Update obstetrician–gynecologists about human papillomavirus (HPV) vaccination for adult women with Febrasgo position about this matter.Emphasize there is a generation of women who reached adulthood without HPV vaccination opportunity and highlight benefits provided by vaccine immunization.Address epidemiological and immunological aspects of HPV infection and available vaccines.Assess the susceptibility of unvaccinated adult women to oncogenic types of HPV and to lesions caused by HPV.Assess the difference in susceptibility to recurrence and reinfections after treatment of HPV-associated lesions among vaccinated adult women compared to unvaccinated adult women.Provide knowledge of best evidence for HPV vaccination among adult women and collaborate for an updated clinical practice.Consider vaccination even in adult women with previous HPV infection history, as the natural infection does not seem to offer sufficient immunity to prevent new infections occurrence by the same viral type, unlike the immunogenicity induced by HPV vaccines.Consider most adult women have negative serological and molecular tests for the viral types included in vaccines.Consider second HPV infection peak in the woman’s fifth decade of life.Consider adult women without vaccination coverage as still at risk for acquisition of HPV and for developing HPV lesions throughout their lives.Consider evidence of recurrences and / or reinfections risk reduction after vaccination of patients with previous lesions caused by HPV and who have already been treated.Consider adult women can benefit from individual protection even they are not eligible for vaccination in official programs based on population studies.Therefore, we endorse that adult women without HPV vaccination in adolescence, with or without a history of previous infection, may have protection benefits if immunized. In young women (up to 30 years old), these benefits are significant and were demonstrated in several publications. Therefore, this should be part of the medical prescription. However, there is also individual protection for women aged up to 45 years or more who may still be at risk of new infections. This information must be shared by their gynecologists.Human papillomavirus (HPV) infection is very prevalent. It occurs early, most of the times after onset of sexual activity. Among diseases associated with HPV infection, cervical cancer stands out. It continues to affect many women worldwide, especially in developing countries like Brazil, even though screening programs are effective when organized. The knowledge about genetic structure of different HPV types and the technological evolution provided vaccines development to prevent infection by oncogenic and non oncogenic HPV types.Since 2007, HPV vaccines have been administered to adolescents in Immunization Programs around the world. They promote prevention of HPV cervical cancer and clinical lesions. In this target group, mainly between 9 and 12 years old, there is no concerns about vaccine safety and effectiveness.In Brazil, the National Program for Immunization  implemented HPV vaccination in 2014, but vaccination coverage is still low. Currently, there are generations of adult women who have not benefited from HPV vaccination. The aim of this analysis was to present the main scientific evidence in vaccine indication for these women, especially after 25 years old. The PNI covers 9-14-year-old girls. In 2021, the MS/PNI extended the vaccination age for women with HIV, transplant recipients and cancer patients, from 9 to 45 years.(3) The Technical Immunization Advisory Board (CTAI) at a meeting on May 30, 2022, decided to also expand to men with HIV, transplanted and oncological .As for non-vaccinated young women (up to 26 years old), although they are outside PNI, there is no further scientific discussion, as they have an obvious benefit and vaccination should be indicated.Human Papillomavirus (HPV) infection is the sexually transmitted virus with higher incidence worldwide.It is estimated that about 600 million people are infected with HPV globally and that 80% of the sexually active population becomes HPV infected during a lifetime. The first peak of incidence occurs during the second decade of life and the second peak during the fifth and sixth decade of life. While the first peak is related to onset of sexual activity, the second can be explained by new exposure or immunity loss. The immunity against HPV infections in adult women is much lower than the immunity against HPV in adolescents.The relevance of HPV infection was consolidated when its association with cervical cancer was proven. It has been considered as the cause of all cases. The presence of HPV oncogenic DNA was found in 99.7% of cases of cervical cancer. It is the largest cause and effect relationship between an agent and cancer in humans. Several studies have shown that persistent HPV infection is the main risk factor for cervical intraepithelial neoplasia (CIN) and cervical cancer in young and adult females.There is increasing estimate of cervical cancer incidence in countries where there is no organized screening. Despite the availability of vaccines, the last few years estimative are around 530 thousand new cases and 275 thousand deaths annually. In Brazil, the Brazilian National Cancer Institute (INCA) estimates 16,710 new cases for the next years (2020-2022).It is important to note that women remain at HPV infection risk throughout their lives, even though the highest contamination rates are in the young population group. Contamination rates are up to 25% over five years in women between 30 and 44 years old. In addition, persistent HPV infection is the main risk factor for CIN and cervical cancer for every age group.Women exposed to HPV infection developed immunity after clearing this infection. This was the subject of several discussions regarding the protective ability for the same viral type. A pioneer study carried out in Costa Rica analyzed 10,049 women. It was observed that the incidence of HPV infection in seropositive women for a certain virus type was similar to seronegative women. This indicate inefficiency of the naturally acquired immunity in protecting against new infection or recurrence. This study evidenced that humoral immunity after natural infection may not prevent new infections, because antibodies levels produced are, generally, low and fall rapidly. They may even be negative.Although vaccines were developed for prophylactic use in adolescents before exposure to HPV infections, data show a low adolescent number completing the immunization schedule recommended by PNI in Brazil. On the other hand, studies show that vaccines are effective in adult population even after onset of sexual activity. Besides, a considerable proportion of women did not have active infection due to the types of HPV contained in the vaccine after maturity.Literature also shows evidence of a reduction in relapses with vaccines administration even in patients with previous lesions triggered by HPV and who have already been treated. Although relapses are low (3% -7%), these numbers can decrease by 60% to 80% after vaccination.About 99.6% of sexually active women up to 45 years old would benefit from HPV vaccines. Studies analyzed the viral infection presence of vaccine virus types in groups of women aged 16 to 23 and 24 to 45 years-old or more women. It was found that most women were seronegative or positive for only one of the viral types studied regardless of age.The recommended vaccination for women up to 30 years old aims to rescue who have not been properly vaccinated between 9 and 14 years old. The decision must be shared between the physician and 30 to 45-year-old women. It should be recognized that some not adequately vaccinated women may be at risk for new HPV infections and this age group may benefit from vaccination. Logically, the vaccine utility with the coming-of-age will depend on the person’s exposure risk to new infections. The HPV types 6, 11, 16 and 18 vaccine is not licensed for use in women aged > 45 years.A recent cohort study in Sweden showed that HPV vaccination with quadrivalent vaccine was associated with a significant decrease of invasive cervical cancer risk among girls and women aged 10 to 30 at the population level.There is no record of serious adverse events related to vaccination in any age group. Several regulatory agencies evaluate its safety globally. The HPV vaccines confirm, in practice, an excellent safety profile consistent with initial HPV vaccines trials. Therefore, there is no contraindication to vaccinate women aged up to 45 years or older (depending on the vaccine), since the vaccines are immunogenic and safe for various age groups. They must be individualized for each patient.Besides many adolescents did not receive HPV vaccination at the appropriate time, as discussed, most women seen by gynecologists are above the age limit recommended in the immunization schedule. Therefore, not missing the opportunity to indicate vaccination and avoid HPV infection complications is a fundamental point of the gynecologist care. Even for women who had high-grade precursor lesions and were treated, several studies showed that vaccination after treatment can decrease relapses. It is known that women who have developed HPV lesions have cofactors that facilitate viral action. As these cofactors tend to remain, it may result in pathologies elsewhere. Thus, women with precursor lesions are theoretically at greater risk for other related lesions. In that fashion, vaccination would have a more accurate indication.Antibody response, i.e. immunogenicity in women aged between 24 and 45 years was compared to immunological data of women aged 16 to 23 years, and these were comparable for the HPV-16 type and slightly smaller for HPV-6, 11 and 18. Furthermore, in a study, viral types contained in the vaccine were comparable to those observed at month 48 (end of baseline study), indicating no subsequent reduction in titers between four and six years after vaccination.Studies show that vaccination of women aged 30 to 45 years is less effective when compared to vaccination in adolescents and young women (up to 30 years old), especially when DNA-HPV status is ignored or positive. This does not justify the systematic recommendation or calling protocol for vaccination. The woman must be evaluated individually.The reduction in diseases caused by HPV is causally related to high