Traditional population-based cervical screening programs, based on cytology, have successfully reduced the burden of cervical cancer. Nevertheless limitations remain and new screening methods are emerging. Despite vaccination against the 2 most oncogenic types (HPV 16/18), cervical cancer screening will have to continue as an essential public health strategy. As the acquisition of an HR-HPV infection is critical in the progression to (pre-)cancerous cervical lesions, recent research has focused on HR-HPV detection. The sensitivity of HPV testing in primary and secondary prevention outweighs that of cytology, at the cost of slightly lower specificity. Although most of the HR-HPV infections are cleared after conization, new evidence from numerous studies encourages the implementation of HR-HPV testing and genotyping to improve posttreatment surveillance. An HR-HPV test 6 months after conization is a promising useful clinical marker to detect persistence and prevent progression. This review highlights the clinical role of HPV testing in primary and secondary cervical cancer screening. Cervical cancer (CC) is the third most common cancer among women worldwide 15%) and the second most common in developing countries 5% and th.More than 80% of the global burden occurs in developing countries, where it accounts for 13% of all female cancers. In western countries, the incidence and mortality of CC have declined substantially over the past decades, whereas in developing countries there is a slight increase in mortality . This isInfection with a high-risk HPV (HR-HPV) genotype has been identified as the most important etiologic risk factor for the development of CC and is the necessary step in carcinogenesis. The median age of diagnosis is 45 years, and there are two major histological types; 85% of all cases are squamous cell carcinomas (SCC) and 15% are adenocarcinomas (including adenosquamous cancers) . SCC is Cervical cancer screening by regular pap smear cytology exams and/or HPV testing should, in short term, increase the likelihood of diagnosis of CC but should in the longer term decrease the likelihood of diagnosis.HPV infection is the most common sexual transmitted disease with more than 80% of the population infected at some time in their life. In rare cases (1%), this infection will eventually lead to CC. Simultaneous infections with multiple HPV types are common .Only 40 of the 200 known HPV genotypes present tropism for the anogenital mucosa and 18 of those 40 types are directly related to CC , 6. FiftHPV exposure is critically dependent on risky sexual behavior, such as the age of first sexual intercourse, the selection of contraceptive methods, and most importantly the lifetime number of sexual partners . Most inHR-HPV infection is an essential factor in the development of CIN and CC. When HPV acquisition is followed by HPV persistence instead of clearance, there is a high chance for progression to precancerous lesions and ultimately invasive lesions.HPV 16 and 18 are the most common HR-HPV types worldwide and account for about 70% of all SCC and for up to 85% of all adenocarcinomas. HPV 16 is the most carcinogenic HPV genotype and HPV 18 causes a greater proportion of glandular cancers than squamous cell carcinoma. After HPV 16 and 18, the six most prevalent types that account for an additional 20% are types 31, 33, 35, 45, 52, and 58 [HPV is a double stranded closed circular DNA virus with the capacity to incorporate in the human DNA. HPV 16, 18, and 45 are predominant HPV types in CC as they are more likely to integrate into the human genome than other HPV types. When CC is caused by one of these three types, CC patients are on average diagnosed 4 to 5 years earlier (44 versus 49 years) than those caused by other high-risk types .in situ and invasive CC) than other high risk HPV types  and increased length of screening intervals (decreasing harms) . CotestiCC screening should, regardless of the age of sexual debut or other risk factors, begin at the age of 21 years. In the general population under the age of 30 years, there is a low prevalence of underlying high-grade lesions and a high prevalence of transient HPV infections. Hence, the use of HPV testing as a screening tool limits the effectiveness of primary screening and could lead to unnecessary evaluation and overtreatment.Women aged older than 65 years with adequate negative screening within the last 10 years and with no history of CIN2+ within the last 20 years should not be screened any longer. Women following a hysterectomy with removal of the cervix who have no history of CIN2+ should not be screened for vaginal cancer. Once screening is discontinued, it should not be resumed for any reason [Screening practices should not change on the basis of HPV vaccination status. After HPV vaccination, serial screening remains necessary to further decrease cervical cancer incidence and mortality from other high-risk HPV not covered by vaccine. One important reason to continue screening involves inclusion of only HPV 16/18 in the first generation vaccines. Secondly, as recommendations include HPV vaccination for women up to age of 26 years, efficacy declines due to a high probability of postexposure HPV vaccination.Even in countries with high HPV vaccination coverage, modifications to cervical screening practices are not immediately anticipated as it will take more than a decade to see the full impact of vaccination on screening outcomes. A key question is the duration of protection from HPV vaccination and the impact on age-specific cancer risks. More evidence is needed on the effect of vaccination on the HPV genotype distribution, the impact on the screening test performances, and screening adherence.It is important to acknowledge that preventing all CC is unrealistic. No screening test has perfect sensitivity and therefore there will always be a residual cancer risk, especially for rapidly progressive CC. The optimal balance of benefit and harm should be chosen and remains a matter of discussion .Technological improvements in screening are unlikely to have a substantial impact on the burden of CC incidence and mortality if they do not reach women living in low-resource, medically underserved regions. The largest immediate gain in reducing the burden could be attained by increasing access to screening among women who are currently unscreened or screened infrequently. The incorporation of HPV testing may be advantageous as it provides longer term safety following a negative test. This is a useful characteristic for women who are screened infrequently.In a meta-analysis in 2006, HPV testing has been shown to have greater sensitivity (+37%) but lower specificity (−7%) for CIN2+ and better reproducibility than cytology using a positive cut-point of LSIL .This screening tool should not be used in women younger than 30 years because of the high prevalence of HPV in young adult women. Therefore, for women aged 21 to 29 years, screening with cytology alone every 3 years is recommended as it provides the best balance of benefits and harms of screening in this age group.New recommendations state that women aged 30 to 65 years should be screened with cytology and HPV testing every 5 years or with cytology alone every 3 years. Based on risks and harms assessment, cotesting is preferred to cytology alone. The addition of HPV testing results in an increased detection of CIN3 with a concomitant decrease in CIN3+ detected in subsequent rounds of screening. This increase in diagnostic lead time translates into lower risk following a negative screen, permitting a lengthening of screening intervals with similar or lower incident cancer rates than screening with cytology alone at shorter intervals. The introduction of HPV testing also enhances the identification of women with adenocarcinoma and its precursors.The main harms associated with adding HPV testing can be alleviated by extending the screening interval to 5 years, thereby reducing the detection of transient HPV infections and related lesions. Cotesting more frequently than recommended is predicted to exacerbate the harms by increasing the number of colposcopic referrals and treatments.Women cotesting HPV positive, cytology negative should not be referred directly to colposcopy. Cotesting should be repeated after 12 months or immediate HPV 16/18 genotype specific testing should be performed. Only those women testing positive on either test (HPV positive or LSI L or more severe lesions) or testing positive for HPV 16/18 should be referred to colposcopy.The risk of precancerous lesions following HPV-negative ASC-US cytology is very low and not qualitatively different from a negative cotest. Because of the very low CC risk observed in these cases, continued routine screening is recommended. Women with HPV-positive ASC-US or more severe cytology should be referred to colposcopy, regardless of their HPV status.HPV testing alone for primary screening appears promising in women aged 30 years and older. A negative HPV test provides greater reassurance against CI N3+ in the subsequent 5 to 7 years than cytology alone and is nearly as reassuring as a negative cotest . TherefoWomen with high-grade cervical lesions are treated by local excision or ablation to prevent progression to invasive CC. Although conization is proven to be an effective treatment in removing CIN, it does not necessarily mean eradication of the virus. Failure of treatment for CIN3 has been reported to vary between 5 and 25% . In a cuIn a recent meta-analysis, Kocken et al. described the value of testing for cytology and/or HR-HPV in the surveillance of women treated by conization for CIN2+ . At the This review confirms the advantage of implementing HR-HPV testing as virological surveillance in predicting therapeutic failure , 11. As Evidence-based posttreatment followup consists of retesting at 24 months for women with a negative cotest at six months after treatment , 23.Moreover, other recent studies firmly stress the importance of type-specific persistence after treatment. A retrospective case-control study by McCredie et al. demonstrated that a type-specific persistent HPV infection at first control 6 months after conization was an independent risk factor associated with a higher frequency of recurrent CIN in the next 24 months . CompareIn the future, the introduction of HPV genotyping promises the potential to refine the algorithm for the management of HR-HPV positive women after treatment. However, further work is required to investigate the role of HPV genotyping, cofactors, viral load determination, and molecular markers to recommend the most appropriate test for patient management after treatment.


