More than 100 different mucosal types of human papillomavirus (HPV) have been identified. The existence of different HPV types at different sites of the human body was recognized in the late 1960s. Human papillomavirus infection is considered the most common sexually transmitted disease and can infect the ocular surface, as well . The modHuman papillomaviruses have been tangled in the pathogenesis and recurrence of conjunctival neoplasia, including conjunctival papillomas, conjunctival intraepithelial neoplasia (CIN) and even squamous cell carcinoma of the conjunctiva (SCCC). Human papillomavirus may coexist in SCCC lesions with other oncogenic viruses, such as the human immunodeficiency virus (HIV). According to their oncogenic potential, HPVs are divided into low - and high-risk types. The oncogenic properties of HPVs are attributed mainly to the viral oncoproteins E6 and E7. The involvement of HPV in the pathogenesis of pterygium remains controversial, although suggested by several studies using polymerase chain reaction (PCR) and immunohistochemical techniques.Human papillomaviruses are DNA viruses that have a marked tropism for squamous epithelium explaining the association of HPV infection with squamous cell papilloma of the conjunctiva. On the other hand, the role of HPV infection in the etiology of SCCC remains unclear -4.Human papillomaviruses types 6 and 11 are the most frequently found in conjunctival papillomas. Low-risk (LR) HPV 6 and HPV 11 are found in the majority of conjunctival papillomas along with dysplasia in several cases. In spite of such a dysplasia, carcinoma rarely develops in conjunctival papillomas. Other types found are HPV 33, HPV 45, and HPV 13. In addition, 6a and 45, two new subtypes, have been reported to be associated with conjunctival papilloma. On the other hand high-risk (HR) HPV 16 and HPV 18 have been also found in conjunctival papillomas; these types are strongly associated with the occurrence of high-grade uterine cervical intraepithelial neoplasia progressing to cervical cancer. However, according to the 2007 International Agency for Research on Cancer, available evidence on conjunctival carcinogenicity of HPV in humans is limited (Squamous cell carcinoma of the conjunctiva is a rare tumor that has been strongly linked with UV radiation and immunosuppression (particularly in HIV patients). Conjunctival intraepithelial neoplasia (CIN) is a precursor of SCCC but the role of HPV infection in the etiology of SCCC remains unclear. The DNA and mRNA of HPV 16 and HPV 18 corresponding to the E6 region have been detected in CIN. A few other studies have identified the presence of HPV 16 and HPV 18 in severe dysplastic lesions and carcinomas of the conjunctiva. HPV 6 and HPV 11 have also been found in severe dysplasias and carcinomas of the conjunctiva. In addition, mainly in HIV-positive patients, cutaneous HPV types (commonly HPV 5 and HPV 8) have been found in SCCC lesions. In contrast, a strong relationship of HPV and SCCC was not found in multiple other studies . Prevalence of conjunctival papillomas depends on geographical area, but generally is higher than that of conjunctival carcinomas. In some African countries with high HIV prevalence  a possible role of both HPV and HIV as co-factors in SCCC pathogenesis has been suspected, even though controversial. It is noteworthy that even though there are no cross-sectional epidemiological studies, evidence suggests that people without explicit clinical presentation may host the virus and HPV DNA can be identified in an even asymptomatic conjunctiva. However, the worldwide dissemination of HPV infection deserves our attention for the successful management of ocular morbidity .We have to bear in mind that, even though conjunctival papillomas are not life-threatening, they may be large enough to be displeasing or cosmetically unacceptable and affect vision. Furthermore, the recurrence rate for infectious papillomas is high; limbal papillomas have a recurrent rate of 40%. Therefore, accurate diagnosis is an indispensable step in preventing recurrences. The major clinical findings indicating conjunctival papilloma are papillomatous lesions  characterized by reiterating fibro-vascular cores with a geometrically arranged set of red dots. Squamous cell papilloma with an infectious viral etiology has the tendency to recur after medical and surgical treatment. Most papillomas are benign but rarely they can undergo malignant transformation what is visible as inflammation, keratinization, or symblepharon formation .The differential diagnosis of conjunctival papillomas includes a variety of tumors:1) Benign tumors of the surface epithelium (i.e. keratoacanthoma and actinic keratosis)2) Malignant lesions of the surface epithelium as CIN and SCCC,3) Conjunctival lymphomas,4) Vascular tumors (i.e. lymphangioma and capillary hemangioma),5) Nonpigmented conjunctival melanomas, and6) Secondary tumors.There is a diffuse variant of conjunctival squamous cell neoplasia that can mimic chronic conjunctivitis and the differential diagnosis is difficult in cases of tumor thickening. Therefore, a conjunctival biopsy should be considered in cases of conjunctivitis lasting more than three months. The diagnosis of squamous conjunctival neoplasia is typically made by biopsy and invasion spreading into the substantia propria beneath the epithelium defines these lesions as carcinomas , 6. Tumor within the conjunctival epithelium does not have access to the lymphatic system . This tumor can extend onto the cornea (avascular and opaque in appearance), around the limbus but rarely inside the eye and orbit. Squamous conjunctival neoplasia commonly contains characteristic corkscrew-shaped blood vessels .The medical history, slit-lamp examination, and the specific clinical and histopathological features of each tumor are used for accurate diagnosis. In the presence of a papillomatous growth pattern along with koilocytosis (nuclear pyknosis and cytoplasmic clearing), the morphological hallmark of HPV infection and mild epithelial dysplastic changes, further laboratory investigation to confirm the clinical diagnosis of HPV infection must be performed. Therefore, Immunohistochemical staining, in situ hybridization and PCR are the appropriate laboratory procedures in the detection of HPV and combination of the mentioned methods increases the diagnostic reliability , 5.Immunohistochemical staining concerns the detection of HPV and p16 protein. The p16 INK4a (p16) is a cyclin-dependent kinase inhibitor and shows marked overexpression in cancerous and precancerous cervical lesions caused by persistent infections with HR HPV types. Immunohistochemical staining of the biopsy specimens is a natural crucial step regarding conventional histopathological findings in HPV infections. It is possible to directly isolate HPV DNA from a biopsy specimen with in situ hybridization (ISH). This method, whatsoever, needs a large quantity of purified DNA, and its sensitivity is relatively limited, especially in obtaining cells from the ocular surface via non invasive methodologies (for example exfoliation cytology techniques). In cases where the biopsy specimen is small with a limited quantity of HPV DNA, nucleic acid amplification assays can be used to increase the sensitivity and specificity of the test. Therefore, the material provided by invasive methods is preferred for laboratory examination of conjunctival lesions with suspected HPV infection .Hybrid Capture II (HC-II) is a non radioactive signal amplification technique, accurate for mucosal lesions but is not appropriate for genotyping; it is useful in distinguishing HR from LR HPV types. Conversely, due to its high sensitivity, PCR is frequently associated with a high frequency of false-positive results. Southern blot, dot blot, reverse dot blot, digestion with restriction endonucleases or direct sequence analysis performed after DNA amplification can help increase the sensitivity and specificity of the test. More specifically real-time PCR or quantitative PCR (qPCR) permits rapid detection and quantification of the material during the various cycles of the PCR process , considered the first choice assay for the detection of viral gene expression , 7.However, the technique of sample collection, affecting the quantity of the HPV DNA of the isolated sample, and the use of various HPV DNA detection techniques with different sensitivity and specificity, are factors that may determine the detection rates of HPV infections. Combination of the described methods increases the rates of HPV detection. Nevertheless, it is imperative that a careful excision of the lesion and appropriate fixation of the specimen are preconditions for success of the diagnostic procedure. An excisional biopsy is preferred to an incisional biopsy whenever possible and consultation with a general pathologist or, ideally, an ophthalmic pathologist is compulsory. Performing an excisional biopsy is recommended to exclude premalignancy in adults .Regarding squamous cell neoplasia, the lesion is removed surgically. After that, cryotherapy is applied to the adjacent conjunctiva and appears to be an effective technique, especially for squamous cell papillomas. Carbon dioxide CO2) laser has also been used, what allows for precise tissue excision with minimal trauma and blood loss. Rapid healing occurs without significant scarring, edema, or symblepharon formation. Recurrence is low, resulting from the destruction of viral particles and papillomatous epithelial cells. Mitomycin-C (MMC) is an antineoplastic agent applied as 0.2 or 0.3 mg/mL dose via a cellulose sponge to the involved area(s) after surgical excision. The sponge is held in place for 3 minutes followed by meticulous irrigation. It is adjuvant to surgical removal but is also indicated for recalcitrant conjunctival papillomas or those refractive to previous multiple treatments; it is sometimes even administered to prevent recurrences of CIN and SCCC. In addition, amniotic membrane transplantation is used to restore extended conjunctival defects  Cimetidine (H2-receptor antagonist), indicated for recalcitrant and quite large conjunctival papillomas; cimetidine has been also found to enhance the immune system by inhibiting suppressor T-cell function and augmenting delayed-type hypersensitivity responses.2) Interferon is an adjunct therapy to surgical excision of nonrecurring or recurrent multiple lesions. Alpha interferon is given intramuscularly for several months. Because of its antiviral and antiproliferative properties, this form of therapy is designed to suppress tumor cells. Additionally, topical interferon alpha-2b has been shown to be an effective adjunct therapy for small-to-medium size lesions but not for large lesions without surgical excision. Topical interferon alpha-2b can be utilized as an adjunctive therapy for recurring conjunctival papilloma and it is successful in treating also CIN lesions.3) Dinitrochlorobenzene (DNCB), an immune modulator, may induce delayed hypersensitivity reaction causing the tumor to regress. The mechanism is not known. DNCB is applied directly to the papilloma once the patient has been sensitized to DNCB. This treatment modality is reserved for cases when surgical excision, cryoablation, and other treatment modalities fail .Concerning squamous cell papillomas, the prognosis is generally good. However, recurrences of viral papilloma are not uncommon. On the other hand, recurrences of completely excised squamous cell papillomas are uncommon.Surgical excision alone of CIN and SCCC lesions has been associated with frequent recurrences. This is because the tumor's edges and deep margins (often clear and avascular) are generraly difficult to determine, misleading the operator pretending the tumor is smaller than it is. Local freezing of the tumor nest (sclera and adjacent conjunctiva) has improved local management and decreased the incidence of tumor’s recurrence .According to another approach, radiation therapy is administered to decrease tumor’s recurrence rate. In addition, topical chemotherapy, or "chemotherapy eye drops" have been found effective in several clinical trials. Therefore, large clinical trial is needed to compare the effectiveness of topical chemotherapy to excision, cryotherapy and combinations .Intraocular penetration of tumor is extremely rare in developed societies; it is typically treated by enucleation of the eye or eye-wall resection. Orbital invasion brings along the risk of spread into the sinuses and brain, the most common cause of death related to this tumor. When squamous conjunctival neoplasia metastasizes outside of the eye and orbit, it can affect regional lymph nodes  or/and the lungs and bone. In general, early detection allows for removal of these tumors with excellent local cure rates. Outdoor occupation, living close to the equator, tendency to sunburns and history of actinic skin lesions are risk factors. Theoretically, decreasing of sun exposure may prevent squamous cell lesions . As already mentioned, the role of HPV infection in human eye disease is controversial, but it is likely that HPV6/11 plays a role in the pathogenesis of conjunctival papilloma , 7. HoweThus, in ophthalmology, the quadrivalent vaccine is expected to decrease the incidence of conjunctival papillomas due to HPV infection. In contrast, the HPV vaccination is not expected to prevent SCCC because HPV is not the main oncogenic agent in SCCC. Nevertheless, it will take many years before the benefits of a vaccination program become apparent, because even though papillomas occur in a relatively young, conjunctival carcinoma is usually a disease of the elderly . In addition, despite controversies in the medical literature concerning HPV involvement in pterygium development, the results of most studies agree that HPV is detected in at least a subgroup of pterygia. In these cases HPV infection may affect both pathogenesis and clinical behavior (including recurrence) of pterygium . Therefo.However, clinicians should be aware of a possible bilateral uveitis and papillitis following HPV vaccination . MultiplThe authors report no conflicts of interest in this work.


