The emerging evidence showed that long noncoding RNAs (lncRNAs) are involved in cell growth and apoptosis as well as cancer progression and metastasis of malignant tumor, however, limited data are available on the role of lncRNAs in human papillomavirus (HPV)-associated Head and neck squamous cell carcinomas (HNSCC). Here, we demonstrated that 23.98% of 196 HNSCC cases in Southwest China could be classified as HPV16 infection. The number of MDSCs in HPV-positive HNSCC was significantly higher than normal control, indicating that HPV infection may promote MDSCs aggregation. Then, we applied an array-based approach to monitor the lncRNA expression between HPV-positive HNSCC, HPV-negative HNSCC and normal oral mucous, and obtained 132 different lncRNAs in different HPV infected states of HNSCC. HOTAIR, PROM1, CCAT1, and MUC19 mRNA levels, determined by qRT-PCR were inversely correlated with MDSCs collection of HPV-associated HNSCC in 2 independent patient cohorts. The results may provide a rationale for the further evaluation of lncRNAs as a molecular target to elucidate the molecular mechanism of HPV promoting MDSCs collection of HNSCC. Head and neck squamous cell carcinoma (HNSCC) is considered as one of the most prevalent and lethal cancers worldwide , 2. TobaLong non-coding RNAs (lncRNAs), with length longer than 200 nucleotides, work by modifying chromatin and adjusting the networks of genetic and signal pathways in the pathogenesis of cancer . The abeA better understanding of molecular principles will result in innovative concepts for precision medicine of both HPV-positive and HPV-negative HNSCC, based on the etiology and biology of these tumors. Consequently, we focused our attention on HPV dependent alterations of lncRNAs . Here, iA total of 288 patients with HNSCC were confirmed as eligible for the study. Among these, 62 patients rejected to take part in this research and 30 did not finish their questionnaires, leaving 196 enrolled case subjects and a case participation rate of 68.06%. The samples from 180 fresh primary tumor tissues, 196 peripheral blood samples and 196 paraffin sections from the same patient were successfully obtained . To our P<0.001), indicating that HPV 16 infection linked the malignant progression of oral mucous.180 fresh tumor tissues and 196 blood samples with available tumor DNA were successfully assayed by HPV 16 or HPV 18 viral DNA PCR, and 196 paraffin sections were examined by P16 immunostaining and HPV 16 DNA PCR. The result showed that the positive expression of HPV16 and 18 in peripheral blood was shown in 23.98% (47/196) and 6.12% (12/196) of HNSCC, respectively Figure . The posP=0.001). The HPV 16 positive expression in HNSCC patients associated with pathological grade of patients (P=0.034). However, there was no significant association of the HPV 16 status with sex and clinical stage of patients (P>0.05).The examination results of the HPV16 expression and the demographic characteristics in the HNSCC cases were presented in Table P=0.000). This data indicated the consistence of HPV expression in blood samples and tumor tissue. In paraffin sections, the overall prevalence of HPV16 DNA by PCR was 20.41% (40/196), and the prevalence of HPV16 by IHC was 26.53% (52/196). The concordance between PCR method and IHC in paraffin sections was high, suggesting that the HPV expression rate by PCR in paraffin sections was almost the same as the HPV expression detected by P16 IHC.The concordance of HPV16 by PCR, P16 immunostaining, and their combinations with measures of HPV16 was shown in P=0.002). Then, to exclude the other disease resulting in the change of MDSCs in the peripheral blood of whole body, we detected the expression and level of MDSCs in fresh tumor tissue samples. The same results were obtained in the tissue samples of cases. Representative figure of the blood and tissue samples of one patient was presented in Figure The balance between active immune responses against HPV and HPV-induced immune escape regulates viral clearance and carcinogenesis . MDSCs aP=0.002, P=0.001, respectively, P>0.05). This indicated that MDSCs may be recruited to HNSCC areas and the clinic stage and pathological grade of HNSCC patients may influence the recruitment of MDSCs.Further, the analysis of the relationship between the expression of MDSCs and clinicopathologic features of HNSCC showed that the number of MDSCs in cases with T3-4 was more than cases with T1-2, and the number of MDSCs in cases with pathological grade II and III was more than that with grade I (P=0.004). The same results were obtained in tumor tissue sample . These samples included 3 patients with the HPV-positive HNSCC, 3 patients with HPV-negative HNSCC, and 3 normal oral mucous classified as the controls. Feature Extraction software  was applied to process raw data and figures, and Genespring software  was used to normalizate quantile of the raw data.To further investigate the molecular mechanism of HPV16 accelerating MDSCs aggregation, we analyzed the lncRNAs profile of HPV-related HNSCC, which are emerging as a novel class of noncoding RNAs that are pervasively transcribed in the genome . From thDifferentially expressed lncRNAs and genes among the control, HPV-positive HNSCC and HPV-negative HNSCC were analyzed by unsupervised hierarchical clustering and the data were shown in the heat map of Figure P <0.05) between HPV-positive HNSCC and HPV-negative HNSCC. WFDC2 (fold change=44.73664) was the most down-regulated mRNA, and NONHSAT083749 (fold change=21.536058) was the most down-regulated lncRNA between HPV-positive HNSCC and HPV-negative HNSCC.Twelve lncRNAs (5 up-regulated and 7 down-regulated) were significantly differently expressed in HPV-positive HNSCC compared with control group (fold change > = 10). There were 1 up-regulated and 10 down-regulated lncRNAs with more than 10-fold changes between HPV-positive HNSCC and HPV-negative HNSCC. Using the same criteria of lncRNAs, we found 28 up-regulated mRNAs, and 241 down-regulated mRNAs  showed that the most enriched GOs associated with differentially expressed transcripts were blood coagulation  “inflammatory response”     , which was associated with 16 differentially expressed genes. Many of these pathways were linked to inflammation and immunity, such as “B cell receptor signaling pathway” (associated with 11 genes), “Natural killer cell mediated cytotoxicity” (associated with 9 genes), “Primary immunodeficiency” (associated with 3 genes), “Viral myocarditis” (associated with 6 genes).The GO analytical data of aberrantly expressed mRNAs between HPV-positive HNSCC and HPV-negative HNSCC  Figure  Left, “e) Figure  Middle, ) Figure  Right. P) Figure . The mosP <0.01), however, it is too complicated. Then, the network of top 10 different mRNAs and top 10 different lncRNAs between HPV-positive HNSCC and HPV-negative HNSCC was built and shown in Figure To explore the potential relationship between the 132 lncRNAs and 118 mRNAs, the correlated expression networks were done. The association between mRNA and lncRNA is close  between HPV-positive and HPV-negative group to detect their expression levels by qRT-PCR. The data demonstrated the same trends of up-and down-regulation and the fold changes of qRT-PCR as the microarray data Figure . AdditioTo investigate the role of lncRNAs in HPV16 promoting MDSCs aggregation in HNSCC, we examined 4 lncRNAs  expression in 47 HPV-positive blood samples using qRT-PCR. It turns out that the expression of HOTAIR, PROM1, CCAT1, and MUC19 was negatively associated with the number of MDSCs in HPV-positive HNSCC Figure .To confirm the association of PROM1, HOTAIR, CCAT1, and MUC19 with the number of MDSCs in HPV-positive HNSCC, we examined their expressions for another independent HNSCC patient cohorts. The cohorts (Weifang), consisted of 30 patients of a current prospective study. qRT-PCR of HOTAIR, PROM1, CCAT1, and MUC19 in HNSCC patients revealed similar findings. The close correlation of HOTAIR, PROM1, CCAT1, and MUC19 with MDSCs in HPV-positive HNSCC has been shown in Figure Additionally, the survival curves were computed with the Kaplan-Meier method and compared between groups by using the log-rank test, though the following time is only 3-42 months. The result demonstrated that there was no significantly association between survive rate and the expression level of HOTAIR and PROM1 in 47 HPV-positive HNSCC Figure . The folThe comparative genomic hybridization, whole exome sequencing and CpG island arrays have been applied to identify genomic imbalance, somatic gene mutations and CpG island hypermethylation in HPV-associated HNSCC –29. ThesHPV causes an epidemiologically and clinically distinct form of HNSCC , 31, yetMDSCs have obtained much attention due to their roles in tumor immunity suppression as well as promotion of angiogenesis, invasion, and metastases. In our previous study, we showed that hypoxia could stimulate the migration of CD11b+Gr-1+ myeloid cells through increased production of macrophage migration inhibitory factor (MIF) and interleukin-6 (IL-6) in HNSCC cells . The latTo provide some molecular evidence for MDSCs collection in HPV-associated HNSCC, lncRNA analysis was applied to elucidate the difference between HPV-positive and HPV-negative HNSCC. We obtained 132 different lncRNAs in different HPV infected states of HNSCC, and confirmed the data by qRT-PCR in 2 much larger, independent HNSCC cohorts. This result was supported by previous findings. Gibb et al.  describeThis work allows us to propose a model in which abnormally expressed lncRNAs occur at oral mucous following HPV infection and these lncRNAs may aggregate MDSCs and contribute to the progression of tumor formation Figure . Cells iOne hundred and ninety-six patients with HNSCC who underwent resection of their tumors without preoperative chemotherapy, hormone therapy or radiotherapy at the Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University between 2012 and 2015 were recruited for the study after giving informed consent. A complete medical history was obtained, and tumor assessment was performed at baseline  was counted from the date of random assignment to the date of death. PFS  were counted from the date of random assignment to loco-regional recurrence, distant metastasis, or death resulting from any cause. The average follow-up time of all of the patients was 20 months (range 3-42 months) till August 10, 2015 and it will continue to follow-up.Fresh