Published human papillomavirus (HPV) vaccine trials indicate efficacy is strongest for those naive to the vaccine-types. However, few high-risk young women have been followed and cervical HPV has been the predominant outcome measure.We collected cervical and anal swabs, as well as oral rinse specimens from 645 sexually active inner-city young females attending a large adolescent health-clinic in New York City that offers free care and HPV vaccination. Specimens were tested for HPV-DNA using a MY09/MY11-PCR system. Type-specific prevalence of HPV at each anatomic site was compared for individuals by vaccination dose using generalized estimating equation logistic regression models.The majority of subjects reported being of non-Caucasian (92%) and/or Hispanic ethnicity (61%). Median age was 18 years (range:14–20). All had practiced vaginal sex, a third (33%) practiced anal sex, and most (77%) had also engaged in oral sex. At enrollment, 21% had not received the vaccine and 51% had received three doses. Prevalent HPV infection at enrollment was detected in 54% of cervical, 42% of anal and 20% of oral specimens, with vaccine types present in 7%, 6% and 1% of specimens, respectively. Comparing prevalence for vaccine types, the detection of HPV in the cervix of vaccinated compared to unvaccinated adolescents was significantly reduced: HPV6/11 , HPV16  and HPV18 . For anal HPV, the risk of detecting vaccine types HPV6/11  and HPV18 were significantly reduced for vaccinated adolescents however, the risk for HPV16 was not significantly decreased .HPV Prevalence is extremely high in inner-city female adolescents. Administration of the HPV vaccine reduced the risk for cervical HPV; however continued follow-up is required to assess the protection for HPV at all sites in young women with high exposure. Cervical human papillomavirus (HPV) infection is the most common sexually transmitted viral infection (STI). Adolescents and young women have the highest rates of cervical HPV. The FDA-approved quadrivalent vaccine, GARDASIL® , targets HPV16 and 18 , as well as HPV6 and 11 , and has the potential to reduce the burden of genital HPV and disease. The HPV vaccine clinical trials, however, focused almost exclusively on low-risk, primarily non-Hispanic Caucasian women with few sexual partners who were highly compliant with the vaccine schedule. When women who had a current infection  with an HPV vaccine type were assessed, the vaccine was shown to provide no benefit for preventing future infections by that type The association of HPV with anal and oropharyngeal papillomas and neoplasia is an important public health concern. Yet few clinical trials have reported on the effectiveness of the vaccine against anal or oral HPV Subsequent to the approval and release of GARDASIL, we initiated a cohort study of sexually active inner-city, mostly minority, adolescent females attending the largest adolescent-specific primary care facility in the U.S. – the Mount Sinai Adolescent Health Center in New York City; that provides free health services, including HPV vaccination. The data obtained from this study will be essential to understanding the real-world impact of HPV vaccination in high-risk adolescents, and for determining future cervical cancer prevention and screening practices in cohorts of women with different HPV vaccine coverage.In this report, we present data on the prevalence of HPV in this high-risk population and describe the cross-sectional association between the detection of cervical, anal and oral HPV with vaccine exposure.The Mount Sinai Adolescent Health Center (MSAHC) uses a unique model that integrates medical, dental, sexual/reproductive, mental health and health education services. All services are confidential and free to patients. It is located on the border of East Harlem and supports an underserved population of children, adolescents, and young adults (ages 10–24); ∼80% of who are females, come from all five Boroughs of New York City: 50% from Central and East Harlem, and other parts of Manhattan, 29% from the Bronx, and 20% from other Boroughs.Women are eligible to participate if they: 1) are between 12 and 19 years of age at time of consent, 2) have ever engaged in vaginal or anal intercourse, and 3) intend to get or have already received the FDA approved HPV vaccine (GARDASIL®). Women pregnant at time of recruitment or who have terminated a pregnancy within the last 4 weeks are excluded.www.myspace.com/hpvinfo; www.facebook.com/MSAHC).Adolescent women presenting to the MSAHC are informed about the study by research staff. Study flyers are also handed out instructing women attending the adolescent-health clinic to contact research staff if they are interested in participating. In addition, MySpace® and Facebook® social-networking pages were created as health education tools to explain facts related to HPV in more detail , and anticipatory guidance and age-specific health education. Screening for Chlamydia, gonorrhea and Syphilis is done routinely, and Herpes if symptoms are present.A self-administered questionnaire consisting of items to assess risk behaviors for HPV acquisition includes questions on: sexual behaviors, history of STIs and warts, characteristics of sexual partners, condom use, use of alcohol and illicit substances for participants and their sexual partners. The questionnaire is reviewed by a study coordinator at the time of the visit and any items not completed are queried. The enrollment clinical interview and questionnaire data were combined to describe the population and risk factor profiles for this analysis.Specimen collection is performed by MSAHC clinicians. Cervical cells are collected using an endocervical Cytobrush® placed in PreservCyt transport medium  medium. Anal cells are also collected in PreservCyt using a Dacron swab moistened in tap water. Oral cell samples are collected by oral rinse and gargle using a Scope® mouthwash . Specimens are stored at −20°C immediately following collection. Additional cervical and anal specimens are collected for Pap cytology at enrollment.The polymerase chain reaction (PCR) detection and typing of HPV-DNA has been described in detail elsewhere Samples hybridizing to the β-globin probe but negative for the generic probe are considered HPV negative. PCR products positive by Southern blot and any sample having a specific DNA fragment migrating at ∼450 bp are analyzed for HPV-DNA type. Filters are individually hybridized using biotinylated type-specific oligonucleotide probes for multiple HPV including vaccine types HPV 6, 11, 16 and 18. Samples that test positive by the generic probe mix but negative by all type-specific probes are considered to represent “uncharacterized” HPV types. Hybridization signals of the HPV type-specific probes are recorded using a 1–5+ validated scale for signal intensity alpha PV genus and uncharacterized HPV types. Related HR-HPV for vaccine type 16 included HPV31, 33, 35, 52, and 58  and HPV18-related types 39, 45 and 59 . No HPV6/11-related HPV types  were specifically identified. Statistical analyses were conducted with the STATA 12.0 and SAS 9.2 statistical software packages.Clinical and demographic characteristics of the study cohort were examined using frequency distributions. Associations between risk factors and HPV detection, including vaccine and related HPV types, were estimated by odds ratios (OR) and 95% confidence intervals (CI) using multivariable logistic regression. In addition, to examine the vaccine effect over multiple HPV types, we fit two models using a previously described generalized estimating equation (GEE) approach The cohort consisted of a predominantly minority population with a median age of 18 years who had not completed high-school at the time of enrollment Table 1.History of STIs in the population was high including Chlamydia (36.0%), trichomoniasis (7.6%), gonorrhea (5.7%), and genital warts (5.3%). Almost half (47.3%) of adolescents reported using condoms ‘never’, ‘rarely’ or only ‘sometimes’ when practicing vaginal sex, and many (55.2%) also reported using the withdrawal or rhythm method for contraception. The majority of adolescents, however, used some form of recurrent prescription-based contraception including oral contraceptive pills (52.7%), vaginal rings (25.4%) or Depo-Provera injections (23.1%). More than a quarter (31.3%) of subjects reported having been pregnant.Overall HPV-DNA detection at enrollment was 53.5% in the cervix, 41.5% in the anal canal, and 19.6% in the oral cavity. The prevalence of at least one vaccine type  was 6.6%, 6.2% and 1.3% in the cervical, anal and/or oral specimens, respectively. Among the most commonly detected cervical HPV types  were HR-HPV types HPV51 and 58, as well as low-risk types 53, 66, 84 and 90/106 Figure 1We examined the risk factors for HPV-vaccine, vaccine-related HR-types and all HPV types in the cervix or anal canal, using logistic regression adjusting only for vaccine dose Table 2.alpha-9 and -7) types. Whereas vaccine types were significantly less likely to be detected in the cervix and anal canal with any vaccine exposure, this was not observed for other related HR-HPV types or all types combined. Subjects who had engaged in vaginal sex more than two years prior to vaccination were also more likely to present with an HPV infection independent of vaccine dose.Except for vaccine exposure, similar risk factor associations were observed for detection of vaccine types alone and related HR-HPV , anal canal , and oral cavity  and anal canal , as well for HPV18 in the anal canal .alpha-9 and -7 genera by vaccine exposure . In addition, we assessed cross-sectional associations between HPV-DNA infection, vaccine exposure and risk factors. As such, the history of HPV exposure prior to vaccination is not known for those individuals enrolled after vaccine initiation. Furthermore, it is impossible to ascertain via HPV-DNA detection alone if test positivity is equated with true  viral infection that may cause neoplastic disease. With longitudinal follow-up, we will be able to assess the HPV incidence and risk factors for “breakthrough” persistent infections  The reported study has strengths and limitations. The current study evaluated HPV at multiple anatomical sites associated with sexual exposure. While it is generally understood that acquisition and prevalence of cervical HPV is at its highest in adolescent women, how this relates to the prevalence and acquisition of HPV in other tissues susceptible to HR-HPV associated tumorigenesis , is not currently known. Among the limitations, it should be noted that because we are specifically targeting sexually active adolescent females, either at the time they receive the HPV vaccine or soon thereafter, our population is older than the targeted age for vaccination, but covers the age range recommended for catch-up vaccination , the study cohort is younger (mean patient age in 2010 was 18.6 vs. 17.7 in this study) but comparable in terms of prior STIs. The high-risk nature of the population is also evident in the observed prevalent HPV detection. Among the strongest risk factors for detection of cervical and anal HPV (independent of vaccination) were number of sexual partners, anal intercourse, oral-to-anal sex, receipt of a Depo-Provera injection, and history of Chlamydia. Vaccination was significantly associated with cervical and anal HPV detection only after the vaccine types were assessed separately.Recent evidence suggests the HPV vaccines will impact both cervical and anal HPV co-incidence rates, although efficacy against anal HPV depends on cervical HPV positivity Finally, whereas the odds of detecting HPV vaccine types in the cervix decreased significantly among vaccinated adolescents, the odds of detecting other vaccine related and un-related HR-HPV types did not show consistent decreases with vaccination. We observed significant univariate declines in detection only for HPV16 and 18-related HR-HPV types 31 and 45 in the cervix and anal canal, respectively, as did other studies. While history of previous infection with a vaccine type could not be controlled for in the analyses, it is unlikely the result is solely due to prior exposure given the observed prevalence among unvaccinated individuals. Vaccine efficacy has been shown against persistent infection in the trial cohorts for HPV33, 31, 45 and 51 (with or without HPV16/18 co-infection) In summary, our data to date suggest continued detection of cervical and extra-cervical infection with HPV vaccine types after vaccination, in addition to other HR-HPV types. This study provides the ‘real-world’ impact of vaccinating high-risk adolescent populations  with potentially frequent prior exposures to HPV vaccine types, as well as to related HR-HPV types. Findings from studies such as this are therefore critical to document the continued burden of HPV and to properly design future multi-type prophylactic HPV vaccines and continued screening strategies to prevent HPV-related disease.


