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Stier EA, Jain M, Joshi H, Darragh TM, Deshmukh AA, Lee J, Einstein MH, Jay N, Berry-Lawhorn JM, Palefsky JM, Wilkin T, Ellsworth G, French AL, Barroso LF, Levine R, Guiot HM, Rezaei MK, Chiao E. Two-Year Incidence and Cumulative Risk and Predictors of Anal High-Grade Squamous Intraepithelial Lesions (Anal Precancer) Among Women With Human Immunodeficiency Virus. Clin Infect Dis 2024; 78:681-689. [PMID: 37805952 PMCID: PMC10954341 DOI: 10.1093/cid/ciad614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/17/2023] [Accepted: 10/04/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Detection and treatment of anal histologic high-grade squamous intraepithelial lesions (hHSIL) prevents anal cancer. However, anal hHSIL incidence among women with human immunodeficiency virus (HIV, WHIV) remains unknown. Performance of anal high-risk human papillomavirus ([hr]HPV), anal cytology (anal-cyt), and both for hHSIL detection longitudinally over 2 years also remains undetermined. METHODS We determined 2-year incidence and cumulative risk estimates (2-y-CR) of anal hHSIL among WHIV using prevalence and incidence (per 100 person-years [py]) observations stratified by baseline hrHPV and/or anal-cyt results. RESULTS In total, 229 WHIV with complete baseline data were included in the analysis; 114 women without prevalent anal hHSIL were followed with 2 annual evaluations. Median age was 51, 63% were Black, and 23% were Hispanic. Anal hrHPV or abnormal anal-cyt was associated with an increased risk of incident anal hHSIL at 2 years (18.9/100py [95% confidence interval {CI} 11.4-31.3] and 13.4/100py [95% CI 8.0-22.7], respectively) compared with no detection of anal HPV or negative cytology (2.8/100py [95% CI 1.1-7.4] and 4.2 [95% CI, 1.8-10.2]) The presence of anal hrHPV with abnormal cytology was associated with 2-y-CR of anal hHSIL of 65.6% (95% CI 55.4%-75%); negative hrHPV with negative cytology was associated with 2-y-CR of anal hHSIL of 9.2% (95% CI 7.0-16.0). CONCLUSIONS Detection of anal hrHPV or abnormal anal cytology are comparable predictors for 2-y-CR of anal hHSIL. The absence of anal hrHPV combined with negative cytology was predictive of a lower (but measurable) risk of developing anal hHSIL. These findings provide important data to inform anal cancer screening guidelines for WHIV.
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Affiliation(s)
- Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Mayuri Jain
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, NewYork, New York, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NewYork, New York, USA
| | - Himanshu Joshi
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, NewYork, New York, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NewYork, New York, USA
| | - Teresa M Darragh
- Department of Pathology, UCSF Mt. Zion Medical Center, SanFrancisco, California, USA
| | - Ashish A Deshmukh
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mark H Einstein
- Department of OB/GYN & Women's Health, Rutgers- NJMS, Newark, New Jersey, USA
| | - Naomi Jay
- Anal Neoplasia Clinic, Research, and Education Center, University of California San Francisco, San Francisco, California, USA
| | - J Michael Berry-Lawhorn
- Anal Neoplasia Clinic, Research, and Education Center, University of California San Francisco, San Francisco, California, USA
- Division of Hematology Oncology, University of California San Francisco, San Francisco, California, USA
| | - Joel M Palefsky
- Anal Neoplasia Clinic, Research, and Education Center, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Timothy Wilkin
- Division of Infectious Diseases, Department of Medicine, Cornell University, NewYork, New York, USA
| | - Grant Ellsworth
- Division of Infectious Diseases, Department of Medicine, Cornell University, NewYork, New York, USA
| | - Audrey L French
- Division of Infectious Diseases, CORE Center/Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Luis F Barroso
- Department of Internal Medicine (Infectious Diseases), Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | | | - Humberto M Guiot
- Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR, USA
- Department of Microbiology & Medical Zoology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico USA
| | - M Katayoon Rezaei
- Department of Pathology, George Washington University, Washington, DC, USA
| | - Elizabeth Chiao
- Department of Epidemiology, Division of Cancer Prevention, University of Texas - MD Anderson Cancer Center, Houston, Texas, USA
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Rajdev L, Wang CCJ, Joshi H, Lensing S, Lee J, Ramos JC, Baiocchi R, Ratner L, Rubinstein PG, Ambinder R, Henry D, Streicher H, Little RF, Chiao E, Dittmer DP, Einstein MH, Cesarman E, Mitsuyasu R, Sparano JA. Assessment of the safety of nivolumab in people living with HIV with advanced cancer on antiretroviral therapy: the AIDS Malignancy Consortium 095 Study. Cancer 2024; 130:985-994. [PMID: 37962072 PMCID: PMC10922055 DOI: 10.1002/cncr.35110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/08/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Although immunotherapy has emerged as a therapeutic strategy for many cancers, there are limited studies establishing the safety and efficacy in people living with HIV (PLWH) and cancer. METHODS PLWH and solid tumors or Kaposi sarcoma (KS) receiving antiretroviral therapy and a suppressed HIV viral load received nivolumab at 3 mg/kg every 2 weeks, in two dose deescalation cohorts stratified by CD4 count (stratum 1: CD4 count > 200/µL and stratum 2: CD4 count 100-199/µL). An expansion cohort of 24 participants with a CD4 count > 200/µL was then enrolled. RESULTS A total of 36 PLWH received nivolumab, including 15 with KS and 21 with a variety of other solid tumors. None of the first 12 participants had dose-limiting toxicity in both CD4 strata, and five patients (14%) overall had grade 3 or higher immune related adverse events. Objective partial response occurred in nine PLWH and cancer (25%), including in six of 15 with KS (40%; 95% CI, 16.3-64.7). The median duration of response was 9.0 months overall and 12.5 months in KS. Responses were observed regardless of PDL1 expression. There were no significant changes in CD4 count or HIV viral load. CONCLUSIONS Nivolumab has a safety profile in PLWH similar to HIV-negative subjects with cancer, and also efficacy in KS. Plasma HIV remained suppressed and CD4 counts remained stable during treatment and antiretroviral therapy, indicating no adverse impact on immune function. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02408861.
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Affiliation(s)
- Lakshmi Rajdev
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Himanshu Joshi
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Jeannette Lee
- University of Arkansas for Medical Sciences, Little Rock, AK
| | | | - Robert Baiocchi
- Ohio State University James Comprehensive Cancer Center, Columbus OH
| | | | - Paul G. Rubinstein
- Stroger Hospital of Cook County (Cook County Hospital), Ruth M. Rothstein Core Center, Division of Hematology/Oncology, University of Illinois, Chicago, IL
| | | | | | - Howard Streicher
- Division of Cancer Treatment and Diagnosis, National Cancer Institute (NCI), National Institutes of Health, Bethesda, MD
| | - Richard F. Little
- Division of Cancer Treatment and Diagnosis, National Cancer Institute (NCI), National Institutes of Health, Bethesda, MD
| | | | | | | | | | - Ronald Mitsuyasu
- University of California Los Angeles Care Center, Los Angeles, CA
| | - Joseph A. Sparano
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, Huh WK, Kim JJ, Moscicki AB, Nayar R, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M. 2019 ASCCP Risk-Based Management Consensus Guidelines: Updates Through 2023. J Low Genit Tract Dis 2024; 28:3-6. [PMID: 38117563 PMCID: PMC10755815 DOI: 10.1097/lgt.0000000000000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
ABSTRACT This Research Letter summarizes all updates to the 2019 Guidelines through September 2023, including: endorsement of the 2021 Opportunistic Infections guidelines for HIV+ or immunosuppressed patients; clarification of use of human papillomavirus testing alone for patients undergoing observation for cervical intraepithelial neoplasia 2; revision of unsatisfactory cytology management; clarification that 2012 guidelines should be followed for patients aged 25 years and older screened with cytology only; management of patients for whom colposcopy was recommended but not completed; clarification that after treatment for cervical intraepithelial neoplasia 2+, 3 negative human papillomavirus tests or cotests at 6, 18, and 30 months are recommended before the patient can return to a 3-year testing interval; and clarification of postcolposcopy management of minimally abnormal results.
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Affiliation(s)
| | | | - Philip E. Castle
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - David Chelmow
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark H. Einstein
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Francisco Garcia
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Warner K. Huh
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Jane J. Kim
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Anna-Barbara Moscicki
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Ritu Nayar
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mona Saraiya
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - George F. Sawaya
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Nicolas Wentzensen
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark Schiffman
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - 2019 ASCCP Risk-Based Management Consensus Guidelines Committee
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
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Einstein MH, Zhou N, Gabor L, Sahasrabuddhe VV. Primary Human Papillomavirus Testing and Other New Technologies for Cervical Cancer Screening. Obstet Gynecol 2023; 142:1036-1043. [PMID: 37708516 DOI: 10.1097/aog.0000000000005393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/22/2023] [Indexed: 09/16/2023]
Abstract
Cervical cancer screening has saved the lives of millions in regions where routine gynecologic care is readily accessible. As screening continues to evolve away from cervical cytology to primary human papillomavirus (HPV) testing, robust prospective cohort data have allowed for precise risk stratification and improved our ability to identify those at greatest risk of high-grade dysplasia and decrease unnecessary diagnostic procedures. New technologies such as p16/Ki-67 dual stain testing and HPV methylation panels, which offer comparable performance to co-testing and can be developed into high-throughput workflows, could lead to a fully molecular Pap test. Self-sampling in the United States, where the initial screen can be done in the home, in conjunction with new screening technologies, may decrease the existing hurdles of routine cervical cancer screening. Implementation barriers include issues with workflow, workforce, and cost. These need to be addressed to achieve an improved and more equitable cervical cancer screening program in the United States.
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Affiliation(s)
- Mark H Einstein
- Division of Gynecologic Oncology, Rutgers New Jersey Medical School, Newark, New Jersey; and the Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
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5
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Kohler RE, Hemler J, Wagner RB, Sullivan B, Macenat M, Tagai EK, Miller SM, Wen KY, Ayers C, Einstein MH, Hudson SV. Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown". Patient Educ Couns 2023; 114:107810. [PMID: 37244133 PMCID: PMC10527466 DOI: 10.1016/j.pec.2023.107810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy. METHODS We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti. RESULTS We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion. CONCLUSION Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments. PRACTICE IMPLICATIONS Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.
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Affiliation(s)
- Racquel E Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA.
| | - Jennifer Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Rachel B Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Brittany Sullivan
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Myneka Macenat
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Charletta Ayers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark H Einstein
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Shawna V Hudson
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
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6
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Mittal A, Neibart SS, Kulkarni A, Anderson T, Hudson SV, Beer NL, Einstein MH, Kohler RE. Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis. Cancer Causes Control 2023:10.1007/s10552-023-01703-0. [PMID: 37165111 DOI: 10.1007/s10552-023-01703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/13/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services. METHODS Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model. RESULTS We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening. CONCLUSION Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.
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Affiliation(s)
- Avni Mittal
- Department of Obstetrics and Reproductive Health and Gynecology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Shane S Neibart
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Abha Kulkarni
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Taylor Anderson
- University of Queensland Ochsner Clinical School, Brisbane, QLD, Australia
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Mark H Einstein
- Department of Obstetrics and Reproductive Health and Gynecology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Racquel E Kohler
- Department of Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health , Piscataway, NJ, USA
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Atkinson TM, Lensing S, Lee JY, Chang D, Kim SY, Li Y, Lynch KA, Webb A, Holland SM, Lubetkin EI, Goldstone S, Einstein MH, Stier EA, Wiley DJ, Mitsuyasu R, Rosa-Cunha I, Aboulafia DM, Dhanireddy S, Schouten JT, Levine R, Gardner E, Logan J, Dunleavy H, Barroso LF, Bucher G, Korman J, Stearn B, Wilkin TJ, Ellsworth G, Pugliese JC, Arons A, Burkhalter JE, Cella D, Berry-Lawhorn JM, Palefsky JM. Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03. Qual Life Res 2023:10.1007/s11136-023-03391-4. [PMID: 37020153 PMCID: PMC10330891 DOI: 10.1007/s11136-023-03391-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI). METHODS The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization. RESULTS Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness. CONCLUSION A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.
