Although more than 95% of viral sequences found in skin tumors typically belong to human papillomaviruses (HPVs), HPV transcription has so far not been detected. As current technology allows very deep transcriptome sequencing, we examined skin tumors and precursor lesions for HPV transcription.Fresh frozen biopsies from 12 skin specimens (11/12 were positive for HPV DNA) were subjected to total RNA sequencing. The cervical cancer cell line CaSki was included as a positive control for HPV transcription.HPV RNA was detected and confirmed in 1/12 skin lesions at a median depth of 66 million reads per sample. One specimen was positive for HPV 110 transcripts mapping to E6, E7, E2/E4 and L2 open reading frames, as well as to a spliced E1^E4 transcript.In conclusion, the study revealed that a minority of skin lesions contains HPV transcripts and that HPV DNA detection does not predict HPV transcriptional activity. Human papillomaviruses (HPVs) infect keratinocytes in both mucosa and skin and can cause several diseases from benign lesions to malignant tumors , 2. CutaL1 gene which is the most conserved gene within the HPV genome [The traditional methods to identify HPV-related lesions/cancer are based on PCR, targeting usually the V genome . PCR metV genome , 16. UnkV genome . Most ofV genome , 18, 19.V genome .Detection of HPV DNA does not necessarily mean that an HPV infection has been detected, as it may represent a viral deposition on the skin surface . Simple Metagenomic sequencing without prior PCR allows detection of all HPVs present in a sample, without previous knowledge on which types might be present , 18, 25.Written informed consent was obtained from all participants in the clinical study. The study was approved by the Ethical review Committee of Karolinska Institutet and of Lund University (Sweden) . We included a set of 12 fresh frozen biopsies from immunocompetent patients  prepared for RNA analysis. Samples had been whole genome sequenced using MiSeq or HiSeq Illumina platforms in a previous study . The RNARNA was extracted using RNeasy Lipid Tissue Mini kit (Qiagen), following the manufacturer´s instructions, including the DNase digestion, and kept at -70°C until further analysis.A cervical cancer cell line (CaSki (ATCC CRM-CRL-1550)) known to contain approximately 600 copies of HPV type 16 genome integrated into the human genome, was used as a positive control for virus presence and transcription. The cell line was cultured and harvested cells were treated with RNAlater and RNA was extracted using the same RNeasy Lipid Tissue Mini kit (Qiagen), following the manufacturer´s instructions.The RNA extracted samples  together with two negative controls containing lab-grade water, were rRNA depleted, reverse transcribed and ligated to individual indexed adapters using the TruSeq Stranded Total RNA kit according to the user´s guide, Revision E . All 16 individual libraries were validated, normalized to 2 nM and pooled accordingly  before sequencing. Sequencing was performed in the NextSeq500 system  at 151 paired-end cycles. A total of 4 runs were carried out. The first 2 runs contained a pool of 6 skin lesions, 1 negative control (lab-grade water) and 1 positive control (CaSki cell line) each. In the third run, only two lesions were sequenced. The fourth run was performed as a validation of the HPV 16 RNA-positive specimen in the second run, now sequenced without the CaSki cell line positive control to discard possible index-hopping.Indices, included in the Illumina adapters, were used to assign raw sequence reads obtained from the NextSeq500 (Illumina) platform to the originating samples. Reads were quality checked and adapter trimmed with Trimmomatic . High quOnce human reads were filtered from the data set, reads from each sample were queried against all HPV protein sequences included in the PaVE database , using the open source software Diamond blastx with default parameters and—top 1  . SamplesSpecimen adequacy was confirmed for all samples, except for the negative controls, through coverage analysis of human reference genes known to be expressed in skin (ACTB and GAPDH) . All samhttps://www.ncbi.nlm.nih.gov/sra/PRJNA493709).The Illumina sequencing generated high quality sequencing data with a median of 66 million reads per sample . Most ofWhen the skin lesions were sequenced with multiplexing for 8 samples, only 2 specimens (both actinic keratosis) were positive for HPV RNA transcripts, one positive for HPV 16 (53 reads) and one positive for HPV 110 (10 reads) . The HPVIn order to investigate if increased sequencing depth would detect more HPV transcripts, we increased the depth 4 times by multiplexing only two lesions  . In addiHPV 16 RNA-reads were detected only in one actinic keratosis lesion (specimen LH130). No other sample nor water controls generated any HPV 16 reads. As HPV 16 is a mucosal high risk type for cervical cancer it would be interesting if an HPV 16 transcript was detected in a pre-malignant skin lesion, suggesting an active HPV 16-infection. We considered whether the HPV 16 reads found in LH130 might have resulted from contamination from the HPV 16-positive control (CaSki cell line) used in the experiment, most likely due to a phenomenon known as “index hopping”, where similar indexed adapters are mis-read during multiplexed sequencing. LH130 index was AR013 (AGTCAA) and the CaSki index was AR015 (ATGTCA). These indices only differ in an extra T at the second position in AR015 and an extra A in the last position in AR013.Comparing sequences of HPV 16 reads from LH130 and CaSki positive controls, one mutation was detected (substitution C3470T) between specimens. While LH130 showed 87% reads (13/15) with a thymine at position 3470, CaSki controls presented 100% cytosine .To validate this positive HPV 16 results we sequenced this specimen at 8 times greater depth (2x75 cycles) without the CaSki positive control in the same run. No HPV reads were detected for this sample at a deeper sequencing.The DNA and RNA detection of HPV 16 in the different skin lesions do not coincide as 2 skin lesions were positive for HPV 16 DNA, but negative for HPV 16 RNA . An explCutaneous HPVs are commonly detected both on healthy skin , 35 and In 11/12 skin lesions, we did not find any HPV expression. Besides true negativity for HPV expression, possible explanations for not finding HPVs might include: specimen inadequacy and detection method still not sensitive enough . SpecimeWe choose to align our sequencing reads against all HPV protein sequences present in the PaVE database, not to miss a large number of recently reported HPV types, which are not established yet, and to see if we were able to detect divergent putative novel HPVs. We did not find any novel HPV type, nor did we detect any of the HPV types previously detected by DNA sequencing in the same specimens, which may suggest that these types are only present as environmental deposition rather than active infections. DNA from HPV 197  wasIn conclusion, RNA sequencing can detect presence of HPV transcription. While HPV is actively transcribed in cervical cancers, HPV transcription in skin lesions seems to be a rare event. Using this strategy of RNA-seq in further studies on the non-human transcriptome in NMSCs and precursor lesions may give more insight into the role of viruses in these tumors. In addition, all tumors with increased incidence among immunosuppressed patients may be analyzed in the same manner in order to investigate putative viral etiologies in those cancers.S1 TableNormalization of reads (RPKM units) for ACTB (actin beta) and GAPDH  protein coding genes for skin specimens.(DOCX)Click here for additional data file.S1 FigThe height of the grey bars corresponds to the number of reads at each nucleotide position. The exons of the genes ACTB is visualized at the bottom as blue boxes and the introns as blue lines. The high coverage of most of the exons and lack of coverage of intron regions indicates that the sequences originate from RNA with no or very little DNA contamination.(TIF)Click here for additional data file.S2 FigThe height of the grey bars corresponds to the number of reads at each nucleotide position. The exons of the gene GAPDH is visualized at the bottom as blue boxes and the introns as blue lines. The high coverage of most of the exons and lack of coverage of intron regions indicates that the sequences originate from RNA with no or very little DNA contamination.(TIF)Click here for additional data file.