Epidemiological studies on genital human papilloma viruses infection (HPVs) in general population are crucial for the implementation of health policy guidelines for developing the strategies to prevent the primary and secondary cervical cancer. In different parts of Iran, there is a lack of population-based studies to determine the prevalence of HPV in the general population. The aim of this population-based study is to compare the prevalence rate of genital HPV infection among reproductive women with our previous clinic-based data, which showed a prevalence rate of 5% in women in southern Iran.Using general primers for all genotypes of HPV, of 799 randomly selected women, five  tested positive for HPV DNA. Overall, seven different HPV genotypes were detected: six types  were carcinogenic, or “high risk genotypes” and one genotype (HPV-66) was “probably carcinogenic.”In a population-based study, the prevalence of HPV infection among southern Iranian women was lower than that observed worldwide. However, our gynaecological clinic-based study on the prevalence of HPV infection showed results comparable with other studies in the Middle East and Persian Gulf countries. Since gynaecological clinic-based data may generally overestimate HPV prevalence, estimates of prevalence according to clinic-based data should be adjusted downward by the population-based survey estimates. Cervical cancer is an important public health problem worldwide, especially in developing countries, where more than 80 percent of the estimated global cases occur ,2. PersiOncogenic HPV DNA is detected in more than 90 percent of the cervical tissues of patients with cervical carcinoma or cervical intraepithelial neoplasia ,6. WorldMost epidemiological data for HPV infection comes from cross-sectional studies with samples taken from women in different hospitals and gynecological clinics -14. ThesRegarding the widespread use of HPV vaccines against oncogenic HPV types that potentially reduce the incidence of cervical and other anogenital cancers, Data on the HPV burden in the general population is essential to strengthen the guidelines for the implementation of health policy strategies for the prevention of primary and secondary cervical cancer .Therefore, we carried out The purpose of this population-based study is to investigate the HPV burden among women in southern Iran Since we are particularly interested in understanding the level of and the difference in the prevalence of HPV infection between our population-based study and our clinic-based data, we compared the results of our previous clinic-based study with those of the present study.This study was approved by the medical-ethical committee of Bushehr University of Medical Sciences.A cross-sectional, population-based study was used to select women of childbearing age (21–50 years old) from Bushehr Port  from November 2009 to May 2010.Participants were an age-stratified random sample of women aged 21 to 50 years. They were selected from 51 urban and 24 suburban areas in Bushehr Port. The first cluster in each area was selected using a random number table. The sampling interval was added sequentially to the random number to complete the selection of the remaining clusters in each area. The total number of women selected in each area was proportional to the total number of childbearing women in that area.Regarding our previous study on women who had routine Pap tests in Bushehr Port , it was The selected participants were informed about the study through a letter distributed door-to-door by the survey groups employed in the study. After briefing the respondents to the letter with some basic information about cervical cancer and its associated risk factors, they were invited to participate in the screening program at the Persian Gulf Tropical Medicine Research Center at Bushehr University of Medical Sciences.All participants were asked to come to the survey centre at 07:30 am and stay until 9:30 am. Upon their arrival, information regarding age, marital status, education, socioeconomic status, smoking, obstetrics history, history of oral contraceptive usage, and sexually transmitted diseases were recorded on a questionnaire used by trained interviewers.Written informed consent was obtained from the all participants for publication of this report.Based on national reports, 200,000 Tomans (200 US $) income per month was defined as the line for poverty. The women below the poverty line or in the range which households could maintain a minimum standard of living  were considered to be in the low socioeconomic status.Two separate samples were taken from the ectocervix and endocervix using a wooden Ayre spatula  and endocervical cytobrush (for the PCR test).http://www.bethesda2001.cancer.gov). Cells showing koilocytic change, multinucleation, and dyskeratosis, with the addition of anucleate keratinised squamous cells and keratinised squamous were considered cytological changes of HPV infection.The Pap smear slides were immediately fixed with ethanol and further processed for diagnosing by cytopathologists. Bethesda System 2001 for reporting cervical/endocervical/vaginal cytology (Pap smears) was used , which amplifies a 150 bp product from the HPV L1 ORF. The validity of the PCR test was approved in previous studies [β-Globin positive samples were subjected to HPV PCR by forward primer GP5+: 5 studies ,17,18. PThe DNA extracted from the HPV PCR positive samples were subjected to genotyping using the INNO-LiPA HPV genotyping system  at the Keyvan Virology Laboratory, Tehran, Iran. Briefly, the 28 oligonucleotide probes that recognize 25 different types Table  were taiAll statistical analyses were performed using the PASW Statistics GradPack 18 .A total of 799 women of reproductive age, 17 to 50 years, were evaluated. The mean (± SD) age of women in the study was 35.96 (± 8.08). Of 799 participants, 26.3% were between 17 and 30 years, 36.5% were between 31 and 40 years, and 37.2% were between 41 and 50 years.The educational level of 112 (15.07%) women was elementary school, and 33 (4.44%) women were illiterate. A total of 112 (15.07%) participants had low socioeconomic status.The majority of the studied population (98.7%) was married. The mean age of first sexual intercourse (during marriage) was 19.16 ± 3.97 years. None of the women had a history of multiple sexual partners. The median number of pregnancies was three for the studied population. The history of tobacco smoking was found in 14.4% of the women. A total of 464 (58.1%) women had used oral contraceptive pills. However, 124 (15.5%) of the studied population reported that they were current users of oral contraceptives. The median duration of oral contraceptive usage by the participants was three years.Previous sexually transmitted disease was reported by 44 (5.5%) women. However, 11 (1.4%) women reported a positive history of previous sexually transmitted disease via their husbands. Of the studied population, 375 (46.9%) had never had a Pap test.Using general primers for all genotypes of HPV, of 799 tested samples by PCR, five  women were positive for HPV DNA.Genotyping of the PCR positive samples revealed that two women were infected with more than one genotype . The other three patients were infected with one genotype of HPV . Therefore, seven different HPV genotypes were detected, among which six types  were carcinogenic, or “high risk genotypes” and one genotype (HPV-66) was “probably carcinogenic.” Table The Pap tests of 40 (5.0%) women showed epithelial cell abnormalities. Atypical squamous cells of undetermined significance (ASCUS) and cervical intraepithelial neoplasia (CINI) were found in 32 (4.0%) and eight (1.0%) participants, respectively. Cellular changes associated with HPV were detected in nine (1.12%) women. However, two were found to be HPV-positive by PCR. On the other hand, three women who were identified as HPV DNA positive by the PCR method were negative for HPV infection when they were evaluated by the Pap test.The overall prevalence of HPV infection among the women in our study is lower than that observed worldwide. To the best of our knowledge, this is the first population-based study in the south part of Iran to investigate the prevalence rate of HPV infection in this region.The prevalence rate of HPV infection differs notably according to geographical region . The worComparisons of HPV prevalence by geographical area or country are generally hampered by the heterogeneity in laboratory assays employed for HPV infection detection, the population included , and the variation in HPV types detected .Although a few population-based studies on the prevalence of HPV infection in the Persian Gulf and the Middle Eastern countries could be found in the medical literature, the low prevalence of oncogenic HPV infection in Iran (the current study) and Kuwait (1.39%)  comparedThe present community study did not confirm our previous study on reporting HPV prevalence among women in southern Iran  despite In the previous study, we determined the prevalence of various HPV genotypes among women who had routine Pap smear tests in a university gynecology clinic Table . In thatAlthough, in a recent population based study on genital HPV by Khodakarami and her colleagues  among 23Similarly, the observed prevalence of HPV high and low risk types in cervical samples taken in a population-based study in Italy was lower than those in studies that were performed on women undergoing voluntary cervical cancer screening in gynaecological clinics ,25. NotaBased on the present study nine samples were detected HPV positive by Pap smear test meanwhile two of them were approved by HPV DNA PCR test. Moreover, there are other three HPV DNA positive samples among the Pap smear test negatives. This observation could be because of the lack of specificity of Pap smear test for HPV detection.Previous studies have indicated a significant geographic variation in the pattern of oncogenic HPV types. HPV 16 was the most commonly identified type in most countries of the world . In the A comparison of our results with some similar studies in Muslim and Middle Eastern countries ,32 showeOur study has several limitations. The small sample size of this study in a population-based setting may have underestimated the prevalence of HPV infection in the general population. Indeed, this limitation may decrease the chance of detection of different genotypes with lower prevalence such as HPV-42 and HPV-6 compared to the prevalent genotypes. In addition, the participation rate in the current study was 87.60%. The non-responders may produce a selection bias. It is probable that the non-responders may be at higher risk of HPV acquisition. However, the major reasons for non-participation were having to work, anxiety and doing Pap smear examination before the invitation time. The cross-sectional design of the study did not provide the opportunity to examine trends over time. We also did not evaluate risk factors for the acquisition and persistence of oncogenic HPV types. We also did not have information on the husband’s sexual behavior and therefore potential confounding effects cannot be evaluated in our study. Because of the low prevalence of HPV infection in the current study, we cannot evaluate the prevalence of oncogenic HPV types among women with epithelial abnormalities in cervical cytological examinations. Moreover, The small number of HPV positive cases in our study precludes any age-specific incidence rate.Thus, larger population-based studies in different regions are needed to eliminate the drawbacks of our study and to determine the accurate prevalence of HPV infection among women in Iran. Based on the very low prevalence of HPV infection in this study, there are currently no indicative data to support use of HPV vaccine in southern Iranian women. Since cervical cancer ranks as 12th most frequent cancer among women in Iran , screeniIn conclusion, in a population-based study, the prevalence of HPV infection among southern Iranian women was very low. Indeed, the prevalence of HPV was significantly lower than we reported in our clinic-based study. In other words, gynaecological clinic-based data generally overestimate HPV prevalence. Therefore, estimates of prevalence based on clinic-based data should be adjusted downward according to population-based survey estimates . UndoubtThe authors declare that they have no competing interests.RA and NO designed and conceived the PCR test. SSE performed the pap smear test. SM, FA, ZA and RP have collected the samples. ZS co operated as lab staff for PCR performing. IN, KV and KZ conceived the whole study and edited the manuscript. We confirm that all authors read and approved the final manuscript.