tissues were cut in half for parallel RNA and genomic DNA extraction with the TRIzol reagent (Invitrogen) and the QIAamp Mini Kit (Qiagen), respectively. For PCR amplification of the HPV 16, 100 ng of DNA was amplified using consensus primers HPV 16 (457-bp product). PCR primer sequence for HPV 16 is Forward 5- CAC AGT TAT GCA CAG AGC TGC-3; Reverse 5-CATATATTCATGCAATGTAGGTGTA-3.IHC of P16 and MPO, human MDSC marker, was performed on 4-mm-cut representative sections of paraffin-embedded samples by the streptavidin-peroxidase method followed.3 tissue block and put into burnisher. Then cell suspension was collected and centrifugated. To blood specimen, heparin sodium and PBS/Hanks was added into blood of individuals. Ficol was used to separate lymphocyte. Serum free medium containing 1% BSA was added into cell suspension, and then incubated on ice for 10 minutes. PE-Cy Mouse Anti-Human CD11b, FITC-Mouse Anti-Human LIN, APC Mouse Anti-Human HLA-DR, PE Mouse Anti-Human CD33 (BD Biosciences) were added to cell suspension and incubated on ice for 30 minutes. Cells were washed and resuspended in 500 mL buffer and analyzed.Cells were analyzed using Flow Cytometer . Tissues were trim into 1-2mmTotal RNAs were extracted using Trizol reagent  following manufacturer's instruction. Microarray hybridization and bioinformatic analysis were done according to the manufacturer's instruction. Feature Extraction software  was applied to process raw data and figures, and Genespring software  was used to normalizate quantile of the raw data.qRT-PCR analysis was performed for selected lncRNAs. The total RNA extraction with Trizol reagent  and cDNA preparation  were done following manusfactures’ instruction. The total RNA of specimens was collected with TRIzol reagent (Invitrogen) and treated with RNase-free DNase I (Takara) to avoid genomic DNA contamination. The complementary (c)DNA was stored at −80°C until used for PCR. PCR amplification of the cDNA template was done using Thunderbird SYBR qPCR mix (TOYOBO) on ABI PRISM 7300 sequence detection system (Applied Biosystems).t-test. Chi-square was used to analyze the associations between HPV status and clinical-pathological characteristics. Correlation between the number of MDSCs and the transcript levels of lncRNAs was performed by Spearman method. The Kaplan–Meier method was applied for survival analysis and the statistical significances between the groups were evaluated using the log-rank/Mantel-Cox test. All the statistical analyses were performed using SPSS 13.0 . Statistical analysis was considered to be significant when the probability value <0.05.The difference of MDSCs number between HPV-positive and HPV-negative groups was evaluated with


This study was aimed at determining the knowledge and acceptability of HPV vaccine among women attending the gynaecology clinics of the Lagos University Teaching Hospital (LUTH).P < 0.05. This was a descriptive cross-sectional study involving 148 consecutively selected women attending the gynaecology clinic of LUTH. Relevant information was obtained from these women using an interviewer-administered questionnaire. The data was analysed and then presented by simple descriptive statistics using tables and charts. Chi-square statistics were used to test the association between the sociodemographical variables and acceptance of HPV vaccination. All significance values were reported at P = 0.013). The mean age of the respondents was 35.7 ± 9.7 years. The study showed that 36.5% of the respondents had heard about HPV infection while only 18.9% had knowledge about the existence of HPV vaccines. Overall, 81.8% of the respondents accepted that the vaccines could be administered to their teenage girls with the level of education of the mothers being the major determinant of their acceptability ( Awareness of HPV infections and existence of HPV vaccines is low. However, the acceptance of HPV vaccines is generally high. Efforts should be made to increase the awareness about cervical cancer, its aetiologies, and prevention via HPV vaccination. Cervical cancer is the most common gynaecological cancer among women in sub-Saharan Africa and a leading cause of cancer deaths in Nigeria . In 2012Various molecular and epidemiological evidences have shown that cervical cancer is caused by oncogenic human papillomavirus (HPV), a sexually transmitted infection, especially serotypes 16, 18, and 31 –6. HPV aOne of the major prevention strategies for cervical cancer is vaccination against HPV infection among adolescents prior to their first sexual exposure . The appFortunately, in 2013, the vaccine manufacturers (Merck and GSK) offered the Global Alliance on Vaccines and Immunization (GAVI) a reduced price of US$4.50 per dose from the initial selling price of US$30–40 . This reDespite these efforts, barriers to obtaining these vaccines individually in low-income countries like Nigeria still remain as the cost of the vaccine is prohibitive and out of the reach of the poor. Other major contributors to this are the poor vaccine delivery efforts, low cervical cancer screening levels, ineffective health system capabilities, inaccessibility to medical care, low awareness and knowledge of HPV and cervical cancer, and failure to recognize cervical cancer as a major health concern , 15–18. This study was a descriptive cross‐sectional survey that involved women attending the gynaecology outpatient clinics of the Lagos University Teaching Hospital (LUTH) between August and October 2015. LUTH is the teaching hospital of the College of Medicine of the University of Lagos. It is situated in the heart of Lagos Mainland, which has a population of over 2,150,100 inhabitants. It serves the whole of Lagos and its suburbs, and it is open to all categories of patients. The hospital has over 800-bed spaces and records over 9,000 patients' attendances per month. It operates at the tertiary level of the healthcare delivery system in Nigeria. Referrals are received from both private and public hospitals in Lagos as well as other parts of the country.These were nonpregnant women with non-life threatening gynaecological complaints attending the gynaecological outpatient and cytology clinics of LUTH during the study period and the sample population included all consenting women recruited by consecutive sampling method. Excluded from the study were women being evaluated or managed for any gynaecological malignancy.Informed consent was obtained from the women prior to their recruitment for the study and interviews were conducted by the investigators to collect relevant data from the participants. The interview guide was divided into three main sections (A to C) which included data on (A) sociodemographic variables of participating women, (B) their knowledge of genital HPV infection and HPV vaccines, and (C) their acceptance of HPV vaccines for their adolescent girls after 5- to 10-minute group health talks on HPV vaccination.P < 0.05.Relevant data were analysed using SPSS statistical package version 21.0 for windows manufactured by IBM Corp., Armonk, NY, United States. The data were presented as chart and frequency distribution tables. The association between the sociodemographic variables  and acceptance of HPV vaccination was tested using Chi-square test or Fisher's exact test where appropriate. All significance values were reported at  ADM/DCST/HREC/2179) was obtained from the hospital's Health Research and Ethics Committee prior to the commencement of the study and the ethical principles according to the Helsinki Declaration were considered during the course of the research.Ethical approval for the study  were between 26 and 35 years. The largest proportion of the respondents were married (68.9%), had one or more daughters (58.1%), and had at least tertiary level of education (82.4%) .P > 0.091) (P = 0.098) and them having a daughter (P = 0.084) did not influence their awareness of the existence of HPV vaccination, their level of education played a significant role in this respect (P = 0.001) (Only 54 (36.5%) of the respondents have heard about genital HPV infection with a large proportion of them (87.0%) knowing correctly that it was a sexually transmitted infection while a further 91.5% of these knew that it can cause cervical cancer  thus giv> 0.091) . However> 0.091) . Althoug= 0.001) . Three oA major proportion of the total respondents (81.8%) expressed their willingness to vaccinate their daughters while the others were either unwilling (10.8%) or indifferent (7.4%) to the idea of vaccination against HPV infection . The reaP = 0.013) but no similar associations were observed with the respondents' age (P = 0.256) and them having a daughter (P = 0.101)  , althouge P = 0.26 and theThis study reported a very low awareness level of HPV infection (36.5%) despite a high literacy level of over 80% with tertiary education among the respondents. This finding is somehow similar to the report from a community-based study carried out in Shomolu local government area of Lagos State where a similarly low level of awareness (27.9%) was reported . SimilarThis current study just like other previous studies carried out in Nigeria with awareness of HPV vaccines ranging between 19.7% and 25.3% –18 had aThe high level of willingness shown by the respondents in this study (81.8%) to accept HPV vaccinations for their daughters is consistent with the reports from previous studies in Nigeria with levels of acceptance ranging between 70.0% and 88.9% –18, 25 aThe finding of a significantly higher level of knowledge and acceptance of HPV vaccination among women with higher educational qualifications in this study was a likely indication that the more educated women are generally more exposed to information on HPV infection and vaccination against it from various sources just as previously reported in various other studies , 22, 24.The low awareness of the existence and availability of the HPV vaccine in this study showed that much work is still needed to create awareness for HPV vaccines in Nigeria. This can be achieved with the development of health promotion and educational strategies for the public considering that education was shown to have significantly influenced the level of acceptance of the vaccines. It is therefore recommended that continuous efforts should be made to improve mothers' knowledge through education and to also ensure the possible inclusion of the vaccine in the national immunization schedule.


