Review of the economic and quality-of-life burden of cervical human papillomavirus disease

A Randomized Controlled Trial on Pranayama and Yoga Nidra for Anxiety and Depression in Patients With Cervical Cancer Undergoing Standard of Care

Introduction Cervical cancer might intensify the psychological distress among patients with cervical cancer and the distress caused by the diagnosis and treatment. So, depression and anxiety are at higher levels in patients with cervical cancer. Yoga Nidra and Pranayama are thought to reduce the aftereffects of chemotherapy and radiotherapy potentially. So, in this study, we used the techniques of Yoga Nidra and Pranayama to evaluate their effect on patients with cervical cancer undergoing standard care. Methodology Seventy women with cervical cancer were randomized into experimental and control groups. The experimental group of patients with cervical cancer received 30 minutes of yoga intervention twice daily five days a week, for six weeks. The control group was given only the standard of care. The outcome measures were assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire. The assessment was done at baseline, second, fourth, and sixth weeks. Results The results of within‑group comparisons in both groups showed that there was a significant improvement in depression and anxiety scores, with P ≤ 0.05 being considered statistically significant. Between groups, analysis shows that in the preintervention, there was no difference between the yoga and control group as P > 0.05. After the yoga intervention, there was an enhancement in depression and anxiety scores.  Conclusions The results of the study concluded that the Yoga Nidra and Pranayama module can be given as adjuvant therapy to the standard of care in patients with cervical cancer for treating the disease and treatment-related anxiety and depression.

Impact of Head and Neck Cancer Diagnosis and Treatment on Patient-Partner Intimacy

OBJECTIVE

To determine the effects of head and neck squamous cell carcinoma diagnosis and treatment on patient- and partner-perceived intimacy and to understand if a diagnosis of HPV-related head and neck squamous cell carcinoma influences patient-partner intimacy.

STUDY DESIGN

Prospective observational.

SETTING

Single tertiary care center.

METHODS

An investigator-developed questionnaire was used to prospectively survey patients and partners in 2 groups based on human papillomavirus (HPV) status: HPV+ and HPV- at diagnosis (visit 1) and after treatment (visit 2). Surveys were scored on a 60-point scale, and results were categorized as follows: loss of intimacy (0-30), stable relationship (31-41), or improvement in intimacy (42-60). Responses of couples who participated together were assessed for concordance. Responses were considered discordant if patient and partner scores equated to different levels of perceived intimacy. Median patient and partner scores were compared via Mann-Whitney U test, and concordance was assessed with a chi-square test.

RESULTS

Thirty-four patients and 28 partners completed surveys at visit 1 and 28 patients and 15 partners at visit 2. Median scores among patients and partners were similar at the first time point (HPV+, 45 vs 45, P = .64; HPV-, 42.6 vs 40.8, P = .29) and the second (HPV+, 44.5 vs 44, P = .87; HPV-, 40.2 vs 39.6, P = .90). Concordance rates between HPV+ and HPV- couples were 63% vs 44% (P = .43) for the first time point and 89% vs 50% (P = .24) for the second.

CONCLUSION

Patients and partners reported stable or improved intimacy at both time points, and most couples tended to agree on their levels of perceived intimacy. A diagnosis of HPV did not appear to significantly affect intimacy scores.

Psychosexual Impact on a Sample of Hispanic Women With Human Papillomavirus

OBJECTIVES

Our study investigates the psychosexual impact of human papillomavirus (HPV) diagnosis and its associated conditions on Hispanic women living in Puerto Rico.

MATERIALS AND METHODS

A cross-sectional quantitative study was conducted on 205 women between 21 and 65 years old who received services at the Gynecology Clinics of the Medical Sciences Campus from April 2019 to December 2019. After obtaining approval from the institutional review board (March 27, 2019) and the informed consent of participants, participants completed a sociodemographic questionnaire and 4 psychological symptomatology-based questionnaires that measured levels of anxiety, depression, sexual satisfaction, and self-esteem.

RESULTS

Of the participants, 48.8% had a known diagnosis of HPV ( n = 100) compared with 51.2% without a known HPV diagnosis ( n = 105). A Mann-Whitney U test analysis for independent samples was used, which showed that patients with known HPV diagnoses had higher reported levels of anxiety in the Generalized Anxiety Disorder Scale with a statistical significance of 0.03, as compared with patients without a known HPV diagnosis. There was no significant difference in reported levels of depressive symptoms, self-esteem, or sexual satisfaction between the groups.

CONCLUSIONS

Our findings show that in this group of Hispanic women living in Puerto Rico, being diagnosed with HPV and its associated conditions can be associated with higher anxiety symptoms. Further studies are warranted in this population to help improve their health outcomes and access to proper primary and preventive care.

HPV-related cervical diseases: Alteration of vaginal microbiotas and promising potential for diagnosis

Vaginal microbiota is closely associated with women's health, however, the correlation between HPV-related cervical disease (HRCD) and vaginal microbiota is still obscure. In this study, patients with HRCD (n = 98) and healthy controls (n = 58) in Hangzhou were recruited, and their vaginal microbiota were collected and analyzed. The composition of the vaginal microbial community was explored, and a disease classification model was developed by random forest algorithm. The results suggested that the diversity of vaginal microbiota was significantly higher in HRCDs than that in healthy controls (p < 0.05). Firmicutes is the dominant phylum in vaginal microbiota, and Lactobacillus was identified as the most altered genus between two groups (p < 0.01). Kyoto Encyclopedia of Genes and Genomes analysis suggested the difference in vaginal microbial community functions between two groups. Furthermore, we identified 10 biomarkers as the optimal marker sets for the random forest model and found a higher probability of disease values in HRCD group in discovery cohort (p < 0.0001), with an area under the receiver operating characteristic curve reaching 89.7% (95% confidence interval: 78.3%-100%). We further validated the model in both validation and independent diagnosis cohorts, confirming its accuracy in the prediction of HRCD. In conclusion, this study revealed the community composition of vaginal microbiota in HRCDs and successfully constructed a diagnostic model for HRCD.