Women veterans are a fast-growing segment of the veteran population, yet they face many barriers to medical care. The objective of this study was to examine factors that put women veterans at risk for a financial barrier to medical care.We conducted repeated cross-sectional analyses of data from the 2003, 2004, 2009, and 2010 Behavioral Risk Factor Surveillance System. We used weighted logistic regression to examine the risk of a financial barrier to medical care as the primary outcome in a multivariate model controlling for factors in health-related domains.In 2010, there were an estimated 1,719,750 (11.6%) working-aged veterans who needed to see a doctor in the previous 12 months but could not because of cost. For women, 13.4% faced this financial barrier. Over the study period, facing a financial barrier was consistently associated with insurance coverage, physical and mental distress days, and having children in the home. Other associations emerged in particular years, such as binge drinking in 2010. The trends for women veterans relative to men and for younger women veterans relative to older women veterans show reduction in financial barriers to health care.The Veteran’s Health Administration (VHA) should continue efforts to reduce financial and other barriers, especially among the higher risk groups we identified. This will help meet the VHA’s objectives of providing comprehensive care to all veterans including women. Women are a growing proportion of veterans in the United States ,2. The fFor women veterans, functional status and general, physical, and mental health are all substantially worse for those facing a financial barrier to medical care . CompareThe primary objective of our study was to examine sex disparity associated with a self-reported financial barrier to medical care using a nationally representative survey of working-age veterans. We examined sex and age group differences in the prevalence of a financial barrier and other health-related factors. We used a repeated cross-sectional analysis of the Behavioral Risk Factor Surveillance System (BRFSS) survey from the entirety of the OEF/OIF/OND era.We analyzed data from the 2003, 2004, 2009, and 2010 Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional computer-assisted random-digit–dialed telephone survey conducted by US states and territories with support from the Centers for Disease Control and Prevention (CDC). Although 2011 data are available, that period should be considered a baseline year for data analysis; it is not directly comparable to previous years because of the changes in weighting methods and the addition of the cellular telephone sampling frame . CDC addVeterans were identified as those respondents indicating military service and not currently on active duty. The BRFSS for 2005 through 2008 did not allow us to distinguish active duty status so we did not include these years in the analysis. We excluded respondents older than 65 because our study focused on working-age veterans. The BRFSS does not capture data from military personnel living in closed quarters or in foreign countries . The finWe chose 15 variables for analysis: a financial barrier to medical care (outcome), sex (primary covariate), age, race/ethnicity, education level, annual income, marital status, employment status, number of children in household, insurance status, self-reported health status, physical distress days, mental distress days, smoking history, and binge drinking. We chose covariates because they are 1) a priori important for exploring health care access issues in this population and likely confounders and 2) consistently asked in each year in the analysis.Respondents who answered affirmatively to the question “Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?” were defined as having a financial barrier (outcome). Our primary covariate was sex.To examine health care coverage status, we used the question “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs [health maintenance organizations], or government plans such as Medicare?” Respondents who answered “no” were considered to be uninsured.We dichotomized self-reported general health status as “poor and fair” and “good, very good, and excellent.” Two health-related quality of life questions were used to capture physical and mental distress: “How many days during the past 30 days was your physical health not good?” and “How many days during the past 30 days was your mental health not good?” We dichotomized both of these variables to 14 or more days and less than 14 days . SmokingOther sociodemographic characteristics included age , race/ethnicity , employment status (employed and unemployed), education level , marital status (married and unmarried), and children in the household (yes or no). We categorized annual household income as <$15,000, $15,000–$34,999, ≥$35,000, and “unknown.” Proportions of missing income data were higher for 2003 and 2004 than 2009 and 2010. The median annual household income for veterans in 2009 was approximately $35,000 .The BRFSS data are weighted for the characteristics of the sample design — disproportionate sampling by geographic and population density strata, number of telephones and adults in the household, and in terms of respondents’ characteristics  related to key health and risk outcomes on the survey . First, In 2010, an estimated 1,719,750 (11.6%) working-aged veterans needed to see a doctor in the previous 12 months but could not because of cost . The preThree primary comparisons are of interest for women veterans: 1) women veterans versus men veterans, 2) women veterans versus the general women population, and 3) younger women veterans versus older women veterans. In 2010, 13.4% of women veterans  reported a financial barrier compared with 11.3% of male veterans . For this year, the overall sex difference was not significant but 1) middle-aged women veterans were more likely to report a financial barrier  than middle-aged male veterans and 2) women veterans reported financial barriers more frequently than their male counterparts in all prior years. Women veterans were less likely to report a financial barrier than women in the general population . When anFor brevity, we do not present the bivariate analysis. We found evidence from the general US population that indicates an improvement in accessing health care for women veterans during the OEF/OIF/OND era. In 2010, the prevalence of a financial barrier for women veterans declined to levels similar to those historically reported by men veterans. Women veterans also show increasing improvement relative to nonveteran women in the general population. Although younger women veterans tended to seek medical care less frequently than middle-aged women veterans in the OEF/OIF/OND era, this gap decreased to parity in 2010.We found that, perhaps for the first time in the OEF/OIF/OND era, reporting a financial barrier was equally as prevalent among younger women veterans as among middle-aged women veterans. This trend coincides with expanded care provisions of the National Defense Authorization Act of 2008, which gave many OEF/OIF/OND veterans eligibility for free VA care for 5 years after leaving the service . FurtherExperiencing a financial barrier as a function of insurance coverage, physical and mental distress days, children in the home, and binge drinking are worth noting. Not surprisingly, health care coverage had the strongest association with reporting a financial barrier of any independent variable in our study. Uninsured, working-aged veterans were nearly 4 to 5 times more likely to report a financial barrier to medical care than those with insurance. In 2010, we estimate that there were approximately 1.9 million working-aged veterans, approximately 176,000 (9.2%) of whom were women, without health care coverage. This proportion of women among the uninsured is only slightly higher than that reported from the BRFSS in 2000 (8.7%) .Our study has several limitations. The sample size for women veterans in the BRFSS is stable but still small, leading to high year-to-year variability. Our dependent variable, which is essentially a self-assessment of medical need, is self-reported and subject to bias. For example, women soldiers on active duty underreport health problems perhaps to maintain an appearance of strength among their male peers . This tyThe strengths of our study include 1) our examination of longitudinal trends from a nationally representative sample of women veterans where several similar studies only use a single year of data, 2) a robust sample size for women veterans in each year, 3) multivariate adjustment for veterans’ sociodemographic characteristics, health care access and use, and health-related characteristics, and 4) comparisons of the prevalence of reporting a financial cost barrier to medical care by sex, age group, and veteran status.More than 10% of women veterans in the general population during the OEF/OIF/OND era still report a lack of some medical care due to financial barriers. This work adds to ongoing women veterans’ health research by using a nationally representative sample of veterans from the general population. The VHA should continue making efforts to reduce financial and other barriers, especially among some of the higher risk groups identified in this analysis, as it seeks to meet the objectives of providing comprehensive care that “addresses all medical, behavioral, psychosocial, and functional status issues” (p. 1) such as that described in its Patient Centered Medical Home concept .


