DNA was extracted from the baseline smears and tested for HPV by PCR using GP5+/6+ consensus primers. HPV+ samples were tested for HPV types 16 and 18 using specific PCR primers. In all, 27.0% of cases tested positive for HPV at baseline, compared with 15.4% of controls (odds ratio (OR)=2.00; 95% confidence interval (CI), 1.50–2.68). Among women aged 40 years or over, the OR for HPV 16 was 8.95 . These results support the need for further cervical screening of HPV− older women, as many of the cases were HPV− at baseline.Human papillomavirus (HPV) testing might identify older women who could be withdrawn from the cervical screening programme, or require less frequent screening. A case–control study using the United Kingdom cervical screening population was set up to help address this issue. Cases comprised 575 women who developed cervical intraepithelial neoplasia (CIN) grade 2 or worse over a 13-year period following a cytologically normal baseline smear, and were stratified by age group . Controls ( Human papillomavirus (HPV) infection has been found to be present in 99.7% of cervical cancers, and is thus acknowledged as a necessary cause of this disease  and who subsequently received a histologically confirmed diagnosis of CIN grades 2 or 3 or cervical cancer up until September 2002. In the UK, cervical smears have to be retained for 10 years for legal reasons, meaning that cervical smears taken after 1992 could not be retrieved for HPV testing. In total, 204 cases aged 40 years or over at baseline were identified as eligible and had baseline smears that could be retrieved. Women aged under 40 years at baseline were also recruited to increase the overall sample size of the study and to test the hypothesis that the relationship between the HPV measures and outcome was modified by age . The younger cases were selected consecutively on the basis of the date of their baseline smear beginning from May 1988 until around the end of 1988, in order to achieve a sample size of 100 cases aged under 20 years and 275 cases aged 20–39 years. For all age groups, the earliest smear was chosen when more than one was available (between May 1988 and November 1992) from each woman in the study, so as to maximise the length of follow-up available. Any women who had an abnormal cervical smear of mild severity or worse prior to the baseline smear were excluded from the list of possible cases. If a smear of ‘borderline’ severity was recorded prior to baseline, the woman would be eligible if this was followed by two cytologically normal smears (including the baseline smear).Controls for this study were frequency matched by 10-year age band  and year of baseline smear, in a ratio to cases of 1 : 1. The eligibility criteria for the control group were a normal baseline smear and no subsequent development of abnormal cytology (mild severity or worse) or diagnosis of CIN 2/3 or invasive cancer up until September 2002 (the time at which the case group was selected). Women with a smear recorded as having borderline dyskaryosis during follow-up were eligible as controls if this was followed by two normal smears. Selection as a control was not conditional on having a complete history of normal smears over the subsequent 10–13 years, as the purpose was to select a group of women representative of all women who did not develop cervical disease over this time period. However, all controls were required to have had a minimum of one follow-up smear in order to limit the potential for the control group to have contained women who received a diagnosis of CIN 2 or worse outside of the Nottingham area. Exclusion criteria for controls on the basis of smear abnormalities prior to baseline were identical to those for cases.n=224 controls vs n=204 cases) due to the fact that replacement smears were available for controls but not for cases.Controls were selected at random from all those eligible, ensuring that the number of cases and controls were equal within each age band and for each year of baseline smear. At the time of slide retrieval, replacement of damaged or missing smears was carried out for controls by randomly selecting a smear from another woman on the list of eligible controls. There was a slight imbalance in the number of cases and controls aged 40 years or over  for 2–3 days to remove coverslips. Cells were then scraped into an Eppendorf tube containing ethanol (1 ml) using a sterile scalpel blade and centrifuged to remove any traces of xylene. DNA was extracted using Qiagen™ extraction kits .β-globin PCR was carried out for 354 samples (a mixture of cases and controls) in order to test the integrity of the DNA extraction process, of which 342 samples (96.6%) tested positive. Owing to the high percentage of women with β-globin+ smears and the need to preserve the DNA sample, it was decided that no further β-globin PCR's would be performed.−1) and DNA template (5 μl) were added. Standard tubes of HPV 16 DNA (0.01–10 pg tube−1) and blank tubes (no DNA) were included in all assays. In all, 40 amplification cycles were performed. Samples that were HPV+ using the GP5+/6+ primer sequence were also tested for HPV 16 and HPV 18 using type-specific PCR primers located within the E7 gene.HPV DNA was amplified using real-time PCR (Stratagene Mx4000)  containeOdds ratios and 95% confidence intervals (CIs) were calculated using logistic regression analysis adjusted for age at baseline. Age was fitted as a linear term for these analyses, although results were similar when models were rerun with age as a categorical variable. Subgroup analyses were carried out for age group , and with the case group stratified by both grade of diagnosis ) and time in years between baseline and diagnosis . Exposure measures were infection with any genital HPV type (based on results from the GP5+/6+ assay) and infection with HPV types 16 and 18 specifically.in situ). Among cases, the median length of time between the baseline smear and diagnosis of outcome was 6.8 years (range=0.1–13.5 years) and the median age at diagnosis was 36.2 years (range 19.1–76.1 years). Of the four cancer cases who were under age 20 years at baseline, all developed the outcome 9 or more years after the time of their baseline smear (minimum age at diagnosis=27 years). Exclusion of four cases where the time between baseline and diagnosis was less than 6 months had little impact on results presented below.A total of 1176 women were selected for this study (575 cases and 601 controls). Four cases were excluded when a review of the biopsy report found that the outcome lesion did not conform to a grading of CIN 2 or worse. There were insufficient cells for DNA extraction for 17 smears (seven cases and 10 controls); hence, these women were excluded. This left a final sample size of 564 cases and 591 controls. The numbers of cases and controls by age group are shown in vs 15.4%). Overall, HPV+ women had a two-fold increase in the risk of developing an outcome lesion. The OR was highest for women aged 40 years or older at baseline, while for the smaller group of women under age 20 years, the difference in HPV status between cases and controls was not statistically significant. A test for interaction to compare the magnitude of the ORs across the three age groups (with age group fitted as a linear term) failed to reach statistical significance (P=0.15).A comparison of the rates of infection with any genital HPV type (high or low risk) between cases and controls both for the entire sample and among specific age groups is provided in Cases were stratified according to grade of outcome  and the length of time between the baseline smear and diagnosis; these results are presented in P=0.086). HPV 18 does not have a significant effect upon the odds of being a case, despite raised ORs for all three age groups. The interaction between age group and HPV 18 was also nonsignificant (P=0.77). When additional models were fitted to control for infection with the other high-risk HPV type (16 or 18) and for other HPV types (positive using GP5+/6+ primers but negative for HPV 16/18), the ORs remained significant for HPV 16 and nonsignificant for HPV 18. The interaction term with age group remained of borderline significance for HPV 16 (P=0.066) and nonsignificant for HPV 18 (P=0.67) when the other HPV terms were adjusted for. When analyses were performed separately for the three grades of cases with results combined over age groups and adjusted for the other HPV types, the effect of HPV 16 was significant among all case groups (data not shown). For HPV 18, there was a higher OR among cancer cases, although this was not statistically significant , 0.94–9.49; P=0.063).A total of 70 cases and 18 controls tested positive for HPV 16 and 27 cases and 17 controls were positive for HPV 18. These results are described in more detail in This study found that HPV significantly predicts the development of high-grade cervical disease an average of 6.8 years later. The magnitude of the ORs varied according to age at baseline smear, grade of outcome, time to development of outcome and HPV type. For women aged 40 years or over, infection with HPV 16 was associated with an approximate 10-fold increase in risk of CIN 2 or worse. Despite this, however, 73% of cases were HPV− at baseline. Strengths of the study include the large number of cases, the long period of follow-up and relevance of the study sample to a population where HPV testing could be introduced in practice (older women based in the United Kingdom).β-globin assay). The conditional logistic regression method of analysis needed for matched case–control data requires data to be nonmissing for both case and control(s); hence, a large number of missing values for the exposure variable would make such an analysis highly inappropriate. All logistic regression analyses presented here were adjusted for age to allow for the fact that within each age band, the age distribution of cases was not always uniform, whereas it was for controls. Second, the selection criteria for our control group was for women to have had just one subsequent normal cervical smear, as opposed to a complete history of normal smears over the 10–13 year follow-up period. We cannot therefore be sure that all controls remained disease free over this period, as they may have migrated and presented with CIN outside of Nottingham. Among a retrospective cohort of women aged 40 years or over participating in the Nottingham screening programme, less than 1 woman per 1000 was diagnosed with CIN (grades 2 or 3) or cancer each year (unpublished data). This would therefore have had a negligible impact on our results, although we acknowledge the possibility that such misclassification could have been greater for the younger age groups, among whom the incidence of CIN is higher.Several aspects of the study design merit attention. First, controls were not individually matched to cases, instead it was ensured that numbers of cases and controls were equal within categories defined by age (10 year bands) and year of baseline smear. At the time of inception of this study, there was some concern that many archival cervical smears would contain insufficient DNA for HPV analysis  who developed cancer more than 6 years after baseline were positive for HPV using a consensus PCR method (MY09/11) (