Human papillomavirus (HPV) is now known to cause a significant proportion of head and neck cancers (HNC). Qualitative research has shown that some health professionals find it difficult to discuss HPV with patients due to its sexually transmitted nature, and have concerns about their own knowledge of the virus. We used a survey to quantify attitudes towards discussing HPV among HNC health professionals.We carried out a cross-sectional survey of HNC health professionals (n = 260) in the UK and Ireland, assessing participants’ knowledge of HPV, their experiences of and attitudes towards discussing HPV with patients, and their willingness to discuss HPV with their patients in the future.Overall, health professionals had good knowledge of HPV (mean score: 9.97 out of 12). Oncologists had significantly greater knowledge than specialist nurses, speech and language therapists and ‘other’ health professionals. Most were willing to discuss HPV with patients (mean = 4.3 out of 5). Willingness to discuss HPV in the future was associated with higher HPV knowledge , fewer negative and more positive attitudes towards discussing HPV , fewer personal barriers  and greater confidence .Knowledge, experiences and attitudes to discussing HPV varied across HNC health professionals. Addressing gaps in health professionals’ HPV knowledge and improving their confidence in discussing HPV with patients may increase their willingness to have such conversations. This may help minimise the negative psychosocial consequences of an HPV diagnosis in this patient group. Overwhelming evidence has demonstrated that human papillomavirus (HPV) plays a causal role in some oropharyngeal squamous cell carcinomas (OSCC) Consistent with findings from the cervical cancer literature There is wide variation in awareness of the association between HPV and HNC among health professionals involved in the diagnosis and treatment of HNC. A recent review Previous studies suggest that greater knowledge influences communication related to HPV, for example health professionals with greater knowledge about HPV and the HPV vaccination, are more likely to recommend the vaccine This study was carried out in the UK and Ireland, and aimed to assess knowledge of HPV, experiences, and attitudes to discussing HPV across different groups of health professionals involved in the treatment of HNC. We also examined how these factors were associated with willingness to discuss HPV with patients in the future.Health professionals in roles working directly with HNC patients  in the UK or Ireland completed an online or paper survey. A number of methods of recruitment were used. Professional organisations  and ‘If you have informed a patient about their HPV status, have you discussed HPV in detail with a patient?’ . Health professionals were also asked, ‘If you discuss HPV during consultations, who usually initiates the discussion?’ .Knowledge of HPV: Health professionals were asked ‘Have you ever heard of HPV?’ . Health professionals were also asked to respond ‘true’, ‘false’ or ‘don’t know’ to twelve knowledge items. Seven of these were from a validated measure of HPV knowledge Twenty-five items assessed health professionals’ attitudes towards discussing HPV with patients (see supplementary information). Responses to these questions were on a 5-point Likert scale . These items were developed based on the findings from the existing literature Willingness to discuss HPV in future: Health professionals were asked, ‘Generally, how willing are you to discuss HPV with your patients in the future?’ .Socio-demographic and professional background items assessed age, sex, profession , number of years in profession, whether they had trained in the UK and their main place of work . Participants were also asked, ‘Have you ever looked for any information on human papillomavirus (HPV) and head and neck cancer?’ and ‘if yes, where have you looked?’: internet, medical journals, other colleagues, conferences, professional organisations, media, other.Chi-square tests were used to compare responses to individual knowledge items across health professional groups and ANOVA was used to compare total knowledge score between groups.ANOVA was used to compare each attitudinal factor from the PCA across health professional groups. Pearson’s correlations were run to explore the relationships between the attitudinal factors, willingness to discuss HPV in the future, years practising in their profession and knowledge. A binary logistic regression was carried out to investigate the factors that predicted willingness to discuss HPV in the future .260 health professionals from the UK and Ireland completed the survey (193 online and 67 on paper). It was not possible to calculate a response rate because an accurate denominator could not be calculated. The median age of the sample was 45 years (range: 21–66). Health professionals had worked in their profession for a median of 17 years (range: 0 to 45 years). Almost all (99.2%) had heard of HPV.2 (12) = 78.49, p < 0.001) and discussing this in detail with their patients (X2 (8) = 23.48, p = 0.003) than the speech and language therapists (SLTs) or the ‘other’ group of health professionals. Over two-thirds of oncologists reported initiating the discussion about HPV themselves , compared with 54.8% (n = 46) of surgeons and 25.7% (n = 9) of specialist nurses (X2 (12) = 95.94, p < 0.001). Among SLTs who had discussed HPV with patients (n = 40), 55.0% (n = 22) reported that the patient had initiated the discussion.Around 75% had previous experience of discussing HPV with a patient. Surgeons, oncologists and specialist nurses had more experience of telling their patients that their cancer was caused by HPV  = 10.48, p < 0.001). Surgeons had a significantly higher mean knowledge score than the ‘other’ group of health professionals (p < 0.001) and SLTs (p < 0.001); and oncologists had a significantly higher mean score than specialist nurses (p = 0.017), SLTs (p < 0.001) and the ‘other’ group of health professionals (p < 0.001). Item by item differences across the professional groups are shown in Confidence in discussing HPV: The mean (M) score was 3.41 (standard deviation (SD) = 0.83, range 1–5), suggesting overall health professionals were fairly confident about discussing HPV. Confidence talking about HPV varied by professional group  = 22.80, p < 0.001; Negative attitudes to discussing HPV: In general, negative attitude scores were low  but there was variation across the health professional groups  = 3.49, p = 0.009; Positive attitudes to discussing HPV: Conversely, positive attitude scores were high  with similar differences across professional groups  = 5.59, p < 0.001; Personal barriers to discussing HPV: The mean score for personal barriers was 2.87 (SD = 0.69), suggesting some level of disagreement from health professionals about personal barriers to discussing HPV. When comparing professional groups, a significant main effect was found  = 8.89, p < 0.001; Needing more information: Mean scores were above the mid-point (M = 3.85 and SD = 0.54), suggesting health professionals felt they needed more information about HPV. There were significant differences between health professional groups  = 9.83, p < 0.001; Willingness to discuss HPV in the future was significantly positively associated with confidence in discussing HPV , positive attitudes to discussing HPV  and knowledge  model Knowledge was shown to be highest in surgeons and oncologists, and lowest in SLTs and the ‘other’ group of health professionals. Surgeons and oncologists also showed a greater confidence about discussing HPV than the other health professional groups. SLTs and health professionals in the ‘other’ group reported more personal barriers (e.g. embarrassment) to discussing HPV, and these groups were less willing to discuss HPV. Previous research in dentists has found confidence in performing oral examinations or providing advice about risk habits to be directly correlated with their subsequent performance of oral examinations or provision of advice to patients Greater proportions of oncologists, surgeons and specialist nurses than allied health professionals in this sample had told all or most of their patients that their cancer was caused by HPV, had discussed HPV in detail with those patients, and were willing to discuss HPV in the future. These health professionals are ideally situated to have this discussion with patients as they are likely to see patients more frequently than allied health professionals. As there was still a proportion of allied health professionals who had discussed HPV in detail with these patients, this demonstrates that it is possible for questions to come up at any point during patients’ diagnosis, treatment and aftercare, consistent with previous findings This study has some limitations. Due to the recruitment methods used, it was not possible to calculate a response rate and therefore it is difficult to assess the representativeness of the sample. The associations and differences found in this sample are more likely to be generalisable than the prevalence estimates. The sample was also self-selected and it is possible that those who were most interested in HPV were those who took part. Further research would also be needed to determine whether these results extend to other countries, beyond the UK and Ireland. As some of the participants completed the survey at study days, it is possible that some of them completed it following the talks given that day and this could have influenced their responses, perhaps leading to inflated estimates of knowledge. Although some of the questions assessing participants’ knowledge were from a validated scale, not all of the questions were taken from validated scales. Future work should look at validating a measure assessing knowledge of HPV-OSCC.This study shows that knowledge and attitudes about HPV-OSCC varies across health professional groups, with surgeons, oncologists and specialist nurses having more experience of discussing HPV-OSCC with their patients. Behaviour change models could provide useful frameworks for future training and interventions to equip all health professionals with the vital components to be able to discuss HPV-OSCC with their patients and increase their willingness to do so.RD, LM and JW conceived of the study and developed the questionnaire. RD was responsible for data collection. Data analysis was done by RD, with input from AF, LM and JW. RD was responsible for the interpretation of the analyses and write-up of the results, with input from AF, LM and JW. All authors have seen and approved the final version of the manuscript before submission.None declared.Funders have had no role in the study design, the collection, analysis, interpretation of data, the writing of the article or the decision to submit it for publication.