To monitor the impact of human papillomavirus types 16 and 18 vaccine on HPV infection dynamics in the Netherlands, we started an ongoing study in sexually transmitted infection (STI) clinics in 2009. Here, we analyze baseline type-specific HPV DNA and HPV-specific antibody positivity rates.We enrolled 3569 men and women, 16–24 years of age, from 14 STI clinics, and estimated genital and anal HPV DNA and antibody positivity rates of 7 main carcinogenic HPV types. Generalized estimating equations regression analyses were applied to determine risk factors for, and associations between, type-specific HPV DNA and antibody positivity.Genital HPV DNA positivity rates were higher in women than in men; anal HPV DNA was especially high in men who have sex with men (MSM). HPV antibody seropositivity rates were also highest in women and MSM. High-risk sexual behavior was predictive of both HPV DNA and antibody positivity. Despite a strong correlation in serological profiles for multiple HPV types, seropositivity was independently associated with homologous HPV DNA detection.HPV DNA and antibody positivity rates are higher in women and MSM than in heterosexual men, but their association is similar across gender. This suggests a site-specific natural course of infection. Human papillomavirus (HPV) is a common sexually transmitted virus known for its causal relation to cervical cancer. There are more than 100 HPV genotypes, with more than 15 carcinogenic types HPV infection does not always induce an immune response that results in HPV-specific antibodies (Ab) The aim of our study was to describe HPV DNA and HPV-specific Ab detection rates of women, men who have sex with women only (MSW), and men who have sex with men (MSM), all of whom were without benefit of HPV vaccination. Furthermore, we explored associations between homologous and heterologous pairs of HPV DNA and HPV Ab types. This description will serve as a baseline measurement to which we can compare future monitoring rounds on HPV dynamics within the Netherlands.The medical ethics committee of the University of Utrecht, the Netherlands, confirmed in writing that they waived the need for separate ethical approval and the need for written consent. This anonymous study used serum already collected for routine STI consultation, therefore no additional invasive procedures were needed. All eligible participants were informed about the purpose of the study prior to the regular STI consultation and full information was provided about the samples to be collected and the additional questionnaire to be administered. Only participants who consented verbally with all conditions were included in the study.In 2009, the bivalent HPV vaccine was introduced in the Netherlands among 12- to 16-year-old girls. To monitor the effects of HPV-16/-18 vaccination on type-specific HPV dynamics in a young highly sexually active population, the PASSYON (PApillomavirus Surveillance among STI clinic YOungsters in the Netherlands) study was set up Chlamydia trachomatis, Neisseria gonorrhoea, syphilis, HIV). The questionnaire covered sexual risk factors such as condom use, number of sex partners, and history of STI. Demographic data were also collected. Ethnicity was not recorded, but we asked the participants which population they belonged to, regardless of country of birth, and used their responses as proxies.A genital self-sample  of all participants was requested  and eluted in 100 µL elution buffer. HPV-DNA was amplified using the SPF10 primer set according to the manufacturer's instructions  for serotypes -16, -18, -31, -33, -45, -52 and -58 were assessed using a VLP-based multiplex immunoassay in which the VLPs were coupled to a set of seven distinct fluorescent microspheres. VLPs were kindly donated by GSK. Most samples were analysed with a 1/100 or 1/200 dilution, some in 1/2000 dilution. Serum samples were assumed to be antibody seropositive at cut-offs determined previously with this assay: 9, 13, 27, 11, 19, 14, 31 Luminex Units/millilitre (LU/ml) for HPV-16, -18, -31, -33, -45, -52, -58, respectively. The serological measurements and control steps have been described in more detail elsewhere Since no significant differences were observed in HPV DNA or Ab positivity rates between the first two rounds (2009 and 2011), we chose to combine these rounds in this study to gain more power. We included only HIV-negative persons having a urogenital DNA sample as well as a serum sample. Women who reported HPV vaccination were excluded in these baseline analyses. We did not exclude men who reported to be HPV vaccinated (n = 17), since Ab concentrations of HPV-16/-18 were not significantly different from those of persons who reported not to be HPV vaccinated, and since men are not (yet) vaccinated in the Netherlands for HPV, it was unlikely that they actually had been vaccinated. Type-specific positivity rates for the seven detectable HPV DNA and HPV Ab types were estimated, stratified by women, MSW, and MSM. Positivity rates were estimated by dividing the number of type-specific HPV DNA positives by the total number tested, with 95% confidence intervals (CI) based on Wilson's score method. The Student's t-test was used to compare positivity rates. When the number testing positive was below five the Fisher's exact test was used.x) between an independent risk factor (x) and a multivariate outcome variable, while assuming a particular correlation structure between the repeated measures, in this case multiple HPV types p≥0.05) variables were removed by backward selection.Generalized estimating equations (GEE) analyses were performed to assess independent risk factors associated with the presence of HPV DNA, and separate analyses were performed to asses independent risk factors associated with HPV Ab seropositivity. GEE models are marginal and take into account multiple measurements, making them highly suitable for estimating population-averaged risks associated with repeated measures p values based on Wald tests, and this procedure was repeated until all remaining parameters were significant. Final estimates were obtained after orthonormal transformation of the log odds ratio estimation matrix. In modelling the association between pairs of responses, we made use of the alternating logistic regression algorithm of the SAS GENMOD procedure GEE models were also used to estimate possible type-specific associations between the presence of HPV DNA and HPV Ab. These analyses were also stratified by gender, but could not be performed for MSM because of the small group size. For these analyses, we used a saturated model for the independent risk factors and started with a fully parameterized model for the pair-wise log odds ratios between all 14 genital HPV DNA and HPV Ab outcome variables. The starting log odds ratio model was composed of 14×13/2 = 91 linear parameter combinations, one for each unique binary pair of type-specific DNA and/or Ab of the seven HPV types. All nonsignificant parameters were subsequently deleted from the model using Bonferroni-corrected In 2009 and 2011, 1637 and 1932 participants, respectively, were tested for a genital HPV infection. Of these 3569 participants, 3439 (96%) were also tested for HPV Ab. After exclusion of 6 HIV-positive persons and 105 self-reported HPV-vaccinated women, a study population of 3328 participants remained, of whom two-thirds were females (n = 2233). A subgroup of 118 (5%) women, 56 (6%) MSW, and 124 (72%) MSM also had a test result for anal HPV DNA infection.Characteristics stratified for women, MSW, and MSM are given in Women had the highest genital HPV DNA positivity rate (45%) with the highest type-specific rate for HPV-16 . Among men, MSM had lower positivity rates for genital (penile) DNA than MSW, 16% versus 26%, respectively. Although low genital HPV DNA positivity rates were seen in MSM, anal HPV DNA positivity rates were high. Within the subgroups that also provided anal samples , similar anal HPV DNA positivity rates were seen in MSM (33%) and women (32%), whereas anal HPV DNA positivity was rare in MSW (4%) . HPV serComparing HPV DNA positivity and HPV Ab seropositivity rates by gender, the main differences were the lower positivity rates for HPV Ab -16, -18, -31, and -52 compared to homologous HPV DNA positivity rates in MSW . Women aSimultaneous detection of type-specific HPV DNA and homologous HPV Ab genotype was most frequent for genotype 16 among all genders and sites. From Multivariable analyses resulted in different risk factors for genital HPV DNA positivity, anal HPV DNA positivity, and HPV Ab seropositivity. Most noticeable was the significant association of ethnicity with HPV Ab seropositivity for women as well as MSM, whereas ethnicity was not significantly associated with HPV DNA positivity. Persons who reported they were non-Dutch were more likely to be HPV Ab seropositive. Furthermore, in women the site of the current chlamydia infection corresponded with the site of the associated HPV DNA positivity: a genital chlamydia infection was associated with genital HPV DNA infection and an anal chlamydia infection with an anal HPV DNA infection. In MSM, reporting passive anal sex in the past six months was associated with HPV Ab seropositivity. All significant risk factors resulting from the multivariable GEE analysis are shown in The log odds ratio model for genital HPV DNA positivity and HPV Ab seropositivity could be reduced from a total of 91 parameters to as few as 7 independent parameters in women. The results of the log odds ratio model provided a justification for the assumption of an ‘exchangeable correlation’ structure in assessing independent risk factors for the presence of HPV DNA and for HPV Ab seropositivity. The associations between HPV DNA genotypes or between HPV Ab genotypes estimated by the log odds ratio model corresponded well with the alphas estimated in the multivariable GEE analyses , 4 and 5Positivity rates were high in this young and sexually active population, without the benefit of HPV vaccination. HPV DNA positivity and HPV Ab seropositivity were higher in women than in MSW, with MSM in between, but the association between detection of type-specific DNA and serum Ab was similar across gender. The PASSYON study sheds new light on differences in the natural history of HPV infection between men and women, indirectly providing evidence for a site-specific natural course of infection.In women, HPV DNA positivity rates were lower for each HPV genotype than HPV Ab seropositivity rates, whereas in MSW, type-specific HPV DNA positivity rates were higher than HPV Ab seropositivity rates with the exceptions of HPV Ab-33, -45, and -58. These specific Ab types had high positivity rates in all genders, which was confirmed by the results of the GEE analyses. Significantly higher association between Ab-33 and -45 and between Ab-33 and -58 was found, meaning that when an individual is positive for one of these Ab types, he or she is also frequently found positive for the other type. The gender differences we observed in HPV DNA positivity and HPV Ab seropositivity may be related to the type of tissue being infected. The dry keratinized tissue of the penis is much harder for the virus to infect than the soft mucosal tissue of the vagina or the anus, therefore men are less likely than women to develop a humoral response Multivariable GEE analyses helped clarify risk factors for HPV positivity. One risk factor for a HPV DNA infection in women was a current chlamydia infection. The site-specific relation between a chlamydia infection and an HPV infection was noticeable: a current genital chlamydia infection was associated with genital HPV DNA positivity and a current anal chlamydia infection with anal HPV DNA positivity. The underlying mechanism could be less efficient clearance because of this concurrent infection, resulting in a persistent infection, or easier invasion into the body. There were also behavioral factors, such as reported number of lifetime sex partners, associated with HPV DNA positivity and HPV Ab seropositivity. These results are in line with previous studies The added value of GEE analyses is the possibility to include all type-specific HPV DNA and HPV Ab outcomes in one model, thereby making optimal use of the available data. In addition, including both HPV DNA and HPV Ab test results in one model gave us the option to estimate associations between homologous and heterologous pairs of HPV DNA and HPV Ab genotypes. Despite the difference in HPV DNA positivity and HPV Ab seropositivity between women and MSW, no significant gender difference was seen in the association between a homologous or heterologous pair of HPV DNA and HPV Ab types. Equal odds ratios for the associations between HPV DNA positivity and HPV Ab seropositivity in women and MSW do not imply that the natural course of the infection would be similar between the sexes. As shown, women have a higher probability to be seropositive when HPV DNA positive then MSW. A higher degree of persistence could be an explanation for the higher seropositivity in women. Furthermore, a higher association between any two HPV Ab genotypes in MSW was observed as compared to women. This higher association in MSW could be due to the less frequent occurrence of seroconversion. It is conceivable that characteristics related to seroconversion are restricted to specific persons such that, on a population level, it will lead to a stronger clustering of seropositivity in MSW than in women, where seroconversion is more common.We also found type-specific HPV DNA and HPV Ab associations and found some associations between homologous HPV DNA and HPV Ab types, and between two heterologous HPV DNA types.These associations could have occurred because of the high level of multiple HPV infections. However, the HPV types tested in the VLP-MIA are phylogenetically related to each other, and belong to the alpha-7 species  and alpha-9 species  To summarize, the higher HPV DNA and Ab positivity rates in women and MSM as compared to heterosexual men, and the similar HPV DNA and Ab associations across gender suggest a site-specific natural course of infection. These findings in combination with the determinants for HPV DNA positivity and HPV Ab seropositivity can help us interpret the results of future rounds with more accuracy and will enable us to detect changes in HPV infection dynamics, both of vaccine and nonvaccine types.