Some genotypes of human papillomaviruses can infect the genital tract and they are important infectious agents which their oncogenicity is regardable. Thus the aim of this study was to determine the prevalence of various genital human papillomaviruses (HPV) among women being subjected to routine pap smear test in Bushehr city of Iran.Based on the collected data, 11(5.5%) samples were detected positive for HPV DNA and 189(94.5%) samples out of 200 samples were detected negative for HPV DNA. Meanwhile 4(2%) samples detected positive for HPV DNA by PCR were detected positive for HPV by pap smear test as well. On the other hand 5 samples which were detected positive for HPV by pap smear test didn't have HPV DNA after being tested by PCR method. Among the 11 positive samples 7 samples were identified as HPV-16, 3 samples were HPV-18 and one was HPV-53.Regarding the prevalence of highly carcinogen genotypes of HPV in our study determination of genital HPV prevalence among the normal population of women of Bushehr city is recommended. Worldwide, cervical cancer is the second most common cancer affecting women. Nowadays screening programs have reduced the mortality and morbidity of this disease, but 500,000 new cases of invasive cancer of the cervix are still diagnosed annually. Epidemiological and molecular studies have demonstrated that certain types of human Papillomaviruses (Highly carcinogen genotypes) are the major cause of most cases of cervical cancer .Human papillomaviruses (HPVs) belong to Papillomaviridaefamily. So far,HPV-16 is the most prevalent type worldwide -9. HPV18HPV DNA testing has been used as an adjunct to Pap smear cytology test in the diagnosis of cervical cancers to improve screening sensitivity and negative predictive value -13. In fIn this study, we determined the prevalence of various HPV genotypes among the women subjected to routine Pap smear test in Abolfazl outpatient clinic of Bushehr University of Medical Sciences, Iran, by PCR and subsequent sequencing. Cytological diagnoses were also done on all samples based on the new Bethesda system.This study has been approved by the Ethical Committee of Bushehr University of Medical Sciences.Two hundred samples were collected from women admitted at Abolfazl outpatient clinic in Bushehr and voluntarily subjected to gynecological examination by gynecologist from 2008 to 2009. Two Samples were collected from each patient by cytobrush: one for Pap-smear test for detection of cytopahic effects of HPV and another one for HPV DNA PCR assay which was stored at -20°C until PCR test time.All samples were subjected to centrifugation 2000 rpm for 5 minutes and precipitated cells were digested using digestion buffer containing proteinase K, followed by extensive extraction with phenol/chloroform . The extβ-Globin positive samples were subjected to HPV PCR by forward primer GP5+: 5'-TTTGTTACTGTGGTAGATACTAC-3' and reverse primer GP6+:5'-AAAAATAAACTGTAAATCATATTC-3' for L1 open reading frame (ORF) that amplifies a 150 bp product from the HPV L1 ORF . PCR wasGU076513 through GU076523.HPV positive PCR products were subjected for automated sequencing . Nucleotide sequences were aligned with CLUSTALW program using BioEdit software  and confirmed by visual inspection. Genetic distance was estimated using the Kimura two-parameter matrix. A phyloData was processed by SPSS 16 Package program for statistical analysis .The result of HPV DNA PCR for collected samples revealed that there were 11(5.5%) samples with HPV DNA by using general primers for all genotypes of HPV. The result of genotyping based on MEGA software using which is based on genetic distances and phylogenetic tree informations (Table Results of pap smear showed that 9(4%) samples were detected as HPV positive meanwhile 4 of them were detected as HPV DNA positive by PCR method. On the other hand 7 samples which identified as HPV DNA positive by PCR method were negative for HPV infection when they investigated by pap smear test.Mean of age for HPV infected women were 31.9 years old and it is concordant with the sexual active age which is very important for incidence of any kind of genital infections. The youngest one was 24 years old and the oldest one was 44 years old.Based on clinical findings of HPV positive women we have found that five HPV infected women didn't have any clinical manifestations and there was no evidence for cervisitis and/or genital warts. Six women out of 11 HPV infected individuals have shown acute cervisitis but there was no sign related to genital warts and just one women showed the cervisitis and gentital warts together.Besides, among five women who were detected positive for HPV infection by pap smear meanwhile they were detected negative for HPV infection by PCR method we have found that just two of them showed acute cervisitis without any genital warts manifestation.By using SPSS software and regarding to the collected data, the sensitivity of pap smear test comparing to PCR method in our study was calculated 36.36%. Besides the specificity value of our pap smear test was 97.35.Cervical cancer is an invasive cancer affecting approximately 500000 women each year of whom 80% live in developing countries. The vast majority of cervical cancer cases are caused by infection with certain genotypes of human papillomaviruses.Pap smears for the detection of cytomorphologically abnormal cells have decreased the number of deaths from cervical cancer but have not eradicate the disease in any screened population to date,20. cervin situ hybridization are two of the most sensitive methods[There is international consensus that "high risk" genotypes, including genotypes 16,18,31,33,35,39,45,51,52,56,58,59 and 66 can lead to cervical cancer. Infections with low risk genotypes, including 6, 11, ... can cause benign or low grade cervical tissue changes and genital warts,22. HPV e methods. The dete methods. In thisBy using PCR, it was revealed that out of 200 samples, there were 11 (5.5%) positive samples for HPV DNA but there were only 4 (2%) positive samples with HPV related cytopathologic evaluation.Based on results, seven samples (3.5%) were detected as negative for HPV by cytopathology method meanwhile they were positive for HPV DNA by PCR method. Such results express the false negativity of cytophatologic method. On the other hand five samples (2.5%) were recognized positive by cytopathology method for HPV, meanwhile they were negative for HPV DNA by using PCR method. This result confirmed the false positivity of cytopathologic methods. The sensitivity and specificity of cytopathology method in our study were 36.36% and 97.35% respectivly. Meanwhile in one study these criteria were reported as 58% and 64%, respectively . In our Out of 11 positive samples for HPV DNA 7 samples were HPV-16, determined by genotyping method, meanwhile 3 samples were HPV-18 and one sample was recognized as HPV-53. This showed that HPV-16 is the most prevalent type among high risk HPV in Bushehr city. Also the prevalent type of HPV in most studies was reported HPV-16 ,21. So aThe authors declare that they have no competing interests.KZ and RH designed and conceived the PCR test. SSE performed the pap smear test ER, ID and SA have collected the samples. HA, ZR and FF co operated as lab staff for PCR performing. We confirm that all authors read and approved the final manuscript.


In order to be widely accepted by users, the implementation of a new health intervention requires them to be adequately informed about its clinical importance, benefits and risks. The aim of this study was to provide data on the knowledge of Italian adolescents and parents concerning human papillomavirus (HPV) infection and its prevention in order to allow the development of adequate training programmes.Between 2 May and 15 June 2008, we made a cross-sectional survey of 863 high school students and 2,331 parents of middle and high school students using two anonymously completed questionnaires covering the knowledge of HPV infection and related diseases, and attitudes to vaccinations. The approached schools were a convenience sample of the schools of the greater Milan area, Northern Italy.vs 53%; p = 0.004) and were favourable towards vaccinating their children against HPV ; among the students, more females than males were aware that HPV infection could concern themselves  and would undergo vaccination against HPV . The parents' propensity to vaccinate their children against HPV was significantly associated with professing the Catholic religion , the gender of the offspring , a propensity to vaccinations in general , a knowledge that HPV vaccine is aimed at preventing cervical cancer , and an awareness that HPV could affect their own children . The students who were aware that HPV infection could affect themselves were more in favour of to HPV vaccination, regardless of whether they were male  or female .More mothers than fathers were aware that HPV infection could concern their children (58% Both students and parents seem to underestimate the likelihood of HPV infection, and this is associated with a lower propensity for vaccination. This is an important indication for future training programmes concerning HPV prevention designed to increase the acceptance of HPV vaccine in families. Persistent infection with high-risk human papillomavirus (HPV) can cause cancers of the cervix and other genital sites, anus, oral cavity and oropharynx, and possibly the larynx and skin -6.In March 2008, the Italian Ministry of Health suggested to the Vaccine Committee of the Regions to start an active, free vaccination campaign against HPV as cause of cervical cancer aimed at 12-year old girls in line with the guidelines of a number of other industrialised countries ,8. The cIn order to be widely accepted by users, the implementation of a new health intervention requires them to be adequately informed about its clinical importance, benefits and risks. HPV vaccination is more complex than other health initiatives because the targets are young, decisions are generally made by their parents, and may not be based on reliable information. Moreover, even when younger subjects are still being followed by pediatricians, the physicians may be poorly informed about HPV-related diseases because most of these occur in adulthood . In ordeThis means previously acquiring adequate information concerning the knowledge and attitudes of the different subjects involved. A number of investigations carried out in different parts of the world have shown that such subjects are inadequately aware of the problem -22, althBetween 2 May and 15 June 2008, we carried out a cross-sectional survey of high school students and parents of middle and high school students in order to verify their knowledge of HPV infection and HPV-related diseases, and their attitudes to vaccinations (particularly HPV vaccine).The survey involved two middle schools in Milan (one private and one state run), five high schools specialising in classical, linguistic or scientific studies (two private and three state run) in the greater Milan area and Varese, and one state-run technical school in Milan. The schools were a convenience sample chosen on the basis of contacts of the authors of this paper with school boards. We varied the type of schools included in the investigation in order to obtain a composite distribution of subjects reflecting the characteristics of the baseline population, with specific reference to age of the students and educational level of the parents. S.E. and N.P. had repeated contacts with boards of each school before the distribution of the questionnaires in order to assure the best compliance of teachers to the survey. After the study had been approved by the Ethics Committee of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy, and the boards of each school, all of the students attending the high schools were given three questionnaires: one for the student and one for each parent. Because of the age of the students attending the middle schools (10-13 years), school boards decided that only their parents had to complete a questionnaire.The students' and parents' questionnaires were designed to collect information concerning the compilers' knowledge of HPV infection and their attitudes to vaccination. Both were to be anonymously self-completed (at home), and were accompanied by a formal letter describing the aims of the study and explaining how to complete the questionnaires. The same information was also given orally when the questionnaires were given to the students.The questionnaires, that were prepared by a multidisciplinary group including pediatricians  and epidemiologists , were pilot-tested on a convenience sample of adolescents and parents attending the outpatient clinic of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico in Milan in order to ensure clarity and ease of administration. The student questionnaire [Additional file The students had to return the questionnaires to their teachers within a week of their distribution, and the completed questionnaires were collected from the schools by members of the research team.