borderline or mild dyskaryosis (BMD), 16 (14.4%) women were hrHPV positive, as were 11 (91.7%) of 12 (0.4%) women with moderate dyskaryosis or worse (>BMD). Among the 123 (5.2%) women who had abnormal cytology, nine (7.3%) cases of prevalent lesions ⩾CIN3 were present (including three squamous cell carcinomas) , resultiThe median follow-up time until histological or cytological diagnoses was 4.6 years (range 0.1–8 years). The follow-up results of women with normal cytology at baseline are presented in vs 64.3%, respectively; P=0.065), but was less specific , and had an increased NPV  with a similar PPV . High-risk human papillomavirus testing alone was more sensitive than cytology alone , more specific , and had an increased NPV  and an increased PPV . Comparing the sensitivity and NPV of cytology and hrHPV combined screening to cytology with a random test, no different significance levels were revealed as when compared to cytology alone.The performance characteristics of cytology, cytology and hrHPV combined, and hrHPV testing, for the detection of lesions ⩾CIN3 are given in Combined screening revealed a much higher sensitivity, at the cost of a small decrease of specificity, and a higher NPV at the next screening interval (after 5 years) than cytology alone. Cytology alone had reasonable performance characteristics, but on adding hrHPV testing we can achieve much better performance characteristics in population-based screening.The overall detection rate by cytology of 0.3% lesions ⩾CIN3 at baseline and 0.5% after 5 years in this study is comparable to the detection rate of lesions ⩾CIN3 in cervical cancer screening in The Netherlands (P⩽0.05). This might be due to our relatively small population with a low prevalence of lesions ⩾CIN3, resulting in wide 95% CIs. However, with this low prevalence of lesions ⩾CIN3, still a borderline significance was reached (P⩽0.1). The increase in sensitivity by combined testing compared to cytology alone may be misleading because improvements in sensitivity would be expected by adding a second test, even if the second test performed randomly with respect to disease identification. For this reason, expected performance characteristics for cytology combined with a random test were computed to determine if any gain in test performance from the addition of the second test (hrHPV testing) was greater than that expected if the second test offered no diagnostic information (Our data are the first that were prospectively obtained in population-based screening, with a 5-years screening interval in women 30–60 years of age. Some methodological aspects of this study need to be discussed. The fact that histology was not obtained in all women might induce a verification bias in advantage of combined screening and hrHPV testing. However, women were followed according to current practice standards in nationwide screening with cytology after 5 years, and in this setting women with normal cytology are considered to be free of disease. As indicated by the overlapping 95% CIs, the gains in sensitivity and NPV by combined testing or hrHPV testing compared to cytology alone were not significant (ormation . By compCost-effectiveness studies and modelling studies show that cervical screening may become much more efficient in terms of decreasing numbers of false-negative and false-positive smears, if a test is used with a substantial higher sensitivity and long-term NPV than conventional cytology (The use of hrHPV testing in cervical screening could lead to several different screening strategies, including combined cytology and hrHPV testing, or primary screening by hrHPV with cytology reading only of women tested hrHPV positive. In addition, the high sensitivity and NPV of hrHPV testing opens possibilities for longer screening intervals with still acceptable rates of incipient lesions. Modelling studies and confirmation of our results in larger studies will help to clarify this discussion and to devise more efficient cervical screening strategies.


Basal cell carcinoma (BCC) is the most common skin cancer among Caucasians, and in most cases, occurs in the sun-exposed areas. In recent years, in addition to many other etiologies such as exposure to UV radiation, and occasionally xeroderma pigmentosa, burns, tattoos, and pox scars, human papillomavirus (HPV) is also considered to have an etiologic role. Different studies were conducted with varied results in this regard.We evaluate this plausible relationship between HPV and BCC by means of immunohistochemistry (IHC) staining method.This is an analytic cross-sectional study in which 160 samples were selected randomly consisting of 80 BCC lesions and 80 safe margins. Sampling was done among paraffin-embedded blocks in pathology ward of Kashani and Alzahra hospitals, Isfahan-Iran, from 2004-2007. A section of each block was IHC stained for HPV immunoreactivity . This was followed by microscopic evaluation in terms of being positive or negative.P > 0.05, power > 90%).Fifty seven point five percent of the samples belonged to men and the others to women. In 10%, HPV marker was positive, both in lesion and margin. In 83.8% neither the lesions nor the margins were immunoreactive for HPV. Only in 5 cases (6.3%) the lesion was positive and the margin was negative for this marker. There was no case of immunoreactivity for HPV marker in margins, while it was negative in lesions. Our study results followed by McNemar analysis did not show a significant relationship between BCC incidence and HPV existence. This was consistent in both genders (In this study we did not find a significant relationship between BCC and HPV, but based on review of articles it appears that large multicentric studies are to be conducted in this regard. Basal cell carcinoma (BCC), also known as rodent or mariner's ulcer, is the most common skin cancer among Caucasians and represents approximately 75% of all skin cancers.2 Mortali34BCCs are commonly subdivided according to their histological appearances. The major histological patterns include: nodular, morpheaform, and superficial types that have different disease outcome.The risk for BCC development is associated with environmental factors as well as several patient-dependant factors.2 BCCs ge1210101212Recently, it has been proven that there is an association between smoking and BCC in young women.Although infection with human papilloma viruses (HPVs) is a major risk factor for several epithelial cancers,–19 an et2020Several authors have suggested an association between infection with the oncogenic types of HPV and development of BCC.–27 The iIn this analytic cross-sectional study, 160 paraffin-embedded blocks, microscopically diagnosed as BCC by two expert dermatopathologists, and also their safe margins  were analyzed. Safe margin was defined as a part of perilesional skin that had no evidence of involvement by BCC. This group of samples was considered as control group. These samples were selected from patients admitted to pathology wards of Kashani and Alzahra hospitals (Isfahan-Iran), from 2004-2007.Blocks without sufficient information  or without a safe margin following surgery were excluded from our study. Sampling was done randomly in a simple way and then IHC staining was performed briefed as follows.Four-micron sections were prepared from paraffin blocks and were placed on poly-l-lysin slides. These slides were dried in an oven at 60°C for 60 min followed by deparaffinization and rehydration. At this stage antigen retrieval was performed by heating in Tris/EDTA buffer (pH 8) for 20 min in a microwave oven at 20% of power. Thereafter, the sections were incubated with HPV monoclonal antibody (1:50) for 20 min at room temperature. Neoplastic cells linked to antibody were visualized at the final step using the LSAB method  according to the manufacturers' instructions.Finally, the stained slides were evaluated microscopically by this study's administrators separately and the results were documented in terms of being immunoreactive (positive) or not for HPV marker. Immunoreactivity is defined as dark-brown staining of neoplastic cell nuclei.We used a paraffin-embedded block of a proven cervical intraepithelial neoplasia (CIN) as a positive control (recommended positive control for HPV marker) and analyzed our results with McNemar chi-square test by the use of SPSS software (version 12).P > 0.05, power > 90%).Fifty seven point five percent of the studied samples belonged to men and the other 42.5% were of women. The average age was 64.2 62.15-66.35) years. The most prevalent tumor locations, the mode groups, were face and nose . On the other hand, the least locations were eyelids and auricles (10 and 15% in sequence) . HPV pos5-66.35 yThe human papilloma viruses (HPV) are small viruses with double-stranded DNA that have a particular tropism for the epithelium inducing its proliferation, and can 31HPV can produce immortality in keratinocytes and most cervical carcinomas express high-risk E6 and E7 HPV proteins that neutralize cellular tumor suppressor function. In the c31et al., suggest that high-risk genital HPV types recently identified as significant risk factor for cervical cancer may also represent a risk factor for nonmelanoma skin cancer in a nonimmunosupressed population.[In general, the relationship between HPV and BCC (compared with those conducted about HPV and SCC) is not well studied. However, the role of HPV infection as a major factor in some epithelial cancers is substantiated,–19 but ipulation.et al., in their study suggest that HPV may play a role in the development of some chronic giant BCCs.[et al., support a role for HPV types from the genus beta in the pathogenesis of SCC, but not BCC.[Nortingthon ant BCCs. The find not BCC.Following the analysis of this study results, we observed that the difference between the lesion and the surgical margins in terms of being immunoreactive for HPV was not statistically significant. This difference was also analyzed for each gender, and again no significant difference was seen. Therefore, we thought HPV doesn't play a significant role in development of BCC.The study results did not find a significant relationship between HPV existence and BCC development. Such a correlation was neither found in women and men after separate assessments in the present study. But, different and occasionally contradictory results in different studies indicate that large multicentric study is needed for a definite conclusion.