The incidence of oropharyngeal cancers has increased in the western world and Human Papilloma Virus (HPV) has been recognised as a risk factor in the last decades. During the same period the prevalence of HPV in oropharyngeal tumours has increased and HPV has been suggested responsible for the increase. The HPV-positive tumours are today recognized as a distinct subset of head and neck cancers with its own clinopathological and risk profile and have a significantly improved prognosis regardless of treatment strategy. This review summarizes current knowledge regarding human papillomavirus biology, oncogenic mechanisms, risk factors, and impact of treatment. Head and neck squamous cell carcinoma is the sixth most common cancer worldwide . The incThe prognosis for HNSCC is generally low in the more advanced stages and there has been only a modest improvement in recent years and the treatment frequently sentences the patient to life-long sequelaes such as difficulties with swallowing, dryness of the mouth, esophageal strictures, and osteoradionecrosis. Head and neck cancer is a heterogeneous group that differs greatly in tumour aggressiveness and response to treatment. The treatment is today based on tumour stage which thus leads to suboptimal outcome for some patients. The identification of predictive markers is urgent to enable optimization of treatment and reduction of sequalae for the individual patient. Despite a decreasing incidence of head and neck squamous cell carcinoma in general, attributed to a decrease in the prevalence of smoking , the incHPV was first identified in 1949  and todaHigh-risk HPVs produce 2 oncoproteins, E6 and E7, which are necessary for viral replication through their proliferation stimulating activity and play a key role in malignant transformation and maintenance. The E6 oncoprotein binds and induces the degradation of the p53 tumour suppressor protein via an ubiqutin-mediated process disrupting the p53 pathway which leads to uncontrolled cell cycle progression , 21. TheIn head and neck cancer caused by the traditional risk factors, tobacco and alcohol, p53 is commonly mutated , 26 and In contrast to the HPV-negative cancers in the head neck region the vast majority of HPV-positive cancers lack association with the traditional risk factors, tobacco and alcohol . EpidemiAs for other head and neck cancers, the incidence of orophayrngeal cancer rates varies widely around the world and even within population significant differences have been observed. The black population in the United States, for instance, tends to have higher incidence rates than whites and hispanic populations all over the country. The SEER, Surveillance Epidemiology and End Results, covers approximately 14% of the US population and the age-standardized rates of tonsillar cancer in whites were 1.4 for men and 0.4 for women in 1993–1997. For blacks the rates were 2.9 and 0.6, per 100 000 person-years, respectively. By contrast, in China, the rates of tonsillar cancer are generally low, for instance, in Beijing where the rates were 0.1 for men and 0.0 for women, respectively. Interestingly, in Hong Kong and in Taiwan, places with great western influence, the rates were 6 to 12 times higher than in Beijing. In India, with high rates of oral cancer, the rates of tonsillar cancer were between 0.8 and 2.8 in men and 0.2 and 0.5 in women, respectively. In most countries the rates tend to be higher in males than in females with a ratio from 2 : 1 to 5 : 1. However, in the Philippines and in Vietnam women had higher incidence rates than men. Interestingly, this was true also for the Philippine population in California.Also in Europe, the incidence rates show great variations with intranational variability in some countries. The highest rates were seen in parts of France, in Somme, where the rates were as high as 6.4 for men and 0.8 for women . In several western countries, the incidence of oropharyngeal cancer has increased greatly in the last decades –9, 42–44Apart from having a different epidemiology and aetiology, the HPV-positive oropharyngeal cancers also constitute a distinct subgroup clinopathologically. HPV-positive tumours are usually poorly differentiated and nonkeratinizing and have a basaloid appearance in contrast to the HPV-negative that is more moderately differentiated and keratinizing , 50. HPVThe prognosis for HPV-positive oropharyngeal cancer patients is better than that for patients with HPV negative tumours independent of nodal status, age, stage, tumour differentiation, or gender , 58–60. While it is still unclear whether tobacco is a risk factor for HPV-induced oropharyngeal tumors, it seems clear that smoking has a negative impact on relapse and survival for the HPV-positive tumours . The risTreatment of head and neck tumours today is often standardized and based on tumour stage despite the knowledge of the heterogeneity regarding tumour aggressiveness and response to treatment of the tumours varies greatly. Treatment of patients with advanced disease often includes both oncological and surgical treatment as both carry acute side effects and lifelong sequelae. The surgical trend in the last years, especially regarding neck dissection, has turned from a very radical operation towards more organ preserving selective/modified neck dissections when possible, reducing the morbidity. In contrast, the oncological treatment has turned in the opposite direction including the development of altered fractionation radiotherapy, integration of chemotherapy with radiotherapy, incorporation of intensity-modulated radiotherapy, and the introduction of targeted biological therapy. The combined modality treatment and the altered/intensified fractionation have improved outcome for head neck cancer patients in general , 65, butPatients with HPV-positive tumours in the oropharynx show an improved survival regardless of treatment strategy. Superior outcome for HPV-positive tumours has been shown for surgery , convectStrengthening this theory, a recent published study by Ang et al.  showed nThe reason for the better response to treatment for patients with HPV positive tumours is not known. There are studies that have found an inverse relationship between tumour HPV status and presence of p53 mutations in head and neck cancer , 70. TheToday, there is a subgroup of the HPV-positive oropharyngeal cancers that have worse clinical outcome, that do not respond as well to given treatment, and have a higher rate of relapses and worse survival than the majority of the tumours in this group. A question for the future is how to separate the HPV-positive oropharyngeal tumours in this relative small group. Several potential clinical markers have been suggested, p16 , 55, 72,Based on the profound impact of HPV on the response to treatment for patients with oropharyngeal tumours, HPV-status should be included to standard pathological reporting in clinic and the planning of treatment strategies for this group of patients. Future clinical trials comprising patients with oropharyngeal tumours should include HPV status as a stratification factor in order to identify the least morbid treatment to cure this group of patients.HPV-positive oropharyngeal cancer is recognized as a distinct subset of head and neck squamous cell carcinoma with a favourable outcome. HPV status is a profound prognostic factor for overall and progression-free survival, treatment response, and tumour control. The superior outcome is independent of nodal status, age, stage, tumour differentiation, or gender and regardless of treatment strategy. The explanation for this difference is not clearly understood today and is probably a combination of several factors, patient-related  as well as tumour-related factors (presence of p53-mediated apoptosis). HPV-positive oropharyngeal tumours represent a distinct clinopathological profile where there still exist many questions to be answered regarding tumour biology and how the disease develops (tumouregenesis). In future, clinical trials on oropharyngeal tumours need to take HPV-status in consideration. There is a possibility that less intense treatment strategies with lower rate of acute and long-term side effects do not compromise the survival outcome for this group of patients. Since patients with HPV-positive oropharyngeal cancers often are younger and in good health, few severe life-long complications are very important considerations. We need further knowledge about the tumour biology and identification of additional clinical useful markers to combine with HPV-status for appropriate risk stratification in future clinical trials in order to optimize the treatment for each individual patient in the future.


