Using demographic, epidemiological, and cancer data from Brazil, we developed a dynamic transmission model of HPV infection between males and females. Model-projected reductions in HPV incidence under different vaccination scenarios were applied to a stochastic model of cervical carcinogenesis to project lifetime costs and benefits. We assumed vaccination prevented HPV-16 and -18 infections in individuals not previously infected, and protection was lifelong. Coverage was varied from 0-90% in both genders, and cost per-vaccinated individual was varied from I$25 to 400. At 90% coverage, vaccinating girls alone reduced cancer risk by 63%; including boys at this coverage level provided only 4% further cancer reduction. At a cost per-vaccinated individual of $50, vaccinating girls alone was <$200 per year of life saved (YLS), while including boys ranged from $810–18 650 per YLS depending on coverage. For all coverage levels, increasing coverage in girls was more effective and less costly than including boys in the vaccination programme. In a resource-constrained setting such as Brazil, our results support that the first priority in reducing cervical cancer mortality should be to vaccinate pre-adolescent girls.We assessed the cost-effectiveness of including boys  Cervical cancer is the second most common cancer in women worldwide , with thReductions in cervical cancer mortality by pre-adolescent HPV vaccination would not be observable for many years. Mathematical models that synthesize the best available data while ensuring consistency with epidemiological observations can project outcomes beyond those reported in clinical trials, can provide insights into cost-effectiveness, and can be modified as new information becomes available  transmission probability of HPV-16 per infected-susceptible partnership, (2) transmission probability of HPV-18 per infected-susceptible partnership, (3) clearance rate of HPV-16 and -18 infection, and (4) progression rate of CIN 2,3 to invasive cancer. We employed the following approach: more than 100 000 model simulations were run in the absence of vaccination or screening. For each simulation, one value for each of the four parameters was randomly selected from a uniform distribution over pre-specified plausible ranges, creating a unique natural history parameter set. Model outcomes using each parameter set were scored according to their fit with calibration targets established using epidemiological data from studies in Brazil and other South American countries. Good-fitting sets were identified based on a composite goodness-of-fit score. Details of these methods are provided in the vs boys and girls. We assumed vaccination occurred in girls and boys before age 12 and provided lifetime protection against all incident HPV-16 and -18 infections. Coverage rates were varied from 0 to 90% in girls and boys independently. After the epidemic achieved equilibrium post-vaccination, age-specific incidence rates of HPV-16 and -18 were generated for each vaccination scenario. The reductions in HPV incidence projected from the dynamic transmission model were then used as direct inputs to our previously described stochastic model  are documented elsewhere .Following published guidelines for economic evaluations, we adopted a societal perspective and included all costs and benefits regardless to whom they accrue and discounted future costs and life years by 3% annually  and coverage rates . In a vaccination programme for pre-adolescent girls alone, benefits were generally proportional to the level of coverage; for example, reduction in overall cancer risk was 14% with 25% coverage, and 63% with 90% coverage. When boys were added to the vaccination programme, cancer reduction was consistently higher than when covering girls alone; however, the magnitude of the incremental benefit of including boys depended on the level of coverage achieved for girls. For example, at 50% coverage of girls, reduction in lifetime risk of cancer increases from 29 to 40% when including equal coverage of boys; in contrast, at 90% coverage, reduction in cancer increases from 63 to 67% when including boys.Shown in At a composite cost of $25 per-vaccinated individual (approximately $5 per dose), vaccinating pre-adolescent girls alone was cost-saving compared to no vaccination, at all coverage levels. When this cost increased to $50 (approximately $12 per dose), vaccination was no longer cost-saving, and the cost-effectiveness ratios varied by level of coverage; while vaccinating girls only was consistently less than $200 per year of life saved (YLS), the ratio for vaccinating both girls and boys increased from $810 per YLS to $18 650 per YLS, as coverage increased. This trend was consistent at higher costs.vs including boys in a vaccination programme , resulting in less attractive cost-effectiveness ratios. When we comparatively assessed the impact of increasing coverage in girls to including boys in the vaccination programme, we found that even a modest increase in coverage of girls was less costly, yet more beneficial, than covering an equal percentage of boys. In other words, at any specific coverage level, a decision maker faced with the choice of trying to expand coverage in girls The Commission on Macroeconomics and Health has suggested that interventions with ratios below per capita GDP should be considered ‘very cost-effective’ . For BraAs recommended in guidelines for health economic evaluations , and in particular HPV-16 and -18, is underestimated, we may be overestimating the protective effects of the vaccine. We did not model bisexual or homosexual partnerships, nor did we include risk factors that may be changing over time, such as smoking (We assumed individuals had an equal chance of getting vaccinated, but in reality, uptake may be lower in settings with less access to adolescents, such as rural areas and where children are not in school. It will therefore be important to monitor differential uptake and post-vaccination behaviour. Finally, as we have previously reported, potentially influential uncertainties such as the duration of vaccine efficacy, magnitude of herd immunity, cross protection, interactions between HPV types and natural history of multiple infections all represent data gaps; modelled estimates will improve as better information becomes available.In light of the range of uncertainties and the unavoidable limitations inherent in modelling methods, we present our findings as exploratory and aim to provide qualitative insight into decisions that countries will be facing in the coming years regarding HPV vaccine implementation. On the basis of the most current epidemiological data, the results of this analysis suggest that the benefits of including boys in an HPV vaccination programme depend on the level of coverage achievable for girls, and in particular, the added benefit on cancer reduction is relatively small provided coverage of girls is greater than 75%. Moreover, even at this coverage level, expanding coverage in girls is more cost-effective than adding boys to the vaccination programme. In a resource-constrained setting such as Brazil, our results support that the first priority in reducing cervical cancer mortality should be to vaccinate pre-adolescent girls.


There were 171 pairs of paraffin embedded and freshly frozen samples analyzed from cervical carcinoma cases from Kampala, Uganda.Human Papillomavirus (HPV) detection results comparing paraffin embedded cervical tissue and other cervical specimens have been done with varying degrees of agreement. However, studies comparing freshly frozen specimens and paraffin embedded specimens of invasive cervical carcinomas are lacking. The aim of the study was to compare HPV detection using SPF88.9% (95% CI: 83.2%-93.2%) of paraffin embedded samples were HPV positive compared with 90.1% (95% CI: 84.6%-94.1%) of freshly frozen samples, giving an overall agreement in HPV detection between fresh tissue and paraffin embedded tissue at 86.0% (95% CI: 79.8%-90.8%). Although the proportion of HPV positive cases in freshly frozen tissue was higher than those in paraffin blocks, the difference was not statistically significant (p > 0.05). In both types of tissues, single HPV infections were predominant, with HPV16 accounting for 47% of positive cases. Comparison in the overall agreement, taking into accounts not only positivity in general, but also HPV types, showed a 65% agreement  and complete disagreement of 35.0%. HPV detection in squamous cell carcinomas (SCC) and adenocarcinomas (ADC) was similar in fresh tissue or paraffin blocks (p ≥ 0.05).p16 immunostaining in samples that had at least one HPV negative results showed that 24 out of 25 cases had an over-expressed pattern.HPV DNA detection was lower among ADC as compared to SCC. However, such differences were minimized when additional p16 testing was added, suggesting that the technical issues may largely explain the HPV negative cases. A numm (LiPA) ,6. This tigators ,8 with gtigators . In viewThe materials for this study were obtained as part of a case-control study  conducted at Mulago Hospital, Kampala, Uganda which is the teaching hospital for the College of Health Sciences of Makerere University from September 2004 to December 2006. Tumour specimens were obtained from new incident cases of cervical carcinoma presented to the hospital as part of routine care. The tumour specimens were divided into two parts. One part was fixed in 10% formalin and entered in the register of Department of Pathology for processing (paraffin blocks), while the other part was stored at -80°C until transferred to the laboratory for analysis. In cases where the tissue was deemed to be very small, the whole tissue was formalin fixed and processed for histopathological diagnosis. Each case was given an identification number so that the paraffin block could be linked with the fresh specimen. The samples from the cases were all biopsies. The local histopathological diagnosis was performed by Michael Odida.10 broad-spectrum primers PCR followed by DEIA and genotyping by LiPA25 (version 1).HPV detection and genotyping in 195 freshly frozen cervical cancer specimens was performed at the DDL Diagnostic Laboratory in The Netherlands during the period from June to August 2008, also 1,5 up to 4 years after diagnosis. HPV detection was performed using