χ2 or Fisher's exact test as appropriate. All of the analyses were two tailed, and p values of 0.05 or less were considered significant. Odds ratios (OR) and 95% confidence intervals (CI) were calculated in order to measure the associations between selected factors chosen on the basis of literature review and the parents' propensity to have their children vaccinated against HPV, or the students' propensity to undergo HPV vaccination themselves. The ORs were obtained by means of unconditional multiple logistic regression adjusted for: 1) age, education, gender and religion of the parents, and age and gender of their children in the case of the parents' data; or 2) age and religion of the student and education of the parents in the case of the students' data. All of the analyses were made using SAS version 9.1 .The responses were analysed by means of descriptive statistics. In the case of categorical data, the gender groups  were compared using the vs 52.1%; p < 0.0001). There was also no significant difference in response rates and data obtained in the different schools.A total of 3,026 questionnaires were distributed to parents , 2,331 (77.0%) of which were returned with more than 70% of the questions answered. The students received a total of 1,092 questionnaires , 863 (79.0%) of which were returned with more than 70% of the questions answered. There was no difference in the response rates of the mothers and fathers, whereas female students answered significantly more frequently than male students  and, among the parents who were aware of HPV, the mothers were also more often aware of the dangerousness of the virus  and more informed as to how it is transmitted . Similarly, a higher proportion of female (72%) than male students  had ever heard of HPV but, among those who were aware of HPV, there was no significant gender-related difference in its perceived dangerousness (about 90% in both sexes) or how it is transmitted (90% vs 92%). With reference to their knowledge of HPV vaccination, 90% of the mothers and 87% of the fathers knew that HPV vaccine is aimed at preventing cervical cancer (p = 0.02); the corresponding figures for the female and male students were 75% and 63% (p = 0.008). About 75% of the mothers, fathers and female students knew that the vaccination should be given before sexual activity begins; this decreased to 67% of the male students, although the between-gender difference among the students was not significant.Table vs 53%, p = 0.004) and were more in favour of them being vaccinated . When these last two questions were answered by the students, 45% of females and 26% of males were aware that HPV infection could concern themselves (p < 0.001), and 68% of females and 40% of males said they would undergo HPV vaccination (p < 0.001).Table Table Table This study of an upper-middle class population in the greater Milan area, Northern Italy, found that teenagers and parents still have a number of gaps in their knowledge of HPV infection and its prevention by means of vaccination. In particular, they seemed to underestimate the likelihood of HPV infection and were therefore less likely to see HPV vaccination favourably. This is an important indication for future family HPV training programmes designed to increase the acceptance of HPV vaccination.Most of the parents were aware of HPV and correctly answered a number of questions about it. This might be at least partially explained by their higher education level in Northern Italy in comparison with the general Italian population . There aNevertheless, a proportion of our parents still need to be better informed about HPV-related health topics. The facts that parents, who are key decision makers in the uptake of this vaccine, are still hesitant to have their daughters receive HPV vaccine, and that strategies to ensure optimal HPV vaccine uptake need to be employed have been recently reported in a population-based evaluation in British Columbia, Canada . In our Among the students, about 70% of the females and 50% of the males had ever heard of HPV, and about 75% of the former and 66% of the latter know about the aim and mode of HPV vaccination. The data from other studies are mixed ,31-34. AHowever, although our findings indicated a better knowledge of HPV among students, it is of concern that only 45% of the female teenagers perceived themselves at risk of HPV infection. This might be explained by a lack of awareness of the high prevalence of HPV infection ,35, as hWe found that the attitude of both parents to vaccinations was very positive, not only because the overwhelming majority were in favour of vaccination in general, but also because about two-thirds said they were in favour of a new vaccination against HPV, even though complete data on the vaccine are not yet available. Fewer than 7% of the parents declared they were certainly against the vaccination, and similarly encouraging results were found among the female students. It is interesting to note that 47% of the parents named pediatricians as their preferred counsellor in the case of decisions concerning vaccinations, and 65% of those with children aged aged <12 years. The recommendation of other physicians (mainly family doctors) was important for 26%, and so these might also play a major role in decision making. In agreement with previous studies -45, thesAnother finding was that parents consider the indications of the Ministry of Health (48%) rather than Regional institutions (about 3%) as a reference for decision making. This highlights the fact that the general population does not realise that recommendations concerning vaccines (and the availability of free vaccinations) is determined not centrally but at Regional level in Italy.The main factors associated with the parents' propensity to accept HPV vaccination were: 1) having at least one daughter; 2) being in favour of vaccinations in general; 3) knowing that the vaccine is aimed at preventing cervical cancer; and 4) being aware that their children could be infected by HPV (this association was particularly strong). As also found by other studies -49, therIn addition to their awareness of possible HPV infection, a few other factors were also associated with the propensity of students to undergo vaccination. In particular, having a boyfriend or having already had sexual intercourse were associated with a decreased propensity among female students, possibly because of the high proportion who knew the vaccination should be given before the start of sexual activity. However, this highlights the need for a training programme focused on the epidemiology of HPV infection in different age groups and the risk factors associated with acquiring it, in order to show that vaccination can also be useful even after the beginning of sexual activity provided that the infection has not already been acquired.The limitations of this study include the fact that our sample was not representative of the general Italian population, recruitment was limited to one Italian Region, a convenience sample of schools was selected and mainly upper-middle class population was included. Though the proportion of respondents to the survey was satisfactorily high, those with higher knowledge and interested by HPV-related health problems were more likely to participate in the study. These considerations are reflected by the high level of education of parents  and larIn conclusion, our data highlight the fact that a better understanding of HPV infection and the possibility of preventing cancer by means of HPV vaccination could increase the acceptance of vaccination by both students and parents. This underlines the need to plan adequate educational programs. Moreover, as physicians (both pediatricians and family physicians) can play a critical role in counseling, their knowledge of HPV infection and its prevention should also be evaluated and improved if necessary.CI: confidence interval; HPV: human papillomavirus; OR: odds ratio.The authors declare that they have no competing interests.CP, created the database and wrote the manuscript. SE, designed the study and co-wrote the manuscript. CG, performed the statistical analysis. MS, CS, IP, SC, and GM, explained and collected the questionnaires. NP, designed the study and co-wrote the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/378/prepubThe student questionnaire. Questionnaire for the adolescents concerning their knowledge on human papillomavirus infection and its prevention.Click here for fileThe parent questionnaire. Questionnaire for the parents concerning their knowledge on human papillomavirus infection and its prevention.Click here for file


Virtually all cases of cervical cancer and its precursor intra-epithelial lesions are a result of infection with one or other of a subset of genital human papillomaviruses (HPVs), suggesting that prevention of HPV infection by prophylactic vaccination would be a highly effective anticancer strategy. Two HPV L1 virus-like particle vaccines have been developed, a quadrivalent HPV16/18/6/11 product and a bivalent HPV16/18 product; both have been shown to be highly immunogenic with a good safety profile and 100% efficacy against HPV16/18-related high-grade cervical intra-epithelial neoplasia (CIN2/3), implying that they will be effective at preventing HPV16/18-related cervical cancer. Papillomaviruses are a large family of small, double-stranded DNA viruses that cause benign epithelial proliferations or warts in the natural infection. These viruses have two key characteristics; first they are absolutely host-specific, thus rabbit viruses only infect rabbits, dog viruses only infect dogs, human papillomaviruses (HPVs) only infect humans, secondly they are tissue-specific, a complete infectious cycle occurs only in a fully differentiating keratinised squamous epithelium. The HPVs are a very large family, classified by genotype (DNA sequence) not by serotype. To date, at least 200 HPVs have been isolated from tissue biopsies and, of these, approximately 100 have been fully sequenced. Despite their very large numbers, HPVs can be classified into two large groups: those that infect skin, or cutaneous surfaces, and those that infect the internal wet-squamous mucosal surfaces. Within these groups there are low-risk types, which generate benign lesions, in other words, warts, and high-risk or oncogenic types, which are associated with cancers and their precursor lesions.This is particularly apparent in the genital tract, where approximately 40 HPV types regularly or sporadically infect the mucosal epithelial surfaces. Low-risk HPV types, HPV6 and 11 cause more than 90% of genital warts with minor types  and some high-risk HPVs contributing to about 10%. Oncogenic HPVs in the genital tract are dominated by HPV16 and HPV18 which, with their close relatives, 31, 33, 35, 52, 58, 39, 45, 59, 56, 66 and 51, are the cause of cervical cancer . HPV16 iThe natural history of cervical intraepithelial neoplasia CIN is, in effect, the natural history of HPV infection in the cervix. Transient genital HPV infections, both of high- and low-risk HPVs, are very common in young sexually active women with the lifetime risk for acquiring a genital HPV infection in the UK of the order of 70 to 80%. Most of these infections are transient and resolve. If lesions develop, they are low-grade CIN1 and represent the infectious cycle of the virus and are, in fact, flat papillomas. However, a fraction of infected women (approximately 10 to 15%) develop persistent HPV infection, and fail to clear virally infected cells possibly because of the failure to develop a strong cell-mediated immune response to HPV early proteins. These persistent infections with oncogenic HPVs are at risk for progression to the high-grade precursor lesion CIN2/3 and approximately 30 to 40% of CIN2/3 then progress on to invasive carcinoma , and Gardasil™ also know as Silgard, a quadrivalent HPV16/18/6/11 vaccine from Merck Vaccines  . AlthougThe assumption is that the neutralising antibody to L1 generated by VLP vaccines or, after exposure to virus in natural infections, provides protection but what is the evidence to support this? The most convincing evidence is from preclinical experiments in dogs and rabbits, in which passive transfer of purified immunoglobulin-G from hyper-immune donors immunised with CRPV L1 VLPs, or dogs after spontaneous regression of canine oral papillomavirus (COPV), completely protected the naïve rabbit or dog recipient from challenge with high viral innocula  although manufacturers have declared their willingness to tier prices for countries of different economic settings. The price at which the vaccine is available is almost certainly going to be a major determinant of the cost and affordability of any vaccine programme. Universal programmes for delivering health care to preadolescents are rare in the developing world, so the costs of establishing and maintaining a new system for HPV vaccination are likely to be considerable. Furthermore, social and cultural values in many countries will make vaccination of female adolescents extremely difficult. Infant vaccination reaches more than 70% of children in the world even in the poorest countries and realistically if HPV vaccines are to be delivered in such settings then it will be as infant vaccines. However, immunogenicity-bridging trials to support this have not been implemented.An important issue is whether the L1 vaccines will both be, and remain, efficacious in immunocompromised subjects particularly those who are HIV infected. In developing countries, there is limited access to effective antiretroviral therapy raising questions of safety, immunogenicity and the induction of effective immune memory in such individuals. Clinical trials in HIV-infected individuals are underway but no data are available as yet, although one might predict that limited protection will be achieved in individuals with low T-cell counts.The HPV L1 VLP vaccines are immensely important developments in public health and the benefits that they promise are immense, offering the opportunity to prevent, in the long term, 80% of cervical cancers, 60% of vulval and 90% of anal cancers in women. They will impact significantly in the short to medium term on the incidence of high-grade CIN reducing the number of women who have to undergo large loop excision of the transformation zone (LLETZ) and economically, in the long term, they will reduce health-care costs. But the overwhelming benefit is the major improvement for human health and well-being of women everywhere.