The Src family tyrosine kinases (SFK) are cellular regulatory proteins that influence cell adhesion, proliferation, invasion and survival during tumor development. Elevated activity of Src was associated with increased cell proliferation and invasivity in human papillomavirus (HPV)-associated malignancies; therefore, transduced human foreskin keratinocytes (HFK) were used to investigate whether SFK activation is a downstream effect of papillomaviral oncoproteins. Activation of ubiquitously expressed SFKs, namely Src, Yes and Fyn, was investigated in both proliferating and differentiating keratinocytes.In proliferating keratinocytes, Src, Yes and Fyn mRNA levels were not affected by HPV 16 E6 or E7 oncoproteins, while at the protein level as detected by western blot, the presence of both E6 and E7 resulted in substantial increase in Src and Yes expression, but did not alter the high constitutive level of Fyn. Phospo-kinase array revealed that all ubiquitously expressed SFKs are activated by phosphorylation in the presence of HPV 16 E7 oncoprotein. Keratinocyte differentiation led to increased Yes mRNA and protein levels in all transduced cell lines, while it did not influence the Src transcription but resulted in elevated Src protein level in HPV16 E7 expressing lines.This study revealed that HPV 16 oncoproteins upregulate Src family kinases Src and Yes via posttranscriptional mechanisms. A further effect of HPV 16 E7 oncoprotein is to enhance the activating phosphorylation of SFKs expressed in keratinocytes. The Src family cytoplasmic tyrosine kinases (SFK) are important signal transducers that are activated by many different classes of cell-surface receptors including receptor tyrosine kinases, cytokine receptors, and integrin extracellular matrix receptors -3. This The major etiological factors of cervical cancer are human papillomaviruses (HPV), as nearly 100% of cervical cancers are positive for high-risk HPVs, HPV16 and HPV18 being the most prevalent genotypes detected in cervical carcinomas . HPVs arIn the present study, we investigated both the expression and the activation by phosphorylation of the ubiquitously expressed SFKs, namely Src, Yes, and Fyn in retrovirus transduced keratinocytes expressing HPV 16 E6, E7 or both oncoproteins under proliferating and differentiating culture conditions. Src and Yes expression was influenced differently by papillomaviral oncoproteins and differentiation, whereas the constitutively high Fyn expression was not affected by them. Nevertheless, the phosphorylation of the above SFKs was uniformly increased in the presence of E7 oncoprotein.Human foreskin keratinocytes (HFK) expressing HPV 16 oncoproteins were tested for the expression and the activity of SFKs. HFK cells were transduced by recombinant retroviruses carrying either the empty control vector (LXSN) or vectors encoding HPV 16 E6, E7 or both oncogenes as described previously . The celIn light of recent publications indicating that certain SFKs might be overactivated during the process of HPV-associated cervical carcinogenesis -18, we eSince western blot analysis revealed that the presence of HPV 16 E7 is associated with elevated SFK phosphorylation in HFK cells, we wished to evaluate the effect of E6 and E7 oncoproteins on the phosphorylation state of the individual members of the Src family on those tyrosine residues that are phosphorylated upon activation and therefore indicating increased kinase activity. To this end, human phospho-kinase array was performed from whole cell lysates. The results showed that in the presence of E7 there was a significant increase in the phosphorylation levels of all three ubiquitously expressed SFKs, while E6 had no effect on their activating phosphorylation when compared to control cells Figure A-B.The phospho-kinase array also provided further information on activating phosphorylation of relevant proteins such as p53 and four other SFKs. As expected, the level of p53 protein phosphorylated at serine residues S15, S46 or S392 increased in the presence of E7 oncoprotein and reflected well the p53 degradation in the presence of E6  that are activated in the presence of HPV 16 oncoproteins. Enhanced activity of SFKs has been detected in a wide range of malignancies including cervical cancer, where the most studied member of the family, Src was shown to be overactive based on the presence of activating phosphorylation at Y416 ,7,8. BesIn this study, transduction of primary human keratinocytes ensured the detection of early downstream effects of the papillomaviral oncogenes in the natural host cells. The experiments were performed from 5 to 8 passages after transduction, therefore, our observations were probably unaffected by clonal expansion of any random genomic alteration. Primary human keratinocytes can also be driven towards differentiation, which leads to changes similar to those in the upper layers of the stratified squamous epithelium. Differentiating squamous cells lose their ability to proliferate and to replicate DNA which results in an intracellular condition targeted and reverted by papillomaviral oncoproteins. This mechanism ensures the effective viral replication in natural HPV infection ,29. As pCervical carcinogenesis has the unique feature of requiring papillomaviral i.e. exogenous oncoproteins from initiation to final stage. The E6 and E7 oncoproteins of the high-risk HPV types promote viral replication by interacting with cellular regulatory proteins . More spThe key role of papillomaviral oncoproteins in cervical carcinogenesis, the ubiquitous availability of Src, Fyn and Yes non-tyrosine receptor kinases and the observed Src activation in cervical cancer suggest a link between these important oncogenic factors and the papillomaviral oncoproteins. Indeed, increased Src Y416 phosphorylation has been observed in both established cell lines  and biopsies of cervical carcinoma origin . FurtherTo investigate the involvement of high-risk HPV oncoproteins in SFK activation, first the effect of HPV 16 E6 and E7 oncoproteins was analyzed on SFK protein expression in transduced human primary keratinocytes, which revealed a heterogeneous response by Src, Yes and Fyn. In details, Src and Yes had similar requirement for both E6 and E7 to be upregulated in proliferating but not in differentiating keratinocytes. The latter condition itself made all transduced cell lines upregulate Yes protein expression with no further effect by papillomaviral oncoproteins. For Src upregulation, differentiation maintained the necessity of E7 activity but abrogated that of E6. Fyn protein expression was not influenced by the studied papillomaviral oncoproteins at all. Noteworthy, mRNA alterations could not be identified in the background of HPV 16 mediated SFK upregulation suggesting the importance of posttranscriptional regulatory mechanisms.Despite the heterogenous effects on the protein expression, activation of Src, Yes and Fyn by phosphorylation was uniformly dependent on the presence of HPV 16 E7. Thus, the HPV 16 E7 oncoprotein, assisted also by the E6, might have dual effect on SFK activity. It can activate constitutively available non receptor tyrosine kinase Fyn and it can also elevate the intracellular level of others such as Src and Yes. Being available, Src, Yes and Fyn are uniformly activated by phosphorylation on Y416 and homologous tyrosine residues, respectively, in the presence of HPV 16 E7.In this study, we observed HPV related alterations in the protein expression and activation of SFKs as a phenomenon. Underlying mechanisms can be proposed based on other studies. Our results on HPV mediated SFK activation are in agreement with a recent study where a kinase screen performed in HPV 16 E7 expressing RKO colorectal carcinoma cell lines revealed, that HPV 16 E7 expression results in substantially altered kinase requirements for viability of RKO cells . The preIn addition to the multiple intracellular pathways affected by papillomaviral oncoproteins, one has to consider their effect also on transmembrane tyrosine kinase receptors, since HPV has been shown to upregulate EGF-R and the associated focal adhesion kinase as well ,36. The Recent studies focusing on the downstream effects of Src activation in cervical cancer suggest that our results describing the phenomenon can be verified by functional assays to assess the effect of HPV oncoproteins on migrating or invading properties of the host cell -18. In tWe believe the present study enlightened an important mechanism of papillomaviral oncoproteins which contributes to the development of malignant phenotype of the host epithelial cell. Since HPV oncogene expression is necessary to maintain the malignant phenotype of cervical cancer cells, the HPV related alterations such as the altered SFK expression or activity can be regarded as both initiating and maintaining oncogenic mechanisms.In addition to the high constitutive level of Fyn in keratinocytes, the E6 and E7 oncoproteins of HPV 16 increase the level of other Src family kinases such as Src and Yes via posttranscriptional mechanism. A further effect of HPV 16 E7 oncoprotein is to enhance the activating phosphorylation of all available SFKs. Taken together, our findings imply that high-risk HPV oncoproteins might influence the activation of SFKs during the development of HPV-associated malignancies, which should be taken into consideration during the development of treatment strategies with SFK inhibitors for these cancers.Primary neonatal human foreskin keratinocytes (HFK) purchased from Invitrogen were transduced with the control LXSN retroviral vector or LXSN-based retroviral vectors expressing HPV16 E6, HPV16 E7 or both HPV16 E6 and E7 genes as described previously . Infecte3VO4. The total protein concentration of the lysates was estimated using Bradford protein assay. The extracts were mixed with Laemmli buffer, incubated at 95°C for 5 minutes, and electrophoresed on 10% SDS-polyacrilamide gel. 25 μg of each sample was loaded per lane. The separated proteins were electrotransferred onto nitrocellulose membrane  and after transfer, the membrane was blocked using 3% BSA in phosphate-buffered saline (pH 7.2) containing 0.05% Tween20 (PBST). Membrane was probed with mouse monoclonal anti-p53 , mouse monoclonal anti-Rb , mouse monoclonal anti-Src , mouse monoclonal anti-Yes , mouse monoclonal anti-Fyn , rabbit polyclonal anti-pY416 Src , or rabbit polyclonal anti-actin  primary antibodies diluted in 3% BSA in PBST. The blot was then incubated with a HRP-conjugated goat anti-mouse , or HRP-conjugated goat anti-rabbit  at a dilution of 1:10000 in 3% BSA in PBST for 1 h at room temperature. The signals were detected by using SuperSignal West Pico Chemiluminescent Substrate (Pierce) followed by exposure to X-ray film (Thermo Scientific).Proliferating and differentiating HFK cells were collected by trypsin treatment and whole cellular protein extracts were obtained by using RIPA lysis buffer  supplemented with Complete EDTA-free Protease Inhibitor Cocktail (Roche), 1 mM NaF, and 1 mM NaProtein phosphorylation was detected using the Human Phospho-Kinase Array Kit . Total protein extracts were prepared from HFK cells transduced by recombinant retroviruses carrying either the control vector (LXSN) or vectors encoding HPV 16 E6, E7, or E6/E7. The signals were detected by using SuperSignal West Pico Chemiluminescent Substrate (Pierce) followed by exposure to X-ray film (Thermo Scientific). The obtained signals were quantified with ImageJ software.Total RNA was isolated from cells using TRI reagent (Sigma) according to the manufacturer’s instructions and revers transcribed using the High Capacity cDNA Reverse Transcription Kit (Life Technologies). Quantitative real-time PCR was performed on 7500 Real Time PCR System (Life Technologies) using TaqMan Gene Expression Master Mix and Assays according to the manufacturer’s recommendations  at a total volume of 20 μl. The applied TaqMan Gene Expression Assays were for Src , Yes , Fyn , Hck , and glyceraldehyde 3-phosphate dehydrogenase  as endogenous control. Each PCR reaction was performed in triplicate at least three times.For the analysis of real-time RT-PCR results, the comparative Ct method was used to obtain the Relative Quantification (RQ) values . Statistical anlysis of gene expression data was performed with two-tailed Student t test with P < 0.05 considered as statistically significant.To analyse the results of the phospho-kinase arrays, mean and SEM of standardized spot densities were calculated (from two independent experiments with duplicates).AP1: Activator protein 1; ATM: Ataxia telangiectasia mutated; BRCA1: Breast cancer type 1; CDK: Cyclin-dependent kinase; DK-SFM: Defined Keratinocyte-Serum Free Medium; DMEM: Dulbecco’s modified Eagle’s medium; EDTA: Ethylenediaminetetraacetic acid; HDAC: Histone deacetylase; HFK: Human foreskin keratinocyte; HPV: Human papillomavirus; HRP: Horseradish peroxidase; NaF: Sodium fluoride; Na3VO4: Sodium orthovanadate; PBS: Phosphate buffered saline; PBST: Phosphate-buffered saline–Tween; PCAF: P300/CBP-associated factor; RB: Retinoblastoma protein; SDS: Sodium dodecyl sulfate; SEM: Standard error of mean; SFK: Src family kinase.The authors declare that they have no competing interests.AS designed and performed the experiments and drafted the manuscript. EG and GV provided and characterized the human cells used in the experiments. AF, BL, and PC helped in experiments. LG and TK contributed to writing the manuscript. JK participated in the financial support and contributed to writing the manuscript. All authors have read and approved the final manuscript.Department of Medical Microbiology, Medical and Health Science Center, University of Debrecen, H4032 Debrecen, Nagyerdei krt. 98., Hungary, Tel: +36-52-255425, Fax: +36-52-255424.