P ≤ 0.05). This data demonstrates the therapeutic potential of PV VLPs in a well-understood animal model with potential important implications for human therapeutic vaccination for low-risk HPVs.There is overwhelming evidence that persistent infection with high-risk human papillomaviruses (HR-HPV) is the main risk factor for invasive cancer of the cervix. Due to this global public health burden, two prophylactic HPV L1 virus-like particles (VLP) vaccines have been developed. While these vaccines have demonstrated excellent type-specific prevention of infection by the homologous vaccine types (high and low risk HPV types), no data have been reported on the therapeutic effects in people already infected with the low-risk HPV type. In this study we explored whether regression of CRPV-induced papillomas could be achieved following immunisation of out-bred New Zealand White rabbits with CRPV VLPs. Rabbits immunised with CRPV VLPs had papillomas that were significantly smaller compared to the negative control rabbit group ( Papillomaviruses (PVs) are small, non-enveloped viruses containing a 8 kb double-stranded closed circular DNA genome, encoding six early proteins , two late proteins (L1 and L2) and a non-coding regulatory region, the long-control region (LCR) . The mosIn order to reduce the burden of HPV-induced infections, many studies have investigated the efficacy of different prophylactic and therapeutic vaccines in various animal models ,6. PreclThese animal studies have demonstrated that the expression of PV L1 genes in a number of cell systems results in the assembly of virus-like particles (VLPs), which elicit high titers of virus-neutralizing serum antibodies when administered as an immunogen ,12. As aHowever, while the current prophylactic vaccines would be effective in preventing type-specific infection it is not known whether these vaccines would afford protection to women who are already infected with the non-oncogenic HPV-associated disease. Recently, it was demonstrated that women with existing oncogenic HPV DNA infection did not benefit from HPV-16/18 L1 VLP vaccination . FurtherA successful therapeutic vaccine should elicit a strong cell-mediated immune response and induce lesion regression in HPV established infection with no recurrence . Indeed,Spodoptera frugiperda (Sf21) cells via recombinant baculovirus as previously described [Escherichia coli cells to generate bacmids which were then transfected into Sf21 cells (Invitrogen) according to the manufacturer's Bac-to-Bac protocol. The infected Sf21 cells were pelleted, resuspended in PBS containing 0.4 g/ml CsCl and complete protease inhibitor (Roche), and sonicated. The sonicated suspension was centrifuged at 100,000 g at 10°C for 24 h. Two distinct bands were observed on the CsCl gradient: the top band was extracted by puncturing the tubes and dialyzed against PBS  for 48 h. Dialyzed protein was divided into 100-l aliquots and frozen at 70°C for further use.The CRPV L1 VLPs were produced in escribed . EssentiDQ019612), cloned in BCG, was used and prepared as previously described and designated pControl [As a negative control, the rotavirus VP 6 gene, Edim  at 10-2 and 10-3 (2 sites per dilution for each rabbit) as previously described [7 cfu/ml, as a negative control. Each rabbit received 3 immunisations at 2 weekly intervals. Starting at week 7 post CRPV infection the papilloma sizes were measured as length × width × height in millimetres and the geometric mean diameter (GMD) was calculated for each papilloma every week. The mean GMDs and the standard error of mean (SEM) for each group was plotted against time for sites infected with 10-2 dilution of infectious CRPV. Data were compared using the unpaired non-parametric, Mann-Whitney U-test. Differences were considered significant at P ≤ 0.05.All animal procedures were approved by the Research Ethics Committee, Faculty of Health Sciences, University of Cape Town, South Africa. A total of nine out-bred New Zealand White rabbits  were infected with infectious CRPV (CRPVescribed . The rab-2 dilution of virus (two sites per rabbit) was plotted against time after immunisation with CRPV VLPs and pControl   for the 10The results produced in this study show that immunisation with CRPV L1 VLPs is able to elicit a significant therapeutic effect in rabbits with existing CRPV induced papillomas. This is a novel result, which at first sight has significant implications for therapeutic human vaccination, given the close correspondence of the animal model to human wart pathology. However, the literature is replete with studies that show that HPV L1 VLPs generate mainly humoral responses against type-specific HPVs, and they are only effective in prophylaxis without affording a therapeutic effect against oncogenic HPV-induced infections ,21.bystander effect [The rationale for this is that the HPV life-cycle is totally intraepithelial and the virus requires a differentiated squamous epithelium to complete its life cycle and produce infectious viral particles . Furtherr effect . Thus thr effect ,26.P ≤ 0.05) papilloma regression following vaccination with CRPV L1 VLPs compared to the control group which grew papillomas progressively. Thus, the results of this pilot study are surprisingly encouraging as it demonstrates for the first time in a controlled based robust animal model the therapeutic potential of the CRPV L1 VLP vaccines.Interestingly, the findings presented in the current study are in agreement with those mentioned above and we believe that the therapeutic effect afforded by CRPV L1 VLP is true. In deed, the CRPV VLP vaccine results presented here and the published commercial oncogenic HPV VLP vaccines have generated disparate results. One possible explanation for the differences observed in the CRPV model and the human trials is the route of immunisation, which could induce different immune pathways rendering different degrees of papilloma regression. Furthermore, the incidence of virus induction is dose dependant  and woulThe author(s) declare that they have no competing interests.VAG designed the study, carried out the study and drafted the manuscript. EPR provided the VLPs. A-LW participated in the coordination of the study. All authors read and approved the final manuscript.


In the HPV FOCAL trial, we will establish the efficacy of hr-HPV DNA testing as a stand-alone screening test followed by liquid based cytology (LBC) triage of hr-HPV-positive women compared to LBC followed by hr-HPV triage with ≥ CIN3 as the outcome.Control arm: LBC at entry and two years, and combined LBC and hr-HPV at four years among those with initial negative results and hr-HPV triage of ASCUS cases; Two Year Safety Check arm: hr-HPV at entry and LBC at two years in those with initial negative results with LBC triage of hr-HPV positives; Four Year Intervention Arm: hr-HPV at entry and combined hr-HPV and LBC at four years among those with initial negative results with LBC triage of hr-HPV positive casesHPV-FOCAL is a randomized, controlled, three-armed study over a four year period conducted in British Columbia. It will recruit 33,000 women aged 25-65 through the province's population based cervical cancer screening program. To date, 6150 participants have a completed sample and epidemiologic questionnaire. Of the 2019 women enrolled in the control arm, 1908 (94.5%) were cytology negative. Women aged 25-29 had the highest rates of HSIL (1.4%). In the safety arm 92.2% of women were hr-HPV negative, with the highest rate of hr-HPV positivity found in 25-29 year old women (23.5%). Similar results were obtained in the intervention arm HPV FOCAL is the first randomized trial in North America to examine hr-HPV testing as the primary screen for cervical cancer within a population-based cervical cancer screening program.International Standard Randomised Controlled Trial Number Register, ISRCTN79347302 Cervical cancer screening using cervical cytology (the Pap smear) has been an extremely successful public health intervention, achieving reductions in cervical cancer incidence of up to 80% where practiced effectively. Howeversingle primary screening test with cytology reserved only for the triage of women having a positive test, especially following the advent of HPV vaccination[There is now ample evidence that infection with high-risk types of the Human Papillomavirus (hr-HPV) is a requisite intermediate step for the development of cervical cancer and its precursors,5. On thccination,13. Thissensitivity (hr-HPV testing);• Screening would be undertaken with the test having higher • 85-90% of women would be returned immediately to routine screening with a negative hr-HPV test without incurring the cost of cytology, which would be reserved only for those with a positive hr-HPV;• The high-volume screening of samples would be undertaken with a non-subjective test that can be automated, while the subjective, labour-intensive test would be restricted to high-risk samples that could be examined with greater vigilance because of the reduced number to be interpreted;• It represents a more robust screening approach that could serve the additional purpose of post-vaccination surveillance in the population;• The recommended cervical cancer screening interval can be extended, as the long term risk of CIN3 or worse in women with a negative hr-HPV test is much lower than those who have a negative cytology, thus providing greater reassurance to women and also resulting in potential cost savings.To examine these concepts, several international large randomized controlled trials (RCT) are being conducted in Europe and in Canada to evaluate HPV testing as part of primary cervical cancer screening,14-21. WThis paper describes the design and preliminary screening results of the HPV FOCAL Trial. The primary objective of the HPV FOCAL trial is to establish the efficacy of hr-HPV testing followed by liquid based cytology (LBC) triage of hr-HPV-positive women compared to LBC followed by hr-HPV triage for cervical cancer screening with ≥ CIN3 as the outcome, through a comparison of the estimated decreases in cervical intraepithelial neoplasia (CIN 2/3) that can be achieved by each screening modality in successive screening rounds. The secondary objectives of this trial are to establish the appropriate screening interval for hr-HPV negative women, using the current standard of a 2-year