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Affiliation(s)
- Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA.
| | - Shelly Lensing
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeannette Y Lee
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Di Chang
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Soo Young Kim
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Yuelin Li
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Kathleen A Lynch
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
- School of Global Public Health, New York University, New York, NY, USA
| | - Andrew Webb
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Susan M Holland
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | | | | | | | | | - Dorothy J Wiley
- University of California, Los Angeles School of Nursing, Los Angeles, CA, USA
| | - Ronald Mitsuyasu
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, CA, USA
| | | | | | | | - Jeffrey T Schouten
- Virginia Mason Medical Center, Seattle, WA, USA
- Harborview Medical Center, Seattle, WA, USA
| | | | - Edward Gardner
- Public Health Institute at Denver Health, Denver, CO, USA
| | - Jeffrey Logan
- Public Health Institute at Denver Health, Denver, CO, USA
| | | | - Luis F Barroso
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Gary Bucher
- Anal Dysplasia Clinic MidWest, Chicago, IL, USA
| | - Jessica Korman
- Metropolitan Gastroenterology Group, Washington, DC, USA
| | | | | | | | - Julia C Pugliese
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Abigail Arons
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Jack E Burkhalter
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Einstein MH, Roden RBS, Ferrall L, Akin M, Blomer A, Wu TC, Chang YN. Safety run-in of intramuscular pNGVL4a-Sig/E7(detox)/HSP70 DNA and TA-CIN protein vaccination as treatment for HPV16+ ASC-US, ASC-H, or LSIL/CIN1. Cancer Prev Res (Phila) 2023; 16:219-227. [PMID: 36607735 PMCID: PMC10068439 DOI: 10.1158/1940-6207.capr-22-0413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/09/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
Patients with HPV16 infection and low-grade cervical dysplasia (LSIL/CIN1) or atypical squamous cells (ASC-US/ASC-H) require active surveillance for disease progression. A safe and effective immunotherapy to clear HPV16 is an unmet medical need. The safety run-in cohort of a randomized double-blind, placebo-controlled Phase II trial of PVX2 (vaccination twice with HPV16-targeting pNGVL4a-Sig/E7(detox)/HSP70 plasmid and once with the HPV16 L2E7E6 fusion protein "TA-CIN") as immunotherapy for patients with HPV16+ ASC-US, ASC-H, or LSIL/CIN1 (NCT03911076) was recently completed. The primary objective of this cohort was to determine the safety and tolerability of PVX2 vaccination. Subjects were confirmed to have HPV16 infection and LSIL/CIN1, ASC-US, or ASC-H. Adverse events were evaluated using CTCAE v5.0. HPV typing by HPV16 18/45 Aptima Assay was done at baseline, month 6, and month 12, with simultaneous cytology analysis. Cervical biopsies and ECC were performed at baseline and month 6. In the safety run-in cohort 12 eligible patients were enrolled. Each received three monthly immunizations. One was lost to follow-up after week 12. There were no serious adverse events. A total of five adverse events were noted by four patients; 4 were considered not vaccine-related, and one 'unlikely related' by the investigator. At month 6, 45% (5/11) of participants converted to HPV16-negative and 2 others developed CIN2+ and received a LEEP. At month 12, 64% (7/11) were HPV16-negative, including those HPV16-negative at month 6. In conclusion, PVX2 immunotherapy was well tolerated and associated with viral regression, supporting further testing.
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Affiliation(s)
- Mark H Einstein
- Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | | | - Louise Ferrall
- Johns Hopkins University, Baltimore, Maryland, United States
| | - Mark Akin
- Austin Area Obstetrics, Gynecology, and Fertility, Austin, Texas, United States
| | - Allison Blomer
- Health Awareness, Inc., Port St. Lucie, Florida, United States
| | - T-C Wu
- Johns Hopkins University, Baltimore, MD, United States
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Lin LL, Ndlovu N, Lowenstein J, Wirth M, Lee J, Stier EA, Garg M, Kotzen J, Kadzatsa W, Palefsky J, Krown SE, Einstein MH. Quality Assurance in Clinical Trials Requiring Radiation Therapy in Sub-Saharan Africa. Int J Radiat Oncol Biol Phys 2022; 116:439-447. [PMID: 36493958 PMCID: PMC10360026 DOI: 10.1016/j.ijrobp.2022.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Given the increasing availability of radiation therapy in sub-Saharan Africa, clinical trials that include radiation therapy are likely to grow. Ensuring appropriate delivery of radiation therapy through rigorous quality assurance is an important component of clinical trial execution. We reviewed the process for credentialing radiation therapy sites and radiation therapy quality assurance through the Imaging and Radiation Oncology Core (IROC) Houston Quality Assurance Center for AIDS Malignancy Consortium (AMC)-081, a multicenter study of cisplatin and radiation therapy for women with locally advanced cervical cancer living with HIV, conducted by the AIDS Malignancy Consortium at 2 sites in South Africa and Zimbabwe. METHODS AND MATERIALS Women living with HIV with newly diagnosed stage IB2, IIA (>4 cm), IIB-IVA cervical carcinoma (per the 2009 International Federation of Gynecology and Obstetrics [FIGO] staging classifications) were enrolled in AMC-081. They received 3-dimensional conformal external beam radiation therapy (EBRT) to the pelvis (41.4-45 Gy) using a linear accelerator, high-dose-rate brachytherapy (6-9 Gy to point A with each fraction and up to 4 fractions), and concurrent weekly cisplatin (40 mg/m2). IROC reviewed EBRT and brachytherapy quality assurance records after treatment. RESULTS All of the 38 women enrolled in AMC-081 received ±5% of the protocol-specified prescribed dose of EBRT. Geometry of brachytherapy applicator placement was scored as per protocol in all implants. Doses to points A and B, International Commission on Radiation Units and Measurements (ICRU) bladder, or ICRU rectum required correction by IROC in >50% of the implants. In the final evaluation, 58% of participants (n = 22) were treated per protocol, 40% (n = 15) had minor protocol deviations, and 3% (n = 1) had major protocol deviations. No records were received within 60 days of treatment completion as requested in the protocol. CONCLUSIONS Major radiation therapy deviations were low, but timely submission of radiation therapy data did not occur. Future studies, especially those that include specialized radiation therapy techniques such as stereotactic or intensity modulated radiation therapy, will require pathways to ensure timely and adequate quality assurance.
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Affiliation(s)
- Lilie L Lin
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas.
| | - Ntokozo Ndlovu
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Jessica Lowenstein
- Department of Radiation Physics and the Imaging and Radiation Oncology Core, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
| | - Madhur Garg
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, New York, New York
| | - Jeffrey Kotzen
- Department of Radiation Oncology, University of the Witwatersrand, Johannesburg, South Africa
| | - Webster Kadzatsa
- Department of Radiotherapy and Oncology, College of Health Science, University of Zimbabwe, Harare, Zimbabwe
| | - Joel Palefsky
- Department of Medicine, University of California, San Francisco, California
| | - Susan E Krown
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark H Einstein
- Department of Obstetrics, Gynecology, and Women's Health, Rutgers New Jersey Medical School, Newark, New Jersey
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Palefsky JM, Lee JY, Jay N, Goldstone SE, Darragh TM, Dunlevy HA, Rosa-Cunha I, Arons A, Pugliese JC, Vena D, Sparano JA, Wilkin TJ, Bucher G, Stier EA, Tirado Gomez M, Flowers L, Barroso LF, Mitsuyasu RT, Lensing SY, Logan J, Aboulafia DM, Schouten JT, de la Ossa J, Levine R, Korman JD, Hagensee M, Atkinson TM, Einstein MH, Cracchiolo BM, Wiley D, Ellsworth GB, Brickman C, Berry-Lawhorn JM. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med 2022; 386:2273-2282. [PMID: 35704479 PMCID: PMC9717677 DOI: 10.1056/nejmoa2201048] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking. METHODS We conducted a phase 3 trial at 25 U.S. sites. Persons living with HIV who were 35 years of age or older and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer. RESULTS Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI], 90 to 332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI, 262 to 616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI, 6 to 80; P = 0.03 by log-rank test). CONCLUSIONS Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT02135419.).
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Affiliation(s)
- Joel M Palefsky
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeannette Y Lee
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Naomi Jay
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Stephen E Goldstone
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Teresa M Darragh
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Hillary A Dunlevy
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Isabella Rosa-Cunha
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Abigail Arons
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Julia C Pugliese
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Don Vena
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Joseph A Sparano
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Timothy J Wilkin
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Gary Bucher
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Elizabeth A Stier
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Maribel Tirado Gomez
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Lisa Flowers
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Luis F Barroso
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Ronald T Mitsuyasu
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Shelly Y Lensing
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeffrey Logan
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - David M Aboulafia
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeffrey T Schouten
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Juan de la Ossa
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Rebecca Levine
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jessica D Korman
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Michael Hagensee
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Thomas M Atkinson
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Mark H Einstein
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Bernadette M Cracchiolo
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Dorothy Wiley
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Grant B Ellsworth
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Cristina Brickman
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - J Michael Berry-Lawhorn
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
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Abedin Y, Alpert E, Rego E, Larios K, Cheung E, Gabrilovich S, Zhao Q, Einstein MH, Douglas N. Abstract 6074: Resistance to MK-0752 alters Notch activity and expression of stemness markers in uterine leiomyosarcoma cell lines. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-6074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Uterine leiomyosarcoma (uLMS) is a rare tumor with poor survival and few therapeutic options. The Notch pathway is evolutionarily conserved, is active in uterine processes, has oncogenic properties in many cancers, but has not been well studied in uLMS. Cancer stem cells (CSC) are subpopulations of cancer cells that are treatment resistant. In certain tumors, activation of canonical Notch signaling, via gamma secretase, supports CSC survival and the acquisition of chemoresistance. Our objective is to identify and characterize the subpopulation of uLMS cells that are viable after treatment with the half maximal inhibitory concentration (IC50) of MK-0752, a gamma secretase inhibitor (GSI) in phase I trials. We will determine Notch signaling activity and expression of markers associated with stem-like potential in GSI resistant uLMS cells.
Methods: MTT assays were performed on SK-LMS-1 and SK-UT-1B, two uLMS cell lines, to identify the IC50 for MK-0752. Cells were exposed to MK-0752 at the IC50 or DMSO (control) for 24 hours and viable cells were collected. First, expression of stemness markers, CD133, cMYC and SOX2, in uLMS cells was compared to human uterine smooth muscle cells (hUT-SMC) at baseline. After treatment with MK-0752, the remaining subpopulations of resistant uLMS cells were evaluated for Notch signaling activity by expression of HES1. Stemness marker expression was also assessed. Gene expression was measured with qRT-PCR. Mean fold change (FC) gene expression was determined by FC experimental divided by FC control, relative to expression of 18S rRNA. P≤0.05 was considered significant.
Results: In untreated uLMS cells, expression of CD133 and c-MYC was significantly higher in SK-LMS-1 (fibroblast morphology) vs hUT-SMC, while expression of CD133 and SOX2 was significantly higher in SK-UT-1B (epithelial morphology) vs hUT-SMC. After treatment with MK-0752 at IC50 (427.4 µM for SK-LMS-1 or 128.4µM for SK-UT-1B) expression of HES1 was decreased in SK-LMS-1 (0.35x, p≤0.05) and increased in SK-UT-1B (2.38x, p≤0.01) in treatment resistant, viable cells as compared to untreated cells. Expression of c-MYC was decreased (0.38x, p≤0.01) and CD133 was similar (1.64x, p>0.05) in GSI resistant SK-LMS-1 cells, while expression of CD133 and SOX2 was similar (1.43x and 1.30x, respectively, p>0.05) in GSI resistant SK-UT-1B cells compared to untreated cells.
Conclusions: Cellular morphology, Notch signaling activity and expression of stemness markers differs in GSI resistant SK-LMS-1 compared to GSI resistant SK-UT-1B cells. The subpopulation of MK-0752 resistant SK-LMS-1 cells have reduced Notch activity and reduced expression of stemness marker, c-MYC, while the resistant SK-UT-1B cells have increased Notch activity. Further studies are required to identify additional factors associated with uLMS resistance to GSIs and the importance of this heterogeneity of uLMS in vivo.
Citation Format: Yasmin Abedin, Emily Alpert, Erica Rego, Karla Larios, Emma Cheung, Sofia Gabrilovich, Qingshi Zhao, Mark H. Einstein, Nataki Douglas. Resistance to MK-0752 alters Notch activity and expression of stemness markers in uterine leiomyosarcoma cell lines [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6074.
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Affiliation(s)
| | | | - Erica Rego
- 1Rutgers-New Jersey Medical School, Newark, NJ
| | | | - Emma Cheung
- 1Rutgers-New Jersey Medical School, Newark, NJ
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Abedin Y, Gabrilovich S, Alpert E, Rego E, Begum S, Zhao Q, Heller D, Einstein MH, Douglas NC. Gamma Secretase Inhibitors as Potential Therapeutic Targets for Notch Signaling in Uterine Leiomyosarcoma. Int J Mol Sci 2022; 23:ijms23115980. [PMID: 35682660 PMCID: PMC9180633 DOI: 10.3390/ijms23115980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
Uterine leiomyosarcoma (uLMS) is a rare and aggressive cancer with few effective therapeutics. The Notch signaling pathway is evolutionarily conserved with oncogenic properties, but it has not been well studied in uLMS. The purpose of our study was to determine expression of Notch family genes and proteins and to investigate the therapeutic effect of γ-secretase inhibitors (GSIs), indirect inhibitors of Notch signaling, in uLMS. We determined expression of Notch genes and proteins in benign uterine smooth muscle tissue, fibroids, and uLMS samples by immunostaining and in two uLMS cell lines, SK-UT-1B (uterine primary) and SK-LMS-1 (vulvar metastasis) by RT-PCR, Western blot and immunostaining. We exposed our cell lines to GSIs, DAPT and MK-0752, and measured expression of HES1, a downstream effector of Notch. Notch proteins were differentially expressed in uLMS. Expression of NOTCH3 and NOTCH4 was higher in uLMS samples than in benign uterine smooth muscle and fibroids. Expression of NOTCH4 was higher in SK-LMS-1 compared to SK-UT-1B. Exposure of SK-UT-1B and SK-LMS-1 to DAPT and MK-0752 decreased expression of HES1 and decreased uLMS cell viability in a dose- and time-dependent manner that was unique to each GSI. Our findings suggest that GSIs are potential therapeutics for uLMS, albeit with limited efficacy.
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Affiliation(s)
- Yasmin Abedin
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
- Correspondence:
| | - Sofia Gabrilovich
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
| | - Emily Alpert
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
| | - Erica Rego
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
| | - Salma Begum
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
| | - Qingshi Zhao
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
| | - Debra Heller
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
- Department of Pathology, Immunology and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA
| | - Mark H. Einstein
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
| | - Nataki C. Douglas
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA; (S.G.); (E.A.); (E.R.); (S.B.); (Q.Z.); (D.H.); (M.H.E.); (N.C.D.)