HPV vaccination coverage among the target groups (children and adolescents). The vaccine is routinely administered before virus exposure.If universal coverage is available, it will be possible to substantially decrease morbidity and mortality of diseases attributed to HPV worldwide. This could provide a breakthrough in global public health. The school-based vaccination program was suspended years ago. Its return may increase adolescent vaccination coverage. Therefore, it will no longer be necessary to discuss adult female vaccination in the future. Stimulating wide vaccination of adolescents is a fundamental point in primary health care that must not be overlooked. However, we must not miss the opportunity to indicate vaccination for adult women who have not benefited from vaccination as teenagers, especially in countries with lower than expected vaccination rates. This can provide clear benefits as shown by studies. It is important to note that the HPV vaccine administration, at any age, does not replace health promotion actions. Cervical cancer screening should be maintained according to the age group. HPV vaccine and cervical cancer screening are complementary methods to protect women from developing genital cancer. Some fundamental points regarding vaccination still need to be better elucidated among gynecologists and health professionals.Among them, the indication of vaccination stands out, regardless of whether there is any suspicion or evidence of active HPV infection. In addition, vaccination can be recommended after the treatment of high-grade cervical lesions. It has benefits in reducing relapses, although these are extremely low. Concluding about HPV vaccination in adult women who have not been previously vaccinated, there is no discussion about vaccinating them routinely up to 30 years old, as the benefits have already been demonstrated, and gynecologists should be aware of vaccine prescription. National programs around the world recommend calling these women up for vaccinations. However, data demonstrate there are also benefits in vaccinating women aged up to 45 years or more. These women must be evaluated individually, and the indication must be shared with them. The benefit of vaccinating with the coming-of-age depends on the risk of exposure to new infections.National Specialty Commission for Vaccines of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO)President:Cecília Maria Roteli MartinsVice-President:Nilma Antas NevesSecretary:Susana Cristina Aidé Viviani FialhoMembers:André Luís Ferreira SantosAngelina Farias MaiaFabíola Zoppas FridmanGiuliane Jesus LajosIsabella de Assis Martins BallalaiJuarez CunhaJúlio Cesar TeixeiraManoel Afonso Guimarães GonçalvesMarcia Marly Winck Yamamoto de MedeirosRenata RobialRenato de Ávila KfouriValentino Antonio Magno


Introduction: Human papillomavirus (HPV) is a virus infection and can lead to different epithelial lesions and cancer. Nevertheless, HPV infection is a disease that can be prevented with vaccine. Genital warts, cancer, and HPV infections can all be prevented with this vaccine. In this study, we aimed to investigate awareness, knowledge of HPV infection, and acceptance of its vaccine among the general population in Saudi Arabia.Methodology: An observational cross-sectional study was conducted in Eastern Province, Saudi Arabia between September and October 2022, using a self-administered validated questionnaire. beginning with informed consent, followed by questions about demographic data. Finally, there were questions about participants’ knowledge, awareness, and attitudes around HPV and its vaccine.Rustles: The results showed 645 participants and only 4% of them had received their HPV vaccination. Knowledge, awareness, and attitude levels were all 35% with mean of 1.14, 28% with mean of 3.03, and 51% with mean of 2.02, respectively. Social media was found to be the most reliable source of information about the HPV vaccine (33%), followed by health practitioners (21%). The most common reasons for refusing vaccinations are “belief we are healthy” (48%), followed by “lack of information” (38%).Conclusion: Regarding HPV infection and its vaccination, Saudi Arabia significantly lacks knowledge and awareness. It is essential to provide instructions and information in schools for students, families, and healthcare providers about infection and its vaccination. Human papillomavirus (HPV) is a sexually transmitted infection that can cause various epithelial lesions and malignancies. It has been linked to cervical, penial, oropharynx, and lung cancer. HPV subtypes 16 and 18 carry a high substantial risk of causing cervical and penial malignancy ,3. In 20Study design and selection criteriaWe conducted an observational cross-sectional study using a self-administered validated questionnaire to obtain responses from the male and female citizens of Eastern Province, Saudi Arabia who were older than 12 years old, and willing to participate in the study. Non-Saudi citizens, not living in Eastern Province, Saudi Arabia who were younger than 12 years old, and anyone who refused to participate or had not completed the entire questionnaire were excluded. The questionnaire was distributed randomly as Google form using social media platforms. WhatsApp, Telegram, and Instagram applications were utilized to collect different groups and people.Questionnaire design and validityWe did an extensive literature review before writing the questionnaire. After that, we wrote our questionnaire and presented it to three experts to get face validity. After getting face validity, we conducted a pilot study on 20 participants who were excluded from the final rustle. Our questionnaire was designed in Arabic, as it is the native language of Saudi Arabia. It had three sections and was developed and published between September 2022 and October 2022. The questionnaire took approximately three minutes to be completed. The first section started with informed consent from participants. Then the second section was designed to obtain information about the demographical data such as age, gender, marital status, educational level, and income. The third section included questions regarding the participants’ knowledge, awareness, and attitude toward HPV.Statistical analysisDescriptive analysis and Chi-square test were used to analyze the data from the questionnaire, with a significance level of 0.05. The sample size was 645; with a confidence level = 95%, and an acceptable error = 5%. The target population = 34.81 million. This study was approved by the Ethics Committee of King Faisal University . Before filling out the survey, and according to the Helsinki declaration, there was a statement that declared that participants’ confidentiality and privacy were guaranteed. After data was extracted, it was revised, coded, and entered into the statistical software IBM Statistical Package for the Social Sciences (SPSS) version 22 .Demographic characteristics of participantsThe results showed, there were 644 participants; 64% females and 36% males. Age ranged from 12 to 60 years with a mean of 28.82 years, 38 participants were younger than 18 years and 606 were older than 18 to 60 years, and a standard deviation of 11.35. 4.8% only knew someone with cervical cancer and only 2.20% had a Pap smear in the last 3 years while 0.50% had it more than 3 years ago , then “HPV causes penis cancer” (36%), then “HPV is a virus that is sexually transmitted” (30%), and finally “HPV will usually go away on its own without treatment” (11%) Table . The mosAcceptance and attitude of participants about HPV vaccineThe attitude level was 51% with a mean of 2.02. 4% only of the participants got their vaccinations for HPV. There were 23 88.5%) participants who knew the benefits and risks of vaccination, and three (11.5%) did not. 47.7% were willing to receive the HPV vaccine which can protect against HPV infection while 52.3% weren’t. There were 17.7% who would recommend the HPV vaccine for a child or adolescent (age between 9 and 12 years old), and 14.8% wouldn’t. 67.3% could not decide according to their information. 28.3% would recommend the HPV vaccine for a friend or relative, 6.2% wouldn’t, and 65.5% couldn’t decide according to their information (Table 8.5% partHPV is a sexually transmitted infection that can cause various epithelial warts and malignancies, it has been linked to many types of cancer ,10. ThisAwareness and knowledge levelIn our study, the result showed that the awareness level of HPV infection and vaccine was significantly low which explains why only 4% of participants had received the vaccination. Almost one-third of the participants believed that HPV can be transmitted by sexual activity, 65% agreed that cervical cancer could be caused by HPV, and almost one-third of participants believed penial cancer could be caused by HPV. The present findings seem to be consistent with a study conducted in India showed that knowledge and awareness levels were poor regarding HPV and its vaccine and there was a statistically significant difference between the awareness level and educational level and age . AnotherAttitude and acceptanceAttitude and acceptance levels were significantly low obviously among females and with low education levels. The findings of the current study are consistent with two studies conducted in Saudi Arabia. The first study conducted in the capital of Saudi Arabia, Riyadh, reported a significant low attitude and acceptance level which was the lowest rate among other studies . The secLimitations and recommendationThe limitations of our study are that gender differences were not evaluated and not covered in large demographic areas in Saudi Arabia. We were not able to include Saudi citizens who live in other countries. A future study should include a large area in different regions and include Saudi citizens who live abroad and compare and assess knowledge, awareness, and acceptance with them.Our study showed a significant lack of knowledge and awareness regarding HPV infection and vaccines. Providing education and knowledge in schools for students and family, making campaigns, and using social media for education are important to increase the level of awareness and attitude. Additionally, the Ministry of Health should print educational materials and make them available in public and governmental organizations. Increasing levels of knowledge, awareness of screening, and early detection of malignancy are crucial.