INK4a and Ki-67 expression, cells with integrated HPV and copy number gain of TERC and c-myc were quantified in a panel of 104 benign, intraepithelial neoplastic  and cancerous lesions using fluorescence in situ hybridization. Optimal cut-off values were calculated; Kaplan-Meier curves and a Cox proportional hazard regression model were used to evaluate prognostic signatures. The assay reliably identified HPV integration, TERC and c-myc copy number gain as determined by comparisons with established biomarkers. All biomarker levels increased with the progression of the disease. However, only c-myc copy number gain independently prognosticated a low probability of dysplastic regression. Our results suggest that c-myc plays a key role in the process of dysplastic transformation and might thus be exploited for treatment and follow-up decision-making of cervical dysplasia.Cervical carcinoma develops from preneoplasia by a multistep process. Although most low-grade dysplastic lesions will regress without intervention and even high-grade changes exhibit a substantial rate of regression, a small percentage of dysplasia will progress over time. Thus, indicators are needed to estimate the biological risk and to help avoid overtreatment in women who desire to preserve fertility. In addition to the classical biomarkers, PCR-ELISA-determined HPV genotype and immunohistochemically assessed p16 Squamous cell carcinoma (SCC) of the cervix continues to be the fourth most common malignancy in women worldwide and the fourth leading cause of cancer-related death, even though the tumor is nowadays virtually preventable through the combination of human papillomavirus (HPV) vaccination and screening programs. The early detection system of SCC is based on the fact that the tumor develops through a well-defined continuum of premalignant lesions  that can be identified and treated before malignant transformation. However, detailed insights into the natural history of SCC point out that not all untreated premalignant abnormalities would develop into cancer . Even foINK4a and the proliferation-associated gene Ki-67, reflect this deregulation of the cell cycle [TERC) gene at 3q26.3 and the protooncogene c-myc at 8q24.2 [TERC and c-myc copy number gains have been proposed as two of the most promising biomarkers [Several candidate prognostic indicators have been evaluated in the last years . Most oft 8q24.2 –13. Consomarkers .in situ hybridization (FISH) assay that simultaneously tested for HPV integration, TERC and c-myc copy numbers in formalin-fixed paraffin-embedded (FFPE) tissue specimens. Correlation with HPV genotypes and expression of the classical biomarkers p16INK4a and Ki-67 validated the FISH assay. Signatures were then tested for their potential to prognosticate the cumulative risk of persistent and progressive disease over time in a cohort of women that were followed-up and treated according to guidelines.Due to ethical limitations of follow-up research in preneoplastic changes the disease behavior according to the status of a specific biomarker is only poorly documented in the literature. We established a fluorescence TERC and c-myc FISH spots were of comparable intensity in HeLa cells prepared by liquid-based cytospin and tissue processing  and of c-myc in 81 (78%) cases.Integrated HPV, ocessing . We thenens Fig. . SuccessTERC and c-myc copy number gain suggesting a false-negative PCR result due to HPV integration that may have disrupted PCR primer target sequences. According to HPV genotype data also the prevalence of HPV integration was more frequent in cancerous and high- than low-grade dysplastic lesions .In the next step, we analyzed the cumulative hazard of persistence and progression over time in low- and high-risk groups. The risk of persistent and progressive disease was significantly elevated in patients with high c-myc copy number gain as a risk factor for the persistence and progression of dysplasia  led to the identification of a higher number of positive cells than did the hybridization with the small-sized TERC probe (495 kb). However, not only in FFPE tissue but also in cytological specimens a rate of unsuccessful hybridization for TERC of 16–47% has been reported [Although we have optimized the protocol for FFPE tissue a remaining limitation of the FISH-procedure was the inability to achieve successful hybridization for reported , 15.In agreement with previous data, our FISH analysis revealed low-level copy number changes in dysplastic transformations , 12. AlsINK4a and Ki-67. According to previous studies, staining values of both proteins increased stepwise with rising grades of malignant transformation [TERC copy numbers with rising grades of cervical lesions are similarly in agreement with previous work [TERC, which is the RNA matrix for telomere synthesis, has been identified in several cancer entities and its effects on tumor growth include both telomerase activity-dependent and -independent pathways [c-myc copy number gain are in line with previous findings showing an upregulation of c-myc parallel to increasing dysplastic transformation [Classical biomarkers are widely used for squamous differentiation including p16ormation , 19. In ormation , 13. Ourous work , 11, 13.pathways . Howeverpathways . Additioormation , 14.Our analysis focused on the capacity of biomarkers to provide information on the malignant potential of dysplastic changes. To date, only little information is available on rates of persistence and progression of dysplasia according to risk factors , 23. We c-myc copy numbers are prone to persist and progress. To the best of our knowledge, this is the first report providing evidence that c-myc copy number changes have the potential to identify precursor lesions at risk. It is well documented, that c-myc overexpression drives malignant transformation by controlling cellular proliferation, differentiation and apoptosis [c-myc has been shown to contribute to the development of several tumor types [c-myc region is a hotspot of HPV integration suggesting that the virus might alter gene copy numbers at this locus thereby harnessing c-myc for the course of the disease [c-myc gene [c-myc amplification in SCC [We found that lesions with high poptosis . Accordior types . In SCC, disease . Furthermyc gene , 33. Morn in SCC .TERC as a prognostic factor [In contrast to recent reports we were unable to identify c factor , 34–36. c factor  used CINc factor . Based oc-myc.The strength of our investigation lies in the histological verification of all cervical lesions. It is well known that studies using cytology cannot provide precise estimates of disease trends over time and that tissue specimens better reflect the course of the disease . HoweverTERC and c-myc copy number changes as well as the analysis of HPV genotypes and p16INK4a and Ki-67 overexpression is suitable for a reliable differentiation of cervical changes. However, only c-myc copy numbers independently identified high-risk groups for disease persistence and progression making it a potential future ancillary tool in risk determination and a valuable help in the clinical decision-making process.In conclusion, FISH-based detection of HPV integration, After approval by the Institutional Review Board of the Medical faculty FFPE tissue specimens were retrospectively collected from 104 patients treated between 2004 and 2008 at the University of Bonn. Clinical parameters were assessed using medical records; follow-up data were updated until June 2013. Samples obtained by colposcopy-directed biopsy were classified according to their histopathologic diagnosis based on World Health Organization (WHO) criteria: benign squamous lesions , squamous intraepithelial lesions , SCC. CIN I lesions were referred to as low-grade and CIN II and III as high-grade changes . Due to ® CCL-2™), maintained in DMEM/F12 supplemented with 10% FBS, 200 IU/ml Penicillin, 200 μg/ml Streptomycin and 1% L-Glutamine. The identity of the cell line was verified by DNA profiling . Using a cytospin centrifuge  2.5 × 104 HeLa cells were transferred to microscope slides, fixed with methanol / glacial acetic acid, air dried and stained. Alternatively, HeLa cells were fixed with 4% paraformaldehyde, suspended in 2% agar and paraffin-embedded.The FISH protocol was established using the human cervical cancer cell line HeLa  and screened for the presence of HPV-6/-11/-16/-18/-31/-33/-35/-45/-52/-56/-58 DNA according to a published protocol .1 monoclonal antibody  and the CINtec® Histology kit for the evaluation of p16INK4a .Immunostaining was performed on an automated staining system  using the streptavidin-biotin complex method. Antibodies included the mouse anti-human Ki-67 IgGINK4a and Ki-67 expression. Labeling indices were computed as the percentage of positive cells among the total number of epithelial cells scored in representative areas. For Ki-67 a nuclear staining was interpreted as positive. For p16INK4a a moderate or strong nuclear and cytoplasmic labeling was regarded as positive. We favored this simple method over a semiquantitative scoring system since both protocols gave similar results for the determination of p16INK4a expression [Immunostained cells were analyzed at 20x magnification with a Leica DM LB2 microscope . Continuous variables were generated for p16pression .TERC and c-myc copy numbers in FFPE tissue samples by modifying a previously reported method [TM-labeled 3q26 (TERC) probe, a SpectrumRedTM-labeled 8q24 (c-myc) probe and a biotinylated probe for HPV-16/-18/-26/-31/-33/-35/-39/-45/-51/-52/-53/-56/-58/-59/-66/-68/-82 (kindly provided by Abbott). The green fluorescent Alexa Fluor 488 tyramide  allowed visualizing the biotin-labeled DNA. Sections were further counterstained with 4,6-diamidino-2-phenylindole (DAPI). To account for potential problems of FISH in FFPE, especially with regard to the absence of probe signals and nonspecific hybridization, HeLa cells were used to confirm proper tissue treatment. In detail, the number of FISH signals in HeLa controls were counted and compared with the number of spots expected from the literature. Thus, we were able to identify the loss of target genes due to non-optimal assay conditions and to consequently repeat the assay when the correct pattern was not obtained.A FISH assay was developed for the analysis of HPV integration, d method . HeLa ced method –48. CytoTERC and c-myc copy number gain two consecutive analyses were performed. First, we enumerated TERC and c-myc FISH signals in 20 cells of hotspot areas defined as the region where the most atypical cells were found. In the next step, the average number of TERC and c-myc signals per cell was assessed. From these data, the cut-off between normal and abnormal was achieved (> 2 FISH spots / cell). Using this threshold cells with TERC and c-myc copy number gain were enumerated in the whole slide.Slides were analyzed at 100x magnification using a Leica DM5500 fluorescence microscope (Leica Microsystems) with a triple bandpass filter for simultaneous detection. The entire surface of each slide was evaluated for FISH analysis; in cases with a high amount of FISH signals only the first 50 spots or abnormal cells were recorded. For the determination of HPV integration cells with ≥ 1 punctate HPV FISH signal localized to the nucleus indicative of HPV integration were quantified; a diffuse nuclear pattern that constitutes episomal HPV was excluded from quantification. For the determination of p-values for tests with only a small number of counts were computed based on Monte Carlo simulations using 1.000.000 replicates. The cumulative risk of persistence or progression was assessed using the Kaplan-Meier method as a function of the length of the follow-up; the log-rank test was used to determine a statistical significance of differences. To define cut-off values samples were divided into two subsets, the training and the validation set. The former consisted of benign and SCC samples and was used to detect optimal thresholds by receiver operator characteristics (ROC) curve analysis. The precancerous samples were used separately to validate the cut-off points identified by the training set. To study the simultaneous effect of prognostic factors multivariate analysis was performed using the Cox proportional hazard regression model. The median follow-up time was calculated using the reverse Kaplan-Meier estimator [p-value of <0.05 were considered to be significant. Conservative Bonferroni correction for p-values was used to account for multiple testing. Analysis was performed using the statistical softwares SPSS version 21  and ‘R’ version 2.15.1 .Comparisons between continuous data were performed using the Mann-Whitney U test; comparisons between categorical variables were carried out using the Fisher's exact test; stimator . Results