recall interval for cytology negative women as the benchmark of acceptable risk in British Columbia; to establish the appropriate clinical follow-up for hr-HPV positive women; and to establish the cost-effectiveness of hr-HPV testing for primary screening, all within the context of a population based Canadian cervical cancer screening program. The results of this trial will demonstrate whether or not the use of hr-HPV testing as a single primary screening test within a population based cervical cancer screening program will be able to provide further reductions in the incidence of cervical cancer and its precursor lesions, allow the screening interval to be extended, and improve the cost-effectiveness of cervical cancer screening.HPV FOCAL is a three-armed, RCT over a four year period Figure .Control arm: LBC at entry and again at two years; ASCUS cases are triaged with hr-HPV testing; combined LBC and hr-HPV at four years (exit screen) among those with initial negative results.Two Year Safety Check arm: hr-HPV at entry; LBC at two years (exit screen) in those with initial negative hr-HPV results with LBC triage of hr-HPV positives at either round.Four Year Intervention Arm: hr-HPV at entry with LBC triage of hr-HPV positives; combined hr-HPV and LBC at four years (exit screen) among those with initial hr-HPV negative results.Since the 1960s, cervical cancer screening in British Columbia has been organized as a centrally administered program. A singlWomen aged 25 to 65, registered with Medical Services Plan in British Columbia, who receive care from a participating family physician (FP) for routine cervical screening are eligible. Exclusion criteria are: a history of histologically proven CIN2 or worse requiring treatment in the last five years; a history of histologically proven invasive cervical cancer; a Pap smear within the preceding twelve months; no cervix; pregnant at time of enrolment; HIV positive or on immunosuppressive treatments; or unwilling or unable to provide informed consent.Women are invited to participate in the study when they present for cervical cancer screening and are deemed eligible to participate by their FP or when pre-identified as being due for screening from the BCCA centralized provincial cytology database. For the pre-identified, the FP office sends the woman a study package that includes an invitation letter, a study information pamphlet and the informed consent form. The invitation letter requests women to phone their FP to make an appointment for their cervical screening test and also provides them with the opportunity to contact, or be contacted by study staff to learn more about the trial and decide on participation. All participants are consented by their FP and are asked to complete an epidemiologic questionnaire. A financial implications questionnaire is also completed by a random sample of participants. Full cervical cancer screening history is available through data linkage to the cervical cancer screening program, and HPV vaccination status is self reported.In addition to the control arm and the intervention arm, a 'two year safety-check' arm is included in this trial. At the time of the trial design, there were ethical concerns identified in changing the screening interval at the same time as changing the primary screening tool in a clinical trial. To that end, we included a safety check arm, to examine the safety of hr-HPV testing within the usual screening interval. This information will be used by the data safety monitoring board to verify the safety of hr-HPV testing at the two year interval and infer the suitability of the intervention arm as the trial proceeds.® Broom-like collection device and is placed in a ThinPrep® PreservCyt vial  and is used for all the HPV FOCAL trial testing. Specimen 2 is collected in Digene STM®  and is frozen for future use. Both specimens are sent to the central laboratory in Vancouver, for trial testing (specimen 1) and for storage (specimen 2). Upon sample receipt, the woman is randomized to one of the three study arms and specimen 1 is aliquoted  is collected first with the ThinPrepn system .If the woman's test results indicate that a colposcopy referral is recommended Figure , this wiWomen referred for colposcopy fall into the following major groupings:a) Cytology: AGC (hr-HPV positive or not done);b) Cytology: ASC-H or ≥ LSIL (hr-HPV positive or not done);c) Cytology: ASC-US; .Women are managed according to the standard provincial guidelines in the province of British Columbia. ColposcPathological interpretation of biopsies is conducted at two centres which provide services to the participating colposcopy clinics. Pathologists are blinded to cytology and hr-HPV result when interpreting the slides. Histology results are stored in the same Laboratory Information System (LIS) as the cytology results.Following standard practice, if there is significant discordance between the cytologic and histologic evaluation which would potentially influence patient management, the colposcopist contacts the laboratory to request review and correlation of the histology and cytology in order to resolve the discrepancy  and determine an appropriate disease management strategy.A review of exit screen histology is an essential component of the trial. Approximately 50% of exit screen histology results will undergo second review by senior study pathologists. If the primary and review histology results agree, this will be the final study diagnosis, but in the case of disagreement between primary and review histology, the slide will be referred to another senior pathologist. If this result agrees with either the primary result or first review the agreed results will be the final study diagnosis. If all 3 results are different, the final study diagnosis will be established by consensus between all three pathologists.A database has been developed specifically for the HPV FOCAL trial. Randomization occurs through this database when samples are received at the laboratory. At the time of randomization a Study Identification Number (SIN) is allocated to the participant. Samples are stratified by age and simple equal (1/3 probability) random allocation occurs at the laboratory. Upon randomization, study staff label and batch the specimens for initial processing (hr-HPV or LBC).FPs and participants are blinded to study arm allocation. Participant results are communicated from the BCCA to the FP office as soon as they are known. If the participant's initial screening results (hr-HPV or cytology) are "negative" the report states "within normal limits". The report also states that the recommended follow-up for that participant will be communicated to the FP in two years' time. This ensures blinding is maintained for as long as possible and prevents any bias that may potentially occur from knowledge of negative results. If the screening results are hr-HPV and/or cytology positive, the results are communicated from the BCCA to the FP along with the recommended follow-up.The planned intake sample size is 11,000 women per arm . Power calculations were performed using the nQuery Advisor, version 2, software package. Rates of hr-HPV infection and associated histologically proven disease were based on results from the HART study, prevale• Control and intervention arms: Cumulative incident ≥ CIN3 detected up to and including four years in both the control arm and the intervention arm• Control and safety check arms: Incident ≥ CIN2 detected at two years. If the number of ≥ CIN2 in the safety-check group exceeds 0.8 times that in the control arm at the 2 year screen, then the trial will conclude and women in the four year intervention arm will be recalled at two years for their exit screen.• Rates of ≥ CIN2 and hr-HPV respectively at initial screen in control and safety/intervention arms;• Rates of incident ≥ CIN2 at two years in control arm and at four years in intervention arm;• The total estimated cost per woman screened and the total estimated cost per quality-adjusted life-year gained for each technology;• Clearance of hr-HPV infection in women who are hr-HPV-positive and cytology negative at initial screen.The primary outcome analysis will be a comparison of histologically confirmed ≥ CIN3 between the intervention and control arms. Rates of lesion occurrence will be calculated using person-time denominators for the different study intervals and compared via Kaplan-Meier plots. Rates whttp://www.nserc-crsng.gc.ca/NSERC-CRSNG/governance-gouvernance/ethics-ethiques_eng.asp. Ethics approval has been obtained from appropriate local research ethics boards. The trial registration number is International Standard Randomised Controlled Trial Number Register: ISRCTN79347302. All information about this trial is kept behind locked doors or in secure computer files. On interim and final reports, all data will be de-identified.This study is being conducted in accordance with the Ethical Conduct for Research Involving Humans Tri-Council Policy Statement Recruitment for trial participants commenced in December 21, 2007 through 147 FP offices. As of December 31, 2009, 37,347 women were identified as potentially eligible through the Cervical Cancer Screening Program database. Of the above identified, 28,525 women were sent invitation letters from their family physicians to participate in this study, 613 were ineligible and 2995 declined participation (data on non responders not available). 