This pilot study sought to evaluate the feasibility of utilizing vaginal self-swabs and urine samples for HPV-based cervical cancer screening in 700 women who had undergone conventional Pap smear screening via the national cervical cancer program in Korea. The cobas 4800 HPV test was utilized to detect HPV in the self-samples. Pap smear results revealed three cases of atypical squamous cells of undetermined significance, 649 cases of negative for an intraepithelial lesion or malignancy, and 48 non-specific inflammatory findings. High-risk HPV was detected in 6.7% of urine samples and 9.6% of vaginal self-swab samples. The overall agreement for HPV 16/18 between urine and vaginal self-swab samples was 99.1% (95%CI 98.1% to 99.6%). Colposcopic biopsy revealed one cervical intraepithelial neoplasia (CIN) 3 lesion, 12 CIN1 lesions, and 23 normal or chronic cervicitis lesions. In conclusion, urine and vaginal self-swab sampling was feasible and deemed a potential alternative for HPV detection in women who hesitate to participate in cervical cancer screening programs. Meanwhile, due to overall lower rates of abnormal cytology and sexual risk behaviors in Korea, a larger sample size than expected is needed to assess the sensitivity of CIN2+ detection via self-samples. The age-standardized incidence of cervical cancer in 2013 was estimated at 9.5 per 100,000 in South Korea1 To address these rates, the National Cancer Prevention and Screening Program of Korea began to offer cervical cancer screening via cytology (Papanicolaou test or liquid-based cytology) to women aged over 30 years old every 2 years since 1999, extending to those over 20 years of age in 2016. However, cervical cancer screening with cervical sampling is invasive, time consuming, and suffers from poor screening attendance. In Korea, the participation rate in the national cervical cancer screening program was only about 51.5% in 20143, although cervical cancer incidence has been increasing in younger age groups4. This suggest a need for new strategies to facilitate participation in the cervical cancer screening program in Korea.Cervical cancer is the seventh most commonly diagnosed cancer and the ninth leading cause of cancer death among females in Korea, with more than 3,633 incident cases annually and more than 892 deaths8. Recently, evidence suggests that screening based on a validated test for oncogenic HPV DNA following an appropriate protocol is more effective than cytology-based screening for the prevention of invasive cancers of the uterine cervix11. As such, in 2014, the FDA approved the use of the cobas HPV test for primary cervical cancer screening for women over the age of 25 years, without the need for a concomitant Pap test7.Human papilloma virus (HPV) testing can be incorporated into screening programs as a triage for atypical squamous cells of undetermined significance (ASCUS) cytology, as a means to test for both HPV and cervical cytology , and as a primary screening option for HPV13. As a noninvasive, self-sampling method, urine-based HPV DNA testing has been suggested to be of use in women who do not attend cervical cancer screening clinics14. Although non-invasive HPV testing may improve poor participant rates for cervical cancer screening in Korea, especially among young women, prospective cervical cancer screening with self-sampling for HPV in Koreans has not yet been extensively studied.Self-sampling has been found to show high concordance with physician-acquired samples for HPV detection and to be readily acceptable to women17. Previously, we showed that using vaginal swabs could be an alternative to collecting cervical samples for RQ-PCR-based HPV DNA testing12. We also demonstrated that fully-automated RQ-PCR systems could reduce the variability in HPV detection with non-invasive urine samples18.A few studies have compared HPV tests based on real-time qualitative PCR (RQ-PCR) of urine samples and cervical samplesThis pilot study was conducted to obtain basic data necessary for larger-scale study to implement self-sampling in the national cervical cancer screening program in Korea. We also aimed to compare self-sampling methods, urine and vaginal self-swab samples, for HPV detection using the Roche cobas 4800 HPV Test .At enrollment, 12 women had missing or invalid test results, leaving 700 women available for analysis. The median age of the participants was 52 years (range 21–71 years). Among the study participants, cytology revealed three cases of ASC-US, 649 cases of negative for an intraepithelial lesion or malignancy (NILM), and 48 non-specific inflammatory findings. The self-sample results according to cytology are listed in Table High-risk HPV (hrHPV) was detected in 6.7% of the urine samples and in 9.6% of the vaginal self-swab samples Table . Among tThe overall agreement between urine and vaginal self-swab results for any hrHPV was 94.9% (95% CI 93.0 to 96.4%), with a kappa of 0.66, and the overall agreement for HPV 16/18 was 99.1% (95% CI 98.1% to 99.6%), with a kappa of 0.75. A statistically significant difference in detection of hrHPV was observed between urine and vaginal self-swab samples  was found to have CIN2+ or CIN3+ disease in this pilot study.19. In this study, hrHPV was detected in 6.7% of urine samples and in 9.6% of vaginal self-swab samples. HPV16/18 was detected in 1.5% of urine samples and in 2.0% of vaginal self-swab samples. Other hrHPV was detected in 5.2, and 7.6% of the urine and vaginal self-swab samples, respectively. Although a statistically significant difference in the detection rate of hrHPV was noted between urine and vaginal self-swab samples (p < 0.001), the agreement for HPV 16/18 was relatively high , with a kappa of 0.75. Discrepancies arose mainly in the positive samples for hrHPVs other than HPV 16 and 18.HPV detection rates for the general population of Korea have been found to vary according to age groups, region, socioeconomic status, and methods for detecting HPV DNA, ranging from 10% to 15%20. A recent meta-analysis showed that HPV 16/18 detection in urine has a pooled sensitivity of 73% (56% to 86%) and a specificity of 98% (91% to 100%)21. Similar to these studies, for hrHPV detection using Roche_HPV in urine samples we found relative sensitivities of 70.4~79.2% and relative specificities of 93.5~100.0%18. Increasing the sensitivity of hrHPV detection in urine samples is needed prior to the use thereof in cervical cancer screening programs22. One of the reasons for the relatively inferior sensitivity of urine samples in the detection of hrHPV is due to the use of random-void urine samples with no preservatives, instead of an initial stream of urine. Stanczuk et al. suggested that the sensitivity of the cobas 4800 HPV test for the detection of CIN2+ could be increased if the cut-off value was increased to 45 PCR cycles17. We also showed that RQ-PCR with an adjusted cut-off CT value increased the relative sensitivity of HPV detection in urine samples in our previous study18. Thus, if the adjusted cut-off values of RQ-PCR-based tests would be applied for urine samples, detection of HPV DNA using urine samples could be promising for full prospective study for cervical cancer screening.A previous study indicated that the sensitivities for detecting HPV were 96.4% in vaginal self-samples and 83.9% in urine samples relative to cervical samples acquired by a clinician23. Compared to the general population, the prevalence of abnormal cytology (12–83%) or HPV infection (4–91%) in referred populations has been shown to be much higher24. Due to overall lower rates of abnormal cytology and lower sexual risk behavior in Korea, a larger sample size than expected may be needed to comprehensively evaluate the effectiveness of self-sampling in detecting CIN2 disease or greater. For a sufficient number of women with CIN2 disease or greater in the ATHENA trial, an estimated 45,000 women were required for analysis: calculations were based on reported rates of ASC-US cytology25. The prevalence of ASCUS in the ATHENA study was 4.1%26. In this pilot study, however, an unexpectedly low ASCUS rate was discovered, although this finding is similar to rates of abnormal cytological results (0.52%) reported for the national cervical cancer screening program in Korea in 20143. In addition, the number of CIN2 or CIN3 cases included in this pilot study was also unexpectedly low, compared to that in previous studies28. Thus, a much larger sample size than that in the ATHENA study is needed for definitive study.The reported prevalences of HPV infection in several studies have been found to vary. In several studies, subjects comprised highly-selected, high-risk individuals referred for further evaluation with abnormal cytology in primary cervical screening4. This participation rate is much lower than that in Europe29 and the US30. In addition, cervical cancer incidence rates have been increasing in younger, sexually active groups4. For early detection in screening programs, the use of non-invasive self-sampling HPV tests may help with promoting participation among younger women and in preventing cervical cancer in Korea. Indeed. among the participants in the present study, overall satisfaction was 91.4% with the urine sampling and 92.7% with the vaginal self-swab sampling, which was higher than that with clinician-guided cervical swabs (88.1%) (data not shown). Additionally, embarrassment with vaginal self-swabs and with urine sampling was significantly lower than that with clinician-guided Pap smear.In Korea, women aged 30–39 years have had the second-lowest (27.7–44.9%) participation rate in cervical cancer screening, but the highest rate of abnormal results, compared to other age groups, since 2012This study had several limitations, including the relatively small sample size. The number of women with ASCUS was very small (n = 3), and only one of the women who underwent colposcopy had a CIN2+ disease. In addition, not all women with NILM underwent colposcopy. Thus, we could not assess the sensitivity of CIN2+ detection by hrHPV DNA testing, although population-based cervical cancer screening samples were collected. In addition, the use of random-void urine samples with no preservatives could compromise the performance of RQ-PCR assays using urine samples.In summary, Roche_HPV showed relatively good concordance between urine and vaginal self-samples. However, hrHPV DNA detection using urine samples seemed to be inferior to HPV DNA detection using vaginal self-swab samples. A large prospective study should be performed to determine if urine and vaginal self-swab samples may be an effective alternative for HPV detection in women who hesitate to participate in cervical cancer screening programs that use conventional methods.To evaluate the performance of Roche_HPV for HPV DNA detection, paired urine and vaginal self-swab samples were collected prospectively from 712 women who visited the National Cancer Center in Korea between July 2016 and November 2016. This study was approved by the Institutional Review Board of the National Cancer Center, Seoul (IRB No. NCC2014-0183 and NCC2015-0066). All women provided informed consent to participate in the study. We confirmed that all experiments were performed in accordance with relevant guidelines and regulations.12. Vaginal swabs were collected via a dry cone-shaped flocked swab  stored in a dry tube.The research ethics committee of the Institutional Review Board of the National Cancer Center approved the guidelines and regulations for all study methods. The collecting and processing procedure was the same as that described in a previous studyStudy participants also provided urine samples of approximately 30 mL. Before high-risk hrHPV DNA testing using Roche_HPV, each urine sample was washed with Roche Transport Medium. Briefly, 5 mL of each urine sample was mixed with 5 mL of Roche medium and then centrifuged at 3000 rpm for 15 min. After removing the supernatant, the pellet was resuspended in 2 mL of Roche medium and used for HPV testing.The self-samples were compared to cervical cytology samples, which were collected by a clinician using ThinPrep solution  as per routine protocol in the cancer screening program. Colposcopy was performed and directed biopsies were obtained if clinically indicated. In addition, colposcopy with biopsy was performed for women with hrHPV DNA positive results and, if desired, for those with normal cytological results.31 and in accordance with the manufacturer’s instructions. Roche_HPV is a fully automated system for DNA extraction and detection, and provides specific genotype information for HPV types 16 and 18, while concurrently detecting the other 12 hrHPV types in a pooled analysis12.All samples were tested with Roche_HPV based on RQ-PCR as described in a previous studyTo investigate the participants’ satisfaction with all three sampling methods, we administered a survey questionnaire. Satisfaction and embarrassment were assessed via two respective questions for each sampling method: for example, “Overall, how satisfied were you with the urine sampling?” and “How embarrassed were you with urine sampling?” The items were answered on a 4-point Likert scale, ranging from “very satisfied” to “very unsatisfied.” Overall satisfaction was defined as “Yes” with a Likert score of 1–2 and “No” with a Likert score of 3–4, while embarrassment was defined as “Yes” with a Likert score of 3–4 and “No” with a Likert score of 1–2. In total, 551 participants completed to this questionnaire, and the overall response rate was 78.7%.Kappa coefficients with 95% confidence intervals (CIs) were calculated to estimate agreement between the results of Roche_HPV tests. McNemar’s test was applied to assess the significance of differences between two correlated proportions. Statistical significance was defined as p < 0.05. All statistical analyses were performed using NCSS software, version 10 .