Development and psychometric properties of the human papillomavirus-quality of life (HPV-QoL) questionnaire to assess the impact of HPV on women health-related-quality-of-life

Purpose

The HPV-Quality-of-Life (HPV-QoL) questionnaire was developed to determine the impact of Human-Papillomavirus (HPV) infection and related interventions on women health-related quality-of-life. This study provides the development and preliminary psychometric properties of a novel HPV-QoL questionnaire for adult women with HPV.

Methods

After reviewing literature and cognitive debriefing interviews in women who had experienced HPV-related conditions, instrument items and domains were developed. A draft questionnaire was pilot tested for comprehension and ease of completion. Psychometric evaluation of the final HPV-QoL scale was conducted in a psychometric study including 252 adult women derived to our centre by a positive HPV test in the cervical cancer screening program and/or presenting genital warts.

Results

The present study reveals that the HPV-QoL questionnaire, structured in four domains: general well-being [including psychological well-being and social well-being subdomains], health, contagiousness and sexuality, showed good metric properties of feasibility irrespective of age or educational level, and time to administer was less than 5 min. Internal consistency and temporal stability (reliability) showed values above the acceptable standards. The instrument showed its concurrent validity by means of a significant correlation with mental and sexual existing instruments; GHQ-12 and FSFI questionnaires, respectively, and also known groups validity showing significant differences among the subgroups regarding either sexual dysfunction or mental deterioration.

Conclusion

This study provides an HPV-QoL questionnaire with an innovative patient-reported outcomes specific measurement tool to assess HRQoL in women with HPV infection. The present study suggests this questionnaire has satisfactory psychometric properties, including validity and reliability. Results support the use of the HPV-QoL questionnaire as a HRQoL measurement instrument for daily medical practice and clinical research.

Women's experiences after abnormal Pap smear results: a qualitative study

Background: Abnormal Pap smear result means there have been cell changes on the cervix but are not cancer. Women with abnormal test result may be affected from this situation. What do women with abnormal Pap smear results experience from a biopsychosocial perspective?Objective: This study aimed to explore the experiences of women with abnormal Pap smear results according to the biopsychosocial model.Methods: This phenomenological study's data were collected in interviews with 12 women who had abnormal Pap smear test results. Data collection tool consists of two parts that are an "Women's Information Form (WIF)" identifying women and semi-structured "Interview Form". Interviews were done face-to-face by using in-depth interviews technique. Semi-structured interview was recorded in audio recording device. Thematic approach was used to assess the data.Results: The average age of the women was 42.5 ± 3.64, their age at first sexual intercourse was 23.0 ± 2.8 years and all of them were legally married. Five main themes were determined, which were grouped under the Biopsychosocial Model Domains. The Biological Domain themes were Perception of Health and Disease, and Cervical Cancer Risk Factors; the Psychological Domain themes were Positive Feelings and Negative Feelings; the Social Domain theme was Continuing Social Life.Conclusions: It was concluded that the cultural beliefs, perceptions, emotions and practices of women with abnormal Pap smear results should be considered in the diagnostic and treatment processes. These characteristics of women's experience are also important to consider when developing strategies to address barriers to effective cervical screening, diagnosis and treatment.

The psychosexual impact of testing positive for high-risk cervical human papillomavirus (HPV): A systematic review

Objectives

Many countries are implementing human papillomavirus (HPV)‐based cervical screening due to the higher sensitivity of the test compared with cytology. As HPV is sexually transmitted, there may be psychosexual consequences of testing positive for the virus. We aimed to review the literature exploring the psychosexual impact of testing positive for high‐risk cervical HPV.

Methods

MEDLINE, PsycINFO, CINAHL Plus, Web of Science, and EMBASE were searched with no date limits. We also searched the grey literature, reference lists of included articles and carried out forward citation searching. Eligible studies reported at least one psychosexual outcome among HPV‐positive women. Qualitative and quantitative papers were included. We extracted data using a standardised form and carried out a quality assessment for each article. We conducted a narrative synthesis for quantitative studies and a thematic synthesis for qualitative studies.

Results

Twenty‐five articles were included. Quantitative study designs were diverse making it difficult to determine the impact that an HPV positive result would have in the context of routine screening. The qualitative literature suggested that psychosexual concerns cover a broad range of aspects relating to women's current and past relationships, both interpersonal and sexual.

Conclusions

The psychosexual impact of testing positive for high‐risk cervical HPV is unclear. This review highlights the need for further research in the context of HPV‐based cervical screening. As primary HPV testing is introduced more widely, it is important to understand women's responses to testing HPV positive in the cancer screening context to minimise any adverse psychosexual impact.