9842 women were enrolled in the trial through 147 FP clinics from Vancouver Island and Metro Vancouver and 6150 had completed both the epidemiology questionnaire (Epi-Q) and had a preliminary study specimen result. Data will be presented on women who had both a study specimen result and completed Epi-Q.Participant age ranged from 25 to 65 years, with a median age of 45 Table . As partOf the 2019 women enrolled in the control arm, 1908 94.5%) were cytology negative. Sixteen women (0.8%) had high grade squamous intraepithelial lesions (HSIL) on their cytology evaluations, and women aged 25-29 had the highest rates of HSIL (1.4%) Table . In the .5% were The HPV FOCAL study is the first RCT to examine hr-HPV testing followed by LBC triage compared to LBC followed by hr-HPV triage as the primary screen for cervical cancer within the context of a population based cervical cancer screening program in North America. This study will provide generalizable evidence to inform policy decisions concerning cervical cancer screening internationally, particularly in settings where LBC has already been adopted or is under consideration. Participants are women who are part of a long established cervical cancer screening program and represent a population based cohort of women at average risk for cervical cancer in North America. Study characteristics for the first 6,000 participants were well balanced across the three trial arms. In each arm of the trial, over 90% of women were negative on their screening examination, with the majority of abnormalities found in women in under the age of 35.Important design elements in HPV FOCAL include the use of LBC  as opposed to conventional cytology; the use of FPs as study collaborators to recruit participants; blinded analysis of cytology and pathology results with respect to hr-HPV status; use of a single laboratory for cytology analysis; inclusion of a two year safety arm and standardized colposcopy protocols. The use of LBC is of particular relevance because of the ability to use the sample for reflex testing. LBC, which involves taking a sample and placing it into a vial with liquid, and then producing a slide for examination from a suspension of the cells has been compared to conventional cytology in many studies. StudiesFindings from this preliminary analysis contribute to available literature on the prevalence of HPV in Canadian women. In this study of women recruited from a population based screening program, eight percent were positive for hr-HPV, with the highest prevalence rates being found in women aged 25-29. In the first Canadian study comparing Pap screening with hr-HPV screening, women aged 30-69 from Newfoundland and Quebec presenting for routine cervical cancer screening found to have an hr-HPV prevalence of 6.1% overall,19,25. IIn a recent joint analysis of several European cohort studies and clinical trials, Dillner found that hr-HPV results had a high negative predictive value (99%), with women who were negative for hr-HPV having a very low risk of development of ≥ CIN3 in the next six years. This stData from ongoing randomized trials comparing primary screening for cervical cancer with HPV and cytology have found that HPV-based screening offers improved sensitivity for high grade CIN lesions, but with a commensurate loss in specificity. In Dillner's review, he note* ELF has served as occasional consultant to biotechnology companies involved with cervical cytology  and HPV testing .GSO, DVN, MK, REM, TGE, LK, SP, GCES, ELF and AJC all contributed to the conception, design and secured funding for the study. DVN, MK, KC, LK, DAC, WM lead and carried out cytology and molecular studies in the laboratory. GSO, MK, REM, LS, LK, ELF and AJC developed and conducted the epidemiological and statistical analysis. GSO, MK, REM, TGE, LS, WM, DAC, ELF and AJC drafted the preliminary manuscript. DVN, LK, GCES, KC, SP made substantive revisions to the preliminary version. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/10/111/prepub


P=0.20). Detection of AGUS during cervical cytologic screening, especially with a coexisting ASCUS, indicates the existence of serious pathologic processes; management by cervical colposcopy, endocervical curettage, and cervical biopsy is recommended.The adjusted incidence of cervical carcinoma among Israeli Jewish women is ∼5 out of 100 000. This retrospective study sought to determine the clinical implications of finding atypical glandular cells of undetermined significance (AGUS) in cervical cytologic specimens in this population. Cervical cytologic examinations during January 2001–June 2003 diagnosed as AGUS were identified by a computerised database. Medical records were reviewed to determine the presence or absence of associated significant pathologic conditions of the cervix and identified 45 out of 11 800 patients (0.38%) with AGUS. AGUS was the only cytologic diagnosis in 14 patients, while 31 patients had both AGUS and an additional atypical squamous cell of undetermined significance (ASCUS). All subjects underwent colposcopy, endocervical curettage, and cervical biopsy. A clinically significant diagnosis  II, CIN III, or carcinoma) was made in 24 patients (53.3%), including cancer in three (6.7%): one had microinvasive adenocarcinoma and two had microinvasive squamous cell carcinoma. Squamous carcinoma coexisting with a clinically significant lesion carried a risk of 61.3%, compared with a risk of 35.7% for AGUS alone ( Israeli Jewish women are at low risk for cancer of the uterine cervix (The Bethesda System for cytologic reporting of Papanicolaou (Pap) smears was originally developed in 1988 (revised in 1991) in order to provide a standardised method of reporting cytologic findings for facilitating peer review and quality assurance. The 2001 version of the Bethesda System reflects the most current knowledge about the biology of Pap test abnormalities  was reserved for atypical cells in which a squamous origin was suspected.In contrast to both preinvasive and neoplastic squamous lesions of the cervix, where the evaluation and treatment are usually straightforward, glandular lesions of the cervix are diagnostically and therapeutically more challenging to the cytopathologist and clinician because of their relative rarity, the relative absence of colposcopic findings, irregular shedding, small size, endocervical location (making lesions less amenable to cytologic sampling), and broader differential diagnosis .The classification of glandular abnormalities was significantly revised in the 2001 Bethesda System, reflecting a reappraisal of the strengths and weaknesses of cytology in assessing these findings. According to that system, glandular cell abnormalities are classified as ‘atypical endocervical, endometrial, or glandular cells.’ In most cases, the morphological features of the condition enable differentiating between atypical endometrial and endocervical cells . The manThis study was conducted over a period of 2 years and 6 months (from January 2001 to June 2003). During this period, 11 800 patients were examined by the Colposcopic Unit of the Balfour-Maccabi Women's Healthcare Center . This unit is a public facility and is subsidised by the national governmental health insurance scheme. Two senior gynecologists who are specialists in cervical medicine performed the colposcopies (RB and ES).Of these 11 800 samples, 45 (0.38%) Pap smears showed AGUS and comprised our study data. These 45 women were examined by colposcopic examination, colposcopic-directed biopsy, cone biopsy, and/or endocervical curettage.The medical records of all AGUS patients were reviewed and the retrieved data consisted of the woman's age, gravidity, parity, menopausal status, as well as any history of abnormal bleeding, smoking, use of oral contraceptives, intrauterine devices, replacement of hormones, prior abnormal Pap smear, or previous cancer. In addition, the results of the clinical evaluation of their AGUS smear were collected, including the findings of the physical examination, colposcopy, cytology, and biopsy results. Cervical biopsies were classified according to the modified Richart classification system for cervical intraepithelial neoplasia (CIN), where lesions consistent with flat condyloma and CIN I are referred to as ‘low-grade CIN’ and lesions consistent with CIN II or CIN III are grouped together as ‘high-grade CIN’ . The AGUThere were 45 patients (mean age 41.3 years) in the study cohort. The smears of 14 of them (31%) were reported as due to AGUS alone and 31 (69%) smears had coexistent squamous pathology. Seven (16%) patients had a recent history of abnormal vaginal or postcoital bleeding. Four patients had a history of nongynecologic cancer: three had breast cancer and one had carcinoma of the rectum. One of the patients was pregnant at the time of her AGUS cytology finding.All 45 patients were colposcoped and biopsied shortly after AGUS was confirmed: 16 women (36%) underwent colposcopy with cervical biopsies, 29 (64%) underwent colposcopy with cervical biopsies and endocervical curettage, and 25 (55%) of the women who underwent cervical biopsies required diagnostic conisation during their workup. Since our protocol dictates that women with AGUS and without clear external lesions undergo endocervical curettage, the 16 women who had clear external lesions did not undergo this procedure.P>0.05). Only one of the 45 patients with AGUS was found to have adenocarcinoma of the cervix.In total, 14 (31%) of the study patients were postmenopausal, and our results indicated that both premenopausal and postmenopausal patients were at risk for clinically significant lesions. Moreover, there was no difference between pre- and postmenopausal women in terms of pathology. Even so, endometrial biopsy is recommended in postmenopausal women with Pap-diagnosed AGUS who do not have an external lesion on cervical or endocervical biopsy. All of our postmenopausal study women had significant cervical lesions and did not require endometrial biopsy.The optimal clinical evaluation of the diagnosis of AGUS by the Pap test has yet to be determined. Therefore, the clinician is faced with uncertainty as to the aggressiveness of the abnormal cells and the proper sequence of clinical evaluation. Some physicians choose a conservative approach to AGUS and treat it much like ASCUS, with repeated cytologic examination alone, whereas others take a more comprehensive approach, performing colposcopy and biopsy of the endocervix.The diagnosis of AGUS is made in routine clinical practice in 0.13–2.5% of the smears; most rates quoted in the literature are less than 1%  of all women with an AGUS smear is warranted. An endometrial biopsy is warranted in the absence of persistent AGUS in the cervical findings from the biopsy (We found significant squamous lesions in 51% of the AGUS smears and only 2.2% glandular lesions. The possible explanation for the relative absence of glandular pathology is the fact that the cells were so badly deformed that they appeared to be glandular to the cytopathologist but were actually squamous in origin.Finally, the results of this study strongly support that the presence of AGUS cells upon a routine cytologic specimen examination indicates the existence of a pathologic condition that mandates appropriate management.