The regression model that was developed based on the predictors had a moderate effect size (adj-R2 = 0.33). To conclude, the HPV vaccination rate among undergraduate students in Hong Kong was low. They should be provided with more active education and activities to promote HPV vaccination to improve their knowledge on the subject.The Human Papillomavirus (HPV) vaccine has the great potential to prevent HPV-related infections for millions of women and men worldwide. However, the success of the vaccine is highly dependent on the vaccination rate. Factors influencing the attitudes of undergraduate students towards HPV vaccination should be studied. This is a cross-sectional survey that was conducted to estimate the HPV vaccination rate among undergraduate students in Hong Kong, and to identify the predictors of their attitude towards HPV vaccination. The results showed that the HPV vaccination rate was 13.3%. Factors related to knowledge of vaccination were the main predictors of the students’ attitude towards vaccination (there were seven predictors, with B = 1.36 to 2.30;  The Human Papillomavirus (HPV) is one of the main causes of anogenital warts and cervical cancer . It is tIt is believed that HPV vaccines can effectively protect the recipient against such HPV-related diseases as cervical cancer, vaginal cancer, vulvar cancer, and genital warts . The HPVet al. [There are many studies investigating the perceptions of adolescent girls of the risk of contracting diseases related to HPV, the effectiveness and safety of the HPV vaccine, and their intention to receive the HPV vaccination . Accordiet al. , despiteet al. . This suet al. investigated the attitudes of male college students in Thailand towards HPV vaccination [Regarding studies on male attitudes, these have mostly been conducted in foreign countries. One of the studies conducted by Songthap cination . The resAcceptance of the HPV vaccine might be influenced by factors affecting the decision-making process that individuals go through when deciding whether or not to be vaccinated. Several local studies have consistently suggested that the cost of the HPV vaccines is a major barrier to their acceptance by mothers and female adolescents ,11,15,16et al. in England indicated that more than 50% of girls aged 15–16 had little knowledge about HPV, the vaccine, and the need for future screening, even if they had been vaccinated [et al. also noted that among whites and Hispanics, males were less aware and knowledgeable about HPV and the HPV vaccine than females [A local study found that young teenage girls aged 13–20 had a limited knowledge of HPV and its relationship with cervical cancer . For exaccinated . Female ccinated ,29. Reim females . There hThere have been many studies investigating the attitudes of school students and their parents toward HPV vaccination, but research focusing on young adults is limited ,13,14. AThis is a cross-sectional survey that was conducted in a major university in Hong Kong from April to September 2015.Convenience sampling was conducted to recruit subjects for this study. There was no special event or news related to HPV according to the press releases issued in the study period by the Centre of Health Protection and the Department of Health. The selected university has 18,777 undergraduate students, 13,954 of whom were enrolled in publicly funded programs. These students constitute 17.25% of the total number of publicly funded undergraduate students in Hong Kong. The result of the sample size calculation showed that at least 377 students are required to keep the margin of error within 5% and the confidence level at 95% . A set oThe criteria for inclusion were: (1) undergraduate students studying in the selected university; and (2) capable of communicating in English. The criteria for exclusion were: (1) undergraduate students under the age of 18; (2) students from Mainland China and overseas; and (3) undergraduate students 25 years of age or older. Students from Mainland China were excluded because they only comprised around 8% of the undergraduate students in the university . MoreoveThe set of questionnaires used in this study was modified from a study conducted by a Thai research team that was also investigating similar issues among Thai students . The eigt-test was adopted because only two groups of students were involved in this cross-sectional study. Finally, through a bivariate analysis, the students’ socio-demographic and medical backgrounds, and their acceptance and knowledge of HPV vaccination were correlated with their total score on their attitude towards HPV vaccination. Potential predictors with a p-value of smaller than 0.1 found in the bivariate analysis were further analyzed using multivariate regression analysis, in order to further confirm the significant predictors of the students’ attitude towards HPV vaccination. All of the statistical analyses were conducted using SPSS version 23 . The alpha level was set at 0.05.Descriptive statistics were used to identify a general picture of the demographics and medical backgrounds of the students, and their attitudes, knowledge, and acceptance of HPV vaccination. To compare gender differences in the students’ attitude and knowledge of HPV vaccination, an independent sample Before completing the questionnaires, the subjects were well informed about the purpose and contents of the study. They were given an information sheet and asked to sign a consent form to document their voluntary participation. They were also informed that their participation was totally voluntary and that they had the right and freedom to withdraw from the study at any time without providing a reason. This study was approved by the Human Subjects Ethics Committee of the related university (HSEARS20150326003).A total of 520 sets of questionnaires were distributed; 437 sets of completed questionnaires were collected, for a response rate of 84%.The estimated vaccination rate was 13.3%, with the female vaccination rate (24.4%) being significantly higher than that of the male (0.5%). Virtually all of the participants had no history of cervical cancer (100%), genital warts (99.5%), or anal cancer (99.8%). Around 90% of them had heard about cervical cancer (87.9%) and the HPV vaccine (92.2%), with television being the main source of this information (around 75%), followed by the Internet, newspapers/magazines, and their healthcare provider . More than two-thirds of them stated that they would like to be vaccinated if the HPV vaccine can protect them against cervical/anal cancer and genital warts (69.6%), while one-fifth of them were unwilling to be vaccinated (19.5%) .Near half of the subjects preferred to be vaccinated at the health clinic of a university (43.2%) followed by a public hospital (34.1%). Of the participants, 77.6% believed that both males and females should get the vaccination equally if the HPV vaccine can protect against both cervical cancer and genital warts, while only 22% of them believed that “only females” or “females should get the vaccine rather than males”. If the HPV vaccine is beneficial for adolescents who are not sexually active, most of the respondents believed the ideal age for vaccination to be between the ages of 11 and 18, with 15–16 years old being the age range chosen by the largest percentage of respondents (26.8%) .Regarding expectations of the appropriate price for HPV vaccination, most of the respondents chose the lowest price option (<$500). Regardless of the efficacy of the vaccine, the proportion of respondents who indicated that the price was acceptable decreased as the price increased a,b. The i.e., 3), with the exception of the following four statements: “(1) I think I can be easily infected by HPV” ; “(4) People with only one sexual partner have a low risk of getting infected with HPV” ; “(11) Women are embarrassed to get a Pap test” ; and “(20) I need extra information about the efficacy of the vaccine”   .p < 0.05); “(11) Women are embarrassed to get a Pap test” (p < 0.05); “(12) HPV vaccination is not necessary because a Pap test can be done to rule out cervical cancer” (p < 0.01); and “(13) It is better to be vaccinated before becoming sexually active” (p < 0.05)  Cervical cancer is not a big problem for women” ( < 0.05) .Regarding knowledge of HPV vaccination, it was found that a high proportion of questions were answered incorrectly. In particular, there were five questions that received a correct response from less than one-third of the respondents. The questions were: “(1) More than 50% of sexually active women in Hong Kong have been infected with HPV once in their life” (14% correct); “(2) More than 50% of sexually active men in Hong Kong have been infected with HPV once in their life” (8.9% correct); “(7) Having a single sexual partner can prevent HPV infection” (24.9% correct); “(12) HPV that causes cervical cancer and genital warts is the same type” (30% correct); and “(15) Women over the age of 50 should start to get a Pap test” (26.5%) .vs. females 70.1%, p < 0.05); “(20) It is good to get vaccinated against HPV after becoming sexually active” ; “(21) The HPV vaccine is available in Hong Kong now” ; and “(22) The HPV vaccine can provide 100% protection against HPV-related diseases”  (Significant gender differences were seen in the responses to the following four questions: “(18) Women who were vaccinated against HPV do not need to get a Pap test”  .p-value of smaller than 0.1. The final regression model included 10 predictors. Three of them were on gender, the acceptable maximum price of the vaccine when the efficacy is 100% for