Cross-cultural adaptation and validation of the Functional Assessment of Chronic Illness Therapy - Cervical Dysplasia (FACIT-CD) questionnaire for Serbian women

OBJECTIVES

The FACIT-CD (Functional Assessment of Chronic Illness Therapy - Cervical Dysplasia) questionnaire is a disease-specific instrument for assessing the health-related quality of life (HRQoL) in women with cervical dysplasia. Our aim was to perform a cross-cultural adaptation and psychometric evaluation of the FACIT-CD scale in Serbian women with cervical squamous intraepithelial lesions (SIL).

STUDY DESIGN

Our study included women of reproductive age diagnosed with SIL in a single university-affiliated hospital. A total of 160 participants with histologically confirmed low-grade (LSIL) or high-grade (HSIL) squamous intraepithelial lesions responded to the Serbian version of the FACIT-CD instrument, the Short Form-36v2 questionnaire (SF-36v2), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI). Women also participated in an interview regarding their socio-demographic data. We evaluated the validity and reliability of the Serbian version of FACIT-CD.

RESULTS

The Cronbach's alpha coefficient was 0.710 for the entire sample (0.702 for LSIL and 0.711 for HSIL). We found numerous correlations between the FACIT-CD scores and SF-36v2 scores, as well as between the BAI and BDI scores for both the total score and most of the domain scores. The mean FACIT-CD total score was high (114.47 ± 13.25 out of 136.00 which is the maximum score). There were no significant differences in the mean scores between the LSIL and HSIL groups.

CONCLUSIONS

Our study demonstrated that the Serbian FACIT-CD has overall good psychometric properties in women with both LSIL and HSIL. We propose the use of the FACIT-CD questionnaire as an indicator for HRQoL in women with cervical dysplasia.

Modern therapy of anogenital warts

Modern views on human papilloma virus are presented. Actual approaches to diagnostics and treatment of patients with anogenital warts are discussed. Clinical cases of high efficiency of Imiquimodum (Keravort) in treating anogenital warts of men and women are illustrated.

Cost of illness of the cervical cancer of the uterus in Japan--a time trend and future projections

BACKGROUND

Cervical cancer is associated with high morbidity and mortality rates among young women in Japan. The objective of this study was to assess and project the economic burden associated with cervical cancer in Japan and identify factors affecting future changes in this burden on society.

METHODS

Utilizing government-based statistical nationwide data, we used the cost of illness (COI) method to estimate the COIs for 1996, 1999, 2002, 2005, 2008, and 2011 to make predictions for 2014, 2017, and 2020. The COI comprised direct and indirect costs (morbidity and mortality costs).

RESULTS

The COI was estimated to have increased by 66% from 96.1 billion yen in 1996 to 159.9 billion yen in 2011. The number of deaths increased, but the proportion of those aged ≥65 years as a percentage of all deaths remained mostly unchanged, with no increase in the average age at death. The mortality cost per person was estimated to have increased (31.5 million yen in 1996 vs. 43.5 million yen in 2011). Assuming that the current trend in health-related indicators continues, the COI is predicted to temporarily decrease in 2014, followed by almost no change in 2020 (the estimated COI is 145.3-164.6 billion yen). The mortality cost per person is predicted to remain almost unchanged (39.4-46.3 million yen in 2020).

CONCLUSIONS

The fact that the life expectancy of affected individuals is not being prolonged and that the mortality in young individuals with a high human capital value is not decreasing may contribute to future sustainment of the COI. We believe that the results of the present study are applicable to discussions of disease control priorities.

Costs associated with management of cervical human papillomavirus-related conditions

BACKGROUND

Oncogenic types of human papillomavirus (HPV) have been linked to 99.7% of cervical cancer cases worldwide.

METHODS

This retrospective claims-based analysis was conducted to assess patterns of use and costs associated with diagnostic and treatment procedures for disease attributed to HPV performed before the introduction of HPV vaccination (January 1, 2001-May 31, 2006). Percentages of commercially insured health plan enrollees who underwent each procedure of interest were calculated for each year. Annual costs (combined patient and health plan-paid amounts) were calculated from qualifying medical claims. Descriptive statistics were used to assess trends in procedure rates and costs.

RESULTS

Data for approximately 14.2 million enrollees were obtained. Hysterectomy was the most commonly administered treatment. With the exception of colposcopy with LEEP, all other treatment procedures experienced a decline in rate of use. The most frequently performed diagnostic procedure was colposcopy with endocervical curettage (ECC). With the exception of ECC, rates of diagnostic procedures reached a peak among 20- to 24-year-olds, and followed a downward trend across older groups. Hysterectomy was the most expensive treatment (median $7,383; mean $8,384) per procedure in 2006.

CONCLUSION

Results reveal high rates of use and high-associated costs of diagnostic procedures and treatments related to disease attributed to HPV.

IMPACT

The data presented may be useful in cost-effectiveness analyses and to guide decision makers evaluating how best to optimize prevention strategies.

The cost effectiveness of human papillomavirus vaccines: a systematic review

INTRODUCTION

Human papillomavirus (HPV) is one of the world's most common sexually transmitted infections, and has been associated with a number of cervical and non-cervical diseases, including cancer. HPV vaccines have been licensed for use in females for some time, but the quadrivalent vaccine has only recently become licensed for use in males. Many countries have adopted a vaccination programme for adolescent females based on results of cost-effectiveness analyses. However, given the new indications for use of the vaccine in males, decision makers require information on the cost effectiveness of vaccinating males in order to make policy decisions on whether or not to fund such programmes.

OBJECTIVE

Our objective was to conduct a qualitative systematic review to update a previously conducted review of HPV vaccine studies.