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Castle PE, Einstein MH, Sahasrabuddhe VV. Cervical cancer prevention and control in women living with human immunodeficiency virus. CA Cancer J Clin 2021; 71:505-526. [PMID: 34499351 PMCID: PMC10054840 DOI: 10.3322/caac.21696] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 12/16/2022] Open
Abstract
Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.
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Affiliation(s)
- Philip E Castle
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Mark H Einstein
- Department of Obstetrics, Gynecology, and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Vikrant V Sahasrabuddhe
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
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Neibart SS, Smith TA, Fang JH, Anderson T, Kulkarni A, Tsui J, Hudson SV, Peck GL, Hanna JS, Beer NL, Einstein MH. Assessment of Cervical Cancer Prevention and Treatment Infrastructure in Belize. JCO Glob Oncol 2021; 7:1251-1259. [PMID: 34351814 PMCID: PMC8389877 DOI: 10.1200/go.21.00138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Belize has one of the highest cervical cancer burdens among Latin American and Caribbean countries, despite the implementation of national policies to increase access to prevention and treatment services. This study evaluates the policies, infrastructure, and workforce of the cervical cancer management system in Belize to inform capacity building efforts. METHODS In 2018, health facility assessments were conducted across all six districts of Belize at the national pathology facility and 12 public facilities identified as critical to cervical cancer control. Human and infrastructure resource availability and existing policies related to cervical cancer screening and treatment services were assessed through a structured instrument. RESULTS The public cervical cancer screening workforce in Belize consists of 75 primary care nurses and physicians—one per 1,076 screening-eligible women, with 44% conducting rural outreach. All districts have at least one screening facility, but 50% perform screening services only once per week. Colposcopy and loop electrical excision procedures are available in three and four districts, respectively; radical hysterectomy and chemotherapy are available in two districts; and radiation therapy is unavailable. Of essential pathology equipment, 38.5% were present and functional, 23% were present but nonfunctional, and 38.5% were unavailable. Additionally, 35% of supplies were unavailable at the time of assessment, and 75% were unavailable at least once in the 12 months before assessment. CONCLUSION Public-sector cervical cancer management services differ among districts of Belize, with tertiary service availability concentrated in the largest district. Screening, outreach, and pathology are limited mostly by resource availability. This study characterizes the current capacity of services in Belize and pinpoints health system components for future investment and capacity-building efforts.
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Affiliation(s)
- Shane S Neibart
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Tiffany A Smith
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jennifer H Fang
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Taylor Anderson
- University of Queensland Ochsner Clinical School, Brisbane, QLD, Australia
| | - Abha Kulkarni
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jennifer Tsui
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gregory L Peck
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.,Rutgers School of Public Health, Piscataway, NJ
| | - Joseph S Hanna
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Mark H Einstein
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.,Rutgers New Jersey Medical School, Newark, NJ
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Desai KT, Alfaro K, Mendoza L, Faron M, Mesich B, Maza M, Dominguez R, Valenzuela A, Acosta CD, Martínez M, Felix JC, Masch R, Gabrilovich S, Plump M, Novetsky AP, Einstein MH, Douglas NC, Cremer M, Wentzensen N. Multi-site clinical validation of Isothermal Amplification based SARS-COV-2 detection assays using different sampling strategies. medRxiv 2021:2021.07.01.21259879. [PMID: 34268516 PMCID: PMC8282105 DOI: 10.1101/2021.07.01.21259879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Isothermal amplification-based tests were developed as rapid, low-cost, and simple alternatives to real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests for SARS-COV-2 detection. METHODS Clinical performance of two isothermal amplification-based tests (Atila Biosystems iAMP COVID-19 detection test and OptiGene COVID-19 Direct Plus RT-LAMP test) was compared to clinical RT-PCR assays using different sampling strategies. A total of 1378 participants were tested across four study sites. RESULTS Compared to standard of care RT-PCR testing, the overall sensitivity and specificity of the Atila iAMP test for detection of SARS-CoV-2 were 76.2% and 94.9%, respectively, and increased to 88.8% and 89.5%, respectively, after exclusion of an outlier study site. Sensitivity varied based on the anatomic collected site. Sensitivity for nasopharyngeal was 65.4% (range across study sites:52.8%-79.8%), mid-turbinate 88.2%, saliva 55.1% (range across study sites:42.9%-77.8%) and anterior nares 66.7% (range across study sites:63.6%-76.5%). The specificity for these anatomic collection sites ranged from 96.7% to 100%. Sensitivity improved in symptomatic patients (overall 82.7%) and those with a higher viral load (overall 92.4% for ct≤25). Sensitivity and specificity of the OptiGene Direct Plus RT-LAMP test, conducted at a single study-site, were 25.5% and 100%, respectively. CONCLUSIONS The Atila iAMP COVID test with mid-turbinate sampling is a rapid, low-cost assay for detecting SARS-COV-2, especially in symptomatic patients and those with a high viral load, and could be used to reduce the risk of SARS-COV-2 transmission in clinical settings. Variation of performance between study sites highlights the need for site-specific clinical validation of these assays before clinical adoption.
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Affiliation(s)
- Kanan T. Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | | | - Laura Mendoza
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | | | | | | | - Rhina Dominguez
- Research Unit, El Salvador National Institute of Health (INS), El Salvador
| | - Adriana Valenzuela
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Chyntia Díaz Acosta
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Magaly Martínez
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | | | - Rachel Masch
- Basic Health International, Pittsburgh, USA
- The Mount Sinai Hospital, New York, USA
| | | | | | - Akiva P. Novetsky
- Rutgers New Jersey Medical School, Newark, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Mark H. Einstein
- Rutgers New Jersey Medical School, Newark, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Miriam Cremer
- Basic Health International, Pittsburgh, USA
- Cleveland Clinic Lerner College of Medicine, Clevland, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
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Strickler HD, Keller MJ, Hessol NA, Eltoum IE, Einstein MH, Castle PE, Massad LS, Flowers L, Rahangdale L, Atrio JM, Ramirez C, Minkoff H, Adimora AA, Ofotokun I, Colie C, Huchko MJ, Fischl M, Wright R, D'Souza G, Leider J, Diaz O, Sanchez-Keeland L, Shrestha S, Xie X, Xue X, Anastos K, Palefsky JM, Burk RD. Primary HPV and Molecular Cervical Cancer Screening in US Women Living With Human Immunodeficiency Virus. Clin Infect Dis 2021; 72:1529-1537. [PMID: 32881999 DOI: 10.1093/cid/ciaa1317] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH). METHODS We enrolled n = 865 WLWH (323 from the Women's Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[-]/Pap[-] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry. RESULTS Mean age was 46 years, median CD4 was 592 cells/µL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). "PHS with reflex HPV16/18-genotyping and Pap testing" had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. "Concurrent oncHPV and Pap Testing" (Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy. CONCLUSIONS PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH.
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Affiliation(s)
- Howard D Strickler
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Marla J Keller
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Nancy A Hessol
- University of California, San Francisco, California, USA
| | | | | | - Philip E Castle
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | | | - Lisa Flowers
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lisa Rahangdale
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica M Atrio
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Catalina Ramirez
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Adaora A Adimora
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Igho Ofotokun
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christine Colie
- Georgetown University, Washington, District of Columbia, USA
| | - Megan J Huchko
- University of California, San Francisco, California, USA
| | - Margaret Fischl
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rodney Wright
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Gypsyamber D'Souza
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Olga Diaz
- Jacobi Medical Center, Bronx, New York, USA
| | | | | | - Xianhong Xie
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Xiaonan Xue
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Kathryn Anastos
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | | | - Robert D Burk
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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17
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Merritt MA, Strickler HD, Hutson AD, Einstein MH, Rohan TE, Xue X, Sherman ME, Brinton LA, Yu H, Miller DS, Ramirez NC, Lankes HA, Birrer MJ, Huang GS, Gunter MJ. Sex Hormones, Insulin, and Insulin-like Growth Factors in Recurrence of High-Stage Endometrial Cancer. Cancer Epidemiol Biomarkers Prev 2021; 30:719-726. [PMID: 33622671 PMCID: PMC8026669 DOI: 10.1158/1055-9965.epi-20-1613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/18/2020] [Accepted: 02/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The influence of sex hormone and insulin/insulin-like growth factor (IGF) axis signaling on endometrial cancer recurrence is unknown. We evaluated these pathways in a prospective cohort of Gynecologic Oncology Group (GOG)0210 trial endometrial adenocarcinoma patients. METHODS Stage II-IV patients (N = 816) were included in this study. Pretreatment specimens were tested for tumor mRNA and protein expression of IGF1, IGF2, IGF-binding proteins (IGFBP)-1 and -3, insulin (IR) and IGF-I receptors (IGF1R), phosphorylated IR/IGF1R (pIGF1R/pIR), and estrogen (ER) and progesterone receptors (PR) using qPCR and IHC. Serum concentrations of insulin, IGF-I, IGFBP-3, estradiol, estrone, and sex hormone binding globulin were measured. HRs and 95% confidence intervals (CI) for progression-free survival were calculated from Cox models adjusting for age, stage, and grade. RESULTS Recurrence occurred in 280 (34%) cases during a median of 4.6 years of follow-up. ER positivity (HR, 0.67; 95% CI, 0.47-0.95), IR positivity (HR, 0.53; 95% CI, 0.29-0.98), and circulating IGF-I (highest vs. lowest quartile: HR, 0.66; 95% CI, 0.47-0.92) were inversely associated with recurrence risk. Circulating estradiol (highest vs. lowest tertile: HR, 1.55; 95% CI, 1.02-2.36) and pIGF1R/pIR positivity (HR, 1.40; 95% CI, 1.02-1.92) were associated with increased recurrence risk. CONCLUSIONS Circulating estradiol and tumor tissue phosphorylated (activated) IGR1R/IR were independently associated with higher risk of recurrence in patients with endometrial cancer. IMPACT This study may inform future clinical trials of endocrine-targeted adjuvant therapies in patients with endometrial cancer that could include baseline assessment of serum and tissue biomarkers of estradiol and insulin signaling pathways.
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Affiliation(s)
- Melissa A Merritt
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, Hawaii
| | - Howard D Strickler
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, Bronx, New York
| | - Alan D Hutson
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Mark H Einstein
- Department of Obstetrics, Gynecology & Women's Health, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Thomas E Rohan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, Bronx, New York
| | - Xiaonan Xue
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, Bronx, New York
| | | | - Louise A Brinton
- Division of Cancer Epidemiology and Genetics, NCI, Bethesda, Maryland
| | - Herbert Yu
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, Hawaii
| | - David S Miller
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Heather A Lankes
- NRG Oncology/Operations Center-Philadelphia East, Philadelphia, Pennsylvania
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael J Birrer
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gloria S Huang
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut.
| | - Marc J Gunter
- Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
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18
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Rasmussen TA, Rajdev L, Rhodes A, Dantanarayana A, Tennakoon S, Chea S, Spelman T, Lensing S, Rutishauser R, Bakkour S, Busch M, Siliciano JD, Siliciano RF, Einstein MH, Dittmer DP, Chiao E, Deeks S, Durand C, Lewin SR. Impact of anti-PD-1 and anti-CTLA-4 on the HIV reservoir in people living with HIV with cancer on antiretroviral therapy: The AIDS Malignancy Consortium-095 study. Clin Infect Dis 2021; 73:e1973-e1981. [PMID: 33677480 DOI: 10.1093/cid/ciaa1530] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Antibodies to PD-1 and CTLA-4 may perturb HIV persistence during antiretroviral therapy (ART) by reversing HIV-latency and/or boosting HIV-specific immunity leading to clearance of infected cells. We tested this hypothesis in a clinical trial of anti-PD-1 alone or in combination with anti-CTLA-4 in people living with HIV (PLWH) and cancer. METHODS This was a substudy of the AIDS Malignancy Consortium-095 Study. ART-suppressed PLWH with advanced malignancies were assigned to nivolumab (anti-PD-1) with or without ipilimumab (anti-CTLA-4). In samples obtained pre-infusion and one and seven days after the first and fourth dose of immune checkpoint blockade (ICB), we quantified cell-associated unspliced (CA-US) HIV-RNA and HIV-DNA. Plasma HIV-RNA was quantified during the first treatment cycle. Quantitative viral outgrowth assay (QVOA) to estimate the frequency of replication-competent HIV was performed before and after ICB for participants with samples available. RESULTS Of forty participants, 33 received nivolumab and seven nivolumab plus ipilimumab. Whereas CA-US HIV RNA did not change with nivolumab monotherapy, we detected a median 1.44 fold-increase (IQR 1.16-1.89) after the first dose of nivolumab and ipilimumab combination therapy (P=0.031). There was no decrease in the frequency of cells containing replication-competent HIV, but in the two individuals on combination ICB for whom we had longitudinal QVOA, we detected decreases of 97% and 64% compared to baseline. CONCLUSION Anti-PD-1 alone showed no effect on HIV-latency or the latent HIV-reservoir, but the combination of anti-PD-1 and anti-CTL-4 induced a modest increase in CA-US HIV RNA and may potentially eliminate cells containing replication-competent HIV.