We bring you a report from the CSHL Genome Sequencing and Biology Meeting, whichhas a long and prestigious history. This year there were sessions on large-scale sequencingand analysis, polymorphisms , comparative genomics of mammalian and model organism genomes, functionalgenomics and bioinformatics.


Cervical cancer, a potentially preventable disease, remains the second most common malignancy in women worldwide. Human papillomavirus (HPV) is the single most important etiological agent in cervical cancer, contributing to neoplastic progression through the action of viral oncoproteins, mainly E6 and E7. Cervical screening programs using Pap smear testing have dramatically improved cervical cancer incidence and reduced deaths, but cervical cancer still remains a global health burden. The biomarker discovery for accurate detection and diagnosis of cervical carcinoma and its malignant precursors  represents one of the current challenges in clinical medicine and cytopathology. Worldwide, cervical cancer is the second most common cancer in women; and is estimated to cause over 470,000 new cases and 233,000 deaths each year. Based on strong epidemiological evidence, supported by basic experimental findings, there is no doubt that persistent infections with high-risk types of human papillomavirus (HPV) represent a necessary cause of cervical cancer . HPVs inin situ; CIS) and a few of them will develop invasive cancer unless the precancerous lesions are detected and treated with such cases having been found to carry the oncogenic HPVs (e.g. types 16 and 18) that cause cervical cancer.Although HPV infection is widespread, few people even know they are infected as the symptoms are seldom noticeable. It is even less well known is that nearly all cervical cancers (99.7%) are directly linked to previous infection with one or more of the oncogenic types of HPV . It is eThe HPV genome consists of 8 kb, and is a double-stranded DNA molecule. The relative arrangement of the 8–10 open reading frames (ORFs) within the genome is the same in all papillomavirus types, and a particular characteristic of papilloma viruses is that the partly overlapping ORFs are arranged on only one DNA strand. The genome can be divided into three regions: the long control region (LCR) without coding potential; the region of early proteins (E1–E8); and the region of late proteins (L1 and L2) . E6 and E7 are the most important oncogenic proteins. These proteins have pleiotropic functions, such as transmembrane signaling, regulation of the cell cycle, transformation of established cell lines, immortalization of primary cell line and regulation of chromosomal stability. Both E6 and E7 proteins can bind to multiple cellular targets. The interactions that are thought to be most relevant for their transforming functions are E6 binding, via the cellular protein E6-AP, to the tumor suppressor gene product p53, and E7 binding to the retinoblastoma tumor suppressor gene product pRb and its related pocket proteins, p107 and p130 . The firHPV infection causes changes in expression of host cervical cell cycle regulatory proteins. Such differentially expressed host proteins and nucleic acids may have a role as ‘biomarker’ of dysplastic cells. Investigation of potential biomarkers may also help to unravel new pathways involved in the HPV-mediated pathogenesis of cervical dyskaryosis.For more than 50 years the Pap smear has been the mainstay of cervical screening resulting in a dramatic decrease in death from cervical cancer. However, the Pap smear has certain disadvantages . It has Presently, new technologies such as liquid-based cytology, HPV DNA test have been introduced. This test is used to detect the HPVs, which is considered the primary cause of virtually all cervical cancers. There are at least 30 different types of HPV strains that target the genital area, and are transmitted through sexual, skin-to-skin contact. Of these, approximately 13 are considered to be ‘high risk’ because they can trigger the development of abnormal cells associated with cervical cancer. The remaining ‘low-risk’ types can cause genital warts. Although the Pap smear can pick up the cellular changes caused by high-risk types of HPV, it’s not as sensitive as the HPV test, which specifically detects the viral DNA. The HPV test is not yet routinely used by the majority of doctors, in part because it is more expensive than a regular Pap test. Therefore, it would be important to improve the cost-effectiveness of screening and reduce the psychologic burden of benign positive test results.O-methylguanine-DNA methyltransferase (MGMT)    .Cip1 (kip1 (Drosophila tumor suppressor protein Tid56 (hTid-1)  , interfe(hTid-1) , Smad pr(hTid-1) , insulin(hTid-1)  and hist(hTid-1)   .DNA replication occurs only once in a single normal cell cycle, due to a mechanism known as ‘licensing’ of DNA replication. This process requires the assembly of a protein complex which includes the mini chromosome maintenance (MCM) proteins and the cell division cycle protein 6 (CDC6) . DisasseIn normal cervical epithelium, MCM protein staining is limited to the basal proliferating layer and is absent in differentiated and quiescent cells. In cervical glandular and squamous dysplasia, however, MCM expression is dramatically increased, suggesting its potential as a biomarker of cervical dysplasia . MCM5 haBoth MCM5 and CDC6 play essential roles in the regulation of eukaryotic DNA replication. CDC6 was first identified in 1998 as a marker of cervical dysplastic cells in cervical biopsies and in smears using polyclonal antibodies. Not only MCM5 but also CDC6 protein expression are present in proliferating cells and absent in differentiated or quiescent cells. In normal cervical epithelium, CDC6 staining is absent or limited to the basal proliferative layer. However, CDC6 protein expression is dramatically up-regulated in squamous and glandular cervical carcinomas. Several studies have illustrated a linear increase in CDC6 expression observed in normal cervix, preinvasive neoplasia and invasive cervical carcinoma. CDC6 was preferentially expressed in areas exhibiting histological HPV changes. Interestingly, the expression pattern of CDC6 closely mirrors that of the high-risk HPV E6 oncoprotein, which is mainly expressed in higher grade lesions and invasive carcinomas .INK4A is a tumor supressor gene and a key regulator of the cell cycle. The expression pattern of p16INK4A in dysplastic squamous and glandular cervical cells in tissue sections and in cervical smears has been extensively investigated  lesions do not show any detectable expression of p16INK4A. While p16INK4A identified dysplastic squamous and glandular lesions with a sensitivity rate of 99.9% and a specificity rate of 100% in cervical biopsy sections, only a few studies have examined the possible prognostic value of p16INK4A in cervical lesions , which is expressed during the G1 and early S phases of the proliferative cycle, and Ki-67, which is expressed during the G2 and mitotic phases of the cycle. Ki-67 is the more reliable indicator of the growth fraction of a tumor, largely because PCNA has a long half-life and may still be demonstrable in post-mitotic cells . The stuAlthough few new markers have reached the clinic in recent years, several reported cancer biomarkers have been found to have low sensitivity in that they are found only in a small subset of patients with a particular type of cancer.The future of clinical cancer management belongs to the prognostic and predictive biomarkers of cancer. These markers are of utmost importance as they will be the used to make clinical decisions that will eventually save lives. In the future, biomarkers will guide decision making during cancer management. Biomarkers that correctly predict outcome in a specific disease and allow physicians and patients to make informed treatment decisions need to be developed. Biomarkers will not only help screen, detect, diagnose, help in prognostic evaluation, monitor treatment and predict recurrence, but also play a major role in clinical decision making.Concern remains as to whether the tools available are well suited to provide the technological support to meet the demands of new biomarker development. Until recently, the discovery of cancer biomarkers has been a slow approach to identify proteins that are dysregulated as a consequence of the disease and shed into the body fluids such as serum, urine or saliva. Unfortunately, this approach is arduous and prolonged as each candidate markers must be identified among thousands of proteins. The recent advancements in genomic and proteomic technologies including gene array technology, serial analysis of gene expression (SAGE) improved 2-DE and new mass spectrometric techniques coupled with advancements in bioinformatic tools, shows great promise of meeting the demand for the discovery of a variety of new biomarkers that are both sensitive and specific . Like th