METHODS

Articles were obtained from an extensive literature search to determine the cost effectiveness of implementing an HPV vaccination programme with routine cervical cancer screening. A total of 29 studies were included in this review. Seventeen of the included articles looked only at cervical disease outcomes, and 12 studies also included non-cervical disease outcomes. Four studies explored the economic impact of vaccinating both boys and girls. One study focused on a population of men who have sex with men (MSM).

RESULTS

While different model structures, input parameters and baseline assumptions were used, the consistent message in studies that focused on female-only vaccination programmes was that routine vaccination of females is cost effective compared with cervical cancer screening alone.

DISCUSSION

Based on the currently available literature, it appears that the addition of boys to a vaccination programme generally exceeds traditional cost-effectiveness thresholds. The MSM population represents a potential additional target for routine HPV vaccination; however, more cost-effectiveness studies are required before making such a policy change.

TriVax-HPV: an improved peptide-based therapeutic vaccination strategy against human papillomavirus-induced cancers

BACKGROUND

Therapeutic vaccines for cancer are an attractive alternative to conventional therapies, since the later result in serious adverse effects and in most cases are not effective against advanced disease. Human papillomavirus (HPV) is responsible for several malignancies such as cervical carcinoma. Vaccines targeting oncogenic viral proteins like HPV16-E6 and HPV16-E7 are ideal candidates to elicit strong immune responses without generating autoimmunity because: (1) these products are not expressed in normal cells and (2) their expression is required to maintain the malignant phenotype. Our group has developed peptide vaccination strategy called TriVax, which is effective in generating vast numbers of antigen-specific T cells in mice capable of persisting for long time periods.

MATERIALS AND METHODS

We have used two HPV-induced mouse cancer models (TC-1 and C3.43) to evaluate the immunogenicity and therapeutic efficacy of TriVax prepared with the immunodominant CD8 T-cell epitope HPV16-E7(49-57), mixed with poly-IC adjuvant and costimulatory anti-CD40 antibodies.

RESULTS

TriVax using HPV16-E7(49-57) induced large and persistent T-cell responses that were therapeutically effective against established HPV16-E7 expressing tumors. In most cases, TriVax was successful in attaining complete rejections of 6-11-day established tumors. In addition, TriVax induced long-term immunological memory, which prevented tumor recurrences. The anti-tumor effects of TriVax were independent of NK and CD4 T cells and, surprisingly, did not rely to a great extent on type-I or type-II interferon.

CONCLUSIONS

These findings indicate that the TriVax strategy is an appealing immunotherapeutic approach for the treatment of established viral-induced tumors. We believe that these studies may help to launch more effective and less invasive therapeutic vaccines for HPV-mediated malignancies.

Human papillomavirus vaccination in the resourced and resource-constrained world

Human papillomavirus has been established as the causal agent for cervical cancer. The identification of a clear cause presents an unparalleled opportunity for cancer control. As such, the development of prophylactic human papillomavirus vaccines has been rightly hailed as one of the significant scientific triumphs of the past 20 years. This story of scientific triumph over disease, however, is not yet complete. The fruit of scientific labour must be delivered to the people in order to fulfil the underlying intent of the research (i.e. to prevent cancer and save lives). The success of a vaccination programme, however, does not depend on the biological efficacy of the vaccine alone. Various other local factors, such as poverty, gender inequality, cultural traditions, or religious beliefs, can significantly constrain the success of any vaccination programme. In this chapter, we provide an overview of how the human papillomavirus vaccine works and its global uptake, as well as, how variations in local contexts can affect the successful implementation of a vaccination programme. Other factors besides vaccine costs also need serious attention. With better understanding of such factors, policy makers and medical health professionals will be better equipped to make informed decisions to maximise the potential benefits of the human papillomavirus vaccines for the most number of people in individual countries.

Clinical perspectives on the role of the human papillomavirus vaccine in the prevention of cancer

The role of human papillomavirus (HPV) in the genesis of cervical cancer has been well documented, and an increasing body of literature exists with regard to the role of HPV in other cancers, including cancers of the head and neck. With the recent expansion of the United States Food and Drug Administration's approval of the quadrivalent HPV virus-like particle vaccine to include men and boys and approval of the bivalent vaccine this year, the controversies regarding who should be vaccinated, at what age is vaccination most appropriate, and the limitations of the available HPV vaccines are increasing. Health care providers are challenged with evaluating the current, but continually changing, clinical evidence when making critical decisions for their patients. A literature search of MEDLINE and SciVerse Scopus was conducted for articles published from 1998-April 2010 regarding HPV, HPV-related cancers, and HPV vaccines. Although both HPV vaccines were greater than 90% effective in the prevention of cervical cancer precursors in an according-to-protocol cohort, both vaccines were significantly less effective in the intent-to-treat population. In patients who achieved seroconversion, the geometric mean titers decrease dramatically within the first 2 years after vaccination, and then continue to decline at a slower rate. No effective antibody titer has been defined for either vaccine, and no studies have been conducted with documented HPV exposure after vaccination. With low efficacy rates in an intent-to-treat population and the potential for waning immunity, it is imperative for women to continue to receive regular Pap tests and gynecologic examinations. Although vaccine administration was shown to be cost-effective when administered to adolescent girls, many of these simulations overestimated the durability of protection, efficacy rates in sexually active women, impact of incomplete vaccination, or necessity of boosters in the future. Whereas the introduction of the HPV vaccine was an enormous advancement in the cancer prevention research arena, optimization of its clinical use is still needed.