HPV) have developed into hijackers of human cellular and immune systems in which they replicate and remain silent. Systematic studies on oral HPV infections and their outcomes are still scarce. Oral HPV infections have been linked to sexual behaviour, but recent evidence supports their horizontal, mouth‐to‐mouth, transmission. Most HPV infections in infants are acquired vertically from the mother during the intrauterine period, during delivery, or later via saliva. The best‐known benign clinical manifestations of HPV infection are oral papilloma/condyloma and focal epithelial hyperplasia. Evidence is emerging which suggests that some oral HPV infections might persist. Persistent HPV infection is mandatory for HPV‐associated malignant transformation. However, progression of HPV‐induced lesions to malignancy requires additional cofactors. In the early 1980s, we provided the first evidence that a subset of oral cancers and other head and neck cancers might be causally linked to HPV infection. This review summarizes current knowledge on the virus itself, its transmission modes, as well as the full spectrum of oral HPV infections – from asymptomatic infections to benign, potentially malignant oral lesions, and squamous cell carcinoma.Papillomaviruses are one of the oldest viruses known, dating back 330 million years. During this long evolution, human papillomaviruses ( Alphapapillomavirus, Betapapillomavirus, and Gammapapillomavirus are the largest Papillomaviruses are the oldest existing viruses, originating from the late Paleozoic Era some 330 million years ago. Papillomaviruses have strict species‐specificity with a broad genotypic diversity. The ancient papillomaviruses with mucosal tropism started developing some 90 million years ago Human papillomavirus contains a circular double‐stranded DNA of approximately 8,000 base pairs that is enclosed by a non‐enveloped icosahedral capsid of 55 nm in diameter Classification of HPVs is based on the nucleotide sequence of the ORF coding for the capsid protein L1 as this sequence is the most conserved among all HPVs. Human papillomavirus types with less than 60% homology within the L1 part of the genome belong to different genera. Different viral species within a genus share homology of between 60% and 70%. The HPV genotype is considered as novel if the homology of the L1 ORF to any other HPV type is less than 90%  HPV infection, making comparison of different clinical trials difficult. The schematic presentation of viral progression and gene expression in differentiating squamous epithelium is summarized in Fig. ∧E4 fusion protein during the late stages of the HPV life cycle. E4 binds to cytokeratin filaments, disrupting their structure, and is thought to play a role in viral escape from the desquamated epithelium  to vegetative viral DNA replication must occur to allow the production of genomes for packaging into virions. The mechanism regulating this switch is still unknown. E4 is embedded within the E2 gene and is primarily expressed as an E1E5 is an oncogenic small, hydrophobic, single‐pass transmembrane protein that forms dimers and interacts with and activates receptor tyrosine kinase receptors, including the epidermal growth factor (EGF) and platelet‐derived growth factor (PDGF) receptors. Human papillomavirus E5 proteins play a role in apoptosis and also in evasion of the immune response. Human papillomavirus E6 and E7 proteins both drive cell‐cycle entry to allow genome amplification in the upper epithelial layers. High‐risk HPV E6 proteins have oncogenic activities. They bind and degrade p53, as well as cellular host signaling proteins with protein–protein interaction domains (i.e. PDZ proteins), and they activate telomerase  can also have an impact on oral carcinogenesis During carcinogenesis, the HPV genome frequently integrates into a host‐cell chromosome. Integration is random, and each site is unique depending on how and where the virus integrates Betapapillomaviruses (HPV) are common in children, in whom they are known to be acquired mostly through horizontal transmission. Cutaneous HPV infections can persist asymptomatically for years in children, and even in newborns Betapapillomaviruses (HPV) have also been found in virgins, infants, and children, in both oral and genital mucosa. This implies a non‐sexual mode of transmission Cutaneous warts caused by In our Kuopio cohort (1981–1998), we showed, several years ago, that vertically transmitted HPV was detectable for a period ranging from 2 d to 3 yr in 44% of the infants whose nasopharyngeal aspirate fluid tested HPV‐positive at birth. The overall concordance between HPV types found in the mother's genital sample and her infant's nasopharyngeal aspirate fluid was 69% trottier et al. In our Finnish Family HPV Study, we showed that HPV DNA was detected in 17.9% of baseline oral samples from newborns and in 16.4% of the maternal cervical samples. The at‐delivery HPV genotype‐specific concordance between the newborns and their mother was almost perfect (weighted kappa = 0.988). We also showed earlier that oral HPV carriage in newborns was highly significantly associated with HPV presence in the placenta and/or cord blood These data strongly support the hypothesis that HPV can be transmitted vertically and cause a true infection of the newborn's oral mucosa. In a proportion of these children, oral HPV infections acquired at birth can persist for years without development of any significant clinical lesions. Importantly, these early childhood infections also represent an active infection because HPV‐specific cell‐mediated immunity (CMI) is seen in these sexually inexperienced children P < 0.005) d'souza et al. reported that oral sexual behavior was the primary predictor of oral infection with HPV‐16. However after adjusting for, age cohort and race, oral sex was no longer associated with oral HPV We have also reported that oral sex does not predict the partner's oral HPV status. Rather, horizontal HPV infection  could be a mode of HPV transmission as persistent oral HPV infection of a person was predicted by the presence of persistent oral HPV in his/her spouse  is seen in estimates of oral HPV prevalencesouza et al. in 2005 kay et al. The wide variation in detection rates of asymptomatic oral HPV can be explained by three main variables: (i) the sampling site; (ii) the sampling method; and (iii) the HPV testing methods. In most studies, the exact anatomic sites of the samples are not given and thus the origin of HPV infection  is impossible to trace. Samples are obtained as mucosal scrapings, oral rinses, or tissue biopsies. There are two types of normal oral mucosa: keratinized and non‐keratinized. When a scraping is taken from an orthokeratinized mucosa (similar to the skin), the sample is frequently inadequate because of a lack of nucleated cells. In addition to the HPV genotype coverage, sensitivity and specificity of the HPV testing method, as well as the transport medium, are of key importance. Based on our method validation study on HPV testing from 309 scrapings, we found that three sequential swabs from the buccal mucosa will result in approximately 100,000 cells, which is optimal for HPV testing The Finnish Family HPV Study was started in 1998, with the author as the principal investigator, to understand the dynamics of HPV infection within healthy young Finnish families. This study (still ongoing) is a continuation of our previous studies on HPV in oral mucosa and its transmission modes In our Finnish Family HPV Study, the prevalence of HPV DNA in the oral mucosa of infants fluctuated from 14% at delivery to 21% at 6 months, and reached a low of 12% at 36 months Alphapapillomaviruses do clear but a minority remain persistent. The HPV‐16 genotype is the most common HPV genotype to persist in oral and oropharyngeal mucosa souza et al. reported that oral HPV infection clearance was reduced among male subjects  In 2007, the 7th World Workshop on Oral Medicine launched a task force to find evidence for association of HPV with oral cavity carcinoma based only on case–control studies. A systematic literature search from January first 1966 to September 30th 2010, without language restriction, was performed dayyani et al. it has been estimated that, before 2000, 40.5% of oropharyngeal cancers were HPV associated, and that during 2000–2004 and 2005–2009, HPV was present in 64.3% and 72.2% of oropharyngeal carcinomas, respectively schache et al. reported that in the UK, the proportion of oropharyngeal carcinomas testing HPV positive remained unchanged during 2002–2011 Albeit the main focus of this paragraph is the association of HPV with oral cavity carcinoma, some key aspects of HPV in oropharyngeal carcinoma are also summarized. Human papillomavirus‐associated oropharyngeal carcinoma differs from other HNSCCs with respect to its epidemiology and disease outcome. The prevalence of HPV‐associated oropharyngeal cancer, especially tonsillar and base‐of‐tongue cancer, has increased significantly in Western part of the Europe and North America since the early 1970s The survival of patients with HPV‐positive oropharyngeal carcinomas is better than seen for any other HNSCC. The outcome of oropharyngeal cancer is related to HPV status, nodal metastasis, and other comorbidities. In addition, smoking and tobacco exposure seem to modify the survival and recurrence of HPV‐positive carcinomas PIK3CA, novel alterations involving loss of TRAF3, and amplification of the cell cycle gene E2F1, in contrast to the classical smoking‐related HNSCCs that demonstrate near‐universal loss‐of‐function TP53 mutations and CDKN2A inactivation with frequent copy number alterations, including amplification of 3q26/28 and 11q13/22 HRAS or PIK3CA, coupled with inactivating mutations of CASP8, NOTCH1, and TP53MYC and Ras. We have characterized the stepwise early events in the progression of HPV‐induced lesions toward malignancy in the UT‐DEC‐1 cell line established from vaginal intra‐epithelial neoplasia with mild dysplasia (VAIN 1). Vaginal carcinoma mimics oral carcinoma in many respects, including the fact that only a subgroup is HPV associated. In the UT‐DEC‐1 cell line during the passaging from 7 up to 185, we could identify events previously shown to be important in the progression to malignancy: (i) virus integration into the cell genome and episome loss; (ii) selection of cells with an acquired growth advantage and ability to maintain telomerase activity; and (iii) a final stage of malignancy with permanently upregulated telomerase HPV‐associated tumors are also different from the smoking‐associated HNSCCs at genome level During HPV infection, the replicating virus does not kill the host cell and therefore viral antigens are not presented and inflammation is not induced. Human papillomavirus escapes immune attack through a number of mechanisms, which include (i) establishment of immunological ignorance, (ii) modulation of apoptosis, (iii) dysregulation of interferon responses, (iv) perturbation of antigen processing and presentation, (v) modulation and trafficking of antigen‐presenting cells, and (vi) polarization of T‐cell phenotypes. The microenvironment of keratinocytes is modified mostly by E6 and E7 proteins but also by E5 using several strategies E5 plays an important role in escaping both innate and cell‐mediated immunity P = 0.045) . We recently showed that the HLA‐G allele concordance might affect the vertical transmission of HPV, especially to the oral cavity ∗01:01:01/01:04:01 increased the risk of positivity for the high‐risk HPV genotype in umbilical cord blood and infant's oral mucosa. The mother‐to‐child concordance of G∗01:01:02/01:01:02 increased the risk of positivity for oral HPV with high‐risk HPV genotypes, both in the mother and the offspring, with an OR of 2.45 (95% CI: 1.24–4.85).As discussed before, the results of our Finnish Family HPV study show that HPV infections are present in sexually naïve children. This raised the question about the role of early HPV infections in either protecting from or predisposing to further HPV infections. We therefore studied HPV‐16‐specific CMI in 10 children born to mothers with an incident CIN diagnosed during a 14‐yr period and in 21 control children born to mothers who remained HPV negative Generally, there are several methods available