HPV18 was more prevalent in SCC than CIN2/3 . Other high-risk types prevalences corresponded in CIN2/3 and SCC. Evaluations using CIN2/3 as a measure of efficiency underestimate the contribution of HPV18 to SCC.In one geographical area, 14 high-risk human papillomavirus types in cervical intraepithelial neoplasia (CIN2/3;  Human papillomavirus (HPV) infections are the cause of cervical cancer and its precursors lesions  as intermediate end point of cervical cancer. This may lead to underestimation or overestimation of the contribution of certain HPV types in case the HPV type distribution between CIN2/3 and cervical cancer differs. Indeed, several studies suggest that HPV18 is underrepresented in CIN2/3 compared to SCC  diagnosed after screening between 1996 and 2000, and 90 specimens of SCC from the period 1981 to 1998. The department of pathology serves the population of the Walcheren peninsula, where follow-up of screened women is approximately 90% complete. All histological samples were collected retrospectively and were subjected to revision. The Medical Ethics Committee of VU University Medical Center approved the study (2001/179).β-globin gene was performed to test the integrity of DNA  and 95% confidence intervals (95% CIs). Statistical significance was tested by Cochran's Mantel-Haenszel test. Data were stratified by age  and whether infections were single or multiple. The presence of an association between ORMH and age was tested by Breslow–Day's test of homogeneity. Analyses were repeated for women with single infections only.Differences in prevalence of hrHPV types for CIN2/3 compared to SCC were examined using the Mantel-Haenszel common odds ratio  was 37 years (range 26–57 years). Women with SCC (n=84) had a mean age of 49 years (range 27–88 years). The mean age of women with SCC was higher than the mean age of women with CIN2/3 (P<0.001). Multiple HPV infections were present in 9.4% (13 out of 139) of CIN2/3, and in 10.8% (9 out of 83) of SCC (P=0.719).The mean age of women with CIN2/3 . The prevalence of HPV18 was significantly higher in SCC than in CIN2/3 . The other high-risk HPV types were not associated with increased risks individually, but when all hrHPV-positive infections without HPV16 and HPV18 were analysed as one group, the result was significant . For none of the HPV types OR varied with age (data not shown). Results for single infections were comparable.Women having SCC carried HPV16 more often than women with CIN2/3, although the estimated ORP=0.035).Even when assuming that the odds to detect an HPV18-associated SCC compared to an HPV18-associated CIN2/3 differed by a factor 2, HPV18 would still be increased in SCC compared to CIN2/3 . To calculate approximately how robust this finding is against underdetection of HPV18-associated lesions by cytology in a cervical screening programme (The increased prevalence of HPV18 in cervical cancer compared to CIN2/3 as found in our study is in agreement with a recent meta-analysis and data from Australia, South Africa and the US (In conclusion, HPV18 prevalence is high in invasive SCC compared to CIN2/3 lesions. Thus, when CIN2/3 is used as intermediate end point for cervical cancer, the contribution of HPV18 to the development of invasive SCC is underestimated. As the vast majority of both SCC and adenocarcinomas is attributable to HPV16 and HPV18, women with screen-detected HPV16 and HPV18 infections should be offered more intensive follow-up schemes compared to women infected with other high-risk HPV types.


However, this finding is contradicted by several observers. In the present investigation, 111 cases of adenocarcinoma of the cervix collected through the Swedish Cancer Registry and 188 controls  were analysed with regard to p53, codon 72, polymorphism using a PCR- and SSCP-based technique. In the controls, 9% showed pro/pro, 44% pro/arg and 47% arg/arg, whereas in the invasive adenocarcinomas, the corresponding figures were 0%, 29% and 71%, respectively. The difference was statistically significant (P = 0.001). HPV DNA was identified in 86 tumours  and 25 tumours were HPV negative. The p53, codon 72, genotypes observed in HPV-positive and HPV-negative cervical adenocarcinomas were not statistically different (P = 0.690). The results indicate that women homozygotic for arg/arg in codon 72 of the p53 gene are at an increased risk for the development of cervical adenocarcinomas. However, this genetic disposition seems to be unrelated to the HPV infection. © 2001 Cancer Research Campaign  http://www.bjcancer.comInfection with the human papillomavirus is an important co-factor in the development of cervical carcinomas. Accordingly, HPV DNA is recognised in most of these tumours. Polymorphism of the


The implementation of highly active antiretroviral therapy (HAART) among HIV-positive patients results in immune reconstitution, slower progression of HIV disease, and a decrease in the occurrence of opportunistic infections. However, the impact of HAART on cervical human papillomavirus (HPV) infection, clearance, and persistence in high-risk adolescents remains controversial.HIV-positive and high-risk HIV-negative female adolescents were enrolled in the Reaching for Excellence in Adolescent Care and Health (REACH) longitudinal cohort study. At each semi-annual clinical visit, cervical lavage samples were tested for 30 HPV types. Type-specific and carcinogenic risk-specific HPV prevalence and incidence were compared in 373 eligible participants: 146 HIV-negative female adolescents with a median follow-up of 721.5 [IQR: 483-1301] days and 227 HIV-positive female adolescents. Of the 227 HIV-positive participants, a fixed set (n = 100) were examined both before and after HAART initiation; 70 were examined only before HAART initiation; and 57 were examined only after HAART initiation, with overall median follow-up of 271 [IQR: 86.5-473] and 427.25 [IQR: 200-871] days respectively for before and after HAART initiation.+ change within the short post-HAART follow-up period.Of the 373 eligible participants, 262 (70%) were infected with at least one type of HPV at baseline, and 78 of the remaining 111 (70%) became infected with at least one type of HPV by the end of the study. Overall, the incidence and prevalence of HPV types 58, 53/66, 68/70, and 31/33/35 were much higher than the established carcinogenic and HPV vaccine types 16 and 18, especially in HIV-positive females both before and after HAART initiation. Baseline prevalence for individual high-risk HPV types ranged, depending on type, from 0.7-10%, 1-17%, and 1-18% in the HIV-negative group, the HIV-positive before HAART initiation group, and the HIV-positive after HAART initiation group, respectively. Likewise, the incidence ranged, depending on HPV type, from 0.64-9.83 cases/100 PY, 3.00-12.80 cases/100 PY, and 1.49-17.05 cases/100 PY in the three groups, respectively. The patterns of each HPV type infection, clearance, and persistence did not differ considerably before or after the introduction of HAART and were clearly independent of CD4HAART did not immediately affect the incidence of type-specific HPV infections within a short-period follow-up; however, future studies are warranted in larger populations to evaluate HAART's impact over longer periods. Human papillomavirus (HPV) infection is the most prevalent sexually transmitted infection (STI) in the United States (U.S.) and the world ,2. In th+ T-cell (CD4+) counts <200 (cells/mm3) [+ count [+ counts, compared to HIV-negative individuals [+ is important in the pathogenesis of HPV infection in HIV patients.HIV-negative females effectively clear cervical HPV infections 4-10 times more frequently than HIV-positive females, with the lowest rate of clearance among severely immunocompromised females with CD4lls/mm3) -15. A pr[+ count . Likewisividuals ,17,18. T+ count and cervical cancer incidence was observed in either period in the same study [The cervical cancer incidence among HIV-infected females in the U.S. is higher  since the introduction of HAART 1996-2002) than it was in 1990-1996 , although the difference is not statistically significant  [96-2002 t+ T-cells and the decrease in HIV viral load through HAART therapy, immune reconstitution as a result of HAART may be associated with the clearance of HPV infection. In this report, the immediate effect of HAART on the incidence, persistence, and clearance of type-specific HPV among HIV-positive female adolescents is examined.Studies of the impact of HAART on the natural history of HPV infection and HPV-related diseases, however, are limited and inconsistent . While s+ counts, and collection of biological specimens along with demographic, risk behavior, and other clinical data for this cohort have been previously described in detail [+ ≥200 at baseline), and two sero-converted and were excluded from the study. We included follow-up data from all HIV-negative and HIV-positive female adolescents off HAART (HAART-naïve throughout the study or until initiation) and follow-up data from all HIV-positive female adolescents initiating HAART during the REACH study.Participants in this analysis were HIV-positive and HIV-negative female adolescents enrolled in the Reaching for Excellence in Adolescent Care and Health (REACH) study. The study design and methods for quarterly follow-up, HIV-1 testing, immunophenotyping of CD4n detail ,32. Brien detail . Of the For the case-crossover sub-study, we included only HIV-positive female adolescents who were HAART-naïve at enrollment but initiated HAART during the course of the study, providing adequate follow-up periods before and after the introduction of HAART (referred to as before HAART initiation and after HAART initiation). This allows for internal controlling of potential confounders. Therefore, those who self-reported previous initiation of HAART or had chart documentation of HAART initiation prior to enrolling in the REACH cohort, as well as those who did not initiate HAART during the study, were excluded from this sub-study sensitivity analysis. All the participants provided written informed consent in the parent study, and the UAB Institutional Review Board approved this sub-study.Participants who were prescribed HAART, consistent with the Public Health Service Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents , were inAt enrollment and every six months thereafter, cervical lavage samples were tested for the presence of HPV. In