This study investigated regional variations in the contribution made by different human papilloma (HPV) types to invasive cervical cancer (ICC). A total of 85 studies using polymerase chain reaction to estimate HPV prevalence in ICC were identified. Data on HPV prevalence were extracted separately for squamous cell carcinoma (SCC) and for adeno- and adenosquamous-carcinoma (ADC). A total of 10 058 cases  were included in pooled analyses. The most common HPV types in ICC were, in order of decreasing prevalence, HPV16, 18, 45, 31, 33, 58, 52, 35, 59, 56, 6, 51, 68, 39, 82, 73, 66 and 70. In SCC, HPV16 was the predominant type (46–63%) followed by HPV18 (10–14%), 45 (2–8%), 31 (2–7%) and 33 (3–5%) in all regions except Asia, where HPV types 58 (6%) and 52 (4%) were more frequently identified. In ADC, HPV prevalence was significantly lower (76.4%) than in SCC (87.3%), and HPV18 was the predominant type in every region (37–41%), followed by 16 (26–36%) and 45 (5–7%). The overall detection of HPV DNA was similar in different regions (83–89%). A majority of ICC was associated with HPV16 or 18 in all regions, but approximately a quarter of all ICC cases were associated with one of 16 other HPV types, their distribution varying by region. Epidemiological studies have clearly established human papilloma-virus (HPV) infection as the central cause of invasive cervical cancer (ICC). This is the second most common cancer among women worldwide and the most common female cancer in large areas of the developing world where an estimated 80% of new cases arise  types, are significantly associated with progression to ICC . The review was limited to studies that included a minimum of 20 ICC cases; carcinomas in situ were excluded. Studies had to provide a clear description of the use of PCR-based assays to identify HPV DNA. Studies using nonamplified hybridisation methods only were excluded based on the reduced sensitivity of such methods in comparison to PCR  and PCR primers used to detect HPV positive samples; type-specific and overall prevalence of HPV infection. Where available, data on HPV-specific prevalence were extracted independently for squamous cell carcinoma (SCC) and for adeno- and adenosquamous carcinoma (henceforth collectively termed ADC). Where histology-specific HPV prevalence was not reported, cases were classified as being of ‘unspecified’ histology. Each study was classified into one of five geographical regions: Africa, Asia, Europe, North America and Australia, or South and Central America. For studies comparing HPV prevalence across regions . Three studies were conference abstracts containing the detailed information required for inclusion  were separated into constituent types, thus type-specific prevalence represents that in either single or multiple infections. Cases with specimens considered to be inadequate for PCR testing were excluded. Type-specific prevalence is presented for the 18 most common HPV types as identified by this review  in order of descending prevalence for each subgroup analysis. Consensus PCR primers My09/11 . DNA detection in ICC of unspecified histology (89.2%) was similar to that in SCC.Adjusted overall HPV prevalence ranged from 79.3% in Asia to 88.1% in North America and Australia, but did not differ significantly between regions  than from studies testing either cervical exfoliated cells (78.9%) or fixed biopsies (83.3%) only. For PCR primers, highest HPV prevalence was obtained in studies using SPF10 primers (97.2%) and the lowest in studies using type-specific PCR (TS-PCR) only (74.7%). Adjusted overall HPV prevalence varied between 77.8 and 90.1% for other primer sets, but these differences were not statistically significant.P<0.001). The same was found for the HPV16 phylogenetically related types 31, 33, 52 and 58 (P<0.001), but not 35. Conversely, HPV18 was more prevalent in ADC (37.7%) than in SCC (12.3%) (P<0.001). The HPV18 phylogenetically related type 45 was also more prevalent in ADC (5.8%) than in SCC (3.4%) (P=0.04).Owing to their similar overall and type-specific HPV prevalence, ICC of unspecified histology were combined with SCC for comparison of HPV type-specific prevalence by histological type  were all less prevalent in ADC cases than in SCC cases from each region.Sufficient ADC-specific data existed for the comparison of HPV-specific prevalence across Asia, Europe and North America and Australia  or 18 (16.2%) infection. However, more than 16 other HPV types were also associated with ICC, of which the most prevalent were types 45, 31, 33, 58 and 52 (collectively accounting for 18.3% of cases). The HPV16 family of viruses were more commonly found in SCC than ADC, whereas the HPV18 family were more common in ADC.Overall detected HPV prevalence varied little between geographical regions (83–89%), but was low compared to the almost 100% HPV prevalence identified in studies using the most sensitive HPV detection methods  and fourth (9%) most common genotypes in ICC  and Asia (30.7%) in this study under-represent their proportional burdens of worldwide cervical cancer, which are 14.1 and 49.4%, respectively  by weighFurthermore, the cases in this meta-analysis were not drawn uniformly from across each region. Large areas have not been included , while other specific populations such as Japan in Asia are over-represented. There is also evidence of inter-regional variation in HPV-type distribution; the high prevalence of HPV52 and 58 in Asia is more apparent in cases from China/Korea/Japan than in those from South East Asia. Hence, for the comparison of alternative regional groupings, HPV-specific prevalence is presented by study in the Given that HPV is considered a virtually necessary cause of ICC, we further examined results restricted to HPV DNA-positive cases. This increased type-specific prevalence by a factor of ≈1.1 consistently for each HPV type, with no impact on the relative distribution of HPV types. However, given that many of the PCR systems used by the included studies amplify only a subset of HPV types, many HPV-‘negative’ cases may actually be infected with other, unascertained, HPV types. Thus, we did not consider it appropriate to restrict to HPV-positive cases when comparing type-specific prevalence across studies where PCR methodology differed considerably.However, in order to make a broad overall estimate if one does assume that, HPV DNA should be detectable in 100% of ICC and that the distribution of undetected types in HPV-negative cases is similar to that in positive cases, this meta-analysis suggests that vaccinating against HPV16 and 18 should prevent over 70% of worldwide ICC. However, a worldwide vaccine against only HPV16/18 may prevent a larger proportion of ICC in Europe, North America and Australia (≈75%), than in Africa, Central and South America and Asia (59–64%), where a larger proportion of ICC cases were associated with other HPV types. Although this study identifies at least 18 HPV types associated with ICC from around the world, the most important type after HPV16 and 18 appears to be HPV45, followed by types 31, 33, 58 and 52, the relative importances of which vary by region.