cervical cancer and genital warts, and the willingness to receive the HPV vaccine if it can protect against cervical/anal cancer and genital warts. The regression coefficients showed that female students, students willing to receive the HPV vaccine, and students who would pay a higher acceptable maximum price were likely to have a better attitude towards HPV vaccination. The remaining seven predictors were about the correctness of answering questions related to the HPV vaccine. All seven predictors indicated that students who correctly answered the questions had a better attitude towards HPV vaccination. The overall adjusted R2 of the regression model was 0.33, which was considered large  are at a higher risk of contracting HPV than heterosexual men, and a higher perceived susceptibility among this group should be anticipated. The study also found that MSM were more capable of getting the HPV vaccine than heterosexual men [First, as convenience sampling was used and all of the respondents were from the same university, the results may not be representative enough for the findings to be generalizable to the entire population . Studentxual men . In addiThis study found that male undergraduate students have a lower perception of the risks of HPV infection, which may be due to a knowledge deficit. Public health professionals and policy makers should conduct better health promotion efforts in universities based on the factors and knowledge deficit that have been identified, in order to increase HPV vaccination among undergraduate students. Promotion of HPV vaccination may be delivered through an online platform or on television, which, according to the results of this study, are the two most common channels through which information about HPV is acquired. The health promotion activities should also focus more on male vaccination, due to the very low male vaccination rate. Emphasizing the link between HPV infections and genital warts may draw more attention from males than emphasizing cervical cancer only. The government might also provide some financial subsidies, which could increase the willingness of students to get vaccinated. A vaccination promotion program and registry should be established, thus providing a more reliable source of HPV vaccination rate and statistics. Further studies could be carried out to investigate factors affecting the attitudes towards vaccination of people in homosexual relationships, e.g., MSM.The knowledge and awareness of local undergraduate students in Hong Kong concerning HPV infection is not high and their HPV vaccination rate is relatively low. More aggressive education and promotion activities on HPV and HPV vaccination should be organized for undergraduates, especially for male students, as their knowledge and attitude towards the subject is poorer than that of female students. Awareness of HPV infection should be promoted among male students.


High-risk human papillomavirus (HPV) has been suspected to play a role in the carcinogenesis of epithelial ovarian cancer (EOC). However, results from previous studies are conflicting. In most of these studies, the number of tissue samples was small. The current study was therefore undertaken to examine the prevalence of high-risk HPV DNA in EOC in a large series of patients.Formalin-fixed, paraffin-imbedded tumor tissue samples from 198 cases consecutively included in the Danish Pelvic Mass Study were analyzed. The material included 163 serous adenocarcinomas, 15 endometrioid adenocarcinomas, 11 mucinous adenocarcinomas and nine clear-cell carcinomas. Genotyping for high-risk HPV DNA was performed by real-time Polymerase chain reaction (PCR) using an in-house TaqMan singleplex assay targeting the E6/E7 region of the HPV 16 and 18 genomes. Additionally, 20 random samples without HPV 16 and/or 18 infections were reanalyzed for HPV subtypes 31, 33, 35, 39, 45, 51 and 52.The quality criteria were fulfilled in 191 samples. HPV 18 DNA was detected in one sample only, while the rest tested negative. The subgroup analysis for seven additional high-risk HPV subtypes was also negative.Only one in 191 samples was positive for HPV DNA. We therefore conclude that high risk HPV is unlikely to be associated with EOC in a Caucasian population. Future studies should focus on other microorganisms as possible etiological factors in EOC carcinogenesis.The online version of this article (doi:10.1186/s13027-016-0087-4) contains supplementary material, which is available to authorized users. Epithelial ovarian cancer (EOC) is the most lethal cancer of all the gynecological cancers. It is characterized by late and unspecific onset of symptoms and thus the presence of disseminated disease at the time of diagnosis . Ten perThe study was a part of the Danish Pelvic Mass Study, a prospective, ongoing collection of blood and tumor tissue samples. Oral and written consent were given by each patient before enrollment, and the Danish Ethical Committee approved the study protocol . Ninety-five percent of patients that were eligible for inclusion accepted to participate. In the period from 2004–2010, 246 patients with EOC were consecutively included. The study was a single center study  in the first few years, accounting for the relatively low rate of inclusion. The study has since expanded to be nation-wide. The patients were included when admitted to the tertiary center, the Gynecologic Clinic, Copenhagen University Hospital, Copenhagen, Denmark due to a pelvic mass or pelvic pains potentially caused by EOC. Patients with preoperatively known relapse of previous cancer or an active cancer other than EOC were excluded. Forty-eight patients were excluded for the following reasons: 24 patients were excluded due to insufficient tumor tissue for analysis. Fifteen patients were excluded since they had been treated with neoadjuvant chemotherapy. An additional eight patients were excluded after pathology revision, since two patients did not have EOC, four patients had carcinosarcomas and two patients had an additional cancer diagnosis. Patients were examined according to the Danish Cancer Fast Track Guidelines. All patient data were registered continuously online in the Danish Gynecologic Cancer Database by gynecologists, pathologists and oncologists. Biological material was collected and stored at the time of surgery through the Danish Cancer Biobank . For theA pathologist, specialized in gynecological oncology, revised tumor FFPE material and a 2-mm biopsy punch was then used to sample the tumor tissue. DNA extraction was carried out on a Qiagen® Qiacube using the DNA FFPE kit. DNA concentration was measured on Nanodrop® and diluted to 5 ng/μl. Genotyping was performed with an in-house singleplex assay based on published studies by Lindh et al.  for subtThe tissue material included in this study consisted of 163 serous adenocarcinomas (82.3 %), 15 endometrioid adenocarcinomas (7.6 %), 11 mucinous adenocarcinomas (5.5 %) and nine clear cell neoplasms (4.5 %). The International Federation of Gynecology and Obstetrics (FIGO) stage distribution of the study population was as follows: 31 had stage I EOC (15.7 %), 20 patients had stage II (10.1 %), 122 had stage III (61.6 %) and 25 had stage IV EOC (12.6 %). The median age was 64 years (range 31–89 years). No differences in age, stage and distribution of histology were found between the 198 included patients with EOC and the 24 patients with EOC excluded due to insufficient tumor tissue. Please be referred to Table The carcinogenic potential of high-risk HPV is well described and includes several mechanisms. Viral oncogenes E6 and E7 are pivotal elements, since expression of these genes impairs the function of host-cell tumor suppressors p53 and retinoblastoma protein, thus favoring malignant transformation , 24. FurTNFA-308G/A (rs1800629) and -238G/A (rs361525) or the p53 codon 72 polymorphism [The strength of the present study was the large number of samples compared to previous studies. In addition, the detailed description of the characteristics of the patients, including information on tumor histology and FIGO stage, should be noted. Some limitations should also be addressed. Indeed, HPV DNA detection may be less optimal in FFPE tumor material compared to fresh frozen tissue due to nucleic acid degradation , 36. Rec13morphism . Despitemorphism . This spOur results do not support the theory that HPV is associated with EOC. However, other microorganisms may play a role in the development of EOC. Thus, pelvic inflammatory disease (PID) has been associated with an increased risk of EOC in some epidemiological studies that also report a dose–response effect, with more episodes of PID associated with a stronger risk of EOC , 46. OthThe present comprehensive study of 198 patients with EOC does not support an association between high-risk HPV infection and EOC. It confirms the findings from previous, smaller, studies that also report no or little association in Western countries. Future studies examining the role of infectious agents involved in the pathogenesis of EOC should focus on other microorganisms as possible etiological factors in EOC carcinogenesis.EOC, epithelial ovarian cancer; FFPE, formalin-fixed and paraffin-embedded; FIGO, international federation of gynecology and obstetrics; GAPDH, glyceraldehyde-3-phosphate dehydrogenase; HPV, human papillomavirus; PCR, polymerase chain reaction; PID, pelvic inflammatory disease


Human papillomavirus (HPV) self-sampling (Self-HPV) may be used as a primary cervical cancer screening method in a low resource setting. Our aim was to evaluate whether an educational intervention would improve women's knowledge and confidence in the Self-HPV method.Women aged between 25 and 65 years old, eligible for cervical cancer screening, were randomly chosen to receive standard information (control group) or standard information followed by educational intervention . Standard information included explanations about what the test detects (HPV), the link between HPV and cervical cancer and how to perform HPV self-sampling. The educational intervention consisted of a culturally tailored video about HPV, cervical cancer, Self-HPV and its relevancy as a screening test. All participants completed a questionnaire that assessed sociodemographic data, women's knowledge about cervical cancer and acceptability of Self-HPV.A total of 302 women were enrolled in 4 health care centers in Yaoundé and the surrounding countryside. 