Is the positive predictive value of abnormal cervical cytology lower among individuals who have been vaccinated against human papillomavirus?In a cohort study of 46 988 patients aged 21 to 35 years participating in cervical cancer screening, the positive predictive value of cervical cytology for cervical intraepithelial neoplasia 2 and more severe diagnoses was significantly lower among vaccinated individuals (17.4%) than unvaccinated individuals (21.3%).The observed increased risk of a false-positive cervical cytology result for individuals vaccinated against HPV may warrant screening guidelines that stratify by vaccination status to minimize the risks of overscreening and overtreatment among individuals with low risk for cervical cancer. This cohort study evaluates whether human papillomavirus (HPV) vaccination is associated with decreased positive predictive value for abnormal cervical cytology. Current US cervical cancer screening guidelines do not differ by human papillomavirus (HPV) vaccination status. However, as the positive predictive value (PPV) of a screening test decreases, the risk of a false-positive result increases.To evaluate whether HPV vaccination is associated with decreased PPV for abnormal cervical cytology.This retrospective cohort study conducted via electronic medical record review included eligible patients aged 21 to 35 years who had at least 1 cervical cytology result within a single health system between January 2015 and December 2018. The health system comprises a partnership between an academic health center and a private not-for-profit health center. Patients with abnormal screening cytology and no diagnostic test results were omitted from analysis. Data were analyzed from December 2019 to November 2021.HPV vaccination, defined as receiving at least 1 dose of HPV vaccine. Subgroup analyses were performed for those completing all vaccination doses per Advisory Committee on Immunization Practices guidelines and by age at vaccination initiation, dichotomized as younger than 21 years vs 21 years or older.PPV of abnormal cervical cytology for risk of cervical intraepithelial neoplasia (CIN) 2 or more severe diagnosis.A total of 46 988 patients  were included; 15 494 (33.0%) were at least partially vaccinated, and 4289 (9.1%) had abnormal cytology results during the study period. Among the individuals with abnormal cytology, the PPV for CIN 2 or more severe diagnosis was lower among vaccinated individuals  than unvaccinated individuals . Among vaccinated individuals, PPV was significantly lower among those completing vaccination  than those with incomplete vaccination , especially among those initiating vaccination when younger than 21 years  vs those initiating at age 21 years or older .Among a population with relatively low HPV vaccine coverage, the PPV of cervical cytology for CIN 2 or more severe diagnosis was significantly lower among vaccinated individuals. PPV will likely further decrease in the future as a population with higher HPV vaccination coverage ages into screening. Confirmation of these results will call for changes in screening strategies, particularly for completely vaccinated individuals who initiated vaccination when younger than 21 years. A meta-analysis showed the relative risk of infection with nonquadrivalent HPV vaccine types was 0.73  in populations with vaccination coverage of greater than 50%, and 1.09  with vaccination coverage of less than 50%.6 Furthermore, observational studies have shown the risk of cervical intraepithelial neoplasia (CIN) 2 or more severe diagnosis after a single dose of HPV vaccine to be similar to the risk among unvaccinated individuals,7 although early results from a prospective longitudinal study in India show similar protection for 1 to 3 doses among individuals vaccinated up to 18 years of age,8 and studies to determine whether there is a group for whom a single dose of HPV vaccine is adequate are ongoing. Vaccine protection against CIN 2 or more severe diagnosis is also greater for individuals initiating the vaccine series by age 17 years  compared with those initiating vaccination at age 20 to 21 years or older .9Vaccination against human papillomavirus (HPV) decreases infection risk with vaccine-type HPV up to 90%, with absolute prevalence of only 1.3% among vaccinated individuals.11 Current cervical cancer screening recommendations do not differentiate by vaccination status. Modeling for screening of vaccinated individuals predicts initiating screening at age 25 to 30 years with an interval of 10 years to be the best strategy.12 However, this model assumed vaccination initiation at 12 years of age and prior to HPV exposure as well as completion of the vaccine series with 100% efficacy against vaccine-type HPV infection. Unfortunately, in the United States, only 61.4% of female individuals are currently up-to-date on HPV vaccination by age 17 years.13 Thus, additional estimates using clinical data are needed to determine the optimal screening strategy for vaccinated individuals.As prevalence of CIN 2 and more severe diagnoses decrease, the positive predictive value (PPV) of cervical cancer screening tests will decrease.The primary objective of this study was to compare the PPV of cervical cytology to diagnose CIN 2 or more severe diagnosis by HPV vaccination status. The secondary objectives were to determine variations in PPV by age at vaccination initiation and number of doses received.STROBE) reporting guidelines for cohort studies. Study participants were individuals aged 21 to 35 years who had undergone cervical cancer screening between January 1, 2015, and December 31, 2018, within the MHealth Fairview System, an academic and not-for-profit health system partnership. The age limits were chosen to exclude persons younger than 21 years who were not yet eligible for cervical cancer screening15 and to include individuals vaccinated at the upper age limit of 26 years in 2006, when the first HPV vaccines were approved for use in the United States.16This retrospective cohort study was approved by the University of Minnesota institutional review board. Informed consent was waived for this minimal risk study. The study manuscript follows the Strengthening the Reporting of Observational Studies in Epidemiology  tool NLP-PIER was then applied to abstract unstructured text from pathology notes and health care professional progress notes.18 Data cleaning was conducted via manual medical record review on an as-needed basis. Discrepancies in data coding were reviewed by 3 investigators  and resolved by consensus.The Clinical Data Repository comprising electronic health record (EHR) data of 2.5 million patients was queried to identify eligible participants. The EHR integrates vaccination information from the state vaccination registry. An automated query was first performed using laboratory, The following data, selected based on associations with cervical cancer screening adherence and cervical cancer risk, were abstracted from the electronic health record: (1) demographic characteristics, including birthdate; race ; and ethnicity (Hispanic or Latina and not Hispanic or Latina); (2) smoking status ; (3) HPV vaccination status (≥1 dose or none), number of vaccine doses and dates of administration, type of HPV vaccine ; (4) cervical cytology results; and (5) diagnostic test results, including colposcopic findings and biopsy pathology results.19Age at HPV vaccination initiation was calculated. For the primary analysis we defined vaccinated as receiving at least 1 dose of the HPV vaccine, per the definition used most commonly in the literature. Vaccinated was further categorized as completely vaccinated if vaccination was initiated at age 14 years or younger and at least 2 doses were administered, or if vaccination was initiated at age 15 years or older and 3 doses were administered, as recommended by the Advisory Committee on Immunization Practices (ACIP).21 Abnormal cytology or HPV test results for which diagnostic testing or follow-up was recommended by the 2013 ASCCP cervical cancer screening management guidelines22 but for which there were no subsequent records were coded as unknown dysplasia and omitted from data analysis. For individuals with more than 1 cervical cytology test during the study period, data associated with the most significant diagnostic finding were used.Diagnostic test results were categorized as normal if colposcopic impression was normal and no biopsies were taken or if biopsy results showed no dysplastic changes. Low-grade histology included CIN 1 or low-grade squamous intraepithelial lesion (LSIL). High-grade histology included CIN 2 (stratification by p16 staining was not used given that it was not consistently performed throughout the study period), CIN 3, carcinoma in-situ, adenocarcinoma in-situ, or high-grade squamous intraepithelial lesion (HSIL).4The primary end point was the PPV of cervical cytology for high-grade histology or cancer (CIN 2 or more severe diagnosis), ie, the proportion of participants who screened positive by abnormal cytology and actually had CIN 2 or a more severe diagnosis. Secondary objectives were PPV of cervical cytology for individuals completely vs incompletely vaccinated per ACIP guidelines and by age at vaccination initiation, dichotomized as younger than 21 years vs 21 years or older. The age cut point was chosen based on study results showing no significant risk reduction for CIN 2 or more severe diagnosis when vaccination was initiated at age 21 years or older.Automated data query identified 51 339 study participants. Initial data review excluded 335 participants who had no cervical cytology results documented. An additional 4016 participants were excluded because of missing or illogical dates for vaccination and/or screening tests, abnormal screening documented before or on the same day as vaccination, or a diagnosis of noncervical lower genital tract dysplasia .P < .05 was considered statistically significant, and all tests were 2-tailed.Descriptive statistics were used to describe patient demographic and clinical characteristics. The PPVs were compared by HPV vaccination status using logistic regression models adjusting for available confounding variables determined a priori, ie, age, race, and smoking status. Additional subgroup analyses among the vaccinated cohort were performed, focusing on comparisons by complete vs incomplete vaccination and dichotomized age at vaccination initiation. Point estimates and associated 95% CIs are presented. Data were analyzed using SAS version 9.4 (SAS Institute). The final study population comprised 46 988 individual patient records . Mean S.P < .001)  had received at least 1 dose of the HPV vaccine, and 11 644 (24.9%) were completely vaccinated. HPV vaccination coverage varied by race, with 562 Asian participants (18.4%), 1021 Black participants (24.5%), and 12 696 White participants (35.8%) vaccinated  had at least 1 abnormal cervical cytology result, with significant differences in prevalence of abnormal results by age, race, and smoking status (eTable 2 in the P < .001).Prevalence of