SPF25 , a reverse hybridization technique that detects 25 high-risk (HR) and low-risk (LR) HPV types . Both labs, DDL and ICO, performed routine cross-validation testing for SPF10, DEIA and LiPA with high agreement between them, concordant results of >98% (data not shown).The paraffin embedded blocks were prepared in Uganda for diagnostics purposes between September 2004 and December 2006 when the patients were recruited for the study. HPV detection and genotyping of 201 paraffin blocks was performed by pathologists at the Unit of Infections and Cancer at the Catalan Institute of Oncology (ICO) during January 2010, also 3 to 5.5 years after diagnosis. The detailed methods have been previously described in Odida et al. [Since the number of samples received at DDL and ICO differ, the comparison was performed based on the cases that were HPV analyzed in both laboratories, n = 171. Data generated at Makerere Hospital , at DDL (HPV detection in freshly frozen tissue) and at ICO  were merged into one dataset using the common identifier first provided by Makerere University. A descriptive analysis of global HPV positivity and HPV types globally and by histological diagnosis of cervical carcinoma and type of specimens was performed. Global HPV detection concordance analysis, in terms of positive or negative result was done to assess differences between the fresh and paraffin, as well as between squamous cell carcinoma (SCC) and adenocarcinomas (ADC).Further analysis for the overall agreement, taking into account not only general positivity but also HPV types, was done to assess the exact agreement between the two samples. The agreement was classified as complete, partial or complete disagreement according to the definitions below.The result is exactly the same .The cases have at least one identical type.The cases are totally different (different type or HPV positive-HPV negative).It has been largely described that p16 over-expression is a surrogate marker of HPV E7 oncoprotein-mediated catabolism of pRb in premalignant and malignant lesions of the cervical mucosa. In the present study, p16 immunostaining was performed in a selected number of paraffin embedded tissue from cancer cases in order (1) to obtain more insight regarding the HPV oncogenic role in the discordant cases and (2) to discard non-HPV related cancers in the concordant HPV negative cases. The cases included in this analysis were all HPV discordant cases (n = 24), all concordant HPV negative cases (n = 6) and a random sample of approximately a 10% of the concordant HPV positive cases (n = 15). p16INK4a was detected using the CINtec histology kit , following the manufacturer's protocol. In each series, a negative control, and a positive control consisting of an invasive cervical carcinoma were included. The percentage of stained cells  and the pattern  was recorded, and a positive case was considered when the percentage was 5 and above (++ or more) with a diffuse pattern.The Kappa statistics and McNemar test were used to test the statistical significance of HPV detection between fresh samples and paraffin blocks, while the Chi square test and Fisher exact test were used to test the statistical significance of HPV detection between SCC and ADC in both fresh and paraffin blocks. Where appropriate, 95% confidence intervals (CI) were computed, and the level of statistical significant test was set at 0.05.Overall, 154 of freshly frozen tissue were positive for HPV  and 152 of tissue in paraffin blocks were HPV positive , giving an overall agreement in HPV detection between fresh tissue and paraffin blocks at 86.0% (95% CI: 79.8%-90.8%), which was statistically significant . Although the proportion of HPV positive cases in fresh tissue was higher than those in paraffin blocks, the difference was not statistically significant . The details are shown in Table In both types of tissues, single HPV infections were predominant. Only one case has been DEIA positive, and LiPA negative  and has been detected in paraffin embedded tissue. The proportion of multiple HPV infections was higher in freshly frozen tissue cases than tissue in paraffin blocks. However, the differences between both kinds of tissues were not statically significant . The details are shown in Table In both kinds of tissue, HPV16 was the most frequently identified in 47.4% among HPV positive cases. The proportion of HPV33, HPV52 and HPV58 were almost identical. A higher proportion of HPV18 and HPV35 were identified in paraffin blocks compared to fresh tissue and, conversely, a higher proportion of HPV45, HPV68 or 73, HPV51 and HPV39 in fresh tissue. HPVs 66 and 31 were only identified in fresh tissue and HPVs 59, 11 and HPVX were only detected in paraffin embedded tissue. The details are shown in Figure Table When analyzed for the overall agreement, also taking into account HPV types, complete agreement was found to be 59.7% , partial agreement: 5.3% and complete disagreement: 35.0%.For performing the HPV detection concordance analysis stratified by histological diagnosis, we selected the cases that had a concordant histological diagnosis between the local and ICO pathology evaluation: SCC (n = 130) and ADC (n = 7).The HPV positivity in freshly frozen tissue was 91.5% (95% CI: 85.4%-95.7%), and the corresponding HPV positivity in paraffin embedded tissue was 93.1% (95% CI: 87.3%-96.8%), giving an overall agreement in HPV detection between fresh tissue and paraffin embedded tissue of 90.8% (95% CI: 84.4%-95.1%), which was statistically significant, although the strength of concordance is weak . Although identifying a higher HPV positivity in tissue from paraffin blocks, this difference was not statistically significant .The HPV positivity in freshly frozen tissue was 85.7% (95% CI: 42.1%-99.6%), and the HPV positivity in paraffin embedded tissue was 71.4% (95% CI: 29.0%-96.3%), giving an overall agreement in HPV detection between fresh tissue and paraffin blocks: 85.7% (95% CI: 42.1%-99.6%), which was not statistically significant . Although identifying a higher HPV positivity in fresh tissue, this difference was not statistically significant .Comparing HPV positivity by diagnosis and tissue preservation, adenocarcinomas were more likely to be HPV negative than SCC, both in freshly frozen tissue and paraffin embedded tissue. This difference was higher in paraffin embedded tissue than in fresh tissue , although the differences were not statistically significant (p > 0.05), as is shown in Table 45 cases were included in the p16 analysis. From these cases p16 was successfully performed in 40 (88.9%). In the other 5 cases, there was no tumour in the p16 slide (11.1%). All cases except one showed a positive p16 over-expressed pattern , see Table The goal of this study was to examine whether HPV genotyping on FFPE invasive cervical carcinoma specimens give comparable results with freshly frozen specimens obtained from the same patient simultaneously. Our study suggests that detection of HPV using SPFAnother interesting observation was the negative HPV results in both freshly frozen specimens and FFPE tissues. Our analysis of p16 immunostaining in samples with at least one negative result showed that all but one sample tested p16 positive, suggesting that the cases are HPV mediated and that the most probable reason for not detecting the virus is related to viral, specimen preservation or technical issues such as denatured DNA by alkali  or by foThe low detection of HPV in adenocarcinoma in both types of specimens is also of interest. A number of previous studies have also found low detection of HPV in adenocarcinoma of the cervix ,20,21. POur results have some implications. For areas with low resources, use of FFPE samples for HPV detection is feasible, especially HPV testing for clinical management of women with abnormal smears. In case a biopsy is taken, the paraffin embedded tissue could be referred to laboratory for HPV testing. This would make use of HPV results, whether for prognosis or detection of progression of cervical lesions like high-grade squamous intraepithelial lesion (HSIL) possible in many areas. However, there would be a need to have standard protocols so that fixation time is controlled. In some situations, the preference for fresh or paraffin tissue will depend on the amount of available tissue and the questions being addressed.10 and LiPA technology are quite sensitive and specific for HPV [Our study had some strengths. Compared with a recent study which compared the use of cervical scrapes and tissues from women with cervical carcinoma , our sam for HPV . The stuThere were no differences in HPV positivity between freshly frozen tissue and paraffin embedded tissue in general, but for specific types, only 65% of the cases had complete or partial agreement on the HPV detection. HPV DNA detection was lower in ADC as compared to SCC, the difference being higher in paraffin blocks than in fresh tissue . However, such differences were minimized when additional p16 testing was added, suggesting that technical issues largely explain the HPV negative cases.10: short PCR fragment.ADC: adenocarcinoma; CI: confidence interval; DDL: Diagnostic Laboratory; DEIA: deoxyribonucleic acid enzyme immunoassay; FFPE: formalin fixed paraffin embedded; HPV: human papillomavirus; HSIL: high-grade squamous intraepithelial lesions; ICO: Catalan Institute of Oncology; INK4: tumour suppressor protein; LiPA: line probe assay; p16INK4a: prototypic INK4 protein on p16 gen, identified as a tumour suppressor in many human cancers; PCR: polymerase chain reaction; SCC: squamous call carcinoma; SPFThe authors declare that they have no competing interests.MO, EW and SdS were responsible for developing concept, full proposal development and getting ethical approvals. MO was responsible for samples selection, histological review of origin and data cleaning. SS, BQ and LA were responsible for data analysis. BL and MA were responsible for histological review of the paraffin cases and p16 analysis. WQ, BK and LJvD were responsible for HPV DNA detection in fresh samples. MO, EW and SdS wrote the manuscript. All co-authors: SS, BL, BQ, LA, WQ, BK, LJvD, MA revised and gave valuable comments to the first draft of this manuscript. MO and EW were responsible for preparing the manuscript for submission. All authors approved the final version submitted.