301 women (149 in the “control group” and 152 in the “intervention group”) completed the full process and were included into the analysis. Participants who received the educational intervention had a significantly higher knowledge about HPV and cervical cancer than the control group (p<0.05), but no significant difference on Self-HPV acceptability and confidence in the method was noticed between the two groups.Educational intervention promotes an increase in knowledge about HPV and cervical cancer. Further investigation should be conducted to determine if this intervention can be sustained beyond the short term and influences screening behavior.ISRCTN78123709International Standard Randomised Controlled Trial Number (ISRCTN) Register  In developed countries, cervical cancer screening with Pap smear and treatment of precancerous lesions has led to an important reduction of invasive cervical cancer incidence and mortality VIA and VILI are attractive screening tests for low-resource countries, because they give an immediate result and allow treatment of abnormal lesions during the same medical visit in a “screen-and-treat” approach Prior to introducing a new screening method, it should be determined if the test is acceptable for the target population. This requires women's understanding of the role of HPV infection and its link with cervical cancer. Previous studies conducted in sub-Saharan African countries report a low awareness of HPV infection and cervical cancer indicating the need to inform the population To date, very few studies describe the effects of educational interventions on cancer prevention in sub-Saharan Africa The protocol for this trial and supporting CONSORT checklist are available as supporting information; see The required sample size (182 participants) was calculated for a comparison of proportions with an α of 0.05 and a β of 0.20, assuming that a difference of at least 20% for the primary outcome between interventional group and control would be scientifically interesting. The thus determined sample size was 182 participants. As we experienced high dropout rates in our previous studies in Cameroon and to answer the on-site demand of inclusion we recruited 66% more participants than calculated as at least necessary.During July and August 2012, we recruited women aged between 25 and 65 years in 4 health care centers in Yaoundé and the surrounding countryside. Our visits to the health care centers were prepared by the local staff by word-of-mouth advertising and the suspension of informational posters indicating the dates of our visits, eligibility criteria and content of the study. The information clarified as well that the participation in the study with screening test and further investigations and treatment, if necessary, was free of charge for the participants. Interested women were invited to present themselves on the days of sampling.Exclusion criteria included current menstruation, current pregnancy, previous hysterectomy or cervical surgery. A written informed consent was obtained from all participants.Participants were randomized in groups of 10 by order of arrival alternating into intervention or control group. We used subunits of 10 women instead of alternating one by one by order of arrival to avoid waiting time and diffusion of information given during the intervention in the waiting room .“Basic information” was provided to all participants involving a discussion of approximately 5 minutes consisting of a brief explanation about the cervical screening campaign conducted by the University Center Hospital of Yaoundé and University Hospitals of Geneva and the use of Self-HPV as our method for cervical cancer screening. Explanations on how to perform the test were also given to all participants. The intervention group received in addition to the “basic information”, an “educational intervention” in the shape of a culturally-tailored video promoting a positive attitude towards cervical cancer screening. The video took 6 minutes to explain the role of HPV in cervical cancer and pre-cancer as well as the way to perform the Self-HPV test, its reliability and its relevancy as a screening test; see Primary outcome was the knowledge about cervical cancer. Secondary outcome was the acceptability and confidence/trust in the Self-HPV. To address these outcomes we designed a questionnaire consisting of 3 parts:The first part assessed socio-demographic characteristics , sexual behavior  and gynecological history .The second part assessed knowledge about cervical cancer, screening and HPV. This part consisted of 7 closed-ended questions with 3-point scaled answers . Does HPV cause AIDS? (No), Does HPV cause Cervical Cancer? (Yes), Is HPV a Sexually Transmitted Disease? (Yes), Can men be infected with HPV? (Yes), Does a vaccination against HPV exist? (Yes), Can HPV induced lesions be treated? (Yes).The third part evaluated Self-HPV acceptability by assessing embarrassment, pain, anxiety, discomfort, degree of relaxation and confidence. Responses were evaluated on a 4-point scale as follows: “not at all”, “slightly”, “moderately” and “very”.The general willingness to perform Self-HPV was tested by evaluating the willingness to perform Self-HPV regularly and whether participants would recommend Self-HPV to friends and/or family. Furthermore we evaluated the preferred sampling side and the willingness to perform Self-HPV at home. We drafted this third part based on the methodology of previous studies This questionnaire was addressed to all participants. All women answered part 1 of the questionnaire onto inclusion. The control group answered part 2 and 3 after performance of Self-HPV. The intervention group answered these two parts following the educational intervention and Self-HPV.OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 2.3.1. Mann-Whitney-U-test and chi-square test were used to analyze differences between intervention and control group. Tests were considered statistically significant when the p-value was <0.05.All statistical analysis were performed using Microsoft Office Excel 2007 and th to August 8th 2012 (approbation number: 159/CNE/SE/2012). The trial was registered with ISRCTN (registration number: ISRCTN78123709). The authors confirm that all ongoing and related trials for this intervention are registered.The study was approved by the National Research Committee of Cameroon in early July 2012 for an recruiting period from July 24A total of 302 women were randomized of which 301 completed the full process and were included in the analysis. One subject was excluded because she did not answer the questionnaire. The randomization divided 152 women in the interventional group and 149 in the control group. The women were from Yaoundé or its surroundings with an average of 19 minutes walking distance from their home to the healthcare center (range 1–120 min). They were essentially French speakers (97%) and Christian (59.8% catholic and 23.9% protestant). The mean age was 38.3 years (range 25–65 years). Most of them were married (56.1%) and had children (88.0%) with a mean number of 3.6 deliveries. The mean age of first sexual intercourse was 17.7 years and mean number of sexual lifetime partners was 3.7. The majority of them were educated . Twenty-five percent indicated having had at least one previous cervical cancer screening by a health-care professional .Women in the intervention group showed significantly higher knowledge about HPV than women in the control group (p<0.05) . AcceptaA group of 17 women (5.6%) considered that they had religious beliefs, which were contradicting Self-HPV, however all of them performed Self-HPV voluntarily during the study. 5 women (1.7%) felt unable to judge whether their religion allowed Self-HPV and 276 (91.7%) confirmed that they had no religious belief against Self-HPV. Inquiring the need of their partner's approval to perform Self-HPV 52 women (17.3%) answered that they needed their partner's agreement, 8 women (2.7%) did not know or did not answer and 241 (80.1%) responded that they did not need their partner's agreement to perform Self-HPV.“To know the HPV status” (n = 15), “Because Self-HPV is easy to do” (n = 7), “quickly performed” (n = 2) and “because it is better to screen than to treat” (n = 2).A total of 291 women (96.7%) would recommend Self-HPV to their friends or family . Among tPromoting cervical cancer screening in low resource settings like sub-Saharan African countries should be an important issue for health policy makers. To date, only a limited number of studies about educational interventions for cancer prevention were conducted in sub-Saharan Africa Our findings support that a culturally sensitive short video-based intervention influenced and improved knowledge about HPV and cervical cancer. These results were consistent with other studies where video interventions improve knowledge and uptake of available screening methods for colorectal cancer Our results indicated that Self-HPV was well accepted by participants and that most of them felt confident about their self-performance. They would also recommend the test to others or would do it again if they had the opportunity. Overall acceptability did not differ between the control and interventional group and analysis of subscale scores did not show that participants perceived Self-HPV differently or were less confident of their ability to perform it. We noticed that the educational intervention did not affect the willingness to perform Self-HPV probably because the participant's motivation was already high before the educational intervention Important determinants to be considered for Self-HPV implementation were religious believes and the entourage's approval, as they may be a barrier to the participation in screening The strength of this study was its large sample size, drawing participants from different areas of Yaoundé, and the use of validated measures for assessing acceptability for HPV self-sampling. One weakness was that acceptability may be overestimated as this study was voluntary-based. The study was conducted in healthcare centers, in which the women were seeking healthcare and where the availability of health workers was higher, thus providing more health information than in other settings. This more welcoming setting and the voluntary participation may limit the generalization of the high acceptability of Self-HPV detected in our study. Finally, as women agreed to perform Self-HPV as a condition of study participation, they may represent a group that had higher knowledge about cervical cancer screening as well as a higher Self-HPV acceptability than others. Notwithstanding the limitations of the study, an educational intervention did not improve knowledge, and Self-HPV could be pointed out as one of the main instrument for future cervical cancer prevention in low resource settings like Cameroon.Finally, healthcare centers appeared to be a favorable place for Self-HPV. It was the same case in Uganda In conclusion, a simple educational intervention can lead to significant improvement in health knowledge. No significant difference of acceptability to perform Self-HPV test was observed between women with good or poor knowledge as acceptability to perform Self-HPV was notably high in both groups.Further information would be required in order to understand the relation between the improved knowledge and cervical cancer screening adherence.Checklist S1CONSORT checklist.(DOCX)Click here for additional data file.Protocol S1Trial protocol in English.(DOCX)Click here for additional data file.Protocol S2Trial protocol in French.(DOCX)Click here for additional data file.Video S1Video with English subtitles. A culturally-tailored video explaining the role of HPV in cervical cancer and pre-cancer as well as the way to perform the Self-HPV test, its reliability and its relevancy as a screening test. The video is available, in French with English subtitles.(MP4)Click here for additional data file.