CIN 2 or more severe diagnosis among all study participants was 1.8% (855 participants). Prevalence among unvaccinated participants was 1.9% (594 participants) and 1.6% (187 participants) among those who were completely vaccinated. Initiating HPV vaccination when younger than 21 years was associated with decreased prevalence of CIN 2 or more severe diagnosis compared with vaccination initiation at age 21 years or older , with 327 (53.7%) upgraded and 282 (46.3%) downgraded. In a data set of nearly 50 000 patients, these changes did not significantly affect study conclusions.P = .002). This difference seemed to be driven by the completely vaccinated group, where the PPV was 15.9%  compared with 22.4%  in the incompletely vaccinated group. Age at vaccination initiation was associated with the greatest difference in PPV, with PPV of 11.9%  in the group initiating vaccination when younger than 21 years compared with 30.7%;  when vaccination initiation was at 21 years of age or older. Additionally, the PPV among current  or former  vs never  smokers was higher in both the vaccinated (P = .004) and unvaccinated (P < .001) groups  . PPV wasThe results of our study show significantly lower PPV of cervical cytology for CIN 2 or more severe diagnosis among individuals vaccinated against HPV, even with HPV vaccination coverage of only 33%. Our results also suggest vaccinated should be defined as those who have completed vaccination per ACIP guidelines if screening recommendations are stratified by vaccination status. Lastly, our data suggest decreased screening intensity may only be appropriate for individuals initiating HPV vaccination when younger than 21 years.23 Observational studies have shown less of a difference in efficacy by number of doses received when vaccination was initiated prior to age 14 years.24 Data from our study suggest cervical cytology PPV is not significantly different between those who have been inadequately vaccinated and those who are unvaccinated. Thus, modifications to the cervical cancer screening guidelines for vaccinated individuals should be restricted to those who have completed the vaccine series per ACIP guidelines until we have additional data defining an age at vaccination initiation which may result in adequate clinical efficacy after a single dose.Data from clinical trials have shown reduced geometric mean antibody titers of single vs multiple doses of the HPV vaccine, but determination of noninferiority was inconclusive; furthermore, it remains unknown at what titer adequate clinical efficacy is achieved.26 Our findings are similar to results from a register-based cohort study from Denmark that showed no decrease in atypical squamous cells of undetermined significance–positive cytology in a vaccinated cohort compared with an unvaccinated cohort despite a decrease in HSIL cytology (and its inherent risk of CIN 2 or more severe diagnosis) in the vaccinated cohort.3 Likewise, a retrospective cohort study from Kaiser Permanente showed decreased accuracy of cervical cytology to predict current or 3-year risk of CIN 2 or more severe diagnosis.27 This means there is a significantly higher proportion of a false-positive screening results after vaccination. While the primary goal of cervical cancer screening is to detect clinically significant lesions and ultimately prevent cancer, the negative impact of false-positive results cannot be ignored. For individuals with an abnormal screening test, 50% to 80% will experience pain, bleeding, and/or discharge associated with diagnostic procedures or treatment.28 Studies have shown anxiety associated with an abnormal screening test result can last up to 24 months, even after a subsequent normal diagnostic test result.29 Lastly, false-positive screening tests add cost to the health care system with minimal additional health benefit.30 To date, HPV primary or cotesting has not been recommended in the youngest screening age group because of a high infection prevalence with subsequent clearance. However, as vaccination against HPV increases and the prevalence of HPV infection decreases, incorporation of HPV testing in this age group may need to be reconsidered, with focus on its negative predictive value  to identify a group requiring the least intensive screening strategy.The modest increase in odds of abnormal cytology associated with complete vaccination in our study is intriguing. Patients with documented abnormal screening results prior to or on the day of HPV vaccination were omitted from the study population, decreasing the risk of clinically significant HPV infection prior to vaccination. The adjusted analyses controlled for age at vaccination initiation, which is often used as a proxy for HPV exposure, but study methods did not allow for reliable collection of data on sexual debut, thus we cannot entirely discount the possibility that sexually active individuals were more motivated to complete the HPV vaccine series. We also acknowledge the possibility that vaccination may be associated with increased screening frequency and thus increased detection of transient abnormal cytology.4 The importance of early vaccination to decrease cervical cancer incidence is further supported by population-based studies. A study from the United Kingdom showed vaccination initiation at age 12 to 13 years was associated with an 87% lower risk of cancer  compared with a 34% risk reduction  among those initiating vaccination at age 16 to 18 years.9 In a Swedish study, cervical cancer incidence among individuals vaccinated prior to 17 years of age was significantly less  than for those vaccinated at age 17 to 30 years .5 Concordant with these data, the findings of our study suggest that future guidelines for less intensive cervical cancer screening may only be indicated for individuals who have initiated HPV vaccination prior to age 21 years given that the PPV for cervical cytology is similar among those initiating vaccination at 21 years of age or older and those who are unvaccinated.While the optimal age of HPV vaccination is 9 to 12 years, the HPV vaccine has been approved by the US Food and Drug Administration for female individuals as old as 26 years since 2006 and updated to age 45 years in 2018. However, clinical efficacy of the vaccine decreases as the age at vaccination initiation increases. This is demonstrated by the relatively high prevalence of CIN 2 and more severe diagnoses in the group vaccinated at age 21 years or older in our study, which likely minimizes the change in CIN 2 or more severe diagnosis prevalence among the larger vaccinated group. A case-control study showed the vaccine is most effective if initiated at 17 years or younger , with no significant decrease in risk of CIN 2 or more severe diagnosis if vaccination was initiated at 21 years or older .13 The lower vaccination coverage in this study is representative of the older population studied  and lower vaccination coverage in the early years of vaccine availability. Thus, our estimated decrease in the PPV of cervical cancer screening tests is likely conservative and is anticipated to further decrease as a larger proportion of vaccinated individuals age into screening. However, it is notable that in 2020 there were still states where vaccination coverage among female residents was less than 50%.13The HPV vaccination coverage reported in this study is low. Current HPV vaccination coverage in Minnesota is above the national average, with 81.9% of female individuals receiving at least 1 dose of the vaccine by age 17 years and 73.2% completing the HPV vaccine series.Strengths of our study include the large number of patient records with access to state immunization records. Our data review was thorough, comprising automated data query, NLP, and manual medical record review. This data abstraction process demonstrated that for a sufficiently large data set, automated data query may be sufficient, as the additional diagnostic information gained from the NLP was not substantial enough to change the study results.This study also has limitations. Despite comprehensive medical record review, misclassification of data is still possible. Additional study limitations include those inherent to any retrospective study. Our data analyses were limited to results present in the system, and it is possible that screening frequency may differ by vaccination status. Among individuals with abnormal cervical cytology, 147 (0.3%) did not have a documented diagnostic evaluation and were ultimately omitted from the data analysis. Our data were limited to patients seen within a single health system with a predominately White, non-Hispanic population, and it is unclear whether these findings are generalizable to other populations. A majority of participants in our study received the quadrivalent HPV vaccine, and protection against CIN 2 and more severe diagnoses is anticipated to be even greater with increasing coverage with the nonavalent vaccine. The results of our study do not consider prevaccination HPV exposure or the vaccination status of the patients’ sexual partners, which may provide additional protection through herd immunity. Additionally, we are unable to comment on the predictive value of HPV testing because of the lack of cotesting or HPV primary testing in a large proportion of the study population.12 should be restricted to individuals who initiated HPV vaccination prior to age 21 years and who have completed the recommended vaccine series.The results of our study show that despite only modest HPV vaccination coverage, PPV of cervical cytology for CIN 2 and more severe diagnoses was significantly lower among individuals who completed HPV vaccination, particularly when vaccination was initiated at younger than 21 years. While these results need to be confirmed in additional studies conducted among diverse populations in the United States, our results do suggest that delayed screening initiation and/or increased interval between screening tests as proposed by the modeling study by Kim et al