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Affiliation(s)
- Thomas A Rasmussen
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Rajdev
- Department of Haematology and Oncology, Lennox Hill Hospital, New York, USA
| | - Ajantha Rhodes
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Ashanti Dantanarayana
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Surekha Tennakoon
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Socheata Chea
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Tim Spelman
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Shelly Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Rachel Rutishauser
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sonia Bakkour
- Vitalant Research Institute and Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | - Michael Busch
- Vitalant Research Institute and Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | - Janet D Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert F Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark H Einstein
- Department of Obstetrics, Gynecology, & Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Dirk P Dittmer
- Lineberger Comprehensive Cancer Center and Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Steven Deeks
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Christine Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sharon R Lewin
- The Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia.,Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
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19
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Stier EA, Lensing SY, Darragh TM, Deshmukh AA, Einstein MH, Palefsky JM, Jay N, Berry-Lawhorn JM, Wilkin T, Wiley DJ, Barroso LF, Cranston RD, Levine R, Guiot HM, French AL, Citron D, Rezaei MK, Goldstone SE, Chiao E. Prevalence of and Risk Factors for Anal High-grade Squamous Intraepithelial Lesions in Women Living with Human Immunodeficiency Virus. Clin Infect Dis 2021; 70:1701-1707. [PMID: 31292602 DOI: 10.1093/cid/ciz408] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Women living with human immunodeficiency virus (WLHIV) have disproportionately high rates of squamous cell carcinoma of the anus compared with the general population of women. Anal high-grade squamous intraepithelial lesions (HSILs) precede anal cancer, and accurate studies of HSIL prevalence among WLHIV in the United States are lacking. METHODS The AIDS Malignancy Consortium 084 study was a multicenter national trial to evaluate the prevalence of and risk factors for anal HSIL in a US cohort. Eligible participants were WLHIV aged ≥18 years with no history of anal HSIL. Study participants had an examination including collection of cervical/vaginal and anal specimens, followed by high-resolution anoscopy with biopsy. RESULTS We enrolled 256 women with evaluable anal pathology. The mean age was 49.4 years, 64% women were non-Hispanic black, 67% were former or current smokers, and 56% reported ever having anal sex with a man. The median CD4 T-cell count was 664 cells/μL. The prevalence of anal histologic HSIL (hHSIL) was 27% (95% confidence interval [CI], 22%-33%). There was a strong concordance (240/254) between local and consensus pathologists for hHSIL vs less than hHSIL (κ = 0.86 [95% CI, .79-.93]). Current CD4 count of ≤200 cells/μL was the strongest predictor of consensus anal hHSIL diagnosis (adjusted odds ratio [aOR], 10.34 [95% CI, 3.47-30.87]). History of anoreceptive intercourse was also associated with hHSIL (aOR, 2.44 [95% CI, 1.22-4.76]). CONCLUSIONS The prevalence of anal hHSIL in WLHIV in the United States was 27% in this study where all participants received high-resolution anoscopy and biopsy.
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Affiliation(s)
- Elizabeth A Stier
- Obstetrics and Gynecology, Boston University School of Medicine, Massachusetts
| | - Shelly Y Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock
| | - Teresa M Darragh
- Department of Pathology, Mount Zion Medical Center, University of California, San Francisco (UCSF)
| | - Ashish A Deshmukh
- Department of Management Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston
| | - Mark H Einstein
- Department of Obstetrics/Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark
| | | | - Naomi Jay
- Anal Neoplasia Clinic, Research, and Education Center, San Francisco, California
| | - J Michael Berry-Lawhorn
- Anal Neoplasia Clinic, Research, and Education Center, San Francisco, California.,Division of Hematology Oncology, UCSF
| | - Timothy Wilkin
- Clinical Trials Unit, Department of Medicine, Cornell University, New York, New York
| | | | - Luis F Barroso
- Department of Internal Medicine, Infectious Diseases, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Ross D Cranston
- University of Vic, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Rebecca Levine
- Department of Surgery, Montefiore Medical Center, Bronx, New York
| | - Humberto M Guiot
- Department of Medicine and Department of Microbiology and Medical Zoology, University of Puerto Rico School of Medicine, San Juan
| | - Audrey L French
- Division of Infectious Diseases, CORE Center/Stroger Hospital of Cook County, Chicago, Illinois
| | - Deborah Citron
- Department of Pathology, Baylor College of Medicine, Houston, Texas
| | - M Katayoon Rezaei
- Department of Pathology, George Washington University, Washington, District of Columbia
| | | | - Elizabeth Chiao
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine.,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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20
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Desai KT, Ajenifuja KO, Banjo A, Adepiti CA, Novetsky A, Sebag C, Einstein MH, Oyinloye T, Litwin TR, Horning M, Olanrewaju FO, Oripelaye MM, Afolabi E, Odujoko OO, Castle PE, Antani S, Wilson B, Hu L, Mehanian C, Demarco M, Gage JC, Xue Z, Long LR, Cheung L, Egemen D, Wentzensen N, Schiffman M. Design and feasibility of a novel program of cervical screening in Nigeria: self-sampled HPV testing paired with visual triage. Infect Agent Cancer 2020; 15:60. [PMID: 33072178 PMCID: PMC7556552 DOI: 10.1186/s13027-020-00324-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/22/2020] [Indexed: 01/18/2023] Open
Abstract
Background Accelerated global control of cervical cancer would require primary prevention with human papillomavirus (HPV) vaccination in addition to novel screening program strategies that are simple, inexpensive, and effective. We present the feasibility and outcome of a community-based HPV self-sampled screening program. Methods In Ile Ife, Nigeria, 9406 women aged 30-49 years collected vaginal self-samples, which were tested for HPV in the local study laboratory using Hybrid Capture-2 (HC2) (Qiagen). HPV-positive women were referred to the colposcopy clinic. Gynecologist colposcopic impression dictated immediate management; biopsies were taken when definite acetowhitening was present to produce a histopathologic reference standard of precancer (and to determine final clinical management). Retrospective linkage to the medical records identified 442 of 9406 women living with HIV (WLWH). Results With self-sampling, it was possible to screen more than 100 women per day per clinic. Following an audio-visual presentation and in-person instructions, overall acceptability of self-sampling was very high (81.2% women preferring self-sampling over clinician collection). HPV positivity was found in 17.3% of women. Intensive follow-up contributed to 85.9% attendance at the colposcopy clinic. Of those referred, 8.2% were initially treated with thermal ablation and 5.6% with large loop excision of transformation zone (LLETZ). Full visibility of the squamocolumnar junction, necessary for optimal visual triage and ablation, declined from 68.5% at age 30 to 35.4% at age 49. CIN2+ and CIN3+ (CIN- Cervical intraepithelial neoplasia), including five cancers, were identified by histology in 5.9 and 3.2% of the HPV-positive women, respectively (0.9 and 0.5% of the total screening population), leading to additional treatment as indicated. The prevalences of HPV infection and CIN2+ were substantially higher (40.5 and 2.5%, respectively) among WLWH. Colposcopic impression led to over- and under-treatment compared to the histopathology reference standard. Conclusion A cervical cancer screening program using self-sampled HPV testing, with colposcopic immediate management of women positive for HPV, proved feasible in Nigeria. Based on the collected specimens and images, we are now evaluating the use of a combination of partial HPV typing and automated visual evaluation (AVE) of cervical images to improve the accuracy of the screening program.
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Affiliation(s)
- Kanan T Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA.,Oak Ridge Institute of Science and Education, Oak Ridge, USA
| | - Kayode O Ajenifuja
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | | | - Clement A Adepiti
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Akiva Novetsky
- Rutgers New Jersey Medical School and Cancer Institute of New Jersey (CINJ), Newark, USA
| | | | - Mark H Einstein
- Rutgers New Jersey Medical School and Cancer Institute of New Jersey (CINJ), Newark, USA
| | - Temitope Oyinloye
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Tamara R Litwin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | | | - Fatai Olatunde Olanrewaju
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Mufutau Muphy Oripelaye
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Esther Afolabi
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Oluwole O Odujoko
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | | | | | | | | | | | - Maria Demarco
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | - Julia C Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | - Zhiyun Xue
- National Library of Medicine, NIH, Bethesda, USA
| | | | - Li Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, USA
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21
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Hu L, Bell D, Antani S, Xue Z, Yu K, Horning MP, Gachuhi N, Wilson B, Jaiswal MS, Befano B, Long LR, Herrero R, Einstein MH, Burk RD, Demarco M, Gage JC, Rodriguez AC, Wentzensen N, Schiffman M. An Observational Study of Deep Learning and Automated Evaluation of Cervical Images for Cancer Screening. J Natl Cancer Inst 2020; 111:923-932. [PMID: 30629194 DOI: 10.1093/jnci/djy225] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/12/2018] [Accepted: 12/03/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Human papillomavirus vaccination and cervical screening are lacking in most lower resource settings, where approximately 80% of more than 500 000 cancer cases occur annually. Visual inspection of the cervix following acetic acid application is practical but not reproducible or accurate. The objective of this study was to develop a "deep learning"-based visual evaluation algorithm that automatically recognizes cervical precancer/cancer. METHODS A population-based longitudinal cohort of 9406 women ages 18-94 years in Guanacaste, Costa Rica was followed for 7 years (1993-2000), incorporating multiple cervical screening methods and histopathologic confirmation of precancers. Tumor registry linkage identified cancers up to 18 years. Archived, digitized cervical images from screening, taken with a fixed-focus camera ("cervicography"), were used for training/validation of the deep learning-based algorithm. The resultant image prediction score (0-1) could be categorized to balance sensitivity and specificity for detection of precancer/cancer. All statistical tests were two-sided. RESULTS Automated visual evaluation of enrollment cervigrams identified cumulative precancer/cancer cases with greater accuracy (area under the curve [AUC] = 0.91, 95% confidence interval [CI] = 0.89 to 0.93) than original cervigram interpretation (AUC = 0.69, 95% CI = 0.63 to 0.74; P < .001) or conventional cytology (AUC = 0.71, 95% CI = 0.65 to 0.77; P < .001). A single visual screening round restricted to women at the prime screening ages of 25-49 years could identify 127 (55.7%) of 228 precancers (cervical intraepithelial neoplasia 2/cervical intraepithelial neoplasia 3/adenocarcinoma in situ [AIS]) diagnosed cumulatively in the entire adult population (ages 18-94 years) while referring 11.0% for management. CONCLUSIONS The results support consideration of automated visual evaluation of cervical images from contemporary digital cameras. If achieved, this might permit dissemination of effective point-of-care cervical screening.
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22
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Xue Z, Novetsky AP, Einstein MH, Marcus JZ, Befano B, Guo P, Demarco M, Wentzensen N, Long LR, Schiffman M, Antani S. A demonstration of automated visual evaluation of cervical images taken with a smartphone camera. Int J Cancer 2020; 147:2416-2423. [PMID: 32356305 DOI: 10.1002/ijc.33029] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/19/2020] [Accepted: 04/09/2020] [Indexed: 02/05/2023]
Abstract
We examined whether automated visual evaluation (AVE), a deep learning computer application for cervical cancer screening, can be used on cervix images taken by a contemporary smartphone camera. A large number of cervix images acquired by the commercial MobileODT EVA system were filtered for acceptable visual quality and then 7587 filtered images from 3221 women were annotated by a group of gynecologic oncologists (so the gold standard is an expert impression, not histopathology). We tested and analyzed on multiple random splits of the images using two deep learning, object detection networks. For all the receiver operating characteristics curves, the area under the curve values for the discrimination of the most likely precancer cases from least likely cases (most likely controls) were above 0.90. These results showed that AVE can classify cervix images with confidence scores that are strongly associated with expert evaluations of severity for the same images. The results on a small subset of images that have histopathologic diagnoses further supported the capability of AVE for predicting cervical precancer. We examined the associations of AVE severity score with gynecologic oncologist impression at all regions where we had a sufficient number of cases and controls, and the influence of a woman's age. The method was found generally resilient to regional variation in the appearance of the cervix. This work suggests that using AVE on smartphones could be a useful adjunct to health-worker visual assessment with acetic acid, a cervical cancer screening method commonly used in low- and middle-resource settings.
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Affiliation(s)
- Zhiyun Xue
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Akiva P Novetsky
- Rutgers New Jersey Medical School, Cancer Institute of New Jersey (CINJ), Newark, New Jersey, USA
| | - Mark H Einstein
- Rutgers New Jersey Medical School, Cancer Institute of New Jersey (CINJ), Newark, New Jersey, USA
| | - Jenna Z Marcus
- Rutgers New Jersey Medical School, Cancer Institute of New Jersey (CINJ), Newark, New Jersey, USA
| | - Brian Befano
- Information Management Services, Inc, Rockville, Maryland, USA
| | - Peng Guo
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Demarco
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Nicolas Wentzensen
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Leonard Rodney Long
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark Schiffman
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sameer Antani
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
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Van Arsdale A, Patterson NE, Maggi EC, Agoni L, Van Doorslaer K, Harmon B, Nevadunsky N, Kuo DY, Einstein MH, Lenz J, Montagna C. Insertional oncogenesis by HPV70 revealed by multiple genomic analyses in a clinically HPV-negative cervical cancer. Genes Chromosomes Cancer 2020; 59:84-95. [PMID: 31407403 PMCID: PMC6916423 DOI: 10.1002/gcc.22799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 12/21/2022] Open
Abstract
Cervical carcinogenesis, the second leading cause of cancer death in women worldwide, is caused by multiple types of human papillomaviruses (HPVs). To investigate a possible role for HPV in a cervical carcinoma that was HPV-negative by PCR testing, we performed HPV DNA hybridization capture plus massively parallel sequencing. This detected a subgenomic, URR-E6-E7-E1 segment of HPV70 DNA, a type not generally associated with cervical cancer, inserted in an intron of the B-cell lymphoma/leukemia 11B (BCL11B) gene in the human genome. Long range DNA sequencing confirmed the virus and flanking BCL11B DNA structures including both insertion junctions. Global transcriptomic analysis detected multiple, alternatively spliced, HPV70-BCL11B, fusion transcripts with fused open reading frames. The insertion and fusion transcripts were present in an intraepithelial precursor phase of tumorigenesis. These results suggest oncogenicity of HPV70, identify novel BCL11B variants with potential oncogenic implications, and underscore the advantages of thorough genomic analyses to elucidate insights into HPV-associated tumorigenesis.