We aimed to study the relationships between educational level, women's knowledge about cervical cancer (CC), and acceptance of HPV vaccination for their daughters.We analysed data from a quantitative (self-administrated questionnaire) and qualitative (semi-structured interviews) cross-sectional study performed in 2008 among 1,229 French 18–65-year-old women recruited by general practitioners. Women were categorized into three educational level groups: low (LEL: 43.9%), medium (MEL: 33.4%) and high (HEL: 22.6%).Knowledge about CC and its prevention was lower among LEL women. In the 180 mothers of 14–18-year-old daughters , acceptance of HPV vaccine was higher in LEL (60.4%) and MEL (68.6%) than in HEL mothers (46.8%). Among LEL mothers, those who were favourable to HPV vaccination were more likely to be young (OR = 8.44 [2.10–34.00]), to be vaccinated against hepatitis B (OR = 4.59 [1.14–18.52]), to have vaccinated their children against pneumococcus (OR = 3.52 [0.99–12.48]) and to present a history of abnormal Pap smear (OR = 6.71 [0.70–64.01]).Although LEL women had poorer knowledge about CC and its prevention, they were more likely to accept HPV vaccination than HEL mothers. Human Papillomavirus (HPV) provides a new opportunity to decrease the CC burden. Since 2007 in France, the HPV vaccine has been recommended for all girls and young women aged 14 and aged 15–23 years who are within the first year of sexual activity A total of 2,800 cases of cervical cancer (CC) leading to 1,000 deaths occurred in France in 2011 Mothers play a crucial role in the uptake of vaccination, and it is therefore important to assess factors associated with their intention to vaccinate their daughters, especially in underserved populations. Knowledge of the link between CC and HPV is very poor among the less well educated Most studies on HPV vaccination perceptions in underserved population have been performed in developing countries, in ethnic minorities or in the United States Our objectives were 1) to assess knowledge about CC, PS and the HPV vaccine among 18–65 year-old women in relation to socio-economic status measured by educational level; and 2) to investigate determinants of HPV vaccine acceptance among mothers of low educational level. The latter investigation was focused on women with daughters aged 14–18, an age range chosen to encompass girls above the age at which vaccination is recommended in France and below the age at which they can themselves legally assent to the procedure.This study was part of the REMPAR  programme aimed at evaluating means of preventing HPV-mediated disease.This study is based on the data collected for the HPV-FEM study Socioeconomic status was defined by educational level. It has been shown that women with low educational status have a higher cancer and CC incidence and mortality rate The HPV-FEM study used two interrelated methodologies: quantitative, by self-administered, anonymous questionnaire, and qualitative, with face to face semi-structured interviews. Women who agreed to participate were asked to complete the questionnaire after their GP consultation and before they left the practice premises. The questionnaire has been described elsewhere in detail We compared the characteristics and knowledge of women according to educational level and analyzed factors related to the acceptability of the HPV vaccine among LEL mothers of a 14–18 year old daughter: women favourable to vaccination were compared against those who were unfavourable (ie uncertain or opposed) . CategorThis study was approved by the French National Committee for personal data protection in medical research. Each included women was given oral information and a written information notice by her GP. In accordance with the French regulatory on research participation, a verbal consent was obtained by the GP for women who filled the questionnaire and a written consent was obtained for women who participated to interviews with the sociologist.On the 1,478 women included, 100 (6.8%) were students at the time of the study and 149 (10.1%) did not provide information on their educational level. As a result, data from 1,229 women were analyzed, of whom 540 (43.9%) were categorized as LEL, 411 (33.4%) MEL and 278 (22.6%) HEL. A total of 188 (15.3%) were mothers of at least one 14–18 year-old daughter: 99 (8.1%) of LEL, 54 (4.4%) of MEL and 35 (2.8%) of HEL. Eighteen of the LEL mothers of a 14–18 year old daughter were interviewed.The socio-demographic characteristics, attitudes towards prevention and gynaecological history of participants are presented in “to check for abnormalities” but without mentioning CC. In relation to the cause of CC, 15.7% of LEL, 33.1% of MEL and 47.8% of HEL women responded with “HPV” or a closely related answer  (p<0.001). LEL women were significantly less likely than more educated groups to have heard of the HPV vaccine and to know the target population and the recommended age of immunization. In interviews, only 2 (of 18) LEL mothers were able to mention HPV as the cause of CC. Even though 6 knew that the CC vaccine targeted an STI, they had not made the link between HPV and CC.LEL women had significantly poorer knowledge about PS screening . In intefear of cancer”. The majority of mothers' decisions to vaccinate were based on their physicians' opinion: “I can trust him”, was a typical response. Whatever their level of education, the main reason given by unfavourably disposed mothers was the newness of the vaccine or the fear of side effects , as evoked during interviews: “Sometimes vaccines induce diseases. I’m afraid because this vaccine is new”. As an example, LEL interviewees mentioned their belief that the hepatitis B vaccine could cause multiple sclerosis, reflecting the French controversy. Other barriers related to the young age of their daughters: 4 mothers (2 LEL and 2 HEL) thought their daughters were too young to talk about sexual issues. The cost of the vaccine was mentioned by one HEL mother. In interviews, some LEL mothers explained that, for religious reasons, their daughters should have no sex before marriage and so should not be at risk of infection. They thought HPV vaccination was not a priority as their daughters were too young to become sexually active and therefore preferred to wait. Another barrier specifically raised by three LEL mothers interviewed was the fear that HPV immunization could affect their daughters' fertility.A total of 188 women were mothers of a 14–18 year old daughter. Among the 174 mothers who gave an opinion, 60.3% were favourable towards the vaccine and 47.6% of them had already had their daughters vaccinated. Interestingly, HEL mothers had the lowest acceptance rate (46.9%) vs. 68.6% for MEL and 60.4% for LEL . Among tpneumococcus (OR: 3.52 (0.99–12.48)) and history of abnormal PS (OR: 6.71 (0.70–64.01)) were borderline  gave their opinion on HPV vaccination: 55 (60.4%) were favourable while 36 (39.6%) were uncertain/opposed. rderline .Our results revealed disparities in CC prevention knowledge and practice across educational levels. Importantly, although LEL women had poorer knowledge about CC, PS screening and HPV immunization than women with more education, they were more likely than HEL mothers to accept HPV vaccination.Knowledge of CC and HPV was poor, especially in LEL women: 8% of LEL women were able to mention HPV as the cause of CC. Interviews among LEL women highlighted that they were unaware of the relationship between PS, HPV and CC Whatever their educational level, mothers justified their acceptance of the vaccine mainly in terms of wanting to keep their daughters healthy and protecting them against this anxiogenic and potentially fatal disease Factors associated with HPV vaccine acceptance among LEL mothers in our study were a younger age and their opinion of vaccination in general. In contrast to previous studies There were certain limitations in our study. Firstly, due to recruitment during a GPs consultation, our sample is drawn from women with access to healthcare. Secondly, the use of a self-administered questionnaire could to some extent bias our LEL population by excluding the least educated women who could not read or write in French. Thirdly, the identification of underserved women was only based on educational level. However this criterion is one of the most widely used socio-economic indicators; and its association with cancer incidence and mortality (including CC) and with PS uptake is established Although LEL mothers are less compliant with gynaecological follow-up and PS screening and have more limited knowledge about CC and its prevention, their acceptance of HPV vaccination is good. However, further information on vaccine is required to avoid misconceptions among LEL mothers and to improve its acceptance by HEL mothers. The major limitation to extending HPV immunization among the daughters of LEL mothers' may not be attitudes and beliefs but their restricted access to health care which prevents the translation of intentions into action.Figure S1HPVFEM Questionnaire. The questionnaire was given by the general practitioner to the included women. It was a self-administered questionnaire, anonymously filed by the women.(PDF)Click here for additional data file.


Cervical cancer is still a major health problem in Tunisia and over the world. HPV infection may induce malignant transformation of lesions, especially in case of colonization by oncogenic HPV genotypes. Early detection of viral genome by molecular biology in women with normal cytology in cervical screening test (CST) can be a part of a screening policy to improve cancer prevention. Our aim was to evaluate HPV prevalence and genotype distribution in routine CST.It was a prospective study conducted over a six month period . 665 women were screened by an examination of the cervix, a cervical screening test and a detection of the HPV DNA by PCR. This detection of the high oncogenic risk HPV was made from the cytobrush that was used for the spreading of the cervix cells.The mean age was 41.5 ±9.1 years (20-71 y). The mean age of the marriage was 24.8±5 years (16-50 y). The age of the first pregnancy was 24.8±5.7 years (14-48 y). Six percent reported history of genital lesion in their partner. 37% used or are still using Intra Uterine Device and 48% used or are still using contraceptive pills. 58% had never had a routine CST and 27% had one CST. 65% of the women reported a history of vaginal discharge, 25% a genital ulceration and 4.5% condylomas. The cervix examination showed 51% of normal cervix, without any clinical macroscopic anomaly. 41% had a cervix inflammation, 18% had leucorrhea, 7% had polypus and 3% had condylomas. HPV prevalence was 3%.Our results showed lower HPV prevalence, probably due to later onset of sexual practice and fewer sexual partners.