Attention Deficit Hyperactivity Disorder, also known as ADHD, is a neurodevelopmental disorder diagnosed in children. The exact cause of ADHD is not known, but, along with genetic factors, it is possible that environmental factors including toxins and diet may affect symptom severity. Of these dietary components, artificial food coloring (AFC), while approved by the Food and Drug Administration (FDA), has been suspected to be associated with ADHD symptoms. Of the nine FDA-certified food colors, two are used for artificial blue coloring: Blue No. 1 and Blue No. 2. There is limited literature describing the possible role of blue AFC in causing symptoms of ADHD in children. This paper provides a review of the literature surrounding artificial food coloring and its ability to affect the neurodevelopment of children in a way that could increase the behavioral indicators of ADHD. To do this, search criteria were established using a combination of MeSH terms about blue AFCs and ADHD and were entered into PubMed, along with limits on article types and publication dates from January 2000 to June 2022. There was a total of 20 articles that met this search criterion. These articles were reviewed by authors, and the ones not relevant to the topic were excluded. In total, four studies were chosen to be included in this article. After reviewing the literature, it was found that restriction diets, specifically those excluding AFCs, may affect symptom severity. The source of these changes is not known, but possible mechanisms include AFCs causing nutritional deficiencies and allergic reactions or altering neurotransmitter levels. More research is necessary to describe the neurotoxicity of artificial blue dyes in humans. Attention Deficit Hyperactivity Disorder, also known as ADHD, is a neurodevelopmental disorder that is one of the most common disorders of its type in the United States, with a worldwide prevalence of 3.4% . Since tOf the nine FDA-certified food colors, two are used for artificial blue coloring: Blue No. 1, also known as Brilliant Blue FCF, and Blue No. 2, also known as Indigotine. These artificial blue coloring agents are used in beverages, ice cream, candy, and baked goods. Blue No. 1, along with its structural analogs such as Brilliant Blue G, is the only AFC that the blood-brain barrier is known to be permeable to. DespiteFor this review on artificial blue food coloring and ADHD symptoms in children, we established search criteria using a combination of MeSH terms. Those terms consisted of ‘Blue 1’, ‘Blue 2’, ‘Blue No. 1’, ‘Blue No. 2’, ‘brilliant blue FCF’, ‘blue shade’, ‘Indigotine’, ‘indigo carmine’, ‘blue dye’, ‘blue food dye’, ‘blue pigment’, ‘synthetic blue’, ‘synthetic food coloring’, ‘bright blue’, ‘artificial food color’, or ‘food coloring agent’ and the terms ‘ADHD’, ‘attention deficit hyperactivity disorder’, ‘attention deficit’, ‘attention deficiency’, ‘hyperactivity’, ‘inattention’, ‘hyperactivity disorder’, ‘ADD’, ‘attention deficit disorder’, ‘short attention span’, or ‘disordered attention’ , no mention of artificial food coloring (n=6), no mention of ADHD n=1), or no mention of ADHD or artificial blue food coloring (n=1). This process is described in Figure , or no mDiets and ADHDWhile pharmacological intervention is common for children with ADHD, there is an increasing number of parents who would prefer a treatment option that does not require pharmaceuticals, if possible . One of The article by Nigg et al.  looked iAFCs must be approved by the FDA before being used as a food additive in the United States. Data from the FDA shows that consumption of AFCs has been steadily increasing in the United States as more foods are being made to look brighter and more appetizing to consumers . Among sA double-blind placebo-controlled study done by Bateman et al.  specificEffects of blue artificial food coloringIn foods that are artificially colored blue, FDA-approved synthetic additives Blue No. 1 and Blue No. 2 can be found. Blue No. 1, also called Brilliant Blue, Brilliant Blue FCF (for coloring food), and FD&C Blue No. 1, is used to add a bright, neon blue color mainly to food but additionally to drugs and cosmetics. Blue No. 2, also called Indigo Carmine, Indigotine, and FD&C Blue No. 2, is derived from indigo and is also used in food, drugs, and cosmetics to give a darker blue-indigo color. The accepted daily intake (ADI) for Blue No. 1, a value established by the FDA in 1969 that indicates the amount of an AFC that is safe to consume throughout the day, is 12.0 mg/kg/day, and is higher than the ADI for Blue No. 2, which is 2.5 mg/kg/day .The toxicity of artificial blue food coloring has been studied in mice and rats in laboratory settings as questions about the safety of AFCs continue to rise. A study was done in rats to test for the carcinogenicity of Blue No. 2, but the results concluded that while there was an increase in gliomas in the rats given a high dose of Blue No. 2, these changes did not meet the requirements to be considered neurocarcinogenic since the trends were consistent with historical controls . In regaThe effects of artificial blue dyes Blue No. 1 and Blue No. 2 have also been studied in children, along with other AFCs. A study done by Miller et al. , which wMechanism of action/pathophysiologySince ADHD does not have a known etiology, it is not immediately clear how blue AFC could cause increased hyperactivity or inattentiveness in children. One possible explanation is that artificial food coloring could cause nutritional deficiencies that could lead to impaired neuronal development. One study showed that adding yellow AFC to the diets of male children both with and without ADHD resulted in a decrease in zinc levels in serum and blood, along with worsening behavioral symptoms in children with ADHD . Zinc deThe ability of AFCs to alter levels of trace elements in the body like zinc and manganese may also affect people with ADHD because of these elements’ role in the creation and breakdown of neurotransmitters in the central nervous system (CNS). The neurotransmitter dopamine has been thought to be associated with ADHD symptoms because the chemical is involved in the executive functions of the brain that people with ADHD struggle with . MedicatHNMT gene, which codes for a protein involved in the metabolism of histamine, were linked to hyperactive behavior and sensitivity to AFCs in the participants. This shows that the body’s response to histamine could play a role in the extent to which AFCs may affect a child with ADHD, though further testing with only blue AFCs would need to be done to determine its specific effect.Since the link between artificial food coloring and ADHD was made in the 1970s , there hA limitation of studies on blue artificial food coloring is that some food and beverages that contain the dye are high in refined sugar as well, which may also play a role in ADHD symptom exacerbation. A meta-analysis that assessed how ADHD was affected by dietary patterns found that diets high in refined sugar increased the risk of ADHD or hyperactivity . WithoutImplications for treatment and future directionsFor treating children with ADHD, pharmacological intervention is widely used. In many countries, including the United States, the use of psychostimulants to treat ADHD is recommended, sometimes before behavioral management is considered . StimulaThe studies that were reviewed for this article support the suggestion that dietary intervention, particularly the elimination of AFCs, should be considered for children with ADHD. The study by Nigg et al.  concludeThe studies that were reviewed in this article show that diet, especially consumption of artificial food coloring, produces statistically significant increases in ADHD symptoms in children. The mechanism for how AFCs cause such neurological and behavioral changes is not definitively known, but there are a few possible explanations. These include some well-studied hypotheses for the mechanism of ADHD that AFCs could contribute to, such as the dopamine hypothesis, but some less-studied causes like nutritional deficiencies and histamine release may also be possible. While several studies examine the effect of a combination of AFCs on ADHD symptoms in children, there is very little research done on just Blue No. 1 or Blue No. 2 in children. This is illustrated by the low number of studies reviewed in the article after the PubMed search on blue AFC and ADHD, limiting the strength of the conclusions that can be made from the results. In mice and rats, Blue No. 1 specifically has been found to affect neurodevelopment and hyperactive behavior, while Blue No. 2 has not been shown to have any definitive toxicity. There is a need for more research to determine how these individual compounds affect humans, especially because of Blue No. 1’s ability to cross the blood-brain barrier. Understanding how artificial blue food dyes affect the brain and behavior of humans through increased research on the topic could provide alternative treatment options for children with ADHD.


The disparities of hr-HPV infection among races/ethnicities have not been fully discussed. This study aimed to investigate the difference of hr-HPV infection between Chinese Han and Mongols minority women in Inner Mongolia.Genotyping and histopathology data of Chinese Han and Mongols minority women in Inner Mongolia from Chinese Multi-Center Screening Trial were used to analyze the hr-HPV prevalence, and type-specific distribution in abnormal pathology results.P < 0.001). The most prevalent genotypes in Han women were ranked as HPV-16,−52,−18/-58,−31/-39, and−59 while in Mongols were−16,−31,−58,−18 and−52. When analyzing the age-specific of hr-HPV infection, two peaks were found at age of 40–44 (20.5%) and 55–59 (23.5%) years in Han women while three peaks were observed at age of 30–34 (22.1%), 45–49 (22.9%), and 55–59 (31.8%) years, respectively, in Mongols. HPV-16 accounting for 62.5 and 53.8% of the CINII+ in Han and Mongols, respectively.The hr-HPV infection rates of Han women was 15.9% while of Mongols was 21.6% (The prevalence of hr-HPV was significantly different between the Han and Mongols minority women in Inner Mongolia, races/ethnicities background should be taken into consideration for the refinement of cervical cancer screening strategies and vaccine implementation in China. Invasive cervical cancer (ICC) is one of the top threats to women's health in many regions of the world, particularly in low- and middle-income countries (LMICs) . In ChinNumerous studies have demonstrated that a significant geographical variation exists in the prevalence and age-distribution of HPV infection. For example, HPV prevalence varies from 2.8% in North American women aged 55–64 years to 50.5% in Eastern African women aged 25-34 years ; and theThe Inner Mongolia Minority Autonomous Region (Inner Mongolia), located on the northern border of China, is a multi-ethnic region with an estimated over 4 million Mongolian. This is ranked second to the Han according to the seventh census report published online by the National Bureau of Statistics. People of different ethnicities in Inner Mongolia have lived together over vast areas while some still live in individual concentrated communities. To better understand the prevalence and type-specific distribution of hr-HPV among the women in Inner Mongolia, we analyzed the data from the Chinese Multi-Center Screening Trial among Chinese Han and Mongol women.This Chinese Multi-Center Screening Trial (CHIMUST) (Registration number: ChiCTR-EOC-16008456) is a multi-center, cross-sectional, population-based cervical cancer screening trial conducted between Aug 2016 and Jan 2018 at 15 sites located in 6 provinces as Beijing , Inner Mongolia, Hebei, Hubei, Jiangxi, and Guangdong in mainland China. The inclusion criteria were: 30–59 years of age, sex exposed and no cervical cancer screening in the past 3 years. The exclusion criteria were: in pregnant, or had pelvic radiation and hysterectomy history. A total of 10,885 women were enrolled. The protocol of this trial was approved by the Institutional Review Board (IRB) of Peking University Shenzhen Hospital (IRB: PUSH2016001) and Cleveland Clinic Institutional Review Board (IRB: 15–1549). All participants signed an informed consent document before enrollment.All participants were required to provide a self-collected cervical-vaginal sample when they arrived at hospital, self-sampling methods can be obtained from researcher or a special brochure printed for the research. Then a physician-collected endocervical sample was also obtained. The brush with self-collected sample was first applied onto a solid media transport card and then be placed in PreservCyt solution, The physician collected samples were obtained by a trained gynecologists by using a “broom” sampler and then placed in 20 mL of Thin-Prep PreservCyt Solution. All samples were tested with the PCR-based high-risk HPV assays: Cobas4800 (Roche) and SeqHPV . The physician-collected samples were also processed for cytology and interpreted by cyto-pathologists from Peking University Shenzhen Hospital (PUSH) with facilitation of the Hologic I2 Imager (computer assisted cytology). Women tested positive of hr-HPV on either or both Cobas4800 or/and SeqHPV for either or both of self- or/and direct-collected samples were referred for colposcopy using the quadrant-based POI  protocol of directed and random biopsies plus ECC . The matFor this manuscript, the data of CHIMUST related to the 3,375 women aged 30–59 years enrolled in Inner Mongolia was analyzed. Participants were not included in the analysis for the prevalence of hr-HPV infection in Han and Mongols if they were demographically neither Han or Mongols or failed HPV testing for SeqHPV due to inadequate DNA or failed PCR. Women positive of hr-HPV but not returned for colposcopy were excluded from the evaluation of the distribution of individual hr-HPV genotypes among the women with pathological abnormalities. The project was conducted at sites in two counties, Xianghuangqi and Wushenqi, in Inner Mongolia. Data was also analyzed by regions since the distance between these two subregions is nearly 600 kilometers .The SeqHPV is a NGS (next-generation sequencing) based assay for hr-HPV, which uses multiplex PCR to amplify DNA and next generation sequencing to identify HPV genotypes. It amplifies the HPV L1 gene and human β-globin gene (HBB)  of cervical exfoliated cells in the sample. It is a high-throughput technology that can identify 14 hr-HPV genotypes  . All proThe colposcopy protocol used in this trial was done by quadrant. Based on the protocol, direct biopsies were performed on where lesion was visible and random biopsies were performed at the squamocolumnar junction in the normal quadrants. All colposcopy patients had an endocervical curettage (ECC) . CytologTo minimize the possibility of selection bias being introduced by deleting cases without histologic diagnose, women with SeqHPV testing results were included in the analysis of the agreement between self-and physician-collected sample and the prevalence and type-specific distribution of hr-HPV in Han and Mongols minority. The race/ethnicity of the participants were self-reported. Consistency between self-and physician- collected sample was measured by absolute agreement and Kappa statistics (Cohen's Kappa). Pearson's Chi-squared test with two-tailed was performed to calculate differences at a significant level of 0.05 to compare the prevalence and distribution of hr-HPV infection between Han and Mongols minority. The prevalence of hr-HPV genotypes was also calculated separately for 6 age groups  race/ethnicity and by region. Women of the two ethnicities with both SeqHPV and histologic diagnose were included in the analysis of the prevalence of type-specific hr-HPV infection in abnormal pathology results. The 95% confidence interval (CI) was established using a binomial distribution analysis. SPSS v.24.0 software  was used for all data analysis in this study.A total of 3,375 women aged 30–59 years were enrolled in Inner Mongolia. Of these, 5 who were non-Han and non-Mongols and 38 who failed SeqHPV testing for inadequate DNA/ failed PCR were excluded, leaving 3,332 women with SeqHPV testing results for the analysis of the prevalence and distribution of hr-HPV between Han and Mongols. The mean age of the analyzed women was 43.8 ± 7.7 years (median age 44 years and range 30–59 years). The overall prevalence of Hr-HPV was 18.7% (95% CI 17.4–20.1%) for the self-collected HPV testing, with the most prevalent genotypes being HPV-16 (3.8%), −31(2.6%), −58 (2.3%), −18 (2.1%), and −52 (2.0%) in respective orders. After excluded 72 women who did not return for colposcopy (no histologic diagnoses) 3,260 women with a mean age 43.9 ± 7.6 years (median age 44 years and range 30–59 years) were included in the analysis of the risk of having histologically confirmed high-grade disease relative to HPV genotypes. Among these 3,260 women, 96.2%  were pathologically normal, 2.5%  had CINI, 1.3%  had CINII+.P < 0.001).Among the 3,332 women included for the analysis, hr-HPV prevalence was 18.7%  for self-collected testing while 16.8%  for physician-collected testing, with 530  women positive of hr-HPV on SeqHPV for both self-and physician-collected samples. The concordance of HPV positive between physician-collected and self-collected samples was 81.2% (530/653), showing an “near perfect” consistency in SeqHPV detection between self-and physician-collected samples . The most prevalent genotypes in Han women were HPV-16 (3.2%),−52(2.1%),−18 and−58 (both 1.8%),−31 and−39 (both 1.6%), and−59 (1.3%) in order, while those in Mongols were−16 (4.5%),−31 (3.7%),−58 (2.7%),−18 (2.4%) and−52 (1.9%) , significantly higher than that in Han women, which was 15.9% (95% CI 14.2–17.7%) (χ2 (1.9%) .2 = 15.414, P < 0.001). In Wushenqi (WSQ), the hr-HPV infection rates between Han-WSQ and Mongols-WSQ women was 17.9% (95% CI 15.7–20.1%) and 23.6% (95% CI 20.7–26.5%), respectively, and the difference was also statistically significant , the Hr-HPV infection rates between Han- XHQ and Mongols- XHQ women was 11.4% (95% CI 8.6–14.2%) and 19.6% (95% CI 16.9–22.3%), respectively, significantly different with each other . Two peaks of hr-HPV infection were found at age 40–44 (20.5%) and 55–59 (23.5%) years in Han women. In Mongol minority women, the age-specific hr-HPV infection curve is just like a “W,” with three peaks at age 30–34 (22.1%), 45–49 (22.9%) and 55–59 (31.8%) years, respectively. Interestingly, a highest prevalence at age 55–59 years was observed in two ethnicities prevalence curves .The prevalence of hr-HPV in Han-XHQ women raised steadily from age 30–34 years and reached the peak at age 40–44 (14.3%) years then dropped down and had a less pronounced second peak at 50–54 (11.2%) years. In contrast to Han-WSQ and Mongols minority, Han-XHQ women had the lowest prevalence of hr-HPV at age 55–59 years .2 = 8.207, P = 0.004). However, no significant difference was observed between the two ethnicities for the diagnosed CINII+ . In Han women with CINI, HPV-52 together with−58 and−59 , were the most detectable genotypes, while in Mongols, HPV-16 and−31 (both 16.7%) were the dominant genotypes. In high grade disease (CINII+) HPV-16 was dominant among the 14 genotypes, representing 62.5 and 53.8% of the diagnosed cases in Han and Mongols, respectively. Particularly, HPV-52 and−59, the most prevalent genotypes in Han women, were not found to be related with CINII+ cases  per the screened Mongols women, significantly higher than the same rate of 1.8%  in Han Women (χI+ cases .P < 0.001). Exfoliative cytology had been the foundation of worldwide cervical screening strategy for a long term. It works with its modest sensitivity and high specificity in detection of pre-cancers. However, since the sensitivity and negative prediction value determinant to the efficiency of a population screening project for prevention of cervical cancer, a shift of primary screening from cytology to hr-HPV testing in screening strategy occurred, with HPV genotyping further development to risk-based screening and management algorithms , the other was collected by trained gynecologists (physician-collected), the concordance between self-collected and physician-collected sample in detecting hr-HPV on SeqHPV was “near perfect” in Kappa terms , higher than the rate of 14.5% in the same region reported by Wang et al. . This isNotably, HPV-16 was the most prevalent genotype in the overall study population or stratified by region or ethnicity. HPV-16 can be classified into four main evolutionary-derived variant lineages and nine sub-lineages: A1–4, B1–2, C, and D1–3 . By usinEvidence on the prevalence of cervical hr-HPV infection across age group has been discussed in previous studies, with young women (<25 years) tending to have a higher incidence of hr-HPV infection than women in the other age groups , 28. NevNo statistical differences were observed in histologic diagnosis between Han and Mongols. Our prior study had demonstrated the paramount role of HPV-16,−52, and 58 attributable to CINII+, but the majority of the study population were Han, the Mongol minority was <1% . AnotherA major strength of this study is that it is a component of a large well-organized screening program. In addition, the study protocol included available technologies for screening and analysis as well as the uniform requirements for colposcopy referral, and the standard POI protocol for colposcopy/biopsy.However, there are several limitations of this study. There was no data on the use of vaccination, occupations, smoking history, and number of sexual partners. Despite that, most enrolled women in the population were likely unvaccinated against HPV given that HPV vaccines have not been incorporated into our National Immunization Program yet, thus the coverage is low to non-existent. In addition, there might be some verification bias since women with a result of HPV negative were referred for routine screening.In summary, we have characterized the prevalence and distribution of HPV infection in self-collected samples between the Han and Mongol minorities in Inner Mongolia, which demonstrated race/ethnicity differences in the prevalence of hr-HPV and their hr-HPV type-specific distribution. Given that China is a multi-ethnic country, the present study provided guidance for the refinement of cervical cancer screening strategies and vaccine implementation in China.The original contributions presented in the study are included in the article/The protocol of this trial was approved by the Institutional Review Board (IRB) of Peking University Shenzhen Hospital (IRB: PUSH2016001) and Cleveland Clinic Institutional Review Board (IRB:15–1549). All participants signed an informed consent document before enrollment. The patients/participants provided their written informed consent to participate in this study.RW, LW, and JLB were involved in the conception of the study and obtaining ethical approval. CG, HD, and XQ analyzed and interpreted the patient data and drafted the manuscript. XD, JL, HJ, CW, CZ, JB, and HL selected participants and collected the data. All authors have contributed significantly to the final article and have approved it.The study was supported by Shenzhen High-level Hospital Construction Fund (YBH2019-260), Shenzhen Key Medical Discipline Construction Fund (Grant No. SZXK027), and Sanming Project of Medicine in Shenzhen (Grant No. SZSM202011016).JB was employed by Preventive Oncology International, Inc., and the Cleveland Clinic. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective. To assess the predictive worth of HPV E6/E7 mRNA detection in the outcome of the cervical low-grade squamous intraepithelial lesion (LSIL). From September 2017 to early September 2019, patients screened for high-risk HPV positive or abnormal cervical liquid-based cytology were retrospectively analyzed and diagnosed with LSIL by cervical biopsy were recruited. The independent influencing factors of the regression of LSIL lesions after follow-up were analyzed, and the outcome of LSIL was calculated. The results of the initial colposcopy in this study were CIN I, CIN II/P16-negative, CIN II/P16-positive, and CIN III. At the time of re-examination, LSIL patients had three outcomes: regression, persistence, and progression. In the two follow-ups, 330 patients were finally included, including 276 CIN I patients (group A) and 54 CIN II/P16-negative patients (group B). The positive rates of HPV E6/E7 mRNA in each group were 66.67% and 70.37% for A and B, respectively. The total positive rate of E6/E7 mRNA was 67.27%, and there was no significant difference between the two groups (P > 0.05). After 1 year follow-up, whether HPV E6/E7 mRNA regressed or was negative was associated with the outcome of LSIL-related lesions (P < 0.05). The regression or negative rate of HPV E6/E7 mRNA was 1.57 times higher than the progression rate of HPV E6/E7 mRNA-positive diagnosis of LSIL lesions. Univariate logistic regression analysis showed that age at first sexual intercourse, HPV E6/E7 mRNA results, and lesion type were statistically significant (P < 0.05). Whether HPV E6/E7 mRNA was negative  and age at first sexual intercourse ≥20 years  were independent influencing factors associated with LSIL regression. Multivariate logistic analysis showed that age of first sexual intercourse ≥20 years  and HPV E6/E7 mRNA-negative  were independent factors associated with LSIL. HPV E6/E7 mRNA detection can be used for predicting the outcome of LSIL and has a good application value. Cervical cancer is a malignant tumor that occurs frequently in the female reproductive system. Research shows that the global incidence of cervical cancer is as high as 500,000 new cases every year . In ChinThe research subjects were screened from sexually active women who were referred from other hospitals or other departments in our hospital to our hospital's cervical disease specialist because of high-risk HPV-positive or abnormal cervical liquid-based cytology results from September 2017 to September 2019. The clinical data of the selected patients were collected, and the patient's age, pregnancy, number of sexual partners, age at first sex, menstruation, marriage and childbearing history, contraception history, disease history, tumor family history, and educational background were recorded. Inclusion criteria were as follows: age 18–45 years old; sufficient colposcopy results; colposcopy found lesions and site biopsy and pathological diagnosis of LSIL (including CIN I and CIN II and P16 negative); no previous history of cervical cancer and CIN; nonpregnant period; and patient informed consent. Exclusion criteria were as follows: vaccinated against HPV vaccine; previous precancerous lesions of the vulva and vagina; precancerous lesions or malignant tumors in other parts; autoimmune diseases or diseases that require immunosuppressive agents, such as systemic Lupus erythematosus, glomerulonephritis, and those who received physical therapy or drug therapy during the follow-up period. This study was approved by the medical ethics committee of our hospital, and the subjects participated voluntarily and signed the informed consent.After the patients were enrolled, pathologists detected HPV E6/E7 mRNA  in accordance with the kit instructions. The cervical exfoliated cell specimens were obtained by brush and placed in the preservation solution and then transferred to the pathology department for HPV E6/E7 mRNA detection. The test results were kept in the pathology department, and statistics were carried out after the follow-up. The method uses capture hybridization to detect 14 high-risk subtypes , and for HPV16, 18/45 perform type testing. All tests were expressed as the ratio of the sample measurement value/reference value; with a ratio ≥1.0, the result was “positive;” and with a ratio <1.0, the result was “negative.”After the medical staff collected the cervical epithelial cells of the enrolled patients, they used the liquid-based ultra-thin cytology technology (TCT) to prepare and read the films. Diagnostic criteria : patholoTo analyze the relationship and predictive value of different HPV E6/E7 mRNA expressions and lesion outcomesBinary logistic regression was used to analyze the independent influencing factors related to LSIL regression statistical methodsP < 0.05 was supposed statistically important.SPSS 23.0 version was applied for data analysis, count data were expressed as rate (%), the chi-square test was applied for comparison between groups, and the rank sum test was applied for independent group rank count data. A binary logistic regression model was used to analyze the independent influencing factors related to the prognosis of LSIL lesions, and the 95% confidence interval (CI) of the OR value was calculated. The results of the initial colposcopy histological examination were CIN I, CIN II/P16-negative, CIN II/P16-positive, and CIN III. The re-examination results showed that the lesions of LSIL patients regressed, persisted, and progressed .P=0.596). The composition ratio of other 11 types was not statistically different (P=0.428), as given in A total of 330 patients were eligible for inclusion and completed two follow-up visits, including 276 patients with CIN I (group A) and 54 patients with negative CIN II/P16 (group B). The overall positive rate was 67.27% (222/330), the positive rate of group A was 66.67%, and the positive rate of group B was 70.37%. There was no statistical difference between the two groups (P=0.012). Among the 36 patients with progressive LSIL lesions, 22 had HPV E6/E7 mRNA regressed or negative, 14 had HPV E6/E7 mRNA persistently positive, and HPV E6/E7 mRNA regressed or negative rates were HPV E6/E7 mRNA-positive diagnosis of LSIL lesions 1.57 times the progression rate. Among the 92 patients with persistent LSIL lesions, 52 had HPV E6/E7 mRNA regressed or negative, and 40 were persistently positive. HPV E6/E7 mRNA regression or negative rate was 1.3 times the progression rate of HPV E6/E7 mRNA-positive diagnosis of LSIL lesions. Of the 202 patients with regressed LSIL lesions, 148 had regressed or negative HPV E6/E7 mRNA and 54 had persistently positive HPV E6/E7 mRNA, as given in Between the two visits, 36 patients were upgraded to HSIL (10.9%), 92 patients continued to LSIL (27.9%), and 202 patients had disease resolution (61.2%). The relationship and predictive value of different HPV E6/E7 mRNA expressions and lesion outcomes were analyzed. It was found that whether HPV E6/E7 mRNA was negative after a 1-year follow-up, and the type of lesion was associated with the outcome of LSIL lesions (P < 0.05), as given in Lesion outcome was divided into regressed and nonregressed (persistent and progressive) as a binary outcome. Univariate logistic regression analysis was performed. The results showed that the age at first sexual intercourse, HPV E6/E7 mRNA results and lesion type were statistically significant (P=0.002) and whether HPV E6/E7 mRNA was negative  were independent factors associated with LSIL, as given in The factors with statistical significance in the univariate analysis were included in the multivariate analysis, and the distribution is given in According to previous reports, LSIL is mostly caused by HPV sexual infection, most of which can be cleared by the body's immune system. It can be seen that LSIL has a high natural negative rate. However, due to the preventive examination of vaginal and cervical smears, Pap test and HPV DNA detection, and other screening methods, the prognosis of LSIL patients cannot be well predicted, and there are many clinical overtreatment and treatment of LSIL patients. The phenomenon of frequent biopsies . TherefoPrevious studies have reported that the oncogenic proteins encoded by HR-HPV E6/E7 genes are generally in a dormant state, and persistent infection with HPV virus can activate the expression of HPV E6 gene, resulting in the degradation of the tumor suppressor gene p53, while the HPV E7 gene is in a dormant state. Combine with the tumor suppressor gene Rb to degrade it, eventually leading to the occurrence of malignant tumors. Both E6 and E7 are important factors leading to CIN –12. HR-HWhen E6/E7 mRNA is detected, it means that the HPV oncogene has been integrated into infected cells and may gradually develop into malignant lesions. Therefore, some scholars speculate that HPV E6/E7 mRNA may be related to the prognosis of lesions. Liu  and otheIn this research, the outcome of cervical LSIL patients was analyzed from different HPV E6/E7 mRNA results; it turns out that HPV E6/E7 mRNA regressed or negative patients was better than that of HPV E6/E7 mRNA-positive patients. Therefore, clinical attention should be paid to patients with HPV E6/E7 mRNA-positive. In this research, the independent influencing factors related to LSIL regression were analyzed by multivariate regression analysis. The results displayed that whether HPV E6/E7 mRNA was positive at the time of enrollment was not associated with the prognosis of LSIL and whether HPV E6/E7 mRNA was negative during a 1-year follow-up and the age of first sexual life ≥ 20 is related to the regression of LSIL lesions, suggesting that the focus should be on the age of first sexual life <20 years old, and the follow-up of such patients should be strengthened to detect the HPV E6/E7 mRNA.This research is a small sample analysis, and the conclusions have great limitations. Some enrolled patients were referred from other hospitals or interdepartmental referrals in the hospital. The HPV detection methods used initially before enrollment were different, so it was impossible to compare the worth of HPV E6/E7 mRNA in the prognosis of LSIL lesions compared with other HPV detection methods. Subsequent studies can use the comparative study design of HPV DNA detection and simultaneous detection of E6/E7 mRNA detection to contrast the advantages and disadvantages of the two.In general, the detection of HPV E6/E7 mRNA can predict the outcome of LSIL and has a good application value. One-year follow-up of LSIL patients if HPV E6/E7 mRNA changes from positive to negative or continues to be negative; it is predicted that LSIL may subside. If HPV E6/E7 mRNA remains positive, clinical intervention should be actively performed.