Cervical cancer and infection with human immunodeficiency virus (HIV) are both important public health problems in South Africa (SA). The aim of this study was to determine the prevalence of cervical squamous intraepithelial lesions (SILs), high-risk human papillomavirus (HR-HPV), HPV viral load and HPV genotypes in HIV positive women initiating anti-retroviral (ARV) therapy.A cross-sectional survey was conducted at an anti-retroviral (ARV) treatment clinic in Cape Town, SA in 2007. Cervical specimens were taken for cytological analysis and HPV testing. The Digene Hybrid Capture 2 (HC2) test was used to detect HR-HPV. Relative light units (RLU) were used as a measure of HPV viral load. HPV types were determined using the Roche Linear Array HPV Genotyping test. Crude associations with abnormal cytology were tested and multiple logistic regression was used to determine independent risk factors for abnormal cytology.3, 66.3% had an abnormal Pap smear, the HR-HPV prevalence was 78.9% (Digene), the median HPV viral load was 181.1 RLU (HC2 positive samples only) and 78.4% had multiple genotypes. Among women with abnormal smears the most prevalent HR-HPV types were HPV types 16, 58 and 51, all with a prevalence of 28.5%. On univariate analysis HR-HPV, multiple HPV types and HPV viral load were significantly associated with the presence of low and high-grade SILs (LSIL/HSIL). The multivariate logistic regression showed that HPV viral load was associated with an increased odds of LSIL/HSIL, odds ratio of 10.7 (95% CI 2.0 – 57.7) for those that were HC2 positive and had a viral load of ≤ 181.1 RLU , and 33.8 (95% CI 6.4 – 178.9) for those that were HC2 positive with a HPV viral load > 181.1 RLU.The median age of the 109 participants was 31 years, the median CD4 count was 125/mmWomen initiating ARVs have a high prevalence of abnormal Pap smears and HR-HPV. Our results underscore the need for locally relevant, rigorous screening protocols for the increasing numbers of women accessing ARV therapy so that the benefits of ARVs are not partially offset by an excess risk in cervical cancer. Cervical cancer and infection with human immunodeficiency virus (HIV) are both important public health problems in South Africa (SA). Among South African women cervical cancer is the second commonest cancer, with an age standardized incidence rate of 30 per 100 000 per year, and is the leading cause of cancer mortality . StudiesHighly active antiretroviral therapy (HAART) has been shown to decrease HIV viral loads, increase CD4 cell counts and decrease most opportunistic infections. Since the introduction of HAART there has been a decline in certain malignancies in HIV infected individuals ,14. HoweA cross sectional survey was conducted at a public sector ARV treatment clinic in Cape Town, South Africa, between January and May 2007. Women, eighteen years and older, who were being considered for initiation of ARV therapy were informed of the study by the clinic staff. Those indicating interest were referred to the research nurse, who explained the details of the study and obtained informed consent. Women who had a hysterectomy, were menstruating or pregnant at the time of the study were excluded. The research nurse collected data on socio-demographic status, sexual behavior, history of a sexually transmitted infection (STI), obstetric and gynaecology history and risk factors for cervical cancer using a structured questionnaire; conducted a pelvic examination; took a Pap smear using a cytobrush and collected cervical samples for HPV testing with Digene cervical samplers. The samples for HPV testing were stored in Digene transport medium at -80°C until required. CD4 count data were extracted from clinical records. Pap smears were interpreted at the South African National Health Laboratory Service and classified according to the Bethesda classification system . Women wData analysis was conducted using the statistical program STATA 9.0 . Descriptive statistics (medians and proportions) were used to characterize the variables. Basic crude associations with abnormal cytology were tested using Wilcoxon Rank Sum tests for medians and Chi-square and Fischer's Exact tests for proportions. Multivariate logistic regression was carried out to determine independent risk factors for low-grade squamous intra-epithelial lesions (LSILs) and high-grade squamous intra-epithelial lesions (HSIL). To avoid co-linearity in the model between HPV infection measured by the HC2 test and HPV viral load, we derived categories of HPV infection as follows: HPV HC2 negative as the referent group and HPV HC2 positive in categories according to the median viral load. Other variables included in the model are known to be associated with cervical abnormality and were: age, number of sexual partners, age at first sexual intercourse and CD4 count. Median values were used as cut-offs to categorize these variables. Ethical approval was granted by the Research Ethics Committee of the University of Cape Town.A total of 120 women were referred by clinic staff to participate in the study. Nine women were excluded because they were menstruating and two declined to participate because of time constraints. In total 109 women were included in the study. The socio-demographic and reproductive characteristics for the overall study population and according to cervical cytology results are presented in Table Overall the median age was 31 years (range 20 – 60 years). The majority of women were unemployed (80.7%), just under half (47.7%) were either married or in a stable relationship and most participants had attended high school (median of 10 years of schooling). There were no significant socio-demographic differences between women with normal/ASCUS Pap smears and women with LSIL/HSIL Pap smears.3 (range 14.0 – 1047.0/mm3), with no significant difference in the median CD4 count between women with normal/ASCUS Pap smears and women with LSIL/HSIL Pap smears.The majority of the participants (55.0%) were currently on contraception (data not shown). Of these, 40% were using condoms only, 28% condoms and another contraceptive method, 23% injectable contraception, 2% oral contraception and 6% another method. There was no significant difference in contraceptive use between women with a normal/ASCUS Pap smear and those with a LSIL/HSIl Pap smear. Most women reported having had an STI (84.4%). Of these 27.1% gave a history of having an STI in the preceding week. The median CD4 cell count was 125.0/mmWomen with LSIL/HSIL Pap smears had a significantly higher prevalence of HR-HPV compared to those with normal/ASCUS Pap smears on both the Digene (95.9% vs. 58.3% and Roche assays (100% vs. 77.1%), had a higher median HPV viral load (444.1 vs. 60.3 RLU) among those with HC2 positive samples and a higher prevalence of multiple HPV types present (91.8% vs. 62.2%). Of the 109 participants: 85 tested positive on both the Roche Linear Array and Digene HC2 tests, 12 were positive on the Roche but negative on the Digene test, 11 were negative on both tests and 1 was negative on the Roche test but positive on the Digene test. The prevalence of HR-HPV using the Digene test was 78.9% (95% CI 69.8% – 85.9%) and using the Roche Linear Array HPV Genotyping test the prevalence of HR-HPV was 89.0% (95% CI 81.20 – 93.93).The estimated median HPV viral load was 64.8 RLU for all samples that had HC2 testing and 181.1 RLU for those that samples that were HC2 positive based on the 1.0 pg/ml clinical cut-off point. Table When stratified by CD4 count category, median HPV viral loads were as follows: for those with CD4 < 100 (N = 38), median HPV viral load = 23.5 RLU; CD4 ≥100 < 200 (N = 63), median HPV viral load = 97.3 RLU and CD4 ≥200 (N = 8), HPV viral load = 8.9 RLU. The correlation between log CD4 load and log HPV viral load was not significant (correlation coefficient r = -0.005)On Roche Liner Array testing a total of 35 HPV genotypes were detected in the 109 women. The median number of HPV types per woman was 3 (range 0 – 12), with multiple genotypes (≥2 types) being detected in 69.7% of all participants and in 78.4% of participants with a positive HC2 test. Figure Multivariate logistic regression was carried out to determine independent risk factors for HSIL/LSIL. The model showed that HPV viral load was associated with an increased odds of LSIL/HSIL. The odds of LSIL/HSIL was 10.7 (95% CI 2.0 – 57.7) for those that were HC2 positive and had a viral load of ≤ 181.1 RLU , and for those that were HC2 positive with a HPV viral load > 181.1 RLU the odds was 33.8 (95% CI 6.4 – 178.9). The odds ratio (OR) for LSIL/HSIL for the other variables were as follows: age OR = 0.94 (95% CI 0.36 – 2.45), number of sexual partners OR = 0.88 , and CD4 count OR = 1.11 (95% CI 0.42 – 2.96).Our study of women initiating ARV therapy recorded an exceptionally high prevalence of cervical abnormalities (66%). This is much higher than that recorded in studies conducted among HIV positive women in developed countries ,10,19-21HR-HPV was present in 79% (Digene) of the women in our study. This is amongst the highest HR-HPV prevalence recorded in the literature ,24 and iClifford et al have shown that there is considerable variation in regional HPV type distribution . In our The small sample size limited our power to assess the association between LSIL/HSIL and potential predictors. A strong association between HIV viral load and cervical abnormalities has been demonstrated in other studies ,20,37. WIn summary, women initiating HAART in SA have an extremely high prevalence of abnormal Pap smears and HR-HPV and this has major health planning and resource implications. It is critical that we develop locally relevant, rigorous screening protocols for the increasing numbers of women accessing ARV therapy. Further studies are needed to explore the predictive role of HPV viral load using higher cut-off points in HIV-positive women.The authors declare that they have no competing interests.JM was involved in designing the study and in the data analysis, and drafted the manuscript. DC was involved in proposal writing and responsible for detailed data analysis. MH was involved in proposal writing, supervision of field staff and data analysis. AS carried out the HPV typing assessments and was involved in aspects of the data analysis. BA carried out the viral load assessments and was involved in data analysis. ER was involved in HPV typing assessments and aspects of data analysis. IH was involved in HPV typing assessments and aspects of data analysis. AW was involved in proposal writing, was responsible for virological assessments and involved in aspects of data analysis. All authors and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/9/275/prepub