CDKN1A (p21) C31A, TP53 C72G, ATM G1853A, HDM2 promoter T309G, HDM2 A110G, LIG4 A591G, XRCC1 G399A, XRCC3 C241T and TGFβ1 T10C, presumed to predispose to cancer.Cervical cancer incidence is low in Saudi Arabian women, suggesting low prevalence to HPV infection due to environmental, cultural and genetic differences. Therefore, we investigated HPV prevalence and genotype distribution in cervical cancer as well as the association with 9 genetic single nucleotide polymorphisms (SNPs): One hundred cervical cancer patients (90 squamous cell carcinoma and 10 adenocarcinoma) and 100 age/sex-matched controls were enrolled. SNPs were genotyped by direct sequencing and HPV was detected and typed in tumors using the HPV Linear Array Test.XRCC1 SNP was significantly associated with cervical cancer . However, nested analysis revealed a preponderance of HPV-positivity in patients harboring the presumed risk allele TP53 G (P=0.06). Both XRCC1 and TP53 SNPs tended to deviate from Hardy-Weinberg equilibrium .Eighty-two cases (82%) were positive for HPV sequences. Seven HPV genotypes were present as single infections  and five double infections  were detected. Most common genotypes were HPV-16 (71%), 31 (7%), and 18, 45, 73 (4% each). Only XRCC1 G399A was significantly associated with cervical cancer, TP53 G72C showed borderline association only in HPV-positive patients. Deviation from HWE in HPV-positive patients indicates co-selection, hence implicating the combination of HPV and SNPs in cancer predisposition. Thus, SNPs could be more relevant biomarkers of susceptibility to cervical cancer when associated with HPV infection.HPV prevalence (82%) in cervical cancer is at the lower range of the worldwide estimation (85 - 99%). While  Cancer of the uterine cervix is the 3rd most frequent malignancy affecting women worldwide and the seventh overall, with an estimated 530,000 new cases in 2008 ,2. Amonget al. reported a prevalence of 31.6% infection with HPV-16/18 . The test has the betaglobin gene as an internal control to show adequacy of the sample. The manufacturer states a sensitivity of 96% (95% CI: 92-98%) and a specificity of 99% (95% CI: 98-100%) and has included 3 controls, 2 negatives and 1 positive for HPV-16. The kit also enables detection of multiple infections. The primers and PCR reaction conditions were provided with the test kit. The manufacturer’s recommended methodology was strictly followed as also described previously [We used the Linear Array HPV Genotyping Test eviously . Positivhttp://ihg.gsf.de/cgi-bin/hw/hwa1.pl).A total of 100 patients and 100 controls subjects were included in the project following signing an informed consent. Samples were coded with no identifiable personal data. HPV status was compared between the patients in 5-year age groups. The association between SNPs and cervical cancer was evaluated by the odd ratio (OR) with its confidence interval. The degree of significance was calculated using the Chi-Squares method. A p-value of 0.05 or less was considered statistically significant. Statistical analysis was carried out using the SigmaPlot platform  and the free online software: Case Control Studies, Tests for Association, Institute of Human Genetics, Helmholtz Center Munich, Germany (n=76) had stage II/III disease. By histology, 90 patients had squamous cell carcinoma while 10 had adenocarcinoma of the cervix. The distribution of these two histopathological types by 5-year age groups is given in Figure Normal controls had similar socio-economic and demographic distribution and age range  as the patients. Age of patients at diagnosis of cervical cancer ranged between 30 and 76 years, with a median of 46 years. The FIGO stage of the cancer ranged between IA2 and IVA but most patients  in a nearby country [HPV detection and genotyping showed that 82 patients (82%) were positive for HPV infection while 18 specimens proved to be negative (18%) after at least two independent testing. This prevalence of HPV infection in Saudi cervical cancer patients is at the lower range of the estimated 85% to 99% worldwide ,30, and  country .By histology, 60% of adenocarcinomas and 84% of squamous cell carcinomas were HPV-positive. Linear Array HPV genotyping test had detected seven different single HPV genotypes and five double infections in this cohort. Results are summarized in Table The most common HPV genotypes were HPV-16 (71%), followed by HPV-31 (7%), HPV-18, 45, 73 (4% each). Seven patients had double infections involving HPV-16/18 (4%), HPV-16/39, 16/70, 35/52, and 45/59 (1% each). In agreement with other studies, the most common HPV genotype was HPV-16  with an LIG4 rs2232641 and HDM2 rs11177386 were all majority alleles, and therefore, were omitted from the analysis. Cancer predisposition study showed significant association between XRCC1 rs25487 and having cervical cancer  have about 2-fold increased risk to develop cervical cancer (P = 0.02). These results suggest that the variant (or minority) allele could confer higher susceptibility to cervical cancer and probably the HPV-related transformation.Genetic polymorphic variation in candidate SNPs were determined for all 100 cervical cancer patients in addition to the 100 age-matched female volunteers without cancer (controls). The two SNPs, A/A) are HPV-positive compared to 82% (27/33) in heterozygous and 79% (42/53) in majority allele (G/G), suggesting a trend toward an association between the HPV-positivity and XRCC1 G399A genotype; however, it did not reach statistical significance , by comparing observed-to-expected distributions in HPV-positive (cases) and HPV-negative (controls) patients (Table P = 0.03) but not for the controls. Therefore, in HPV+ cervical cancer patients, the null hypothesis that the population is in Hardy–Weinberg frequencies is rejected, which put forward the hypothesis of probable selection. This suggests that the co-occurrence of XRCC1 G399A genotypes and HPV-positive cancer is not random, thus, implicating this SNP as a susceptibility locus to develop cervical cancer. At the molecular level, XRCC1 protein is required for efficient DNA single-strand breaks repair to maintain genomic stability in human cells  of patients with homozygous variant alleles  for HPV-positive cases, meanwhile no significant deviation was observed for HPV-negative controls. Again, these results suggest that cervical cancer occurrence is not random in the population and that certain factors such as genetic SNPs, for instance having the XRCC1 A-allele or the TP53 G-allele in connection with HPV infection, favors its development. To answer the question whether these 2 SNPs exhibit cumulative effect towards HPV mediated cervical cancer, , we have computed the number of risk alleles for XRCC1 and TP53 in patients and controls. Although the patients had higher median number of risk alleles (2 compared to 1), the difference was not statistically significant  suggesting independent effects.In contrast, no association was found for TP53 codon 72 polymorphism and cervical cancer in various populations; however, results were inconsistent [Italy and United Kingdom[et al. confirmed that the TP53 codon 72 G (arginine) is significantly overtransmitted in Caucasian cervical cancer subjects, especially in cases infected with HPV16- and/or HPV-18 [Since the first identification of the potential role of Arg/Arg genotype as a risk marker for uterine cervix neoplasia , there hnsistent . Althougnsistent . Nonethed Kingdom, two othd Kingdom,41, In lr HPV-18 .XRCC1 G399A was significantly (P = 0.02) associated with cervical cancer, while TP53 G72C showed borderline association (P = 0.06) only in HPV-positive patients. In addition, both SNPs showed degrees of deviation from Hardy-Weinberg equilibrium only in HPV-infected tumors, indicative of non-random distribution, hence implicating the combination of HPV and SNPs in cancer predisposition. Thus, SNPs could be more relevant biomarkers of susceptibility to cervical cancer when associated with HPV infection. Further studies with larger cohort are needed to confirm these results and better postulate the use of SNPs as biomarkers of susceptibility to cervical cancer.The prevalence of HPV infection in invasive cervical cancer in Saudi Arabia (82%) is at the lower range of that observed in the world (85%-99%), the most common HPV genotype was by far HPV-16 (71%), followed by HPV-31 (7%), HPV-18, 45, and 73 (4% each) with double infections were present in 8.5% of HPV-positive patients. Genetic predisposition showed that among the nine SNPs studied, only cyclin-dependent kinase inhibitor 1A; TP53: Tumor protein p53; ATM: Ataxia-telangiectasia mutated; HDM2: Human double minutes 2 ; LIG4: DNA ligase IV; XRCC1: X-ray repair cross-complementing 1; XRCC3: X-ray repair cross-complementing 3; TGFB1: Transforming Growth Factor Beta 1; HWE’: Hardy-Weinberg equilibrium; OD: Odd Ratio; CI: Confidence interval.SNP: Single nucleotide polymorphism; HPV: Human papilloma virus; CDKN1A: The authors declare that there are no conflicts of interest related to this research manuscript.GA designed the study, analyzed results and drafted manuscript. NAH processed and genotyped samples. MES and IA selected study population, gynecological sampling and patient care. All authors read and approved the final manuscript.