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Affiliation(s)
- Anne Van Arsdale
- Department of Obstetrics & Gynecology and Women's HealthAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Nicole E. Patterson
- Department of GeneticsAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Elaine C. Maggi
- Department of GeneticsAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Lorenzo Agoni
- Department of Women's and Children's HealthObstetrics & Gynecology Unit, Fondazione Poliambulanza Istituto OspedalieroBresciaItaly
| | - Koenraad Van Doorslaer
- School of Animal and Comparative Biomedical SciencesCollege of Agriculture and Life Sciences BIO5 Institute University of ArizonaTusconArizonaUSA
| | - Bryan Harmon
- Department of PathologyAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Nicole Nevadunsky
- Department of Obstetrics & Gynecology and Women's HealthAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Dennis Y.S. Kuo
- Department of Obstetrics & Gynecology and Women's HealthAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Mark H. Einstein
- Department of Obstetrics, Gynecology, and Women's HealthRutgers New Jersey Medical SchoolNewarkNew Jersey
| | - Jack Lenz
- Department of GeneticsAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
| | - Cristina Montagna
- Department of GeneticsAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
- Department of PathologyAlbert Einstein College of Medicine, Yeshiva UniversityBronxNew York
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24
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Harper DM, Nieminen P, Donders G, Einstein MH, Garcia F, Huh WK, Stoler MH, Glavini K, Attley G, Limacher JM, Bastien B, Calleja E. The efficacy and safety of Tipapkinogen Sovacivec therapeutic HPV vaccine in cervical intraepithelial neoplasia grades 2 and 3: Randomized controlled phase II trial with 2.5 years of follow-up. Gynecol Oncol 2019; 153:521-529. [PMID: 30955915 DOI: 10.1016/j.ygyno.2019.03.250] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND While prophylactic human papillomavirus (HPV) vaccination exists, women are still developing cervical intraepithelial neoplasia (CIN) grade 2 or 3 for which an immunotherapeutic, non-surgical, approach may be effective. The primary aim was to assess the efficacy of tipapkinogen sovacivec (TS) vaccine in achieving histologic resolution of CIN2/3 associated with high risk (HR) HPV types. METHODS Women 18 years and older who had confirmed CIN2/3 were enrolled in a randomized, double blind, placebo-controlled phase II trial and assigned to drug in a 2:1 ratio (vaccine:placebo). The primary endpoint occurred at month 6 when the excisional therapy was performed; cytology and HR HPV typing were performed at months 3, 6 and every six months through month 30. The safety population included all patients who received at least one dose of study drug. RESULTS Of the 129 women randomized to vaccine and 63 to placebo, complete resolution was significantly higher in the vaccine group than placebo for CIN 2/3 regardless of the 13 HR HPV types assayed (24% vs. 10%, p < 0.05); as well as for only CIN 3 also regardless of HR HPV type (21% vs. 0%, p < 0.01). Irrespective of baseline HPV infection, viral DNA clearance was higher in the vaccine group compared to placebo (p < 0.01). The vaccine was well tolerated with the most common adverse events being injection site reactions. CONCLUSIONS The TS vaccine provides histologic clearance of CIN 2/3 irrespective of HR HPV type in one third of subjects and is generally safe through 30 months.
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Affiliation(s)
- Diane M Harper
- Department of Family and Community Medicine, Obstetrics and Gynecology, University of Missouri Kansas City, 7900 Lee's Summit Road, Kansas City, MO 64139, USA.
| | - Pekka Nieminen
- Department of Obstetrics and Gynaecology, Helsinki University Hospital and Helsinki University, Box 615, 00029 HUS, Helsinki, Finland.
| | - Gilbert Donders
- Department of Obstetrics and Gynaecology, University Hospital Antwerp, Wilrijksesteenweg 10, 2000 Antwerp-Ekeren, Belgium.
| | - Mark H Einstein
- Department of Obstetrics and Gynecology, Albert Einstein Cancer Center and Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Francisco Garcia
- Center of Excellence in Women's Health at the University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85714, USA.
| | - Warner K Huh
- Department of Obstetrics and Gynecology, University of Alabama, 1700 6th Avenue South, WIC Room 10250, Birmingham, AL 35233, USA.
| | - Mark H Stoler
- Surgical Pathology, P.O. Box 800214, Department of Pathology, University of Virginia Health System, University of Virginia, Charlottesville, VA, USA.
| | - Katerina Glavini
- Roche Pharmaceutical Research & Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd. Building 93, Room 7.38.01, Grenzacherstrasse 124, Basel 4070, Switzerland.
| | - Gemma Attley
- Roche Pharmaceutical Research & Early Development, Roche Innovation Center New York, 430 E. 29th Street New York City, New York 10016, USA.
| | - Jean-Marc Limacher
- Department of Medical Affairs, Transgene SA, 400 Bb Gonthier d'Andernach Parc d'innovation, CS80166, 67405 Illkirch-Graffenstaden Cedex, France.
| | - Berangere Bastien
- Department of Biostatistics, Transgene S.A., Boulevard Gonthier d'Andernach Parc d'innovation, CS80166, 67405 Illkirch-Graffenstaden Cedex, France.
| | - Elizabeth Calleja
- Roche Pharmaceutical Research & Early Development, Roche Innovation Center New York, 430 E. 29th Street New York City, New York 10016, USA.
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25
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Einstein MH, Ndlovu N, Lee J, Stier EA, Kotzen J, Garg M, Whitney K, Lensing SY, Tunmer M, Kadzatsa W, Palefsky J, Krown SE. Cisplatin and radiation therapy in HIV-positive women with locally advanced cervical cancer in sub-Saharan Africa: A phase II study of the AIDS malignancy consortium. Gynecol Oncol 2019; 153:20-25. [PMID: 30773222 DOI: 10.1016/j.ygyno.2019.01.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/17/2019] [Accepted: 01/23/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE To determine the feasibility, safety, and tolerability of concomitant chemoradiotherapy administered at standard doses in HIV-infected women with locally-advanced cervical cancer (LACC) receiving antiretroviral therapy (ART). PATIENTS AND METHODS Eligible participants had HIV infection and untreated, histologically-confirmed, invasive carcinoma of the uterine cervix, FIGO stages IB2, IIA (if tumor >4 cm), IIB, IIIA, IIIB, or IVA and met standard eligibility criteria. Subjects were prescribed 41.4-45 Gy external beam radiation therapy followed by high dose rate brachytherapy concomitant with up to six weekly doses of cisplatin 40 mg/m2 and were followed for 12 months. RESULTS Sixty-four women were screened at two sites in sub-Saharan Africa, of whom 40 eligible participants were enrolled, for a screening ratio of 1.60. Of the 38 eligible participants who initiated study treatment, 31 (82%) completed treatment. By the 12-month follow-up visit, 7 women had died of disease and 29 of 31 (94%) returned for follow-up. One-year progression-free survival was 76.3% (95% CI, 59.4-86.9%), and did not significantly differ according to stage at entry (p = 0.581). Participant-reported adherence to ART was high; by 12 months, 93% of participants had an undetectable viral load. The most common grade 3 or 4 adverse event was decreased lymphocyte count that affected all treated participants. Non-hematologic serious adverse events were similar to those observed in women with LACC without HIV infection. CONCLUSIONS The majority of HIV-infected women with LACC can complete concomitant chemoradiotherapy with the same cisplatin dose used in HIV-uninfected women with comparable tolerability and high ART adherence while on treatment.
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Affiliation(s)
- Mark H Einstein
- Department of Obstetrics, Gynecology, & Women's Health, Rutgers New Jersey Medical School, Newark, NJ, United States of America.
| | - Ntokozo Ndlovu
- College of Health Sciences, University of Zimbabwe Harare, Zimbabwe
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, United States of America.
| | - Jeffrey Kotzen
- Department of Radiation Oncology, University of the Witwatersrand, Johannesburg, South Africa.
| | - Madhur Garg
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, United States of America.
| | - Kathleen Whitney
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, United States of America.
| | - Shelly Y Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Mariza Tunmer
- Radiation Oncology Wits Donald Gordon Medical Centre, Johannesburg, South Africa.
| | - Webster Kadzatsa
- Department Radiotherapy and Oncology, College of Health Science University of Zimbabwe, Harare, Zimbabwe
| | - Joel Palefsky
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America.
| | - Susan E Krown
- AIDS Malignancy Consortium, New York, NY, United States of America.
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26
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Ellsworth GB, Lensing SY, Ogilvie CB, Lee JY, Goldstone SE, Berry-Lawhorn JM, Jay N, Stier EA, Logan JS, Einstein MH, Saah A, Mitsuyasu RT, Aboulafia D, Palefsky JM, Wilkin TJ. A delayed dose of quadrivalent human papillomavirus vaccine demonstrates immune memory in HIV-1-infected men. Papillomavirus Res 2018; 6:11-14. [PMID: 29807211 PMCID: PMC6121157 DOI: 10.1016/j.pvr.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/20/2018] [Accepted: 05/23/2018] [Indexed: 12/20/2022]
MESH Headings
- Adult
- Antibodies, Neutralizing/blood
- Antibodies, Viral/blood
- HIV Infections/complications
- HIV Infections/immunology
- Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18/administration & dosage
- Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18/immunology
- Humans
- Immunologic Memory
- Male
- Middle Aged
- Papillomavirus Infections/immunology
- Papillomavirus Infections/prevention & control
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Affiliation(s)
- G B Ellsworth
- Division of Infectious Diseases, Weill Cornell Medical College, 53W 23rd St, 6th Fl, New York, NY 10023, USA
| | - S Y Lensing
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - C B Ogilvie
- Weill Cornell Medical College, New York City, USA
| | - J Y Lee
- University of Arkansas for Medical Sciences, Little Rock, USA
| | | | | | - N Jay
- University of California at San Francisco, USA
| | - E A Stier
- Boston University Medical Center, Boston, MA, USA
| | | | - M H Einstein
- Albert Einstein College of Medicine, USA; Albert Einstein Cancer Center, Montefiore Medical Center, New York City, USA
| | - A Saah
- Merck Laboratories, Whitehouse Station, NJ, USA
| | | | - D Aboulafia
- Virginia Mason Medical Center, Seattle, WA, USA; Division of Hematology, University of Washington, USA
| | | | - T J Wilkin
- Division of Infectious Diseases, Weill Cornell Medical College, 53W 23rd St, 6th Fl, New York, NY 10023, USA.
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27
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Burkhalter JE, Atkinson TM, Berry-Lawhorn J, Goldstone S, Einstein MH, Wilkin TJ, Lee J, Cella D, Palefsky JM. Initial Development and Content Validation of a Health-Related Symptom Index for Persons either Treated or Monitored for Anal High-Grade Squamous Intraepithelial Lesions. Value Health 2018; 21:984-992. [PMID: 30098677 PMCID: PMC6093301 DOI: 10.1016/j.jval.2018.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 01/19/2018] [Accepted: 01/21/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Anal cancer, caused by oncogenic types of human papillomavirus, is a growing problem in the United States. A key focus of anal cancer prevention has been screening for and treating precancerous high-grade squamous intraepithelial anal lesions (HSILs). OBJECTIVES To develop a health-related symptom index for HSIL using qualitative techniques because anal HSIL and its treatment may have a negative impact on health-related quality of life (HRQOL), and no HRQOL measure specific to this condition and treatment currently exists. METHODS Expert consultation was used to guide one-on-one concept elicitation interviews with participants to identify HRQOL aspects they attribute to their anal HSIL and its treatment. This resulted in a draft instrument, which was administered to an independent participant sample, where cognitive interview techniques assessed comprehension. RESULTS Eighteen anal HSIL-related concepts were identified by the expert panel. Across the 41 concept elicitation interviews, 23 items representing physical symptoms, physical impacts, and psychological symptoms were identified to comprise the initial measure, which was then evaluated during three rounds of cognitive interviews (n = 45). Several questionnaire aspects were refined on the basis of participant input, with three additional items added per expert/participant recommendation. One item was removed because of poor comprehension, resulting in a 25-item measure. CONCLUSIONS Using state-of-the-art qualitative methodology, we have established the content validity of this new instrument, the ANCHOR Anal HSIL Health-Related Symptom Index. Quantitative validation efforts are currently underway. The participant-driven process of developing this tool will facilitate a participant-centered evaluation of the impact on morbidity for treatment of anal HSIL or observation without treatment.