Disparities in human papillomavirus vaccine completion among vaccine initiators

OBJECTIVE

To estimate rates of completing the full three-dose prophylactic human papillomavirus (HPV) vaccination regimen in patients who initiated the series and to identify variables associated with not completing vaccination.

METHODS

This single-institution review identified all patients initiating HPV vaccination at one of four affiliated clinics between January 2007 and June 2008. Vaccination "completers" were defined as patients who had completed all three vaccinations within 12 months of initiating the vaccination series. Logistic regression was used to identify factors associated with vaccine completion. Variables analyzed included age, type of insurance (private compared with public), practice location (urban compared with suburban), practice type (pediatrics, gynecology, or family practice), and race or ethnicity (white or African American and Hispanic).

RESULTS

Of the 1,413 girls and young women who initiated HPV vaccination, 469 (33.2%) completed the vaccine series. Overall, private insurances (odds ratio 1.87, 95% confidence interval 1.26-2.76) and suburban practice locations (odds ratio 1.44, 95% confidence interval 1.04-1.98) were associated with higher vaccine completion rates. African American race was associated with lower completion rates (odds ratio 0.50, 95% confidence interval 0.38-0.65). In multivariable analyses, the combination of younger age (11-17 years) and urban practice location was associated with very low likelihood of completing HPV vaccination (22%; P=.023).

CONCLUSION

The HPV vaccine completion rate is low. When resources are limited, disparities in HPV vaccine completion should be considered when developing programs to improve vaccine utilization. Urban girls and young women should be targeted as an at-risk population.

Estimating the Economic Burden of Racial Health Inequalities in the United States

The primary hypothesis of this study is that racial/ethnic disparities in health and health care impose costs on numerous aspects of society, both direct health care costs and indirect costs such as loss of productivity. The authors conducted three sets of analysis, assessing: (1) direct medical costs and (2) indirect costs, using data from the Medical Expenditure Panel Survey (2002–2006) to estimate the potential cost savings of eliminating health disparities for racial/ethnic minorities and the productivity loss associated with health inequalities for racial/ethnic minorities, respectively; and (3) costs of premature death, using data from the National Vital Statistics Reports (2003–2006). They estimate that eliminating health disparities for minorities would have reduced direct medical care expenditures by about $230 billion and indirect costs associated with illness and premature death by more than $1 trillion for the years 2003–2006 (in 2008 inflation-adjusted dollars). We should address health disparities because such inequities are inconsistent with the values of our society and addressing them is the right thing to do, but this analysis shows that social justice can also be cost effective.

Human papillomavirus 16-associated cervical intraepithelial neoplasia in humans excludes CD8 T cells from dysplastic epithelium

High-grade cervical dysplasia caused by human papillomavirus (HPV) type 16 is a lesion that should be susceptible to an HPV-specific immune response; disease initiation and persistence is predicated on expression of two viral Ags, E6 and E7. In immune-competent subjects, at least 25% of HPV16(+) high-grade cervical dysplasia lesions undergo complete regression. However, in the peripheral blood, naturally occurring IFN-γ T cell responses to HPV E6 and E7 are weak, requiring ex vivo sensitization to detect, and are not sufficiently sensitive to predict regression. In this study, we present immunologic data directly assessing cervical lymphocytes from this cohort. We found that nearly all cervical tissue T cells express the mucosal homing receptor, α(4)β(7) surface integrin. T cells isolated from dysplastic mucosa were skewed toward a central memory phenotype compared with normal mucosal resident T cells, and dysplastic lesions expressed transcripts for CCL19 and CCL21, raising the possibility that the tissue itself sustains a response that is not detectable in the blood. Moreover, lesion regression in the study window could retrospectively be predicted at study entry by the ability of CD8(+) T cells to gain access to lesional epithelium. Vascular endothelial expression of mucosal addressin cell adhesion molecule-1, the ligand that supports entry of α(4)β(7)(+) T cells into tissues, colocalized tightly with the distribution of CD8 T cells and was not expressed in persistent dysplastic epithelium. These findings suggest that dysregulated expression of vascular adhesion molecules plays a role in immune evasion very early in the course of HPV disease.

Qualitative study of women's anxiety and information needs after a diagnosis of cervical dysplasia

AIM: Each year almost 15,000 Danish women are diagnosed with cervical dysplasia, a precursor to cervical cancer. The period of medical follow-up, or 'watchful waiting', to monitor for regression or progression of the lesion before deciding if treatment by conisation is necessary can be long. The aim of this study was to examine the experiences of women with different stages of cervical dysplasia and to examine whether their knowledge of human papillomavirus (HPV) as the cause of cervical dysplasia influenced their perception of their disease. SUBJECT AND METHODS: We used focus group and individual interviews with 12 women diagnosed with different stages of cervical dysplasia-women who had and had not been conised. Interview guides were prepared on the basis of a literature review that identified important issues and questions for the participants. RESULTS: The participants considered cervical dysplasia to be a highly distressing condition and experienced monitoring as a worrying delay before regression of the lesions or treatment could be initiated. Women expressed a fear of cancer that was not proportional to the stage of their dysplasia, but was determined by their degree of knowledge about their condition. Unlike other sexually transmitted diseases, information about HPV did not result in stigmatisation as the perception of this disease was dominated by cancer. CONCLUSION: This study showed that it is extremely important to address women's fears, their need for information and to ensure better communication with medical practitioners about cervical dysplasia immediately after diagnosis, irrespective of the disease stage.