for routine viral diagnosis. These include viral cultures, detection of pathognomonic (cytopathic) cellular changes caused by the virus, and detection of viral proteins or nucleic acids in the samples or antibodies in the sera. Unfortunately, HPV cannot be cultured. For many years, routine light microscopy was almost the only method used to identify HPV in the biopsies. In light microscopy, the cytopathic cellular changes caused by HPV include koilocytosis, multinucleation, dyskeratosis, and parakeratosis, and these can be reliably detected in cytological smears [e.g. in PAP  smear] or in biopsies taken from the uterine cervix In‐situ hybridization methods are specific because the HPV‐positive signals can be localized and tissue morphology is simultaneously visualized. The current HPV diagnostics is mostly based on PCR‐based methods Currently, HPV infection can be identified reliably only by detecting the viral DNA or RNA in the samples At present, there are no indications for screening for asymptomatic oral HPV infections because the natural history is incompletely understood. However, if the biopsied sample shows any HPV‐suggestive morphological changes, the presence of high‐risk HPVs, and specifically HPV‐16, should be excluded by in‐situ hybridization, using any of the commercial kits. The newest test – RNAScope – is a sensitive and specific test for detecting mRNA of 16 high‐risk HPV types Human papillomavirus serology has been disappointing in the diagnosis of genital HPV. Studies indicate that about half of patients with HPV‐positive cervical cancer have no HPV antibodies Several recent studies suggest that the presence of HPV‐16 E6 and E7 antibodies in sera can predict oropharyngeal cancer, even 5–10 yr in advance hanna et al. Human papillomavirus antibodies are also detected in saliva but their value in oral HPV diagnosis is not known. According to our unpublished data from the Finnish Family HPV cohort, both IgG and IgA to HPV‐16 L1 can be found in saliva of non‐vaccinated subjects. There was a correlation between salivary and serum antibody levels but only for HPV‐16 IgG. The patterns of HPV‐16 L1 IgG and IgA levels in saliva and sera were similar in women with persistent oral HPV infection and in those in whom oral HPV infection was cleared. Recent studies showed no statistically significant correlations between IgG in sera and saliva against HPV‐6 and HPV‐18. In contrast, the levels of HPV‐16 IgG in sera and in oral fluids were statistically significantly correlated roden & sternThe discovery that the major capsid antigen L1 could self‐assemble into empty virus‐like particles (VLPs) was the starting point for the development of prophylactic VLP‐based HPV vaccines. It was soon demonstrated that L1 VPLs were highly immunogenic and protective against CIN lesions. At present, three commercially available prophylactic HPV vaccines exist: Cervarix, a bivalent (HPV‐16/18) vaccine ; Gardasil, a 4‐valent (HPV‐6/11/16/18) vaccine ; and the recently launched Gardasil 9, a 9‐valent (HPV HPV6/11/16/18/31/33/45/52/59) vaccine (Merck). The licensed vaccines are safe and highly effective against the most common types of HPV found in cervical and other anogenital cancers. The extensive clinical trials with the bivalent (HPV‐16/18) and the 4‐valent (HPV‐6/11/16/18) vaccines have been successful. The implementation of vaccination programs in adolescent female subjects has been completed or is underway in many countries, but the impact of such programs critically depends on the population coverage and is improved by herd immunity. At the time of writing, HPV vaccination programs in adolescent men had been implemented in a few countries. The current key question is whether the HPV vaccines also prevent HPV infections in the head and neck region. By now it is known that HPV vaccination induces HPV‐specific antibodies in saliva Therapeutic vaccines in humans have so far not been successful, even if experimental studies have been successful. However, vaccination with 13 synthetic long peptides (25–35 amino acids long) derived from the E6 and E7 oncogenic proteins of HPV‐16, together with nivolumab , has been promising in treating HPV‐16‐positive oropharyngeal cancers To conclude, as HPV antibodies can be detected in saliva, they will most probably be effective in preventing HPV‐induced head and neck diseases. The prophylactic vaccines should be taken before any HPV infection with the genotype present in the vaccine. Thus, the key question is the timing of vaccination, because some oral HPV infections are acquired during early childhood.Papillomaviruses are among the oldest viruses, being ubiquitous in animals and humans. During their long evolution, the most oncogenic HPV, HPV‐16, has acquired the capacity to hijack human cellular and immune systems to replicate and remain silent. The genotype distribution in asymptomatic oral HPV infection is similar to that found in the genital tract. The mother has a central role in infecting her offspring. The oral cavity might even be the first site of HPV entry into the human body. Oral papillomas/condylomas can be detected at any age, and as in the genital tract, they are caused by the most prevalent low‐risk HPV types, namely HPV‐6 and HPV‐11. Human papillomaviruses 13 and 32 do cause a specific clinical entity in oral mucosa – FEH or Heck's disease – which is not seen in the genital tract. A subgroup of HNSCCs is caused by HPV, mostly by HPV‐16. Oropharyngeal (tonsillar and base‐of‐tongue) cancers differ from the other HNSCCs in that (i) they are mostly caused by HPV, (ii) they have a better prognosis, and (iii) high levels of HPV‐16 E6/E7 antibodies can predict the development of cancer nearly 10 yr before it becomes apparent. Human papillomavirus antibodies can be detected in saliva, and their concentrations are increased after HPV vaccination. This supports the view that HPV vaccines can be protective also in the head and neck region, if given before the first exposure to HPV.


Gardasil) in Eldoret, Kenya, the knowledge and source of information of cervical cancer and acceptance of prevention strategies among vaccinated and unvaccinated adolescents were evaluated. A cross-sectional comparative study enrolled 60 vaccinated and 120 unvaccinated adolescent women. Institutional ethical approval was obtained and signed consent was obtained from the parents. Data collection was performed using interviewer-administered questionnaires derived from factual statements based on information from print material used for community sensitization on cervical cancer. The median age of the participants was 14.0 years (interquartile range [IQR] = 13.0–15.0). Of 60 vaccinated adolescents, 56 (93.3%) had heard of the HPV vaccine compared with 6 (5%) of unvaccinated participants (p < 0.001). Of 60 vaccinated participants, 58 (96.7%) had heard of cervical cancer compared with 61 (50.8%) unvaccinated participants (p < 0.001). Both cohorts identified the school as the main source of information for cervical cancer. The two groups also showed similarity in their selection of cervical cancer prevention strategies acceptable to them such as delaying sexual debut, limiting number of sexual partners, and use of condoms for protection against sexually transmitted infections. Of 120 unvaccinated participants, 63.7% expressed willingness to be vaccinated. Exposure to the HPV vaccine was associated with a higher knowledge of cervical cancer. The adolescents predominantly rely on the school for health information. Both cohorts of adolescents showed remarkable acceptability for cervical cancer prevention strategies.Cervical cancer is a critical public health concern in sub-Saharan Africa. Adolescents are key targets in primary prevention strategies. Following a human papillomavirus (HPV) vaccination initiative ( There were 530,000 new cases in 2012 worldwide.2 Cancer of the cervix is increasingly becoming a public health concern in sub-Saharan Africa; it ranks as the first cause of female cancers in Kenya, and is the leading cause of cancer deaths/mortality among all cancers in women.2 Annually, the estimated number of cervical cancer cases in Kenya is 5250, whereas the mortality is 3286.3Cancer of the cervix has ascended the oncological ladder to be the primary fatal gynecological cancer in developing countries.5 In sexually active adolescents, HPV prevalence is high with 50–80% of adolescents having active infections within 12 months of sexual debut.6Human papillomavirus (HPV), a sexually transmitted virus, is the causative agent of cervical cancer with the highly oncogenic HPV types 16 and 18 present in >90% of invasive cervical carcinoma specimen in Western Kenya.7 Recent scientific advances also evidenced the inception of HPV vaccines that have proved effective in the prevention of HPV infection and associated disease with many nations incorporating it in their national adolescent vaccination schedule.It follows that the contemporary approach is shifting toward primary prevention strategies with principal emphasis on adolescents to foster early behavioral modification including but not limited to delaying sexual debut, restricting number of sexual partners, consistent correct condom use, and not engaging in smoking.8 A study in Kenya showed that most Kenyan women had very little knowledge about HPV and HPV vaccination. Some women confused HPV with HIV or hepatitis B. They were willing to let their daughters be vaccinated if it meant prophylaxis against cancer; however, they stated that they would prefer a more inexpensive option with fewer dosages.9The success of these primary cervical cancer prevention strategies is related to the level of awareness and knowledge regarding various aspects of the disease and vaccine.However, there are a dearth of data on the level of awareness of cervical cancer among Kenyan adolescents and their acceptance of cervical cancer prevention strategies. Therefore, a study was conducted to compare the knowledge and source of information of cervical cancer and acceptability of prevention strategies among vaccinated and unvaccinated adolescent girls after a HPV vaccination initiative in Eldoret, Kenya that was carried out by Gardasil Access Program, under Merck and Co., Inc., in 2012 to 2013.This cross-sectional comparative study was carried out between May and October 2016 in six randomly selected public schools that had participated in the Gardasil Access Program's hospital-based HPV vaccination initiative in Eldoret, Kenya 3 years before this study was conducted. Using lists from each school with the names of the vaccinated adolescents, we randomly selected a total of 60 vaccinated adolescents by proportionate allocation from 3 of the schools. For the comparative cohort, we selected 120 unvaccinated adolescents from the remaining 3 schools also by proportionate allocation. The eligibility criteria included being 12–18 years of age at the time of enrollment (3 years after the vaccination initiative) and being female gender; this is in accordance to the World Health Organization definition of an adolescent (10–19 years).The Moi University and Moi Teaching and Referral Hospital Institutional Research and Ethics Committee in Eldoret, Kenya approved the study protocol. As all participants were minors (<18 years) in accordance to the Kenyan constitution, written informed consent was required from each parent/guardian with subsequent participant informed assent.After enrolment, the adolescents had face-to-face interviews with the principal investigator and trained research assistants in classrooms or under tree shades depending on the participant's preference in a bid to create an informal set up. The interviews were carried out in English, as it is the primary language for communication at all schools in Eldoret, covering demographic details, questions on HPV transmission, and identification of cervical cancer symptoms and treatment options. The questions were based on print material used to disseminate information about cervical cancer. Each question had three choices: “Yes,” “No,” and “Don't know” . The adoCategorical variables were summarized using frequencies and the corresponding percentages. Continuous variables were summarized using mean and the corresponding standard deviation if the Gaussian assumptions were holding. The median and