TERC, which maps to chromosome band 3q26, was determined in primary cervical adenocarcinomas. Interphase nuclei prepared from archival material of 12 primary cervical adenocarcinomas, eight of which were human papillomavirus positive, were hybridised with a triple colour probe set specific for centromeres of chromosomes 3 and 7 and the TERC gene. We observed high proportions of nuclei with increased absolute copy numbers for TERC in all tumours . Amplification of the human telomerase gene TERC is a consistent aberration in cervical adenocarcinomas. Therefore, application of our probe set may provide an objective genetic test for the assessment of glandular cells in Pap smears and hence for the diagnosis of cervical adenocarcinomas.The level of genomic amplification of the human telomerase gene  Cervical cancer is a disease that mainly affects women in the forth or fifth decade of life. According to the International Agency for Research on Cancer (IARC), it is the second most common cancer in women worldwide, and in developing nations it is the most common cancer in women ; howeverEpidemiological and molecular biological studies have shown that infection with high-risk human papillomavirus (HPV) is an important aetiological agent in the pathogenesis of cervical adenocarcinoma . More thTERC is almost invariably found in Pap smears assessed as HSIL . In addition, a more recent study unambiguously established the central role of 3q for progression from low-grade dysplastic lesions to higher grades and to invasive carcinomas and showed that the gain of 3q can occur in morphologically normal Pap smears of women who developed cervical carcinomas after only a short latency  on cytospins prepared from single-cell suspensions of disintegrated archival paraffin-embedded tissue and correlated the findings to the presence of HPV infection and the clinical course.In this study, we have determined The study includes formalin-fixed paraffin-embedded tumour tissue specimens from 12 primary cervical adenocarcinomas diagnosed and surgically treated at the Karolinska University Hospital-Huddinge during 1992–2000 . All tumThe clinical information for each case is detailed in www.ncbi.nlm.nih.gov/BLAST). Eight of the 12 tumours were thus found to be HPV-positive; five tumours were infected with HPV 18, two with HPV 16 and one with HPV 45  at 45°C for 45–60 min. The reaction was stopped by adding 500 μl 1 × PBS at room temperature. The sample was then filtered through a nylon membrane , centrifuged and resuspended in 1 × PBS. Cytospin slides were prepared using a Shandon Cytospin® centrifuge and fixed in an ethanol series.Single-layer nuclei preparations for interphase FISH hybridisations were prepared using the Hedley method with modifications . The details for this probe set, its sensitivity and specificity, as well as experimental conditions were published previously (TERC contig with Spectrum Orange™ (SO), using chemical labelling as described ; a centromere-specific probe for chromosome 3 (CEP3) and a contig consisting of four overlapping BAC clones containing the in situ hybridisation and image analyses were carried out using a Leica DM-RXA fluorescence microscope  equipped with custom optical filters for DAPI, SA, SG and SO  and × 40 Plan Apo (NA 1.25) objective. Images were taken in areas of optimal cell density with minimal cellular clumps using an ORCA ER (IEEE1394 I/F) digital camera . Leica Q-Fluoro was used to acquire multifocus images for each of the DAPI, SA, SG and SO optical filters. Ten to 16 images were acquired and signal enumeration was performed on these digital images for 208–641 nuclei for each case. The counted signals were listed and evaluated in Excel-based customised software.Fluorescence TERC in a given nucleus. Nuclei with normal signal numbers for the three probes  were recorded as ‘diploid’, and nuclei with four signals for each probe (pattern 4-4-4) were considered ‘tetraploid’. The background level for the CEP7–CEP3–TERC probe panel was previously evaluated on cytological slides that contained nuclei from normal cervical cells  were excluded from further analysis. The results for all ‘countable’ nuclei were registered in relocation charts in the form of patterns for the entire probe panel. For example, the pattern (2-3-3) refers to two signals for CEP7, three signals for CEP3 and three signals for TERC locus at chromosomal band 3q26 using interphase FISH. The three-colour probe panel consisting of CEP7-CEP3-TERC was simultaneously hybridised to cytospin slides with interphase nuclei prepared from formalin-fixed tissue sections. All cases were successfully hybridised and analysed, whereby 208–641 nuclei per case were scored. TERC signals were found in similar frequencies as cells with ‘nondiploid’ pattern, and almost all nuclei with ‘nondiploid’ pattern exhibited >2 TERC signals. In the ‘nondiploid’ nuclei, a ‘tetraploid’ pattern (4-4-4) was not commonly observed. In 10 of the tumours, less than 1% of the nuclei exhibited (4-4-4) and in two cases (4-4-4) was seen in 4 and 12%, respectively  and 5.2 (case 10), and in five of the tumours nuclei with more than 10 signals were repeatedly encountered  as well as HPV-negative (86–99%) tumours. The absolute numbers of TERC signals per nucleus were similarly increased in HPV-positive  and HPV-negative  tumours. No apparent associations between TERC copy numbers and clinical characteristics, such as age at diagnosis, stage, differentiation, lymph node involvement or outcome at follow-up, were noted. Thus, gain of TERC is characteristic of cervical adenocarcinomas per se.The clinical and follow-up information as well as HPV status of the 12 cervical adenocarcinomas are provided in TERC, which maps to chromosome band 3q26. Eight of the 12 carcinomas (67%) were HPV-positive  (TERC) to assess the potential of this genetic marker to ameliorate the morphological diagnosis of cervical adenocarcinomas. This is the first study that reports the consistent gain of the human telomerase gene TERC in cervical adenocarcinomas.In our study, we analysed a series of 12 primary cervical adenocarcinomas for gain or amplification of the human telomerase gene in situ hybridisation, of course, detects changes on a single-cell basis and is therefore not sensitive to dilution. Additionally, small regional low-copy number amplicons might escape detection by CGH.In our study, HPV infection was not detected in four of the cases, which could either reflect true HPV negativity or represent ‘false negatives’ owing to technical difficulties in HPV genome detection. In the current literature, HPV infection has not been reported in the same proportion in adenocarcinomas as in squamous cervical carcinomas , we showed high copy numbers of this locus in cervical adenocarcinomas. Gain or amplification of 3q was found in all cervical adenocarcinomas investigated. Therefore, the application of this probe set may provide an objective genetic test for the diagnosis of cervical adenocarcinomas and might assist in the interpretation of smears with a high degree of glandular cells.Cervical squamous cell carcinomas are defined by a nonrandom and recurrent distribution of genomic imbalances. In addition to HPV, the sequential transformation of cervical squamous epithelium requires the acquisition of additional copies of chromosome arm 3q. In the current study, we wanted to analyse and understand whether the gain of 3q plays a similar role in the tumorigenesis of cervical adenocarcinomas. Using a genomic probe for the TERC gene amplification is able to distinguish normal epithelium and low-grade dysplasia from the group of high-grade lesions with high specificity and sensitivity. In another paper, the same group showed that gain of TERC was found in 33% of cytological normal Pap smears from women who developed carcinoma in situ or invasive cervical squamous cancer in the future (TERC probe panel (CEP7–CEP3–TERC) eventually regressed to normal Pap smears, whereas the CIN1/CIN2 lesions with TERC amplification progressed. Lesions with a tetraploid pattern for the panel  could develop either way. The author concluded that the detection of gain and amplification of TERC in routinely collected Pap smears can assist in identifying lesions with a high progression risk. As the results of the current study indicate, TERC appears to play a similar important role in the carcinogenesis of cervical adenocarcinomas. Interestingly, even the patterns of gain found in the adenocarcinomas are very comparable to the patterns found in cervical dysplasias of squamous cell type . Given the similarity to the results of the studies of TERC in cervical squamous cell lesions, it seems to be a distinct possibility that analysis of TERC gain may also help to find women at risk for developing adenocarcinoma. An objective molecular marker in this patient group is of extreme importance because of the cytomorphologically difficult identification of these cells and the limited numbers of representative cells owing to technical problems in sampling these lesions. As shown in our study, many women with cervical adenocarcinoma presented with morphologically normal Pap smears, often only 1–2 years before diagnosis. A marker like TERC could have considerable impact on the detection of cervical adenocarcinomas at an earlier stage. Fluorescence in situ hybridisation analyses of precursor lesions, that is, adenocarcinomas in situ and dysplasias will be the next step to verify the potential of TERC as a marker of early detection and progression in cervical adenocarcinomas. We are therefore planning to conduct both retrospective studies with archival Pap smears and prospective randomised studies with routinely collected Pap smears.ell type . The mos


A series of 257 cases of carcinoma of the male breast in Denmark has been examined with a view to establishing the factors which might influence the prognosis. Observed and corrected 5-year survival rates of 36% and 46% respectively correspond well with the results in other series. Expressed by corrected survival rate, the prognosis appears to be somewhat more favourable during the period 1958-71 than during the period 1943-57. This improvement of prognosis can be related to a significantly better clinical stage of advancement during the latter period. Comparison of the 5-year corrected survival rates in series of male and female breast cancer shows that the prognosis in male breast cancer is not much worse than the prognosis in females. It has been proved that the duration of disease, the clinical stage and the histological degree of malignancy influence the prognosis considerably. The therapeutic results in our series correspond well with the results found in other series. We did not find any evidence to indicate that it would be better to carry out radical mastectomy than to do simple mastectomy since radical mastectomy has not given consistently better results. It is recommended that treatment of this rather uncommon disease be centralized as far as possible.


Human papillomavirus (HPV) type 16 and 18 viral genomes are frequently detected in cervical and penile cancer biopsies. Although this strongly suggests a prominent role for HPV infection in the development of genital cancer, other genetic or environmental factors are also involved. Genital cancer is postulated to result from loss of cellular control functions, which leads to an unregulated expression of HPV oncogenic proteins. In our study, we determined the trans-activating properties of nuclear proto-oncogene proteins c-Fos, c-Jun and c-Myc on P97 enhancer/promoter activity of HPV16. Using a CAT-reporter construct containing the HPV16 enhancer/promoter element, we investigated the trans-activating effects of c-Fos, c-Jun, c-Myc, and E2 in cervical HT-3 cells. c-Fos and c-Jun overexpression resulted in a 3.3- and 3.1-fold up-regulation of CAT activity. Only 2-fold induction was determined by co-transfection with c-myc and the viral transcription factor E2. Based on these findings, we investigated the expression of HPV DNA (16 and 18) as well as nuclear proto-oncogenes  in nine cervical cancers by in situ hybridisation. In six out of nine carcinomas, HPV16 and/or HPV18 DNA was detectable. All tumours showed an intense and homogeneous expression of c-fos and c-jun mRNA, while the signal for c-myc was detectable only in four specimens. These data suggest that deregulation of nuclear proto-oncogene expression may contribute to an overexpression of HPV-derived oncogenic proteins (E6 and E7), which is generally hypothesised to be an important step in the malignant transformation of HPV-associated tumours.