Blue space was identified in 24,721 images (3.6%), with a total of 23 blue recreation events. Visual exposure and participation in blue recreation did not differ by ethnicity, weight status, household deprivation, or residential proximity to the coastline. Significant differences in both visual exposure to blue space and participation in blue recreation were observed, whereby children from the most deprived schools had significantly higher rates of blue space exposure than children from low deprivation schools. Schools may be important settings to promote equitable blue space exposures. Childhood exposures to blue space may not follow the expected income inequality trends observed among adults.Blue spaces (water bodies) may promote positive mental and physical health through opportunities for relaxation, recreation, and social connections. However, we know little about the nature and extent of everyday exposure to blue spaces, particularly in settings outside the home or among children, nor whether exposure varies by individual or household characteristics. Wearable cameras offer a novel, reliable method for blue space exposure measurement. In this study, we used images from cameras worn over two days by 166 children in Wellington, New Zealand, and conducted content and blue space quantification analysis on each image ( Blue spaces have been defined as visible surface water  ,2. Blue Among adults, most studies have investigated the mental health benefits of living near the coast or living in a neighborhood with a high percentage of blue space coverage. A cross-sectional study found that those living nearer the coast in England had higher self-rated health, after adjustment for multiple measures of socioeconomic status . In anotAmong the few studies to have explored these relationships in children, it has been found that visits to and living in close proximity to beaches are beneficial to children’s behaviors and to encouraging physical activity ,10. AmonMost studies examining blue space exposure and mental health have been limited to adult populations, and related to exposures at home. However, the functional and structural changes occurring in the child and adolescent brain reflect a sensitive period in brain development. Evidence suggests that changes in the social environment that occur during adolescence may lead to heightened social sensitivity and influence a number of adolescent behaviors . Thus, mactual visual exposure, with most studies using spatial proxies based on two-dimensional mapping of the amount of blue space near the home [Although the evidence on potential benefits of blue space is still emerging, one of the limitations in this research has been a lack of quantification of the home  or proxithe home , or selfthe home . Anotherthe home . UnderstUsing wearable cameras as a novel method to quantify blue space exposures, in a sample of children in Wellington, New Zealand, this study aimed to: (1) assess actual visual exposure to blue space in everyday activities, including those occurring outside the home; (2) objectively measure ‘blue recreation’ behaviors rather than relying on self-report; and (3) use these variables to explore the context of blue space exposures and to test whether exposures vary between children based on child characteristics including residential coastal proximity.This study utilizes data from a larger study of the world in which children live and their interactions with it, called Kids’Cam. Kids’Cam is a cross-sectional observational study of the world in which children live. Sixteen out of 28 invited schools (57%) agreed to participate. A total of 192 out of 443 children (43%) consented to participate in the study. Of the 192 that provided consent, 168 (88%) were chosen to participate so as to avoid over-sampling from some schools. Participants were, thus, 168 randomly selected children, aged 11–13 years in the Wellington region of New Zealand. No information was collected for non-consenting children.Each child wore a wearable camera for 4 days (two school days and the two weekend days). Data were collected over a one-year period. Ethical approval was obtained from the University of Otago Human Ethics Committee  (13/220). During data collection, both students and staff were blinded to the blue space focus of the current study, as it is one of many studies generated from the data. For full details of the study methodology, see Signal et al. . Wellinghttp://www.autographer.com) over a 4 day period (Thursday to Saturday). Participants were asked to wear the cameras for their entire waking day/evening. Cameras were configured to capture a 136° image every ~7 s, thus each image accounted for seven seconds of observation time. Children actually wore the cameras for a total of about 2500 h, leading to approximately 1.3 million total images over the study period (or approximately 31% of four 12-h days). Children were instructed to remove the cameras in situations where privacy could be expected, when swimming or playing sports, or if requested. Images were then compiled and processed.The participants in the study wore wearable cameras , household deprivation status, and school decile (a measure of school socioeconomic status). In addition, each geocoded house location was assigned a neighborhood deprivation score, based on the 2013 census data at the meshblock level . This measure of neighborhood deprivation is called NZDep and is a widely used measure by both government agencies  and hean = 749,389) from all 168 participants were extracted from the Kids’Cam dataset. One weekday and one weekend day were selected to maximize variation in settings where blue space exposure occurred, activities during exposure, time of exposure, and social contacts during exposure. Children with no images on these two days were excluded (n = 2), leaving a total of 166 children included in this study. Images taken between 7:00 a.m. and 7:00 p.m. on these two days  were systematically examined by a researcher for the presence of blue space, which included natural blue space  and human-built blue space . The study hours included in this study were selected to be relatively consistent “daylight hours” throughout a year.Image data for Thursdays and Saturdays (If it was difficult to determine if an image contained blue space (due to blurriness or glare in the image see ), then sEach image containing blue space was then assigned an exposure quantity, whereby blue space pixels were counted (more detail below). Image sequences separated by a break of more than 30 min between images containing blue space were considered separate exposures. Each exposure was then coded in an Excel file, noting the setting, activity , and social contacts .n = 5420) were counted. The duration of exposure in minutes was calculated by multiplying the number of images by 7 s . The number of separate exposures were tallied. Then, each image was processed by hand (over 80 h) in order to count the number of blue space pixels in each image. Each applicable image was loaded into ArcGIS 10.3 software . A polygon was then digitized around all blue space and descriptive statistics were calculated to count blue pixels for each image.To assess visual exposure to blue space, images containing blue space were processed to quantify (per daylight hour observed) the following: (i) the number of images containing blue space; (ii) the minutes exposed to blue space  but rescaled, given that each image is treated as being of constant duration); (iii) the number of exposures; and (iv) the number of blue space pixels in each image. To accomplish this, all images containing blue space  or during blue recreation. Blue recreation was defined as personal engagement with water, prolonged camera focus on others engaging in water-based recreational activities, or camera focus on bodies of water for at least 30 continuous seconds during some form of recreation  . The median distance (2.4 km) was then set at the cut-off for high versus low. Sensitivity analyses were carried out using other thresholds, including the mean, 1 km, and 5 km, as conducted in other studies . Howevern = 166), and home locations were mapped  [In order to compare various blue space exposure variables, descriptive statistics were calculated for each of the blue space exposure metrics . Spearman’s rank correlations were used to assess similarities between these measures of blue space exposure. Next, we calculated mean blue space images per hour observed by day of the week, time of day, setting, and companion status to explore trends. Lastly, to explore the context and potential differences between sub-groups, rate ratios of both blue space images per hour observed and blue recreation events per hour observed  were calculated by ethnicity, sex, household, neighborhood and school deprivation status, and the child’s residential distance to the coastline. We selected these two measures of exposure to blue space, as one indicates visual exposure and one indicates behavior and physical activity related to blue space. To calculate means, 95% confidence intervals and rate ratios, zero-inflated negative binomial models were fitted, offset by the daylight hours observed, with zero-inflation by age. The complex sampling design for the Kids’Cam data collection  was acco-values)  using Stn = 157).n = 691,606, equivalent to 1338.2 daylight hours), blue space was identified in 24,721 images (3.6%). Children were exposed to an average of 11.6 images/h containing blue space (95% CI: 5.3–18.0) for an average of 1.4 min/h (95% CI: 0.6–2.1) and 0.1 exposures/h (95% CI: 0.1–0.1). Children were exposed to 1.9 million blue space pixels (95% CI: 0–4.4 million). Children engaged in a total of 23 blue recreation events including hiking, biking along the coastline, swimming, horseback riding along a river, and taking a picnic at the water , with the lowest correlation observed between the number of visual exposures and the number of blue space recreation events (p < 0.005).On average, exposure to blue space was higher on Thursday, compared to Saturday, and in the morning, compared to the afternoon or evening . Althougn events . In addiIn exploring the differences in visual blue space exposures (counts of images containing blue space) based on child characteristics, similar rates were found across ethnic groups, by sex, weight status, and household deprivation status . SurprisSimilar trends were observed for rates of blue recreation events. However, the rate estimates were less precise, as the events were less common. Still, significant