the corresponding interquartile range (IQR) whenever the Gaussian assumptions were violated. Gaussian assumptions were assessed using Shapiro–Wilk test, the normal probability plots and histograms.t-test or one-way analysis of variance test between more than two levels of a categorical variable. The two-sample Wilcoxon rank sum test was used to compare two continuous variables whenever the Gaussian assumptions were violated. The knowledge score was compared between the vaccinated and the unvaccinated using a linear regression model adjusting for potential confounding variables. This was reported by the regression estimates and the corresponding 95% confidence intervals (CIs). The statistical package used for data analysis was carried out using R: A Language and Environment for Statistical Computing for summarizing and comparing the variables for significant statistical inference.10Proportions were compared using Pearson's chi-squared test. However, whenever the chi-squared assumptions were violated, Fisher's exact test was used. Normally distributed continuous variables were compared between two levels of a categorical variable using independent sample The median age of all 180 participants was 14.0 years (IQR = 13.0–15.0) with a range of 12.0–18.0 years. Eighteen of 180 girls (10%) were in grade 6 (12–13 years of age), 56 of 180 girls (31.1%) were in grade 7 (13–14 years of age), and 106 of 180 girls (58.9%) were in grade 8 (14–15 years of age). No vaccinated girls were in grade 6. Forty-nine of the 60 (81.7%) vaccinated adolescents were in the eighth grade with the mean age for vaccination being 14 years.p < 0.001). A majority of the vaccinated adolescents  had heard of the HPV vaccine, whereas only 5% (6/120) of the unvaccinated adolescents had heard of the vaccine (p > 0.001). HPV was correctly identified as a sexually transmitted virus by 41.7% (25/60) vaccinated adolescents but only by 5% (6/120) unvaccinated adolescents (p < 0.001).Of the vaccinated adolescents, 96.7% (58/60) had heard of cervical cancer as compared with 50.8% (61/120) of the unvaccinated adolescents (p = 0.001). There was no statistically significant difference in knowledge between the vaccinated and unvaccinated adolescents in selecting other risk factors for cervical cancer such as smoking and having multiple sexual partners  vaccinated girls knew that an early sexual debut was a predisposing factor for cervical cancer, compared with 70.8% (85/120) of unvaccinated girls (partners .p < 0.001)  .p = 0.015)  from the vaccinated cohort and 50% (60/120) from the unvaccinated cohort indicated that they did not know the cervical cancer screening modalities available but there was no significant difference between the two groups. For the adolescents who correctly selected Pap smear and visual inspection with acetic acid as screening modalities, 28.4% (17/60) were from the vaccinated group, whereas 20% (24/120) were from the unvaccinated group, also with no significant difference between the two groups. Blood tests were ruled out as cervical cancer screening modalities by 53.3% (32/60) of the vaccinated adolescents and by 33.3% (40/120) of unvaccinated adolescent girls (= 0.015) .There was no statistical difference between the vaccinated and unvaccinated adolescents in their opinion that cervical cancer was preventable.In multivariate analysis, adolescents who were vaccinated were more likely to be knowledgeable about cervical cancer than those in the unvaccinated counterparts, regardless of the current grade of school  .The potential sources of information the adolescents relied on to obtain information about cervical cancer were categorized to include the school, health care workers, social media, and community outreach programs. Both cohorts selected the school as the main source of information for cervical cancer . Despitep < 0.001)  of the vaccinated participants reported a higher sense of self-perceived risk compared with 22.5% (27/120) of the unvaccinated cohort (< 0.001) .p = 0.791) rather than the 10–20 years age range or >31 years of age.A 21- to 30-year-old age range was selected by both the vaccinated and unvaccinated cohorts as being the most preferable for initiating a sexual debut  and the unvaccinated  adolescents.Seventy-five of 118 unvaccinated adolescents (63.6%) would accept the HPV vaccine with a majority of those who would not accept it , reporting it was because of the lack of knowledge on what it is.Among those vaccinated, 18.3% (11/60) thought that because they were vaccinated, they were protected from all sexually transmitted infections (STIs) and so would not need to engage in safe sex practices.p = 0.940).A bivariate analysis tested for association between uptake of cervical cancer screening with relation to the vaccination status. As given in 10 The adolescent women in this study were matched for age, sex, and socioeconomic status by selection of schools in the same low resource setting. The defining element was vaccination status. The vaccinated adolescents were predominantly in grade 8 as they had been vaccinated 3 years before this study.Numerous studies have been carried out locally and internationally with regard to knowledge and attitudes toward HPV and HPV vaccine.13 In this study population, the adolescents in both groups perceived themselves to be at a higher risk of acquiring the virus but this could be attributed to the very low knowledge they had on the transmission of HPV, or to undisclosed sexual activity. Adolescents from both the vaccinated and unvaccinated cohort could identify some of the risk factors for acquisition of HPV, including an early sexual debut, multiple sexual partners, or having a sexual partner with multiple sexual partners and smoking. Knowledge of treatment and screening modalities for cervical cancer was low in both groups as seen in other adolescent populations where there is a low level of knowledge of HPV, its transmission, causes, and prevention strategies for cervical cancer among adolescents.14–16 This shows that as much as a positive vaccination status may be associated with better knowledge of cervical cancer, it does not afford sufficient awareness of the same if education offered during vaccination is not comprehensive and sufficient.It was anticipated that the vaccinated adolescents would be more knowledgeable about cervical cancer and thus perceive themselves to be at a higher risk of HPV infection.18 Neither group in this study believed that the vaccine would prevent all STIs, similar to a previous study19 that strove to dispel this myth by exploring the association between getting the vaccine and engaging in risky sexual behavior, finding no such evidence. Studies looking for risky sexual behaviors after HPV vaccination found that vaccination was a good opportunity to reiterate the need for safe sex practices among adolescents and young women.20 In Western Uganda,21 it was established that HPV vaccination, knowledge and perceived sexual risk did not predict sexual behavior intentions, and with high parental involvement and communication, sexual debut could be delayed. The importance of this lies in the fact that early sexual debut and early age at first pregnancy have been linked to the development of cervical cancer later in life.22Previous studies have shown concern among parents that HPV vaccination may give the adolescent a perception of being safeguarded from all sexually transmitted illnesses and thus propelling them into promiscuity.23 A study in Sweden showed that a school-based program promoting condom use increased the uptake of condoms for HPV prevention among adolescents.24The adolescents reported a high potential for use of condoms primarily as a protective measure against pregnancy and HIV/AIDS. Several studies locally and internationally recount several barriers for adolescents to accessing condoms such as unavailability of youth-friendly facilities providing free condoms, judgmental health practitioners, and social disapproval; common barriers experienced by adolescents in low- and middle-income countries.There are several sources of information for HPV and cervical cancer such as social media, radio/television advertisements, print material, community outreach health talks, and information garnered from a health professional at a hospital to name but a few.25 that the empowerment of teachers would be a more feasible way to increase uptake of the vaccine through their dissemination of information on the vaccine and cervical cancer in a low resource setting such as in Eldoret, Kenya.From the data accrued from the interviews, the adolescent girls in this study showed immense reliance on their teachers for information on health. This is in line with the surmise of Masika et al.26 saw the need for a collaborative effort between health workers and teachers to provide correct information while tackling stigmatism and myths that are a hindrance to the primary prevention of cervical cancer.Similarly, a previous study in this region27 by adolescents and anyone with limited knowledge of HPV and cervical cancer to learn and understand the disease and the ways to protect oneself.It is clear that adolescents need exposure to other avenues of information disbursement and need to be given access to other sources at their level. For instance, the Cancer Registry of Norway developed an application called FightHPV™, an interactive game that can be downloaded on various android and Apple devices28The unvaccinated group showed great willingness to be vaccinated, which was higher compared with other studies such as that of Moroccan adolescents, which revealed that only 27% (282/1044) of participants were willing to accept HPV vaccination.15 This phenomenon could be explained by the possible exposure to community-based messaging on cervical cancer in this region urging women to go for screening thus making the adolescents realize their own susceptibility to cervical cancer.The acceptability of screening for cervical cancer was remarkably high in both cohorts of adolescents despite their minimal collective knowledge of screening modalities available. This was higher than most studies where the adolescents showed very low levels of desire to be screened.Because of the univariate results, the study was not powered to conduct a logistic regression that sufficiently shows association and predictors. Another potential limitation is that the informal interview settings utilized may have permitted a social desirability bias. However, during the pilot phase of the project, it was noted that the participants had trouble understanding the implication of some medical terms despite attempts to simplify the language. With an interviewer administering where the participants could ask for clarification, ease in responding was noted and thus this was the mode employed.Receiving the HPV vaccine was associated with a higher knowledge of cervical cancer.The adolescent women in this study predominantly rely on their school for health information. Other sources of health information like interactive social media need to be availed to adolescents. Both cohorts of adolescents showed remarkable acceptability for cervical cancer prevention strategies. There is need to increase exposure to the vaccine that may also aid in improving knowledge of cervical cancer. Prevention strategies should be made more accessible to the adolescents to improve acceptability.There is high morbidity and mortality from cervical cancer in sub-Saharan Africa. Thus the need to aggressively involve adolescent women in primary prevention strategies such as increasing HPV vaccination and behavioral modifications like condom use to prevent sexually transmitted diseases, limiting number of sexual partners, and regular screening.A.M., conception and design, development of methodology, acquisition of data, analysis and interpretation of data, writing of article. P.I., project supervision, review, and revising of data critically for important intellectual content. H.M., project supervision, review, and revising of data critically for important intellectual content. A.K., concept design, review, and revising of data critically for important intellectual content. D.R.B., review and revising of data critically for important intellectual content, final approval of the version to be published.