Large numbers of translational breast cancer research topics have been completed or are underway, but they differ widely in their immediate and/or future importance to clinical management. We therefore conducted an international Web-based consultation of breast cancer professionals to identify the topics most widely considered to be of highest priority.Potential participants were contacted via two large e-mail databases and asked to register, at a Web site, the issues that they felt to be of highest priority. Four hundred nine questions were reduced by a steering committee to 70 unique issues, and registrants were asked to select the 6 questions they considered to be the most important.Votes were recorded from 420 voters  from 48 countries, with 48% of voters coming from North America. Half of the voters identified themselves as clinicians, with the remainder being academics, research scientists, or pathologists. The highest priority was to identify molecular signatures to select patients who could be spared chemotherapy, which gained about 50% more votes than the second topic and was consistently voted top by voters in North America, Europe, and the rest of the world. Research scientists voted the determination of the role of stem cells in breast cancer development, progression, and treatment sensitivity as the most important issue, but this was considered the sixth priority for clinicians and fourth overall.This exercise may bring a greater focus of research resources onto issues voted as top priorities. In recent years, there has been a major increase in the application of new scientific tools and knowledge to tissues and fluid samples from patients with cancer in an attempt to better understand the biology of the disease and the consequences that this biology may have for prognosis and response to treatment. The potential importance of this for increasing the individualisation of treatment is now sufficiently well recognised that few clinical trials are initiated without collection of tissues/fluids for future analysis, irrespective of the development of a hypothesis at the time. Of the solid tumours, breast cancer has received the greatest attention in this pursuit of translational research, and a number of resultant highly cited articles have affected our view of the disease ,2.It is clear, however, that although the new technologies such as expression array profiling are powerful tools, their untargeted application is likely to be a missed opportunity for delivering important clinical advances. Translational research frequently reflects the immediate scientific interests of the investigators and the specimens available to them as opposed to a specific attempt to address a question that has been identified as having the potential to advance the management of patients. The identification of high-priority questions for the breast cancer research community may be better obtained by wide consultation within that community than by local opinion based on the challenges posed and opportunities available to individual investigator groups. Such identification might result in a prioritisation of the respective issue in terms of research activity, funding priority, peer-reviewed publications, and symposia presentations.The project reported here involved an international Web-based consultation of breast cancer practitioners and researchers in which opinion was sought to identify an initial set of topics/questions perceived to be of high importance. Voting was then conducted to determine a consensus position on the importance of the questions. The project was named the Top Ten program and arbitrarily gave particular emphasis to those 10 topics/questions receiving the most votes.A steering committee composed of the authors of this paper was created to form a key advisory group on the format and execution of the consultation. An interactive Web site was developed  to allowa. A primary target database of more than 4,000 potential participants was developed by consolidation of the contact e-mail addresses of registrants at the 2005 San Antonio Breast Cancer Symposium and the 2005 St Gallen Consensus Meeting on Primary Therapy of Early Breast Cancer. A letter describing the activity as 'a global program to identify the most important questions for the breast cancer community in the area of translational research' was e-mailed to members on the database in October 2006, inviting them (and any of their colleagues) to register on the Web site and contribute their own priorities for research with a view to voting later on a consolidated list. They were informed that the two-stage process was expected to take them no more than 20 minutes. It was declared that the list of the top ten priorities would be announced at the St Gallen Consensus Meeting in March 2007 and that a simultaneous announcement on the Web site would occur. All registrants would later receive a fuller report on the activity and its results. Registration required a contact e-mail address; identification as a clinician, pathologist, research scientist, or academic; and current home country. The list of registered priorities was cumulative and could be viewed by later registrants who were asked to examine the earlier list and place only previously unlisted issues. Logging of topics/questions ceased on 3 November 2006.b. The steering committee reviewed the listings and created a consolidated list in two phases: (i) exclusion of issues that were not translational in their orientation or that were a clear duplication of another issue and (ii) reduction of markedly overlapping priorities to single unique topics.c. On 8 January 2007, registrants were contacted again by e-mail to invite them to revisit the Web site and place their votes on the consolidated list of priorities on the Web site. Six votes in order of priority were required. Voting ceased on 9 February 2007.d. Votes were counted and allocated scores as follows: top priority, 6 points; second priority, 5 points; third priority, 4 points; fourth priority, 3 points; fifth priority, 2 points; and sixth priority, 1 point. The scores were summed for each of the topics to create the consensus scoring. Descriptive analyses were performed to determine the relationship between profession and region with voting pattern.e. The top ten priorities were announced at the St Gallen Consensus Meeting on 17 March 2007 and simultaneously on the Web site.Four hundred and nine topics were logged by registrants but many were overlapping, and it was clear to the steering committee that the request to registrants to record only those topics that had not been previously logged was not fully adhered to. The initial consolidation to exclude topics that were clearly duplicated or that were not of a translational research nature reduced the number to 139. The aim and expectation of the steering committee had been to consolidate this further to no more than 30 unique topics. However, it became clear that it was not possible to reduce the number below 70 without complete exclusion of certain topics, which would have been contrary to one of the main goals of the project, namely to draw on widespread opinion unaffected by steering committee views. The full set of 70 questions is listed in Supplementary Table S1  were from Europe and the remaining 84 (20%) were from the rest of the world (RoW), with Japan making up the largest group. Registrants from a total of 48 countries voted. Two hundred nine (50%) of the registrants classed themselves primarily as clinicians, 101 (24%) as academics, 86 (20%) as research scientists, 14 (3%) as pathologists, and 10 registrants did not fit any of these categories. Whereas the proportions of research scientists and pathologists were relatively similar between North America and Europe, the proportions of academics and clinicians were not: in North America the proportions were 39% and 36%, respectively, and in Europe they were 59% and 71%, respectively.The emphasis in this consultation was on the top ten priorities, but the focus on 10 was arbitrary, so the list of the top 15 is given in Table Table Figures In recent years, the interest in applying the results of laboratory studies to advance the treatment of breast cancer has increased substantially in so-called translational research. While this is a welcome development, there has been very wide targeting of resources. This may be based on many reasons, including the local opportunities available and a consideration of the most relevant/important questions to an individual's research. The rationale of the present study was that a wide consultation to identify priority questions in translational breast cancer research might help investigators, funding agencies, and journal reviewers/editors to prioritise their resources to address the most pressing clinical questions. The documentation of the questions widely considered to be of high priority may lead investigators to review the priority of their own research in part because such research may be seen by funding agencies as more worthy of support and high-impact journals may be more likely to accept it for publication.In discussions before and during the project, the majority of consulted specialists felt the idea very worthwhile but a minority had strong reservations on a number of fronts. These included the possibility of voting being influenced by what is fashionable but of little real importance and also the possibility that, if this process did influence the research agenda, it might lead to the suppression of novel, but potentially highly important, ideas that inevitably would not feature in most voters' thoughts. The former of these issues probably can be addressed only by the passage of time, but the latter may be avoided by recognition of the possibility and an open-mindedness to new ideas/concepts as well as maintaining a focus on present priorities.The use of the San Antonio and St Gallen e-mail databases as the primary contact sources aimed to achieve worldwide interest and voting, given the predominance of North American participants in San Antonio and of participants from other parts of the world (particularly Europe) in St Gallen. The results of the request for priority questions supported our starting position that there is a very wide opinion of what is important, given that more than 130 individual questions were logged and that these could be reduced by the steering committee to only 70 unique consolidated topics. It is important to consider whether 420 registrant voters is sufficient to provide a representative guide to worldwide opinion: this is supported by the similar voting patterns from the three geographical regions, with the top question being the same for all three and only minor variation existing between them for the other top issues.Professional group appeared to influence voting more substantially. The stem cell question  gained only 151 points from clinicians compared with 391 for the topic of identifying patients who could avoid chemotherapy. In contrast, the respective points from research scientists were 136 and 114. These votes seem to be weighted according to the degree of interest in the topic for the respective professional group, the chemotherapy question being one that challenges clinicians on a frequent basis but that attracts less attention from scientists. The stem cell issue might be seen, particularly by scientists, as of central future importance to the progress in clinical breast cancer research. While this topic was not rated as unimportant by clinicians, the lower likelihood of its delivering clinically influential data in the near future might lead to its being considered less important.It could be argued that if translational research is to be targeted by processes such as this consultation, the opinions of clinicians should be given greater weighting since it is they who will be directly challenged by the issues on a regular basis; the views of other specialists would be likely to be influenced by other factors unrelated to clinical importance. An examination of Figure The goal of identifying molecular signatures to select patients who could be spared chemotherapy being the top priority is likely to reflect the widespread recognition of the very good prognosis of patients diagnosed with breast cancer in recent years. This has resulted from earlier diagnosis largely as a result of screening and the major impact of the widespread application of hormone therapies to patients with oestrogen receptor-positive disease . Thus, tIn contrast, there are fewer well-publicised studies aimed at addressing the second most important topic, namely of identifying molecular features to select the optimal chemotherapy regimen. One of the issues here is that, while molecular signatures to address prognosis can be derived using samples from non-randomised sources, this second topic requires the assessment of large sample sets from clinical trials randomising different chemotherapy regimens. Collections of such tissues have only recently become the norm, so it is only in the last few years that we have achieved the ability to address what in reality is a series of questions on the comparison of multiple different regimens, one against the other. It should also be recognised that unless there is a very large difference between treatment effectiveness according to molecular subtype, a significant statistical interaction with treatment outcome is unlikely. The establishment of a good understanding of mechanisms of response and resistance to particular regimens in laboratory studies is likely to provide the greatest opportunity for providing such markers.in situ and/or atypical ductal hyperplasia which lead to progression to invasive cancer. In common with the first priority, this can be viewed as attempting to identify patients who can avoid major therapy. The stem cell question (at No. 4) has been discussed above. The fifth priority – identifying the response and resistance mechanisms related to triple-negative/basal tumours – is one that itself has emanated from translational research in that the first expression array studies of breast cancer samples led to the identification of this group as an entity with poor prognosis and limited response to conventional therapies [The third choice in the list of priorities was the goal of identifying factors in ductal carcinoma herapies ,7. This To address each of these topics in an instructive fashion, it is essential that there be close adherence to principles of good practise for translational research: (a) a clear understanding and declaration of the question to be addressed, (b) the selection of tissue sample sets suitable for directly addressing the question, (c) the application of well-validated reagents and methodologies to tissue samples characterised as being of high quality, (d) the linkage of the samples to accurate clinical information in cases in which the topic relates to clinical outcome , and (e) the testing of sufficiently numerous samples to meet prospectively derived statistical power calculations. If any of the above guidelines are not met, the study should be declared as hypothesis-generating. If the study does not select markers based on declared hypotheses, the initial study should be recognised as a training set, which requires validation on at least one appropriate, independent test set. The conclusions from these studies should be recognised as being applicable only within the populations studied  unless subjected to further study to establish that the results may be generalised. Finally, to find its place in clinical practise, the new test may require prospective evaluation of its impact on clinical outcome.The success and importance of the present exercise are difficult to judge but may be measured in part by citations of this article or the presentations of the results at the St Gallen meeting. This will determine whether it is repeated in the coming years, as there is no doubt that priorities will change with time.RoW = the rest of the world.The authors declare that they have no competing interests.MD conceived the study and created its structure. All authors acted as members of a steering committee for the study, approved each stage of the study, and jointly consolidated the topic list. All authors read and approved the final manuscript.Table of the 70 questions/topics in the prioritised according to the total number of points.Click here for file


A systematic review of the available evidence on the role of HPV testing in cervical screening has been published by the Health Technology Assessment Committee of the UK Department of Health. The review summarized relevant data on testing methods, natural history, and prevalence of the virus in different disease groups. Cost-effectiveness modelling was undertaken. Ten major conclusions were reached and are reported here. The key conclusions were that HPV testing was more sensitive than cytology, but that there were concerns about specificity, especially in young women. The increased sensitivity led to a recommendation that HPV testing be introduced on a pilot basis for women with borderline and mild smears. HPV testing has great potential as a primary screening test, but large trials are needed to properly evaluate this application and to determine if its introduction can reduce invasive cancer rates. There is an urgent need to undertake a large trial of HPV testing in conjunction with other new technologies (liquid-based cytology and computer-assisted cytology reading) to determine the best way to integrate them into ongoing screening programmes. A range of issues including the age to start and stop screening, the appropriate screening interval, the role of self-sampling for HPV testing and the choice of primary test (HPV and/or cytology) require further evaluation. © 2000 Cancer Research Campaign


To improve our understanding of the relationship and possible associations between human papillomavirus (HPV) infection and the development of cervical malignancies, the presence of multiple types of HPV DNA sequences in cervical carcinoma was determined in Chinese citizens living in two different geographical locations where the incidences of cervical carcinoma are either relatively low or extremely high. HPV DNA sequences were found in 88.5% (54 of 61) of Chinese cervical carcinoma patients living in Taiwan, where the prevalence of cervical carcinoma is 23.7 per 100,000 women. In contrast, in LueYang in Shanxi province, an area with a very high prevalence of cervical carcinoma , only 57.1% (28 of 49) of Chinese cervical carcinoma patients were found to be infected with genital HPV. This result seems to suggest that either the presence of HPV may have different implications in different populations or HPV infection may not be the only factor that determines the development of cervical carcinoma, at least in certain geographical areas. Recently acquired transient or chronic persistent HPV infection may have a different outcome with regard to cervical carcinogenesis. Alternatively, other factors, such as host determinants, may play a role in the development of cervical carcinoma.