differences by school deprivation status were detected, whereby children from the most deprived schools  engaged in significantly more blue recreation events compared to those from the least deprived schools.This study aimed to quantify and understand trends in visual exposure to blue space and participation in blue recreation among children in the Wellington region of New Zealand. We found that, despite living in an island setting where exposure to blue space would be expected to be high, surprisingly, the children in this study were exposed to it only 3.6% of the observed time. We found no significant differences by ethnicity, overweight status, household deprivation, or residential proximity to coastline, with only weak to moderate correlations between exposure to blue space and residential proximity to coastline.Within the sample of children from Wellington, surprising trends by neighborhood and school deprivation were detected, whereby children from more deprived neighborhoods or schools had higher rates of visual exposure to blue space (and higher rates of blue recreation by school deprivation only). Few studies have directly examined exposure to blue space but since higher land values are often observed in coastal areas , it was A key strength of this study was the systematic use of wearable cameras and subsequent digital images to quantify children’s visual exposure to blue space and blue recreation in their everyday lives. This methodology enabled a more robust, objective measurement of exposure than other methods that are more prone to recall bias , and accessed the experiences of children, who are sometimes considered hard-to-reach as a study population . FurtherFuture studies could make use of eye-tracking technologies to quantify visual exposure to blue space. In addition, isolating the effects of different blue space exposure pathways on mental health would be a valuable contribution. For example, such studies could, by design, isolate the mental health benefits of visual  versus auditory  exposure to blue space. However, anthropogenic noise may interfere with the possible mental health benefits and, thus, should be accounted for in such future studies .In terms of linking blue space exposures to mental health, the most useful outcomes are likely indicators of stress (as opposed to severe outcomes like suicide), possibly using biomarkers, neuro-endocrine measurements or cognitive assessments rather than self-report. However, recent, parallel research on green space has shown associations between exposure and more severe mental health outcomes including depression and anxiety. This dose–response research found that neighborhood vegetative coverage of 20–30% yields lower stress, anxiety, and depression in dose–response analyses . SimilarA limitation of this study was that the images do not establish with certainty that a child is visually exposed to the elements detected in the images. For example, a child may be looking the other way when the blue space is recorded by the camera. Eye-tracking technologies would be one avenue to overcome this limitation. For this reason, this study conservatively claims that the visual exposures assessed in this study are “probable visual exposures” rather than “actual visual exposures”. Another limitation was the reliance on the user to both keep the wearable camera charged and to power it on/off each day during the study. Moreover, children’s compliance to the study protocol (not wearing cameras to protect third party privacy and protecting cameras by removing them during sporting activities) reduced the overall number of images captured, and may have led to unobserved blue recreation events. However, review of images leading up to camera removal meant this was unlikely. Therefore, compliance with the study protocol meant that the total possible observation time was reduced and the circumstances requiring removal of the camera typically occurred during daylight hours.The number of cameras and researcher person hours led to a year-long data collection period. In order to account for seasonal differences in daylight, we chose study hours that consistently have daylight throughout the year (and accounting for daylight savings). While visual exposure to blue space is unlikely to vary greatly across seasons, cloudy or overcast conditions may reduce visibility of features in the distance. Engagement in blue recreation may be more likely to differ seasonally or during rain events. Because the Wellington region does not experience dramatic shifts in temperature across seasons , this iImage analysis is a novel and reliable method for quantifying visual exposure to blue space and engagement in blue recreation. High rates of exposures during the weekday, in the morning, with peers, and while at school suggest that schools may be important settings to promote equitable blue space exposures. We also find that childhood exposures to blue space may not follow the expected income inequality trends observed among adults.


Cervical cancer can be prevented by early detection and treatment for precancerous lesions. Since 1995, there has been a national cervical cancer screening program in Norway, where women aged 25–69 years are recommended to take Pap smears every three years. There are 17 cytology laboratories covering a population of 5 million people. The detection rate of cervical abnormalities varies from laboratory to laboratory. We wanted to investigate the accuracy of cytology diagnoses by four different pathologists at three different hospitals in Norway.One hundred Pap smears  screened at UNN in 2015 were evaluated by four pathologists at three hospitals in Norway. All patients were followed up through December 2016. Histologically confirmed high-grade dysplasia (CIN2+) was considered as study endpoint.p<0.05). The accuracy for CIN2+ varied from 74.1% to 83.8% (mean 79.4%). The Pap smear from the woman with cervical cancer was diagnosed as high-grade (ASC-H+) by one of the four pathologists.The number of Pap smears evaluated as abnormal (ASC-US+) by the four pathologists varied from 61 to 85. The number of high-grade cytology (ASC-H+) varied from 26 to 50. There was moderate agreement (weighted kappa 0.45–0.58) between the observers. There were 32 women with high-grade histology (CIN2+) in the follow-up, including 19 CIN2, 12 CIN3 and one squamous cell carcinoma (SCC). Using high-grade cytology (ASC-H+) as cut-off, the sensitivity for CIN2+ varied from 68.8% to 93.8% (mean 77.4%) and specificity from 70.6% to 95.6% (mean 81.3%). The pathologist with the highest sensitivity for CIN2+ had the highest false positive rate and the lowest specificity  contains supplementary material, which is available to authorized users. Since 2015, there has been a pilot for HPV testing in primary screening in four counties [Cervical cancer is caused by human papillomavirus (HPV) and develops over many years through a series of precancerous steps , 2. The counties . In thiscounties . HoweverSince 1995, there has been a national cervical cancer screening program in Norway, where women aged 25–69 years are recommended to take Pap smears every three years [It is well known that cervical cytology has limited sensitivity and reproducibility –12. DiagThere is a high variability in detection rates across hospitals. This may be due to higher sensitivity, lower specificity, differences in HPV prevalence, cervical dysplasia and cancer in some parts of the country compared to other parts of the country, or a combination of these causes. We wanted to investigate the accuracy of cytology diagnoses by four different pathologists at three different hospitals in Norway.One hundred cervical cytological samples screened at UNN in 2015 with the diagnoses normal, ASC-US, LSIL, ASC-H and HSIL were sent to the Departments of Pathology in Bergen (HUS), Bodø (Nordland), Fredrikstad (Østfold), Stavanger (SUS) and Tønsberg (Vestfold). The pathologist at the Department of Pathology in Bergen did not have time to participate in the study, and he forwarded the slides to Stavanger without looking at them. Two cytotechnologist at the Department of Pathology in Fredrikstad diagnosed the slides, but they were trained to screen SurePath samples. Their results were therefore excluded from this study based on ThinPrep samples.All slides were first screened by a cytotechnologist at UNN and then evaluated by a pathologist at UNN . The abnormal cells were marked on the slides before being dispatched for the study. The slides were not screened at the other hospitals. The four other pathologists (P2–P5) at other hospitals were to only evaluate the abnormal cells marked on the slides. The other pathologists were blinded for age, previous findings, clinical information and HPV result. Diagnoses from each of the four pathologists were compared with diagnoses from the three other pathologists. Women with abnormal findings at UNN were followed up according to national guidelines. In Norway, the Bethesda System for Reporting Cervical Cytology is used by all laboratories. All patients were followed up through December 2016. Histologically confirmed high-grade dysplasia (CIN2+) was considered as study endpoint (gold standard). When calculating the sensitivity and specificity, women with normal Pap smears, and women with low-grade cytology (ASC-US / LSIL) and negative HPV test without histology, were considered free of high-grade dysplasia (CIN1-).t-test for continuous variables. For accuracy of cytological diagnoses between different observers, we used weighted kappa with linear weights.All analyses were done in IBM SPSS Statistics, version 23, with Chi-square test for categorical variables and Of the 100 cervical cytology samples, 20 were diagnosed Normal, 20 ASC-US, 20 LSIL, 20 ASC-H and 20 HSIL at UNN. There were 32 women with high-grade histology (CIN2+) in the follow-up, including 19 CIN2, 12 CIN3 and one squamous cell carcinoma (SCC). There were no CIN2+ in women with Normal diagnosis, one CIN2+ in women with ASC-US diagnoses, three women with CIN2+ in the LSIL group, 10 CIN2+ in the ASC-H group and 18 CIN2+ in the HSIL group (Table p<0.05)  had significantly fewer “Normal” cases than the average of the four pathologists (5) Table . The kapp<0.05) (Table p<0.05)  .In our study, the accuracy varied from 74.1% to 83.8% (mean 79.4%). In five published studies the accuracy varied from 64.2% to 78.4% (mean 76.1%) (Table www.kreftregisteret.no).There is a trade-off between sensitivity and specificity in cervical cancer screening. In our study the pathologist with the