The highly infectious human papillomavirus (HPV) causes both genital warts and cervical cancer in women. In 2009, the prevalence of genital warts in Hong Kong was 203.7 per 100,000 person-years. Cervical cancer, more seriously, was the eight most common cancer among women and girls in Hong Kong, accounting for 2.3% of all new cancer cases in females in 2014. Cervical cancer is a significant global public health problem and HPV is a major risk factor leading to the development of cervical cancer. HPV is also the most common sexually transmitted disease among university students. This is the first study to examine the acceptability of HPV vaccines and associations with perceptions related to HPV and HPV vaccines among the male baccalaureate student population locally.A self-administrative cross-sectional survey was used to assess whether male baccalaureate students from eight local Hong Kong universities intended to be immunized for HPV. The study also asked questions concerning how its subjects perceived HPV and HPV vaccines using the Health Belief Model. Data collection spanned from June to September 2015. A multiple stepwise regression model was used to examine associations between cognitive factors and subjects’ intention to take up the HPV vaccine.A total of 1,004 (83.7%) students aged 18 and 26 participated in this study. 23.3% found vaccinating for HPV acceptable, a level correlating with a number of indicators. Subjects were more likely to find vaccinating acceptable if 1) they knew something about HPV vaccines; 2) they understood that men were susceptible to infection by HPV; 3) they realised they could benefit by HPV vaccination, and 4) they were aware of the arguments for and against HPV vaccination, as disseminated by either the media or peers.HPV remains a significant public health concern in Hong Kong and China more broadly. This study’s findings show a disconnect between the perceived and actual risk of being infected with the HPV vaccine among male baccalaureate students. This disconnect may be bridged by informing young men of the benefits of their being vaccinated against HPV, by removing the psychological and financial barriers that prevent them from taking up the vaccine and by improving how primary healthcare providers motivate them to get immunized. Men are also at risk for other HPV- related cancers including penile, anal and oral cancers [Human papillomavirus (HPV) infections are the world’s most common sexually transmitted infections (STI) among men and women in the world . Human p cancers . Penile  cancers . Penal a cancers  than amo cancers . Sexual  cancers . The Cen cancers . The num cancers , regardl cancers .A systematic review conducted in Europe  between Cervical cancer is the eight commonest cancer among females in Hong Kong, being responsible for 2.3% of all new cancer cases in women and girls in 2014. In 2014, 472 new cases of cervical cancer were diagnosed. The crude incidence rate was 12.1 per 100,000 of the female population. In 2015, 169 women died from cervical cancer, representing 2.8% of female cancer deaths [Although HPV vaccine is widely available for male and female in Hong Kong, only a paucity of research has examined gender differences in acceptability of HPV vaccine among baccalaureate students in Asia, China and Hong Kong. Recent research reported that more female university students were taking proactive steps towards HPV vaccination than male counterparts and there were significant gender differences in HPV-related beliefs and attitudes among university students . A recenThe human papillomavirus (HPV) vaccine  is a prophylactic vaccine designed to prevent cervical cancer and other HPV-related cancers or diseases.Currently, three HPV vaccines, namely, Cervarix , Gardasil-4  and Gardasil-9  have been registered in Hong Kong for the prevention of cervical cancer and/or other HPV-related diseases . All thrHPV vaccination is recommended routinely for boys and girls aged between 11 and 12 years old . It can This is, then, the aims of this study to examine the acceptability of HPV vaccines and associations with perceptions related to HPV and HPV vaccines among male baccalaureate students’ in Hong Kong.Perceived susceptibility of contracting HPV will increase the likelihood of taking up HPV vaccination;Perceived severity of HPV is positively associated with the intention to take up HPV vaccination;Knowledge of HPV vaccines is associated with acceptability towards HPV vaccination;Perceived self-efficacy is associated with the intention to take up HPV vaccination.The study implemented a cross-sectional self-administrative survey. Convenience sampling recruited study participants from eight local universities in Hong Kong. To be included subjects needed to be male, currently a full-time student enrolled in a local university, aged between 16 and 29 and able to read Chinese, the language of the survey. Since all participants were 16 years old or above, no parental / guardian consent were required. Part-time students and non-readers of Chinese were excluded from the study. Flyers were posted up on notice boards in canteens and communal areas on-campus one week before commencement of data collection. Mass email invitations were delivered to subject lecturers in all research sites to seek permission to allow research assistants and student helpers to promote this study before and after classes. Participants were recruited within university campus by research assistants and student helpers who introduced the aims and objectives of this study. Confidentiality were assured. Participants were given a self-addressed blank envelope with an information sheet and our survey. Participants were asked to return the completed survey in a sealed envelope to the research assistants / student helpers on-site. Returning the completed survey inferred implied consent. This study was approved by the Human Subjects Ethics Sub-committee, the Institutional Review Board of a local university in Hong Kong.A total of 1,200 eligible baccalaureate students were recruited from eight local universities to participate in this study from June to September 2015. 191 students refused to participate and 5 students missed out data in their survey returns and were removed from analysis.Extensive research has been conducted using HBM to examine the attitudes and beliefs about HPV and HPV vaccination. Nonetheless, there seems to be a paucity of research examining the acceptability of HPV vaccination among university male students in the globe –26. ThisThe survey filled in by participants had 21 items and closely followed the format of Lau’s comparable study . It soliUnivariate analysis first determined odds ratios (ORu) for the likelihood of subjects getting vaccinated. Background variables that could be candidates for significantly affecting this likelihood for subjects were fit into a multiple stepwise regression model to generate a multivariate odds ratio (ORm). Associations between the subjects’ cognitive factors and the dependent variable (their intention to get vaccinated) were assessed, adjusting for those background variables that were found significant in the multivariate analysis. This derived adjusted odds ratios (AOR). Odds ratios were given at a 95% confidence interval (CI). The statistical analysis was performed using SAS 9.2, with p values of < .05 taken as statistically significant.A total of 1,004 baccalaureate students participated in this study. The response rate was 83.7%, of which 80.3% came from non-health related faculties. The vast majority of the participants (97.4%) were aged between 18 and 26. The mean age was 22 (SD: 2.30). 32.9% were sexually active, with past year the participants had previous exposure to HPV-related services , with 6.2% (n = 62) exhibiting self-reported STD-related symptoms and 1.3% (n = 13) actually diagnosed with a sexually transmitted infection (STI) in the past year .A total of 23.3% of respondents said they intended to get vaccinated for HPV in the next six months.The prevalence rate of responding knowing something about HPV on one of the test’s knowledge items ranged from 20.5% to 60.4%. . Survey Regarding perceived susceptibility, 41.6% of the participants perceived that the prevalence of HPV infection among women in Hong Kong as high or very high. In contrast, only 17.9% regarded prevalence among males as at this level. 35.6% believed the infectivity of HPV as high or very high. Nevertheless, only 8.0% of the participants perceived a high or very high chance that they could contract HPV in the future. Item responses reflecting the perceived severity of HPV showed that 53.6% of granted the virus was injurious to physical health. 8% thought that infection could cause genital warts and 35.6% penile or anal cancer .Subjects know little of the availability or price of HPV vaccine. Nor did they know that it was delivered in three shots, or the preferred age range for vaccination. The prevalence rate for correct responses to these question items ranged from 12.2% to 39.5% . 44.5% tFour background variables were statistically significant for whether respondents intended to get vaccinated: previous exposure to HPV services , the presence of self-reported-STD related symptoms in the last year , an STD diagnosis in the past last year  and respondents’ number of sexual partners . Adjusting for these four variables, the results showed that six knowledge variables were subsequently statistically significant: responses to the items ‘‘HPV is a virus that has been newly discovered in the past few years” , “HPV causes a mortality rate of over 5%” , “HPV may cause anal cancers” , “effective HPV vaccines are readily available to me” , an item capturing the perceived price of HPV vaccine per shot  and an item related to the number of shots required to secure immunity  .There were three variables relating to the perceived severity of HPV that significantly influenced subjects’ likelihood of seeking vaccination. Subjects were more likely to get vaccinated if they thought 1) they had a moderate to very high chance of contracting HPV ; 2) that HPV could damage their physical health , and 3) that the chances of their passing on HPV were high or very high . Subjects were further more likely to seek immunization when their knowledge of HPV was at least moderate ; when they believed that there was a moderate to very high prevalence of HPV infection among men in Hong Kong , and when they believed that the prevalence of HPV infection among women in Hong Kong was moderate to very high  .Subjects were also more statistically likely to intend to take up vaccination if they thought they could prevent and treat genital warts , as well as penile and anal cancers . Only one item relating to perceived self-efficacy was of statistical significance: responses to “I am confident that I could take up HPV vaccines if I wanted to”  .Several factors reflecting perceived barriers to vaccination were significant: concerns over cost , ‘‘side effects” , “hassle”  and “embarrassment” . Two variables relating to cues to action were significant: media exposure  and peer discussion . Furthermore, adjusted analysis determined five cognitive composite indicator variables as statistically significant. These related to knowledge of HPV vaccines , perceived susceptibility to infection , perceived benefits from getting immunized , subjects’ sense of the barriers to immunization , and motivations for getting vaccinated  .In addition, the study framed a multiple logistic regression model containing all cognitive composite indicator variables, adjusted for the same significant background variables. It obtained similar results .In this model, subjects’ variable degree of knowledge of HPV, understanding of its severity and perceived self-efficacy in getting vaccinated were not statistically significant with regard to whether they intended to get the vaccine or not.The Centre for Health Protection at the Department of Health in Hong Kong promotes HPV vaccination over an electronic platform. It has secured extensive coverage in the media and has passed to private clinics all the information that is necessary to get vaccinated. Unexpectedly, one third of the study participants (33.8%) had never heard of HPV. About half (50.6%) asserted that HPV was recently discovered.A similar study suggests men know less about HPV than women . Five HBThe knowledge deficit as regards HPV is likely to prevent men from acting in such a way as minimizes the risks of their either becoming infected or passing on infection. Better knowledge of HPV-vaccines  would eqJust under a third of study n = 330, 32.9%) participants reported one sexual partner or more in the past year. Of these, 7.5% (n = 75) had STD-related symptoms or an STD diagnosis. Supposing self-reports of sexual activity are true, this indicates that approximately every 1 in 4 participants who had sex was exposed to sexually transmitted infections. More importantly, 3.3% of our participants had multiple sexual partners. Having >2 sexual partners is associated with a greater risk of HPV infection , 32. It .9% partiIn this study, cost (a supposedly expensive price), cognitive and psychological barriers (perceived side effects and embarrassment), and logistical barrier (it being too much trouble) were of statistical significance in whether participants thought there were barriers in the way of getting immunized. It is important to remove these perceived barriers. Currently, the Centre for Health Protection in Hong Kong does not