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Affiliation(s)
| | | | | | | | | | | | - Jeannette Lee
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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28
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Rajdev L, Chiao EY, Lensing S, Little RF, Dittmer D, Einstein MH, Haigentz M, Sparano JA, Mitsuyasu RT. AMC 095 (AIDS Malignancy Consortium): A phase I study of ipilimumab (IPI) and nivolumab (NIVO) in advanced HIV associated solid tumors (ST) with expansion cohorts in HIV associated solid tumors and classical Hodgkin lymphoma (cHL). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.tps2597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Shelly Lensing
- University of Arkansas for Medical Sciences, Fayetteville, AR
| | - Richard F. Little
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - Dirk Dittmer
- Center for AIDS Research (CfAR) Carolina Center for Genome Sciences, Chapel Hill, NC
| | | | - Missak Haigentz
- Atlantic Health System, Morristown Medical Center, Morristown, NJ
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29
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Naeem RC, Goldstein DY, Einstein MH, Ramos Rivera G, Schlesinger K, Khader SN, Suhrland M, Fox AS. SurePath Specimens Versus ThinPrep Specimen Types on the COBAS 4800 Platform: High-Risk HPV Status and Cytology Correlation in an Ethnically Diverse Bronx Population. Lab Med 2018; 48:207-213. [PMID: 28379422 DOI: 10.1093/labmed/lmx019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To compare the cytologic preparations of 130 cervical specimens (from women of various ethnicities at high risk for human papillomavirus [HPV] infection) using the SurePath (SP) collection system with specimens gathered using the ThinPrep (TP) system, as processed on the Cobas 4800 analyzer, to determine which collection method more accurately identifies HPV infection. Methods In our prospective study, specimens were collected from 130 women of various ethnicities residing in or near Bronx County, NY. The SP-collected specimen was first processed for cytologic findings; if clinical HPV testing was requested on that specimen, it was tested using Hybrid Capture II (HC2) methodology. We tested the remnant SP-collected cell concentrate using the Cobas analyzer. Then, the TP-collected and SP-collected specimens were tested in the same run on that analyzer, and the results were compared. We also compared the results with the concurrent cytologic findings. Results The results were concordant for overall HR-HPV status in 93.8% of cases. Also, a statistically significant lower cycle threshold value was observed with Cobas testing of specimen concentrates tested via the BD SurePath Pap Test (P = .001), suggesting higher sensitivity compared with specimens tested via the ThinPrep Pap Test. Conclusion Cobas 4800 HPV testing of SP-collected specimen concentrates yields comparable results to TP-collected specimen concentrates. Based on the limited data that we derived, SP collection may be a more favorable methodology than TP collection for HPV testing of individuals at high risk in our ethnically diverse, urban patient population.
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Affiliation(s)
- R C Naeem
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - D Y Goldstein
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Mark H Einstein
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - G Ramos Rivera
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - K Schlesinger
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - S N Khader
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - M Suhrland
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - A S Fox
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
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30
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Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 55-year-old postmenopausal woman, gravida 5 para 5, with past medical history significant for hypertension, presented to the emergency department with profuse vaginal bleeding and a hemoglobin level of 9 g/dL. The biopsy from an irregular 6-cm cervical mass was consistent with moderately differentiated cervical squamous cell carcinoma. The physical examination did not reveal vaginal or parametrial extension of the tumor. Pelvic magnetic resonance imaging disclosed the known carcinoma, as well as a 9.2 × 7.7 × 6.7 cm anterior uterine fibroid (Fig 1). A staging positron emission tomography scan was negative for metastatic disease. After blood transfusion and vaginal packing, the patient was referred to discuss the immediate management of her newly diagnosed bleeding bulky cervical cancer. In the absence of parametrial or vaginal extension and in the absence of lymph node metastasis (both on clinical examination and imaging), she was classified as having International Federation of Gynecology and Obstetrics stage IB2 disease.
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Affiliation(s)
- Omar Mahmoud
- Omar Mahmoud, Rutgers University Cancer Institute of New Jersey, New Brunswick, NJ, and Rutgers University New Jersey Medical School, Newark, NJ; and Mark H. Einstein, Rutgers University New Jersey Medical School, Newark, NJ
| | - Mark H Einstein
- Omar Mahmoud, Rutgers University Cancer Institute of New Jersey, New Brunswick, NJ, and Rutgers University New Jersey Medical School, Newark, NJ; and Mark H. Einstein, Rutgers University New Jersey Medical School, Newark, NJ
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31
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Wijetunga NA, Ben-Dayan M, Tozour J, Burk RD, Schlecht NF, Einstein MH, Greally JM. A polycomb-mediated epigenetic field defect precedes invasive cervical carcinoma. Oncotarget 2018; 7:62133-62143. [PMID: 27557505 PMCID: PMC5308716 DOI: 10.18632/oncotarget.11390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/28/2016] [Indexed: 11/30/2022] Open
Abstract
Human papillomavirus (HPV)-associated cervical carcinoma is preceded by stages of cervical intra-epithelial neoplasia (CIN) that can variably progress to malignancy. Understanding the different molecular processes involved in the progression of pre-malignant CIN is critical to the development of improved predictive and interventional capabilities. We tested the role of regulators of transcription in both the development and the progression of HPV-associated CIN, performing the most comprehensive genomic survey to date of DNA methylation in HPV-associated cervical neoplasia, testing ~2 million loci throughout the human genome in biopsies from 78 HPV+ women, identifying changes starting in early CIN and maintained through carcinogenesis. We identified loci at which DNA methylation is consistently altered, beginning early in the course of neoplastic disease and progressing with disease advancement. While the loss of DNA methylation occurs mostly at intergenic regions, acquisition of DNA methylation is at sites involved in transcriptional regulation, with strong enrichment for targets of polycomb repression. Using an independent cohort from The Cancer Genome Atlas, we validated the loci with increased DNA methylation and found that these regulatory changes were associated with locally decreased gene expression. Secondary validation using immunohistochemistry showed that the progression of neoplasia was associated with increasing polycomb protein expression specifically in the cervical epithelium. We find that perturbations of genomic regulatory processes occur early and persist in cervical carcinoma. The results indicate a polycomb-mediated epigenetic field defect in cervical neoplasia that may represent a target for early, topical interventions using polycomb inhibitors.
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Affiliation(s)
- Neil Ari Wijetunga
- Department of Genetics and Center for Epigenomics, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Miriam Ben-Dayan
- Department of Genetics and Center for Epigenomics, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jessica Tozour
- Department of Genetics and Center for Epigenomics, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Robert D Burk
- Department of Pediatrics (Genetics), Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Nicolas F Schlecht
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA.,Department of Medicine (Oncology), Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Mark H Einstein
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA.,Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - John M Greally
- Department of Genetics and Center for Epigenomics, Albert Einstein College of Medicine, Bronx, NY 10461, USA.,Department of Pediatrics (Genetics), Albert Einstein College of Medicine, Bronx, NY 10461, USA
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32
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Merritt MA, Strickler HD, Einstein MH, Yang HP, Sherman ME, Wentzensen N, Brouwer-Visser J, Cossio MJ, Whitney KD, Yu H, Gunter MJ, Huang GS. Insulin/IGF and sex hormone axes in human endometrium and associations with endometrial cancer risk factors. Cancer Causes Control 2016; 27:737-48. [PMID: 27125830 PMCID: PMC4870288 DOI: 10.1007/s10552-016-0751-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 04/16/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Experimental and observational data link insulin, insulin-like growth factor (IGF), and estrogens to endometrial tumorigenesis. However, there are limited data regarding insulin/IGF and sex hormone axes protein and gene expression in normal endometrial tissues, and very few studies have examined the impact of endometrial cancer risk factors on endometrial tissue biology. METHODS We evaluated endometrial tissues from 77 premenopausal and 30 postmenopausal women who underwent hysterectomy for benign indications and had provided epidemiological data. Endometrial tissue mRNA and protein levels were measured using quantitative real-time PCR and immunohistochemistry, respectively. RESULTS In postmenopausal women, we observed higher levels of phosphorylated IGF-I/insulin receptor (pIGF1R/pIR) in diabetic versus non-diabetic women (p value =0.02), while women who reported regular nonsteroidal anti-inflammatory drug use versus no use had higher levels of insulin and progesterone receptors (both p values ≤0.03). We also noted differences in pIGF1R/pIR staining with OC use (postmenopausal women only), and the proportion of estrogen receptor-positive tissues varied by the number of live births and PTEN status (premenopausal only) (p values ≤0.04). Compared to premenopausal proliferative phase women, postmenopausal women exhibited lower mRNA levels of IGF1, but higher IGFBP1 and IGFBP3 expression (all p values ≤0.004), and higher protein levels of the receptors for estrogen, insulin, and IGF-I (all p values ≤0.02). Conversely, pIGF1R/pIR levels were higher in premenopausal proliferative phase versus postmenopausal endometrium (p value =0.01). CONCLUSIONS These results highlight links between endometrial cancer risk factors and mechanistic factors that may contribute to early events in the multistage process of endometrial carcinogenesis.
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Affiliation(s)
- Melissa A Merritt
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St Mary's Campus, Norfolk Place, London, W2 1PG, UK.
| | - Howard D Strickler
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Mark H Einstein
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine and Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Hannah P Yang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892, USA
| | - Mark E Sherman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892, USA
- Division of Cancer Prevention, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892, USA
| | - Jurriaan Brouwer-Visser
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine and Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Maria Jose Cossio
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine and Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Kathleen D Whitney
- Department of Pathology, Jack D. Weiler Hospital, The University Hospital for Albert Einstein College of Medicine, Montefiore Medical Center, 1825 Eastchester Road, Room 338, Bronx, NY, 10461, USA
| | - Herbert Yu
- Cancer Epidemiology Program, University of Hawaii Cancer Center, 701 Ilalo Street, Honolulu, HI, 96813, USA
| | - Marc J Gunter
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St Mary's Campus, Norfolk Place, London, W2 1PG, UK
| | - Gloria S Huang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine and Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
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Nathan LM, Shi Q, Plewniak K, Zhang C, Nsabimana D, Sklar M, Mutimura E, Merkatz IR, Einstein MH, Anastos K. Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study. Matern Child Health J 2016; 19:1949-55. [PMID: 25652061 DOI: 10.1007/s10995-015-1702-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.
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Affiliation(s)
- Lisa M Nathan
- Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA,
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Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FA, Kinney WK, Massad LS, Mayeaux EJ, Saslow D, Schiffman M, Wentzensen N, Lawson HW, Einstein MH. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. J Low Genit Tract Dis 2016; 19:91-6. [PMID: 25574659 DOI: 10.1097/lgt.0000000000000103] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 2011, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology updated screening guidelines for the early detection of cervical cancer and its precursors. Recommended screening strategies were cytology or cotesting (cytology in combination with high-risk HPV (hrHPV) testing). These guidelines also addressed the use of hrHPV testing alone as a primary screening approach, which was not recommended for use at that time. There is now a growing body of evidence for screening with primary hrHPV testing, including a prospective US-based registration study. Thirteen experts including representatives from the Society of Gynecologic Oncology, American Society for Colposcopy and Cervical Pathology, American College of Obstetricians and Gynecologists, American Cancer Society, American Society of Cytopathology, College of American Pathologists, and the American Society for Clinical Pathology, convened to provide interim guidance for primary hrHPV screening. This guidance panel was specifically triggered by an application to the FDA for a currently marketed HPV test to be labeled for the additional indication of primary cervical cancer screening. Guidance was based on literature review and review of data from the FDA registration study, supplemented by expert opinion. This document aims to provide information for health care providers who are interested in primary hrHPV testing and an overview of the potential advantages and disadvantages of this strategy for screening as well as to highlight areas in need of further investigation.
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Affiliation(s)
- Warner K Huh
- 1University of Alabama at Birmingham, Birmingham, AL, USA; 2University of Kansas Medical Center, Kansas City, KS, USA; 3Virginia Commonwealth University Medical Center, Richmond, VA, USA; 4University of Central Florida, Orlando, FL, USA; 5New England Pathology Associates, Springfield, MA, USA; 6Pima County Health Department, Tucson, AZ, USA; 7Kaiser Permanente, Sacramento, CA, USA; 8Washington University School of Medicine, St. Louis, MO, USA; 9University of South Carolina School of Medicine, Columbia, SC, USA; 10American Cancer Society, Atlanta, GA, USA; 11National Cancer Institute, Bethesda, MD, USA; 12American Society of Colposcopy and Cervical Pathology, Frederick, MD, USA; and 13Albert Einstein College of Medicine, Bronx, NY, USA
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Skeate JG, Woodham AW, Einstein MH, Da Silva DM, Kast WM. Current therapeutic vaccination and immunotherapy strategies for HPV-related diseases. Hum Vaccin Immunother 2016; 12:1418-29. [PMID: 26835746 DOI: 10.1080/21645515.2015.1136039] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Carcinomas of the anogenital tract, in particular cervical cancer, remains one of the most common cancers in women, and represent the most frequent gynecological malignancies and the fourth leading cause of cancer death in women worldwide. Human papillomavirus (HPV)-induced lesions are immunologically distinct in that they express viral antigens, which are necessary to maintain the cancerous phenotype. The causal relationship between HPV infection and anogenital cancer has prompted substantial interest in the development of therapeutic vaccines against high-risk HPV types targeting the viral oncoproteins E6 and E7. This review will focus on the most recent clinical trials for immunotherapies for mucosal HPV-induced lesions as well as emerging therapeutic strategies that have been tested in pre-clinical models for HPV-induced diseases. Progress in peptide- and protein-based vaccines, DNA-based vaccines, viral/bacterial vector-based vaccines, immune checkpoint inhibition, immune response modifiers, and adoptive cell therapy for HPV will be discussed.