brief, viral DNA fragments from the samples were amplified by use of consensus primers MY09/11 and HMB01 and hybridized with a consensus probe and 30 different HPV strain-specific probes  by use of a chemiluminescent dot-blot format . PCR-basThe before HAART initiation follow-up duration was estimated from the date of enrollment to the last visit before starting HAART. After HAART initiation follow-up included the time from the start date of HAART to either the end of the REACH study, the last visit before HAART was stopped, the visit at which the patient self-reported not adhering to HAART, or when the patient was lost to follow-up--whichever was applicable.Baseline prevalence and incidence of type-specific HPV infections were estimated and compared among different groups within the REACH cohort: 1) before HAART initiation period only; 2) after HAART initiation period only; 3) HIV-negatives; and 4) a case-crossover subset with both before and after HAART initiation periods. Cumulative prevalence was defined as the percent of female adolescents with an HPV infection detected at either the baseline or at one of the follow-up visits. The type-specific HPV incidence per 100 PY, along with 95% confidence intervals (95% CI), were estimated before and after HAART initiation, and statistical differences were reported with p-values using chi-square tests. To contribute person-time to the before HAART initiation incidence analyses, participants were required to be HPV-negative for a specific HPV strain at baseline, and for after HAART initiation incidence analyses, participants had to be HPV-negative for a specific HPV strain from the before HAART initiation period until the start of HAART. Since exact infection dates are not known, the midpoint between the last HPV-negative visit and the first HPV-positive visit date was used as the estimated infection incident date for calculation of person-time at risk. Time elapsed following the HPV incidence date was not included in estimates of person-time at risk. However, for participants testing negative for a specific HPV type during the before and after HAART initiation periods, person-time was estimated from the beginning through the end of the study in the two periods, respectively. Participants co-infected with different HPV types were analyzed separately for each HPV type. The prevalence and incidence by HIV status and before and after HAART initiation periods were compared.+ counts of the before HAART initiation infection with after HAART initiation clearance , persistence .We also compared the CD4There were a total of 373 eligible female adolescent participants (146 HIV-negative and 227 HIV-positive) in the REACH cohort, of whom 262 (70%) were infected with at least one HPV type at baseline. Of the remaining 111 not infected with HPV at baseline, 78 (70%) became infected with at least one type of HPV by the end of the study. Of the HIV-positives, 192 were HAART-naïve at enrollment but initiated HAART while participating in the REACH study; 62 started HAART on the first visit and lacked before HAART initiation follow-up; 22 had missing dates for the initiation of HAART; and seven lacked adequate follow-up data after HAART initiation. The prevalence and incidence estimates were based on 146 HIV-negative females, 170 for the before HAART initiation period , and 157 for the after HAART initiation period . There were a total of 16 reappearances of type-specific HPV (after two consecutive negative visits) among 100 individuals during the study period. Three reappeared during pre-HAART, three during post-HAART, and 10 were infected pre-HAART, cleared post-HAART, but reappeared post-HAART. Although the numbers were small, there is no significant pattern of reappearance with or without HAART.+ count seems to be higher in participants before HAART initiation than after HAART initiation, but it is noteworthy that some of the sicker individuals (low CD4+) who were treated did not have before HAART initiation visits included in the study. However, among the cross-over set, there was an increase of CD4+ after HAART initiation (mean increase from 482 to 560 and a median increase from 471 to 525 cells/mm3 within a six-month period), indicating an overall immune reconstitution.The demographic and baseline clinical characteristics of the subjects included in this sub-study and the entire REACH cohort did not differ significantly, as shown in Table As shown in Table For individual high-risk HPV types, incidence ranged from 0.64-9.83 cases/100 PY for HPV 67 and HPV53/66, respectively, among HIV-negatives; from 3.00-12.80 cases/100 PY for HPV 39 and HPV53/66, respectively, among the HIV-positives in the before HAART initiation period; and from 1.49-17.05 cases/100 PY for HPV 67 and HPV 53/66, respectively, among the HIV-positives in the after HAART initiation period . Of note, the numbers for clearance were too small during the time period to stratify and compare either by different variables or by specific incidence cases.The absolute CD4+ T-cell counts) from HAART.The prevalence of HPV infection in our study subjects is high: 70% 262/373) at baseline and 70% (78/111) infected during follow-up, with a cumulative prevalence of 91% (340/373). This is as expected for a high-risk cohort of adolescents, judged by their self-reported sexual and other risk behaviors, and for HIV patients in the U.S. . While c2/373 at + T-cells after treatment. On the contrary, we observed higher prevalence and incidence of possible carcinogenic and low-risk HPV types in the after HAART initiation period. Thus, prevention of HPV acquisition is important, especially in vulnerable populations such as sexually active adolescents. Recently, the FDA approved Merck's HPV vaccine, Gardasil [The present data corroborate previous findings that there is no immediate positive effect of HAART on high-risk HPV incidence and clearance, despite immune reconstitution through the increase of CD4Gardasil , for useGardasil . HoweverGardasil . Most of+ count), it is possible that it may take a longer time to clear any infection, including HPV. The long-term period cannot be assessed from this study; however, it would be important in the future to study the long-term effect of HAART, especially in adolescents as they live to adulthood.The small size of our overall study sample limits our ability to perform analyses that would fully answer some relevant questions, such as the impact of HAART on type-specific clearance and persistence. Thus we present only counts of clearance rather than the rates. Additionally, the number of visits in which HPV data were obtained varied considerably from person to person, both during and before/after HAART initiation period, and may have introduced a systematic bias. However, the median number of visits for the two time periods was similar. The follow-up time periods might be shorter, especially to detect clearance with two consecutive negative visits, but they are relevant as they span the initiation of HAART and examine the immediate effect of HAART. The median follow-up time after HAART initiation in the study was 427.5 days. Most (70-90%) HPV infection in healthy women clears between 12-24 months, and the 13-month follow-up time may not be long enough to observe a significant difference and thus may lead to our result. Although we observed the reconstituted immunity (increase in CD4Further, it is possible that the use of cervical lavage samples, rather than cervical exfoliated cells samples, may have resulted in a slightly lower sensitivity for HPV detection, although we do not expect this to unduly affect our study results. Since HPV testing was performed semi-annually, it is possible that a proportion of infections of less than six-month duration were missed. Although this may affect the prevalence and incidence endpoints, more emphasis was placed on evaluation of HPV infections that persisted, since transient infections are less frequently associated with significant high-grade precancerous outcomes. The genotyping of HPV type was performed using a standard, validated method; however, some of the types were combined with a common probe for the analysis. This made it challenging to separate some of the HPV types, such as types 6 and 11, which are included in the quadrivalent HPV vaccine, from types 42 or 44. Additionally, persistence might be overestimated if the infections were different at consecutive visits but were detected by the generic probe, but clearance would be more conservative. However, high-risk and low-risk types still could be clustered for the analyses. In essence, participants of the study were high-risk adolescents, many of whom were likely recently infected with HPV. Thus, this will likely reduce the bias of long-term persistence in this population, specifically among those who were HPV-positive at baseline.Besides HIV infection, the study participants were co-infected with other STIs , which mAlthough HAART increases the life expectancy of HIV patients, it did not show immediate effect on high-risk and vaccine-type HPV incidence, clearance, and persistence in our study. However, it is very important to monitor HIV-infected females receiving HAART for a longer period of time, particularly in regions of the world where cervical screening is not routinely available. Additional studies of other possible carcinogenic HPV types, along with the known HPV 16 and 18, which are highly prevalent in HIV-positive populations such as REACH, are also required for effective HPV prevention programs. More studies of the impact of HAART and immune restoration along with medication adherence on HPV infection and related outcomes are warranted to guide the development of interventions for such at-risk adolescents.DNA: Deoxyribonucleic acid; FDA: Food Drug Administration; HAART: Highly Active Antiretroviral Therapy; HIV: Human Immunodeficiency Virus; HPV: Human Papillomavirus; IQR: Interquartile Range; NHANES: National Health and Nutrition Examination Survey; PCR: Polymerase Chain Reaction; PY: Person-years; REACH: Reaching for Excellence in Adolescent Care and Health; STI: Sexually Transmitted InfectionThe authors declare that they have no competing interests.SSh conceived the idea, supervised the analysis and drafted the manuscript. SSu conducted the literature search and performed the analysis. JSS, LHB, CW, and MC-K assisted with the analysis and interpretation of the results. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/10/295/prepub