provide HPV vaccination on demand . Hong KoSuffering from STD-related symptoms or being diagnosed with an STD is embarrassing. In order to reduce the social stigma attached to HPV vaccines, the Department of Health, Hong Kong, could run a positive campaign on their benefits in collaboration with university health-services , This prHow subjects responded to cues is one of the key determinants of their health-related behaviors. Our study suggested that, in disposing men to get vaccinated for HPV, two out of three types of cues to action (media and peer information) were significant. Although medical doctors are actively involved in primary, secondary and tertiary health promotion, doctors’ recommendations were not a significant factor in the multiple logistic regression model. This may be because half of the participants (50.2%) had never been exposed to HPV-related services and would in all probability not have known what doctors had to say about HPV vaccination. Nevertheless, health professionals play a pivotal role in health promotion . Peer edPerceived self-efficacy was non-significant, possibly due to the small variation in item responses , in thatIn summary, our research hypotheses 1, 2 and 3 could be established. Participants who had higher perceived susceptibility, higher perceived severity and increased level of knowledge on HPV were significantly correlated with their acceptability and intention to take up the HPV vaccination. However, we would reject our hypothesis 4 that perceived self-efficacy was positively associated with the intention to take up the HPV vaccination.This study has some limitations. First, the samples recruited in this study may be subject to selection bias as convenience samples without a sampling frame were used. Second, cross-sectional data cannot establish the causal relationship between risky sexual behavior and willingness to get vaccinated for HPV. Third, participants were asked about their behavioral intention to take up the HPV vaccine, rather than their actual behavior being scrutinized. Fourth, no validated scale can be used to accurately measure people’s willingness to get vaccinated for HPV. As a result, questions were constructed with reference to a similar study conducted in Hong Kong . Lastly,HPV is a significant public health concern for university-aged men. This highly infectious disease can lead to serious health outcomes. This study has uncovered the prevalence of male university students’ willingness to be vaccinated against HPV in Hong Kong, unveiling significant composite factors associated with the perceived acceptability of HPV vaccines. The study cohort seriously underestimate the chance they will get HPV as evidenced by our findings emerging that less than one quarter of our participants had the intention to take up HPV vaccine. Such a disconnect follows from a knowledge deficit. Participants’ sense of their susceptibility mean that the disadvantages (or inconvenience) of taking the course of prophylactics outweigh any benefits they see themselves incurring. Too many barriers stand in the way of their getting immunized; and there are too few cues to action motivating them to self-efficacious preventative behavior. Healthcare providers should focus on removing these psychological and financial barriers before progressing to the next stage of any health promotion campaign. Health policy-makers should consider a sponsored trial of a free HPV vaccination programme of an at-risk population to examine the cost-effectiveness of this preventative measure.The study was approved by the Human Subjects Ethics Sub-Committee, and the Institutional Review Board of the Hong Kong Polytechnic University (Reference No: HSEARS20150513004). Our Human Subjects Ethics Sub-Committee approved the lack of parental consent for participants who were under 18 to participate in this study.S1 File(XLSX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


An association between HIV infection and cervical cancer, a major public health issue worldwide, has been reported. The aim of this study was to estimate the prevalence of human papillomavirus (HPV) infection and the distribution of HPV genotypes in HIV-infected women living in French Antilles and Guiana and to determine HIV-related characteristics associated with HPV infection. This cross-sectional study included 439 HIV-infected women who were followed between January 2011 and May 2014. Variables related to HIV infections were collected, and cervical samples were analysed to determine HPV genotypes. The median age of the population was 46 years. Estimated prevalence of HPV and high-risk (HR)-HPV infection were 50.1% IC95 [45.4–54.7] and 42% IC95 [37.3–46.6], respectively. HR-HPV 16, 52, 53 or intermediate risk-HPV-68 were found in 25% to 30% of the HPV-infected patients. Gynaecological screening revealed abnormal cervical smear in 24% and 42% of HR-HPV-negative and HPV-positive women, respectively (p = 0.003). Approximately 90% of women were on antiretroviral therapy (ART). Demographic characteristics associated with a higher prevalence of HPV infection included alcohol consumption. Regarding HIV-related characteristics, current therapy on ART, its duration, and undetectable plasma concentrations of RNA-HIV1 were associated with a lower risk of HPV infection. Infection rate with HR-HPV was higher than what is commonly reported in HIV-negative women worldwide and was more likely in women with incomplete HIV suppression. These results highlight the need for supporting adherence to ART, cervical cytology, HPV testing and HPV vaccination. Cervical cancer is a major health issue worldwide. In 2012, 528,000 new cases were estimated and approximately 270,000 women died from cervical cancer . Most HPHPV genotypes have been classified according to their oncogenic potential . In the The overall prevalence of HPV infection varies greatly among populations, with a worldwide heterogeneity dependent on behaviours and economic levels . BecauseThe aim of this study was to estimate the prevalence of HPV infection and the distribution of HPV genotypes in HIV-infected women in French Antilles and French Guiana where HPV infection is highly prevalent compared with other countries worldwide  or with rd 2011 and May 2nd 2014 in four hospitals in the French Antilles  and French Guiana  at the time of their annual visits scheduled for gynaecological follow-up. All patients included in the study gave informed consent for HPV testing and cervical-uterine smear. Because screening of the patients was made in the context of their routine follow up for HIV infection, oral non-opposition was considered for sample collection. Written consent was given for the inclusion of data in the French national HIV Nadis database. The study was approved by the Comité de Protection des Personnes (CPP) Sud-Ouest et Outre Mer III ethics committee. ClinicalTrials.gov identifier NCT01226368.This was a cross-sectional study of the HPV genotype’s prevalence in a collection of biological samples and its associated de-identified data. Women were followed between January 3Patients’ inclusion criteria were to be at least 18 years old, to be followed for HIV1 or HIV2 infection in one of the participating centres and to have an indication for cervical-uterine smear analysis for routine screening in the context of HIV infection follow-up, or any cervical-uterine pathology. Exclusion criteria included a history of total hysterectomy and the impossibility of obtaining smear samples.Variables recorded were demographic characteristics, alcohol and drug consumption, history of HIV infection  and medical history . Regarding HIV infection, CD4 counts at the beginning of the study, CD4 nadir, HIV1-RNA load and status regarding past and current antiretroviral therapy, if any, were collected. Macroscopic examination of the cervix with acetic acid or lugol’s iodine was reported.Cervical samples were taken using the ThinPrep-PreservCyt solution kits (Hologic). Samples were then sent to the pathology laboratory of Martinique University hospital for a centralized assessment and, after processing for cytological study (Hologic), to the virology laboratory. The detection and genotyping of HPV-DNA was performed using the Papillocheck kit (Greiner-Bio-one) after DNA extraction on EasyMag (Biomérieux). This kit allows the identification of HPV genotypes including HR or group 1  intermediate risk or group 2  and LR or group 3  genotypes. Abnormal cervical smear analysis identified atypical squamous cells of unknown significance (ASCUS), low-grade (LSIL) or high-grade (HSIL) squamous intraepithelial lesions according to the 2014 Bethesda classification ), with no significant difference between Antilles and Guiana centres . The distribution of HPV genotypes revealed that 63.6% of HPV were HR-HPV  with the predominance of HPV 16, 52, and intermediate risk-HPV 68 found in 25% to 30% of HPV-infected patients . HPV 18 Regarding patients’ demographics and behaviours, alcohol consumption was significantly associated with HPV infection . A high The durations of HIV infection were similar in patients with positive or negative HPV detection, as were the proportions of patients having experienced AIDS (approximately 25%). However, being currently on ART, the duration on ART and undetectable plasma concentrations of HIV1-RNA were significantly associated with a lower risk of HPV infection. There was a negative correlation between low CD4 counts and HR-HPV infection, but that did not reach statistical significance. A significant inverse relationship between mean CD4 counts and HPV was found when considering HPV irrespective of HR or LR type .This study reports the prevalence and genotypes of HPV in HIV-infected women living in the French Antilles and Guiana. HPV infection was found in half of the study population, which mainly corresponded to HR-HPV. These results are in agreement with those reporting that HR-HPV was present in about 50% of HIV-infected women living in Tanzania  or in BrThe estimated rate of HPV infection was also higher than that reported in HIV-negative women living in the same area. A study conducted in the French Caribbean island of Guadeloupe showed a prevalence of HR-HPV of 36% among healthy women , and twoIn the present study, one third of cervical smears showed abnormal cytology, which is far greater than in HIV-negative women in French Guiana where the proportion is 10% and is already considered high . For HSIA meta-analysis based on 21 studies including HIV-infected African women with invasive cervical cancer (ICC) showed that HPV16, found to be highly prevalent in the present study, was the most frequently detected type (42.5%), followed by HPV18, HPV45, and HPV35 . The preThe burden of HPV-related cancers can then be expected to increase in HIV-seropositive patients, and both American and European guidelines recommend pap test for cervical cancer screening for all HIV-positive women older than 21 years of age or within one year after initiation of sexual activity ,41. In H3 and with a protective effect of ART on HIV-associated malignancies in compliant women [The present study did not find any association between HPV positive status and the time since HIV diagnosis. However, HPV infection was statistically associated with the absence of ART and with characteristics such as low CD4 counts or nadir CD4 known to be associated with a lack of ART efficacy or a poor compliance. These data are consistent with those reported in the cross-sectional hospital-based study involving HIV-infected women in Tanzania , showingnt women . A meta-nt women . One of nt women . Taken tThe main limitation of the study is the lack of a control HIV-negative group, which did not allow a direct assessment of the impact of the HIV infection on the prevalence and characterisation of HPV infection. It cannot be excluded that the ethnicity of populations was different dependent on the HIV status and that the higher prevalence of HPV infection in HIV-infected women may be due to a greater genetic susceptibility. However, while an ethnic influence may be addressed, the interpretation is expected to be poorly biased when considering women living in the same area. Finally, one may not exclude that visual inspection or cervical cytology may be result in cervical disease misclassification. However, cervical samples have been taken by gynaecologists and have been sent to one pathology laboratory for a centralized assessment, which limit biases on interpretation.In summary, this prospective cross-sectional study shows that in the population of the French Antilles and Guiana, half of the HIV-infected women are co-infected with HR-HPV, which corresponds to a higher prevalence than that reported in populations not infected with HIV. The detection of HPV was independent from the time of HIV diagnosis but was positively associated with low CD4 levels, which is in agreement with the correlation between HPV persistence and the host immune status. Such a correlation should cause physicians to be particularly cautious regarding treatment compliance and when considering a modification of ART regimen, whatever the reason. Finally, the high prevalence of infections with various types of HR-HPV in HIV-infected women and the associated risks for cancer support a close cervical screening programme coupled with HPV testing. Regarding vaccination-based prevention, the newly approved nonavalent vaccine including HPV-52 should be preferred.S1 Dataset(XLSX)Click here for additional data file.