The oral-cervical human papillomavirus (HPV) infection/cancer relationship is not well established. Oral-cervical HPV studies were reviewed to assess dual-site occurrence, HPV type concordance, and study quality/deficiencies.PubMed, EMBASE, Ovid Medline, and Web of Science were searched between 1/1/1990 and 8/10/2021 for studies investigating HPV infections/cancers and type concordance between the oral cavity/oropharynx and cervix. Dual-site and concordant HPV infection rates were summarized as percentages; cancer diagnoses studies were summarized using standardized incidence ratios (SIR). The Quality Assessment Tool for Quantitative Studies (QATQS) evaluated study methodology.One hundred fourteen papers were identified. Most were cross-sectional , involved synchronous dual-site HPV testing , did not report HPV type concordance , and achieved moderate methodological QATQS ratings . The overall dual-site infection rate averaged 16%; the HPV type concordance rate averaged 41%, among those dually-infected women. Most HPV-related cancer diagnoses studies reported increased secondary cancer risk, with SIRs generally ranging from 1.4 to 29.4 for secondary cervical cancer after primary oral cancer and from 1.4 to 6.3 for secondary oral cancer after primary cervical cancer.Oral-cervical HPV infections/cancers remain understudied. Future research should use stronger methodologies and HPV concordance analyses to better understand oral-cervical HPV epidemiology. Human papillomavirus (HPV) is the most prevalent sexually transmitted infection . The virHPV can be attributed to more than 70% of oropharyngeal cancers in the United States (US) , 10. In Approximately 604,127 women were diagnosed with cervical cancer worldwide in 2020 . EssentiResults from studies of dual-site oral-cervical HPV infections/cancers are inconsistent. Investigating HPV status in both oral and cervical sites in women can aid in determining how HPV is transmitted  . For exaCurrent systematic reviews on the topic of oral HPV infections and cervical cancers have only studied the infections independently of one another. This prohibits a complete assessment of HPV type concordance between the anatomical sites. The one meta-analysis that investigated oral and cervical HPV infections estimated an HPV concordance rate of 27% . HoweverTo date, there is no published comprehensive systematic review incorporating a quality assessment of the literature that examines the potential for both oral and cervical HPV infections in women. This systematic review aims to fill significant gaps in the HPV literature regarding oral and cervical dual-site and concordance rates of HPV. In summary, there is no consensus on whether oral and cervical HPV-related infections and/or cancers are more likely to be related or unrelated events. This systematic review aims to critically assess studies with participants who have at least one HPV-related oral and/or cervical infection/cancer diagnosis, comparing any HPV types across the two biological sites, to determine if there is a higher probability that any HPV types at the two sites had concordance.oropharynx and cervix and human papillomavirus and infection or cancer. Searches were restricted to peer-reviewed papers published from January 1, 1990 to August 10, 2021. For example in PubMed, the following terms were used:A review of the literature was conducted in PubMed, EMBASE, Ovid Medline, and Web of Science databases using variations to the search terms These search strategies were reproduced in each of the other three databases  or asynchronously ; and were full-text papers of original research written in English. Partner studies with both men and women were included if any HPV data pertaining to women could be independently differentiated from any HPV data presented on men. Studies including participants with a positive oral HPV test or any HPV-related oral cancer  were included. Oral sites could range from the oral cavity to the esophagus , including the oropharyngeal region with the base of the tongue and the tonsils (both HPV-related), as long as the original study authors had justified the sites to be at least possibly oral HPV-related , 9. All Studies were excluded if they were not relevant to within-person HPV evaluation of both oral and cervical infections , involved only HPV infections in the oral cavity/oropharynx or cervix, not original research , or were case reports or series .Duplicate citations from the four databases were reviewed and removed. The remaining citations were divided equally, reviewed separately, and then summarized with data extraction by three study authors . Any questions regarding inclusion were resolved by consensus among the three authors listed above.As described by Thomas et al., the Quality Assessment Tool for Quantitative Studies (QATQS) from the Effective Public Health Practice Project criteria was utilized to determine the quality of each included study . The assConcurrent infections were defined as any HPV infection(s) occurring in both the oral cavity/oropharynx and cervix simultaneously due to synchronous site testing. If HPV infection was absent at either or both sites, then any infection was not considered concurrent. “Dual-site infections” were defined as any HPV infections occurring in both the oral cavity/oropharynx and cervix at different times due to asynchronous  testing of the two sites. Concordant infections were identified in women who shared at least one HPV type across oral and cervical sites at any time (synchronously or asynchronously) . Synchronous HPV evaluation studies actively collected oral and cervical samples and tested them both for HPV DNA at the same visit . Asynchronous HPV evaluation studies either HPV-tested the oral and cervical sites at separate visits or one anatomical site was previously diagnosed with a HPV-related cancer and the other anatomical site was actively tested for HPV infection during the study. Cancer diagnoses only studies relied on data from cancer registries or medical records to determine prior primary and secondary cancer diagnoses of the oral cavity/oropharyngeal region and cervix.When individual synchronous and asynchronous studies presented sufficient results, we summarized concurrent/dual-site infection data as percentages of women with any oral-cervical HPV infections at any time. HPV type concordance data was summarized as percentages of women with the same oral-cervical HPV type(s) at any time. Overall concurrent/dual-site and concordant oral-cervical HPV infection rates were determined by averaging respective individual study percentages  , 15–93 eEighty studies synchronously evaluated HPV-related infections at both the oral and cervical sites , 15–93 , 91–93.Overall rates of cervical HPV+ and oral HPV+ cases varied by study , 86–93. Eighty-three percent of all synchronous testing studies n=67/80, , 84–93 pAmong the 67 studies identifying concurrent oral and cervical HPV+ cases, 70% n=47/67)  showed that more women were HPV+ in the cervix than in the oral cavity/oropharynx , 105 whiMost asynchronous studies  differentiated between women with and without dual-site oral and cervical HPV infections at any time –105 Tab–105. On Among studies where women were known to be dually-infected with oral and cervical HPV, 27% (n=3/11) measured concordance in HPV types across both sites at any time , 97, 105Twenty-two retrospective studies focused on the diagnosis of a secondary cervical or oral cancer after a primary cancer diagnosis of oral or cervical cancer –127 Tab, 120–123Among women with a primary diagnosis of oral cancer, the number of secondary cervical cancers was lowest among medical record-based studies , 123, foAmong women with a primary cervical cancer, one provincial-level registry found very few cases of secondary oral cancers . NationaFor the quality assessment of the 114 included papers based on the QATQS tool, 26 studies (23%) were classified as strong , 121–127After an expansive search of four databases for studies of dual-site oral and cervical HPV infections/cancers, we included 114 papers that evaluated the sites synchronously (n=80) –93, asynThe reporting of dual-site oral and cervical HPV infection rates was wide-ranging. On average, 15% of infections occurred concurrently in the oral cavity/oropharynx and cervix. Among concurrent oral-cervical HPV+ cases, HPV types were concordant across the two sites in an average of 41% of women. Asynchronous dual-site  HPV infection rates also varied, spanning from 1.1% to 100%, with an average of 26% of study populations testing positive for both oral and cervical HPV at different times. Oral-cervical HPV type concordance was either very low (2%) or high (100%) for these asynchronously tested and dually-infected women, producing an average concordance rate of 39%. Combining synchronous and asynchronous oral-cervical HPV testing data, it was estimated that 16% of women were dually infected and 41% of the dually infected women had at least one concordant HPV type across sites. Most cancer diagnoses only studies reported an increased risk for a secondary cervical and/or oral cancer, resulting in incidence spanning 1.0-192.5/10,000 women. Regardless of timing, most studies were cross-sectional  , 84–103 Oral HPV infection can be especially difficult to detect which may explain the lower oral-cervical HPV type concordance rates or lack of significant findings in the reviewed studies. Saliva continuously rinses the mouth so it may aid in regional virus clearance, making oral HPV more transient than HPV infections at other sites. Most people clear oral HPV infections, often in as little as a few months, which means it can easily be missed . HPV detOther reasons for non-significant findings within studies might be site-independent or biological in nature. Virus detection methods  vary in sensitivity levels and are often HPV type specific, so the chosen HPV test may not be able to detect the HPV type present, suggesting no infection , 129–131The current systematic review expands upon the narrowly-focused topic-related meta-analysis of 2010  with theAdditional problems with vague data reporting were observed, irrespective of whether or not studies involved synchronous or asynchronous oral and cervical HPV testing or cancer diagnoses only. Many studies provided a general summary statement regarding the oral-cervical HPV relationship across sites with the corresponding statistics  kappa statistics, p-values). Enumeration of sub-sites of oral cancers made it difficult to calculate incidence consistently among cancer diagnoses only papers. Information on HPV type was represented as ranges or in bar graphs, which made it difficult to extract specific values and interpret results. Still others did not stratify oral HPV results by sex so cervical HPV data could not be cross-compared with respective oral samples in females.Without specific HPV type information presented at the person-level for both the oral cavity/oropharynx and cervix, concurrent/dual-site versus concordant infections could not be elucidated. Additionally, not all dual-site HPV+ studies, especially asynchronous and cancer diagnoses only papers, discussed the potential for concurrent infections which made it difficult to determine if the identified oral and cervical HPV infections could be related. Few studies listed participant data individually, making it unclear if a participant had the same infection in both sites. In turn, oral-cervical HPV type concordance data was missing or could not be deduced for more than half of the papers  , 106–127vs. HPV+ women) to account for multiple infections in women, which is an important detail to note, but complicated the estimation of the disease burden. More than 10% of synchronous and asynchronous studies did not discuss if any detected HPV types were high-risk. The interpretation of cancer diagnoses only papers could not be compared collectively with synchronous and asynchronous papers due to different effect estimates being used . Additionally, almost one-third of cancer diagnoses only papers  were missing SIR values  and/or a lack of differentiation between HPV infection sites  potentially prevented some topic-relevant papers from being included in the current review. Regardless, studies had to justify oral cancers as potentially HPV-related to be included. Using strict review criteria, the current review included studies focused on HPV-related oral and cervical infections/cancers only, minimizing misclassification bias concerns. The systematic review also relied on literature-reported “oral HPV-related cancer” terminology to portray results. Inconsistent use of varying terms across publications impeded the summarization of results across studies. The standardized QATQS tool could not be fully utilized due to the topic-related nature of this systematic review relying only on observational studies.The current systematic review also had its limitations. Unpublished works and conference abstracts were excluded, potentially missing some information, however, we evaluated many peer-reviewed publications with broad search terms. Only papers written and published in English were included so there could be a lack of generalizability to international research. However, 94 international studies were captured with our search criteria . The inability to decipher the vagueness in oral cancer types  within women and men are needed to better understand how HPV is transmitted and determine any relationships between potentially HPV-related cancer sites. Pooling of these individual-level study results into a special access HPV database could facilitate future research investigations. From there, risk factors and populations with potentially increased oral and/or cervical HPV cancer risks could more easily be identified and incorporated into future public health prevention and control efforts, locally and globally, to reduce the HPV-related cancer burden in men and women.The original contributions presented in the study are included in the article/All authors agree to be accountable for the content of the work. KJ: validation, formal analysis, investigation, data curation, writing-original draft, writing-review and editing, and project administration. CB: validation, formal analysis, investigation, data curation, writing-original draft, writing-review and editing, and visualization. XZ: validation, formal analysis, investigation, data curation, writing-original draft, and writing-review and editing. EP: conceptualization, methodology, resources, writing-review and editing, and supervision. All authors contributed to the article and approved the submitted version.KJ (P01 CA229143-S1) and XZ (F99CA253745-01) both have National Cancer Institute (NCI) funding through the National Institutes of Health (NIH). CB is funded through The Ohio State University Comprehensive Cancer Center.EP receives grant funding through the university from Pfizer and Merck Foundation.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.