There were no differences in anxiety, distress or health-related quality of life between the four study groups at 6 months. Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result, and were highest in the group untested for HPV. Predictors of concern across all groups receiving an abnormal smear test were perceived risk of developing cancer, being HPV positive or untested for HPV, sexual health worries and the smear being a woman's first smear test. The raised anxiety and distress observed in women immediately after being informed of an abnormal smear test result and that they are HPV positive was no longer evident at 6 months. Concern about the smear test result was however still raised in these women and those who tested negative for HPV, and particularly among those who did not undergo HPV testing.State anxiety (S-STAI-6), distress (GHQ-12), concern and quality of life (EuroQoL-EQ-5D) 6 months after human papillomavirus (HPV) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospective questionnaire study, with 6-month follow-up after the smear test result. Two centres participated in an English pilot study of HPV testing. Participants included two groups of women receiving abnormal smear test results: (tested for HPV and found to be (a) HPV positive ( There is growing interest in human papillomavirus (HPV) testing as part of the management of women with cytological abnormalities , some ofWe report here the 6-month follow-up data for these women. We predicted that, in keeping with systematic review evidence, raised levels of anxiety, distress and concern will no longer be evident 6 months after the receipt of such test results . To date, most economic evaluations only report on the effectiveness of screening in terms of lives or life year gained. HRQoL data permit analysts to incorporate quality of life information directly into economic evaluations.All women who underwent a routine cervical smear test at one of two centres taking part in the English pilot study of Liquid Based Cytology (LBC) and HPV testing (2002–2003), and who received either a normal or a borderline/mildly dyskaryotic test result, were eligible for this study. They were informed of the possibility of being invited into this questionnaire-based study in the letter inviting them to attend for screening. All borderline or mildly dyskaryotic smear samples were tested for HPV. Following the end of HPV testing in the pilot, an extra group of women with such smear test results but no HPV testing was recruited to allow for the assessment of the possible reassuring effects of receiving an HPV-negative test result.A total of 2183 women was sent a questionnaire within a week of the research team being informed that their smear test results had been sent to them. Up to two reminders were sent, within 14 and 28 days. The baseline sample of 1376 (63%) women comprised 366 women who had received a normal test result and 1010 women who had received a borderline or mildly dyskaryotic smear test result. Of this latter group, 331 were HPV negative, 536 were HPV positive and 143 were not tested for HPV.χ2(3)=12.542, P=0.006), with 79% responding in the normal test result group (n=288), 76% in the HPV-negative group (n=252), 69% in the HPV-positive group (n=369) and 71% for the group not tested for HPV (n=102).Of the 1376 women in the initial sample, 1011 (74%) completed a second questionnaire 6 months after the receipt of their test results. The response rate varied significantly between the groups  as well as baseline measures of anxiety, distress, quality of life and concern.P<0.001) and more likely to have had a previous smear test , but there were no significant differences in ethnic status or education. Comparing psychological outcomes immediately after receipt of the smear test result, responders differed from nonresponders in anxiety (mean(s.d.)=33.7(11.3) vs 35.9(12.0); P=0.003), distress (mean(s.d.)=2.3(3.1) vs 2.7(3.2); P=0.039) and concern (mean(s.d.)=4.2(2.0) vs 4.6(1.9); P=0.002), but not in HRQoL.Responders were significantly older (mean(s.d.)=37.5(11.6)) than nonresponders (33.5(11.1); State anxiety was assessed using the short form of the state scale of the Spielberger State-Trait Anxiety Inventory (S-STAI-6) (α) of the scale in this study sample was 0.85 (n=963).-STAI-6) , prorateGeneral distress was assessed using the 12-item General Health Questionnaire (GHQ-12) ) ( n=989)) .Health-related quality of life was assessed using the EuroQol EQ-5D questionnaire. Valuations of responders' health states were assigned using the results from a UK general population survey to estimate utility values on a scale of 0 to 1, where 1 is perfect subjective health and 0 is death , five of which were taken from the standardised Psychosocial Effects of Abnormal Pap Smears Questionnaire (PEAPS-Q) .Repeat smear, HPV and colposcopic examinations: The results of further cervical smear tests and colposcopic examinations were assessed from laboratory records after 6 months. These were used to categorise women as having either normal or abnormal smear test results at 6 months. Normal results include normal repeat smear test results, a negative HPV test result and normal colposcopy results. Abnormal results include all categories of abnormal repeat smear test results (regardless of HPV status), women who were HPV positive but had normal cytology and women with all categories of abnormal colposcopy results.Demographic information: Age, highest educational qualification, ethnic background and smear history were reported at the initial assessment.χ2 tests. For comparisons at baseline, ANOVA with linear trend was used with a priori linear contrasts after adjusting means for baseline differences in age and smear history. Since the four groups were not expected to differ at 6-month follow-up, comparisons were made using ANOVA with Tukey B post hoc tests to test for between-group differences where indicated. Hierarchical multiple linear regression was used to ascertain the best predictors of concern at the follow-up assessment point in the three groups of women with borderline or mildly dyskaryotic smear test results.Differences in the demographic and smear history characteristics of the four groups were assessed using ANOVA  and The groups differed in age, whether the studied smear test 6 months previously was their first one or not, and whether the test was a repeat of a smear following an abnormal smear test result . Women w3, 996=83.39, P<0.001), but not in anxiety , distress  or HRQoL  .Analysis of variance of means adjusted for age and smear history revealed that at follow-up the groups significantly differed in concern (FP=0.554) . Post ho3,985=14.88, P<0.001). Women who were either HPV positive or untested for HPV perceived their risks of developing cervical cancer as significantly higher than women with normal smear test results and women who tested negative for HPV.The four groups also differed in their perceived risks of developing cervical cancer .Overall, none of the three groups with abnormal test results was extremely worried about their sexual health. The group with HPV-positive test results did however score significantly higher than the other two groups : HPV status , the studied smear having been a woman's first smear test , perceived risk of developing cervical cancer  and sexual health-related worries .Four variables independently predicted concern . Similarly, rates of HPV infection are high, occurring in about 20% of women aged between 18 and 35 and about 7% of those aged over 50 . It is tA total of 27% of the women who agreed to take part in the initial assessment did not complete the follow-up questionnaire reported in this paper. Those who were HPV positive who responded at the 6-month follow-up were less anxious immediately after receipt of their test results than those who did not respond. It is therefore possible that the pattern of results we report here at 6 months under-represents the anxiety, distress and concern present for these women at 6 months.Women from ethnic minorities and those with lower levels of education were also under-represented in our sample. While we did not find that education level predicted concern, the study had insufficient power to assess the possible moderating effects of ethnicity on psychological responses to HPV testing.The raised anxiety and distress observed in women immediately after being informed that they had an abnormal smear test result and were HPV positive is no longer evident 6 months later. Concern about the smear test result is, however, still raised in these women as well as those who received an HPV-negative test result and particularly in those who did not undergo HPV testing. Concern may be reduced by informing women of the relatively low absolute chance that they will develop cervical cancer, and that the prevalence of their particular test result is relatively high.