Background. HPV types vary by country and HIV status. There are no data on the prevalent HPV genotypes from Cameroon. Methods. We conducted a cross-sectional, observational study on 65 Cameroonian women. Samples were sent for HPV genotyping and Thin Prep analyses. Results. 41 out of 61 samples tested (67.2%) had HPV subtypes detected. The most common high risk types encountered were: 45 (24.6%) and 58 (21.5%). HIV-positive women were more likely to test positive for any HPV (P = .014), have more than one HPV subtype (P = .003), and to test positive for the high risk subtypes (P = .007). Of those with high risk HPV, HIV-positive women were more likely to have Thin Prep abnormalities than HIV-negative women (P = .013). Conclusions. Oncogenic HPV subtypes 45 and 58 were more prevalent than those subtypes carried in the quadrivalent vaccine. Further studies are needed to assess whether the current vaccine will be effective in this region. Cervical cancer is the second most common cancer in women worldwide, but it is the first in most developing countries, where 80% of cases occur  and onlyThere are at least 15 high-risk (oncogenic) subtypes of HPV . OverallHPV genotypes, however, differ greatly in their geographic distribution. In sub-Saharan Africa, for instance, where two thirds of the world's HIV-infected population live, HPV types vary by country and HIV status and differ significantly from HPV types seen in other regions of the world, possibly in part due to geographic and genetic variation in HLA haplotypes –15. MultThis pilot study seeks to describe the prevalence of HPV genotypes in HIV-positive and HIV-negative fertile Cameroonian women, to determine risk factors for HPV utilizing a culturally appropriate questionnaire and to assess the association of HPV types, squamous intraepithelial lesions (SIL), HIV, and other reproductive tract infections.This study was approved by both the institutional review board of Meharry Medical College and the Cameroon Baptist Convention Health Board (CBCHB). Between June 2005 and March 2006 sixty-five women age eighteen and over were enrolled from two CBCHB clinical sites Baptist Hospital Mutengene and Etoug-Ebe clinic in Yaounde. Women were recruited from both antenatal clinics and existing HIV positive women's support groups. Women were excluded if they had never been pregnant, had a hysterectomy, were in active labor, had abnormal bleeding, had placenta previa, or were unwilling to undergo HIV testing. The study was explained to patients either in English, French, or Pidgin English. Similarly, informed consent was obtained in English or French by clinic nurses or midwives.Participants were then asked to complete a questionnaire designed to elicit demographic characteristics, obstetric, contraceptive and sexual history, and current genital tract symptoms. General, pelvic, and speculum examination and sample collection were performed. Only support group mothers also underwent bimanual exams. Women, and their partners if necessary, were treated free of charge for reproductive tract infections (RTIs) when clinically indicated in accordance with World Health Organization published guidelines . ParticiAn ophthalmic sponge, Zyomed Treace , was placed directly into the cervical os. The spears were allowed to absorb cervical secretions for approximately 30 seconds after which time they were placed in an eppendorf tube and immediately placed on ice, before they were transported on dry ice to the University of South Dakota for possible later cytokine analysis under the direction of Dr. Delf Schmidt-Grimminger.After introduction of a clean, nonlubricated speculum, the endocervical secretions were collected as previously described in  with an Next, a sample for HPV testing was collected with a cervical brush or Dacron swab, placed in a Specimen Treatment Medium , and sent to the South Dakota Health Research Foundation at the University of South Dakota, where the HPV typing proceeded under the direction of Dr. Delf Schmidt-Grimminger. An aliquot of the cervical sample was processed as described previously . BrieflyAll transported specimens were frozen at 0 degrees Celsius due to logistical problems and shipped at −20 C using dry ice according to international standards.T. vaginalis and bacterial vaginosis, and potassium hydroxide (KOH) prep for Candida. Bacterial vaginosis was defined as the presence of “clue cells”  constituting more than 20% of vaginal epithelial cells per high power field, and a pH of >4.5. All identified infections were treated free of charge according to WHO guidelines [Only if a patient complained of, or had signs of an abnormal vaginal discharge or pelvic infection, did we collect a vaginal pool specimen and place it in a test tube containing saline and send it to the on site lab to test for pH, wet saline preparation for idelines .All participants without documentation of HIV or syphilis tests within 6 months underwent testing after pretest counseling. A serial testing protocol of up to 3 rapid HIV tests was used to determine HIV status as previously described in . Our labP-values <.05 were considered significant.Data were analyzed using SPSS 15.0 . Simple frequency analyses, Fisher's exact test, and Chi-square tests were used. Sixty-five women were enrolled in the study, 36 in the antenatal group and 29 in the support group. The median age was 27 years in the antenatal group and 29 in the support group, respectively. 8.3% of the antenatal participants tested positive for HIV while 100% of the support group participants tested HIV positive. The women did not differ with respect to education, marriage status, husband's number of wives, age at sexual debut, or cell phone ownership which was used as a surrogate marker for income. However, over 50% of the antenatal participants reported never using condoms and over 80% reported never or only seldom using condoms during sex. Similarly, only 35% of known HIV positive women participants from the support group reported using condoms often .Overall, out of the 65 women who signed consent forms, 4 had no evidence of specimens in their transport media. 41 of the 61 samples tested 67.2%) had HPV subtypes detected. The most common low risk types detected out of all analyzed specimens were: 62 (20.0%), 11 (18.5%), 6 (15.4%), 70 (12.3%), and 61 (10.8%). The most common high risk types encountered were: 45 (24.6%) and 58 (21.5%). The data is presented by frequency of HPV type detected as a percentage of all women in the study (HPV positive and negative) as shown in Figures % had HPVThirty-five out of the 41 women (85.4%) who tested positive for HPV had more than one HPV subtype identified, while 32 out of 41 (78%) had at least one high risk subtype identified. Twenty-eight out of 41, or 68.3%, with HPV isolated had subtype 6, 11, 16, or 18 which are currently carried in the commercially available HPV vaccine. Those who tested positive for the high risk subtypes carried in the current vaccine (subtypes 16 or 18) totaled 7 out of 41, or 17.1% see .P-value defined as <.05. They were also more likely to have one of the HPV subtypes covered in the current quadrivalent HPV vaccine, although not when including subtypes 16 and 18 only.In comparing HIV-negative to HIV-positive participants, HIV positive women were more likely to have tested positive for any HPV, have more than one HPV subtype, and to test positive for the high risk HPV subtypes than their HIV-negative counterparts when analyzed using the Chi-Square statistic with a significant P-value for HIV positive .013, for HIV negative .235) , low grade squamous intraepithelial lesions (LGSILs), and high grade intraepithelial lesions (HGILs) represent increasing degrees of HPV-related cellular change and are precancerous lesions. Women who were HIV positive with high risk HPV were more likely than HIV negative women with high-risk HPV to have abnormalities on thin prep evaluation, even after controlling for the effect of high risk HPV on thin prep abnormalities using Chi-Square analysis (ve .235) . SurprisOur pilot study results add to a rich body of literature demonstrating that HPV types other than those included in the quadrivalent vaccine are being encountered in many African countries. In a recent international meta-analysis, including 5 African studies, Clifford et al. found that the proportion of HPV prevalence attributable to HPV-16 was lower in HIV-positive women, including those with HGSIL, than in the general population and that other high-risk types  were also prevalent , 27. MuñWe found that the known oncogenic subtypes 45 and 58 were significantly more prevalent than subtypes 16 and 18. With increasing numbers of HIV-infected women in sub-Saharan Africa now accessing life-prolonging antiretroviral therapy, these women may now live long enough to be at higher risk for developing cervical cancer , 34. OurWe noted a prevalence of HPV in our study of 67.2% with 85.4% having more than one HPV type and 78.0% having one of the high risk subtypes. This is at the higher end of previous comprehensive estimates in similar HIV-positive female populations , 38, 39 Although our study set out to determine possible interactions between HPV, HIV, and other reproductive tract infections, we were not able to accurately assess our participants for gonorrhea or chlamydia due to a delay in transferring the Thin Prep samples to appropriate testing media within 7 days, as is recommended by the manufacturer . However, we did not detect a significant number of syphilis, trichomonas, bacterial vaginosis, or vaginal candidiasis infections (data not shown). Our study is further limited by the small number of participants enrolled as it was designed as a pilot study.We were still able to demonstrate, however, that HIV-positive women are more likely to test positive for HPV, have more than one HPV type, and to be infected with high risk HPV than their HIV-negative counterparts. This may be explained by the impact of HIV on the host's immune system resulting in impaired HPV clearance, leading to chronic HPV infection. The higher number of HPV types encountered by the HIV-positive women in our study may be attributed to HIV-mediated upregulation and persistence of HPV –41 or reEven after controlling for the effect of high risk HPV on Thin Prep findings, HIV was still associated with ASCUS or LGSIL on Thin Prep analyses. We cannot explain why no participants demonstrated HGSIL, as previous studies from Senegal (11%) and Burkina Faso (3.8%) did demonstrate a significant number of HIV positive women with HR-HPV to have HGSIL , 38. ForOverall our pilot study includes Cameroon in the growing list of African countries where HPV types differ from those currently included in the prophylactic vaccine. With increasing numbers of women living with HIV longer, cervical cancer has the potential to increase in incidence and prevalence in countries such as Cameroon. Further studies are needed to assess whether the current vaccine will be effective in cervical cancer prevention programs in this region.