significantly highest sensitivity for CIN2+ had the significantly lowest specificity. In general, laboratories with a high detection rate of cytology also have higher sensitivity for CIN2+. If the sensitivity is higher, the hospital detects more women with CIN2/3 that can be treated, and fewer women develop cervical cancer before the next screening round. When women with low-grade cytology (ASC-US / LSIL) are triaged with HPV test, a high detection rate of low-grade cytology should not be considered as a major problem. A false positive ASC-US will have a negative HPV test and does not need follow-up. A false negative “Normal” cytology has no indication for HPV testing, according to Norwegian guidelines (P = 0.0015) [Cytology is subjective with poorly reproducible criteria. HPV testing is more objective with strictly defined criteria. Co-testing with both cytology and HPV test may reduce the risk of false negative cytology when the pathologists take the HPV result in consideration when evaluating the cytological slide. In our study, only the observer at UNN  knew the HPV result. All other observers were blinded for clinical information and HPV result, which might explain the lower sensitivity for CIN2+ for some of the other pathologist. Originally, in the ATHENA study, cytology was reviewed blinded to HPV status. When the same slides were re-reviewed unblinded to HPV status, the sensitivity for CIN3+ of co-testing increased from 54.1% to 62.4% ( 0.0015) . In our The present study also has other weaknesses. For P1 the diagnoses were set in normal routine work, while the cases for the other four pathologists had to be diagnosed in addition to normal workload. This might affect the interpretation. In addition, only P1 at UNN had access to the initial diagnoses suggested by the cytotechnician. In daily practice the pathologist usually compares his or her initial impression with the diagnosis suggested by the cytotechnician. If there is discrepancy, the slide is reviewed. This might explain the lower sensitivity of some of the other pathologist. In normal routine work, difficult cases will be discussed with other pathologists. In this study, the pathologists reviewed all the slides alone.www.kreftregisteret.no). This may delay diagnosis, treatment and worsen her prognosis.Out of the 100 women in this study, there was one woman with cervical cancer. Three of the four pathologists diagnosed her cytology as ASC-US. According to Norwegian guidelines, women with ASC-US and a positive HPV result should be followed up with a new cytology and HPV test after 6–12 months. Only women with persistent HPV infection should be referred to a gynecologist for colposcopy and biopsy (p<0.05) for CIN2+ between the observations, but not in accuracy. In a low resource setting, specificity is important to reduce colposcopy workload. In a high resource setting like Norway, sensitivity is more important to reduce the number of cervical cancer. Specificity of cytology can be improved by HPV test in a triage of ASC-US / LSIL. The costs of a high number of HPV tests are of minor importance in a high resource setting. In the USA, co-testing (cytology and HPV test) every five years is recommended for women 30–60 years of age [There were statistically significant differences in sensitivity and specificity (s of age , 14.Cervical cancer screening based on cytology has limited accuracy. The study revealed a moderate agreement between the observers, along with a trade-off between sensitivity and specificity. This might indicate that hospitals with high detection rate of cervical cytology have higher sensitivity for CIN2+, but lower specificity.


Many countries are transitioning from cytology-based to longer-interval HPV screening. Trials comparing HPV-based screening to cytology report an increase in CIN2/3 detection at the first screen, and longer-term reductions in CIN3+; however, population level year-to-year transitional impacts are poorly understood. We undertook a comprehensive evaluation of switching to longer-interval primary HPV screening in the context of HPV vaccination. We used Australia as an example setting, since Australia will make this transition in December 2017.Policy1-Cervix, we simulated the planned transition from recommending cytology every two years for sexually-active women aged 18–20 to 69, to recommending HPV screening every five years for women aged 25–74 years. We estimated rates of CIN2/3, cervical cancer incidence, and mortality for each year from 2005 to 2035, considering ranges for HPV test accuracy and screening compliance in the context of HPV vaccination .Using a model of HPV vaccination, transmission, natural history and cervical screening, Transient increases are predicted to occur in rates of CIN2/3 detection and invasive cervical cancer in the first two to three years following the screening transition . However, by 2035, CIN2/3 and invasive cervical cancer rates are predicted to fall by 40–44% and 42–51%, respectively, compared to 2017 rates. Cervical cancer mortality rates are predicted to remain unchanged until ~2020, then decline by 34–45% by 2035. Over the period 2018–2035, switching to primary HPV screening in Australia is expected to avert 2,006 cases of invasive cervical cancer and save 587 lives.Transient increases in detected CIN2/3 and invasive cancer, which may be detectable at the population level, are predicted following a change to primary HPV screening. This is due to improved test sensitivity bringing forward diagnoses, resulting in longer term reductions in both cervical cancer incidence and mortality. Fluctuations in health outcomes due to the transition to a longer screening interval are predicted to occur for 10–15 years, but cervical cancer rates will be significantly reduced thereafter due to the impact of HPV vaccination and HPV screening. In order to maintain confidence in primary HPV screening through the transitional phase, it is important to widely communicate that an initial increase in CIN2/3 and perhaps even invasive cervical cancer is expected after a national transition to primary HPV screening, that this phenomenon is due to increased prevalent disease detection, and that this effect represents a marker of screening success. With the introduction of HPV vaccination, and improvement of screening technologies for the secondary prevention of cervical cancer, several countries are planning a programmatic transition from cytology-based cervical screening to primary HPV screening.–4 Reductst 2017, from the current National Cervical Screening Program (‘pre-renewed NCSP’) involving two-yearly (once every two years) cytology to five-yearly (once every five years) primary HPV screening in late 2017 (‘renewed NCSP’). –57 55–57To identify the impacts of HPV vaccination and the changes to the screening program, we estimated rates and case numbers for histologically-confirmed CIN2/3, cervical cancer incidence and mortality under the following four scenarios: the base case  scenario assumed a transition from the pre-renewed NCSP to the renewed NCSP in 2018, taking into account the impact of the HPV vaccination program; Counterfactual scenario 1 assumed no change to the current NCSP and no vaccination; Counterfactual scenario 2 took into account the impact of the HPV vaccination program but assumed no change to the current NCSP; and Counterfactual scenario 3 assumed a transition from the pre-renewed NCSP to the renewed NCSP in 2018 but no vaccination. The base case scenario therefore reflects the best predictions of future outcomes, but other scenarios were modelled in order to unpack the various influences on these outcomes. Further information about specific management assumptions relating to the pre-renewed NCSP and the renewed NCSP can be found in Age-standardised rates and case numbers were estimated for each year from 2005–2035, for CIN2/3, invasive cervical cancer diagnosis, and cervical cancer mortality. Histologically-detected CIN2/3 rates were estimated per 1,000 women screened and per 1,000 women in the population. While it is common practice to present these rates per 1,000 women screened, in this analysis we focused on CIN2/3 detection rates per 1,000 women so we may directly compare between scenarios and years, which we have previously estimated will have vastly different numbers of women screened. The periFor the base case scenario (incorporating the effect of both HPV vaccination and the renewed NCSP) we produced detailed results for CIN2/3 histology, invasive cervical cancer incidence and cervical cancer mortality stratified by age, attributable HPV type i.e. HPV 16/18 versus oncogenic HPV (not 16/18), and stage at diagnosis (for invasive cancer).We estimated the cumulative lifetime risk (CLR) of cervical cancer mortality for cohorts born from 1971–2025 for the base case scenario. We considered women born in 1971 because they were the first cohort eligible to receive the benefit of organised screening from age 20 in Australia, and provided predictions for women born as late as 2025 to incorporate the impact on cumulative lifetime risks across all birth cohorts. All health outcomes were estimated for women aged 0–84 years.Sensitivity analysis on the multiple-cohort outcomes for the base case scenario was conducted . PreviouFor the scenario incorporating HPV vaccination and the transition to the renewed-NCSP (base case scenario), we predicted that in the first screening round (i.e. in 2018), age-standardised rates of CIN2/3 detection per 1,000 women will increase from 1.33 in 2017 to 1.65 (range: 1.55–1.65), a relative increase of 24% (range: 16–24%). Similarly, in the first round, cervical cancer incidence  will increase from 6.52 in 2017 to 7.46 (range: 7.25–7.61), a relative increase of 14% (range: 11–14%). That is, an additional ~4,084 histologically-detected CIN2/3 cases and ~129 invasive cervical cancer cases are expected in 2018 compared to 2017. However, by 2035, decreases are predicted in age-standardised rates of CIN2/3 detection ), invasive cervical cancer incidence  and cervical cancer mortality , compared to 2017 rates. Similarly, in 2035 ~3,958 fewer histologically-detected CIN2/3, ~239 fewer invasive cervical cancer diagnoses and ~40 fewer deaths caused by cervical cancer are predicted, compared to 2017. Ranges are obtained using results from the sensitivity analyses, and presented with the result from baseline analysis in The independent impact of HPV vaccination and screening on disease outcomes, age standardised rates of histologically-confirmed CIN2/3, invasive cervical cancer incidence and