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Affiliation(s)
- Joseph G Skeate
- a Department of Molecular Microbiology & Immunology , University of Southern California , Los Angeles , CA , USA
| | - Andrew W Woodham
- a Department of Molecular Microbiology & Immunology , University of Southern California , Los Angeles , CA , USA
| | - Mark H Einstein
- b Department of Obstetrics & Gynecology and Women's Health , Rutgers New Jersey Medical School , Newark , NJ , USA
| | - Diane M Da Silva
- c Department of Obstetrics & Gynecology , University of Southern California , Los Angeles , CA , USA.,d Norris Comprehensive Cancer Center, University of Southern California , Los Angeles , CA , USA
| | - W Martin Kast
- a Department of Molecular Microbiology & Immunology , University of Southern California , Los Angeles , CA , USA.,c Department of Obstetrics & Gynecology , University of Southern California , Los Angeles , CA , USA.,d Norris Comprehensive Cancer Center, University of Southern California , Los Angeles , CA , USA
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Buckley N, Huber A, Lo Y, Castle PE, Kemal K, Burk RD, Strickler HD, Einstein MH, Young M, Anastos K, Herold BC. Association of High-Risk Human Papillomavirus with Genital Tract Mucosal Immune Factors in HIV-Infected Women. Am J Reprod Immunol 2015; 75:146-54. [PMID: 26685115 DOI: 10.1111/aji.12461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/18/2015] [Indexed: 01/12/2023] Open
Abstract
PROBLEM High-risk human papillomavirus (HR-HPV) is prevalent in HIV-infected women and may be associated with mucosal changes that promote HIV replication. METHOD OF STUDY Innate immune molecules, antimicrobial activity, HIV RNA, and HPV DNA genotypes were measured in a cross-sectional study of 128 HIV-infected women categorized into HPV-16 (n = 8), other HR-HPV (n = 41), and non-HR-HPV controls (n = 79). RESULTS Compared to controls, HR-HPV groups had higher plasma viral loads (P = 0.004), lower CD4 cells (P = 0.02), more genital tract HIV RNA (P = 0.03), greater number of different HPV types (P < 0.001), higher cervicovaginal lavage (CVL) IL-1α (P = 0.03) and human beta-defensin 2 (HBD2) (P = 0.049), and less anti-HIVB al activity (P = 0.03). HPV-16 remained significantly associated with higher HBD2 (P = 0.03), higher IL-1α (P = 0.009), and lower anti-HIVB aL activity (P = 0.03) compared to controls after adjusting for plasma viral load and CD4 T cell count. CONCLUSION HR-HPV is associated with mucosal changes in HIV-infected women that could adversely impact genital tract health.
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Affiliation(s)
- Niall Buckley
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ashley Huber
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kimdar Kemal
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Robert D Burk
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Howard D Strickler
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mark H Einstein
- Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mary Young
- Department of Medicine, Georgetown University, Washington, DC, USA
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
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Einstein MH, Takacs P, Chatterjee A, Sperling RS, Chakhtoura N, Blatter MM, Lalezari J, David MP, Lin L, Struyf F, Dubin G. Comparison of long-term immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine and HPV-6/11/16/18 vaccine in healthy women aged 18-45 years: end-of-study analysis of a Phase III randomized trial. Hum Vaccin Immunother 2015; 10:3435-45. [PMID: 25483701 PMCID: PMC4514070 DOI: 10.4161/hv.36121] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The observer-blind, randomized, age-stratified, head-to-head study (NCT00423046) comparing immunogenicity and safety of HPV-16/18 and HPV-6/11/16/18 vaccines in healthy women aged 18-45 y was completed. Five y after vaccination, in subjects from the Month 60 according-to-protocol cohort (seronegative and DNA negative for HPV type analyzed at baseline), serum neutralizing antibody (nAb) responses induced by HPV-16/18 vaccine remained 7.8-fold (18-26-y stratum), 5.6-fold (27-35-y stratum) and 2.3-fold (36-45-y stratum) higher than those induced by HPV-6/11/16/18 vaccine for HPV-16. For HPV-18, the fold differences were 12.1, 13.0 and 7.8, respectively. At Month 60, all (100%) subjects in HPV-16/18 vaccine group and the majority (95.7%-97.5%) in HPV-6/11/16/18 vaccine group were seropositive for HPV-16. For HPV-18, the majority (98.1%-100%) of subjects in HPV-16/18 vaccine group were seropositive; however, seropositivity rates in HPV-6/11/16/18 vaccine group decreased considerably (61.1%-76.9%) across the 3 age strata. In the total vaccinated cohort (received ≥1 dose regardless of baseline HPV serostatus and DNA status), geometric mean titers for anti-HPV-16 and anti-HPV-18 nAb were higher in HPV-16/18 vaccine group than in HPV-6/11/16/18 vaccine group. Based on the 5-y data, piece-wise and modified power-law models predicted a longer durability of nAb response for HPV-16/18 vaccine compared to HPV-6/11/16/18 vaccine. Beyond the differences apparent between the vaccines in terms of immunogenicity and modeled persistence of antibody responses, comparative studies including clinical endpoints would be needed to determine whether differences exist in duration of vaccine-induced protection.
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Key Words
- 50 μg) adsorbed on aluminum salt (500 μg Al3+)
- AAHS, amorphous aluminum hydroxyphosphate sulfate
- ANOVA, analysis of variance
- AS04, Adjuvant System containing 3-O-desacyl-4’-monophosphoryl lipid A (MPL
- ATP, according-to-protocol
- CI, confidence interval
- Cervarix®
- ED50, effective dose producing 50% response
- ELISA, enzyme-linked immunosorbent assay
- GMT, geometric mean titer
- Gardasil®
- HPV, human papillomavirus
- MSC, medically significant condition
- NOAD, new onset autoimmune disease
- NOCD, new onset chronic disease
- PBNA, pseudovirion-based neutralization assay
- SAE, serious adverse event
- SP, seropositivity
- TVC, total vaccinated cohort
- antibodies
- human papillomavirus
- immunogenicity
- models
- nAb, neutralizing antibodies
- neutralizing
- safety
- statistical
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Affiliation(s)
- Mark H Einstein
- a Montefiore Medical Center and Albert Einstein College of Medicine; Obstetrics & Gynecology and Women's Health ; Bronx , NY USA
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Einstein MH, Levin MJ, Chatterjee A, Chakhtoura N, Takacs P, Catteau G, Dessy FJ, Moris P, Lin L, Struyf F, Dubin G. Comparative humoral and cellular immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine and HPV-6/11/16/18 vaccine in healthy women aged 18-45 years: follow-up through Month 48 in a Phase III randomized study. Hum Vaccin Immunother 2015; 10:3455-65. [PMID: 25483700 PMCID: PMC4514093 DOI: 10.4161/hv.36117] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
We previously reported higher anti-HPV-16 and -18 immune responses induced by HPV-16/18 vaccine compared with HPV-6/11/16/18 vaccine at Month 7 (one month after completion of full vaccination series) in women aged 18–45 y in an observer-blind study NCT00423046; the differences of immune response magnitudes were maintained up to Month 24. Here we report follow-up data through Month 48. At Month 48, in according-to-protocol cohort for immunogenicity (seronegative and DNA-negative for HPV type analyzed at baseline), geometric mean titers of serum neutralizing antibodies were 2.0- to 5.2-fold higher (HPV-16) and 8.6- to 12.8-fold higher (HPV-18) in HPV-16/18 vaccine group than in HPV-6/11/16/18 vaccine group. The majority of women in both vaccine groups remained seropositive for HPV-16. The same trend was observed for HPV-18 in HPV-16/18 vaccine group; however, seropositivity rates in HPV-6/11/16/18 vaccine group decreased considerably, particularly in the older age groups. In the total vaccinated cohort (regardless of baseline serological and HPV-DNA status), anti-HPV-16 and -18 neutralizing antibody levels induced by HPV-16/18 vaccine were higher than those induced by HPV-6/11/16/18 vaccine. CD4+ T-cell response for HPV-16 and HPV-18 was higher in HPV-16/18 vaccine group than in HPV-6/11/16/18 vaccine group. Memory B-cell responses appeared similar between vaccine groups. Both vaccines were generally well tolerated. Overall, the higher immune response observed with the HPV-16/18 vaccine was maintained up to Month 48. A head-to-head study incorporating clinical endpoints would be required to confirm whether the observed differences in immune response between the vaccines influence the duration of protection they provided.
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Key Words
- 50 μg) adsorbed on aluminum salt (500 μg Al(OH)3)
- ANOVA, analysis of variance
- AS04, Adjuvant System containing 3-O-desacyl-4’-monophosphoryl lipid A (MPL
- ATP, according-to-protocol
- CI, confidence interval
- CMI, cell-mediated immune
- CVS, cervicovaginal secretion
- Cervarix®
- ED50, effective dose producing 50% response
- ELISA, enzyme-linked immunosorbent assay
- GM, geometric mean
- GMR, geometric mean (titer) ratio
- GMT, geometric mean titer
- Gardasil®
- HPA, Health Protection Agency
- HPV, human papillomavirus
- IgG, immunoglobulin G
- MSC, medically significant condition
- NOAD, new onset autoimmune disease
- NOCD, new onset chronic disease
- PBMC, peripheral blood mononuclear cells
- PBNA, pseudovirion-based neutralization assay
- SAE, serious adverse event
- TVC, total vaccinated cohort
- VLP, virus-like particle
- human papillomavirus
- immunogenicity
- nAb(s), neutralizing antibody(ies)
- safety
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Affiliation(s)
- Mark H Einstein
- a Montefiore Medical Center; Albert Einstein College of Medicine; Department of Obstetrics & Gynecology and Women's Health ; Bronx , NY USA
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Abstract
Cancer is a disease of aging, and therefore is more prevalent after menopause. Menopausal symptoms resulting from cancer treatments are an important survivorship issue in cancer care. This article reviews the preventive strategies, utilization of health resources, and management of menopausal symptoms after cancer treatment. Preventive screening as informed by genetic and lifestyle risk, and lifestyle modification, may mitigate the risk of cancer and cancer mortality. Despite potential benefits to quality of life, hormone replacement is rarely prescribed to survivors of gynecologic malignancies. Special considerations are needed for the treatment and supportive care of menopausal symptoms in cancer survivors.
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Affiliation(s)
- Mark H Einstein
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, 1300 Morris Park Avenue, NY 10461, USA
| | - Nanci F Levine
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Nicole S Nevadunsky
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, 1300 Morris Park Avenue, NY 10461, USA.
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Shaw JM, Mehta S, Chudnoff S, Levie M, Einstein MH, Goldberg GL, Nevadunsky NS. Abstract 3730: Feasibility of office hysteroscopy for evaluation of women with postmenopausal bleeding and association with improved pathological diagnosis. Cancer Res 2015. [DOI: 10.1158/1538-7445.am2015-3730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Objectives: Endometrial sampling is critical in the evaluation of women for cancers of the uterine corpus. Hysteroscopy in the operating room is associated with monetary and time expense to the patient and health care system. The purpose of this study was to compare histopathological diagnoses of endometrial biopsies obtained by office hysteroscopy (OH) versus endometrial pipelle (EP).
Methods: After IRB approval, records of all women with ICD-9 diagnosis (627.1) for postmenopausal bleeding who had OH attempted in the last 5 years at a single medical institution were evaluated. Demographic data collected included age, BMI, medical comorbidities, and histopathologic diagnosis. “Inadequate tissue” for pathologic evaluation was defined as stated in the pathology report or absence of endometrial tissue on biopsy specimen. Statistical analysis was performed using chi-square and Fisher's exact testing with SPSS software.
Results: 85 OHs were attempted and 50 had prior attempted EPs. 98% of OHs and 94% of EPs were successfully performed. However, adequate pathology was obtained in 93% of OHs verses 38% of EPs (p<0.01). Median age was 61 years (range 48-85) and median BMI was 32 kg/m2 (range 19-71). 5% had a BMI<25. The prevalence of diabetes mellitus, hypertension, hyperlipidemia, and cardiovascular disease were 32%, 74%, 44%, and 21% respectively. There was a significant difference in pathologic diagnoses between OH and EP (p <0.01). Six patients were diagnosed with endometrial hyperplasia, and 3 with endometrial cancers by OH that were not identified by EP.
Conclusions: OH is a feasible procedure that may enhance clinicians’ ability to diagnose benign, pre-malignant and malignant causes of post-menopausal bleeding. Further research is needed to understand the association of cost and quality of life with OH versus hysteroscopy in the operating room.
Table 1.Pathology findings from OH vs. EPPathologyOffice Hysteroscopy (OH)%Endometrial Pipelle Biopsy (EP)%n = 79n = 19Endometrial Cancer34%00%Endometrial Hyperplasia68%00%Benign Endometrium1924%1053%Atrophic Endometrium45%421%Benign Endometrial Polyp4759%526%
Citation Format: Jacquelyn M. Shaw, Sukrant Mehta, Scott Chudnoff, Mark Levie, Mark H. Einstein, Gary L. Goldberg, Nicole S. Nevadunsky. Feasibility of office hysteroscopy for evaluation of women with postmenopausal bleeding and association with improved pathological diagnosis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3730. doi:10.1158/1538-7445.AM2015-3730
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Affiliation(s)
- Jacquelyn M. Shaw
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Sukrant Mehta
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Scott Chudnoff
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Mark Levie
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Mark H. Einstein
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Gary L. Goldberg
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Moscicki AB, Darragh TM, Berry-Lawhorn JM, Roberts JM, Khan MJ, Boardman LA, Chiao E, Einstein MH, Goldstone SE, Jay N, Likes WM, Stier EA, Welton ML, Wiley DJ, Palefsky JM. Screening for Anal Cancer in Women. J Low Genit Tract Dis 2015; 19:S27-42. [PMID: 26103446 PMCID: PMC4479419 DOI: 10.1097/lgt.0000000000000117] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human papillomavirus (HPV), and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions (HSIL). Our goals were to summarize the literature on anal cancer, HSIL, and HPV infection in women and to provide screening recommendations in women. METHODS A group of experts convened by the American Society for Colposcopy and Cervical Pathology and the International Anal Neoplasia Society reviewed the literature on anal HPV infection, anal SIL, and anal cancer in women. RESULTS Anal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with human immunodeficiency virus-infected women and those with a history of lower genital tract neoplasia at highest risk compared with the general population. CONCLUSIONS While there are no data yet to demonstrate that identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and required to have digital anorectal examinations to detect anal cancers. Human immunodeficiency virus-infected women and women with lower genital tract neoplasia may be considered for screening with anal cytology with triage to treatment if HSIL is diagnosed. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.