Since the mid-1990s, there have been growing efforts to prevent cervical cancer in less-developed countries through the development of innovative screening approaches such as visual inspection of the cervix associated with same day management of cervical lesions with cryotherapy or loop electrosurgical excision procedure (LEEP). In the past, promising cancer screening interventions have been widely promoted despite incomplete evidence, only to become the subject of intense controversies about ensuing net health benefit. Because the efficacy and effectiveness of the new protocols for global cervical cancer screening have not been well characterized yet, and as a contribution to the evaluation of the balance between the benefits and risks of these protocols, we reviewed the literature on the safety of cryotherapy and LEEP for cervical intraepithelial neoplasia (CIN) in low- and middle-income countries.We searched 12 databases  for original research published between January 1995 and April 2009. Both peer-reviewed publications and items of "grey" literature were retrieved; no language restriction was applied. We calculated the median  reported rate for each harm considered. Because of limitations and heterogeneity in the data, no formal meta-analysis was performed.The search identified 32 articles that reported safety data from 24 cryotherapy and LEEP studies. The combined sample consisted of 6,902 women treated by cryotherapy and 4,524 women treated by LEEP. Most studies were conducted in reference or research settings in Asia and Africa. Short-term harms of cryotherapy and LEEP appeared to be similar to those described in the literature from high-income countries. Information was sparse on HIV-related harms and long-term reproductive outcomes of treatment.When performed in resource-limited settings by qualified providers, cryotherapy and LEEP are not associated with excess harm. However, available data are insufficient to propose fully evidence-based protocols for routine screening of HIV-infected women and women of reproductive age. In resource-limited countries where cervical cancer is typically the most common cause of premature death among middle-aged women, an estimated 230,000 women die each year from invasive cervical cancer (ICC) ,2. In maWhereas cervical cancer burden in industrialized countries decreased sharply after the widespread introduction of effective cytological screening programs, these favourable results have not been replicated in the developing world. In low-income countries resources and infrastructure proved insufficient to offer quality Pap smear screening to more than a small fraction of adult women and high rates of loss to follow-up associated with multi-visit screening protocols further hampered success. Hence, with evidence suggesting that human papillomavirus (HPV) vaccine will not substitute for secondary prevention , attentiroutine conditions of implementation.This encouraging advance should be viewed with the understanding that cancer screening has often been controversial. Much debate in particular has surrounded the tendency for the medical and public health community to aggressively promote new screening interventions at the population level before obtaining solid evidence that the benefits of early detection reasonably outweigh the harms -9. AccorLooking at pilot studies in low-resource settings, cryotherapy  performWe searched Medline (PubMed), Google Scholar, Scopus (Elsevier), the Cochrane Library, Web of Science, OCLC (Paper First and Proceedings First), PAIS International Database (EBSCO), WHO Global Health Library, CINAHL, Science.gov, the New York Academy of Medicine Grey Literature Report, and POPLINE for single reports, abstracts and other "grey literature" published in any language between January 1995 and April 2009. We chose 1995 for our starting point since the modern concept of low-technology single-visit screening for cervical cancer emerged around that time. With the support of a medical librarian, we combined more than 20 key search terms  recruitment completeness among members of a clearly-defined cohort; (2) report of explicit definitions that allow for reproducible ascertainment of two or more harms; (3) assessment of patients status within seven days to one month of treatment; and (4) attrition rate ≤ 20% until first follow-up assessment ,23.Because the methods and quality of harm ascertainment varied considerably from one study to the other, we only estimated the minimum, median, and maximum rates of each adverse outcome across studies.The literature search produced 32 articles ,27-32], 13 on harms of LEEP ,33-47, aIndication for treatment was a biopsy- or colposcopically-confirmed diagnosis of CIN in 17 studies (71%) and an abnormal screening test result without further diagnosis work-up ("screen-and-treat" approach) in 6 studies 25%); 1 study (4%) included women with either indication for treatment. Age of participants was reported for 17 of the 24 studies and ranged from 13 to 96 years  of the LEEP studies  compared to rates of offensive or disconcerting discharge . In conof women ; whereasof women ,33,40 anof women ,45,46,49of women ,52. Finaof women , SankaraInfectious complications were discussed in 7 cryotherapy and 10 LEEP studies  ,48,51 anOut of 6 cryotherapy studies ,48,51,54In a randomized trial , the 6-mOnly one randomized controlled trial  made dirFew studies attempted to identify risk factors for complications of cryotherapy or LEEP. The factors considered included pregnancy for cryotherapy , and ageOur systematic review of the literature suggests that the short-term adverse outcomes of cryotherapy and LEEP for cervical abnormalities performed by highly skilled providers, or carefully-trained and well-supervised mid-level providers, in low- and middle income countries do not differ substantially from the outcomes previously documented for these procedures in resource-rich countries. Precise estimates of safety rates associated with cryotherapy and LEEP in less-developed countries cannot be determined at this point, however, since information remain sparse, and few of the reviewed studies, if any, met current standards for accurate and comprehensive reporting of harms ,57,58.Overall, the high degree of heterogeneity in quality, reporting, and study results complicated the tasks of abstracting and summarizing data. Most reports focused on a narrow array of perioperative and post-intervention outcomes, and few included any patient-centered measure, assessment of functional outcomes, or evaluation of long-term fertility and pregnancy outcomes. In a majority of reports the description of the data collection methods was superficial. Typically, the study personnel simply recorded the complications that they attributed to treatment; operational definitions of harms were not provided; and degree of harm was not reported on explicitly-defined severity scales. A minority of studies accounted for the possibility that patients experiencing complications may seek care at a non-study health institution. Finally, only one study reported information from a control group of untreated women to account for background risks .In recent years, several decision models have been proposed to compare the cost-effectiveness of a range of cervical cancer screening protocols in resource-limited settings -6. In thresource-rich countries, about 70% of women experienced vaginal discharge for a median of two weeks, typically with light bleeding during the first few days, and some 40% of women complained of menstrual-like pain during an average of three days [In LEEP outcome studies conducted in ree days . Minor cree days ,59,60. Aree days . Our finAlthough innovative models of referral and management services are being tested in resource-limited settings , it mustThe most substantial knowledge gap is that the safety of cryotherapy and LEEP has been the least studied in low-resource settings where the consequences of complications are potentially more serious. Experience with cryotherapy and LEEP, in women living with HIV/AIDS in particular, remains limited. In Africa, prevalence of CIN in these women reaches 50% to 76% ,63. HencOur systematic review identified only one study that assessed the risk of a woman becoming infected with HIV after cryotherapy; none that assessed risk of HIV infection after LEEP; and none that assessed the risk of HIV transmission after cryotherapy or LEEP from an infected woman to an uninfected partner. This is a major concern given what is known about the role of genital ulcerative diseases in the transmission of HIV, the ever-present risk of breeches in the process of instrument disinfection and sterilization in resource-deprived settings, and existing evidence that high levels of HIV-1 are shed in the vaginal secretions of infected women treated for CIN .Finally, our review did not find any study that assessed pregnancy outcomes after first or repeated treatments of cervical abnormalities. This is troubling since HIV-infected women diagnosed with CIN in sub-Saharan Africa are generally of reproductive age and living in societies that allocate a central importance to fulfilling marital and reproductive goals. Although evidence about the effects of cryotherapy and LEEP on future pregnancies in high-income countries have been negative or equivocal , the medOur systematic review of recent studies of the harms of cryotherapy and LEEP in developing countries includes only one study  that wasOur review does not provide evidence that cryotherapy and LEEP for cervical lesions in low- and middle-income countries are associated with more frequent, or more severe, adverse outcomes than in resource-rich contexts. Our review does indicate, however, that current data are insufficient to fully inform decisions on protocols for cervical cancer screening in HIV-infected women and women of reproductive age. Safety of CIN therapy should be further assessed in these populations under conditions of routine delivery by lower-skilled providers before screening becomes widely offered outside of demonstration programs. Finally, alternatives to cryotherapy and LEEP are needed. Since recent developments in the understanding of the HPV life cycle offer new prospect for identifying targets for drug design ,71, reseThe authors declare that they have no competing interests.EC, SK, JS and MM jointly formulated the research question, defined the inclusion/exclusion criteria, interpreted the findings, and wrote the manuscript. EC and CF (see Acknowledgements) served as primary reviewers. SK served as third referee.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/10/11/prepubSearch algorithm in Medline.Click here for fileCharacteristics of cryotherapy studies, and studies of cryotherapy versus LEEP, included in the review.Click here for fileCharacteristics of LEEP-only studies included in the review.Click here for fileSummary of evidence on safety of cryotherapy and LEEP for CIN in less-developed countries, 1995-2009.Click here for file