cervical cancer mortality over a 20-year time interval, from the screening transition, are shown in Rates of CIN2/3 detection per 1,000 women screened are predicted to be higher from 2018 to 2035 under the renewed NCSP than they would be if cytology-based screening were to continue , due botAs illustrated in During the first round of primary HPV screening starting in 2017, a transient spike is predicted in CIN2/3 attributable to HPV 16/18 and (to a lesser extent) oncogenic HPV (not 16/18) . Rates pStratifying cervical cancer incidence rates and case numbers by age, a transient increase, followed by a decrease, is predicted for both age groups 15–29 years and 30–49 years, with the largest decrease in the 30–49 age group . For womAs depicted in Cervical cancer mortality rates are predicted to steadily decline, from about 2020, following the transition to the renewed NCSP, driven by the continued effects of vaccination and screening . The perTo our knowledge, this is the first study to evaluate the implications on health outcomes of a transition to longer interval HPV testing on a programmatic scale, and to provide year-by-year estimates of health outcomes for more than three screening rounds after the transition from cytology to longer-interval HPV based screening. We found that in the year following the transition to the new primary HPV screening program, rates of histologically-detected CIN 2/3 and cervical cancer will increase by 24%  and 14%  respectively. Rates of high-grade histology and cervical cancer detection will continue to fluctuate, with CIN2/3 eventually falling by 40% (range: 40–44%) and cervical cancer incidence rates falling by 50% (range: 42–51%) by 2035 as compared to pre-renewed NCSP rates. The predicted decrease of HPV (not 16/18) attributable cancer in the simulated timeframe is lower than that predicted for HPV types 16/18. This is to vaccine impact on HPV 16/18; the overall patterns over time are also linked to the differences in management for women positive for HPV 16/18 vs non-16/18 oncogenic types. The transient increase in cervical cancer incidence and CIN2/3 after the first round of screening is in line with clinical trial observations, in which an increase in CIN2/3 detection is observed after the first round of screening due to improved test sensitivity. The predThere are many strengths to this study. We separately reported rates of cervical cancer incidence and high-grade histology detection assuming no impact of vaccination, no change in cervical screening, and for a scenario in which no changes are predicted to occur, which meant we could separate out the impacts of HPV vaccination and the change in cervical screening program. We used an extensively calibrated and validated multiple-cohort model of dynamic HPV transmission, vaccination, HPV natural history and cervical screening, which took into account detailed vaccination coverage rates as observed in Australia, the impact of herd effects and screening compliance rates as reported in registry data. Modelling of the new screening program was based on expert advice and the detailed management guidelines in the 2016 recommendations for the renewed cervical screening program.As for all modelled analyses, the predictions here are contingent on our assumptions and should thus be interpreted with some caution. The current analysis is based on currently available evidence, and explorations into the effect of future changes to screening participation, the National HPV Vaccination Program regime, vaccine uptake or cervical cancer treatment are outside of the scope of this analysis (these are the subject of ongoing work). Screening behaviour is assumed to remain constant over time apart from adapting to the renewed NCSP recommendations. This is a significant limitation because 1) women may change their screening behaviour leading up the switchover, 2) participation among currently under-screened women may improve as a consequence of them being able to access screening via self-collection , and 3) Another limitation is that the modelled analysis may underestimate the impact of HPV vaccination, for three distinct reasons. Firstly, we assumed no cross-protection against non-vaccine-included types; although some evidence shows that HPV vaccines provide a degree of cross-protection against HPV types 31, 33, 45, and 58, the long-term duration of cross-protection at a population level is more uncertain.,61 SeconAs a fourth limitation, we assumed use of the quadrivalent HPV vaccine for the cohorts modelled. At the time of this analysis, the quadrivalent vaccine was used in the National HPV Vaccination Program (NVHP), and this has been used for 11 years (since the implementation of HPV vaccination in 2017). However, a switch to HPV9, using a two-dose schedule, was recommended by Australia’s Pharmaceutical Benefits Advisory Committee in August 2017. VaccinatAnother limitation of this analysis is that it does not account for possible losses in vaccine confidence where vaccine coverage rates decrease significantly. For example, this type of event has been observed in Denmark, where HPV vaccine coverage rates have fallen. While suOur study has important implications both for health services planning, and for public communications about the transitional impact of the screening change. Most notably, it is important that screening policy-makers, providers and women are prepared for a transient increase in detection of high grade cervical abnormalities and cervical cancer; and that it is communicated that this represents a success of screening (increased detection with a more sensitive test) and not a failure. It is important to communicate that outcomes for women will continue to improve because of the innovations represented by HPV vaccination and HPV screening.S1 Appendix(DOCX)Click here for additional data file.


It was a highly successful event owing to the number of participants, the quality of the speakers, and the academic programme. Around 48 professors from 8 different countries came and shared their knowledge and experience of cancer management. They also talked about the most recent developments noted or achieved in this area. The keynote speech from Dr Nubia Muñoz was of great interest which was related to the safety of a HPV vaccine and the implications of a mass vaccination programme in developing countries. Geriatric oncology and palliative care were also topics that sparked great interest during the event.The first oncology conference organised by  It was a success owing to the amount of attendees (390) it constituted. They were radiotherapists, clinical oncologists, oncologist nurses, gynaecologists, haematologists, urologists, palliative care professionals, and medical students who welcomed the high quality guest speakers from Spain, France, USA, Chile, Mexico, Peru, Argentina, Cuba and Colombia.The First Oncology Congress organised by ecancer, Professor Umberto Veronesi, who recently passed away and left a large void in the field of global oncology. His medical, personal, and leadership qualities were admired by all in his lifetime. Undoubtedly, he was a great man who will be remembered and admired for many years to come.It was a heartfelt tribute to the co-founder of During the congress, the ‘Umberto Veronesi Award’, established by the man himself was given to Colombian oncologist Dr Haroldo Estrada for his work using film as a tool for communication and teaching. This was also in recognition of his services to both teaching and research in the city of Cartagena de Indias.The congress focused on topics that were considered to be of great importance for Colombia and Latin America in general . TherefoClosing the session, Professor Antonio Lombard, from the Instituto Valenciano de Oncología of Spain, spoke about gastrointestinal stromal tumours (GISTs). His talk was about its management and how new treatments have revolutionised the natural evolution of these tumours.Cervical cancer is a public health problem in developing countries. Nowadays it is a preventable illness. This is thanks to HPV vaccination and the study of the virus DNA which is more sensitive than the traditional Pap smear although more costly. In Colombia, both the vaccination and the DNA test are in the Obligatory Health Plan and are provided free of charge.A few years ago, the vaccination programme against HPV suffered a setback because of a misinformation situation. It arose because of an adverse event that was attributed to HPV vaccination. It left many with a big question mark as to its nature and applicability. Because of this we invited Dr Nubia Muñoz, globally recognised for her fieldwork on the role of HPV and cervical cancer, to talk to us about the effectiveness and security of a tetravalent and nonavalent vaccine in the prevention of infection from HPV. Her dissertation was very clear and useful in dissipating uncertainties and outlining plans to reactivate the vaccination programme . Dr NataLung cancer was another focus for the congress. This topic aroused the keenest interest among all those addressed and high expectations from the speakers. Dr Luis Larrea from Hospital NISA, from Valencia in Spain, illustrated what can be done with radiosurgery and the modern techniques in the management of these tumours. Dr Danay Saavedra, immunologist from the Centro de Investigaciones Moleculares in Cuba, spoke to us about the therapeutic vaccine CIMAVax-EGF and the results taken over several years in non-small cell lung cancer patients. The results were very interesting and raised many concerns among attendees , 6. Dr MThe haematology module focused on multiple myeloma and the recent advances made in its diagnosis, treatment, and prognosis. This disease/illness was explained by Dr Rocío Orduz and Dr Myriam Rodríguez from the Fundación Santa Fe4 de Bogotá . AnotherLastly, an entire session was dedicated to palliative care with the conviction that this forms a fundamental pillar in supporting oncological patients. Dr Juan Guillermo Santacruz spoke about the use of cannabinoids for nausea and pain relief.Another widely attended event was a workshop on radiotherapy advances. It was planned and developed by colleagues Beatriz and Marco Amendola from Miami, USA, in collaboration with other recognised radiotherapists from various countries. It was rated as excellent by 100% of the attendees.ecancer Latin America team. We hope to repeat it in 2018.For the Liga Colombiana contra el Cancer, it was an extraordinary experience and a privilege to have organised the first Oncology Congress in Colombia with the