Beyond cervical cancer: burden of other HPV-related cancers among men and women

Human papillomavirus (HPV) infection is a necessary cause of cervical cancer, and is etiologically associated with a subset of cancers of the anus, oropharynx, penis, vagina, and vulva. Current data indicate that HPV infection is potentially associated with 90%-93% of anal cancers, 12%-63% of oropharyngeal cancers, 36%-40% of penile cancers, 40%-64% of vaginal cancers, and 40%-51% of vulvar cancers. HPV infection accounts for up to 492,800 cervical cancers and 97,215 cases of noncervical HPV-related cancers worldwide during 2002, including up to 50,780 cancers among men (13,485 anal cancers, 26,775 oropharyngeal cancers, and 10,520 penile cancers) and up to 46,435 cancers among women (14,787 anal cancers, 6,048 oropharyngeal cancers, and 25,600 vaginal/vulvar cancers). In the United States annually (1998-2003), up to 10,846 cervical cancers, 4,753 noncervical cancers among men, and 4,128 noncervical cancers among women are potentially attributable to HPV infection. Incidence rates for cervical cancer have declined significantly during the past 30 years in the United States, consistent with the success of Pap smear screening. However, incidence rates for anal, oropharyngeal, and vulvar cancers have increased substantially in recent years. The high proportion of cervical and noncervical cancers caused by HPV types 16 and 18, that is, 70%-76% for cervical cancers and 63%-95% for noncervical cancers, underscores the potential for prevention of a majority of cervical as well as noncervical HPV-related cancers through prophylactic HPV vaccination.

Mothers' preferences and willingness to pay for vaccinating daughters against human papillomavirus

A choice-format, conjoint-analysis survey was developed and fielded to estimate how features of human papillomavirus (HPV) vaccines affect mothers' perceived benefit and stated vaccine uptake for daughters. Data were collected from a national sample of 307 U.S. mothers of girls aged 13-17 years who had not yet received an HPV vaccine. Preferences for four features of HPV vaccines were evaluated: protection against cervical cancer, protection against genital warts, duration of protection, and cost. We estimate that mean maximum willingness-to-pay (WTP)-an economic measure of the total benefits to consumers-for current HPV vaccine technology ranges between $560 and $660. All vaccine features were statistically significant determinants of WTP and uptake. Mothers were willing to pay $238 more for a vaccine that provides 90% protection for genital warts relative to a vaccine that provides no protection against warts. WTP for lifetime protection vs. 10 years protection was $245. Mothers strongly valued greater cervical cancer efficacy, with 100% protection against cervical cancers the most desired feature overall. Adding a second HPV vaccine choice to U.S. consumers' alternatives is predicted to increase stated uptake by 16%. Several features were significantly associated with stated choices and uptake: age of mother, race/ethnicity, household income, and concern about HPV risks. These findings provide new data on how HPV vaccines are viewed and valued by mothers, and how uptake may change in the context of evolving vaccine technology and as new data are reported on duration and efficacy.

Public health issues related to HPV vaccination

The human papillomavirus (HPV) is clearly established as the cause of cervical cancer, and vaccines targeting oncogenic forms of the virus are important as a primary method of prevention. However, barriers to cervical screening and vaccination such as a lack of knowledge of HPV, access to healthcare, and poor follow-up prevent the acceptance and utilization of HPV vaccines. Strategies for prevention of disease and implementation of vaccination are in development, but the importance of primary prevention of HPV infection needs to be stressed. This review assesses the potential impact of vaccination for cervical cancer, barriers to vaccination, and the methods used to increase coverage. With the advent of prophylactic vaccines, HPV, a common infection in the United States, can be prevented in most women.

'Shame on you'--the psychosocial impact of genital warts

We aimed to investigate whether patients with genital warts experience greater feelings of shame and lower self-esteem compared with controls. Sixty patients with genital warts were compared with 60 asymptomatic genitourinary (GU) medicine patients and 60 orthopaedic outpatients. The shame scores of those with warts (31.08) were significantly higher (P < 0.0001) than either control group (GU medicine controls 20.77; orthopaedic controls 19.00). The impact on health-related quality of life (HRQoL) by each of the individual emotional parameters of shame, low self-esteem, intrusive thoughts, avoidance behaviour and self-efficacy impact was examined in the wart sample group. Only internalized shame (P = 0.001) and intrusive thoughts (P < 0.0001) were significant in predicting HRQoL scores. There are emotional implications in having genital warts, which can have a profound effect on a patient's quality of life and these need addressing just as much as the physical warts.

Development and psychometric properties of the HPV Impact Profile (HIP) to assess the psychosocial burden of HPV

OBJECTIVE

A comprehensive questionnaire designed to assess the full spectrum of potential human papillomavirus (HPV)-related psychosocial effects in women does not exist. The HPV Impact Profile (HIP) was developed to determine the psychosocial impact of HPV infection and related interventions.

RESEARCH DESIGN AND METHODS

Draft instrument items and domains were developed using a literature review and cognitive debriefing interviews with women who had experienced HPV-related conditions. An importance rating questionnaire guided item ranking and reduction. A draft questionnaire was pilot-tested for comprehension and ease of completion. Psychometric evaluation of the final HIP was conducted in a survey of 583 women. Data quality, item acceptability, scale acceptability, reliability, and discriminate construct validity were assessed.

OUTCOME MEASURE

The final HIP contained 29 items rated on a 0-10 point discretized visual analog scales grouped into seven hypothesized domains.