Postmenopausal bleeding (PMB) is a common clinical problem. Patients with PMB have 10%–15% chance of having endometrial carcinoma and therefore the diagnostic workup is aimed at excluding malignancy. Patient characteristics can alter the probability of having endometrial carcinoma in patients with PMB; in certain groups of patients the incidence has been reported to be as high as 29%. Transvaginal sonography (TVS) is used as a first step in the diagnostic workup, but different authors have come to different conclusions assessing the accuracy of TVS for excluding endometrial carcinoma. Diagnostic procedures obtaining material for histological assessment  can be more accurate but are also more invasive. The best diagnostic strategy for diagnosing endometrial carcinoma in patients with PMB still remains controversial. Future research should be focussed on achieving a higher accuracy of different diagnostic strategies. Postmenopausal bleeding (PMB) can be defined as uterine bleeding occurring at least one year after menopause. PMB is a common clinical problem in both general and hospital settings , 2. The PMB is often caused by abnormalities of the endometrium, whether they are benign or malignant. Of postmenopausal women with vaginal bleeding, 10%–15% have endometrial carcinoma –8. In coEndometrial cancer is the most common malignancy of the female genital tract in developed countries . Unlike Since two decades TVS has become widely used in the evaluation of women with PMB. Before TVS was introduced in the early 1990s, women with PMB were scheduled for dilatation and curettage (D&C). The goal of TVS assessment of the endometrium is to exclude endometrial carcinoma. The probability of endometrial pathology is strongly reduced in the presence of an endometrial ultrasound with an endometrial thickness ≤4 mm. Endometrial sampling is not recommended below this cutoff value –18. Guidelines –15 almosThe meta-analysis of Smith-Bindman et al.  combinedGupta et al.  conducteTabor et al.  includedBesides the test accuracy, the pretest probability (before any test is done) influences the performance of a diagnostic test in clinical practice. The pretest probability is approximately 10% for the whole population of patients with PMB, but various clinical characteristics can alter this pretest probability. The probability of endometrial carcinoma in women with PMB rises from 1% in women younger than 50 years to 23.8% in women older than 80 years and the incidence of malignancy is, regardless of age, higher in women with PMB and obesity (18%) or diabetes (21%) as compared to women without one of these risk factors (8.0%) [Patients with an increased endometrial thickness should undergo more invasive testing, that is, office endometrial sampling, hysteroscopy or dilation and curettage (D&C), to exclude endometrial pathology.D&C was traditionally the method of choice for investigating patients with postmenopausal bleeding. However, in approximately 60% of the D&C procedures less than half of the uterine cavity is curetted. Another drawback of D&C is that this procedure is performed under general anaesthesia in an inpatient setting . D&C is n = 3) or atypical hyperplasia (n = 1). This finding implicates that women with an insufficient sample and an endometrial thickness of 5 mm or more should not be reassured [Guidelines advocate office endometrial sampling to rule out endometrial carcinoma in women with PMB and an increased endometrial thickness, measured with TVS. Dijkhuizen et al.  performeeassured .Compared with traditional methods such as curettage, hysteroscopy offers the possibility of visualizing macroscopic or focal abnormalities and taking directed biopsies , 29. WitIn clinical practice, tests are commonly combined in diagnostic sequences and disease probabilities are usually estimated in a hierarchical manner, first combining information from history and patient characteristics followed by information from additional testing. Test accuracy studies often do not take this clinical paradigm into account. They usually report on the status of a test disregarding history and patient characteristics. Assessing tests in isolation of other tests in the diagnostic sequence  exaggerates the diagnostic information that test combinations can provide in practice.To determine the most cost-effective testing strategy for diagnosing endometrial carcinoma in women with PMB, Clark et al. constructed a decision model and evaluated 12 different strategies for the initial investigation of PMB. Depending on cancer prevalence , a strategy with TVS as initial investigation with a cut-off of 5 mm or 4 mm followed by endometrial biopsy was most cost effective [There is considerable variability in the endometrial thickness and the likelihood of endometrial carcinoma across women. This variability has been associated with individual patient characteristics including age, time since menopause, obesity, hypertension, diabetes mellitus, and reproductive factors , 32–36. Inclusion of these individual characteristics may allow for a more refined differentiation of women with the same endometrial thickness. This could result in a more individualised and possibly more accurate and efficient work-up strategy, in which a very high a priori chance of endometrial carcinoma warrants further histological testing, whereas women with a very low prior chance might be reassured even without TVS.Multivariable models to predict endometrial carcinoma incorporating patient characteristics in the diagnostic work-up for patients with PMB have been developed –40. Khanpossible diagnostic pathways for PMB. In this figure an evidence-based approach is combined with approaches requiring more research. Two areas require further research: (1) probability modelling to calculate the pretest probability of endometrial cancer based on patient characteristics [eristics  and the eristics .Sensitivity of TVS endometrial thickness measurement in women with PMB is still controversial. Future research should aim at achieving a higher accuracy of the diagnostic strategy applied. Such higher accuracy might be achieved by incorporation of patient's characteristics , presence of hypertension) in the diagnostic work-up. The incorporation of TVS with patient's characteristics in a diagnostic strategy has been studied and resulted in higher diagnostic accuracy , 39, 40.


Little is known about the natural history of human papillomavirus (HPV) infection in Asian women.A follow-up study was conducted, with exfoliated cervicovaginal cells self-collected from, and questionnaires administered to 197 female students, aged 17–26 years, who had been already examined one and half years before. The presence of 25 HPV types was evaluated by a polymerase chain reaction-based assay.The acquisition of new infection for any HPV type among 171 female students at risk who were negative at baseline, 60% of whom had remained as virgins, was 17.5% . Among individual types, HPV16, 18 and 35 showed the highest rate of new infection. Women who had had first sexual intercourse , or had changed sexual partners  during the follow-up period showed a higher risk of new HPV infection than women who had remained virgins since baseline. The rate of new infection also tended to be higher in those who started, or continued smoking during the follow-up period, than in nonsmokers. Clearance of HPV infections since baseline examination was 80.6% (95% CI: 67.6–93.5), and did not differ between high-risk and low-risk HPV types or between single- and multiple-type infections.This study shows that the acquisition of new HPV infection among young women in the Republic of Korea is high and also the clearance is frequent. Self-collection of cervicovaginal cells is applicable to follow-up studies that include virgins. More than half of sexually active women worldwide are infected by one or more genital human papillomavirus (HPV) types at some point in time , and theIn 2002, The Korean National Cancer Center conducted a survey of HPV prevalence among female students in Busan. The study design has been described in detail previously . BrieflyTo those who agreed, we mailed a package that contained an informed consent form, a self-administered questionnaire, instructions for self-collection of cervicovaginal cells in their home, and a self-collection kit (two Dacron swabs and a tube containing buffered methanol). The questionnaire requested information on changes in smoking and sexual habits since baseline examination. After three weeks, we made reminder calls to those who had not responded, and repeated the call once a week for three weeks, or until a response was obtained. We failed to contact 291 (43%) students due to changes in address or telephone number. Among the 381 students contacted, 19 (3%) refused to participate in the follow-up study, and 165 (25%) did not return the questionnaire and specimen. A total of 197 (29%) students sent back the questionnaire and cell sample. The median time interval between baseline and follow-up was 18.1 months (range: 17.1–19.7 months). All participants signed informed consent forms according to the recommendation of the Korean National Cancer Center Ethical Review Committee, which approved the study.g, and the resulting pellets stored at -70°C until needed for HPV DNA testing.The students collected the cell samples themselves in the same way they had done at baseline . They we10 primer set. Amplification products first were tested by probe hybridization in a microtiter-plate assay (DEIA version 1) for the presence of HPV DNA. SPF10 amplimers from HPV-positive samples were subsequently analyzed by reverse hybridization in an HPV line-probe assay . PCR products hybridized, at high stringency, to these probes, generating a type-specific hybridization pattern. The HPV LiPA permits specific detection of 25 HPV types: HPV 6, 11, 16, 18, 31, 33–35, 39, 40, 42–45, 51–54, 56, 58, 59, 66, 68/73, 70, and 74. HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68/73 were considered high-risk types, and all the other were considered low-risk types. Samples that were SPF10-positive by DEIA but could not be identified by the type-specific oligonucleotide probes (LiPA) were classified as HPV X (undetermined HPV types) and categorized as low-risk types.The method used for HPV testing was identical to that used at baseline . BrieflyThe Pearson chi-square test and student T-test were used to compare data from participants and non-participants to the follow-up with respect to social and behavioral characteristics. We estimated the proportion of acquisition of new infection with specific HPV type(s) by calculation on the basis of the number of cases in which a given type was detected in woman whom that the corresponding type had not been detected at baseline. Infections were also classified as high-risk or low-risk HPV type infections . Women iTable Among 197 students who participated in the follow-up study, 26 (13.2%) were positive for HPV DNA at baseline. Table Table HPV X detected at baseline in 26 students, 80.6% were cleared at follow-up, one and half years later. Clearance was not statistically different between low- and high-risk HPV types, or single- and multiple-type infections, though the number of cases was limited. If the 26 HPV-positive women are used as a denominator, 26.9% (7/26) became HPV-negative, 50.0% (13/26) cleared their baseline infection(s) but acquired new HPV types, and 23.1% (6/26) remained positive for the same HPV type(s) as at baseline (including three students with persistent HPV X infection) (data not shown).Table The prevalence of HPV infection in female students in Busan, Korea, at baseline was 15.2% . In the Acquisition of new HPV infection is common, particularly among sexually active young women, and the incidence appears to be higher for oncogenic than for non-oncogenic types ,12. A prCurrent knowledge on the relationship between smoking and incidence of HPV infection is limited, with previous studies reporting inconsistent results ,13,14. IHPV infection is common, but it is highly transient. In our study, 80% of infections cleared and 77% of students who were HPV-positive at baseline became negative for the HPV type(s) present at baseline after one and a half years. Other studies also showed that the majority of HPV infections clear after one or two years -8,12,15.A self-collected Dacron swab sample of cervicovaginal cells is a technically feasible alternative to clinician-administered cervical cell collection in natural history studies of HPV and cervical cancer . Our preOur current study has strengths and weaknesses. It is the first study to apply self-collection of cervico-vaginal cells and a very sensitive HPV testing method in a follow-up study that included many virgins, and to show high rate of acquisition of new HPV infection in young Asian women. The HPV testing method that we used at baseline and also at follow-up was highly sensitive but there could be undetected infections. New infections could be infections that were previously there and were missed, and cleared infections could be due to errors in the follow-up sample. However, these limitations are also important in this study as other studies.Unfortunately, despite repeated efforts, traceability and compliance among female students was low. Only 57% 381/671) of female students were available to contact and 52% (197/381) of those who contacted, participated this study. Furthermore, there were only 36 baseline