Our aim was to compare the 12-month incidence and clearance of oral high-risk HPV infection between HIV-infected men who have sex with men (MSM) and HIV-negative MSM.10-PCR & DEIA-LiPA25 system (version 1). Determinants of oral HPV incidence and clearance were explored using Cox and logistic regression analyses respectively.MSM aged 18 years or older were recruited in Amsterdam, the Netherlands. Questionnaire data and oral-rinse and gargle samples were collected at baseline, and after 6 and 12 months. HPV DNA was genotyped using the SPF433 HIV-negative and 290 HIV-infected MSM were included in these analyses. The median follow-up time per participant was 12 months (range 3–15). During follow-up, 114 incident oral high-risk HPV infections were observed. The incidence rate of HPV-16 was 3.5/1000 person-months (PM) in HIV-infected and 0.9/1000 PM in HIV-negative MSM . The incidence rates of other high-risk HPV types ranged between 1.3-3.5/1000 PM in HIV-infected and 0.0-1.1/1000 PM in HIV-negative MSM. In multivariable analyses, HIV infection  and a higher number of recent oral sex partners  were associated with HPV incidence. Of the 111 baseline oral high-risk infections, 59 (53.2%) were cleared. In multivariable analyses, only a higher number of recent oral sex partners was associated with HPV clearance .The incidence rate of oral high-risk HPV infection was higher in HIV-infected MSM and in those with a higher number of recent oral sex partners. Just over half of the oral high-risk HPV infections at baseline were cleared after 12 months, with a higher likelihood of clearance among MSM reporting higher numbers of recent oral sex partners, but no difference by HIV status.The online version of this article (doi:10.1186/s12879-014-0668-z) contains supplementary material, which is available to authorized users. Human Papillomavirus (HPV), in particular oral infection with high-risk HPV type 16, has recently been recognized as a main etiologic agent for a subset of head and neck cancers , a much The natural history of oral HPV infection is not yet well understood. Previous studies suggest that the incidence rate of oral HPV infection is lower than that of anal and genital HPV infections -7], whe, whe7], Data reported on the incidence and clearance rates of oral high-risk HPV among (HIV-infected) MSM are scarce, especially those describing the effect of HIV-infection ,11],,,14], ou, ou14], In an earlier paper regarding the H2M cohort, we reported 6-month incidence and clearance data of oral HPV infections , but we The Medical Ethics Committee of the Academic Medical Center (AMC) Amsterdam approved this study, and all participants provided written informed consent prior to participation.The H2M study design and sample collection methods have been described previously ,15]. In. In15]. 10-PCR DEIA/LiPA25 system (version 1) . Al. Al21]. In conclusion, oral high-risk HPV incidence was independently associated with HIV infection and a higher number of recent oral sex partners, while just over half of the prevalent infections were cleared within 12 months. As the incidence of HPV-related head and neck cancer is increasing in many parts of the world -26], be, be26],


B line has been adjusted from black to blue, and the line for SA under reacquisition has been adjusted from dark blue to light blue. The corrected versions are provided below.It has come to the authors’ attention that there are errors in


INK4A expression and molecular detection of HPV DNA is the gold standard for the viral identification in tissue and exfoliated cell samples. Differences in the biology of HPV(+) and HPV(-) OSCC may have implications for the management of patients. New immunotherapy drugs based on the release of the co-inhibitory receptors, cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and programmed-death 1 (PD-1) have currently emerged. The goal of therapeutic cancer vaccination is inculcation of a persistent, tumor antigen-specific T cell response which kills tumor cells. The efficacy of the current HPV vaccines, Cervarix and Gardasil, in preventing HPV-related HNSCC is at present unknown. Treatment de-escalation is recommended as the current management of HPV-induced HNSCCs.Human papilloma virus (HPV)-associated head and neck carcinoma is quite heterogeneous and most of the tumors arise in the oral cavity, oropharynx, hypopharynx and larynx. HPV was just recently recognized as an emerging risk factor for oropharyngeal squamous cell carcinoma (OSCC). HPV(+) tumors represent 5-20% of all head and neck squamous-cell carcinomas (HNSCCs) and 40-90% of those arising from the oropharynx, with widely variable rates depending on the geographic area, population, relative prevalence of environment-related SCC and detection assay. Different carcinogenic mechanisms are most likely implicated in cervical and oropharyngeal carcinogenesis. The most certain carcinogenic genotype for the head and neck region and the most common high-risk HPV genotype, HPV-16, is frequently detected in OSCC. A combination of p16 Human papillomaviruses (HPVs) are small double-stranded DNA viruses that comprise a heterogeneous family consisting of more than 130 different HPV types . EvidencHPV infections are mainly sexually transmitted through direct skin or mucosa contact and represent the most common sexually transmitted infections worldwide. The probability of transmission is very high, with an estimated life-time risk of cervical HPV infection in sexually active women of up to 80%. Exposure to HPV is determined by well known risk factors for most sexually transmitted infections, while determinants of susceptibility and infectivity are much less established . KnowledHead and neck carcinomas (HNCs) is the sixth most common cancer with an annual incidence of ~400.000 cases  and reprHPV involvement in head and neck carcinogenesis was initially reported 30 years ago , 11; howINK4A as equivalent to HPV infection [INK4A over-expression is due to different mechanisms and high-risk HPV infection is very rarely detectable in oral SCCs [Nevertheless, the actual incidence of high-risk HPV infection in sites outside the oropharynx, as well as what is the best HPV detection method in HNSCC, have not yet been answered with confidence. Among the other extra-oropharyngeal subsites, HPV might have a role in the supraglottic larynx , whose mnfection , 34. Nevral SCCs , 35.Among the many high-risk HPV types, HPV-16 is the most common, found in almost 90% of the HPV(+) oropharyngeal cancers. At present, HPV-16 remains the only HPV type that is classified as cancer-causing in the head and neck , 36. In The HPV genome is composed of six early , two late (L1 and L2) open reading frames, and a non-coding long control region (LCR) . E5, E6 INK4A. The HPV(+) tonsillar SCC share a disruption of the pRb pathway as a common biological marker. By immunohistochemistry (IHC), most HPV(+) HNSCCs show p16INK4A over-expression. In non-HPV-related HNSCC, continuous tobacco and alcohol exposure can lead to mutational loss of the p16INK4A and p53 genes. These early neoplastic events are detected in 80% of HNSCCs and cause uncontrolled cellular growth [INK4A and low EGFR were associated with improved outcome, suggesting a predictive role in surgically treated patients [HPV E6 in association with host ubiquitin ligase E6-associated protein (E6AP) acts to ubiquitinate p53, leading to its proteasomal degradation . P53 is r growth . The expr growth  and mutar growth . FurtherAlthough the management of OSCC does not require evaluation of HPV status, HPV-testing in OSCC patients is increasingly becoming the standard of care. HPV-induced OSCC constitutes a separate tumor entity with distinct clinical and histopathological features, improved performance status and better prognosis. Nevertheless, heterogeneity both in biological and clinical behavior among HPV(+) cases has been well observed . This heINK4A protein levels by IHC is the most well-known biomarker for the detection of biologically active HPV infection in HNSCC [INK4A is a cyclin-dependent kinase (CDK) inhibitor, encoded by the CDKN2A locus, which arrests the cell cycle in the G1 stage [INK4A immunostaining in conjunction with HPV DNA detection is very a useful tool to establish a diagnosis of HPV-related OSCC [INK4A(+) tumors had favorable prognosis and the presence of HPV in the tumors per se did not have a substantial positive impact on prognosis. As p16INK4A expression lacks specificity for high-risk HPV and does not distinguish p16INK4A up-regulation due to E7-mediated pRb loss from that sustained by other so far unidentified mechanisms , and given the different outcomes in the p16INK4A(+)/HPV(-) subgroups, in the context of personalized treatments, p16INK4A(+)/HPV(-) OSCCs should be considered as a distinct subset. For this reason, it is recommended that HPV should be assessed both by ISH and p16INK4A [HPV-related and HPV-unrelated OSCCs show different genetic signatures which most likely underlie differences in tumor development and progression . These din HNSCC . p16INK4G1 stage , 60. pRbted OSCC . Weinberted OSCC  demonstrp16INK4A .INK4A was evaluated as prognostic marker of treatment response and survival in a cohort of patients treated solely with conventional radiotherapy. p16INK4A positivity was detected in 22% of the tumors; however, no substantial difference was observed between p16INK4A(+) and p16INK4A(-) tumors. Specifically, p16INK4A(+) tumors seemed to be more closely associated with poor histopathologic differentiation compared with the p16INK4A(-) ones, but the difference was not statistically significant, indicating that p16INK4A alone is not an adequate marker. The weakness of this study is that the authors included many p16INK4A(+) tumors that were not HPV(+) in the analysis as if they were HPV(+).In the Danish Head and Neck Cancer Group (DAHANCA) 5 trial  p16INK4AINK4A(+) status was a favorable prognostic marker in patients who received only chemotherapy, suggesting a potential prognostic effect in this population of patients. The authors reported that the p16INK4A status of the tumor, regional differences in overall survival, as well as other factors including the intensity and amount of previous treatment, might be important considerations in the design of future global trials in recurrent or metastatic HNSCC. However, the drawback of this study is that conclusions about EGFR inhibition were erroneously drawn based on the patients' p16INK4A status, since half of the tumors were rated as HPV(+), just by p16INK4A(+) test.Preclinical data for HNSCC cell lines and xenografts showed more antitumor activity when treated with the anti-EGFR monoclonal antibody panitumumab combined with radiotherapy, than when treated with radiotherapy alone. Furthermore, phase 1 response data for panitumumab plus chemotherapy suggested that additional investigation of panitumumab in HNSCC is needed . In the The conclusion of these two studies is that presence of HPV DNA in tissue biopsies is not always sufficient to attribute a cancer of the oropharynx to HPV, depending on the different sensitivity of the various assays relying on DNA detection . Appropriate