Treatment modalities of head and neck squamous cell cancer include surgery, radiation, chemotherapy, targeted agents and immune checkpoint inhibition. Treatment is often toxic and can affect long-term function and quality of life. In this context, identification of biomarker data that can help tailor therapy on an individualized basis and reduce treatment-related toxicity would be highly beneficial. A variety of predictive biomarkers have been discovered and are already utilized in clinical practice, while many more are being explored. We will review p16 overexpression as a surrogate biomarker in HPV-associated head and neck cancer and plasma EBV DNA as a biomarker in nasopharyngeal carcinoma, the two established biomarkers currently utilized in clinical practice. We will also examine novel predictive biomarkers that are in clinical development and may shape the future landscape of targeted head and neck cancer therapy. These emerging biomarkers include the tyrosine kinases and their signaling pathway, immune checkpoint biomarkers, tumor suppressor abnormalities, and molecular predictors of hypoxia-targeted therapy. We will also look at futuristic biomarkers including detection of circulating DNA from clinical specimens and rapid tumor profiling. We will highlight the ongoing effort that will see a shift from prognostic to predictive biomarker development in head and neck cancer with the goal of delivering individualized cancer therapy.N/A. Head and neck squamous cell cancer (HNSCC) is a heterogeneous group of cancers accounting for about 3% of all cancers in the United States. Each year, an estimated 61,000 people develop HNSCC, of whom about 13,000 die –4. In thWith the identification of HPV as an etiologic agent in a subset of HNSCC, p16 overexpression by immunohistochemistry (IHC) as a surrogate marker of HPV association has become the most robust HNSCC biomarker employed in clinical practice. Plasma Epstein Barr Virus (EBV) Deoxyribonucleic Acid (DNA) also plays a role as a predictive and prognostic biomarker specifically in nasopharyngeal carcinoma (NPC) patients.CDKN2A gene, regulates cell cycle by inhibiting the phosphorylation of the retinoblastoma (Rb) tumor suppressor protein by cyclin dependent kinases (CDK) 4 and 6. This leads to inactivation of factor E2F1, an important component of cell-cycle progression. In the setting of HPV-associated tumors, the HPV E7 viral oncoprotein promotes rapid degradation of Rb, and as Rb usually regulates p16, the disruption of Rb permits increased p16 expression [HPV-initiated HNSCC is a biologically distinct category of HNSCC with significantly better prognosis and treatment outcome compared to HPV-negative HNSCC –8. p16 opression . Expressn = 51); and 96% and 96%, respectively, for patients with < T4, < N2c, and <10 pack-year smoking history who were treated with ≤54 Gy of radiation (n = 27). At 12 months, significantly fewer patients treated with a radiation dose ≤54 Gy had difficulty swallowing solids  or had impaired nutrition . The study therefore suggests that for IC responders, reduced-dose IMRT with concurrent cetuximab should be considered in favorable-risk patients with HPV-associated OPSCC since de-intensification with radiation dose reduction resulted in significantly improved swallowing and nutritional status [P = 0.022), and for p16-positive versus p16-negative  tumors. There was also improved median survival for HPV-positive versus HPV-negative patients , and for p16-positive versus p16-negative patients . After adjusting for other covariates, hazard ratio (HR) for OS was 2.69 (P = 0.048) and 2.17 (P = 0.10), favoring HPV-positive and p16-positive patients, respectively [Several studies have shown that patients with HPV-associated OPSCC have a better prognosis than patients with HPV-negative tumors, with significantly decreased risk of death (40–60% reduction) and relapse (60–70% reduction) in HPV-associated tumors compared to HPV-negative tumors, when treated with multimodality therapies , 11–13. l status . Anotherl status . HPV DNAectively . HPV is The predictive role of HPV status with specific therapy has been less well understood. Epidermal growth factor receptor (EGFR) inhibitors in particular have been studied in this regard. Subset analysis of the SPECTRUM phase III trial of chemotherapy with or without the anti-EGFR antibody panitumumab in R/M HNSCC suggested that p16-negative patients had benefit to addition of the human anti-EGFR antibody, panitumumab, unlike p16-positive patients . HoweverP = 0.03), while for OS the adjusted HR was 0.56 . Comparing OPSCC and non-OPSCC patients from the same studies, p16-positive OPSCC have better survival than patients with p16-positive non-OPSCC , but patients with p16-negative OPSCC and non-OPSCC have similar survival, even after adjustment of prognostic variables . A recent study suggested that HNSCC associated with HPV genotypes other than HPV-16 have inferior survival, and that determination of HPV genotypes in HNSCC could provide a more robust risk stratification than p16 IHC findings or HPV-16 detection alone, especially in the era of treatment de-intensification for HPV-associated HNSCC [P = 0.003 [The clinical significance of p16 positivity in non-OPSCC is less clear than for OPSCC, however patients with p16-positive non-OPSCC have better outcomes than patients with p16-negative non-OPSCC, similar to findings in patients with OPSCC. In a retrospective analysis of non-OPSCC tumors from 332 patients enrolled on three RTOG studies, overall p16 expression was positive in 19.3% of the non-OPSCC tumors with the rates of p16 positivity of 14.1%, 24.2% and 19% for RTOG 0129, 0234 and 0522 studies, respectively [ed HNSCC . In this = 0.003 . However = 0.003 . FurtherP < 0.001) [Zta and Rta, and increased transcriptional expression of its lytic gene products, BFRF3 and gp350 [NPC is the predominant tumor type arising in the epithelial lining of the nasopharynx, and differs from other HNSCC in epidemiology, histology, natural history, and response to therapy . The Wor< 0.001) . In vitrnd gp350 . In the nd gp350 .The role of EBV as a primary etiologic agent in the pathogenesis of NPC is well established . EBV DNAThe landscape of HNSCC treatment is changing with the emergence of tumor biomarkers, some of which are potential pharmacologic targets. Downstream abnormalities associated with constitutive activation and signaling of the EGFR pathway may be an important therapeutic target in HNSCC especially in HPV-negative tumors Fig. .Fig. 1EGEGFR, PIK3CA, FGFR, MET and CCND1.Dysregulation of EGFR signaling has been shown to stimulate tumor cell proliferation, inhibit apoptosis, and promote angiogenesis and metastatic spread; and aberrations of the EGFR pathway are a common feature of HNSCC and are associated with worse prognosis . Based oPIK3CA) encodes p110α, a catalytic subunit of PI3K and activated PI3K triggers downstream effects on transcription, protein synthesis, metabolism, proliferation and apoptosis [PIK3CA mutations in approximately 8% of HNSCC samples [PIK3CA mutations in 21% of HNSCC samples, with 73% of the PIK3CA mutations localized to hotspots that promote activation [PIK3CA mutations whereas HPV-positive samples harbored 38% PIK3CA mutations. Additionally, PIK3CA mutations and/or amplifications were observed in 37% of the HNSCC (34% of HPV-negative and 56% of HPV-positive) samples. Approximately 25% of the mutated PIK3CA cases displayed concurrent amplification; while additional 20% of tumors displayed focal amplification without evidence of mutation [PIK3CA mutation hotspots between HPV-positive and HPV-negative tumors. HPV-positive tumors were observed to have mutations in the helical domain, whereas HPV-negative tumors have mutations throughout the entire gene [Genetic aberrations of the phosphoinositide 3- kinase (PI3K) pathway are common in HNSCC . Phosphapoptosis . It was poptosis . Previou samples , but mortivation . HPV-negThe PI3K inhibitor buparlisib (BKM120) is an oral pan-PI3K inhibitor that targets all four isoforms of class I PI3K. When used in combination with paclitaxel, buparlisib has demonstrated improved outcomes in patients with R/M HNSCC compared to paclitaxel alone, with a median PFS of 4.6 versus 3.5 months (HR = 0.65), a median OS of 10.4 versus 6.5 months (HR = 0.72), as well as improved ORR 39% versus 14% [PTEN mutation or post-translational modification, [PTEN genomic alterations (PTEN mutation or loss) in 15% of HPV-positive and 5% of HPV-negative tumors [P = 0.037), with predominant PTEN distribution in the nucleus. Overall, PTEN expression was lost in 47% of tumors and preserved in 53% of tumors. PTEN was negative in 27% of HPV-positive compared to 57% of HPV-negative tumors. The study also showed a significant correlation between nuclear PTEN expression and DFS (P = 0.27). There was no difference in expression of p53, PI3K, Akt and mTOR between HPV-positive and HPV-negative cases [A common downstream abnormality associated with activation and signaling in HNSCC is loss of phosphatase and tensin homolog (PTEN) expression. PTEN is a key negative regulator of the PI3K/AKT/mTOR pathway and PTEN loss results in unrestrained signaling of this pathway . There iication, –42 and tication, . In a stication, . Anotherication, . HPV stae tumors . In anote tumors  This stuve cases .P = 0.07) but not PTEN null/PIK3CA mutant patients  [P = 0.014). In HER3 low tumors, afatinib also demonstrated a significantly improved PFS compared to MTX, with a median PFS of 2.9 vs. 2.0 months  [In preclinical models of breast, prostate and non-small cell lung cancer, PTEN loss has been shown to be associated with cetuximab resistance . BiomarkP = 0.6) . This suP = 0.6) . Biomark= 0.014) , 49.P = 0.99) with addition of cetuximab in patients with very high EGFR expression (IHC 3+ in 80–100% of cells). In contrast, there was a more dramatic improvement in RR, from 12% to 41% (P = 0.03), with addition of cetuximab in patients with low to moderate EGFR expression (IHC 3+ in 0–79% of cells). Although, the interaction between EGFR and treatment group was not found to be statistically significant in a logistic regression analysis of response, there appeared to be reduced benefit of cetuximab in patients with very high EGFR expression compared to patients with low to moderate EGFR expression. Based on this study, highest EGFR expression intensity and density appear to define a group, representing about a third of the cohort, with lesser sensitivity to EGFR inhibition.EGFR over-expression is a negative prognostic factor after radiotherapy but has not been validated as predictive biomarker . The E53The fibroblast growth factor receptor (FGFR) signaling pathway plays a role in cellular