infections available for the analysis of clearance. Thus, there was limitation to detect significant associations between risk factors and HPV acquisition or clearance. However, when we compared the characteristics  of study subjects who were and were not included in the follow-up study, they did not differ significantly  declare that they have no competing interests.JKO carried out the survey, analyzed and interpreted data, and drafted the manuscript. YHJ participated in the design of the study and carried out the survey. SF involved in designing the survey, drafting the manuscript and revising it critically for important intellectual content. WQ carried out the laboratorial works and drafted the manuscript. HRS conceived of the study, and participated in its design and coordination and helped to complete the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Understanding of the indications for hysterectomy and of the rationale for follow-up of women post hysterectomy is currently limited. Guidelines concerning follow-up by means of vaginal vault cytology tests exist but these are not based on 'gold standard' evidence. Furthermore, the extent to which current practice reflects these guidelines is unclear. This study aims to determine the factors associated with variability in hysterectomy rates and subsequent follow-up after surgery by use of the vaginal vault smear cytology test.All women resident in the West Midlands region, of the United Kingdom, who had a hysterectomy operation between 1st April 2002 and 30th March 2003 will be identified from the Hospital Episodes Statistics database which also contains proxy data on deprivation status, derived from postcode and self declared ethnicity. These data will be linked to regional cervical screening records for each woman and histopathology laboratory records from the relevant hospitals. Study objectives are to describe: Indications for the hysterectomy operation, histology at hysterectomy, subsequent follow-up by use or non-use of vaginal vault cytology tests and variation between histological groups. Additionally the data will be categorised according to a woman's cytology screening history prior to surgery  and these different groups compared. Variations in these outcomes according to age, deprivation and ethnic group will also be examined. Analysis will be undertaken using SPSS.This study will clarify patterns of current practice in one large English region and determine whether this practice reflects existing guidelines. The study will also strengthen the evidence base for future guidelines.National Research Register N0138173331 Surgical removal of the uterus (womb) is a 'hysterectomy' operation; over 98% women who have their uterus removed also have the cervix uteri or 'neck' of the uterus removed at the same time, a total hysterectomy. This leThe most common indication for a hysterectomy is menorrhagia which accounts for 46% of all hysterectomies. Prolapse accounts for a further 20%, and fibroids (or leiomyoma) another 18%–21% .Hysterectomy is inversely associated with social class and education with women from lower social classes being more likely to have a hysterectomy . SeveralNo international consensus exists on the appropriate extent of cytological screening in women who have undergone hysterectomy, as evidence for the appropriate use of vaginal vault smears post-hysterectomy and the optimum period of follow-up is sparse. The majority of published studies recommend the use of vaginal vault smears in the follow-up of women who have had a hysterectomy subsequent to the diagnosis of an invasive tumour of the cervix uteri, or where invasive disease is an incidental finding at hysterectomy -12. A syCurrently the UK National Health Service Cervical Screening Programme (NHSCSP) guidelines for the use of vaginal vault smears are: ,17(i) for women on routine recall for at least 10 years prior to hysterectomy, and no CIN in the histopathology sample at hysterectomy, no vault cytology is required.(ii) for women with less than 10 years' routine recall and no CIN at hysterectomy, a sample should be taken from the vaginal vault six months after surgery and there should be no further cytology follow-up if it is negative.(iii) for women with completely excised CIN at hysterectomy, a sample should be taken from the vault at 6 and 18 months after surgery and there should be no further cytology follow-up if both samples are negative.(iii) for women with incomplete or uncertain excision of CIN follow-up should be conducted as if the cervix were still in situ (i.e as for low and high risk follow-up).(iv) women who have undergone a hysterectomy but where the cervix is not completely excised are treated as if the cervix were still present and as such they remain in the normal cervical screening programme.In a survey of primary healthcare professionals in South Birmingham, UK, half of all vault smear tests were conducted in the primary care setting but primary healthcare professionals' knowledge about the role of the test was poor . ProfessNo large-scale population studies have been undertaken to establish the actual patterns of follow-up, by use of vault smear tests, after hysterectomy. One American study compared the results of vault smears with cervical smears, in matched controls, and noted that there was a significantly reduced risk of test abnormality in those followed up post-hysterectomy . Vault sNo international consensus exists as to the most appropriate follow up by vault smear test after hysterectomy ; the UK - Estimate age and socioeconomic specific incidence rates for hysterectomy, in the West Midlands.- Describe indications for hysterectomy in West Midlands.- Describe variations in incidence and establish those factors associated with variability.- Establish the current pattern of follow-up after hysterectomy by means of vaginal vault cytology test.This retrospective population-based analysis of routinely collected data will link data, from three key sources and hence enable us to address the study objectives. Figure Hospital episode statistics (HES) is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. It is the data source for a wide range of healthcare analysis for the NHS, Government and many other organisations and individuals. For this study HES will be used to identify the population of women having a hysterectomy during the 2002 – 2003 fiscal year (1 April 2002 – 30 March 2003). These women's cervical screening history records will be obtained from the local health authority cytology databases; complete records of cytology results for all women who have had cervical screening within a local catchment area, ten such areas cover the West Midlands Health Authority region. All these cytology databases use the same suite of software and contribute to national statistics to ensure uniform reporting. These data will be linked and pseudo-anonymised to just NHS number: A national, unique, ten-digit identifier that makes it possible to share patient information across the whole of the NHS) then supplemental data about specific diagnosis and laboratory advice will be added from hospital pathology laboratory records [The cohort will include all women resident in the West Midlands region who had a hysterectomy operation during the defined study period.The West Midlands conurbation of 5.2 million inhabitants covers a very diverse population: It includes urban, suburban and rural areas ranging from some of the most to the least affluent wards in the country . This reBlack and minority ethnic groups make up 11.3% of the West Midlands population, however the range within the region is quite striking with the 'Birmingham' Local Health Authority recording 29.6% of persons classifying themselves as being of black or minority ethnic group (second only to London) but the 'Staffordshire Moorlands' Health Authority figure is only 0.7% .The study depends upon the extraction of data, from three separate routinely collected datasets, which will then be combined into a relational database (Microsoft Access 2007) in a format suitable for analysis and fully anonymised. Table The Hospital Episode Statistics (HES) dataset is managed by Northgate Information Solutions and access to sensitive confidential information requires permission to be granted by their security and confidentiality advisory group (SCAG) . It is fThe NHS Information Authority (NHSIA) has control over the Exeter database: The NHSIA is a 'special health authority' formed in 1999, the 'Exeter' system or now, more correctly the 'National Health Applications and Infrastructure Service' (NHAIS) is an integrated suite of software used by all health authorities at a regional level for holding administrative details of patients on GPs lists and used to manage patient registration, GP payments, breast and cervical screening programme . The NHSCurrently there are 17 cytopathology units in the West Midlands region and over 20 units where hysterectomy operations are performed routinely. To obtain accurate data concerning the histology at hysterectomy, it will be necessary to access the histopathology records from some hospitals directly. Since 1995 all histopathology laboratories in the West Midlands have had stand alone, computerised databases of their clinical records and thus data extraction will not require access to patient case notes, just to the electronic histopathology and cytopathology records.Once matching and merging of all three data sets is complete, all data will be anonymised to the level of unique study identifier, age at hysterectomy and deprivation index; thus NHS number, surname, date of birth and postcode will be replaced with less identifiable indices.The whole project was registered on the National Research Register in December 2004 entry: N0138173331. The approvals of both Multi Research Ethics Committee (MREC) and Patient Information Advisory Group (PIAG), have already been granted /2005). SCAG of HES granted approval for access to their data on 11th April 2006, Ref: ET0693.This project justifies the use of confidential patient data because the likely benefits to society outweigh the implications of that transient loss of confidentiality. The outcome of this research may have significant implications for the general population of women thus it may be argued that it is in the public's best interests for the research to be undertaken. There is no intention to feed information back to the individuals involved or take any decision that affects them. There are no practicable alternatives to access patient data of this quality that would be of equal effectiveness. Confidentiality has been planned from the outset of this study, and data will be anonymised as soon as is practicable after data validation has taken place.This is a pragmatic sample of all women in the West Midlands Region who underwent a hysterectomy operation but sample size calculations were undertaken during protocol development to ensure the study will have sufficient power to detect important differences.The key groups of women are specified by their histology result at the time of surgery /malignant) as this determines their recommended follow up according to national guidelines. The data in Table ▪ 4,500 hysterectomies annually in West Midlands.▪ 80% of hysterectomies undertaken for benign indications▪ 10% for CIN▪ 5% for cancer▪ 5% will sub-total hysterectomies and excluded from analysis (approximately 225 cases excluded).For the benign histology group, a sample of 1,800 women will be sufficient to estimate prevalence of follow up to within +/-1% (95% CI); for the CIN and cancer groups the estimate would be to within +/-4% (95%CI). Thus the expected sample should be more than adequate and does not need to be expanded further.