RESULTS

Total HIP scores ranged from 0 (no impact) to 100 (worst impact). Data quality was high, with missing data for items ranging from 0 to 0.7% and over 99% of the scores were computable. Cronbach's alpha ranged from 0.64 to 0.90 and was > or =0.7 for 5/7 domains. Discriminant construct validity was demonstrated. Appropriate modifications could potentially be made to improve some aspects of the HIP, including modification to include other HPV diseases such as head and neck, anal, and vulvovaginal cancers and HPV disease in men.

CONCLUSIONS

The disease-specific HIP has favorable reliability and construct validity and a good ability to discriminate among disease severity.

[The effect of anogenital warts on life quality of affected patients]

INTRODUCTION

Anogenital warts represent a clinical manifestation of the infection of the lower female genital tract, human papilloma viruses types 6 and 11. They belong to the group of sexually transmitted diseases and then may be localized either on the female or male genitalia. The aim of the study was to show the effect of anogenital warts on life quality of the affected patients.

MATERIAL AND METHODS

The study was conducted on 200 female patients using the standardized questionnaire filled in by patients under the researcher's supervision immediately before laser wart removal. Each question out of 15 could be answered by one of the suggested answers: always, almost always, sometimes, rarely and never. The answer "always" was worth one point, "almost always" two points, "sometimes" three points, "rarely" four points and never "five" points. Life quality was categorized as bad, tolerable, good, very good and excellent. The lower number of points in the questionnaire indicated the worse life quality and the higher number of points demonstrated a better life quality.

RESULTS

The study results showed that the highest number of subjects was in the third and fourth decade of life. The presence of anogenital warts had an effect on life quality in most patients. 5% of subjects assessed their life quality as bad, 16% as tolerable, 45% as good and 23% as very good. Only in 11% of patients the presence of anogenital warts did not have any effect on life quality (chi2 = 121.680, p < 0.001).

CONCLUSION

The presence of anogenital warts has a significant effect on life quality of affected patients, indicating the significance of their early detection and treatment.

HPV infection in women: psychosexual impact of genital warts and intraepithelial lesions

INTRODUCTION

Genital Human Papillomavirus (HPV) infection is the most commonly occurring sexually transmitted viral infection in humans. HPV is a wide family of DNA viruses, which may cause benign skin and mucosal tumors (genital, anal, or oral warts), intraepithelial neoplasias, and/or malignant cancers in different organs. Women are more susceptible to the oncogenic effect of HPVs, mostly at the genital site on the uterine cervix.

AIMS

This review analyzes the impact of: (i) genital warts (GWs) and their treatment; (ii) HPV-related genital, oral, and anal precancerous lesions on women's sexual function.

METHODS

A Medline search was carried out. Search terms were HPV, GWs, intraepithelial neoplasia, cervical cancer, anal cancer, oral cancer, epidemiology, HPV risk factors, sexual dysfunctions, desire disorders, arousal disorders, dyspareunia, vulvar vestibulitis, vulvodynia, orgasmic difficulties, sexual repertoire, couple sexual problems, depression, anxiety, pap smear, screening program, therapy, and vaccines.

MAIN OUTCOME MEASURES

Sexual consequences of HPV infection in women, specifically GWs and intraepithelial HPV-related neoplasia.

RESULTS

Psychosexual vulnerability increases with number of recurrences of HPV infections. Depression, anxiety, and anger are the emotions most frequently reported. However, to date, there is no conclusive evidence of a specific correlation between HPV infection and a specific female sexual disorder. The relationship between HPV and vulvar vestibulitis/vulvodynia-related dyspareunia seems not to be direct. Counseling problems, the role of anti-HPV vaccine, and the concept of the high-risk partner are discussed. The reader is offered a practical approach with clinically relevant recommendations that may prove useful in his/her daily practice when dealing with HPV-infected women and couples.

CONCLUSION

The evidence of psychosexual consequences of HPV-related GWs and intraepithelial lesions is limited. Specific research on the sexual impact of GWs and intraepithelial HPV-related lesion in women is urgently needed.

Human papillomavirus disease and vaccines

PURPOSE

Human papillomavirus (HPV) disease and vaccines and several controversial issues associated with vaccine administration are reviewed.

SUMMARY

HPV infection is the most common sexually transmitted disease in the United States. It is estimated that 20 million individuals are currently infected with HPV, with 6.2 million new infections occurring each year. Although most HPV infections are benign and are often cleared without clinical sequelae, persistent infections are associated with the development of cervical cancer in women and genital warts in both women and men. The identification of the most common disease-causing HPV types has led to the development of a quadrivalent vaccine and a bivalent vaccine. The prophylactic administration of the quadrivalent vaccine has resulted in a 96% efficacy in preventing persistent infection associated with HPV types 6, 11, 16, and 18. Similar to the quadrivalent vaccine, the bivalent vaccine is highly efficacious (96%) in preventing persistent infection against vaccine-specific HPV types (HPV-16 and HPV-18) among women who were HPV seronegative at the time of vaccination. However, many controversial issues still remain regarding routine administration and widespread acceptance. These include appropriate age at time of vaccination, parental concerns, vaccination of men or women age 26 years or older, inadequate long-term efficacy and safety data, and potential for nonvaccine-related strains to emerge as prominent oncogenic serotypes.

CONCLUSION

HPV vaccines provide a high level of protection for seronegative women against persistent infection and precancerous cervical lesions associated with vaccine-specific HPV types. However, many controversial issues still remain regarding the vaccines' routine administration and widespread acceptance.