algorithms should be used to define an HPV-induced tumor. Assessment of HPV status is indicated in patients with oropharyngeal carcinomas, particularly when no environmental risk factors are present and in patients with neck metastasis and carcinoma of unknown primary as HPV detection in metastatic lymph node samples is strongly indicative of a primary in the tonsils or in the base of the tongue .INK4A up-regulation [INK4A positivity is associated with better outcomes, regardless of HPV positivity. As a consequence, the survival benefit observed in HPV-induced HNSCC may not be the result of HPV positivity per se, but rather the result of the absence of p53 gene mutations or p16INK4A deletion in HPV(+) tumors, which are responsible for poor prognosis in HPV(-) patients [The first line of evidence of the impact of HPV in prognosis comes from various small single-institutional retrospective case series, showing that patients with HPV(+) HNSCC  treated by radiotherapy, chemoradiotherapy, surgery or combined modality therapy, have better outcome than those with HPV-uninduced cancer , 67. HPVgulation . The abspatients . AnotherBoth in environmental-induced carcinogenesis and HPV oncogene-induced transformation, HNSCC is associated with a fundamental failure of immune surveillance, where tumor cells have escaped recognition and lysis by the cytotoxic T lymphocytes (CTLs) of adaptive immunity. The critical effector cells of adaptive antitumor immunity are the activated CD8(+) CTLs. Activation of the naïve, antigen-restricted CD8(+) CTLs first requires binding of the T cell receptor (TCR) to its cognate tumor antigen (TA) in complex with human leukocyte antigen (HLA) I. Although the engagement between a tumor antigen and a T cell receptor (TA-TCR engagement) is necessary, it is not sufficient for CTL activation and tumor cytolysis. Initial activation also depends upon the balance between co-stimulatory and co-inhibitory signaling by dendritic cells (DCs) and CD4(+) helper T cells, as well as freedom from suppression caused by CD4(+) regulatory T cells (Tregs). HNSCC elicits T cell anergy in both peripheral and tumor-infiltrating lymphocytes (TILs). Functional defects in TILs include low production and response to IL-2 ; vulneraSuccessful activation of the CTL following the binding of TA-TCR depends upon predominance of co-stimulatory versus co-inhibitory signaling by accessory receptors. The co-inhibitory receptors CTLA-4 and PD-1 down-modulate CTL response in the setting of chronic antigen stimulation - a useful adaptation for resolving the inflammatory response following infection and in preventing auto-immunity. However, in the setting of cancer these receptors induce pathologic tolerance. A new therapeutic paradigm is the design of mAbs to block co-inhibitory signaling, releasing the CTL from anergy. The first in class is ipilimumab, an IgG1 mAb against the CTLA-4 co-inhibitory receptor expressed on activated CTLs and Tregs. CTLA-4 and the major co-stimulatory receptor CD28 compete for the same ligand on antigen-presenting cells (APCs), B7. The blockade of CTLA-4, releases B7 to bind CD28, thus propagating the B7-CD28 co-stimulatory signal that is required for TA-specific TCR activation. Ipilimumab has been FDA-approved in melanoma . ReleasePD-1 is a second inhibitory member of the CD28/CTLA-4 family of co-receptors. It is expressed on CTLs, NK cells, B cells and macrophages, and it is thought to be a broader negative regulator of immune response than CTLA-4. PD-1 has two ligands: PD-L1 and PD-L2. PD-L1 is up-regulated on DCs and macrophages in response to chronic antigen stimulation, as is the case in the tumor microenvironment; many tumors including HNSCC co-opt expression of PDL1 to induce CTL and NK anergy. Therapeutic mAbs against both PD-1 and PD-L1 are entering advanced stages of clinical development , 86. A pEnthusiasm for the development of head and neck tumor vaccines is motivated by the observation of nascent CTL responses against unique tumor antigens (TAs); the existence of this thwarted immune response implies the potential to harness and amplify adaptive immunity. Fundamentally, the goal of therapeutic cancer vaccination is inculcation of a persistent, TA-specific T cell response which kills tumor cells - abating tumor progression or even resulting in cure. In general, an effective vaccine will require successful TA presentation by professional APCs and a consequent TA-specific CTL response. Vaccines may target two forms of TAs: tumor-specific antigens (TSAs), or tumor-associated antigens (TAAs) . TSAs arUltimately, cancer vaccines must deliver antigenic peptides to professional APCs for presentation in association with MHC to the cognate CTLs. Various vaccination methods exist in HNSCC, each with their own particular advantages and drawbacks: 1) protein-based or peptide vaccines, consisting of pre-assembled proteins; 2) DNA vaccines, consisting of recombinant, TA-encoding DNA in a plasmid backbone; and 3) recombinant vector-based vaccines, where a viral, bacterial or yeast vector is loaded with recombinant DNA encoding the TA of interest. In peptide vaccines, for example HPV oncoprotein peptide vaccines, oncogenic activity must be inactivated while maintaining sufficient peptide length to stimulate CTL response. Advantages to this approach include ease of production and the ability to target TSA, whereas disadvantages include host proteolysis, weak immunogenicity, HLA restriction and poor long-lasting immunity . DNA vac® and Gardasil®. While these marketed vaccines prevent anogenital HPV infection, their impact on the natural history of oral HPV is still unknown. Regardless, the capsid antibodies triggered by these L1 peptide vaccines are useful only for primary prevention; humoral blockade of the viral entry step is not relevant for established, HPV-transformed malignancies. Therapeutic vaccines for HPV-related cancers are of substantial interest in HNSCC. Five promising vaccination strategies have entered clinical development in HPV-induced neoplasia including two peptide vaccines, a detoxified E7 DNA vaccine, and two vector vaccines: 1) The HPV 16 E6 and E7 long peptide vaccine with incomplete freund's adjuvant was studied in 20 women with HPV-16 associated vulvar intraepithelial neoplasia. All patients had vaccine-induced CTL responses; 15 out of 19 patients had clinical responses [HPV is an ideal vaccine target, due to the expression of non-host TSAs and constitutive expression of these viral oncoproteins to maintain the transformed state. Proof-of-principle has been demonstrated by the successful development of HPV prevention vaccines, Cervarixesponses . 2) In aesponses . 3) The esponses . This vaesponses . 5) The esponses . This vaesponses . Dose-liIn HPV(-) HNSCCs, over-expressed wild type (wt) TAAs, such as p53, are potential vaccine targets. Although p53 mutation is the most commonly identified mutation in HPV(-) HNSCCs, most mutations result in the accumulation of p53; non-mutated portions of the protein are susceptible to degradation into wt peptide sequences appropriate for immune presentation. A phase I trial (NCT00404339) examining p53 multiple-epitope/dendritic cell vaccine in HNSCC patients was reported in 2009. Following definitive therapy, patients with locally advanced HNSCC were vaccinated with wt p53 sequences pre-loaded onto autologous dendritic cells. At 15-month follow up 11/16 patients were alive without disease. Analysis of immunogenicity indicated p53-specific CTLs in 5/16 patients .Despite treatment intensification for patients with HNSCC, including altered radiation fractionation and the addition of chemotherapy to radiation, physicians and patients still face the significant challenge of recurrent or second tumors arising within or in close proximity to previously irradiated tissues. Locoregional recurrences develop in ~20% of patients treated with definitive chemoradiation for larynx preservation  or with Patients with recurrent HNSCC after prior radiation are a heterogeneous group. Differences in the location and extent of recurrent tumor, initial radiation treatment parameters, elapsed time since prior treatment, and extent of normal tissue sequelae, as well as relatively sparse data on acute and late normal tissue recovery from prior treatment and tolerance to re-irradiation , pose a Despite the absence of evidence from randomized, controlled trials to support a de-escalation of treatment intensity in HPV(+) oropharyngeal carcinomas, some investigators argue that intensive concomitant chemoradiation regimens may represent overtreatment , 109. AcAside from the Phase II Eastern Cooperative Oncology Group (ECOG) study and the Phase III Quarterback Trial, there are no active trials addressing radiotherapy dose. The Phase II ECOG study  confirmeNevertheless, a de-escalation strategy is not without concerns. A phase III non-inferiority trial for HPV(+) patients is considered difficult to conduct due to the large number of patients required . MoreovePatients with head and neck cancer experience significant changes in their quality of life (qol) associated with disease and the adverse effects of treatment. Frequent problems the patients have to face are usually difficulties with speech, respiration and eating, apart from the psychological impact of loss of function and physical mutilation. These concerns associated with traditional trans-cervical surgical exposure approaches were principal in the clinical development of non-surgical treatment approaches based on fractionated radiotherapy. Over the past 30 years, multiple randomized trials have now established that treatment intensification with the addition of concurrent chemotherapy and altered radiotherapy fractionation schedules  can imprNevertheless, the optimal treatment for HPV(+) HNSCC patients remains uncertain. HPV(+) cancers appear more sensitive to chemoradiation as patients with low risk HPV(+) oropharyngeal cancers have almost double the overall survival as patients high risk HPV(-) cancers. This benefit in HPV(+) patients results from improved locoregional control rather than decreased distant metastasis. Since concurrent chemoradiation at least doubles the rate of acute and long term toxicities, less intense treatment regimens maximizing cure and decreasing toxicities are being investigated. To de-intensify the current standard of care would require reducing the current radiation dose and/or the chemotherapy regimens.To this end, the ECOG Phase II trial (E1308) addressed these questions by testing the efficacy of decreasing the radiation dose. Patients achieving a complete response to induction chemotherapy were treated with lower dose radiation and cetuximab. The fact that cetuximab is an antibody targeting the cancer cell membrane and is thus associated with lower toxicity, renders radiation with cetuximab or bioradiotherapy distinct from chemoradiotherapy. Nevertheless, it remains unclear whether bioradiotherapy provides as good locoregional control as chemoradiotherapy. A retrospective analysis showed that bioradiotherapy may not be as effective as chemoradiation, especially in patients with HPV(+) cancers . Similar