® used to produce descriptive data. A substantial amount of descriptive analysis of the data will be undertaken i.e. frequency distributions, cross tabulations and simple proportions, much of which will be amenable to visual formats.Will be undertaken using SPSS for Windows statistical software, with queries in Microsoft Access 2003Comparison of the whole study population with the West Midlands and England populations (2001 census data) with respect to Index of Multiple Deprivation , age, anPre specified analysis will be used to describe and explore those factors potentially affecting variability within the three main research areas i.e. i. Indications for hysterectomy, ii. duration of hospital stay after hysterectomy and iii. follow up after hysterectomy by means of the vaginal vault smear cytology (vault smear test).2 and t-tests as appropriate.Hospital diagnosis (obtained from HES records) will be used as a proxy for indication for hysterectomy. Indications for hysterectomy will be explored with respect to deprivation score, age, ethnicity and hospital where surgery took place. Duration of hospital stay will be described and explored with respect to age, ethnicity and deprivation score. Each of these will be considered further by histology type; benign, CIN  and malignant. Pre-hysterectomy cervical cytology data will be explored with respect to age, deprivation and ethnicity. This data will be coded according to 'per protocol' and 'non-protocol' patterns, according to UK guidelines, using an algorithm constructed by the cancer registry in the West Midlands, this is to ensure standardised results to facilitate future analysis. Post-hysterectomy vault cytology will be explored with respect to age, histology type, deprivation and ethnicity. Most of this descriptive analysis will be explored using χMultiple regression analyses will aim to determine the relative importance of those factors  on the outcomes of interest.Finally, differences in the rates of vault smear cytology between the different histology sub-groups will be further explored using Kaplan-Meir survival analysis. The sub-groups will be compared with national guidelines to establish compliance.- Hysterectomy rates: Age and deprivation index standardised rates; histology, consultant and unit specific rates.- Proportion of women who have smear tests that undergo a hysterectomy procedure by histology and also by age, deprivation index, hospital and indication for surgery.- Proportions of those women having a hysterectomy which results in the histology being reported as benign/CIN/malignant.- Proportion of those having a hysterectomy that are followed up by vault smear tests, with respect to histology group , age, deprivation index, hospital, origin of test (primary or secondary care) consultant and indication for surgery.- Analysis of over/under use of vaginal vault smears with respect to current national guidelines.Pilot work suggests that too many vault smear tests are probably being undertaken and that this test has poor sensitivity to detect disease in low risk women. These findings fit with some published work but there is a dearth of high quality research in this area.This research will establish which women are currently having hysterectomy operations and determine when vault smear cytology tests are being done, both in terms of time elapsed post-operatively and histological indication for the test. Thus, compliance with current guidelines will be established and evidence to support the development of future guidelines will be generated.Hospital Episode Statistics = HES. Multi-Centre Research Ethics Committee = MREC. Patient Information Advisory Group = PIAG. Papanicolaou smear test = Pap test. Date of Birth = DOB. National Health Service Cervical Screening Programme = NHSCSP. Cervical Intraepithelial Neoplasia = CIN. Security and Confidentiality Advisory Group of HES = SCAG. NHS Information Authority = NHSIA.The author(s) declare that they have no competing interests.HSL and SW conceived the idea for the study, JM advised during the protocol development. HSL will be undertaking the research with SW and JM providing supervision and statistical expertise. HSL wrote the first draft of this manuscript but all authors have contributed to and approved the final version.The pre-publication history for this paper can be accessed here:


Cervical cancer is the most common cancer among women in the Indonesian population, yet little is known about the prevalence of human papillomavirus (HPV). We investigated age-specific prevalence of HPV types and possible risk factors of HPV positivity in a population-based sample of 2686 women, aged 15–70 years, in Jakarta, Tasikmalaya, and Bali, Indonesia. The overall HPV prevalence was 11.4%, age-standardized to the world standard population 11.6%. The most prevalent types found were HPV 52, HPV 16, HPV 18, and HPV 39, respectively, 23.2, 18.0, 16.1, and 11.8% of the high-risk HPV types. In 20.7% of infections, multiple types were involved. Different age-specific prevalence patterns were seen: overall high in Jakarta, and in Tasikmalaya, and declining with age in Bali. The number of marriages was most associated with HPV positivity (OR 1.81 95% CI 1.31–2.51)). Remarkably, in Indonesia HPV 16 and HPV 18 are equally common in the general population, as they are in cervical cancer. HPV 52 was the most prevalent type in the general population, suggesting that this type should be included when prophylactic HPV vaccination is introduced in Indonesia. Cervical cancer is the most common cancer in women in Indonesia, as in most developing countries .Human papillomavirus (HPV) prevalence, age-specific prevalence, and type of distribution differ substantially between populations , the national Indonesian Family Welfare Organization. The smallest branches of this governmental women's movement organise activities at the village level. The attempt was made to invite all women aged 20–65 years in the selected villages and to screen at least 80% of these. Members of this local PKK invited participation by visiting women at home and informing them about risk factors, prevention, early detection, and treatment of premalignant cervical cancer lesions. Participants were individually counselled by public health nurses and their informed consent obtained; all were interviewed about socio-demographic, reproductive and cervical cancer risk factors.A total of 20 834 women, aged 12–70, were screened: 6274 from Jakarta, 8007 from Tasikmalaya, and 6553 from Bali. For the HPV typing, a random age-stratified sample of the participants was taken for each region by categorising the women in 11 5-year age groups: ⩽19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, and ⩾65 years. In each age group, 100 randomly selected samples were used for HPV analysis. As the youngest and oldest groups were under-represented (<100 women), the total samples was less than 1100 per region. For Jakarta 915 were selected, for Tasikmalaya 975, and for Bali 950 samples.g for 5 min. The supernatant was removed, and the cell pellet was re-suspended in 1 ml of phosphate-buffered saline and transferred to a 1.5 ml Eppendorf tube with a safety lock. All tubes were directly frozen and stored in a −20°C freezer and shipped on dry ice to the Department of Pathology, Leiden University Medical Center, the Netherlands.Participants underwent a visual inspection of the cervix and a smear obtained using a wooden Ayre spatula for the ectocervix and a cytobrush for the endocervix. Slides were immediately fixed with ethanol and further processed for diagnosing by cytoscreeners. The exfoliated cells remaining on the spatula and brush were suspended in 25 ml of phosphate-buffered saline in a 50 ml Falcon tube. The tubes were centrifuged at 3000 Furthermore, all women underwent visual inspection with acetic acid and those women with acetowhite lesions and/or cytological abnormalities were treated with cryotherapy. In cases of suspected cervical cancer the women were referred to the collaborating university hospitals.β-globin gene was performed. HPV DNA detection and genotyping was performed, amplified using the SPF10 primer and HPV amplimers tested on agarose gels . For each region odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional multiple logistic regression adjusted for age were calculated to estimate the association between HPV infections and risk factors adjusted for age. To test for linear trend for odds ratios, a standard .β-globin test , of the final study group . 91.2% had never been screened before, 80.7% from Jakarta, 97.4% Tasikmalaya and 95.6% Bali. Based on cytology, five of 880 women in Jakarta were diagnosed with cervical cancer, four of the 919 in Tasikmalaya and three of the 887 in Bali. Based on visual inspection with acetic acid, there were also two suspected cases in Tasikmalaya. In 13 of the 14 cases, the diagnoses were histologically confirmed and in the other the woman repeatedly refused follow up.Of the 2840 patients, 114 cellular samples were missing . Of the remaining 2726, 40 samples were excluded because of a negative Overall, 305 samples (11.4%) were HPV positive (11.6% when world age-standardized), in Jakarta 122 samples (13.9% standardized 13.2%) were HPV positive, in Tasikmalaya 81 (8.8% standardized 9.0%), and in Bali 102 samples (11.5% standardized 12.1%). In total, in 211 samples (7.9%) high-risk HPV type was detected: 77 (8.9%) in Jakarta; 62 (6.7%) in Tasikmalaya and 72 (8.1%) in Bali. Forty-six samples  were positive by the SPF10 primer set but not for HPV types represented in the line probe assay; these indicated as HPV X could not be categorised as cancer-associated or non-cancer-associated types.Twenty-four different HPV types were detected, the commonest in descending order of prevalence being HPV 52, 16, and 18. This most differed by region, as shown in In the 14 cervical cancer cases, single HPV 52 infection was detected in three and HPV 18 was also detected in three cases including one multiple infection with HPV 6. HPV 16 was detected two times, HPV 31, HPV 33 and HPV 39, HPV42 and HPV 45 were detected once. In one cancer case, HPV could not be detected.P<0.01).The age-specific prevalence overall, and by region is shown in P=0.02), while having had more than one partner was associated with a higher HPV positivity than one partner . In Tasikmalaya, the few divorced women had an OR of 6.0 (95% CI 1.39–25.91) with HPV positivity compared with married women. Although not significant, it seemed that nulliparous women were more often HPV positive  than women with 1–2 children. In Bali, being 55 years or older was inversely associated with positivity . In contrast with Jakarta, in Bali higher daily income was associated with higher positivity . In all three regions, HPV positivity was unrelated to having had a previous Pap smear, education level, smoking, the number of miscarriages, age at menarche, age at marriage, or first pregnancy.The association between HPV infection and characteristics of the studied women overall and by region after adjustment for age are shown in Among a mainly unscreened population of women in Indonesia, we found an intermediate overall prevalence of HPV, highest types 52, 16, and 18, with a different age specific pattern in the three regions.et al defined age-standardized HPV prevalence rates as ‘low’, ‘intermediate’, and ‘high’. Using a previous classification, the overall prevalence found (11.3%) was intermediate . Because the method of selection was similar in all regions, and because all households in an area were visited, we assume that participation is similar to that in Bali. The major reasons for non-participation were having to work, sickness or anxiety. The second bias concerns the fact that culturally and religiously, sexual intercourse is not allowed before marriage in Indonesia. For this reason a few questions were believed to be inappropriate and thought not to be answered honestly. Instead we asked acceptable questions: ‘HPV 52 was the most prevalent type in Jakarta and Bali, and the second most prevalent type (after 18) in Tasikmalaya accounting, respectively, for 23.1, 20.1, and 23.4% of the high-risk positive samples. Worldwide, high prevalence of HPV 52 is also reported from China, Taiwan, and Costa Rica (HPV 16 prevalence in this population was comparable to that in most parts of the world . AlthougAs expected, a history of more than one sexual partner was associated with HPV positivity . A smallIn conclusion, in Indonesia HPV 16 and 18 are equally common in the general population, as they are in cervical cancer. HPV 52 was the most prevalent type, suggesting that it should also be included in the prophylactic HPV vaccine when introduced in Indonesia.