Prevalence of high-risk human papillomavirus among older women

OBJECTIVE

To estimate the prevalence, genotypes, and individual-level correlates of high-risk human papillomavirus (HPV) among women aged 57-85.

METHODS

Community-residing women (N=1,550), aged 57-85, were drawn from a nationally representative probability sample. In-home interviews and biomeasures, including a self-collected vaginal specimen, were obtained between 2005 and 2006. Specimens were analyzed for high-risk HPV DNA using Hybrid Capture 2; of 1,028 specimens provided, 1,010 were adequate for analysis. All samples testing positive were analyzed for HPV DNA by L1 consensus polymerase chain reaction followed by type-specific hybridization.

RESULTS

The overall population-based weighted estimate of high-risk HPV prevalence by Hybrid Capture 2 (Digene Corp.) was 6.0% (95% confidence interval 4.5- 7.9). Current marital and smoking status, frequency of sexual activity, history of cancer, and hysterectomy were associated with high-risk HPV positivity. Among high-risk HPV-positive women, 63% had multiple type infections. Human papillomavirus-16 or -18 was present in 17.4% of all high-risk HPV-positive women. The most common high-risk genotypes among high-risk HPV-positive women were HPV-61 (19.1%), -31 (13.1%), -52 (12.9%), -58 (12.5%), -83 (12.3%), -66 (12.0%), -51 (11.7%), -45 (11.2%), -56 (10.3%), -53 (10.2%), -16 (9.7%), and -62 (9.2%). Being married and having an intact uterus were independently associated with lower prevalence of high-risk HPV. Among unmarried women, current sexual activity and smoking were independently and positively associated with high-risk HPV infection.

CONCLUSION

In this nationally representative population, nearly 1 in 16 women aged 57-85 was found to have high-risk HPV, and prevalence was stable across older age groups.

LEVEL OF EVIDENCE

II.

The economic burden of noncervical human papillomavirus disease in the United States

OBJECTIVE

The purpose of this study was (1) to estimate the direct medical costs of 7 major noncervical human papillomavirus (HPV)-related conditions that include genital cancers, mouth and oropharyngeal cancers, anogenital warts, and juvenile-onset recurrent respiratory papillomatosis, and (2) to approximate the economic burden of noncervical HPV disease.

STUDY DESIGN

For each condition, we synthesized the best available secondary data to produce lifetime cost per case estimates, which were expressed in present value. Using an incidence-based approach, we then applied these costs to develop an aggregate measure of economic burden.

RESULTS

The economic burden that was associated with noncervical HPV-6-, -11-, -16-, and -18-related conditions in the US population in the year 2003 approximates $418 million (range, $160 million to $1.6 billion).

CONCLUSION

The economic burden of noncervical HPV disease is substantial. Analyses that assess the value of investments in HPV prevention and control programs should take into account the costs and morbidity and mortality rates that are associated with these conditions.

Human papillomavirus infection: epidemiology and pathophysiology

More than 120 different types of the human papillomavirus (HPV) have been isolated; >40 of these types infect the epithelial lining of the anogenital tract and other mucosal areas. In the majority of individuals, HPV infections are transient and asymptomatic with most new infections resolving within 2 years. Epidemiological data from the U.S. National Health and Nutrition Examination Survey determined that the prevalence of HPV infection in a representative sample of women was highest in those aged 20-24 years (44.8%). HPV infection has been firmly established as the primary cause of cervical cancer. It is not clearly understood why HPV infections resolve in certain individuals and result in cervical intraepithelial neoplasias in others, but several factors are thought to play a role; including individual susceptibility, immune status and nutrition, endogenous and exogenous hormones, tobacco smoking, parity, co-infection with other sexually transmitted agents such as HIV, herpes simplex virus type 2 and Chlamydia trachomatis as well as viral characteristics such as HPV type, concomitant infection with other types, viral load, HPV variant and viral integration. Worldwide, pooled data from case-control studies indicated that HPV DNA could be detected in 99.7% of women with histologically confirmed squamous cell cervical cancer compared with 13.4% of control women. Both HPV infection and cervical cancer are associated with a substantial economic burden. Pharmacoeconomic data from the United States indicate that HPV infection and HIV were associated with similar total direct medical costs, and HPV infection was more costly than genital herpes and hepatitis B combined in the 15-25 age group. Furthermore, false-negative pap smears from women with precancerous lesions are among the most frequent reasons for medical malpractice litigation in the United States.

The impact of cervical cancer on quality of life--the components and means for management

OBJECTIVE

To review how cervical cancer patients are affected on a psychological, psychosocial, and sexual level, resulting in an overall decrease in quality of life (QoL).

METHODS

This article reviews influential studies on QoL in women with cervical cancer, as well as the effects on patients' partners. Based on the decreased QoL, we present three suggestions on how clinicians can better patients' QoL after an abnormal Papanicolaou (Pap) test or diagnosis and treatment of cervical cancer.

RESULTS

Fear, self-blame, distress, and anxiety about cervical cancer are common in women who receive abnormal Pap test results or positive human papillomavirus DNA tests. Such results impact body image, self-esteem, relationships with partners, and sexual and reproductive issues, while adding to an overall decrease of QoL in women with cervical cancer.

CONCLUSIONS

In order to minimize the deleterious effects, the impact of cervical cancer and precancerous lesions on QoL should be managed as part of a complete healthcare plan. To improve QoL, cervical cancer patients should seek supportive counseling and education about self-care and adherence to treatment and follow-up plans, continue cervical cancer screening, and receive vaccination against prevalent oncogenic virus types.