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Affiliation(s)
- Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Teresa M. Darragh
- Department of Clinical Pathology, University of California, San Francisco, CA, USA
| | | | | | - Michelle J. Khan
- Division of Women's Reproductive Healthcare Department of OB/GYN, School of Medicine, University of Alabama at Birmingham, AL, USA
| | - Lori A. Boardman
- Florida Hospital for Women, Florida Hospital System, University of Central Florida College of Medicine, FL, USA
| | - Elizabeth Chiao
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Mark H. Einstein
- Department of Obstetrics and Gynecology & Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY
| | | | - Naomi Jay
- Anal Neoplasia Clinic, Research and Education (ANCRE) Center, University of California, San Francisco, CA, USA
| | - Wendy M. Likes
- College of Medicine, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Mark Lane Welton
- Colon & Rectal Surgery, Stanford University School of Medicine Stanford Hospital and Clinics, Stanford, CA, USA
| | - Dorothy J. Wiley
- School of Nursing, University of California, Los Angeles, CA, USA
| | - Joel M. Palefsky
- Department of Infectious Diseases, University of California, San Francisco, CA, USA
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Van Doorslaer K, DeSalle R, Einstein MH, Burk RD. Degradation of Human PDZ-Proteins by Human Alphapapillomaviruses Represents an Evolutionary Adaptation to a Novel Cellular Niche. PLoS Pathog 2015; 11:e1004980. [PMID: 26086730 PMCID: PMC4472669 DOI: 10.1371/journal.ppat.1004980] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 05/26/2015] [Indexed: 11/29/2022] Open
Abstract
In order to complete their life cycle, papillomaviruses have evolved to manipulate a plethora of cellular pathways. The products of the human Alphapapillomavirus E6 proteins specifically interact with and target PDZ containing proteins for degradation. This viral phenotype has been suggested to play a role in viral oncogenesis. To analyze the association of HPV E6 mediated PDZ-protein degradation with cervical oncogenesis, a high-throughput cell culture assay was developed. Degradation of an epitope tagged human MAGI1 isoform was visualized by immunoblot. The correlation between HPV E6-induced degradation of hMAGI1 and epidemiologically determined HPV oncogenicity was evaluated using a Bayesian approach within a phylogenetic context. All tested oncogenic types degraded the PDZ-containing protein hMAGI1d; however, E6 proteins isolated from several related albeit non-oncogenic viral types were equally efficient at degrading hMAGI1. The relationship between both traits (oncogenicity and PDZ degradation potential) is best explained by a model in which the potential to degrade PDZ proteins was acquired prior to the oncogenic phenotype. This analysis provides evidence that the ancestor of both oncogenic and non-oncogenic HPVs acquired the potential to degrade human PDZ-containing proteins. This suggests that HPV E6 directed degradation of PDZ-proteins represents an ancient ecological niche adaptation. Phylogenetic modeling indicates that this phenotype is not specifically correlated with oncogenic risk, but may act as an enabling phenotype. The role of PDZ protein degradation in HPV fitness and oncogenesis needs to be interpreted in the context of Alphapapillomavirus evolution. It is thought that the ability to degrade PDZ domain containing proteins is a hallmark of oncogenic papillomaviruses. However, since papillomaviruses did not evolve to be oncogenic, this hypothesis does not address the evolutionary importance of this phenotype. The present manuscript attempts to address whether HPV induced degradation of PDZ containing proteins is associated with oncogenic potential as determined by the clinical/epidemiological empirical cancer risk. Using Bayesian approaches to model trait evolution we show that it is highly unlikely for a virus to become oncogenic without first acquiring the ability to degrade PDZ proteins. Furthermore, the ability to degrade PDZ proteins allowed ancestral viruses to colonize a new cellular niche. However, in order to thrive in this new environment, these ancestral viruses had to acquire additional functions. We hypothesize that some of these additional phenotypes lead to oncogenicity. Importantly, our study illustrates the power of combining epidemiological, biochemical and evolutionary data with phylogenetic analysis in attempting to understand the relative role of specific pathogen phenotypes with host pathogenesis.
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Affiliation(s)
- Koenraad Van Doorslaer
- Department of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, New York, New York, United States of America
| | - Rob DeSalle
- Sackler Institute of Comparative Genomics, American Museum of Natural History, New York, New York, United States of America
| | - Mark H. Einstein
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, New York, United States of America
| | - Robert D. Burk
- Department of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, New York, New York, United States of America
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, New York, United States of America
- Department of Pediatrics, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, New York, United States of America
- * E-mail:
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Rossi A, Garber C, Ortiz M, Moadel-Robblee A, Kaur G, Viswanathan S, Einstein MH, Goldberg GL, Nevadunsky N. Feasibility of a physical activity intervention for ethnically diverse endometrial cancer survivors. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.5598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Shankar Viswanathan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | | | - Gary L. Goldberg
- Montefiore Medical Center/Albert Einstein Coll of Medicine, Bronx, NY
| | - Nicole Nevadunsky
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
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Hillemanns P, Garcia F, Petry KU, Dvorak V, Sadovsky O, Iversen OE, Einstein MH. A randomized study of hexaminolevulinate photodynamic therapy in patients with cervical intraepithelial neoplasia 1/2. Am J Obstet Gynecol 2015; 212:465.e1-7. [PMID: 25467012 DOI: 10.1016/j.ajog.2014.10.1107] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/09/2014] [Accepted: 10/29/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of the study was to investigate the efficacy and safety of hexaminolevulinate (HAL) photodynamic therapy (PDT), a novel therapy for women with cervical intraepithelial neoplasia (CIN)1/2, to define the appropriate population and endpoints for a phase 3 program. STUDY DESIGN This was a double-blind, randomized, placebo-controlled, dose-finding study that included a total of 262 women with biopsy-confirmed CIN 1/2 based on local pathology. Patients received 1 or 2 topical treatments of HAL hydrochloride 0.2%, 1%, 5%, and placebo ointment and were evaluated for response after 3-6 months based on biopsy, Papanicolaou test, and oncogenic human papillomavirus (HPV) test. All efficacy analyses were performed on blinded central histology review to avoid interreader variability. Adverse events, blood biochemistry, and vital signs were assessed after 3 months. RESULTS There were no statistically significant differences between placebo and either the CIN 1 or combined CIN 1/2 populations. A clear dose effect with a statistically significant response in the HAL 5% group of 95% (18/19 patients) compared to 57% (12/21 patients) in the placebo group (P < .001) was observed at 3 months in women with CIN 2, including an encouraging 83% (5/6 patients) clearance of HPV 16/18 compared to 33% (2/6 patients) in the placebo group at 6 months. The treatment was easy to use and well accepted by patients and gynecologists. Only local self-limiting adverse reactions including discharge, discomfort, and spotting were reported. CONCLUSION HAL PDT is a novel therapy that shows promise in the treatment of CIN 2 including clearance of oncogenic HPV, but not of CIN 1. The positive risk/benefit balance makes HAL PDT a tissue-preserving alternative in women of childbearing age who wish to preserve the cervix. Confirmatory studies are planned.
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Castle PE, Smith KM, Davis TE, Schmeler KM, Ferris DG, Savage AH, Gray JE, Stoler MH, Wright TC, Ferenczy A, Einstein MH. Reliability of the Xpert HPV assay to detect high-risk human papillomavirus DNA in a colposcopy referral population. Am J Clin Pathol 2015; 143:126-33. [PMID: 25511151 DOI: 10.1309/ajcp4q0nsdhwizgu] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES The Xpert HPV Assay (Xpert; Cepheid, Sunnyvale, CA) was developed for the multianalytic GeneXpert platform. METHODS In a colposcopy referral population of 708 women living in the United States, two cervical specimens, A and B, were collected, and both were tested by the Xpert assay for high-risk human papillomavirus (hrHPV) DNA, permitting an evaluation of its test reliability. Specimen B was also tested by Hybrid Capture 2 (hc2; Qiagen, Germantown, MD) and the cobas HPV Test (cobas; Roche Molecular Systems, Pleasanton, CA). RESULTS The κ and percent agreement for any hrHPV for the two Xpert results were 0.88 and 94.5%, respectively. There was no statistical difference in testing positive on both specimens by Xpert (P = .62). The sensitivity for detection of cervical intraepithelial neoplasia grade 2 or more severe (CIN2+) was 89.0% using specimen A and 90.4% using specimen B for Xpert, 90.4% for cobas, and 81.6% for hc2. CONCLUSIONS The Xpert assay was sensitive and reliable for the detection of hrHPV and the identification of women with CIN2+.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Alex Ferenczy
- McGill University and Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark H. Einstein
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
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Hillemanns P, Einstein MH, Iversen OE. Topical hexaminolevulinate photodynamic therapy for the treatment of persistent human papilloma virus infections and cervical intraepithelial neoplasia. Expert Opin Investig Drugs 2014; 24:273-81. [PMID: 25514095 DOI: 10.1517/13543784.2015.990150] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current treatments for high-grade cervical intraepithelial neoplasia (CIN2/3) are mainly excisional procedures, which are associated with significant side effects and pose risks for future pregnancies. An effective and safe therapy is needed to reduce the requirement for surgical interventions in women of reproductive age. AREAS COVERED This review looks at the pharmacokinetic and clinical data for topical hexaminolevulinate (HAL) photodynamic therapy (PDT), which is currently entering late phase clinical trials for high-grade CIN. The authors include published studies in patients and volunteers but laboratory and animal studies have been excluded as have studies on other porphyrins such as Photofrin, 5-aminolevulinic acid, methyl aminolevulinate and studies reporting other clinical applications for HAL. EXPERT OPINION Topical HAL PDT has potential as a non-surgical tissue-preserving treatment for CIN and persistent oncogenic human papilloma virus infections. HAL PDT selectively treats the entire epithelial sheet, without the tissue destruction seen in excisional procedures. The authors believe that this treatment could replace surgery in a large proportion of patients. It would be of particular value to the high percentage of women who are interested in future child-bearing. If the treatment is approved, it is very likely that physicians will want to use this treatment, as many patients will be keen to consider a non-surgical option.
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Affiliation(s)
- Peter Hillemanns
- Hannover Medical School, Department of Obstetrics and Gynaecology , Hannover , Germany +49 511 532 6144 ; +49 511 532 6145 ;
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Soergel P, Dvorak V, Sadovsky O, Jentschke M, Iversen OE, Einstein MH, Hillemanns P. Photodynamische Therapie der CIN1 und CIN2 mit Hexylaminolevulinsäure – eine Phase 2B-Studie. Geburtshilfe Frauenheilkd 2014. [DOI: 10.1055/s-0034-1388554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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LaVigne K, Chong W, Klobocista M, Einstein MH, Curtin JP, Boyd LR. Ovarian cancer treatment: Is the standard of care met in a public hospital system? J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e16524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Woojin Chong
- Albert Einstein College of Medicine, New York, NY
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Van Arsdale A, Kaur G, Hou JY, Klobocista M, Goldfinger M, Goldberg GL, Einstein MH, Nevadunsky N. Risk factors and prevalence of cognitive deficits in women with gynecologic malignancies. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.9601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Anne Van Arsdale
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | | | - June YiJuan Hou
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
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Herzog TJ, Monk BJ, Rose PG, Braly P, Hines JF, Bell MC, Wenham RM, Secord AA, Roman LD, Einstein MH, Drake RD, Childs BH. A phase II trial of oxaliplatin, docetaxel, and bevacizumab as first-line therapy of advanced cancer of the ovary, peritoneum, and fallopian tube. Gynecol Oncol 2014; 132:517-25. [PMID: 24476788 DOI: 10.1016/j.ygyno.2014.01.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 01/07/2014] [Accepted: 01/18/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of the novel combination of docetaxel, oxaliplatin, and bevacizumab as first-line treatment of advanced cancer of the ovary, peritoneum or fallopian tube after initial debulking surgery. METHODS Eligible patients (stage IB-IV) were treated with 6 cycles of oxaliplatin (85 mg/m(2)), docetaxel (75 mg/m(2)), and bevacizumab (15 mg/kg) every 3 weeks, followed by single-agent bevacizumab 15 mg/kg every 3 weeks to complete one year of therapy. The primary endpoint was 12-month progression-free survival (PFS). RESULTS A total of 132 patients (80 with measurable disease at baseline; 52 with non-measurable, evaluable disease at baseline) enrolled and received study treatment. At diagnosis, 76.5% of patients had stage III disease and 20% had stage IV. 62.9% were optimally cytoreduced. The most common grade 3/4 adverse events were neutropenia (42.4%), leukopenia (13.6%), hypertension (8.3%), fatigue (6.1%), and nausea (6.1%). One patient (0.8%) had a fatal gastrointestinal perforation. The best overall confirmed response rate (complete response+partial response [measurable disease subgroup]) was 58.6% (95% CI 49%, 67%). CA-125 response rates for the measurable and non-measurable disease subgroups were 83.0% and 81.5%, respectively. The 12-month PFS rate for the measurable disease subgroup was 65.7% (95% CI 53.4%, 76.7%); median PFS was 16.3 (95% CI 12.6, 19.6) months. Median overall survival was 47.3 (95% CI 34.1, upper limit not applicable) months. CONCLUSIONS This novel treatment regimen may provide a promising therapeutic approach for women with ovarian, primary peritoneal, or fallopian tube carcinoma. No unanticipated safety concerns were identified.
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Affiliation(s)
- Thomas J Herzog
- Columbia University, NY Presbyterian Medical Center, New York, NY, USA.
| | - Bradley J Monk
- Creighton University School of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | | | | | - Maria C Bell
- Sioux Valley University Hospital, Sioux Falls, SD, USA
| | - Robert M Wenham
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Lynda D Roman
- University of Southern California-Norris Comprehensive Cancer Center and Hospital, Los Angeles, CA, USA
| | - Mark H Einstein
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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