We conducted a preliminary survey on 3064 patients who underwent upper gastrointestinal endoscopy at the Al-Thawra Hospital in Sana'a, Republic of Yemen, between January and December 1991. The age/sex distribution, demographic features and social habits with respect to cigarette and water-pipe smoking and Qat chewing were compared for patients with oesophageal and gastric cancers (n = 183). A preponderance of women with carcinoma of the mid-oesophageal was noted, previously only recorded in areas of high prevalence. Unlike Western populations, smoking and alcohol consumption were not significant risk factors. A high frequency of Qat chewing and water-pipe smoking was found for both men and women and for a group with tumours of the gastro-oesophageal junction or cardia . Numbers were insufficient to identify independent effects of each factor individually. Dietary habits alone were insufficient to account for the excess of affected females. A case-control study is now underway to investigate further the role of dietary factors, social habits, demographic features and Helicobacter pylori infection on the development of upper gastrointestinal cancer in the Yemen.


Several studies have shown that testing for high-risk human papillomavirus (HPV) types results in an improved sensitivity for CIN2+, compared with cytology, although with a somewhat lower specificity.We obtained follow-up results, with at least one smear after participation in the HART study, which compared HPV testing (HC-II) with cytology as a primary screening modality.With a median follow-up of 6 years, 42 additional cases of CIN2+ were identified; women who were HPV positive at baseline were more likely to develop CIN2+ than those who were HPV negative (hazard ratio (HR) 17.2; 95% confidence interval (CI) (9.3–31.6)) and the risk increased with increasing viral load. Compared with HPV-negative women (relative light unit (RLU) <1), the HR (95% CI) was 5.4  for 1–10 RLU and 25.5  for RLU ⩾10. Positive cytology (borderline or worse compared with negative) was also predictive of developing CIN2, although to a lesser extent ). Only one case of CIN3 and three cases of CIN2 were found in women who showed a positive cytology result but were HPV negative at baseline.After 5 years of follow-up, CIN2+ occurred in 0.23% of women who were HPV negative at baseline compared with 0.48% of women who showed a negative cytology result, indicating a much longer low-risk interval for CIN2+ after HPV testing. The introduction of cervical screening programmes based on cytology has led to a substantial reduction in the incidence of cervical cancer in countries in which it has been adequately organised , which was placed into specimen transport medium for transportation to one of two laboratories. This second sample was tested for high-risk HPV types  using the Digene (now Qiagen) Hybrid Capture II kit (HC-II). Patients were considered HPV positive if their result was above the 1 relative light unit (RLU) control value, in keeping with the manufacturer's instructions. Risk associated with increasing RLU levels was also investigated to determine the impact of viral load.Women with mild dyskaryosis or worse or with two to three inadequate cytology results were referred to colposcopy. Women with a borderline smear or an HPV-positive result (or both) were randomised into two equal groups to receive immediate colposcopy or a further cytology and HPV test in 6–12 months. Those with both a negative cytology and a negative HPV test result were considered disease free and continued routine screening. However, 460 of these women were randomly selected for colposcopy to ascertain disease rates in this subgroup of women.Full details of testing and management of women at baseline are given in the baseline paper , the national computerised call/recall NHAIS system  (London) or a combination of both systems . Follow-up colposcopy and histology results were obtained for each centre using their internal computer systems.Criteria for referral to colposcopy varied between different sites: Birmingham – one mild dyskaryosis or worse; three borderline or inadequate smears. After biopsy, all women with high-grade disease were treated, and some cases of low-grade disease as well. Edinburgh – one moderate dyskaryosis or worse, or glandular abnormality; two mild dyskaryosis; three borderline; three inadequate smears. An option of treatment or conservative management was offered to patients with biopsy-confirmed CIN1 and all CIN2 or worse cases were offered treatment. London – one mild dyskaryosis or worse; three borderline or inadequate smears. An option of treatment or conservative management was offered to patients with biopsy-confirmed CIN1 and all CIN2 cases or worse were offered treatment. Manchester – one mild dyskaryosis or worse; three borderline or inadequate smears. After biopsy, all cases of high-grade and some cases of low-grade disease were treated. Mansfield – two mild dyskaryosis or worse; two borderline or three inadequate smears. After biopsy, all cases of high-grade and some cases of low-grade disease were treated.Additional ethical approval for the follow-up stage of the study was obtained by the MREC involved with the original HART study .All eligible women from the baseline study were included (vs 97.1% previously) and for cytology of 82.1% (vs 76.6% previously). For CIN3+, sensitivity was 96.1% for HPV (97.1% previously) and 82.9% for cytology (82.6% previously).Initial results for the baseline period have been published  had a further smear more than 1 year after baseline (50 HPV negative and 3 positive), but among them, no high-grade disease was identified. Three women had an ungraded CIN at some stage in their follow-up, of whom two had an additional histological diagnosis within a period of 2 months, which confirmed CIN3 . The remaining woman had no further follow-up recorded and this result was taken to be CIN2 .n=9574) were identified as having CIN2+ at some stage. Eight (30%) of them were identified in the baseline year and the remaining 19 (70%) after this period. Including disease found at baseline, the risk of developing CIN2+ at 1, 3, 5 and 8 years after a negative HPV test result was 0.09, 0.12, 0.23 and 0.61%, respectively. P<0.0001). There is a clear increase in incidence of CIN2+ as the RLU ratio increases. Compared with an RLU ratio <1, the HR (95% CI) for CIN2+ was 5.4  for 1–10 RLU and 25.2  for RLU ⩾10 .A total of 27 (0.28%) women with a negative HPV test at baseline (n=9782) were identified as having CIN2+ at some stage. Nineteen (39%) of them were identified in the baseline year and the remaining 30 (61%) after this period. Including any disease found at baseline, the risk of developing CIN2+ at 1, 3, 5 and 8 years after a normal cytology result was 0.21, 0.28, 0.48 and 1.04%, respectively. vs 2.44% at 3 years, 0.28 vs 3.40% at 5 years and 0.84 vs 3.40% at 8 years , P<0.0001).In all, 49 (0.50%) women with a normal cytology result at baseline  had CIN2+, including 4 identified within the first year. vs none after HPV testing) (These results confirm previous reports of a longer low-risk period after a negative HPV test result than after a negative cytology result(Women with HPV positive or cytology borderline results (or both) were randomised to either immediate colposcopy or referral to a further smear/HPV test in 12 months. The rate of CIN2+ in the follow-up period was similar regardless of the randomisation group. Therefore, results were unchanged regardless of whether women are referred for immediate colposcopy or managed by follow-up screening. Some overtreatment of lesions with CIN1 (or less) based on the initial biopsy results will lead to lower disease rates during follow-up. We recorded treatment of 17 of 65 (26.2%) women with histologically confirmed CIN1 and 26 of 146 (17.8%) women with a biopsy indicating less than CIN1.vs HPV testing in younger women, wherein both tests have a higher positivity rate.In addition, the histology results in the follow-up phase were not centrally reviewed because of concerns regarding contacting women if there were discrepancies. Therefore, especially for CIN2, which is known to have substantial inter-reader variability and also uncertain progressive potential, it is possible that not all of these were progressive lesions. An exit screen in which all women receive both tests would help to minimise any ascertainment bias. In addition, this study was performed in women aged 30–60 years so that it does not provide any evidence for the relative benefits of cytology In summary, HPV testing offers improved protection from CIN2+ after a negative test result compared with the protection afforded from a normal cytology result. The risk of developing CIN2+ after a negative HPV test result was extremely low at 5 years (0.23%) and was comparable with cytology at 3 years (0.28%). These results provide additional support for using HPV as the primary screening test, and indicate that the very high sensitivity of HPV testing can not only lead to a more effective screening programme but the resulting high negative predictive value can safely allow longer screening intervals and result in a more cost-effective programme as well.