differentiation, proliferation, apoptosis, migration, angiogenesis and wound repair. FGF binding to members of this family of trans-membrane tyrosine kinase receptors with four members (FGFR1–4) leads to FGFR dimerization and activation of downstream signaling pathways including MAPK, PI3K/AKT/MTOR, and STAT pathways . ActivatCCND1 and is a cell-cycle protein that regulates the key G1-to-S phase transition through formation of complexes with CDKs, such as CDK 4 and 6. The cyclin D1-CDK4/6 complex phosphorylates Rb on tyrosine residue 356 (phospho-T356), inactivating Rb and releasing the inhibition of cell cycle progression by Rb [CCND1 amplification can lead to uncontrolled tumor cell proliferation via sustained activation of CDK 4/6 and inactivation of Rb [CCND1 amplification, with 77/243 (32%) in HPV-negative and 2/36 (6%) in HPV-positive samples [CCND1 in HNSCC are associated with poor prognosis and resistance to cisplatin and EGFR inhibition [CCND1 amplification. EGFR activity has been shown to regulate cell-cycle progression via ERK1/2-dependent induction of cyclin D1 [T356 Rb, cyclin D1, and CDK6 in in 99 HPV-negative HNSCC patient samples and correlated this with clinical data [T356 Rb [T356 Rb status and EGFR expression may therefore be useful as predictive biomarkers in this context and should be explored further as predictive biomarkers to select patients for therapy with EGFR/HER2 and/or CDK inhibitors.Cyclin D1 is encoded by on by Rb . Alteraton of Rb , 56. In  samples . Over-exhibition , 59. Taryclin D1 . A recencal data . The stu[T356 Rb , 62. In [T356 Rb . These dMET gene and it is a RTC associated with enhanced migration, invasion and angiogenesis when overexpressed in cancer. Although considerable evidence implicates the MET-HGF axis as a therapeutic target in HNSCC [Hepatocyte growth factor receptor (HGFR) or c-MET is encoded by the in HNSCC , approprP = 0.23) when both tumor and stromal cells were used to score PD-L1 [CXCL9, CXCL10, IDO1, IFNG, HLA-DRA and STAT1) identified in a melanoma cohort in the KEYNOTE-001 study [PD-L1, PD-L2 and IFN-gamma are potential immune biomarkers shown to correlate with response to immunotherapy in R/M HNSCC . Pembrolre PD-L1 . Assessi01 study , showed 01 study . Explora01 study . PatientTP53 is the most commonly mutated gene in HNSCC and is present in about 50–80% of HNSCC [TP53 mutation in tumor DNA has been shown to correlate with worse prognosis after surgical treatment of HNSCC [TP53. Loss of p53 function occurs in more than 90% of HNSCC through loss of heterozygosity, interaction with HPV viral oncoprotein E6 or increased expression of MDM2 (seen in about 5% of HNSCC and promotes rapid degradation of p53 protein) [TP53 mutation and the presence of HPV DNA in OPSCC may be due to the contribution of high-risk HPV infection, in which p53 is rapidly degraded after interacting with E6 [TP53-mutant tumors because cells without functional p53 lack an effective G1 checkpoint and rely heavily on the G2 checkpoint regulators, such as WEE1, resulting in increased sensitivity of TP53-mutant cells to WEE1 inhibitors. Thus, TP53 mutations need to be further investigated as a predictive biomarkers and therapeutic target in HNSCC [of HNSCC , 68. Disprotein) , 69. An  with E6 , 71. Inhin HNSCC .NOTCH-1 is believed to play a role in regulating normal cell differentiation and has dual functions with both oncogenic and tumor suppressor activity. In epithelial tissue, including HNSCC, NOTCH-1 appears to act as a tumor suppressor gene [NOTCH1 mutations in about 14% and 15% of HNSCC respectively [NOTCH1 functions as a tumor suppressor in HNSCC based on its mutational characteristics. Evidence also suggest that the majority of the mutations identified in exome sequencing are likely inactivating or loss of function mutations that affect the EGF-like ligand binding domain or the NOTCH intracellular domain [NOTCH1 was the second most frequently mutated gene found, next to TP53, with alterations present in 15% of patients [NOTCH1 mutations were identified and nearly 40% of these NOTCH1 mutations were predicted to truncate the gene product, again suggesting that NOTCH1 may function as a tumor suppressor gene rather than an oncogene in this tumor type. Other reports also suggest that a subset of HNSCC may have activating NOTCH1 mutations [NOTCH-1 in HNSCC remains an evolving field.The Notch pathway consists of four receptors, Notch 1–4. Activation of the Notch pathway leads to different effects in different cell types. sor gene , 73. Twoectively , 74, andr domain , 73. In utations , with ovα), which is over-expressed in HNSCC, and plays a central role in hypoxia-induced therapeutic resistance in HNSCC through its role in initiating angiogenesis and regulating cellular metabolism to overcome hypoxia [α and its downstream proteins are potential predictive biomarkers and therapeutic targets in HNSCC. Strategies to overcome hypoxia-induced therapeutic resistance include the use of hypoxic cell cytotoxins like tirapazamine (TPZ), enhancing oxygen delivery using hyperbaric oxygen, and use of hypoxic cell radiosensitizers. TPZ is reduced to a reactive radical when exposed to hypoxic conditions, leading to single- and double-strand DNA breaks. In contrast, this reactive radical is oxidized to the inert parent compound in normal oxygen tension. A prospective trial [A hypoxic microenvironment is a common feature in HNSCC, and contributes to the development of tumor aggression and metastasis, playing a key role in radio-resistance, chemo-resistance, and poor prognosis. Acute hypoxic stress leads to the development of an aggressive cancer phenotype with high metastatic rate, resistance to therapeutic agents, and higher tumor recurrence rates . This is hypoxia . Therefove trial  evaluateve trial F fluoromve trial . A prospve trial . Howeverve trial . These fP = 0.053). Similar trends were observed in analyses restricted to p16-negative patients. Four subgroups defined by high and low HGF/IL-8 levels were examined for TPZ effect and TPZ/CIS appeared to be beneficial for patients with high HGF and IL-8, but adverse for low HGF and high IL-8. This highlights the complexity of hypoxia targeting in unselected patients.Attempts have been made to identify molecular predictors for hypoxia-targeted therapy. IL-8 has been shown to be an independent prognostic factor in HNSCC patients irrespective of treatment. A randomized study investigated the prognostic and predictive significance of IL-8 and hepatocyte growth factor (HGF or scatter factor), a hypoxia- induced secretory protein that binds c-MET and regulates IL-8 expression, on the efficacy of TPZ . Four huWith advancements in digital genomic technologies, such as digital PCR and BEAMing, reliable detection of circulating DNA from clinical specimens has become feasible, and is a potential future predictive biomarker in HNSCC therapy.Evaluation of DNA aberrations in blood samples can be quite beneficial as it can be a challenge to obtain tumor DNA in clinical settings. Highly sensitive and specific assays are required to detect mutant DNA fragments in the blood. With advancements in digital genomic technologies, such as digital PCR, tagged-amplicon deep sequencing, pyrophosphorolysis-activated polymerization, and BEAMing, reliable detection of circulating DNA from clinical specimens has become feasible . DNA froA recent study used digital PCR–based technologies to evaluate the ability of ctDNA to detect tumors in 640 patients with various localized and metastatic cancer types, including HNSCC . ctDNA wRapid tumor profiling with sequencing of panels of several hundred cancer relevant genes is now commercially available for use in clinical practice. The relevance of this approach to management of HNSCC has not been demonstrated, given the predominance of mutations in tumor suppressor genes. A recent study compared the genomic profile of the HNSCC tumors obtained through routine clinical practice with sequencing data from frozen tumors in TCGA and University of Chicago public datasets studied in research setting , and theMicroRNAs (miRNA) are a family of small, non-coding, endogenously synthesized, single-strand RNAs which are responsible for post-transcriptional regulation of mRNA expression, and have been shown to play an important role in cellular differentiation, proliferation, apoptosis, and carcinogenesis . MiRNAs There appear to be racial disparities, not only in the incidence and outcome of HNSCC, but also in the role of biomarkers in HNSCC. Many biomarker studies in HNSCC involve mostly Caucasian populations and it remains unclear if these biomarkers are applicable to non-Caucasian populations. No biomarker till date has been specifically validated in African American or other minority populations in the United States. Many prior studies suggest higher rates of HPV- associated OPSCC among Caucasians than AA , 89 but . A variety of predictive biomarkers have been discovered and are already utilized in clinical practice, while many more are being explored as therapeutic targets. Moving forward, it will be necessary for clinicians to educate themselves in order to understand basic technologies used in biomarker studies. Each biomarker needs to be critically assessed and standardized prior to application to patient care. Currently, there is no validated biomarker for minority populations in current clinical practice. Biomarkers that specifically target non- white populations should also be an area of future research as these groups of patients may be under-represented in large research studies. Unfortunately, although the technology and science are available, the clinical research, health-care policy and insurance policy are lagging behind, limiting the implementation of these emerging biomarkers. Nevertheless, we are optimistic that the goal of delivering individualized cancer therapy for patients with HNSCC is within our reach.In this era of individualized medicine and biomarker-driven cancer therapy, it is important to explore robust biomarker data and incorporate them in patient selection for HNSCC therapy. We have well established prognostic biomarkers in clinical practice; however, we need to direct efforts towards development and implementation of predictive biomarkers that will aid patient selection for specific HNSCC therapies. The current standard therapies for HNSCC are either too toxic or have low response rates, and are thus not beneficial to all patients. The emphasis should be to improve patient survival and reduce treatment-related toxicity through the identification predictive biomarkers, in addition to development of specific therapies targeting these biomarkers. In patients with poor prognosis, we need to develop strategies to prevent and control recurrence and distant metastasis