P-values between 0.0009 and 0.03). The proportion of HPV16 in hrHPV-positive infections also decreased with age , 95% CI=0.67–0.85), and a similar trend was observed for HPV16 when selecting hrHPV-positive women with cervical intraepithelial neoplasia grade 2 or worse (CIN2+) . In women eligible for routine screening (age 29–61 years) with confirmed CIN2+, 65% was infected with HPV16 and/or HPV18. When HPV16/18-positive infections in women eligible for routine screening were discarded, the positive predictive value of cytology for the detection of CIN2+ decreased from 27 to 15%, the positive predictive value of hrHPV testing decreased from 26 to 15%, and the predictive value of a double-positive test (positive HPV test and a positive cytology) decreased from 54 to 41%. In women vaccinated against HPV16/18, screening remains important to detect cervical lesions caused by non-HPV16/18 types. To maintain a high-positive predictive value, screening algorithms must be carefully re-evaluated with regard to the screening modalities and length of the screening interval.We determined the prevalence of type-specific hrHPV infections in the Netherlands on cervical scrapes of 45 362 women aged 18–65 years. The overall hrHPV prevalence peaked at the age of 22 with peak prevalence of 24%. Each of the 14 hrHPV types decreased significantly with age ( Infection with high-risk human papillomavirus (hrHPV) is the necessary cause of cervical cancer (n=44 102) participated in the POBASCAM study, a randomised controlled population-based screening trial evaluating the implementation of hrHPV testing in cervical screening (n=1109) or older than 61 years (n=151) obtained a cervical smear for opportunistic screening. All women underwent cytological testing as well as hrHPV testing. Women with abnormal cytology or cervical intraepithelial neoplasia (CIN) in the previous 2 years were excluded.Data from 45 362 Dutch women between 18 and 65 years of age were collected. Cohort participants were recruited from GP practices in the larger Amsterdam area between 1999 and 2002. Women between 29 and 61 years of age  were computed for all women and for women with normal cytology. Overall and type-specific hrHPV prevalences were related to age by logistic regression analyses. To obtain smooth functions of age, cubic splines with knots at age 30 and 50 years were used . The uncvs other types. Separate calculations were carried out for women without confirmed CIN2+ and women with confirmed CIN2+. This was carried out by hierarchically assigning women to (1) HPV16, (2) HPV18 without the presence of HPV16, (3) HPV31 or 45 without HPV16 or 18, or (4) none of the HPV types 16, 18, 31, or 45. This means that, for example, assignment to HPV16 was carried out independently of whether a woman was simultaneously infected with other HPV types. Analyses were repeated for women with single infections.With vaccination in mind, particular attention was paid to HPV types 16, 18, 31, and 45. Types 31 and 45 are of interest because vaccination against 16/18 may result in partial immunity for 31 and 45 through cross-protection . Notably, the double-positive test result is a prerequisite for colposcopy referral in a screening setting where cytology is used as a triage tool in HPV-positive women. The analyses were repeated for women without HPV16, 18, 31, and 45. The positive predictive values were adjusted for women who did not attend repeat screening by Kaplan–Meier estimation.P-values between 0.0009 and 0.03). Significance could also be demonstrated when selecting only those women with normal cytology.P<0.001). For HPV39 and HPV52, a marginal decrease with age was found as well . In the subset of women with confirmed CIN2+, the association between HPV16 and age was in the same direction . No relationship between hrHPV type and age was observed for any of the other types. The impact of age on the proportion of HPV16 infections in hrHPV-positive women is illustrated in Within the set of hrHPV-positive screening-eligible women (age 29–61 years) with a valid HPV typing result, the proportion of HPV16 infections decreased significantly with age , 95% CI=0.67–0.85, In hrHPV-positive women who were eligible for routine screening, 33% was infected with HPV16, 9% was infected with HPV18 without 16, and 59% was infected with HPV16, 18, 31, and/or 45. HrHPV infections with types other than HPV16, 18, 31, and/or 45 were found in 41% of the women. In this study, data from a cohort of 45 362 Dutch women between 18 and 65 years of age were used to estimate the relationship between type-specific hrHPV prevalence and age in the Netherlands. We have shown that the prevalence of hrHPV peaks between 20 and 25 years, and we estimated the peak prevalence at 24%. Furthermore, we have shown that the proportion of HPV16 infections in hrHPV-positive smears decreases with age. We estimated that around 65% of hrHPV-positive women with a confirmed CIN2+ have an HPV16 and/or 18 infection. This indicates that non-HPV16/18 infections remain important with HPV16/18 vaccination.The data set consisted of women aged 29–61 years eligible for routine screening and women younger than 29 or older than 61 years outside the routine screening age range. The hrHPV prevalence in women outside the routine screening age range may be biased because they visited their GP on own initiative. However, comparison of the HPV prevalence in opportunistically screened women aged 27 or 28 years to screening-eligible women aged 29 or 30 years did not show a trend shift in HPV prevalence (data not shown). Moreover, we observed an overall hrHPV prevalence of 21% in the age group 18–24 years, which is consistent with the international literature cancerous lesions caused by non-HPV16/18 infections. We showed that the positive predictive values of cytology and HPV testing decrease when HPV16/18 infections have been removed from the data. The main reason for this is that HPV16 has a relatively high prevalence in hrHPV-positive women with confirmed high-grade CIN. This diminishes the effect of cervical screening on the incidence of cervical cancer and may lead to a discussion about the cost-effectiveness of cervical screening in vaccinated women. Although formal modelling analyses are required to evaluate the cost-effectiveness of screening strategies with vaccination, changes in the length of the screening interval and/or the age at which screening starts can be anticipated. A related discussion concerns the choice of the primary screening instrument. Meta-analyses have shown that, HPV DNA testing has a higher sensitivity than cytology (


Since cervical cancer is reportedly the seventh most frequent cancer in women in Saudi Arabia and the eighth most frequent cancer among women aged between 15 and 44 years, we wanted to determine the prevalence of abnormal cervical cytology among subfertile women attending the reproductive medicine unit of a tertiary care center in Saudi Arabia.This was a retrospective, cross-sectional, hospital-based study. A Pap smear was done for 241 of 493 (48.9%) subfertile women from January 2008 through February 2009.The Pap smear was normal in 166 of 241 patients (67.9%), abnormal in 71 (29.5%), and unsatisfactory for evaluation in 4 (1.7%). According to the revised Bethesda system, epithelial cell abnormality was found in 7 (2.9%), inflammation in 55 (22.8%), and infection in 9 (3.7%) patients. Epithelial cell abnormalities were further classified as atypical squamous cells of undetermined significance (ASC-US) , atypical squamous cells of high grade (ASC-H) , low-grade squamous intraepithelial lesion (LSIL) , and glandular cell abnormalities (AGS) .The high prevalence of abnormal cervical cytology in our subfertile women accentuates the need for screening in patients eligible for in vitro fertilization. In addition, a well-organized screening program for cervical cell abnormalities at the national level should be implemented to allow identification of subfertile women at risk so that potentially life-saving measures can be undertaken early. Cervical cancer, known for its mortality and morbidity, is the second most common cancer in women worldwide, with an estimated 493 000 new cases and 274 000 deaths in 2002.10Cervical cancer is the seventh most frequent cancer in women in Saudi Arabia and the eighth most frequent cancer among women aged between 15 and 44 years.11In the few published studies from Saudi Arabia the prevalence of epithelial cell abnormalities in the western region of the country has been variously reported to be 5.0%,A retrospective, cross-sectional, chart review of Pap smear data was performed for all women presenting with subfertility at the Reproductive Medicine Unit (RMU), Women’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia, during the 14-month interval from January 2008 through February 2009. A total of 493 women attended the clinic during that interval. Routine cervical smear is offered to all patients as part of their subfertility workup. Liquid-based preparation is used to acquire the samples, which are analyzed in the pathology department according to the revised Bethesda system (2001). The samples are sent to the hospital laboratory as a routine procedure and are read by different pathologists according to the lab protocol. Data acquired from the medical records included Pap smear results, patient age, duration and description of subfertility, medical and surgical history, and complaints (if any) at the time of the initial presentation.A cervical smear was taken from 241 of the 493 patients (48.9%); the rest of the patients were not willing to undergo screening. The 241 patients who had cervical smears taken had a mean age of 30.1 years . One hundred forty-nine (61.8%) had primary subfertility, while 92 (38.2%) had secondary subfertility. Major causes of subfertility were female factor in 97 (40.2%), male factor in 84 (35%), combined male and female causes for 23 (9.5%), and unexplained subfertility in 37 (15.3 %) couples . None ofCervical cytology was normal for 166 (68.9%) patients and abnormal for 71 (29.5%); samples from 4 (1.7%) patients were unsatisfactory for evaluation. Abnormalities included epithelial cell abnormality in 7 (2.9%), inflammation in 55 (22.8%), and infection in 9 (3.7%) patients. Epithelial cell abnormalities included three atypical squamous cells of undetermined significance (ASC-US), one atypical squamous cells of high grade (ASC-H), two low-grade squamous intraepithelial lesions (LSIL), and one glandular cell abnormality (AGS) .All patients with abnormal results were managed according to the type of abnormality present. One patient had bacterial vaginosis and was treated with metronidazole. Other patients had candidiasis and were treated with 100 mg clotrimazole for 6 days. Repeat cultures for patients were negative. All patients with epithelial cell abnormalities were referred for colposcopy and managed according to standard practices. Repeat smears for three patients were negative within 6 months of the initial smear, and the other four women are being managed according to standard practice.Screening with Pap smear allows earlier detection of cervical cell abnormalities and prompts action according to set guidelines. Screening has been shown to be accompanied by a dramatic reduction in the incidence of invasive cervical cancer.16Our study adds to the information from the few reports that address patterns of abnormal cervical cytology among subfertile women. Our evidence would have been stronger and more credible if we had compared the prevalence of abnormal cervical cytology among subfertile women to that in similarly matched fertile controls. Larger studies are needed that compare subfertile women with a control group to elicit the prevalence of abnormal Pap smear in these two populations. Additionally, screening for HPV should be done in women with epithelial cell abnormalities to help identify this potential etiological agent.In conclusion, the high prevalence of abnormal cervical cytology in our group of subfertile women stresses the need for cervical cytology screening in patients eligible for IVF. This calls for a well-organized screening program at the national level for cervical cell abnormalities, which would allow identification of subfertile women at risk for whom early potentially life-saving measures can be undertaken. Additionally, national patient information programs are required that will create public awareness and promote understanding of the need for cervical cancer screening. At the clinic level, educational programs can include tutorials presented while women are waiting for appointments, distribution of handouts, and information displays.